What You Can Change . . . And What You Can't*: The Complete Guide to Successful Self-Improvement (7 page)

Here is what florid psychosis look like:

Lester shows up at his father’s dry-goods store one morning in a terrifying costume. He is stark naked, painted a dull brownish red from head to toe, and is daubed with slime. There is an enormous barbed fishhook sticking out of his cheek.
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“I’m a worm!” he babbles as he crawls along the floor. The cashier calls the police, and Lester is dragged off to Baptist Memorial Hospital

In the hospital, Lester is floridly schizophrenic. He hallucinates the sounds offish in a feeding frenzy. He believes that he is the object of their frenzy. He retains the singular delusion that he is a worm, probably related to his despair over his girlfriend’s walking out on him (“You worm!” she shouted as she slammed the door). His mood fluctuates wildly from terror to giddy mania to deep sadness
.

Lester is as crazy as they come. But what happens next seems little short of a miracle. It is the late summer of 1952. One of the residents at Baptist Memorial has just returned to Memphis from a year in France. Before he left Europe, he had heard a startling paper delivered in Luxembourg at the French Congress of Psychiatrists and Neurologists. Professor Jean Delay, chief psychiatrist at the Hôpital Sainte-Anne in Paris, announced a breakthrough in the treatment of psychosis
.

Psychosis: the most ferocious mental illness. In 1952, the back wards of mental hospitals in Paris, New York, Moscow, and Memphis were filled beyond their capacities with patients like Lester. These wards were called “snake pits.” The inmates were hallucinating and unreachable, or mutely catatonic, or wild with delusions and straitjacketed, or giggling out word salad, or simply broken, with their faces turned toward the wall. Everything was tried on these schizophrenics: electroshock therapy, artificial hibernation, lobotomy, insulin shock, cocktails of drugs. Nothing worked. The psychotic might have some remissions, but his future was widely believed to be hopeless.

Delay announced a cure. He and Pierre Deniker had tested a new antihistamine, synthesized for hay fever by the Rhone-Poulenc drug company two years earlier. Their patients became amazingly calm: Delusions dissolved in a matter of days, like shakos of snow melting slowly off a tree after an ice storm on a warm winter morning. The psychotics’ contact with the real world resumed.

At Lester’s case conference there is a heated quarrel. The psychoanalysts advocate psychotherapy. They believe that his delusion is caused by homosexual panic. All schizophrenia is “latent homosexuality,” they say. Drugging Lester will only be cosmetic, and, worse, it may impede his gaining insight into his underlying conflict. But the resident fresh from Paris is dogged. He reiterates Delay’s findings and he prevails. Lester is injected with this new drug, chlorpromazine. He relaxes immediately. (The new drug was described as a “major tranquilizer.”) By the weekend, Lester is aghast at his garb and washes off all traces of the paint. The idea that he is a worm now seems as crazy to him as it does to us. Within three weeks, Lester is back at work as a stock boy
.

The new drug exploded across the psychiatric world. At every major medical center, chlorpromazine was used for psychotic patients, and, by and large, it worked. Most got better in a few weeks. Many got astonishingly better. Even some patients who had vegetated mutely in the back wards for a decade or more recovered and were discharged within months. The back wards emptied out, and psychiatric beds became readily available for the first time in years.

Thus began the drug revolution, dubbed “the third revolution” in psychiatry. The first had been Pinel’s striking the shackles of the insane; the second was Freud’s invention of psychoanalysis. The premise of the drug revolution is that
disordered mood and emotion reflect disordered brain chemistry. Correct the chemistry of the brain with drugs, and correct mood and emotion
.

The drug revolution spread rapidly. Drugs were compatible with the venerable disease model. Giving drugs rescued psychiatrists from the disdainful skepticism of their more traditionally scientific medical colleagues. Drugs were cheap and quick. Drugs were very big business, and there was a huge lobby to sell them to physicians, to Congress, to the media, and to the public.

And drugs worked. Case histories poured in. Outcome studies of the new antipsychotics were done, and the drugs were usually more effective than sugar pills given to control groups. Perhaps 60 percent of the patients improved, though few recovered completely.
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Depression, mania, and anxiety
. As the fervor for drugging psychotics grew, new drugs were tried on patients suffering from other maladies. The first antidepressant was discovered by accident: A new drug had been tried on tuberculosis. The patients improved. They were pleased. Enormously pleased. They danced in the corridors and shouted in ecstasy. The drug—iproniazid—was primarily a euphoriant. It also relieved depression. The first year it was available, 1957, 400,000 patients were treated with it.
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Unfortunately, iproniazid is toxic, even occasionally lethal. It was soon outsold by milder antidepressants, called tricyclics, as the drug companies fell over each other to mint new, slightly different (and therefore patentable) versions. These also worked, and their side effects were subtler. About 65 percent of patients became less depressed.
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Prozac, hyped as “A Breakthrough Drug for Depression” on the cover of
Newsweek
in 1990, works at just the same rate as the earlier medications, but milder side effects were claimed.
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Prozac seized the lion’s share of the market.

The antidepressants were moderately helpful. In contrast, a true “miracle” drug—lithium carbonate—was discovered for mania. John Cade, an Australian physician, working alone and under primitive conditions, found that the urine of his manic patients killed guinea pigs: The rodents trembled, twitched violently, collapsed, and died. He injected them with lithium, an element known to be a poison, and the guinea pigs became calm and lethargic—and they survived injections of the manics’ urine. Cade then tried lithium on the manic humans whose urine was so lethal. Within days their agitation, their racing thoughts, their distractibility, and their euphoric excitement gave way to calm.
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By 1970, psychiatrists prescribed lithium routinely for manic-depression. Before lithium, manic-depression was a crippling and hopeless illness: 15 percent of manic-depressive patients killed themselves, and most—many manic-depressives are very talented—could not hold jobs. So obnoxious are manics that their families were universally miserable, and 60 percent of their marriages ended in divorce (in the days when divorce was rare). With lithium, this is no longer so. Roughly 80 percent of manic-depressives are helped by it, most of them markedly.
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The biggest splash was made with the anti-anxiety drugs. Anxiety has usually been thought of as an inevitable, if uncomfortable and disorganizing, part of life we all face. Freud thought of it as the fundamental emotion, and the first half of this century was dubbed the age of it. When extreme and out of control, however, anxiety is indisputably a clinical problem.

In the mid-1950s, Miltown (meprobamate) was first used with anxious patients, to phenomenal effect: Frenzied patients relaxed almost to jelly in a few minutes, but they remained conscious; and their troubles, which moments before had overwhelmed them, now seemed pleasantly far away. Sleep came easily.

Predictably, Miltown was used promiscuously. The industry race was on. Librium (chlordiazepoxide) replaced Miltown and became the world’s number one prescription drug. Valium (diazepam), five times stronger, soon displaced Librium. These drugs presently rival alcohol in their everyday use by Americans. If your troubles make you anxious and you can find a cooperative physician, taking Valium four times a day is quite acceptable.
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Ours is no longer the Age of Anxiety. It is the Age of Tranquilizers.

The second principle of biological psychiatry seems firmly in place. Drugs, claim their advocates, have conquered psychosis and mania and eliminated the more commonplace moods of depression and anxiety. Emotion and mood are nothing but brain chemistry. If you don’t like yours, you can change them with the right drug.

The Seamy Side of Drugs

I have tried to make as sympathetic a case as I can for drugs. I had to restrain myself. Drugs do work on emotion. Mania can be greatly dampened. Depression can be moderately relieved. Anxiety can be almost instantly dispelled. Psychotic delusions can be chemically dissolved.

But there is another side to the story. Why in general do drugs work? You might entertain the naïve image that the drug swoops down on the invading foreign disease and kills it, like a falcon attacking a rabbit. I have a different image of how a lot of drugs work, and while controversial, it may help you understand the seamy side. In my image, drugs are themselves foreign invaders, just like diseases. Your body regards the drug as a toxin, and your natural defenses are mobilized to fight it off. A side effect is that these mobilized defenses happen to kill off the disease. The true side effect of a drug is to arrest the disease. The main effect of the drug is to produce the unwanted lesser illnesses, euphemistically dubbed side effects.

General paresis itself was first arrested by just such a tactic. In 1917, Julius Wagner von Jauregg, an Austrian psychiatrist, intentionally gave paretics malaria. He reasoned that the “minor” disease of malaria, producing high fever and marshaling other defenses, might kill the major disease of paresis. So it did, and Wagner von Jauregg was awarded the Nobel Prize in 1927, becoming the only psychiatrist ever so honored. In my view, Wagner von Jauregg’s tactic was not a peculiar medical tactic. Drugs usually work the same way: by inducing a lesser malady to cure a greater malady.

Psychosis
. Antipsychotic drugs seem to “work” about 60 percent of the time, although, surprisingly, well-done outcome studies are scarce. A large minority of patients do not benefit
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(though “benefit” is not exactly a straightforward term, even when the drugs
do
work—the drugs
relieve
the symptoms, but the patients do not recover completely). Schizophrenics become more manageable—quieter, less bizarre, more docile—but they are still schizophrenics. This is convenient for hospital staff and can easily be mistaken for a cure.

Lester still finds himself with strange thoughts, but they are not as compelling as they once were. He has also learned not to talk about being a worm, though he often still thinks he really is one
.

Sadly, Lester, plagued once again by delusions, has returned to the hospital for monthlong bouts of delusions six times since
1952.

Back-ward overcrowding was ended by the drugs, but it was replaced with a “revolving door.” Many of the people we see lying on grates in large American cities got there by being released, again and again, from mental hospitals by virtue of the antipsychotic drugs. Out on the street, they deteriorate once more—either because they stop taking their drugs or because their drugs lose effect—and the police soon bring them back to the hospital.

Psychotics do not stop taking their medication only because of confusion or absentmindedness. I once was a “pseudopatient” and got myself admitted to the locked men’s ward of Norristown (Pennsylvania) State Hospital. I noticed a rush to the bathroom at medication time and followed my fellow patients. There I found a long line of patients who had hidden their pills under their tongues and were, one by one, depositing their pills into the toilet bowl.
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The antipsychotic drugs produce nasty side effects. The most noticeable are cardiac arrhythmia; low blood pressure; uncontrollable restlessness and fidgeting; immobility of the face, robbing the patient of the ability to smile; tremor; and a shuffling gait. A few patients die. A devastating, and especially hideous, side effect is tardive dyskinesia, when the drugs destroy something (as yet unknown) in the brain’s control of movement. Its victims suck and smack their lips uncontrollably.

Lester’s family pretends not to notice. But Lester often looks like a frog catching flies
.

Between one-quarter and one-third of drugged patients develop this deformity. The longer you take the drug, the more likely it is that tardive dyskinesia will develop. And once it starts, it is completely irreversible.
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Depression
. Antidepressant drugs work about 65 percent of the time. Like the antipsychotics, they are cosmetic. Once you stop taking them, you are just as likely to relapse or have a fresh attack of depression as you were before. They do not alter the deep pessimism and helplessness characteristic of depressives. When you recover from depression using a drug, you have acquired no new skills and no new insights into how to handle life’s recurrent setbacks. You credit your recovery to a drug or to a benevolent physician, not to yourself.