Newsletter First Quarter - 2005

I am pleased to post this Newsletter on our web site.  Dr. Gersabeck has presented a point of view that I fully agree with and I encourage our readers to regard it seriously.  It has been my experience that many patients who were diagnosed as having schizophrenia or other psychosis really were responding to some foreign substance that induced symptoms that were psychotic like in appearance.  I have found that in my travels throughout the world that many individuals were misdiagnosed and the abuse use of medication perpetuated their condition.  I think that it’s time to see things as they really are.
Jack Rosberg 

A VERY IMPORTANT, NEW, AND PROPOSED - THOUGH "POLITICALLY INCORRECT"- PSYCHIATRIC DIAGNOSIS

by Norman Jay Gersabeck MD. ngersabeck@wideopenwest.com
This new and proposed diagnosis is the very common disorder of "Substance Dependency-Induced Psychosis" (SDIP). I am a 68 year-old American psychiatrist, with a strong background in substance dependency. I discovered the disorder about 30 years ago, and have been on a quest for the past 10 years to get it officially established. This article was originally written for the Canadian Psychiatric Association’s bimonthly Bulletin at the suggestion of the CPA President. I had sent him a message, whose subject I listed as - "Whistleblower Needed." I didn’t even bother to contact the American Psychiatric Association - as the odds against any meaningful response from it would have been extremeIy small. But the reviewer’s of the (edited) article rejected it as "being unscientific." They based this on the idea that no schizophrenia-like psychosis could be considered as having a "functional cause." They should read Matt Ridley’s excellent book entitled "Nature Via Nurture."
The excellent book "Turning Point," by physicist Fritjof Capra, made the important point that medical (and especially psychiatric) science needs to emphasize the issue of "disease origins" - over that of "disease processes" (which are often very theoretical). Of course, the SDIP concept involves a clear "disease origin!" It is well known that substance dependency has a causative role in a number of other mental disorders - such as panic reactions, anxiety and depression. These disorders don’t have the "biological importance" of schizophrenia, or other functional psychoses. Hence, considering such a causal relationship for the former, doesn’t "cross over the line." But substance dependencies can also cause borderline manic behavior. Psychiatrist George Vailant wrote in his acclaimed book, "The Natural History of Alcoholism," that alcoholic persons actually have the same low incidence of bipolar illness as the general population. The diagnosis of bipolar illness is made much too often in cases of substance dependency - where the dependency is often partially or completely ignored. Too many psychiatrists and patients much prefer the "more biological diagnosis" of a bipolar illness - with its promise of effective medication to treat it! Unlike that of a dependency, a bipolar diagnosis is free of negative connotations of any personal responsibility for its development. Besides usually being in error, the bipolar diagnosis also often aids in denial of the dependency.
Unfortunately, even the action taken a couple of years ago by the National Institute of Mental Health (NIMH) Psychotic Disorders Research Director has had only a very minimal effect of diminishing the powerful opposition to the diagnosis. It took the form of his offering to aid in the application for federal research funds for the diagnosis. Particularly as a "psychiatric outsider," I have not been able to personally organize the needed clinical trial for the diagnosis. I had been thinking that only adequate media reporting on the diagnosis (and there has been a serious absence of "true journalism" here) would result in sufficient public pressure to cause a medical school to organize a much needed clinical trial for it. I now have realistic hopes that a Canadian medical school will break free from a restrictive "ideological academic fundamentalism," and be motivated to do so by good medical science and the public welfare.
Biological psychiatrists believe that functional psychotic hallucinations and delusions are "neurological trash," and meaningless. But they are actually distorted abstractions - which a person with an advanced organic psychosis would be unable to produce. My very serendipitous first diagnosis of a case of SDIP occurred in a 45 year-old executive, who awoke in a confused state - having learned the day before of the unexpected death of an older brother. He then told his wife that: "I’m afraid my car will tell my employer that I want to drink." (It was a company car, and his employer didn’t want him to drink.) It was this delusion that led me to the SDIP diagnosis. He had been three months into a good recovery from alcoholism (without any other psychiatric history), and A.A. was his only treatment. I took over on his case two weeks after the onset of his illness - with his having been already diagnosed as schizophrenic by the admitting psychiatrist. He was lucid with the help of medication, and accepted the SDIP diagnosis. In part, this was because of his knowing that I was the consulting psychiatrist at the substance dependency hospital he had recently been in. I explained to him that, had his brother died a few months later into his recovery - he probably wouldn’t have suffered the psychotic episode. He was able to get off all medication a year later, and remained sober and in good mental health for the remaining 15 years of his life.
A few years ago, I received an email from a concerned father from Australia. His teenage son had an almost certain case of SDIP - and was not doing well. He had found an article about the diagnosis that I had written on the Internet. I confirmed the very strong likelihood of his son’s SDIP diagnosis. A few months later, I learned that his son was now doing well in a treatment program - which mirrored my treatment of the SDIP disorder. It took some time for me to learn that the son was being treated in the EPPIC (Early Psychosis Prevention Intervention Centre) program, which was run by the University of Melbourne. Its Psychiatric Chairperson would confirm only that the program’s treatment "shared many of my interests in the SDIP diagnosis." The program was aimed at treating young persons who had a history of substance dependency - and later developed a functional psychosis. Obviously, the "ideological psychiatric climate" of both Down Under and "Up Top" (Canada) is "far milder" than in the U.S. The eventual official establishment of the SDIP diagnosis is certain. But I am trying hard to have this happen years earlier. This would lead to a limitation, or ending, of the suffering of many SDIP-afflicted persons - who are presently being unjustly deprived of the diagnosis.
Correctly making the SDIP diagnosis makes available an additional and individualized effective treatment (largely outpatient). This treatment is potentially of a specific nature - while medication treatment of schizophrenia is always symptomatic. It centers on the existence, nature, and causative role of a prior substance dependency in the development of the mental illness. This treatment is nearly always superior in results to that of the person’s usual previous diagnosis of schizophrenia. Most impressive, is that this treatment has resulted in a complete remission of the mental illness in one third of the cases I have treated. This remission is likely to be permanent - if the person continues to abstain from addictive substances (ideally, with the ongoing help of a recovery program). But complete and permanent abstinence by a SDIP-afflicted person can still result in a lifetime of mental illness. There is an interesting inverse relationship between the activity of the mental illness - and the level of desire for the substance. The resulting lesser use of the substances often serves to obscure the presence of a dependency in an undiagnosed case of SDIP - and also to often strengthen the person’s denial for the dependency.
General knowledge of the SDIP diagnosis would likely have some positive effects in limiting addictive substance use in young people - and also provide for additional motivation for a lasting recovery in persons being treated for substance dependency. There is the "politically correct" and official diagnosis of "Substance-Induced Psychosis." But it is of little use, and is little used. It completely ignores the issue of substance dependency - and has two very arbitrary 30 day time limits. However, unlike the SDIP diagnosis, it doesn’t in the least impinge upon, or threaten the "biological integrity" of the diagnosis of schizophrenia. The four addictive substances most commonly involved in causing SDIPs are alcohol, tobacco, marijuana and cocaine. Tobacco, alone, will only rarely cause the disorder - and its continued use usually doesn’t interfere with a full remission of the mental illness. But later abstaining from it can cause a person to relapse. One two occasions, one SDIP patient in remission needed only to seriously plan to quit smoking, to trigger "crazy thoughts" within a few hours. A resumption of smoking then quickly eliminated them. Increasing chronicity of the dependency and the involvement of multiple substances - all increase the risk of a SDIP.
There was an article about 15 years ago in the "Lancet" about the finding that Swedish army conscripts, with a history of heavy marijuana use - were six times more likely than nonusers to later develop schizophrenia. There was another finding that countered the "biological spin" that common genetic factors are strongly involved in both schizophrenia and substance dependency. It was the fact that the marijuana users had a history of much better personality functioning - than did the nonusers, who later became mentally ill. This finding correlates well with my finding that persons with SDIP are usually less ill than "true schizophrenic" persons. The majority likely wouldn’t have ever become psychotic - without the "help" of the dependency. The majority of "recovered schizophrenic persons" have actually recovered from a SDIP! Establishment of the SDIP diagnosis would aid in research of schizophrenia by eliminating cases of SDIP from such studies. The SDIP diagnosis should have particular relevance for those governmental bodies which are seriously considering the legalization of marijuana. In short, its use represents a double threat.
The high degree of association between substance abuse/dependency and functional psychoses is well known - and there are many state hospitals that have dual diagnosis wards. One university psychiatrist published a journal article in which he cited a greater than 50% comorbidity between the diagnoses of schizophrenia and substance dependency. Interestingly, he did the "politically correct" thing by not mentioning anything about the sequence of the two disorders. He was "less correct," though, then the psychiatrists who wrote about the 70% incidence of Inner City E.R. patients with a schizophrenic diagnosis - who showed positive for cocaine in their urine. They actually concluded that the mental illness preceded the cocaine use! It is standard psychiatric practice to advise patients diagnosed with schizophrenia not to use addictive substances. The reason given is that such use interferes with the treatment of their mental illness. (This is very true - but for many, it doesn’t have the persuasive force of knowing that such use actually caused their illness.) It is a very common finding that patients being treated for schizophrenia, and having a history of substance use prior to the onset of their mental illness - are currently, though usually infrequently, using a relatively small amount of addictive substances. This behavior points rather strongly to the presence of a SDIP. The odds are even stronger if the person terminates medication use - and then begins to use the substance more frequently. Virtually diagnostic is the history of the signs and symptoms of psychosis first occurring very shortly after returning to (usually quite moderate) substance use - following a significant period of abstinence.
The diagnosis has had the support of the National Council on Alcohol and Drug Dependence. It has also had the "indirect support" of two medical schools and a dual diagnosis organization. All three rather quickly backed off of initially strong interest in the diagnosis. The second and most significant "backing off" was two years ago, and involved a prominent eastern medical school. Its Psychiatric Chairperson was obviously impressed with the NIMH support, and wrote me that he would shortly be holding a staff meeting on the diagnosis. I then got no response from him - but did manage to get a comment from his Addiction Chief. He stated that he thought the diagnosis was a "valuable concept." I am sure that its "political incorrectness" was the ultimate reason in each case for the "backing off."
A few years ago, I traded emails with a psychiatrist who had a special interest in dual diagnoses. About 14 years earlier, I had read in his newsletter of a case that he had brilliantly treated. The patient had already been diagnosed as schizophrenic by another psychiatrist - and he achieved a full remission for his patient by treating his substance dependency. He was quite interested in the SDIP diagnosis, and sent me some valuable relevant research material regarding it. But he abruptly broke off all communication - when I finally dared to ask him why he had never given his patient’s disorder a formal name (with the implied question of why he hadn’t tried to establish the SDIP diagnosis). Recently, I entered his name in an Internet search engine - and then learned that he was a clinical professor at the second medical school. This meant that he would have had the main voice regarding doing research on the SDIP diagnosis. His veto on the diagnosis must have involved much ambivalence for him. Obviously, he was aware from the start of the "political incorrectness" of the SDIP diagnosis - at a time when I didn’t know that such an unscientific attitude even existed in the Psychiatric Establishment.
The most recent "backing off experience" I have had with the diagnosis was with a non-profit corporation called Foundations Associates, of Nashville, TN. It concentrates on furthering knowledge and treatment of dual diagnoses, or co-occurring diagnoses - with an emphasis on schizophrenia and substance dependency. Michael Cartwright is the CEO - and is only 32 years-old. Yet, he already had six years of full recovery from the diagnoses of schizophrenia and substance dependency. I met him at a dual diagnosis conference in Las Vegas - and had previously supplied him with information about the diagnosis via email. He immediately offered to have me write an article on the diagnosis for their journal, and to give a lecture on it at the next conference. I immediately accepted - but it wasn’t long before I was forced to realize that he had changed his mind. However, he refused to be candid with me, and did his best to string me along. Mr. Cartwright is the founder of the organization - even though he doesn’t have any academic initials after his name. He used alcohol and marijuana heavily for a few years before becoming mentally ill. He then started on medication, and also received substance dependency treatment. Three years after cessation of addictive drug use - he was able to safely get off medication, and to function well. He almost certainly is a good example of the SDIP disorder - and was very fortunate to have fully recovered. It was very likely that he changed his mind about the diagnosis when he got negative feedback about it from the academic psychiatrists - who gave presentations at that conference. I also gave them written material on the diagnosis - and, of course - never heard from them.
One recovering alcoholism-induced psychosis patient commented that either drinking alcohol, or being psychotic - could make him "feel powerful and important!" The seductive power of any substance dependency upon its subject is obvious, and this psychological phenomenon correlates well with the main point of the book, "The Seduction of Madness," by psychologist Edward Podvol. He listed substance abuse/dependency as one of the four basic causes for functional psychoses. The importance of psychodynamic factors in understanding many mental disorders is critically important. But they are "heretical" from a biological ideological viewpoint - as if such functioning of the mind is somehow "not really biological."
I saw a 36 year-old man on only several occasions at a community mental health clinic for the purpose of medication checks - every 4-6 weeks. He had been diagnosed as schizophrenic at age 22, after a few years of heavy alcohol and marijuana use. Several years later, during a subsequent hospitalization for an exacerbation of his mental illness, he decided that he had better quit using marijuana - and did so with the help of N.A. Then several years later, during another hospitalization, he decided that he also needed to quit his moderate use of alcohol - and then joined A.A. Each of these actions resulted in better functioning and lesser need for medication.
When I first saw him, he was doing very well and was two years from this last hospitalization. He remained on the same low dosage of antipsychotic medication. I wasted no time in telling him that the only thing missing from his treatment was a knowledge of the SDIP diagnosis - for which he was a classical example. He was initially a bit skeptical and negative about the diagnosis - but then he came to gradually accept it. Five weeks later (and one week after my second visit with him), he experienced fairly marked feelings of over-sedation. He then reduced his medication by half - with the quick result of feeling and functioning better than ever. Because of certain circumstances, it took me awhile to realize that his lesser need for medication was the very positive result of his having unconsciously integrated the "psychic reality" of the SDIP diagnosis. I don’t know what eventually happened with him - but I did tell him that his chances of eventually safely getting off his medication were very good. This case is yet further evidence for the very complex nature of a SDIP - and against the seductive practice of too much reductionism currently being used to explain mental disorders.
In the Psychiatric Times Journal (issue of Dec. 96), there was an excellent essay by psychiatrist David Kaiser. It was entitled "Not By Chemicals Alone: A Hard Look At Psychiatric Medicine." Here is a powerful quotation from his essay: "In my opinion, this modern version of the ideology of biologic/genetic determinism is a powerful force that demands a response. And when I use the word "ideology" here, I mean it in its pernicious form, i.e., as a discourse and a practice of power whose true motivations and sources are hidden from the public, and even the practitioners themselves - and which causes real harm to the patients at the receiving end." The unscientific opposition to the SDIP diagnosis is a "poster child" example of this harm. One of the most pernicious results of this ideology has been the elimination of any training in psychotherapy for psychiatric residents - which especially puts those psychiatrists at a disadvantage in understanding substance dependency. A subtle and disingenuous example of the Psychiatric Establishment’s denigration of psychology/psychotherapy is that of some television ads for antidepressants. They are advertised for the treatment of the "medical" (and hence - not psychiatric?) problem of depression.
I was very fortunate to learn of a very recent book by prize-winning journalist Robert Whitaker. It was entitled "Mad In America: Bad Science, Bad Medicine and the Enduring Mistreatment of the Mentally Ill." The most shocking item in this excellent book was the fact that the World Health Organization had reported about ten years earlier that developing countries actually had significantly better outcomes for schizophrenic patients, than those of developed countries - particularly the USA. The only possible explanation for this is that the former countries use antipsychotic drugs much less than the latter. But this knowledge has been completely ignored by the Psychiatric Establishment. Unfortunately (but understandably), publicity about Whitaker’s book has largely been limited to a brief Op-Ed piece - and has never reached the main stream media. The Op-Ed piece mentioned that the movie "Beautiful Mind" was "politically corrected" by falsely portraying John Nash as having taken antipsychotic medication from the time of his being diagnosed as schizophrenic. But the truth is that he stopped its use in the early seventies.
His book told the story of Dr. Loren Mosher, a clinical professor of psychiatry, who was the Director of Schizophrenic Studies for NIMH in the early seventies. He was not against the use of antipsychotic drugs - but felt they were "overhyped." He designed the Soteria Project. It took single and acutely ill young males with a schizophrenic diagnosis, and used a humanistic and empathetic treatment approach in a communal setting by persons - who were not mental health professionals. Mosher didn’t go along with the prevailing "broken brain" biological theories of schizophrenia - and didn’t use any medications in treating these persons. The results of this treatment approach were that these patients did significantly better than did similar populations receiving the standard psychiatric treatment. Despite these very positive results, the project was gradually strangled by funding cuts. Mosher was aware that there was a clubby relationship between NIMH administrators and pharmaceutical representatives. He also realized that the Soteria Project was seen by these representatives as being "anti-drug."(Economic factors may also be at work in the opposition to the SDIP diagnosis - with its "relative anti-drug implications.") Mosher recently resigned from the APA, and has been quoted as stating that: "Today’s psychiatric science is largely wish, myth, and politics."
The following are comments on, and quotations from a recent article in the "Washington Post." It was entitled: "Against Depression, A Sugar Pill Is Hard To Beat." It is important not to get the wrong message from this article. There is a place for antidepressant medications. To quote Wayne Blackmon, a Washington D.C. psychiatrist, whose practice largely is comprised of patients being treated for depression: "The drugs work and I prescribe them, but they are not what they are cracked up to be. I know from clinical experience that drugs alone won’t do the job." He also stated: "It behooved mental health clinicians to better integrate the power of biological treatments with the effects of belief and psychotherapy." The Post article also has an excellent relevant quotation by Thomas Laughren, who heads a group of scientists at the FDA that evaluates antidepressants: "It speaks to the difficulty we have in classifying and identifying the disorders we deal with. Psychiatric diagnosis is descriptive. We really don’t understand psychiatric disorders at a biological level." He further stated: "Patients with similar symptoms may have different problems with their brain chemistry. Scientists don’t understand the neural mechanisms - or why medications like Prozac and Paxil work."
Dr. Elliot Valenstein is a neuroscientist and psychologist from the University of Michigan - who wrote the excellent book "Blaming The Brain: The Truth About Drugs and Mental Health." I talked with him after he had read my material of the SDIP diagnosis - and he felt that the SDIP diagnosis obviously deserved further research. On the book’s back cover is the commentary by a psychiatrist: "Valenstein shows how the current theories of depression and schizophrenia arose, makes the case for them seem more persuasive than their original proponents did, but then in devastating fashion shows where their problems lie. More importantly, he goes on to show why we continue to hold such beliefs that do no good for patients, that are no longer believed by neuroscientists and that hamper the development of more important treatments…"
Alan Hobson is a Harvard Psychiatrist, whose excellent book "Out Of Its Mind: Psychiatry In Crisis" was published in 2001. He talks about the devastating results of modern psychiatry’s largely ignoring psychology and psychotherapy. He uses the term "neurodynamics" to refer to the new version of psychology/psychotherapy that psychiatry desperately needs to lessen its concentration upon "chemical imbalances." To quote directly from his chapter "Neurodynamics: Toward A New Psychology": "Neurodynamics does not compete with brain science. It embraces brain science. It uses brain science to provide a sound foundation for both psychotherapy and biomedicine, and in so doing it seeks to heal the breech between them. What’s more, neurodynamics is an approach to psychology, a method rather than a doctrine. So besides integrating current brain science discoveries, it stands ready to embrace future discoveries."
Another way to characterize "neurodynamics" is that it uses an open-minded and common sense approach to problem solving. For example, it was purely empirical and pragmatic thinking that led Jenner to discover a vaccine for smallpox. Biological psychiatry has largely ignored all of the psychological literature on substance dependency. It considers the general concept of substance dependency as (biologically speaking) being "rather messy," and therefore - not important! For example, an addict will sometimes switch completely from alcohol (a depressant substance), to cocaine (a stimulant) - or visa versa. (Even messier, he may switch to compulsive gambling!) The man on the street knows that a person, first getting addicted to cocaine, is likely to later also become dependent on additional addictive substances. But he hasn’t learned that the same holds true for cigarettes! In short, many persons would never have become alcoholic - without first having become addicted to smoking. Biological psychiatry has also been very silent regarding the potential and obviously great power of an addiction. Such power obviously resides in the large degree of irrational importance that the person has developed for the substance or practice. It is the development of this importance which is the obvious essence of the addictive process - which, most basically - is of a learning nature. The considerable difficulties inherent in discovering the mechanics of, and the reasons for this importance factor - do not take away from its factuality and scientific merit.