Paranoid Schizophrenia: Modes of Recovery

schizophrenia. In addition, he experienced episodes of depression and episodes of manic excitement. He provides a graphic description not only of schizophrenic psychosis but also of depression and of mania. At one point he reports “my brain chemistry felt about as stable as a glass jug of water which was on the point of falling off the edge of the table”. But perhaps the key message of the book is that an individual who suffers from a schizophrenic illness is not defined by that illness, but rather by the range of interests, hopes and personal characteristics that shape him. Dr Travis obtained a PhD in physics; rowed for his college and ran a marathon; embarked on a hair-raising journey across Africa; organised boat trips on the Thames to raise money for charity; founded a recording company that released two CDs, and was devastated by the breakdown of his relationship with the girlfriend he loved dearly. Indeed the announcement by his girlfriend, Amanda, that she did not wish to marry him was one of the factors precipitating his slide into illness. He describes schizophrenia as “partly an experience-derived illness”. Later, he proposes “My main problem was that of heartbreak, which had gone undiagnosed by the NHS”. Many chapters describe his chaotic travels though the length and breadth of Britain, Ireland and parts of Europe. At times his express purpose was to escape from psychiatric treatment, but this does not keep him from his spiritual goal of finding Prince Charles’s dog in this odyssey of self-discovery and healing.

He is critical of the treatment he received from the psychiatric services (1). With some justification, he attributes two of his episodes of manic excitement to treatment with antidepressant medication. He is scathing about the effects of medication, especially the depression induced by these drugs (2). In fact the relationship between psychosis, depression and antipsychotic treatment is very complex. Depression is an integral part of schizophrenia. It can occur at any phase of the illness, and is especially prominent in the resolving phase of a psychotic episode. Under some circumstances, antipsychotic medication can help alleviate depression, but it can also contribute to depression. Stultifying sluggishness induced by blocking the natural energising effects of the brain chemical, dopamine, leaves the individual feeling like a zombie. More paradoxically, blockade of dopamine by antipsychotic medication can also produce extremely distressing restlessness. The complexity of the relationship between psychosis, depression and antipsychotic treatment can lead to apparent conflict between the subjective evidence based on the experience of an individual patient, and the purportedly objective scientific evidence derived from the careful observation of many patients. Dr Travis’s account brings home the importance of listening carefully to the individual’s own reports of the effects of medication, and of adjusting medication to minimise the distressing side effects. However, in predicting the future consequences of treatment, it is equally important to take account of the evidence derived from careful observation of large numbers of patients. There is very strong evidence that continued use of antipsychotic medication reduces the risk of relapse over a time scale of several years. While antidepressant medication probably precipitated the acute manic agitation that led to his first two admissions to psychiatric hospitals, it is equally likely that discontinuation of antipsychotic medication predisposed him to his third relapse in the summer of 1997.

But this speculation brings us to a crucial issue raised by Dr Travis. He reports that none of his doctors suggested the possibility that antipsychotic medication might ever be safely discontinued. The prospect of indefinite treatment with medication having such distressing side effects was intolerable to him. Unfortunately, on this issue there is a gaping hole in the scientific evidence. While an abundance of evidence demonstrates that antipsychotic medication reduces the risk of psychotic relapse over a time scale of several years, there is a paucity of good evidence regarding treatment in the longer term. Virtually all of the available evidence indicates that over a time scale of decades, between a third and a half of individuals suffering severe schizophrenia recover to the point where they no longer require antipsychotic medication (3). The mind and its brain have an amazing capacity to adapt to changing circumstances. It might be argued that the primary goal of psychiatry is to promote the circumstances that will maximise the likelihood that mind and brain adapt constructively rather than destructively. In individual cases, the prediction of the course of adaptive processes over a time scale of decades is fraught with difficulty. However, Dr Travis exhibits several characteristics which bode well. While the intensity of his emotional responses is a source of torment in the short term, it also augurs well for a better outcome in the longer term. In addition, the intelligent way in which he grapples with the illness increases the likelihood of recovery. At one point he attempts to wrest back a sense of personal autonomy from the alien forces that appear to control him by a technique involving a random number generator. He is intelligent enough to realise that this provides only an illusion of autonomy, but this illusion is perhaps the crucial requirement. After all, what is free will? More pragmatically, his battle with the psychiatric services is an expression of his continuing determination to re-establish his autonomy. Perhaps the greatest tragedy in the delivery of psychiatric services to patients with psychotic illnesses is the failure to establish that collaboration might offer the best prospect for recovery of autonomy. In the face of the turmoil of psychosis, there is no easy prescription for achieving collaboration, but this book eloquently makes the point that the first step is engagement in dialogue.

Professor Peter Liddle, August 2007

(1) As a result of medication-produced insight, I am more objective in my criticism than in the draft Professor Liddle read.

(2) However, see the postface “Happy Ending” written after Professor Liddle wrote his foreword.

(3) Professor Thomas Barnes complements the above "1/3 to a 1/2" statistic by saying the patients are not "prospectively identifiable" in other words not all of the patients who went into the system have been covered. He instead cites Jobe & Harrow (2005): “between 21% and 57% show good outcome”. Both statistics give hope to those new to the diagnosis of paranoid schizophrenia. See also Prognosis section.