Re: Interview with Bentall - Clinical Psychiatrist

[Guest guest]

Psychiatry (28 Aug) - Bentall is an unusual clinical psychiatrist.

After experimenting with medication on himself, he has concluded that much

of psychiatry is no more useful than astrology.

http://www.newscientist.com/opinion/opinterview.jsp?id=ns24101

Psychiatry (28 Aug) - Bentall is an unusual clinical psychiatrist.

After experimenting with medication on himself, he has concluded that much

of psychiatry is no more useful than astrology.

This interview was first published in New Scientist print edition,

Saying psychiatry is no better than astrology is a bit strong, isn't

it?

No. I've tried to show in my book that there is truckloads of research

that shows that these categories are meaningless. They are remarkably

similar to star signs because people think that star signs say something

about them and about what will happen in the future. They think the same

with psychiatric diagnoses, which don't predict the course of the illness,

which treatments will work, or say anything about aetiology.

Though bodies like the World Health Organisation say there are core

definitions for, say, schizophrenia...

Those definitions were drawn up by psychiatric committees in smoke-

filled rooms, so they are psychiatric folklore institutionalised by

committee. They look very precise, but that does not make them

scientifically useful. The experiences and behaviour of patients diagnosed

as schizophrenic or whatever are understandable in terms of processes that

are relatively well known by psychologists. Take two of the most extreme

symptoms - delusion and hearing voices. These are usually seen as signs of

schizophrenia. But over the past 10 years, research has shown that many more

people experience them than we thought.

How many?

Two large epidemiological studies in the US and in the Netherlands

show that when people go round knocking on doors and doing psychiatric

interviews, 1 in 10 say that at some point in their lives they have heard

voices.

And they will actually admit this?

Yes. Now that is really baffling because it sounds like 10 per cent of

the population has schizophrenia. But think about how hearing voices relates

to everyday experiences. All of us have an inner voice - this has been

understood by psychologists for centuries as inner speech. What's happening

to people who hear voices is that they are producing this inner speech in

what looks like a normal way, but for some reason are misattributing it to

an external or alien source.

What about delusions?

The most common type is where the patient believes there is an

organised conspiracy to persecute them or to do them harm. There has always

been a problem of defining when a belief is delusional, but it seems that a

history of victimisation or marginalisation markedly increases the

likelihood of developing these beliefs. But perhaps the most striking

evidence is that immigrants have a very high risk of paranoid symptoms.

Is that all immigrant groups?

My guess is all, but the jury is out. It started off with a study of

British Afro-Caribbeans, who have an increased risk of psychosis, especially

paranoid psychosis. Depending on the research , they are somewhere between 4

and 10 times as likely to develop psychotic paranoid symptoms as other

groups. The most likely explanation seems to be that being an immigrant in a

culture that you are not too comfortable with, or which maybe persecutes

you, increases your chances of having paranoid delusions. One of the most

interesting studies published in the British Medical Journal a year ago

found that Afro-Caribbeans in London had a higher rate of psychosis if they

lived in white neighbourhoods, but not if they lived in mostly black areas.

If we can understand delusions and voices, are environmental factors

back in fashion?

Thinking about that led me to two surprising observations. One was

that you could only really understand these symptoms if you looked at

psychosis as the end point of a developmental pathway. That is not radical:

even the biological people may buy that. The other thing that really shocked

me was that I had believed the textbooks, that nobody had proved an

environmental influence on psychosis. But buried in the literature is a lot

of evidence of environmental factors. It is common sense that being

persecuted will make you paranoid. When you are traumatised, it can generate

a flood of intrusive thought and it is probably that that makes patients

mistake inner speech for an external voice. And blows to self-esteem in

development increase the probability of getting mood problems, while

problems in regulating sleep seem to increase vulnerability to mania. So

there is a coherent story to be told about how all these symptoms are

related to developmental processes, which will undoubtedly include

neurobiological factors, but also some major environmental determinants.

How do you differ from the anti-psychiatry advocates of the 1960s and

1970s?

In a word - I am a scientist. The anti-psychiatrists R. D. Laing and

Esterson were very insightful but they couldn't do research to save

their lives. Laing was extraordinarily imaginative, a genius at relating to

patients, but didn't know when his ideas were inconsistent. The idea that

madness is understandable was his real contribution.

So you want to keep your distance?

My approach is grounded in a lot of experimental research. That is

why, although I've tried hard to make my book readable to the

non-specialist, the reference section is over 100 pages long. Because I am

saying things a lot of people will not want to hear so it's important to

show that my ideas have come from research.

Was some of that research a bit personal?

I was involved in an experiment by a colleague, Healy, at the

North Wales Hospital in Bangor. We took a very low dose, 5 milligrams, of

droperidol, very similar to the widely used drug haloperidol. Parts of the

study were never completed because nearly everybody had a terrible reaction

to the drug. Mine was not the most extreme. There was a psychiatrist who

became so deeply depressed that she was put under observation.

What happened to you?

I drank this stuff and I felt lethargic and sedated. I thought I had

got away with it. Then a psychologist walked in and said: " Oh, this is

embarrassing, , but we'd like you to fill in this test. " The

embarrassing thing was I had designed the test myself 10 years earlier. I

looked at it and I could as soon have climbed Mount Everest. I felt a sense

of depression and hopelessness but also an inner sense of restlessness and

agitation. It was a combined wanting to do something and not being able to.

Then she said: " You don't look too well - would you like some lunch? " I

interpreted that as an order - and I've read since that people on

neuroleptic drugs take statements as orders. So I said yes. Then she said:

" We've a sandwich machine - will that do? " And I said yes because it was all

I was up to saying. But I couldn't get the energy to decide what money to

use. I just grabbed a coin and it was enough to get a Mars bar, which I was

too ill to eat.

Did the drug wear off?

I had to do these neuropsychological tests, and it was embarrassing,

but I burst into tears halfway through. I started weeping uncontrollably, so

much so that I was given an anticholinergic drug as an antidote and

took me out to get some fresh air. I suddenly felt I had to tell him about

all the things I had ever felt guilty about. Then I went back and fell

asleep for 3 hours. I woke up with a woozy hangover, like there was a glass

wall between me and the world and that lasted for about a week after a

single dose. The akathisia - the combined agitation and depression I felt -

is experienced by 40 per cent of patients. It tends to go away after about a

week, but imagine: you've had a crisis, you're admitted to hospital, you're

hearing voices, then someone gives you a drug that makes you feel like that!

But they are designed for sick people...

About 40 per cent of patients have the same experience. That's the

great unasked question of psychiatry: what was it like for you? Patients'

experiences have been completely ignored.

So are the antipsychotics effective?

It's more complex. There's no doubt these drugs help some people by

reducing the hallucinations and delusions. But there are really important

caveats. First, something like 30 per cent of patients get benefits from the

drugs - and we don't know which ones they will be. Secondly, these drugs

have the most horrendous side effects. The old type of antipsychotic drugs

produced what we call extrapyramidal effects, including Parkinsonian

tremors, tardive dyskinesia (uncontrolled movements of the mouth and tongue)

and akathisia.

But surely you just give low doses?

There is a scandal which I must get on my soapbox about - neuroleptic

dosage. These drugs were discovered in the late 1940s and in wide use by the

1950s. Bizarrely, the first studies to look at the most appropriate dosage

were not published until the 1990s. It turned out that low doses work at

least as well as high doses. And for much of that period it wasn't uncommon

to find patients on 80 to 90 milligrams of haloperidol. We now consider it

irrational to give more than 10 milligrams and better to keep it at 5

milligrams a day, although you can still find patients on higher doses.

We've got a massive amount of drug-induced illness - millions of people -

and some of them have even been sent to early graves because of the

increased risk from heart attacks and various blood disorders. All

completely unnecessary.

What about the new antipsychotics?

It turned out the new drugs looked great compared to irrational doses

of the old ones, but when compared to rational doses there was hardly any

difference. The new drugs don't produce the old side effects, but there are

a load of new ones: diabetes, sexual dysfunction, weight gain. I'm not

saying drugs never work. If you talk to patients, some will tell you that

drugs are a lifesaver and others that drugs have made their lives worse.

Quite a few patients now on drugs would be better off without. Perhaps the

best thing is to encourage patients to try them and let them decide.

How far can you take this? What about when people are forcibly

admitted to hospital?

The first question is, do they need to be? In a lot of circumstances

it can be avoided by engaging people in the right way. Why do patients get

forcibly admitted? Because they refuse treatment. And why do they refuse?

Because lots of psychiatric treatment is crap, it is abusive and horrible.

So put the lunatics in charge of the asylum?

Maybe we should! If we had patients helping to manage services, it

would guarantee better services. I think patients should protest more and

there should be more progressive services, like the one in Bradford where

they have patients - " service users " as they call them - sitting on

psychiatric team meetings, involved in decisions.

What makes you identify with the patients?

Basically in the space of a few years in my late twenties, my father

was killed in a car smash, I got divorced, my brother committed

suicide and I became depressed. People are nervous about the influence of

the family: a psychologist once told me my research was dangerous, that I

was reviving the idea that families cause psychosis. The thing is, getting

from one end of your life to the other is about negotiating a series of

obstacles. Some find it more difficult than others. I wanted to get away

from the idea that we are a professional elite who have all the answers.

It's not how I feel. And to some extent I talk about my own experiences as

an illustration of that. But it's deeply difficult to talk about. As I talk

I feel this emotional knot.

And did you seek psychiatric help?

Yes. It was an amazing experience. It was scary. I remember sitting in

the waiting room. I remember the anxiety of sitting there and wondering what

people were thinking of me. They must think I'm mad. Do they think I'm

weird? And trying to look normal by holding a big academic textbook! Then I

thought: " This is what people go through waiting to see me. "

[Guest guest]

Psychiatry (28 Aug) - Bentall is an unusual clinical psychiatrist.

After experimenting with medication on himself, he has concluded that much

of psychiatry is no more useful than astrology.

http://www.newscientist.com/opinion/opinterview.jsp?id=ns24101

Psychiatry (28 Aug) - Bentall is an unusual clinical psychiatrist.

After experimenting with medication on himself, he has concluded that much

of psychiatry is no more useful than astrology.

This interview was first published in New Scientist print edition,

Saying psychiatry is no better than astrology is a bit strong, isn't

it?

No. I've tried to show in my book that there is truckloads of research

that shows that these categories are meaningless. They are remarkably

similar to star signs because people think that star signs say something

about them and about what will happen in the future. They think the same

with psychiatric diagnoses, which don't predict the course of the illness,

which treatments will work, or say anything about aetiology.

Though bodies like the World Health Organisation say there are core

definitions for, say, schizophrenia...

Those definitions were drawn up by psychiatric committees in smoke-

filled rooms, so they are psychiatric folklore institutionalised by

committee. They look very precise, but that does not make them

scientifically useful. The experiences and behaviour of patients diagnosed

as schizophrenic or whatever are understandable in terms of processes that

are relatively well known by psychologists. Take two of the most extreme

symptoms - delusion and hearing voices. These are usually seen as signs of

schizophrenia. But over the past 10 years, research has shown that many more

people experience them than we thought.

How many?

Two large epidemiological studies in the US and in the Netherlands

show that when people go round knocking on doors and doing psychiatric

interviews, 1 in 10 say that at some point in their lives they have heard

voices.

And they will actually admit this?

Yes. Now that is really baffling because it sounds like 10 per cent of

the population has schizophrenia. But think about how hearing voices relates

to everyday experiences. All of us have an inner voice - this has been

understood by psychologists for centuries as inner speech. What's happening

to people who hear voices is that they are producing this inner speech in

what looks like a normal way, but for some reason are misattributing it to

an external or alien source.

What about delusions?

The most common type is where the patient believes there is an

organised conspiracy to persecute them or to do them harm. There has always

been a problem of defining when a belief is delusional, but it seems that a

history of victimisation or marginalisation markedly increases the

likelihood of developing these beliefs. But perhaps the most striking

evidence is that immigrants have a very high risk of paranoid symptoms.

Is that all immigrant groups?

My guess is all, but the jury is out. It started off with a study of

British Afro-Caribbeans, who have an increased risk of psychosis, especially

paranoid psychosis. Depending on the research , they are somewhere between 4

and 10 times as likely to develop psychotic paranoid symptoms as other

groups. The most likely explanation seems to be that being an immigrant in a

culture that you are not too comfortable with, or which maybe persecutes

you, increases your chances of having paranoid delusions. One of the most

interesting studies published in the British Medical Journal a year ago

found that Afro-Caribbeans in London had a higher rate of psychosis if they

lived in white neighbourhoods, but not if they lived in mostly black areas.

If we can understand delusions and voices, are environmental factors

back in fashion?

Thinking about that led me to two surprising observations. One was

that you could only really understand these symptoms if you looked at

psychosis as the end point of a developmental pathway. That is not radical:

even the biological people may buy that. The other thing that really shocked

me was that I had believed the textbooks, that nobody had proved an

environmental influence on psychosis. But buried in the literature is a lot

of evidence of environmental factors. It is common sense that being

persecuted will make you paranoid. When you are traumatised, it can generate

a flood of intrusive thought and it is probably that that makes patients

mistake inner speech for an external voice. And blows to self-esteem in

development increase the probability of getting mood problems, while

problems in regulating sleep seem to increase vulnerability to mania. So

there is a coherent story to be told about how all these symptoms are

related to developmental processes, which will undoubtedly include

neurobiological factors, but also some major environmental determinants.

How do you differ from the anti-psychiatry advocates of the 1960s and

1970s?

In a word - I am a scientist. The anti-psychiatrists R. D. Laing and

Esterson were very insightful but they couldn't do research to save

their lives. Laing was extraordinarily imaginative, a genius at relating to

patients, but didn't know when his ideas were inconsistent. The idea that

madness is understandable was his real contribution.

So you want to keep your distance?

My approach is grounded in a lot of experimental research. That is

why, although I've tried hard to make my book readable to the

non-specialist, the reference section is over 100 pages long. Because I am

saying things a lot of people will not want to hear so it's important to

show that my ideas have come from research.

Was some of that research a bit personal?

I was involved in an experiment by a colleague, Healy, at the

North Wales Hospital in Bangor. We took a very low dose, 5 milligrams, of

droperidol, very similar to the widely used drug haloperidol. Parts of the

study were never completed because nearly everybody had a terrible reaction

to the drug. Mine was not the most extreme. There was a psychiatrist who

became so deeply depressed that she was put under observation.

What happened to you?

I drank this stuff and I felt lethargic and sedated. I thought I had

got away with it. Then a psychologist walked in and said: " Oh, this is

embarrassing, , but we'd like you to fill in this test. " The

embarrassing thing was I had designed the test myself 10 years earlier. I

looked at it and I could as soon have climbed Mount Everest. I felt a sense

of depression and hopelessness but also an inner sense of restlessness and

agitation. It was a combined wanting to do something and not being able to.

Then she said: " You don't look too well - would you like some lunch? " I

interpreted that as an order - and I've read since that people on

neuroleptic drugs take statements as orders. So I said yes. Then she said:

" We've a sandwich machine - will that do? " And I said yes because it was all

I was up to saying. But I couldn't get the energy to decide what money to

use. I just grabbed a coin and it was enough to get a Mars bar, which I was

too ill to eat.

Did the drug wear off?

I had to do these neuropsychological tests, and it was embarrassing,

but I burst into tears halfway through. I started weeping uncontrollably, so

much so that I was given an anticholinergic drug as an antidote and

took me out to get some fresh air. I suddenly felt I had to tell him about

all the things I had ever felt guilty about. Then I went back and fell

asleep for 3 hours. I woke up with a woozy hangover, like there was a glass

wall between me and the world and that lasted for about a week after a

single dose. The akathisia - the combined agitation and depression I felt -

is experienced by 40 per cent of patients. It tends to go away after about a

week, but imagine: you've had a crisis, you're admitted to hospital, you're

hearing voices, then someone gives you a drug that makes you feel like that!

But they are designed for sick people...

About 40 per cent of patients have the same experience. That's the

great unasked question of psychiatry: what was it like for you? Patients'

experiences have been completely ignored.

So are the antipsychotics effective?

It's more complex. There's no doubt these drugs help some people by

reducing the hallucinations and delusions. But there are really important

caveats. First, something like 30 per cent of patients get benefits from the

drugs - and we don't know which ones they will be. Secondly, these drugs

have the most horrendous side effects. The old type of antipsychotic drugs

produced what we call extrapyramidal effects, including Parkinsonian

tremors, tardive dyskinesia (uncontrolled movements of the mouth and tongue)

and akathisia.

But surely you just give low doses?

There is a scandal which I must get on my soapbox about - neuroleptic

dosage. These drugs were discovered in the late 1940s and in wide use by the

1950s. Bizarrely, the first studies to look at the most appropriate dosage

were not published until the 1990s. It turned out that low doses work at

least as well as high doses. And for much of that period it wasn't uncommon

to find patients on 80 to 90 milligrams of haloperidol. We now consider it

irrational to give more than 10 milligrams and better to keep it at 5

milligrams a day, although you can still find patients on higher doses.

We've got a massive amount of drug-induced illness - millions of people -

and some of them have even been sent to early graves because of the

increased risk from heart attacks and various blood disorders. All

completely unnecessary.

What about the new antipsychotics?

It turned out the new drugs looked great compared to irrational doses

of the old ones, but when compared to rational doses there was hardly any

difference. The new drugs don't produce the old side effects, but there are

a load of new ones: diabetes, sexual dysfunction, weight gain. I'm not

saying drugs never work. If you talk to patients, some will tell you that

drugs are a lifesaver and others that drugs have made their lives worse.

Quite a few patients now on drugs would be better off without. Perhaps the

best thing is to encourage patients to try them and let them decide.

How far can you take this? What about when people are forcibly

admitted to hospital?

The first question is, do they need to be? In a lot of circumstances

it can be avoided by engaging people in the right way. Why do patients get

forcibly admitted? Because they refuse treatment. And why do they refuse?

Because lots of psychiatric treatment is crap, it is abusive and horrible.

So put the lunatics in charge of the asylum?

Maybe we should! If we had patients helping to manage services, it

would guarantee better services. I think patients should protest more and

there should be more progressive services, like the one in Bradford where

they have patients - " service users " as they call them - sitting on

psychiatric team meetings, involved in decisions.

What makes you identify with the patients?

Basically in the space of a few years in my late twenties, my father

was killed in a car smash, I got divorced, my brother committed

suicide and I became depressed. People are nervous about the influence of

the family: a psychologist once told me my research was dangerous, that I

was reviving the idea that families cause psychosis. The thing is, getting

from one end of your life to the other is about negotiating a series of

obstacles. Some find it more difficult than others. I wanted to get away

from the idea that we are a professional elite who have all the answers.

It's not how I feel. And to some extent I talk about my own experiences as

an illustration of that. But it's deeply difficult to talk about. As I talk

I feel this emotional knot.

And did you seek psychiatric help?

Yes. It was an amazing experience. It was scary. I remember sitting in

the waiting room. I remember the anxiety of sitting there and wondering what

people were thinking of me. They must think I'm mad. Do they think I'm

weird? And trying to look normal by holding a big academic textbook! Then I

thought: " This is what people go through waiting to see me. "

[Guest guest]

Psychiatry (28 Aug) - Bentall is an unusual clinical psychiatrist.

After experimenting with medication on himself, he has concluded that much

of psychiatry is no more useful than astrology.

http://www.newscientist.com/opinion/opinterview.jsp?id=ns24101

Psychiatry (28 Aug) - Bentall is an unusual clinical psychiatrist.

After experimenting with medication on himself, he has concluded that much

of psychiatry is no more useful than astrology.

This interview was first published in New Scientist print edition,

Saying psychiatry is no better than astrology is a bit strong, isn't

it?

No. I've tried to show in my book that there is truckloads of research

that shows that these categories are meaningless. They are remarkably

similar to star signs because people think that star signs say something

about them and about what will happen in the future. They think the same

with psychiatric diagnoses, which don't predict the course of the illness,

which treatments will work, or say anything about aetiology.

Though bodies like the World Health Organisation say there are core

definitions for, say, schizophrenia...

Those definitions were drawn up by psychiatric committees in smoke-

filled rooms, so they are psychiatric folklore institutionalised by

committee. They look very precise, but that does not make them

scientifically useful. The experiences and behaviour of patients diagnosed

as schizophrenic or whatever are understandable in terms of processes that

are relatively well known by psychologists. Take two of the most extreme

symptoms - delusion and hearing voices. These are usually seen as signs of

schizophrenia. But over the past 10 years, research has shown that many more

people experience them than we thought.

How many?

Two large epidemiological studies in the US and in the Netherlands

show that when people go round knocking on doors and doing psychiatric

interviews, 1 in 10 say that at some point in their lives they have heard

voices.

And they will actually admit this?

Yes. Now that is really baffling because it sounds like 10 per cent of

the population has schizophrenia. But think about how hearing voices relates

to everyday experiences. All of us have an inner voice - this has been

understood by psychologists for centuries as inner speech. What's happening

to people who hear voices is that they are producing this inner speech in

what looks like a normal way, but for some reason are misattributing it to

an external or alien source.

What about delusions?

The most common type is where the patient believes there is an

organised conspiracy to persecute them or to do them harm. There has always

been a problem of defining when a belief is delusional, but it seems that a

history of victimisation or marginalisation markedly increases the

likelihood of developing these beliefs. But perhaps the most striking

evidence is that immigrants have a very high risk of paranoid symptoms.

Is that all immigrant groups?

My guess is all, but the jury is out. It started off with a study of

British Afro-Caribbeans, who have an increased risk of psychosis, especially

paranoid psychosis. Depending on the research , they are somewhere between 4

and 10 times as likely to develop psychotic paranoid symptoms as other

groups. The most likely explanation seems to be that being an immigrant in a

culture that you are not too comfortable with, or which maybe persecutes

you, increases your chances of having paranoid delusions. One of the most

interesting studies published in the British Medical Journal a year ago

found that Afro-Caribbeans in London had a higher rate of psychosis if they

lived in white neighbourhoods, but not if they lived in mostly black areas.

If we can understand delusions and voices, are environmental factors

back in fashion?

Thinking about that led me to two surprising observations. One was

that you could only really understand these symptoms if you looked at

psychosis as the end point of a developmental pathway. That is not radical:

even the biological people may buy that. The other thing that really shocked

me was that I had believed the textbooks, that nobody had proved an

environmental influence on psychosis. But buried in the literature is a lot

of evidence of environmental factors. It is common sense that being

persecuted will make you paranoid. When you are traumatised, it can generate

a flood of intrusive thought and it is probably that that makes patients

mistake inner speech for an external voice. And blows to self-esteem in

development increase the probability of getting mood problems, while

problems in regulating sleep seem to increase vulnerability to mania. So

there is a coherent story to be told about how all these symptoms are

related to developmental processes, which will undoubtedly include

neurobiological factors, but also some major environmental determinants.

How do you differ from the anti-psychiatry advocates of the 1960s and

1970s?

In a word - I am a scientist. The anti-psychiatrists R. D. Laing and

Esterson were very insightful but they couldn't do research to save

their lives. Laing was extraordinarily imaginative, a genius at relating to

patients, but didn't know when his ideas were inconsistent. The idea that

madness is understandable was his real contribution.

So you want to keep your distance?

My approach is grounded in a lot of experimental research. That is

why, although I've tried hard to make my book readable to the

non-specialist, the reference section is over 100 pages long. Because I am

saying things a lot of people will not want to hear so it's important to

show that my ideas have come from research.

Was some of that research a bit personal?

I was involved in an experiment by a colleague, Healy, at the

North Wales Hospital in Bangor. We took a very low dose, 5 milligrams, of

droperidol, very similar to the widely used drug haloperidol. Parts of the

study were never completed because nearly everybody had a terrible reaction

to the drug. Mine was not the most extreme. There was a psychiatrist who

became so deeply depressed that she was put under observation.

What happened to you?

I drank this stuff and I felt lethargic and sedated. I thought I had

got away with it. Then a psychologist walked in and said: " Oh, this is

embarrassing, , but we'd like you to fill in this test. " The

embarrassing thing was I had designed the test myself 10 years earlier. I

looked at it and I could as soon have climbed Mount Everest. I felt a sense

of depression and hopelessness but also an inner sense of restlessness and

agitation. It was a combined wanting to do something and not being able to.

Then she said: " You don't look too well - would you like some lunch? " I

interpreted that as an order - and I've read since that people on

neuroleptic drugs take statements as orders. So I said yes. Then she said:

" We've a sandwich machine - will that do? " And I said yes because it was all

I was up to saying. But I couldn't get the energy to decide what money to

use. I just grabbed a coin and it was enough to get a Mars bar, which I was

too ill to eat.

Did the drug wear off?

I had to do these neuropsychological tests, and it was embarrassing,

but I burst into tears halfway through. I started weeping uncontrollably, so

much so that I was given an anticholinergic drug as an antidote and

took me out to get some fresh air. I suddenly felt I had to tell him about

all the things I had ever felt guilty about. Then I went back and fell

asleep for 3 hours. I woke up with a woozy hangover, like there was a glass

wall between me and the world and that lasted for about a week after a

single dose. The akathisia - the combined agitation and depression I felt -

is experienced by 40 per cent of patients. It tends to go away after about a

week, but imagine: you've had a crisis, you're admitted to hospital, you're

hearing voices, then someone gives you a drug that makes you feel like that!

But they are designed for sick people...

About 40 per cent of patients have the same experience. That's the

great unasked question of psychiatry: what was it like for you? Patients'

experiences have been completely ignored.

So are the antipsychotics effective?

It's more complex. There's no doubt these drugs help some people by

reducing the hallucinations and delusions. But there are really important

caveats. First, something like 30 per cent of patients get benefits from the

drugs - and we don't know which ones they will be. Secondly, these drugs

have the most horrendous side effects. The old type of antipsychotic drugs

produced what we call extrapyramidal effects, including Parkinsonian

tremors, tardive dyskinesia (uncontrolled movements of the mouth and tongue)

and akathisia.

But surely you just give low doses?

There is a scandal which I must get on my soapbox about - neuroleptic

dosage. These drugs were discovered in the late 1940s and in wide use by the

1950s. Bizarrely, the first studies to look at the most appropriate dosage

were not published until the 1990s. It turned out that low doses work at

least as well as high doses. And for much of that period it wasn't uncommon

to find patients on 80 to 90 milligrams of haloperidol. We now consider it

irrational to give more than 10 milligrams and better to keep it at 5

milligrams a day, although you can still find patients on higher doses.

We've got a massive amount of drug-induced illness - millions of people -

and some of them have even been sent to early graves because of the

increased risk from heart attacks and various blood disorders. All

completely unnecessary.

What about the new antipsychotics?

It turned out the new drugs looked great compared to irrational doses

of the old ones, but when compared to rational doses there was hardly any

difference. The new drugs don't produce the old side effects, but there are

a load of new ones: diabetes, sexual dysfunction, weight gain. I'm not

saying drugs never work. If you talk to patients, some will tell you that

drugs are a lifesaver and others that drugs have made their lives worse.

Quite a few patients now on drugs would be better off without. Perhaps the

best thing is to encourage patients to try them and let them decide.

How far can you take this? What about when people are forcibly

admitted to hospital?

The first question is, do they need to be? In a lot of circumstances

it can be avoided by engaging people in the right way. Why do patients get

forcibly admitted? Because they refuse treatment. And why do they refuse?

Because lots of psychiatric treatment is crap, it is abusive and horrible.

So put the lunatics in charge of the asylum?

Maybe we should! If we had patients helping to manage services, it

would guarantee better services. I think patients should protest more and

there should be more progressive services, like the one in Bradford where

they have patients - " service users " as they call them - sitting on

psychiatric team meetings, involved in decisions.

What makes you identify with the patients?

Basically in the space of a few years in my late twenties, my father

was killed in a car smash, I got divorced, my brother committed

suicide and I became depressed. People are nervous about the influence of

the family: a psychologist once told me my research was dangerous, that I

was reviving the idea that families cause psychosis. The thing is, getting

from one end of your life to the other is about negotiating a series of

obstacles. Some find it more difficult than others. I wanted to get away

from the idea that we are a professional elite who have all the answers.

It's not how I feel. And to some extent I talk about my own experiences as

an illustration of that. But it's deeply difficult to talk about. As I talk

I feel this emotional knot.

And did you seek psychiatric help?

Yes. It was an amazing experience. It was scary. I remember sitting in

the waiting room. I remember the anxiety of sitting there and wondering what

people were thinking of me. They must think I'm mad. Do they think I'm

weird? And trying to look normal by holding a big academic textbook! Then I

thought: " This is what people go through waiting to see me. "

[Guest guest]

Psychiatry (28 Aug) - Bentall is an unusual clinical psychiatrist.

After experimenting with medication on himself, he has concluded that much

of psychiatry is no more useful than astrology.

http://www.newscientist.com/opinion/opinterview.jsp?id=ns24101

Psychiatry (28 Aug) - Bentall is an unusual clinical psychiatrist.

After experimenting with medication on himself, he has concluded that much

of psychiatry is no more useful than astrology.

This interview was first published in New Scientist print edition,

Saying psychiatry is no better than astrology is a bit strong, isn't

it?

No. I've tried to show in my book that there is truckloads of research

that shows that these categories are meaningless. They are remarkably

similar to star signs because people think that star signs say something

about them and about what will happen in the future. They think the same

with psychiatric diagnoses, which don't predict the course of the illness,

which treatments will work, or say anything about aetiology.

Though bodies like the World Health Organisation say there are core

definitions for, say, schizophrenia...

Those definitions were drawn up by psychiatric committees in smoke-

filled rooms, so they are psychiatric folklore institutionalised by

committee. They look very precise, but that does not make them

scientifically useful. The experiences and behaviour of patients diagnosed

as schizophrenic or whatever are understandable in terms of processes that

are relatively well known by psychologists. Take two of the most extreme

symptoms - delusion and hearing voices. These are usually seen as signs of

schizophrenia. But over the past 10 years, research has shown that many more

people experience them than we thought.

How many?

Two large epidemiological studies in the US and in the Netherlands

show that when people go round knocking on doors and doing psychiatric

interviews, 1 in 10 say that at some point in their lives they have heard

voices.

And they will actually admit this?

Yes. Now that is really baffling because it sounds like 10 per cent of

the population has schizophrenia. But think about how hearing voices relates

to everyday experiences. All of us have an inner voice - this has been

understood by psychologists for centuries as inner speech. What's happening

to people who hear voices is that they are producing this inner speech in

what looks like a normal way, but for some reason are misattributing it to

an external or alien source.

What about delusions?

The most common type is where the patient believes there is an

organised conspiracy to persecute them or to do them harm. There has always

been a problem of defining when a belief is delusional, but it seems that a

history of victimisation or marginalisation markedly increases the

likelihood of developing these beliefs. But perhaps the most striking

evidence is that immigrants have a very high risk of paranoid symptoms.

Is that all immigrant groups?

My guess is all, but the jury is out. It started off with a study of

British Afro-Caribbeans, who have an increased risk of psychosis, especially

paranoid psychosis. Depending on the research , they are somewhere between 4

and 10 times as likely to develop psychotic paranoid symptoms as other

groups. The most likely explanation seems to be that being an immigrant in a

culture that you are not too comfortable with, or which maybe persecutes

you, increases your chances of having paranoid delusions. One of the most

interesting studies published in the British Medical Journal a year ago

found that Afro-Caribbeans in London had a higher rate of psychosis if they

lived in white neighbourhoods, but not if they lived in mostly black areas.

If we can understand delusions and voices, are environmental factors

back in fashion?

Thinking about that led me to two surprising observations. One was

that you could only really understand these symptoms if you looked at

psychosis as the end point of a developmental pathway. That is not radical:

even the biological people may buy that. The other thing that really shocked

me was that I had believed the textbooks, that nobody had proved an

environmental influence on psychosis. But buried in the literature is a lot

of evidence of environmental factors. It is common sense that being

persecuted will make you paranoid. When you are traumatised, it can generate

a flood of intrusive thought and it is probably that that makes patients

mistake inner speech for an external voice. And blows to self-esteem in

development increase the probability of getting mood problems, while

problems in regulating sleep seem to increase vulnerability to mania. So

there is a coherent story to be told about how all these symptoms are

related to developmental processes, which will undoubtedly include

neurobiological factors, but also some major environmental determinants.

How do you differ from the anti-psychiatry advocates of the 1960s and

1970s?

In a word - I am a scientist. The anti-psychiatrists R. D. Laing and

Esterson were very insightful but they couldn't do research to save

their lives. Laing was extraordinarily imaginative, a genius at relating to

patients, but didn't know when his ideas were inconsistent. The idea that

madness is understandable was his real contribution.

So you want to keep your distance?

My approach is grounded in a lot of experimental research. That is

why, although I've tried hard to make my book readable to the

non-specialist, the reference section is over 100 pages long. Because I am

saying things a lot of people will not want to hear so it's important to

show that my ideas have come from research.

Was some of that research a bit personal?

I was involved in an experiment by a colleague, Healy, at the

North Wales Hospital in Bangor. We took a very low dose, 5 milligrams, of

droperidol, very similar to the widely used drug haloperidol. Parts of the

study were never completed because nearly everybody had a terrible reaction

to the drug. Mine was not the most extreme. There was a psychiatrist who

became so deeply depressed that she was put under observation.

What happened to you?

I drank this stuff and I felt lethargic and sedated. I thought I had

got away with it. Then a psychologist walked in and said: " Oh, this is

embarrassing, , but we'd like you to fill in this test. " The

embarrassing thing was I had designed the test myself 10 years earlier. I

looked at it and I could as soon have climbed Mount Everest. I felt a sense

of depression and hopelessness but also an inner sense of restlessness and

agitation. It was a combined wanting to do something and not being able to.

Then she said: " You don't look too well - would you like some lunch? " I

interpreted that as an order - and I've read since that people on

neuroleptic drugs take statements as orders. So I said yes. Then she said:

" We've a sandwich machine - will that do? " And I said yes because it was all

I was up to saying. But I couldn't get the energy to decide what money to

use. I just grabbed a coin and it was enough to get a Mars bar, which I was

too ill to eat.

Did the drug wear off?

I had to do these neuropsychological tests, and it was embarrassing,

but I burst into tears halfway through. I started weeping uncontrollably, so

much so that I was given an anticholinergic drug as an antidote and

took me out to get some fresh air. I suddenly felt I had to tell him about

all the things I had ever felt guilty about. Then I went back and fell

asleep for 3 hours. I woke up with a woozy hangover, like there was a glass

wall between me and the world and that lasted for about a week after a

single dose. The akathisia - the combined agitation and depression I felt -

is experienced by 40 per cent of patients. It tends to go away after about a

week, but imagine: you've had a crisis, you're admitted to hospital, you're

hearing voices, then someone gives you a drug that makes you feel like that!

But they are designed for sick people...

About 40 per cent of patients have the same experience. That's the

great unasked question of psychiatry: what was it like for you? Patients'

experiences have been completely ignored.

So are the antipsychotics effective?

It's more complex. There's no doubt these drugs help some people by

reducing the hallucinations and delusions. But there are really important

caveats. First, something like 30 per cent of patients get benefits from the

drugs - and we don't know which ones they will be. Secondly, these drugs

have the most horrendous side effects. The old type of antipsychotic drugs

produced what we call extrapyramidal effects, including Parkinsonian

tremors, tardive dyskinesia (uncontrolled movements of the mouth and tongue)

and akathisia.

But surely you just give low doses?

There is a scandal which I must get on my soapbox about - neuroleptic

dosage. These drugs were discovered in the late 1940s and in wide use by the

1950s. Bizarrely, the first studies to look at the most appropriate dosage

were not published until the 1990s. It turned out that low doses work at

least as well as high doses. And for much of that period it wasn't uncommon

to find patients on 80 to 90 milligrams of haloperidol. We now consider it

irrational to give more than 10 milligrams and better to keep it at 5

milligrams a day, although you can still find patients on higher doses.

We've got a massive amount of drug-induced illness - millions of people -

and some of them have even been sent to early graves because of the

increased risk from heart attacks and various blood disorders. All

completely unnecessary.

What about the new antipsychotics?

It turned out the new drugs looked great compared to irrational doses

of the old ones, but when compared to rational doses there was hardly any

difference. The new drugs don't produce the old side effects, but there are

a load of new ones: diabetes, sexual dysfunction, weight gain. I'm not

saying drugs never work. If you talk to patients, some will tell you that

drugs are a lifesaver and others that drugs have made their lives worse.

Quite a few patients now on drugs would be better off without. Perhaps the

best thing is to encourage patients to try them and let them decide.

How far can you take this? What about when people are forcibly

admitted to hospital?

The first question is, do they need to be? In a lot of circumstances

it can be avoided by engaging people in the right way. Why do patients get

forcibly admitted? Because they refuse treatment. And why do they refuse?

Because lots of psychiatric treatment is crap, it is abusive and horrible.

So put the lunatics in charge of the asylum?

Maybe we should! If we had patients helping to manage services, it

would guarantee better services. I think patients should protest more and

there should be more progressive services, like the one in Bradford where

they have patients - " service users " as they call them - sitting on

psychiatric team meetings, involved in decisions.

What makes you identify with the patients?

Basically in the space of a few years in my late twenties, my father

was killed in a car smash, I got divorced, my brother committed

suicide and I became depressed. People are nervous about the influence of

the family: a psychologist once told me my research was dangerous, that I

was reviving the idea that families cause psychosis. The thing is, getting

from one end of your life to the other is about negotiating a series of

obstacles. Some find it more difficult than others. I wanted to get away

from the idea that we are a professional elite who have all the answers.

It's not how I feel. And to some extent I talk about my own experiences as

an illustration of that. But it's deeply difficult to talk about. As I talk

I feel this emotional knot.

And did you seek psychiatric help?

Yes. It was an amazing experience. It was scary. I remember sitting in

the waiting room. I remember the anxiety of sitting there and wondering what

people were thinking of me. They must think I'm mad. Do they think I'm

weird? And trying to look normal by holding a big academic textbook! Then I

thought: " This is what people go through waiting to see me. "