Old Wine in New Bottles – Remarketing ‘Depression’

Last year, I watched an interview on ABC News 24 informing us about a “new theory on the cause of depression”. This is that it is caused, not by a “chemical imbalance” but by inflammation in the nervous system (notably the brain). This is being presented as an alternative to the “serotonin theory of depression” that was used to justify the presciption of Selective Serotonin Reuptake Inhibitor (SSRI) drugs, beginning with Prozac in 1987.

I have been watching and analysing the changing hype for many years. When I worked as a family doctor, the drug companies were claiming that depression was caused by a chemical imbalance in the neurotransmitter noradrenaline, not the indole amine serotonin (5-hydroxytryptamine). This was because the market leaders in the “depression market” were the toxic and ineffective “tricyclic antidepressants” which were developed in the 1950s and were the mainstay of depression treatment till they were replaced by the SSRIs in the 1990s. Tricyclics were known to affect noradrenaline (norepinephrine) levels in the brain.

The psychiatrist interviewed by the Australian Broadcasting Corporation (ABC) defended the “chemical imbalance theory” that has been such a successful marketing catchphrase for the drug companies but admitted that the SSRI’s don’t work for everyone and that “we don’t know” why some people with depression have disordered serotonin metabolism and others don’t. As usual, she explained that they needed more money for research to get the answers.

Dr Liz Scott, for that was her name, also agreed that the new theory was plausible, pointing to the fact that stress affects the immune system. She didn’t explain how stress, which usually depresses the immune system, is responsible for this inflammation, or why there is no evidence of such inflammation in the brains of depressed people who commit suicide. At the same time it is known that chronic illness of many types causes unhappiness and “depression”, including viral, bacterial and fungal infections, kidney and heart disease, cancer and chronic arthritis. Forced psychiatric treatment (especially incarceration) is an important cause of stress that Dr Liz Scott did not mention, predictably. Many other things cause unhappiness, and unhappiness has long been termed “depression” by the medical treatment industry, rejecting the older term of melancholia (thought to be due to a preponderance of black bile, one of the four humours of Galenic medicine).

In the 1960s American “experimental psychologists” of the “Behaviorist School” did a series of cruel experiments on baby chimpanzees, which demonstrated, as if there was need for it, that primates (as well as cats, dogs and even rats) pine away and become morose and depressed when they are deliberately made lonely and deprived of social activity and the comfort of others. This was heralded as a “discovery”.

Prozac was released with much hype, including a flurry of books in the “popular science” press, especially by Rupert Murdoch’s Harper-Collins publishers. These promoted Prozac for a range of medical and psychiatric conditions beyond depression, and resulted in profits of 3 billion for Eli Lilly. The other major drug companies followed suit, releasing and marketing (including bribing doctors to prescribe) a growing range of alternative SSRIs.

Eli Lilly have a long history of research into psychedelic drugs and psychoactive drugs that affect the serotonin receptors and pathways in the brain. In the 1960s they bought the rights to LSD (or ‘acid’) from the Swiss company (Sandoz) that had developed it. It was known that LSD could cause “schizophrenia-like” psychotic episodes, according to the psychiatric terminology of the time. This terminology dates back to 1909, when the Swiss psychiatrist Eugen Bleuler coined the term “schizophrenia” and promoted its use for what his colleague Emil Kraepelin of the University of Heidelberg in Germany, known as the “Father of Psychiatric Classification”, had termed “dementia praecox” (adolescent dementia).

Bleuler argued that Kraepelin, in Germany was too pessimistic and that a third of his patients in the Swiss Burgholzli asylum recovered and were discharged from hospital. Kraepelin had taught, for many years, that any young person who “heard voices” was eventually destined to die of dementia (terminal mental degeneration) in a lunatic asylum.

German psychiatry became more brutal under the Nazis when patients with “schizophrenia”, “cyclical madness” (manic depression or bipolar disorder) and “personality disorder”, who had been populating the long-term mental asylum wards, were prescribed “euthanasia” – meaning “good” or “mercy killing”. Needless to say this included political enemies of the regime, since it has long been the case that enemies of the state or ruling regime get branded as mad. The same label of schizophrenia was also used in the Soviet Union to justify locking up and drugging, with chemical restraints, social and political dissidents.

In fact, chemicals do have a lot of effect on human thinking and behaviour, as the well-known effects of alcohol and drunkenness demonstates. To understand the hidden crime of “antipsychotic drugs”, and “antidepressants” one needs to know a few basics about catecholamine and indole amine neiurotransmitters and neurohormones.

Neurotransmitters are small molecules that bind to cell membranes of the nerve cells (neurones) in the brain and nervous system, stimulating or inhibiting “action potentials” or electrical impulses that pulse or vibrate in a constant, complex network through the nervous system. There are many different receptors for the same neurotransmitter – for example there are D1, D2, D3, D4 and D5 receptors in different parts of the brain. This results in the same chemical neurotransmitter having different effects depending on the type of receptor on the effector cell.

This science lies behind the efforts, over many decades, to find antipsychotic drugs that did not cause stiffness, dribbling and uncontrollable writhing movements of the face and limbs (Tardive Dyskinesia) which crippled so many of the long-term inmates of mental hospitals in the 1960s, 70s and 80s, when the main drugs that were used were Largactil (Thorazine), Haldol (haloperidol), Stelazine and Modecate. Thousands were crippled and still are, by these horrible drugs – both in the communist and the capitalist nations. The main “indications” were “schizophrenia”, “mania” and “schizoaffective disorder”, though they were also used as chemical restraints in elderly people diagnosed with dementia, a particularly cruel form of elder abuse that was prevalent in the more abusive nursing homes in Australia.

It is important to realise that the neurotransmitters in the brain are in constant dynamic flux. Every emotion or action results in chemical changes. When one listens to music the chemicals in the brain change. When one does for a walk, the chemicals change. When one gets excited, or relaxes, the chemical balance changes. Some neurotransmitters increase and some decrease in activity, made more complex by the fact that different cells have different neurotransmitter receptors, affecting how they respond to them. It been demonstrated that the successful completion of tasks results in measurable increase in serotonin levels.

Chemical imbalance theories make a lot of money for companies selling chemicals (drugs/medications). Millions of dollars are spent on promoting various chemical imbalance theories and the drugs that affect these chemicals. The dopamine theory of schizophrenia and the serotonin theory of depression were used to market dopamine-blocking “antipsychotic drugs” and SSRI “antidepressants” respectively. Despite numerous people demonstrating the fallacy of the different chemical imbalance theories, opponents are up against a multi-billion-dollar industry that is profit-driven and stands to profit from repeating the theories without mentioning the opposition to them.

Don’t believe the hype.

Reality TV (protest song)

 

The ‘Green Guide’ told us to watch the TV

It claimed that we would finally see reality.

Under the impression that truth is not a digression

I had to ask the question

As to why the strange things I saw that night

Were advertised as real and right

So I waited for the commercial break

To lose my concentration

As my attention wandered away

From the packet filled with cornflakes on the screen

To reality as it has been

From the cornflakes on the screen

To reality as it has been

 

So I looked out of my window

And saw that things were good –

The tree that I had planted

Was still standing where it should;

I thought it seemed real enough

I didn’t need to check

I saw a purple flower

But in the shade it looked black.

 

Then I looked up at the sky

Where the moon had been last night

The moon had gone and in its place

Was a glowing ball of light

A glowing ball of light

 

“Could this be real?” I wondered

As I looked on with delight

As the cotton clouds changed shape

To form a white dove bird in flight

But I knew that it was only a cloud I knew it was the sky

I didn’t wave my arms about

Thinking that I could fly!

 

I didn’t watch the box that night

To tell me what is wrong and what is right

But ‘reality’ blazed its bizarre beams

Into other minds and other brains

And I wonder how many were sane

With ‘reality TV’ in their brains

I wonder how many were sane

With ‘reality TV’ in their brains.

 

(words and music by Romesh Senewiratne-Alagaratnam, copyright 2004)

With One Voice “Peace” (protest song)

words and music by Romesh Senewiratne-Alagaratnam Arya Chakravarti, 2004

recorded in 2006

 

WITH ONE VOICE ‘PEACE’

 

Looking at the sunshine

But kept in the dark

The weatherman said it would be fine

Another glossy, casual remark

‘Cause a new war looms and we’ve seen it all before

A new war looms and we’ve seen it all before

 

The TV talks up the conflict again

It showed the friendly soldiers and some were weeping

It slowed the lonely viewers already sleeping

Said the special correspondent ‘the soldiers are despondent’

This time the administration has acted without consent

And its time to voice some real dissent

 

‘Cause a new war looms and we’ve seen it all before

A new war looms and we’ve seen it all before

 

No longer hypnotised by lies

The masses mobilized

To stop the growth of arms in the skies

The masses have been mobilized

 

They dance and march and wave placards

The poets and the singing bards

They say with one voice “No War!”

They say with one voice “Peace!”

They say with one voice “Peace!”

 

Somebody Else’s War (Protest Song)

SOMEBODY ELSE’S WAR

words and music by Romesh Senewiratne-Alagaratnam Arya Chakravarti

 

They point ahead and their whisper in our ears

They say they’ll show their grand illusion here

Their plan to make the whole world ‘true’

The new world they were born to rule

They point ahead but they tell us to stand here

They point ahead but they tell us to stand here

 

They never try to hide

With blinkered eyes they ride

While there in every land

Are scheming men with plans

 

Fighting in somebody else’s war

What’s right what’s wrong and what’s the law

Familiar rooms and shady deals

Secret handshakes with official seals

They’re fighting in somebody’s corridor

 

So tell me why is it so that their eyes never show

A simple sign of interest, don’t tell me that they do their best

So what do you think that their next crime will be

Another bomb in the Middle East, they put it to the test

 

So battle done, wars been won

The lights come on but the dark is here to stay

And everyone can have a say

And it’s so easy now If we don’t all get blown away

Everyone can have a say

And it’s so easy now, if we don’t all get blown away.

 

Composed in 1989

Recorded in 2006

And still not blown up.

 

Debating Psychiatry with the PA Hospital

 

This is a debate from two years ago (February 2016) between me and Nigel Lewin, an English psychiatric nurse from the Princess Alexandra (PA) Hospital.

Nigel had been appointed my ‘case manager’ and I was being made a “medical case” and “mental case” by my medical colleagues at the hospital that empoyed my father from 1976, when my family migrated to Australia from Sri Lanka. I was 15 then and remember staying in a house on the grounds of the hospital when we first arrived. Later, I avoided the hospital where my father and sister worked, and had a poor opinion of it, reinforced by my father’s claims (for which he was eventually sacked) that the hospital was “in chaos”. This was in 2001 and he got me locked up at the “chaotic” hospital (in his own written opinion) in 2002. In fact, he got me locked up 5 times in 4 months, culminating in my rib and finger being broken by security guards and male “nurses” immobilising me so that I could be injected with a drug called Zuclopenthixol, a treatment for ‘schizophrenia’ and other ‘psychotic disorders’

I began my debate with Nigel by asking him what he thought about “Psychotic Disorder – Not Otherwise Specified”, the label the hospital was trying to pin on me at the time, after revising the diagnosis from one of schizophrenia. Now, under the treatment of Jumoke Banjo (from Nigeria) and Ghazala Watt (from Pakistan) the diagnosis has been changed back to “paranoid schizophrenia”. Nigel Lewin has now gone on long service leave and a new case manager, an Indian man by the name of Raghy Raman, has been appointed. Raghy has expressed the opinion that the leader of the Tamil Tigers, Vellupillai Prabakaran was an “activist” rather than a terrorist, and described me as having “elevated speech” when I debated with him about the Tamil Tigers. In response to this, the psychiatrist Ghazala Watt increased the dose of depot antipsychotic she has abusively ordered.

 

 

 

 

 

 

 

Psychoimmunology, the Nocebo Effect and Psychiatry

©2018 Romesh Senewiratne-Alagaratnam (MD)

In the 5th century BC, the Athenian general and historian Thucydides wrote about how people who lost hope after contracting the plague were more likely to die from the deadly disease. His was the first description of what is now called psychoimmunology – the effect of the mind on the immune system. Another common manifestation of psychoimmunology is the well-known placebo effect, where belief in a treatment results in greater efficacy of the treatment, even if there is no active ingredient in the said treatment. The nocebo effect is the opposite of the placebo effect – when negative effects of an inert treatment occur due to expectations of harm.

The immune system is always subconsciously active, fighting off potential infections and cancers. It can also be over-active, as in allergic reactions, or become misdirected against the body’s own tissues, causing a wide range of autoimmune diseases. It is a common observation that mental stress can aggravate allergies and autoimmune diseases as well as cause depressed immunity.

The term ‘psychoimmunology’ was coined by George Solomon at UCLA in 1964. In 1975 Robert Ader and Nicholas Cohen coined the term ‘psychoneuroimmunology’ (PNI), emphasising the role of the brain and nervous system (neuro) in the processes by which the mind influences the immune system. This was initially viewed with scepticism since medical orthodoxy taught that the immune system was independent of the nervous system (despite knowledge of the placebo effect). There was less focus on how the immune system affects the brain and mind, although at times it obviously does (such as various types of inflammation of the brain). One of Ader’s interesting experiments was one where he conditioned rats to become immunosuppressed by pairing an immunosuppressive drug with saccharin. He found that he was able to stimulate immunosuppression by merely exposing the rats to saccharin after they had been conditioned to link saccharin with the immunosuppressive effects of the drug Cytoxan.

The placebo effect, and its converse, known as the ‘nocebo effect’ illustrate the effect of the mind on the immune system. How these effects arise and what neurological and physiological processes underpin them are partly unanswered questions, but are likely to involve many parts of the brain, especially those areas that affect emotional reactions (such as the amygdala and nucleus accumbens) and the hypothalamus, which affects the endocrine system via the pituitary and pineal glands as well as the autonomic nervous system. The role of the endocrine system in these effects is emphasised by the new term “psychoneuroendoimmunology” (PNEI).

An interesting thing about the placebo effect is that it operates even when the subject knows that it is a placebo. It has also been found that the colour and size of placebo tablets have a bearing on their effectiveness. Red tablets have been found to be more energising, while blue tablets are more calming. This indicates the role of the visual system on the placebo effect. Effective placebos are not just tablets, however. Injections of saline and ‘sham’ surgery have also been shown to be effective placebos. It has also been found that placebos are effective even when the subject knows that they are placebos and have no active ingredients in them. However, belief that an active drug is in the placebo makes the effect more powerful.

The converse effect, the nocebo effect, is the phenomenon by which a drug or treatment that is expected to cause disease does so. For example people become immunosuppressed, nauseated and lose hair if they think the placebo drug they have been given is a cancer chemotherapy drug (and they have been warned about possible side-effects). This indicates the possible negative, as well as possible positive effects, of suggestions.

Studies have shown that depressed mood is associated with impaired immunity and that a good mood promotes health of the immune system. The problem is that improved mood, especially if sudden and accompanied by insights and reduced need for sleep, is liable to be pathologised as hypomania or mania (and ‘elevated’, rather than improved, mood) and treated by dopamine-blocking drugs and lithium, often after locking the person up (which predictably causes the mood to come down). To complicate matters further, it has been reliably reported that people in a good mood (and those who are mentally relaxed) require less sleep. It is also known that meditation can lead to both insights and less need for sleep.

It is generally accepted that the amygdala, an almond-shaped nucleus located deep in the temporal lobes, plays an important role in the placebo and nocebo effects. The amygdala is activated by fear, alarm and anger responses. These emotions activate the hypothalamus and the sympathetic nervous system causing what the Harvard physiologist Walter Cannon termed the “fight or flight reflex”. Activation of the amygdala causes a cascade of hormonal changes via the hypothalamic-pituitary-adrenal (HPA) axis, causing stimulation of the heart, bronchodilation in the lungs, sweating and diversion of the blood flow away from the gut and towards the muscles (in preparation for fight or flight). Though the sympathetic nervous system is known to be involved in “flight and fight” (fear and anger) responses, this branch of the autonomic nervous system is also involved in positive excitement and healthy activation. As well as this, it innervates the pineal gland, where it regulates the synthesis of melatonin from serotonin (during the night).

The body’s response to stress, both physical and mental, is to secrete the hormone cortisol (from the adrenal glands) under influence of adrenocorticotrophic hormone (ACTH) from the pituitary. The ACTH is secreted in response to corticotrophin-releasing hormone from the hypothalamus, a structure at the base of the brain that is neurally connected with the amygdala and other emotion-related parts of the brain. In addition, neuropeptides such as Substance P, which have pro-inflammatory effects, are secreted by the brain and by immune cells such as macrophages and other white cells. The cortisol affects white cells in complex ways, including increasing some populations and decreasing others, causing apoptosis of some cells and chemotaxis of others. It has a generally suppressive effect on the immune system, for which it is often used therapeutically.

While this stress response is essential for escaping from danger, it is thought that in modern society there is often a chronic overstimulation of the stress pathways, leading to increased illness from a range of stress-related maladies (including heart disease, hypertension, autoimmune disease, headaches, peptic ulceration and irritable bowel syndrome).

The sympathetic nervous system is counterbalanced by the parasympathetic nervous system (associated with “rest and digest” physiology according to Cannon). This branch of the autonomic nervous system is associated with a range of physiological activities associated with healing and regeneration. Many stress-reduction techniques (including biofeedback and meditation) aim to increase parasympathetic activity over sympathetic activity in the autonomic nervous system, with the objective of increasing healing and regeneration.

The possible role of the pineal has not been discussed much, but the pineal’s main hormone, melatonin, is known to have effects on the secretion of pituitary hormones, and is thought to have effects on the immune system. In addition, melatonin is known to be a powerful antioxidant. Antioxidants counter oxidative stress and have positive effects on the immune system (and ageing) as well as beneficial effects on the cardiovascular system and nervous system. It is known that conversion of serotonin to melatonin in the pineal (which occurs mainly at night) occurs under the influence of sympathetic activation and the SNS neurotransmitter noradrenaline (norepinephrine).

There has been considerable study on the effects of neurotransmitters and neurohormones, cytokines and endorphins on the immune system. These studies illustrate the complexity of the brain’s effects on the immune system (especially the activity of white blood cells or leukocytes) and the effects of the immune system on the brain and mind (in such diseases as Multiple Sclerosis, AIDS, Parkinson’s Disease and Alzheimer’s Disease). Though complex and incompletely understood, it is clear that loss of hope and pessimism have negative effects on the immune system, as well as other physiological systems.

 

Implications for Psychiatry

 

The detrimental effect of loss of hope, written about by Thucydides 2500 years ago, has serious implications for doctors, especially psychiatrists. Psychiatry is a notoriously pessimistic area of medicine. Hundreds of “mental disorders” have been named, all incurable according to psychiatric orthodoxy. If the signs and symptoms of the “disorder” are no longer evident, the patient is said to have gone into remission, rather than cured. Labels of “personality disorder”, once applied, are never removed and all personality disorders are, according to psychiatric orthodoxy, permanent. This can be expected to depress the mood and the immune system. In addition there is an increasing tendency to regard the normal as abnormal. Excitement, for example, is seen as hypomania and normal sadness as “depression”, while a range of New Age beliefs and alternative science (and political) beliefs are regarded as signs of “schizophrenia”. This leads to self-fulfilling prophesies and partly explains the appalling life expectancy of people once they have been given a label of schizophrenia or bipolar disorder.

In the case of bipolar disorder (manic depression) a single episode of mania or hypomania is taught in psychiatric texts to herald a life-long condition of “mood disorder” requiring long-term mood stabilizing drugs like lithium. These drugs have terrible side-effects and shorten the life, explaining why a diagnosis of bipolar disorder is accompanied by a ten to twenty year shorter lifespan, on average. A diagnosis of schizophrenia shortens the life by 15 to 20 years, on average, and again is treated with long-term antipsychotic drugs that are known to shorten the life and make people lethargic, obese and prone to diabetes and heart disease in addition to causing neurotoxicity in the form of Parkinson’s Syndrome and Tardive Dyskinesia (a permanent condition characterised by involuntary spasms, grimaces and writhing movements that is caused by antipsychotic drugs). Lithium is notorious for causing kidney and thyroid failure.

Though the suicide rate is much higher in people given these diagnoses, most of the morbidity and mortality is not due to suicide. Besides, self-harm and suicide can be partly attributed to the pessimistic diagnosis (resulting in loss of hope), and social stigmatization resulting in loneliness, poverty and other social problems. These commonly lead to loss of motivation and depression, with negative effects on the immune system. The main cause of the shortened life span when on antipsychotic drugs is due the long-term effect of blocking essential neurotransmitters, causing metabolic problems and heart disease. They can also cause irreversible brain damage in the form of cognitive decline, cerebral atrophy and tardive dyskinesia. Though they can be effective in treating hallucinations, they should not be used for behaviour control or as chemical restraints, as they frequently are, especially in the elderly. Delusions are better treated by debate than drugs. The diagnosis of delusions can also be problematic in that the belief system of the interviewer is pitted against, and assumed to be superior, to that of the patient.

To maximise the potential of the body’s own healing mechanisms, and those mediated by the mind, is imperative that people reject labels of incurable mental illness and realise that just because they have been mentally unhealthy in the past does not mean they need to be mentally unhealthy in the future. It is also imperative that doctors and other health workers realise that implanting pessimism in the minds of their patients is a recipe for inducing chronic illness.

Considering ‘Insight’

©2018 Romesh Senewiratne-Alagaratnam (MD)

Being insightful is considered a virtue. It is similar to being thoughtful, but insight implies intuitive knowledge and perception of truth. There has been much study of insight in psychology in recent years, mainly looking at the phenomenon from the perspective of problem solving. It has been found that insight is promoted by good mood and sleep, which help solve problems. An insight is described as an “aha moment”, “penny-drop moment”, “eureka moment” or epiphany.

However, ‘insight and judgment’ mean something quite different in psychiatry – in this medical specialty, insight specifically means willingness to accept that you are, and have been, mentally ill. This is problematic and constitutes a widely used circular argument – that refusal to agree you are mentally ill is itself evidence of mental illness. It means that mentally healthy people who are mistakenly admitted as psychiatric patients harm their chances of discharge if they maintain that they are not mentally ill.

 

The Positive and Negative Syndrome Scale (PANSS), widely used in evaluating antipsychotic drugs for schizophrenia, is explicit about this. Section G12, titled “Lack of Judgment and Insight” states that ‘extreme’ (grade 7) lack of insight is to be recorded due to:

“Emphatic denial of past and present psychiatric illness. Current hospitalization and treatment are given a delusional interpretation (e.g., as punishment for misdeeds, as persecution by tormentors etc.), and the patient may thus refuse to cooperate with the therapists, medication or other aspects of treatment.”

 

Good judgment involves the ability to make sound decisions, based on knowledge of what is true and what is false. It is insulting to accuse someone of poor judgment, and uncalled for if the accusation is based on reasonable refutation of an incurable mental illness label. People can make sound judgments about many things, but not be convinced that they are mentally ill, especially if the illness is claimed to be due to unmeasurable chemical imbalances in their brains that are of uncertain origin, the dominant paradigm in psychiatry.

 

This item in the PANSS is one of 16 items taken from the older Brief Psychiatric Rating Scale (BPRS), which was developed in the USA in the 1960s and used to evaluate “general psychopathology”, as well as to evaluate psychoactive drugs. The PANSS also includes 7 “positive symptoms” and 7 “negative symptoms” for a total of 30 items that are evaluated. This results in a score from 30 to 210. “Improving” scores on the PANSS constitute the main claims for efficacy of the newer antipsychotic drugs; the older drugs were evaluated by the BPRS and other scales, usually when compared to the “benchmark drugs” chlorpromazine and haloperidol, rather than placebo.

 

A glaring problem with the PANSS and BPRS is the fact that known side-effects of dopamine-blocking drugs, such as “flattened affect” are described as signs of schizophrenia, rather than the treatment of the condition. Other signs such as hostility and uncooperativeness can be explained as legitimate objection to being called mad (or insane), by whatever name.

Predictably, people with some mental illness diagnoses resist the label of “illness” more than others. People with phobias, anxiety and depression often come to see doctors for help and so do people with auditory hallucinations (usually diagnosed as schizophrenia or schizo-affective disorder). In these people the diagnosis of illness can be a relief, and they accept drug treatment without objection. In other cases, patients resist the label of illness vehemently, especially when they are said to have elevated mood (diagnosed as hypomania and mania) or delusions.

It is not surprising that many people accused of having an elevated mood resist the judgement. The BPRS grades “moderately severe” elevated mood (rating 5 on a scale from 1 to 7) as:

“Reports excessive or unrealistic feelings of well-being, confidence or optimism inappropriate to circumstances, much of the time. May describe feeling ‘on top of the world’, ‘like everything is falling into place’ or ‘better than ever before’. OR several instances of marked elevated mood with euphoria”.

Needless to say, people who feel on top of the world, better than ever before, or for whom everything is falling into place, are often not inclined to think they are mentally ill, and with good reason. Likewise people with an increase in goal-directed activities, increased zest for life those who see connections they didn’t see before and have insights. Ironically, the process of coming to conclusions through insight, especially if they are unique or ‘idiosyncratic’, is itself viewed as a sign of mental illness.

The Young Mania Rating Scale (YMRS) rates elevated mood on a scale from 1 to 5, with grade 3 being:

“Definite subjective elevation; optimistic, self-confident, cheerful, inappropriate to content.”

The key to the diagnosis is the subjective evaluation of what is “inappropriate to content” or “inappropriate to circumstances”. This is done by the interviewer, and depends on his or her own belief system, judgement and understanding of the patient’s circumstances.

Persecution by Tormentors and Punishment for Misdeeds

 

The belief that one is persecuted is not necessarily delusional. Many people, over the ages, have been persecuted, for various reasons including their race, their ‘caste’ and their beliefs. People are sometimes tormented by the families, or by their peers (for example victims of bullies at school or work). Siblings sometimes torment each other, and so do cousins and other relatives. Sometimes it is neighbours who do the tormenting. People often gang up against people who are stigmatised as strange, mad, crazy or odd and this can amount to persecution. Children are often punished for disobedience and it is not unreasonable for people to regard their imprisonment as mental patients a punishment. This is not helped by a punitive culture in the mental health systems of many nations.

 

There are many dysfunctional families, and family dysfunction comes in many forms. Some families are very competitive and sibling rivalry, as well as competition between parents and children, can be a problem. Some parents, especially fathers, are very authoritarian and demand obedience from their children. Disobedient children are labelled as “difficult” and taken to doctors for diagnosis and treatment. Here the power imbalance is obvious. The child has little power to resist being labelled as the “problem”, however much the doctors protest that they can’t help their behaviour because they have a chemical imbalance in their brains. When the children misbehave it is inevitable that the adults and siblings blame the “illness” and ask if they are complying with taking their their tablets.

The adults in this situation include parents and other family members as well as teachers. Some teachers are inclined to suspect their students of having “attention deficit disorder” when they are not interested in their lessons, and become visibly bored, restless and fidgety. Teachers provide a large number of the referrals for ADD and ADHD. It is rarely asked as to whether the teacher is to blame for being boring and failing to engage the student. This requires introspection, which is sometimes lacking in any profession, including teaching.

Apart from scape-goating a particular family member, there are problems with looking for a chemical solution or “magic bullet” to life’s difficulties. This can form a pattern of behaviour in the child and in their carers and family. When they are down, rather than looking for activities and experiences that will bring them back up, the tendency is to take an antidepressant. When they are anxious, instead of listening to music or going for a walk, or any of a wide range of actions that can lessen anxiety, they look for a benzodiazepine.

It is also a problem when children are medicated for what is basically disobedience. The drugs that are used for ADHD are stimulants, related to amphetamines, known on the street as ‘speed’. Though they can improve concentration and keep you awake when you are tired, it has been known for over a century that amphetamines are addictive, and can also cause psychosis. Despite this they were widely used as weight loss drugs and “pep pills” in the 1960s and were again promoted in the 1990s for the newly-named “mental disorder” known as ADHD (Attention Deficit Hyperactivity Disorder). In the 1980s it was said that only 1 in 200 children had ADD; this rocketed up to 1 in 20 with the new label, with a corresponding explosion in prescriptions for stimulant drugs. This was in the 1990s, and was a precursor to the explosion in addiction to amphetamines a decade later. Many of the youth who are addicted to metamphetamine (‘ice’) were initially diagnosed as having ADHD and given stimulant drugs.

 

Family abuse occurs at all ages. Children and the elderly are especially vulnerable and can easily be pathologised for being “difficult”. Rebellious adolescents are also vulnerable to being given a disease label for their behaviour, as well as young people who reject the religious beliefs of their parents and embrace other philosophies and religions.

 

The concept of insight should be considered holistically. There is a difference between insight (introspection) and insights (epiphanies). One aspect of introspection is to be able to look critically at our own mistakes, flaws, vices and poor judgements in the past. It requires us to challenge our indoctrination from various sources as we grew up. The process of growing up and learning from our environment (including family and school) inevitably results in some false beliefs and delusions. Some of our beliefs are not congruous with reality, and it is a challenge, throughout life, to rid ourselves of such delusions. Sometimes, when one realises ones previous error, especially about long-held beliefs, it comes as an insight. Such insights are often pleasant, and can be exciting. They can elevate the mood.

Seeing connections you didn’t notice before and making new associations can also be exciting and elevate the mood. Elevating the mood itself has the effect of increasing insights and insightful thinking. How many potentially beneficial insights have been suppressed or destroyed by the practice of regarding “gaining insight” as a synonym for accepting that you are mentally ill?