The last decade has seen escalating reliance upon psychiatric drugs, not only within psychiatry, but throughout medicine, mental health, and even education. Nearly every patient who is psychiatrically hospitalized is encouraged or forced to take medications. There is a movement within psychiatry to make it easier to force clinic outpatients to take long-acting injections of drugs. In private practice psychiatry, it is common to give patients a medication on the first visit and then to instruct them that they will need drugs for their lifetime. Family practitioners, internists, and other physicians liberally dispense antidepressants and minor tranquilizers. Nonmedical professionals, such as psychologists and social workers, feel obliged to refer their patients for drug evaluations. Managed care aggressively pushes drugs to the exclusion of psychotherapy. Adult medications are increasingly prescribed for children.
Laypersons have joined in the enthusiasm for drugs. Because of media support for medication, as well as direct advertising and promotion to the public, patients frequently arrive at the doctor's office with the name of a psychiatric drug already in mind. Teachers often recommend children for drug evaluation or treatment.
As a part of this overall resurgence in biological psychiatry, electroshock has become increasingly popular. Even psychosurgery once again has its vociferous advocates (reviewed in Breggin & Breggin, 1994b).
This "drug revolution" views psychiatric medications as far more helpful than harmful, even as an unmitigated blessing. Much as insulin or penicillin, they are frequently seen as specific treatments for specific illnesses. Often they are said to correct biochemical imbalances in the brain. These beliefs have created an environment in which emphasis upon adverse drug effects is greeted without enthusiasm and criticism of psychiatric medication in principle is uncommon heresy.
This book takes a decidedly different viewpoint -- that psychiatric drugs achieve their primary or essential effect by causing brain dysfunction, and that they tend to do far more harm than good. I will show that psychiatric drugs are not specific treatments for any particular "mental disorder." Instead of correcting biochemical imbalances, psychiatric drugs cause them, sometimes permanently.
The critiques in this book coincide with an alternative view that psychological, social, educational, and spiritual approaches are the most effective in helping individuals to overcome their personal problems and to live more fulfilling lives. I have described some of these approaches elsewhere (e.g., Breggin, 1991a, 1992a, 1997; Breggin & Breggin, 19941; Breggin & Stern, 1996). Many others have continued to voice strong criticism of the biological model and physical treatments from a variety of perspectives (Armstrong, 1993; Breeding, 1996; Caplan, 1995; Cohen, 2990; Colbert, 1995; Fisher & Greenberg, 1989; Grobe, 1995; Jacobs, 1995; Kirk & Kutchins, 1992; Modrow, 1992; Mosher & Burti, 1989; Romme & Escher, 1993; Sharkey, 1994). Here I want to re-evaluate the underlying assumptions used to justify drug and shock treatment in psychiatry, and to document their brain-disabling and brain-damaging effects.
The principles that are introduced in this chapter will be documented and elaborated throughout the book. Therefore, citations will be omitted in chapter 1.
Modern psychiatric drug treatment gains its credibility from a number of assumptions that professionals and laypersons alike too often accept as scientifically proven. These underlying assumptions qualify as myths: fictions that support a belief system and a set of practices. In contrast to these myths, this book identifies principles of psychopharmacology that are based on scientific and clinical evidence, as well as on common sense. Together these form the brain-disabling principles of psychiatric treatment. While the book in its entirety provides the evidence for these principles, this chapter will summarize them:
Pharmacologists speak of a drug's therapeutic index, the dosage ratio between the beneficial effect and the toxic effect. The first brain-disabling principle of psychiatric treatment reveals that the toxic dose is the therapeutic effect. This same principle applies to electroshock and psychosurgery.
The brain-disabling principle states that as soon as toxicity is reached the drug begins to have a psychoactive effect, that is, it begins to affect the brain and mind. Without toxicity, the drug would have no psychoactive effect.
Although specific treatments do have recognizable different effects on the brain, they share the capacity to produce generalized dysfunction with some degree of impairment across the spectrum of emotional and intellectual function. Because the brain is so highly integrated, it is not possible to disable circumscribed mental functions without impairing a variety of them. For example, even the production of a slight emotional dullness, lethargy, or fatigue is likely to impair cognitive functions such as attention, concentration, alertness, self-concern or self-awareness, and social sensitivity.
Shock treatment and psychosurgery always produce obvious generalized dysfunction. Some medications may not obviously produce these effects in their minimal dose range, but they may also lack any substantial "therapeutic effect" in that range.
Higher mental, psychological, and spiritual functioning are impaired by biopsychiatric interventions as a result of generalized brain dysfunction, as well as specific effects on the frontal lobes, limbic system, and other structures. Sometimes there is a lobotomy-like indifference to self and to others -- a syndrome that I have called deactivation (see chapters 2 and 4 of this volume).
Biopsychiatric treatments are deemed effective when the physician and/or the patient prefer a state of diminished brain function with its narrowed range of mental capacity or emotional expression. If the drugged individual reports feeling more effective and powerful, it is most likely based on an unrealistic appraisal, impaired judgment, or euphoria. When patients on "maintenance doses" do not experience noticeable effects, either the dose is too low to have a clinical effect or the patient is unable to perceive the drug's impact.
Despite the deeply held convictions of drug proponents, there are no specific psychoactive drug treatments for specific mental disorders.
There is, of course, a certain amount of biological and psychological variation in the way people respond to drugs, shock treatment, or even lobotomy or an accidental head injury. However, as a general principle, biopsychiatric interventions have a nonspecific impact that does not depend on the person's mental state or condition. For example, it will be shown that neuroleptics and lithium affect animals and normal volunteers in much the same way as they affect patients.
There is some variation in the way individuals respond to drugs. For example, the same antidepressant will make one person sleepy and another energized. Ritalin quiets many children but agitates others.
It can be very difficult to separate out drug-induced form psychologically induced responses. For example, nearly all of the antidepressants can cause euphoria and mania2. At the same time, some of the people who receive these drugs have their own tendency to develop these mental states. Similarly, a variety of drugs are capable of generating agitation and hostility in patients, yet people can develop these responses without medication. The docility and compliance seen following the administration of neuroleptics can be caused by the drug-induced deactivation syndrome, but can also result from the patient's realization that further resistance is futile or dangerous.
Later in this chapter, I will introduce the concept of iatrogenic helplessness and denial which addresses the combined neurological and psychological impact of biopsychiatric treatment. In chapter 11, I will discuss some of the criteria for determining that a drug can itself cause abnormal mental and emotional responses, including destructive behavior.
Despite more than two hundred years of intensive research, no commonly diagnosed psychiatric disorders have been proven to be either genetic or biological in origin, including schizophrenia, major depression, manic-depressive disorder, the various anxiety disorders, and childhood disorders such as attention-deficit hyperactivity.
At present, there are no know biochemical imbalances in the brain of typical psychiatric patients -- until they are given psychiatric drugs. It is speculative an even naïve to assert that antidepressants such as Prozac correct underactive serotonergic neurotransmission (a serotonin biochemical imbalance), or that neuroleptics such as Haldol correct overactive dopaminergic neurotransmission (a dopamine imbalance). The failure to demonstrate the existence of any brain abnormality in psychiatric patients, despite decades of intensive effort, suggests that these defects do not exist.
It seems theoretically possible that some of the problems treated by psychiatrists could eventually be proven to have a biological basis. For example, mental function often improves when certain physical disorders, such as hypothyroidism or Cushing's Syndrome, are adequately treated.
However, the vast majority of problems routinely treated by psychiatrists do not remotely resemble diseases of the brain (see chapters 5 and 9). For example, they do not produce the cognitive deficits in memory or abstract reasoning characteristic of brain disorders. They are not accompanied by fever or laboratory signs of illness. To the contrary, neurological and neuropsychological testing usually indicate normal if not superior brain function, and the body is healthy. There seems little likelihood that any of the routinely treated psychiatric problems are based on brain malfunction rather than on the life experiences of individuals with normal brains.
If some patients diagnosed with major depression or schizophrenia do turn out to have subtle biochemical imbalances, this would not justify current biopsychiatric practice. Since these presumed imbalances have not yet been identified, it makes no sense to give toxic drugs, including the currently available antidepressants and neuroleptics, all of which grossly impair brain function.
To claim that an irrational or emotionally distressed state in itself amounts to impaired brain function is simply false. An analogy to television may illustrate why this is so. If a TV program is offensive or irrational, it does not indicate that anything is wrong with the hardware or electronics of the television set. It makes no sense to attribute the bad programming to bad wiring. Similarly, a person can be very disturbed psychologically without any corresponding defect in the "wiring" of the brain. However, the argument is moot, since no contemporary biopsychiatric interventions can truthfully claim to correct a brain malfunction the way an electronics expert can fix a television set. Instead we blindly inflict toxic substances on a brain that is far more subtle and vulnerable to harm than a television set. We even shock or mutilate the brain in ways that would appall TV repair persons or their customers, while ruining their television sets.
It is often suggested that persons suffering from extremes of emotional disorder, such as hallucinations and delusions, or suicidal and murderous impulses, are sufficiently abnormal to require a biological explanation. However, the emotional life of human beings has always included a wide spectrum of mental and behavioral activity. That a particular mental state or action is especially irrational or destructive does not, per se, indicate a physical origin. If extremes require biological explanation, then it would be more compelling to ascribe extremely ethical, rational, and loving behaviors to genetic and biological causes, since they are especially rare in human life.
The fact that a drug "works" -- that is, influences the brain and mind in a seemingly positive fashion -- does not confirm that the individual suffers from an underlying biological disorder. Throughout recorded history, individuals have medicated themselves for a variety of spiritual and psychological reasons, form the quest for a higher state of consciousness to a desire to make life more bearable. Alcoholic beverages, coffee and tea, tobacco, and marijuana are commonly consumed by people to improve their sense of well-being. Yet there's no reason to believe that the results they obtain are due to an underlying biochemical imbalance.
The currently available biopsychiatric treatments are not specific for any known disorder of the brain. One and all, they disrupt normal brain function without correcting any brain abnormality. Therefore, if a patient is suffering from a known physical disorder of the brain, biopsychiatric treatment can only worsen or add to it. A classic example involves giving Haldol to control emotionally upset Alzheimer patients. While subduing their behavior, the drug worsens their dementia.
After psychiatric drugs are developed and marketed by drug companies, attempts are made to justify their use on the basis of correcting presumed biochemical imbalances. For example, it is claimed that Prozac helps by improving serotonergic neurotransmission. Even electroshock and lobotomy are justified on the grounds that they correct biochemical imbalances. There is no likelihood that these intrusions correct a biochemical imbalance. Too wide a variety of brain-disabling agents are used to treat every disorder -- everything from Prozac to Xanax to electroshock is prescribed for depression -- and each treatment ends up disrupting innumerable brain functions. In reality, all currently available biopsychiatric interventions cause direct harm to the brain and hence to the mind without correcting any known malfunctions.
It is often said that psychiatry has specific treatments for specific diagnostic categories of patients: for example, neuroleptics for schizophrenia, antidepressants for depression, minor tranquilizers for anxiety, lithium for mania, and stimulants, such as Ritalin, for attention-deficit hyperactivity. In actual practice, many individual patients labeled schizophrenic to be initially treated with neuroleptics or for depressed patients to be initially prescribed to be initially prescribed antidepressants, this is, in part, a matter of convention within the profession.
When a drug seems more effective in a particular disorder, it often depends on whether it has a suppressive or an energizing effect on the CNS. For example, if depressed patients are already emotionally and physical slowed down, giving them a neuroleptic that causes psychomotor retardation would tend to make them look worse. These patients are more likely to seem improved when artificially energized. Conversely, if schizophrenic patients are agitated and difficult to control, it would not make sense to give them stimulants. They are more likely to be judged "improved" when taking a neuroleptic that reduces or flattens their overall emotional responsiveness. These gross behavioral effects, however, are a far cry from having a "magic bullet" for a specific disease.
The brain does not welcome psychiatric medications as nutrients. Instead, the brain reacts against them as toxic agents and attempts to overcome their disruptive impact. For example, when Prozac induces an excess of serotonin in the synaptic cleft, the brain compensates by reducing the output of serotonin at the nerve endings and by reducing the number of receptors in the synapse that can receive the serotonin. Similarly, when Haldol reduces reactivity in the dopaminergic system, the brain compensates, producing hyperactivity in the same system by increasing the number and sensitivity of dopamine receptors.
It is difficult if not impossible to accurately determine the underlying psychological condition of a person who is taking psychiatric drugs. There are so many complicating factors, including the drug's brain-disabling effect, the brain's compensatory reactions, and the patient's psychological responses to taking the drug.
Because the brain attempts to compensate for the effects of most psychoactive drugs, patients can have difficulty withdrawing from most psychiatric medications. Physically, the brain cannot recover from the drug effects as quickly as the drug is withdrawn, so that the compensatory mechanism can require weeks or months to recover after the drug has been withdrawn. Sometimes, as in tardive dyskinesia, the brain fails to recover. Psychologically, individuals fear that their emotional suffering will worsen without the medication. They may have been told by psychiatrists that they require the medication for the rest of their lives. This can make withdrawal even more difficult.
Generalized brain dysfunction tends to reduce the individual's ability to perceive the dysfunction. Impaired individuals not only tend to minimize their dysfunction, they often see themselves as performing better than ever. Individuals intoxicated with alcohol, for example, often show poor judgment in estimating their capacity to drive an automobile or to carry on a sensible conversation. Many individuals who chronically smoke marijuana believe that it improves their overall psychological and social functioning, but if they withdraw from the drug, it may become apparent to them that their memory, mental alertness, emotional sensitivity, and social skills have been impaired while using the drug. People intoxicated with stimulants, such as amphetamine, may feel they have superior or even superhuman capacities, when they are often seriously impaired. The same is true of all psychiatric drugs. Often the patient will have little appreciation for the degree of mental or emotional impairment until the drug has been stopped for some time and the brain has had time to recover.
In my experience as a clinician and forensic medical expert, I have seen patients remain for years in severe states of intoxication from one or more psychiatric drugs without realizing it. Attributing their condition to their own emotional reactions or to stresses in the environment, they may ask for more medication.
After shock treatment and psychosurgery, patients may also fail to understand the iatrogenic source of their mental dysfunction and instead believe that they need further interventions.
The failure to perceive the extent of treatment-induced impairment can have several interrelated psychological and physiological bases:
Individuals overcome by emotional suffering are likely to deny the degree of their psychological dysfunction. They don't want to admit to being severely mentally impaired. If they are hoping to fell better with the use of a drug, their denial can be further reinforced.
Patients have faith that biopsychiatric interventions will be helpful rather than harmful, encouraging them to disregard drug-induced dysfunction or to mistakenly attribute it to their emotional problems.
To an extraordinary extent, patients will tell doctors what the doctors want to hear. If a psychiatrist clearly wants to hear that a drug is helpful, and not harmful, many patients will comply by giving false information or by withholding contradictory evidence.
Psychologically induced confusion. Emotionally upset individuals can easily lose their judgment concerning the cause of their worsening condition. They can easily mistake a negative drug effect, such as rebound anxiety from a minor tranquilizer or depression from a neuroleptic, for a worsening of their emotional problems. Typically, they blame themselves rather than the medication. This confusion is abetted when the physician exaggerates the drug's benefits and fails to inform the patient of its potential adverse effects.
Almost all biopsychiatric interventions can at times induce confusion, impairing the patient's awareness of the drug-induced mental dysfunction.
Drug-induced anosognosia. Anosognosia refers to the capacity of brain damage to cause denial of lost function. Anosognosia is a hallmark of central nervous system (CNS) disability (see below and chapter 5). It has physical basis in addition to a psychological one.
In recent years, doubt has been thrown on the objectivity of controlled clinical trials in which drugs are compared to placebo or to alternative medications (see chapters 6 and 11). Too often the investigators are influenced by their conscious or unconscious biases.
If clinical and scientific studies can be distorted by bias, it is even more likely that routine clinical practice will be affected by the hopes and expectations of the prescribing physician. Physicians in great numbers have prescribed drugs with unbounded enthusiasm for years before the agents have proven to be worthless or unacceptably dangerous. Amphetamines, for example, were freely dispensed for many years to millions of patients for both depression and weight control without regard for their lack of efficacy and addictive potential. Similarly, minor tranquilizers, such as Valium, were given to millions of patients before the profession recognized that they have little or no long-term benefit and can become addictive. Both psychosurgery and electroshock continue to be utilized, despite obviously devastating effects on the mental life of the patients and the absence of proven efficacy.
I have coined the term iatrogenic helplessness and denial (IHAD) to designate the guiding principle of biopsychiatric interventions. (Breggin, 1983b). It describes how the biological psychiatrist uses authoritarian techniques, enforced by brain-disabling interventions, to produce increased helplessness and dependency on the part of the patient.
Iatrogenic helplessness and denial include the patient's and the doctor's mutual denial of the damaging impact of the treatment, as well as their mutual denial of the patient's underlying psychological and situational problems.
Overall, iatrogenic helplessness and denial account for the frequency with which psychiatry has been able to utilize brain-damaging technologies, such as electroshock and psychosurgery, as well as toxic medications.
Before the potential patient encounters a psychiatrist, he or she has usually been feeling helpless for some time. In my formulation, helplessness is the common denominator of all psychological failure. Helplessness is at the core of most self-defeating approaches to life (Breggin, 1992a, 1997). People who feel helpless tend to give up using reason, love, and self-determination to overcome their emotional suffering, inner conflicts, and real-life stresses. They instead seek answers from outside themselves. In modern times, this often means from "experts."
Iatrogenic helplessness and denial go far beyond relatively benign suggestion (as used in medicine and psychiatry, for example, to help overcome physical pain or addiction). First, in iatrogenic helplessness and denial the psychiatrist compromises the brain of the patient, enforcing the patient's submission to suggestion through mental and physical dysfunction. Second, in iatrogenic helplessness and denial the psychiatrist denies to himself or herself the damaging effects of the treatment as well as the patient's continuing psychological or situational problems.
Often denial is accompanied by confabulation - the patient's use of rationalizations and various "cover stories" to hide the extent of mental dysfunction. Confabulation is well understood in psychiatry and neurology, but is generally ignored in regard to treatment-induced effects. Many patients confabulate good results from drug therapy when they are obviously impaired by it.
Denial is closely linked to indifference. Sometimes it is difficult to tell if the patient doesn't care, or if the patient cares so much that he cannot bear to face up to his mental and physical dysfunction. Denial is also related to euphoria. After lobotomy or shock treatment, and sometimes during drug treatment, the patient can develop an unrealistic "high."3
Denial is one of the most primitive ways of responding to threats. The person avoids facing problems and thereby becomes unable to make headway with them. Denial as a basic defense tends to result in ineffective, impotent lives.
Brain damage and dysfunction from any cause, including accidents and illness, frequently produces helplessness and denial; but only in psychiatry is damage and dysfunction used as "treatment" to produce these disabling effects.
As I have discussed in earlier books (1991a, 1994a, 1994b), I believe that the concepts of "mental illness" and "mental disorder" are misleading, and that none of the problems commonly treated by psychiatrists are genetic or biological in origin. The terms "schizophrenia" and "major depression," for example, are based on concepts whose validity can easily be challenged. However, the brain-disabling principles remain valid even if some of the mental phenomena that are being treated turn out to have a genetic or biological basis. All of the currently available biopsychiatric treatments - drugs, electroshock, and psychosurgery - have their primary or therapeutic effect by impairing or disabling normal brain function.
- The term euphoria as used in psychiatry indicates an exaggerated, irrational, or unrealistic sense of well-being. It can be psychological in origin but is commonly caused by brain damage or drug toxicity.
- Euphoria is unusual in patients treated with the neuroleptics because of the suppressive effects on the CNS (see chapter 2). It is more common among patients treated with antidepressants, stimulants, and minor tranquilizers.
- See footnote 2, (above).