Spitzer dummies

For those interested in what Robert Spitzer actually said about the (over)diagnosis of ADD and ADHD in the BBC2 documentary The Trap: The Lonely Robot, a brief excerpt (including the still below) was featured on last Monday night's episode of the (Australian) ABC's Media Watch. Briefly, it got about that Spitzer, the "Godfather" of the ADD diagnosis, had claimed that 20%-30% of children suffering from ADD/ADHD had been misdiagnosed, and that there was really nothing wrong with them at all. This was repeated in newspapers and email lists all round the world until Spitzer's apparent recantation was revealed as an artifact of some selective editing of the documentary footage, together with the overzealousness of some journalists who demonstrated the same disregard for fact-checking and context as some psychiatrists do when making diagnoses.


Media Watch's take on the whole affair can be viewed here and the transcript can be read here. Needless to say, both the local and international press, as well as the local electronic media, got a bucketing for their failure to confirm Spitzer's comments with him personally. Towards the end of the segment, presenter Monica Attard, who has the demeanour of television's The Nanny (to be fair, that is pretty much a requirement for being the host of this show) couldn't resist sarcastically noting: "Not that ignorance of the subject would get in the way of a bit of moralising," and quoting the following newspaper article as an example of such:

Some of the children misdiagnosed need help, but not necessarily of the chemical kind.

Love, patience and help in overcoming problems in the home and at school are the first steps…

— Sunday Herald Sun, Misdiagnosis disorder, 11 March 2007

What intrigues and somewhat disappoints me is the failure of the blogosphere and the media at large to take the opportunity to critically assess Spitzer's work and opinions in response to the news coverage generated by this blooper. The lack of professionalism of some journalists and the embarrassment that this has caused Spitzer does not make his position unassailable. We have critics deriding common sense (albeit sugar-coated) as 'moralising', when we should be asking ourselves whether there could be anything to what Spitzer was alleged to have said, even if he didn't say it.

Don't try this at home

I insisted on doing it at my boyfriend's instead, which has air-conditioning and internet access. So insistent was I, that when I arrived on his place at 10pm on Sunday night with a key to the main door but not to the security door, I called him and demanded that he arrange a locksmith. At a distance of 400 km, he clearly preferred that I just take a taxi back to my own place and that we sort things out in the morning. But I'd walked nearly a kilometre, God damn it, drifting in and out of consciousness, electric shocks pinballing about in my head, dizzy with the fatigue of travelling 400 km myself just to get home to water his front garden, an activity subject to very precise time, date and method restrictions during this time of drought. My eyes and nose were just about providing enough precipitation to keep his native plants on floral death row for a little longer, so the hose only received a few cursory flicks while I waited for the locksmith to arrive. After he drilled out the original lock and let me in, it was my turn to unpack the tools of my trade, my recipe for potential disaster:

Zoloft cold turkey

One bed, preferably double
One large bottle of the benzodiazepine of your choice
One bucket, for when nausea waits for no toilet
Two boxes of tissues (one for blowing, the other for wiping)
One big plastic bag (for dirty tissues, torn up suicide notes)
One packet of laxatives
Two packets of cold & flu tablets
Lots of lemonade
At least two weeks of sick leave owing

Definitely no alcohol. (I cannot stress this enough - it just amplifies the dizziness.)

I'm now up to Day 10. The dizziness, electric shocks and the 'my foot's asleep' feeling that pervaded my entire body have mostly abated, but have left me with a degree of fatigue that forces me to carefully ration my daily activities. A half-hour walk, yes, but then a half hour nap. My appetite's gone but unlamented as a dry hacking cough can easily turn into a puke session.

Why am I doing this? Quite simply, I began cutting back slowly from a dose of 300mg, and as noted in a previous post, discontinuation syndrome had already struck by the time I was down to 225mg (which is still more than the standard maximum daily dose). Given this inauspicious beginning, I deduced that if I continued with fortnightly reductions of 25mg, I would be too unwell to work for at least ten days out of each fortnight. Given my full-time work and part-time study commitments, such an arrangement hardly seemed feasible - it would amount to six months of being sick. And yes, I'd done it before, and I wanted to see if I had the balls to do it again.

Not that I will ever put myself in this position again, but the one thing I shouldn't have done is attempt to work from home. Those people who go out of their way to give you the shits every time you deal with them? While your synapses are readjusting themselves to the point where you could swallow two tabs of ecstasy and not just sit on the end of the sofa thinking "hmm, nice party, nice people, think I might get up and dance soon", such people should be avoided like Joe Cocker on a plane. In the past few months at work, I've been put through an emotional wringer - a long-overdue promotion was finally 'formally' offered to me, but after a lengthy period during which said promotion was never reflected in my pay packet, I decided to play detective and discovered that no such promotion was ever going to be offered to me as far as HR were concerned - until I played nasty. I guess once your brain clears of the chemical maelstrom inflicted both by the drug per se and your withdrawal from it, you see where the causes of your unhappiness really lie.

Illicit Sexual Liaison in a Park

I'll start this reflection on a certain kind of behaviour that is of particular interest to professionals in psychiatric inpatient settings with a quote from an article published in the Guardian a couple of years ago by a young Australian writer Emily Maguire.

When I was 14, I wanted to have sex more than I wanted anything else in the world. Let me be clear: I did not want to have sex because the media told me I should or because my friends were doing it or my boyfriend was pushing me. I wanted to have sex because my body was flooded with hormones whose entire reason for existence was to make me want to have sex.

Emily turned for reassurance to her high school's Health & Development class, but something was clearly missing. She learned about ovulation, menstruation, tender breasts, swollen nipples, and everything else that "would allow me to one day experience the miracle of motherhood". Health & Development emphasised the messy, painful, uncomfortable aspects of burgeoning female sexuality; in particular, oddly enough, the "testosterone [that] was surging through my body and might cause me to feel 'strange'." However:

Boys would not feel 'strange': they would feel horny. They would be distracted by sexual thoughts and feelings. Their genitals would engorge with blood for no reason at all. They would feel a deep, low-down ache, which could only be eased by sexual release. They would have erotic dreams from which they would wake to find they had messed up their sheets and pyjamas. I am a boy, I thought, my face hot and my thighs pressed together.

Newflash: teenage girls get horny too, but it is near impossible for them them to pursue sexual fulfillment in a culture where 'good girls don't' and it is assumed that the 'bad girls' who 'let boys use them' are merely suffering from low self-esteem. Emily describes her initial acute frustration as she began to appreciate the somewhat mythological nature of relentless male sex drive:

But the teenage boys with one-track minds evidently went to a different school, and the men who coax innocent schoolgirls into bed must have done their seducing in another town. Every day I stepped out into the world exuding sexual heat, and every day I was ignored. Each time I willed someone to touch me and they didn't, I shrunk just a little.

Eventually, coached in the farcical techniques of seduction, Emily began to be pro-active is seeking sexual fulfillment, but sadly was unable to do so without incurring all the usual consequences of being a girl with a reputation.

I was reminded of this article when reading some of my medical records, and noting a reference to 'an illicit sexual liaison in a park' that allegedly took place while I was hospitalised. This report was made by a community psychiatric nurse some time after my discharge, and I am unsure of what permutation of Chinese whispers resulted in its precise formulation. Just for the record, I'm pretty sure that I didn't have sex with anyone in a park, although there was a park up the road from the hospital in question. I do, however, recall having sex with a fellow patient under the fire escape of a nearby hotel and up against the wall of a nearby factory later that night.

Like Emily, when I was a teenager, I was incredibly curious about sex, and just dying to try it, under the right circumstances of course. Like just about any other girl, I wanted to meet a boy, fall in love and fuck like a rabbit. However, the probability of this happening to me was just about nil - I was the friendless, brotherless town freak in her grandmother's hand-me-downs, the walking dictionary, encyclopedia and calculator, and yet somehow already hearing the word slut hurled at me from left right and centre. One the other hand, some people literally thought that I lacked the most prosaic bodily functions, let alone sexual urges. Needless to say, my curiosity was not about to be sated as a fifteen-year-old.

The situation eased a little when I moved to a co-ed school - in fact, a couple of the boys there began 'courting' me, carrying my books from class to class and walking me part of the way home, but I was too dumb to see this for what it was, and tended to respond with polite bemusement. And by that time, of course, I was already a veteran of psychiatric inpatient facilities, where, er, there were men to experiment with.

The man who introduced my by then already deflowered self to various new manoeuvres under the hotel fire escape was in his early forties, and I first met him when I had to apologise to him for falling asleep while he was 'sharing' in group therapy. He was a mechanic and an alcoholic, built like a brick shithouse, told me I reminded him of a young Germaine Greer and played Creedence Clearwater Revival over and over on his walkman. I'd already had my eye on one of the other patients, but after some progress, he took up with my room-mate, and they went back to his place to shag on his black satin-sleeved heart-shaped bed. (Ew!) So I turned my attention to Tim, and asked him if he felt like going for a walk one evening. We returned to the ward as pissed as parrots at about 1 a.m, and the rest, as they say, is (psychiatric) history.

OK, so this is all pretty funny to look back on now: but let us ask: who was the slut back then? Who was inadvertently confirming her keepers' diagnosis of her as bipolar, as borderline, just by being a horny and curious teenage girl, who had no other outlet or opportunity for sexual experimentation because most of her contact with the opposite sex came via her hospitalisations, contexts in which most of her fellow patients were older and had outgrown the tendency to slot their peers into sluthood? Yes, most psychiatric facilities frown on sexual relationships developing between patients (I won't even begin to rant about the blind eye they can turn to relationships between patients and staff), and drug and alcohol rehabilitation facilities often have a flat ban on them, that must be signed off on during admission. But throw a lot of bored, miserable, drug-disinhibited people together and what do you expect?

I was over 16 - the age of consent. As a matter of logic, I could not have had an illicit sexual liaison in a park.

Bipolar Child Paradigm

Pretty much flat on my back thanks to Zoloft withdrawal - will try and post something a bit more substantial soon.

Meanwhile, in view of the debate and interest that the so-called 'Bipolar Child Paradigm' has aroused, I'd be very interested to hear directly from those who experienced severe depressive episodes and/or behaviour that approximates the current DSM definition of mania for adults, between the ages of 5 and 12. By implication, I'm interested to hear from people who had these experiences as children in the '70s, '80s and early '90s, that is well before the explosion of interest in diagnosing the condition in children.

And what position am I taking, at least initially? I believe that it is quite possible for children in this age group to suffer severe depression as well as episodes of heightened mood, activity and escaping into grandiose fantasies. Here, I'm definitely not talking about not being able to sit still in class and other such ADD cliches. I'm talking private suicide attempts, complete and utter social isolation and the valorisation of unconsciousness, and not just indulging in some serious acting-out because they don't want lamb roast for dinner.

All of these things happened to me (except for the lamb roast bit). However, in spite of this, I'm reluctant to adopt the 'Paradigm' as it stands, and would prefer to examine these phenomena in a psychosocial context. My current belief is that looking to psychopharmacology for a solution does far more harm than good where kids are involved. I may have fit the criteria for 'bipolar' as a kid, but I'm definitely not bipolar now, and looking back, it was clear that my environment, not my neurochemistry, was the problem.

Comments are welcome below, and I can be emailed directly via my profile on this blog.

Tolstoy at the Opera

Bipolar Blast has recently featured a couple of posts describing the phenomena of depersonalisation and derealisation, symptoms that have been traditionally associated with panic disorder, post-traumatic stress disorder, mood disorders... and withdrawal from psychiatric drugs. It's something I'm riding the waves of now as I plunge headlong into Zoloft withdrawal. I feel a bit like Marty McFly playing the guitar in Back to the Future, weakening as he watches himself fade from a family photograph as his existential inevitability appears more and more doubtful.

But as Bipolar Blast reader Michael points out, derealisation and depersonalisation can been seen as strategies as well as symptoms.

Sometimes I can (and do) even deliberately trigger such states at times when I'm feeling overwhelmed by despair in public places and just need to hold tight for a while instead of running home and locking myself in my bedroom.

Of course I can't know how other people experience such states and whether my own are really a match for what is pathologised as depersonalisation and derealisation, but if it is its not something I'm particularly eager to be cured of. For me its both a coping mechanism and an insight gaining form of detachment from my own mental/emotional states.

This positive use of derealisation has a literary and artistic manifestation in defamiliarization. This is a technique of forcing an audience to view everyday things and concepts in an unfamiliar or strange way, in order to "see through a child's eye" to an underlying reality, often for satirical purposes. The term was coined by the Russian Formalist Victor Shklovsky in the early 20th century, but the technique itself pre-dates its definition. One of the most frequently cited and humorous examples is that of Tolstoy's description of an opera from the perspective of Natasha in War and Peace. Not only is the opera rendered thoroughly nonsensical but Natasha herself experiences derealisation and depersonalisation as a result of the basic absurdity of the situation:

In the second act there was scenery representing tombstones, there was a round hole in the canvas to represent the moon, shades were raised over the footlights, and from horns and contrabass came deep notes while many people appeared from right and left wearing black cloaks and holding things like daggers in their hands. They began waving their arms. Then some other people ran in and began dragging away the maiden who had been in white and was now in light blue. They did not drag her away at once, but sang with her for a long time and then at last dragged her off, and behind the scenes something metallic was struck three times and everyone knelt down and sang a prayer. All these things were repeatedly interrupted by the enthusiastic shouts of the audience.

After her life in the country, and in her present serious mood, all this seemed grotesque and amazing to Natasha. She could not follow the opera nor even listen to the music; she saw only the painted cardboard and the queerly dressed men and women who moved, spoke, and sang so strangely in that brilliant light. She knew what it was all meant to represent, but it was so pretentiously false and unnatural that she first felt ashamed for the actors and then amused at them. She looked at the faces of the audience, seeking in them the same sense of ridicule and perplexity she herself experienced, but they all seemed attentive to what was happening on the stage, and expressed delight which to Natasha seemed feigned. "I suppose it has to be like this!" she thought... And feeling the bright light that flooded the whole place and the warm air heated by the crowd, Natasha little by little began to pass into a state of intoxication she had not experienced for a long while. She did not realize who and where she was, nor what was going on before her. As she looked and thought, the strangest fancies unexpectedly and disconnectedly passed through her mind: the idea occurred to her of jumping onto the edge of the box and singing the air the actress was singing, then she wished to touch with her fan an old gentleman sitting not far from her, then to lean over to Helene and tickle her.

Now, if you think about it, the technique of defamiliarisation could be applied almost endlessly to the logical and methodological maelstrom that is contemporary psychiatry. Think back to the first time you were hospitalised and the only thing the staff would ask you was who you were, what day it was, who the Prime Minister or President was, and you were thinking well, this is very strange, how is this supposed to help me? You were defamiliarising the situation without even knowing it. I suspect many of us have been soaking so long in the esoterica of the mental health system that its familiarity has rendered many of its standard practices beyond contempt. We're outraged when Seroquel is prescribed to four-year-olds with fatal consequences, and rightly so, but let's also try to "see through a child's eye" the less egregious abuses to which we are subjected, and to appreciate the historical continuity between parody and reality.

PRESCRIPTION, n. A physician's guess at what will best prolong the situation with least harm to the patient.
- Ambrose Bierce, The Devil's Dictionary

Hospital Food #1

In your tribute album to the world
You must never forget
To sing the one about the cat
Who's always getting wet
He's always got a problem
He's a very bitter dude
And now he is complaining
'bout his hospital food

- Eels, "Hospital Food"


At first I was in trouble for expecting my tray to be brought to me in bed - after all, I was in a hospital, and supposed to be sick, right? The B-Man, my good-for-nothing psychiatrist, should have warned me. My next faux pas involved wearing my pyjamas in the so-called dining room. Blue and red flannelette men's pyjamas that hung off me, and that I still eat my breakfast in now and then. The night before I'd tied my hair into two plaits, that were now as frizzled as hangman's rope, and my eyes were still crusty with sleep. I was seventeen, and my skin showed it.

I found my tray, that came with a piece of paper with certain items ticked off: toast, butter, stewed apple, orange juice. I found an empty table; I wasn't ready for conversation yet. The stewed apple held a particular fascination; it didn't taste very good but there was plenty of it, a tongue in the mouth of its hemispherical container. It was an endurance test, requiring my entire energy and focus to plough through, thereby distracting me from my surroundings. This cannot be happening to me.

I became vaguely aware of a presence beside me, a tall young man with a deep voice, who plucked my spare hand from my lap and shook it as I continued to eat. I didn't look at him, didn't look away from the stewed apple, didn't take in his name. He knew what mine was, of course.

"Ruth, may I remind you that pyjamas are not allowed in the dining room, and you need to get dressed for breakfast. You also need to be in the day room by nine o'clock for the daily meeting. And make sure you finish your cereal."

I got up and walked away, still without looking at him, and went back to bed. It was a quarter to nine.

***************************************************************

One day I was escorted over to the clinical sciences building and propped up in a wicker chair in front of a television that played Sally Jessy Raphael, Oprah and Donahue. A nurse gave two pills and a cocktail glass of water, and inserted a hypodermic needle into the crook of my elbow. What's in the pills, I asked. Fenfluramine, she said, it won't hurt you. Half an hour later, when first blood was drawn, I was feeling distinctly sick.

For the next few hours I drifted in and out of consciousness while the residents of nudist complexes and siblings who knock each other's teeth out justified themselves to the world. An ad came on for Pizza Hut, and as the ropes of cheese stretched from pizza to slice as it was picked up from the pan, I realised both how hungry I was, and how sick the thought of food made me.

Every once in a while the nurse came back in and turned the little tap on the needle and syphoned off a few ounces of blood. Then she shot something up my arm, anti-coagulant she said, whatever it was it was like lemonade for my veins. The B-Man wandered in occasionally; I once woke to find his bejewelled hand on mine.

When they finally removed the needle, my arm was stuck in an invisible sling, and so was my appetite.

********************************************************************

My eating habits were the subject of much speculation. The only boxes I ticked on the lunch menu were for sandwiches and jelly, and dinner I couldn't stomach at all. Dinner - some meat, chicken, or fish dish - was cooked en masse well before time and dumped and left to cool in plastic microwave containers, before being given a cursory zap and shipped to the wards. Lifting the lid, I soon learned to recognise the unrecognisable, congealed sauce covering an unspecified form of protein like a wet scab.

Although my weight was normal, my behaviour was taken for an eating disorder. Every day I was warned that I would soon be tube-fed. "If this behaviour continues, there will be consequences, Ruth. And that's not a threat, it's a promise." Every day I was warned about the inappropriateness of sexual relationships between patients and staff. "I am the nurse and you are the patient, there can be nothing between us," he said, in response to my request that he pass the sugar. Apparently my pyjamas were provocative, my manner flirtatious, the way I walked a tease. I was very attractive and I knew it, he said. So I stayed in my room a lot and was careful not to speak to any male, patient or staff, unless they spoke to me first. One weekend while everyone else was on leave, he came into my room, wrenched the blind on the door up - "This stays up when I come in here; I know what you're up to" - and ordered me out into the day room. "You think you're so hot, but you're nothing but a useless brat." I tried to cry discreetly. Later that day he dragged me to the staff cafeteria to watch him eat, wrestled me onto the bed to extract a letter I was writing, and almost tore the door off my wardrobe.

As midnight approached, under the bright lights of the interrogation, or "music", room, he read my palm and told me my misfortune: "You are a very sick little girl and unless you start to cooperate with me you will end up in a nuthouse, a real nuthouse, not just this three-star motel for those dickheads out there. You can't continue to live this way, doing and saying what you please and leaving newspapers lying around everywhere. The world will not allow you to be the way you are."

I shrugged, too tired to argue. "Well, why don't you just kill me now. It would save me a lot of suffering and everyone else a lot of money. Go on, do it - no one will know, they'll just think I killed myself."

"No, that would be too easy. I hate you and I want you to suffer, just as I did. I want you to suffer the most exquisite pain imaginable, and to think of me when you do."

********************************************************************

Lunch time, the next day, and by then I was right off my food. He brought sandwiches and jelly in on a tray, and an uneasy silence reigned as I spooned the jelly out of its cup while sitting at my desk, nose-deep in a textbook. He lay on my bed watching me, after oddly having asked my permission to do so.

"Ruth."

"Mmm-hm?"

"Ruth."

"What?" I said, spinning around. But by then he was on the floor, at my feet, grasping for legs, desk legs it turned out, as I jumped from the chair. "I wish... I want to..." He shook my desk by its legs and the pens and books on top were hit by landslides and earthquakes. "You... I don't know... you have a certain minxish quality that makes me go weak at the knees."

I didn't know what to say. No, actually I did. "Get up. You're regressing."

*******************************************************************

When I got out, I found that my mother had had the carpet steam-cleaned, the front verandah painted and the curtains replaced. She’d ransacked my room and rearranged the furniture so that my bed faced west, away from where I’ve been. The effect was eerie, like a cleft in history, or a step sideways into another dimension. Looking back at the house from the bus stop of a morning, it seemed that Andy Warhol had silk-screened my world. At school, Sister Geraldine, reading from A Brief History of Time, told us that every particle has an antiparticle, and that there could be whole antiworlds made out of antiparticles. “However, if you meet your antiself, don't shake hands! You would both vanish in a great flash of light.” No one asked where I’d been.

On the radio a very annoying little man called Wallace Fairweather flogged insurance to anyone who’d listen. He just would not shut up and leave whatever poor unfortunate he’d buttonholed alone. There were plane crashes and car chases, a black man in a white Bronco; I knew that from then on I’ll always be the first to hear the news. Planes gliding into buildings to the tune of pompous instrumentals and torches shone into the mouths of captured dictators would be the bread and butter of my small hours. But then I had an psychology exam to sit, which I did, two days after I got out. At the forty-five minute mark I put down my pen and whacked my hand hard on the desk until my mind cleared. I'd barely studied. I hadn’t had to: he'd already told me the answers.

When I looked in the mirror I saw that my pupils were dilated, and that my future had screwed down to a dot. I was always hot, slightly puffed, and having to compose myself as if something had just happened. Rather than sudden surges of feeling crashing over me and leaving me stunned, a milder but constant sense of alarm kept me moving, kept my attention from focusing on anything in particular. I knew where I’d been, but often not what I’d seen.

It began as a clear-headed application of operant conditioning, as an elastic band around my arm that I flicked whenever he entered my thoughts. Then, in the bathtub and in a fix, I resorted to pinching myself, so that bruises speckled my arms like kittens’ footprints, and later I found new uses for butterfly clips and clothes pegs. Eventually, I smashed a glass inside a plastic bag and began cutting my arms and legs with the shards.

One day I realised that I’d been branded: under the floral explosion on my left arm there were fresh pink scratches that spelled death in nine letters. When I looked in the mirror, my face was no longer my own.

Hospital Food #2

We had to have our names ticked off at the door of the dining room, as apparently people were just wandering in from out on the street for a meal. We amused ourselves by giving rude names - "Wayne Kerr", "Jack Mehoff", "Richard Head, but everyone calls me Dick" - and watching the poor secretary scour the list, inadvertently muttering obscenities under her breath.

While the meals were cooked on-site, the servings were small, and oil, fat and MSG-free to the point of blandness. We all had huge appetites as a result of the hospital's standard poly-pharmaceutical regimen: Largactil or Stelazine, plus Prozac or Zoloft, plus Xanax during the day, Temaze at night and lithium if you'd really been misbehaving, supplemented by drip-fed nicotine, as well as alcohol from any one of the four pubs within a five minute walk from the hospital. (This was more than ten years ago, with Effexor and Risperdal being the upcoming drugs du jour back then.) One day the guy who was the main source of the jokes snuck into the cafeteria, rubbed the menu off the blackboard and created his own: 'ECT-fried fish', 'Lobotomised lamb's brain' and so forth. This kid was a demon with a red marker pen - there was hardly a surface in the place that he hadn't defaced. I recall how startled I was to look in a mirror on my first day there and be confronted with a big smiley face with the eyes crossed out and 'PROZAC' written across the forehead.

On my first day, I met the psychiatrist assigned to me (or to whom I was assigned; whatever direction this collusion should take), who traced constellations with the toes of his leather shoes as we spoke, sprinkled the word 'fuck' throughout his monologues and practised his swing with an imaginary four-iron in the corridor. He explained that I was a perfectionist, too overly preoccupied with issues of justice and fairness, rights and wrongs, shoulds and oughts and that I required an intensive inpatient program of rational-emotive therapy. He blinked at me intensely while I considered this, his eyes like viciously hewn jewels, deflecting from all angles the white water vectors, the escaping gas of my petty nit-picking dissent. But all this time, have I not been the high priestess of stoicism? Didn't I fight their attempts to reconstruct human nature? When the interview was over, I bummed a cigarette off the third person who reciprocated my slack elastic band smile in the corridor and began sinking artesian wells over the freckles of my left arm out in the courtyard. The trapezium of sky above was as blue as the inside of a lid of a Coke bottle, and the crevasses between the bricks below were thick with ash, the remnants of a thousand personal volcanoes. "Yuck", says the nurse taking my blood pressure afterwards, as spots of shrivelled lemon-yellow skin are sheared off under the denim tourniquet, and my smoking privileges cancelled.

The days ran together in a blur of booze and drugs, highs and lows, infractions and restrictions. One day we went out into the carpark and noticed a car with a number-plate that began "ECT...". We laughed like the pack of lunatics that we were, and someone managed to get hold of a screwdriver to souvenir it. We dyed each other's hair and scratched our arms with broken glass while discussing the best place to get a decent coffee. We signed contracts saying that we wouldn't "self-harm or drink alcohol", which we promptly forgot about. We made our own coffins and tombstones as art therapy. One guy bought himself a piano that he couldn't play and pissed off the top of a high-rise building onto the sun umbrellas below. I learned how to fake-out a breathalyser. If someone got discharged, they'd OD on lithium or slit their wrists and be re-admitted within a couple of weeks. Sometimes there'd be two of them once, flying out the back of an ambulance on stretchers like bread out of a toaster.

There was a McDonald's down the road, directly across from the gay pub where we did most of our drinking. As well as using it as a means for topping-up, we celebrated a 30th birthday there, complete with ice-cream cake, Ronald McDonald paper hats and polaroid photos. That night, I was too restless to sleep, so I took a book into one of the lounge rooms and settled into a chair. Within minutes, I was accosted by a nurse, face blooming bright red with anger: what did I think I was doing, it's past bedtime! I explained that I was too wired to sleep and didn't want to bother my roommates by turning my lamp on to read, and her face burst into scarlet fireworks, a veritable son et lumiere at which I stared and stared, spacing out, timing out. "Go to bed! You have to go to bed!" she kept screaming, until she eventually attracted the attention of another nurse. "Yeah, your doctor's orders are for you to take your medication and go back to bed," this one said, moving closer and closer. He had breadth where he should have had length, and a baritone instead of a tenor, but none of this mattered, for suddenly the B-Man appeared, in his usual three-piece pinstriped suit and reeking of red wine. I hadn't seen him for more than a year, a length of time I could barely conceive of while trapped in a cycle of ups and downs, fractured memories and untrammelled impulses. With all time and space collapsing into that instant and place, and the nurse moving closer, I saw only one possibility, and bolted. There was a door leading outside around there somewhere, I knew that much. "It's locked, Ruth," he taunted as he chased me. It wasn't. It was dark outside and the grass was damp and slippery under my bare feet and I was being chased my a man who wanted me to suffer the most exquisite pain imaginable, who wanted me dead. I hit a rock and went flying, and then there were three of them on top of me, pinning me down in the here and now, as history re-opened like an accordion. My last meal there was a mouthful of dirt.

Zoloft withdrawal

Gianna at Bipolar Blast has posted today on the subject of withdrawing from psychotropic medications. She's had more pills lining her saucer recently than I have, so she's advocating a patient, cautious approach, emphasising diet and exercise. I'm currently withdrawing from Zoloft, after concluding that the side-effects - restlessness, lack of libido, inability to concentrate at work and a hair-trigger temper - outweighed its advantages. Having been on it for about twelve months, it has made me slightly more sociable, at ease with dealing with strangers in shops etc, but has had little impact on my mood.

My original plan was to cut 25mg each fortnight from a starting dose of 300mg. My shrink pooh-poohed this, saying I could easily drop 25mg a week. Being the impatient type, I agreed, and all was fine and dandy - until now. I'm down to 225mg and bloody discontinuation syndrome has kicked in already. Last Wednesday night when I was walking to my boyfriend's place, an odd feeling that had come and gone all day suddenly became overwhelming. What had earlier been the occasional twitch and shudder had morphed into legs of jelly, a face that had just seen the dentist's needle, and a body that felt as if it was trapped within a Van der Graf machine. The all-over tingling had a depersonalising effect, and as I walked through the back streets I felt like I was drifting in and out of consciousness, in spite of my motor function being apparently unimpeded. I felt somewhat better after dinner, but fever and its paradoxical shivering set in during the night, together with blurred eyesight and, of course, the inexplicable and thus unshakeable blues. And my concentration, while poor before, now limits me to performing the most routine and brief tasks at work, while the dishes and dirty washing continue to pile up.

As a teenager, I went cold turkey off Aropax/Paxil after taking it for only few weeks, with catastrophic results. Dizzyness, exhaustion and some spectacular projectile vomiting overcame me right at the end of Year 12, while I had assignments still outstanding. But what stands out in my mind now was that it was probably my first and only experience of true endogenous depression. I had never been unhappy before without a reason, and these sudden crying jags and thoughts of suicide confused me utterly. My psychiatrist ridiculed the notion that my condition had anything to do with stopping the drugs, and told me that my blood pressure was perfectly normal, and that it was all in my head, as indeed it was!

So I'll be slowing down my withdrawal regimen, I guess. People thought I was kidding when I said it might take five or six months...

Psychiatric Mythology

Men have experience, women have pasts, criminals have records, like athletes or thrift stores, and those who have fallen through the ice into the mental health system have histories. I have a history, the indefinite article, not the history, unlike those who have the shakes or the pox. I have a history that is physical as well as temporal – she’s got a history as thick as the phone book is one way they often put it – a compendium of names, addresses and phone numbers of all the people whose sensibilities I offended. Such histories are denoted PHx or ΨHx, although they are not definite, but subject to constant iteration: histories are usually histories of histories of histories and so on. And, as time passes, PHx becomes the history en route to the future, a narrow canal of inevitability meandering through the landscape, obeying some existential version of Stoke’s Law until it strands itself as a billabong, or oxbow lake – close by, there is a sea, the sea’s the possibility, the sea of possibilities. Far above my keepers indulge themselves in aerial acrobatics: precise spirals and steep dives that demonstrate their access to and mastery of an extra dimension. For PHx is no longer a history, but a mythology - PMx.

Newsflash: Teenagers are f**ked

Furious Seasons has a link to an op-ed article from the Boston Globe criticising the over-diagnosis of bipolar disorder, ADD, etc, in children. To quote from the article:

It is outrageous when an adolescent is diagnosed as bipolar. One doesn't need to be a developmental psychologist to realize that the stage of adolescence is potentially the most tumultuous in the human life cycle. Yes, teenagers will be moody and emotional. Yes, adolescents can become seriously out of control, psychotic, and even suicidal. Utilizing a psychosocial road map, a solid psychodiagnostic evaluation can look beneath the surface and analyze the complexity of internal and external pressures, ranging from academic and social to family, physical, and sexual concerns.

But all of these pressures are part of normal human development, and often have little or nothing to do with a biochemical or organic psychiatric disorder.

Philip Dawdy said he could have written it himself. It could have been written about me.

The Fat (and Sugar) of the Land

Last Saturday, Seattle-based journalist and Furious Seasons blogger Philip Dawdy was interviewed on Australian Radio National's All in the Mind program along with Sandy Jeffs, a writer, performer and poet who lives with schizophrenia and David Grainger, the Director of Corporate Affairs and Health Economics for Eli Lilly Australia. The subject under discussion was, of course, Zyprexa, in particular its side-effects of weight gain and Type 1 diabetes, and to what extent Eli Lilly is guilty of downplaying the risk of these, given their potentially life-threatening complications. Further information and documentation about this issue is available at Furious Seasons.

Here we observe the conjunction of two of psychopharmacology's main defense mechanisms: blaming the victim, and the maintenance of the myth of 'the bad old days' when anti-psychotic medications were chemical straitjackets rendering dayrooms a drool-fest of toe-tapping and tongue-poking and long, blank stares. Not that this is a myth, but the idea that it is a thing of the past certainly is. "We don't have to put up with that kind of thing any more," my psychiatrist emphatically reassured me just this morning. "Things have moved on, Ruth, it's not like it was ten years ago when you were in hospital." Right.

Psychiatrists can be downright 'borderline' about drugs. Where I live, the consensus in the psychiatric community with respect to benzodiazepines can be summarised as follows: Xanax = BAD and Klonopin = GOOD, as if being a slower-release drug didn't make the latter any less addictive. Likewise, the first generation of anti-psychotic medications, in use from the 1950's to the 1990's (and still in use here and there), the ones that we were told were lifesavers, that we absolutely must take for the rest of our lives, etc, etc, are now spoken of and written about as if they were the cruel product of some bizarre medieval superstition about the causes of madness. Are we merely (somewhat precipitously) celebrating scientific progress here, or are there other motives behind this anxious disavowal of chlorpromazine and friends? One of the much-vaunted advantages of the second generation drugs are their allegedly superior side-effect profiles, particularly with respect to sedation and tardive dyskinesia. But studies presented to demonstrate this have attracted some criticism - for example, that the reduced risks of tardive dyskinesia can only be inferred by comparing the new drugs with the nastiest of the old ones, e.g. Haldol or Prolixin/Modecate. And don't even try and convince me that Seroquel or Risperdal aren't sedative. The 'bad old days' is a time-honoured form of mythologising designed to obscure the reality of the 'bad new days' in which, as my shrink smugly observed, "we are busier than ever", and patients continue to flush their medication down the toilet. As Kirk and Kutchins put it in Making Us Crazy, their critique of DSM and its constant revisions, "The cycle of denigration, enthusiasm, and denigration makes an old system appear antiquated and a new system necessary, a marketing strategy pioneered by the automobile industry."

Blaming the victim is one of the grand old traditions of psychiatry - think Freud and his abandonment of the seduction hypothesis, which has percolated down the ages into the profound indifference many mental health professionals exhibit towards the familial and social contexts of their patients' problems. In the current biogenetic-oriented climate, the tradition manifests itself in claims that the poor physical health of patients is being misattributed to side-effects of the new drugs. Now, they will rarely come out and put it so bluntly, saying it's all in your head (or or your heart or your pancreas). It's quite enough, and quite skillful use of the media, to just introduce an element of uncertainty, to just say maybe, to get people to deny what's right under their noses. (Those opposing the climate change /greenhouse effect hypotheses have utilised a similar technique, with potentially devastating consequences.)

David Grainger, the Australian Eli Lilly spokesman, exemplified this approach very well:

Natasha Mitchell: In 2002 Eli Lilly Australia distributed a letter to Australian doctors informing them of the association between Zyprexa and hyperglycaemia -- or elevated blood sugar levels, just to explain -- and certainly other metabolic conditions related to diabetes. What was the basis, David, of sending that letter to the medical community in Australia?

David Grainger: Quite a complex little background to that, Natasha, you can appreciate people with serious mental illness, particularly schizophrenia, often have concurrent physical health problems. Things like disturbances to blood sugar levels are not uncommon but it also became apparent that they're perhaps slightly more common in people taking antipsychotic medications.

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But Philip Dawdy, Sandy Jeffs and host Natasha Mitchell are on to it:

Natasha Mitchell: David Grainger from Eli Lilly. The company does fund a Mind Body Life Initiative in clinics around Australia to help people with mental illness deal with issues of wellbeing, weight and exercise. The website has plenty of pictures of smiling folk, cartwheeling in the sunshine, but does this once again put the onus solely on patients rather than on the side effects of the company's drug?

Philip Dawdy: I mean I'm just sorry they haven't a clue how the average schizophrenic or severely mentally ill person lives -- you know they are covering their butts with this one. Unfortunately a schizophrenic who's on 15, 20, 30 milligrams a day of Zyprexa is going to be zonked out for 12 to 15 hours a day and when they're awake they are going to be so foggy that you know they are not going to be out in the front yard doing push-ups.

Sandy Jeffs: I think the problem is though that people with psychotic illnesses aren't in the mind space where they can do that sort of stuff. But there is a tendency to blame people and not see that it's the drugs fault. People's lives don't often have the space for good food, and good hygiene, and good stuff you know. I mean again it's blame the victim, blame the victim.

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David Grainger: The other point that you raise there is in relation to diabetes, and because this is known that there is an increased association of diabetes in people with serious mental illness regardless of any treatment, this has been the subject of a great deal of study as well. There is certainly no association or no direct causality been established between Zyprexa and diabetes.

Natasha Mitchell: There are concerns though that elevated weight gain or rapid weight gain is linked to diabetes, so is there any effort on behalf of Eli Lilly to investigate that in relation to Zyprexa and the weight gain associated with Zyprexa?

David Grainger: Absolutely, this whole topic of what's going on in terms of glucose metabolism and people with serious mental illness and what role does their often lack of physical exercise or less than ideal diet -- what role do those things play and what role does medication play...

Natasha Mitchell: But more importantly what role does their medication play?

David Grainger: Exactly, that's also been a subject of a great deal of research, and in spite of all that body of research there is no clear answer and there is no direct association between the antipsychotic medication and development of diabetes.

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As the bumper sticker goes: 'Give Me Ambiguity or Give Me Something Else'.

The full transcript of the program is available here.