torsdag 28. august 2014

What gives more hope, biology change or psychological retraining?

There is a pressing need for treatment of so-called mental illness in the world. Parents are telling horror stories of how their children become violent, often with very strong psychotic symptoms, voices telling them to kill others or themselves etc. These parents are naturally extremely stressed when the mental health system does not have anything to offer.

Are these children biologically ill? The reason for the problem may actually be found somewhere else. What if it is the treatment that makes these people so violent and crazy at the same time?

A typical, much too typical scenario is the following.  A boy, let’s call him John, is too active and has problems concentrating in class. The parents are concerned that he will not have all the possibilities open for the future if he continues in school with his concentration problems. They take him to a doctor who refers to a psychiatrist, and the psychiatrist, using the diagnostic manual correctly, puts up a diagnosis of ADHD. He tells the parents that the ADHD explains why John has trouble in school.

This is actually circular reasoning since  the items used to diagnose ADHD describe school problems. So what the psychiatrist is actually saying is that the reason John has school problems is that he has problems in school. There are no biological tests for ADHD, and the symptoms were voted into the diagnostic manual DSM III , IV and 5.

The doctor says that john should try out a stimulant medication, such as Ritalin  for his ADHD. This seems to work fine. John becomes quiet and almost obsessive about his schoolwork. He gets problem sleeping and seems bit depressed though.

The doctor gives a “mild sedative” (benzo) for him to sleep more easily every night.

 After some months the depression gets worse and he starts talking about hearing voices, and says he has thought about killing himself.  Stimulants may cause mania or psychosis, and may lead to suicide. John’s parents get very worried and take him to the psychiatrist again. Since the psychiatrist is the one who has prescribed the stimulant, he naturally thinks that John has got other problems now and prescribes an antidepressant for the depression and an antipsychotic for the voices. The parents are worried, but thankful that they have got treatment for their son.

The antidepressant is stimulating just like the stimulant, and the resulting symptoms are more thoughts of wanting to die, more voices, but the antipsychotics seem to make all these things unimportant. Everything starts to seem unimportant to John, especially his hygiene, and this creates problems with bullying in school. John does not like the effect of the antipsychotic. It makes him restless and tired at the same time, so after a while he refuses to take it, claiming he is not crazy. A few days after he has stopped taking the antipsychotics, the voices become really strong and they are talking about suicide and death all the time. John’s parents are now desperate and they get him admitted to psychiatric ER against his will. Here he gets more drugs and is out after 3 days,  quite sedated. However, after some days he does not want to take the new medications either, since they have much of the same side effects as the old ones.  Two days go by, and the same delirious crazy behavior takes over again.

Is John mentally ill or is he the victim of a medical culture which is much too quick to medicate, and not willing to see that these medications have side effects that look like other mental disorders.


It would not be surprising if most of the violently crazy youth are that way  due to side effects of drug cocktails. There is no research on most of the combinations in the cocktails, so one cannot say that they represent evidence based practice.  


Imagine if the name of the medications were alcohol and cocaine. Alcohol is very similar to the benzos and cocaine is so similar to Ritalin that cocaine addicts cannot feel the difference if the snort Ritalin. So your child has been made addicted to cocaine for his concentration problems and then addicted to alcohol at night to sleep since he gets sleepless from the cocaine use. Would we then maybe think that we are doing something wrong with this child and not be so surprised that he can become a danger to self or others ? Would we then think of removing the cocaine and alcohol to see if things calmed down?

The biggest problem may be giving antipsychotics to young people who are unstable and rebellious and who want to live life, have a sex life, not feel drugged in to a stupor and not get fat. It is very much to be expected that a young person will want to stop the medication after a while, quickly, and this is almost a guarantee for a psychotic reaction since the brain has compensated for the drugging by becoming hypersensitive.


Two very big research projects by the World Health Organization has shown that when less medication is given in developing countries, more people get completely well from schizophrenia. Maybe we can learn something from these countries? Less use of drugs may be just a part of it. Closer family ties are probably very important. Young people with psychotic problems are expected to “get over it”, and they are kept in the family as long as it takes. Even the belief that they have been hexed by somebody is better than the western belief that we are dealing with permanent biological disorders that will just destroy the brain more and more. A view that sees even psychotic symptoms as something we all may experience, normalizing , may be very liberating.

Seeing ADHD symptoms as high energy and creativity levels are also very comforting. Since no biological markers have been found for these disorders, with so much money being used and so much prestige at stake, we may be fairly certain that they don’t exist. Thus taking the view that the brains of so-called disturbed people are normal, is very scientifically correct. This should be the so-called null hypothesis, and anyone claiming otherwise would have to prove the abnormality beyond doubt to be taken seriously.

A completely normal computer may function poorly if there is a programming error, or some settings are wrong. In the same way, a brain can function poorly if some of the “settings” are wrong. Schizophrenia may be conceptualized as a problem of audio settings in the brain. Thoughts become audible, but are not really more crazy than our normal thoughts. All people may have severely critical thoughts such as “you are a jerk for doing that”.  Put a sound on that thought, and we call it schizophrenia. Most people can have two voices in the form of thoughts in the form of a running commentary of action. Imagine a shy boy wanting to ask a girl for a dance. The thoughts may go like this: Ask, her, this is your chance! No, I can’t do that, my voice will shake! You can do it. You have talked to her many times before. Yes, but that was before I fell in love with her.

If the person really hears this dialog in his head, it is considered ad a really bad sign of schizophrenia.

However, thought voices are so close to being heard that we can easily describe the tone of voice and often whose voice we are using in our thoughts.

A person with very serious  contamination/handwashing OCD can be totally disabled by it. However, this is also a setting. We all feel the need to was our hands before we eat, and surgeons should was their hand like an OCD patient. So we have different settings at different times.

We can modify these settings through talk therapy (programming) practical experience (exposure) and psychological practice. As a psychologist, I see this every day. It is exciting to see patients again after one or two weeks, to see if they have been able to reprogram themselves between sessions.

Excerpt from my book " Hope in psychology", soon to be published on Amazon Kindle.  

mandag 25. august 2014

Positive explanations for psychological problems

I am a clinical psychologist working in an anxiety and OCD Clinic at the University of Oslo, Norway. In this clinic we do almost all the treatment without starting drugs, and for many patients we help them taper the drugs. One of the reasons for this is that taking drugs for psychological problems often may be seen as avoidance behavior, and this is exactly what maintains the anxiety or in many cases makes it worse.

 If a person starts taking a benzodiazepine every time he feels anxious, he will never discover that it passes by itself and is not dangerous. When doctors give strong drugs to “combat” anxiety symptoms, they may actually be signaling to patients that anxiety is dangerous.
The most effective treatment for anxiety disorders of all kinds, is exposure, and that is exactly the opposite of running away through drugs. Actually stepping down on drugs very slowly (less than 1% per day) may be very good exposure training.
I often tell my patients: it is great if the stepping down gives you a bit more symptoms. Then you get the possibility to learn that anxiety is not dangerous and that it is by going into it, instead of avoiding, that you get better.

Many people who have anxiety actually think the worst part of anxiety is the self loathing. They hate themselves for being so weak, not daring enough, always worried etc.

The opposite should be the case. The ability to be afraid has enabled humans to survive. Those who were of the worrying kind were the best survivors in hard stone age times. They would worry about food supplies for the winter, living conditions, cleanliness, safety for themselves and their offspring.

Many of the best survivors of hard times could be diagnosed with generalized anxiety disorder, phobias, OCD and even social anxiety. In stone age tribes it could be very dangerous to talk to strangers. People with very low social anxiety could be a risk for themselves and their tribe.
Fear of heights, snakes, spiders, open spaces etc. have a distinct survival advantage for humans. It is just in the last centuries that conditions have changed so that some of these fears are problematic.

Even psychotic symptoms may have given a survival advantage in earlier times. We all have several thousand verbal thoughts every day, and often we don’t really pay attention to them. The internal dialog just keeps on chattering.

How can  the brain signal to us that a thought is more important than others, e.g. “you are in danger, run to the cave”? The logical thing would be to give more sound to it than normal thoughts, in other words a thought that sounds like it is spoken by somebody. This would today be called an auditive hallucination. We often see that hallucinations come in response to extremely stressful situations.

Trauma victims may develop internal audible voices in order to make sure the internal dialogue around possibly dangerous situations is very clear.

Depression may be a very useful reaction to overwork, in order to slow the person down and avoid exhaustion. It may also function to slow people down so that they have time to think about things they may have done wrongly, so that they will be able to change their ways.

Bipolar behavior and ADHD may have its function in getting projects started, and bringing up many new ideas, even if most of them have no merit. The energy that is pathologized by these two diagnoses is probably the reason why we are not still in the stone age and why we have works of art. Inventors, artists and entrepreneurs are often seen by others as overly energetic and unrealistic. But they are needed in order to get development.

So what is characteristic with people who get psychological problems and what some may want to call mental illness?
I see this very clearly after 25 years as a therapist. People who get anxiety and depression have three positive traits in common:

1.  They are sensitive in a positive sense. They are very aware of others feelings and actions, and they may react strongly to things that happen in their surroundings, both positive and negative.

2.  They are analytical and thorough thinkers. They think of all possibilities of what may go wrong, often like chess players planning for all possible future problems. “What if” thinking is very useful in hard times, but may be annoying when conditions are very safe.

3.  They have good imagination. They are able to imagine possible things that may happen so vividly that they react strongly to them and take action, or avoid possibly dangerous action in the case of depression. 

All psychological problems are on a continuum from not problematic to very disturbing. It is impossible to put a clear cutoff point, and what is dysfunctional in one setting may be very desirable in another. That is why the concept of mental illness is useless. We may talk of patterns of behavior thoughts and feeling that are more or less functional in different situations, but it is usually not difficult to see that the behaviors thoughts and feelings may be appropriate in other contexts. The most classical may be over active children who would learn much in natural environments but who get diagnosed for their active exploration in classroom settings.