Friday, November 5, 2010

Supersensitivity Psychosis: The Evidence

This is the tenth in my series based on talking points raised by Robert Whitaker's eye-opening "Anatomy of an Epidemic."

We left off with the shocking proposition that our antipsychotics may actually make us more prone rather than less prone to psychosis, thus turning good prognosis patients into chronic bad prognosis ones. The idea was first advanced in 1978 by Guy Chouinard and Barry Jones of McGill University, who coined the term, "supersensitivity psychosis."

We see supersensitivity at work in tardive dyskinesia, when one dopamine pathway (nigrostriatal) is overstimulated after post-synaptic neurons habituate to prolonged antipsychotic exposure. Since we're pretty sure this is true, Chouinard and Jones deduced that it was likely that another dopamine pathway (mesolimbic) was getting overwhelmed, as well. And, of all the crazy things, the particular side effect coming out of this pathway would be psychosis.

That's right - a med administered to treat psychosis with a side effect of psychosis.

This is not as crazy as it sounds. Patients of all categories experience "rebound" symptoms across all classes of meds when they are abruptly withdrawn after long term administration or when doses are lowered too quickly. Usually, the result is temporary, but even a remote prospect of this happening is extremely unsettling. Whitaker states that we may be better off by just saying no to antipsychotics over the long haul, where the best evidence we have indicates that patients fare better by not refilling their prescriptions.

Chouinard and Jones don't go nearly this far, instead restricting their focus to treating supersensitivity psychosis as it occurs and to picking up its early warning signs.

In their 1978 article, Chouinard and Jones referred to a study they conducted on 32 patients. Half the patients were taken off their antipsychotic and given a placebo. The eight patients whose condition deteriorated into psychosis also experienced tardive dyskinesia, lending credence to the  proposition that the two effects were related, induced by the same phenomenon over different pathways.

But here's the catch: How can you tell supersensitivity psychosis from the real thing? After all, if you take a patient off their antipsychotic, it stands to reason the illness will reassert itself. With tardive dyskinesia we know the effect is from the drug rather than the natural course of the illness. But what about psychosis? Chouinard tackled this problem in a 1990 article by proposing diagnostic criteria for "neuroleptic-induced supersensitivity psychosis." His main distinguishing feature was that once the antipsychotic is withdrawn or the dose lowered the psychosis comes on quicker and with greater frequency than illness-related psychosis.

Whitaker doesn't bring this up in his book. Indeed, his whole argument rests on the proposition that you can't tell the two apart, or at least that researchers have not taken the trouble. This is why relapse-prevention studies (which involve taking responding patients off the trial drug) are bogus, according to Whitaker, as the returning psychosis cannot be unequivocally attributed to the illness. As he describes it: "The severe relapse suffered by many patients withdrawn from antipsychotics was not necessarily the result of the 'disease' returning, but rather was drug-related."

Wait. We don't know for sure if it was drug-related. Whitaker has no business saying that. But he does have a point. At the very least, the possibility of supersensitivity psychosis raises "reasonable doubt" in all long-term antipsychotics trials, rendering them null and void.

But the same reasonable doubt exists with Chouinard's studies, as well, meaning that we don't really know the incidence of supersensitivity psychosis (Chouinard claims it may be as high as 43 percent). According to Joanna Moncrieff of University College London in a 2006 review article, "there is the problem of distinguishing the natural history of the underlying disorder from effects related to drug withdrawal," a point that Chouinard acknowledges in a 2008 piece.

Further research would shed light on the situation, but this raises major ethical issues, Moncrieff points out, as "it is difficult to justify experimental studies involving rapid discontinuation of drugs." Whitaker would have no choice but to agree. In the foreword to his book, he mentions clinical trials that came to his attention "that involved withdrawing schizophrenia patients from their antipsychotic medications, which was the unethical thing to do."

So where do we stand? Obviously there is something to the supersensitivity psychosis hypothesis. It may be as serious as Whitaker makes it out to be, but the hard evidence is lacking, and will be for some time to come. It may be as prevalent as Chouinard indicates, but again the hard evidence is lacking. Moreover, Chouinard is quick to add that most of this is reversible, upon the resumption of the antipsychotic. It is worth noting that Chouinard limits his focus to spotting and treating supersensitivity psychosis (often with higher doses and a concomitant mood stabilizer). The wisdom or folly of remaining on an antipsychotic is Whitaker's line of inquiry, not Chouinard's.

Does this mean that Whitaker is off-base? Hardly. His thesis may run far ahead of the evidence, but is nonetheless perfectly in line with the speculative dots he is connecting. We know that antipsychotics are blunt instruments at best. We know that many, if not most, patients on antipsychotics continue to lead miserable lives. Likewise, we know that quite a few patients may be better off not taking antipsychotics. Finally, we know that there is a lot we do not know.

We are already aware that there are many reasons to think twice before taking an antipsychotic, much less remaining on one. Whitaker has given us a few more reasons to be concerned. He may not be right, but someone needs to prove him wrong.


Tony Previte said...

Wow, I had to go back and re-read that section. I went in a whole other direction with the "concept" in my earlier comment.

What I do know!

Thanks goodness I've never been on anti-psychotics for any significant length of time.

Once upon a time when I WAS on a brain-numbing cocktail of anti-psychotics, benzo's & other "stuff" it was determined in my medical record that my cognitive function was deteriorated enough to render me unfit for duty and most likely a candidate for lifelong disability in the civilian sector.

Well, I got off all that stuff and actually went back to the military!

So we at least have one person we both know that can attest to the effects that these drugs can have on people, and the progress they can make if taken off of them.

We just have to be allowed to in a better supported system than I ever was.

John McManamy said...

Hey, Tony. Bullseye! We don't have a system that supports people going off their meds. No safe places, only high risk mean streets. I hope to take this up in a future piece.

Ruth Z Deming said...

hi john! just bought whitaker's book and am under his influence. lots of people in my support group here in philly do go off their meds once they're stable. works out well for the most part but of course not always.

question: i notice you have ads on your blog and am considering doing that w/my blog as well. does it bring a decent source of revenue! cheers always!

John McManamy said...

Hey, Ruth. I very much appreciate your observations. Attending and facilitating support groups is where I learned that a lot of people were not doing well on their meds and that their situations were not likely to improve with a meds-as-usual approach. It's good to hear that in your support group you're seeing good results from people going off their meds. My guess is these are people who lead highly disciplined lives. That they're very observant in diet-exercise-sleep, exercise mindfulness, manage stress, and can spot and react to their triggers, etc etc. Can you comment on this.

It could be very dangerous for people to go off meds who have not yet acquired the necessary coping skills. I know I needed my meds to do the heavy lifting until my new routines and coping tricks became part of my DNA.

I don't make too much from the ads on my blog, but I do have a decent income stream from the ads on my site, which has a very large readership (mostly people looking for specific info doing a Google search).

Porcelaine said...

could it be possible to gain psychotic effects from these drugs when having no previous symptoms of psychosis? i guess that would be hard to tell but could it still be possible?

John McManamy said...

Great question, Porcelaine. My guess - and I emphasize this is only a guess - is this is theoretically possible. We know that street drugs that overstimulate the dopamine pathways can induce psychosis in people who have never experienced psychosis. So - assuming that Chouinard is correct in his hypothesis - a medication with the side effect of overstimulating the dopamine pathways may achieve the same result in certain people.

Again - we have no proof, but there are strong parallels in other meds. An antidepressant, for instance, can induce mania in individuals who never experienced mania.

Anonymous said...

I know this is an old post...

I have NEVER been psychotic in my life, my shrink put me on Zyprexa for 5 years for mild anxiety and my bipolar, which of course i've never been manic in my life. I was completely misdiagnosed and had medications shoved down my throat with no pscyhotherapy whatsoever.

I am in to 1 month of withdrawal and am in psychosis...i am experiencing extreme anxiety, hallucinations,panic attacks, depersonalization and derealization. I have NEVER had this in my life, EVER. I am extremely angry at the fact i was never warned this would happen to me. I wouldn't wish this experience on my worst enemy. I'm completely done with psychiatry.

Anonymous said...

I was a victim of "dual diagnosis drug and alcohol treatment" and once in a florida rehab for drinking a "dual diagnosis medication compliance" attempt for excessive beer drinking disorder. I never would have quit drinking on these motivation and pleasure reducing mind destroying drugs. I was not given informed consent to treatment for dual diagnosis medication managament adherance and compliance. Dual diagnosis is disease mongering more than half the time.

Pat JB said...

I was diagnosed with Bipolar Type 1, rapid-cycling with psychotic features, back in 2000. Over the next 9 years I would start and stop the cocktail of my medications because like the stereotypical Bipolar patient, I hated taking them and couldn't stomach them (literally, in my case).
In late 2009 I moved to a new state to take a high-stress position with a new company. I found a new psychiatrist who agreed to slowly wean me off the constant, high-dose antipsychotic medications I was on.
That was 3 years ago and for the last 2 years, I've not had a single episode or any psychotic relapses.
Her verdict - repeated by other doctors - is a Bipolar misdiagnosis and repeated reoccurences of the psychotic episodes due to the frequent start-stop medicine routine I kept.
If that can happen to me, and to the others who've commented, it is absolutely vital we research this more.

Unknown said...

I disagree with the notion that antipsychotics are of no use and best avoided. Blocking 5-ht2a and d2 receptors has the effect of regulating GSK3 which may be a genetic target from some individuals with schizophrenia. I found the use of low dose antipsychotics indispensable in keeping me stabile (in conjunction with lithium). I live a mostly normal life. The antispychotics really help with sleep, the lack of which sends me into a manic phase. I recommend keeping the dose low, and perhaps augmenting with melatonin.