Into the Void

Anosognosia (impaired awareness of illness): A major problem for individuals with schizophrenia and bipolar disorder.

As the years go by, I am less and less impressed with NAMI. I think their agenda is to improve the family’s comfort at the expense of the patient’s autonomy. They teach the rather disturbing idea that a large percentage of mentally ill people have no self-awareness, no insight into ourselves. Like the lower animals. Anosognosia, they call it.

The article I’ve linked to above has some glaring logical errors and has terrible ramifications for the mentally ill. I’ll list some of them.

1. The article lumps bipolars together with schizophrenics as if we are all one big, happy family. We aren’t. Bipolar disorder is cyclic, often with long periods of remission in between episodes. This is not the case with schizophrenia. Schizophrenia is associated with unremitting cognitive deficits.
2. In either case, there is no “awareness of illness” modifier to the DSM-IV codes. Frankly, it is my opinion that the majority of so-called “normal” folks are wandering around with the same lack of self-consciousness. Why are we pathologizing it?
3. The article doesn’t examine in detail the cognitive effects of certain medications. Most notably, the antipsychotics have been shown to reduce the IQ by an average of about 10 points. In basing the sweeping generalization that we aren’t self-aware upon those individuals whose short-term memory is ravaged by their medications, the article makes a case for putting more individuals on the same meds. This will skew future research in this direction as more and more psychiatric patients are required to take meds that may cause anosognosia.
4. There is considerable evidence that medications may not be necessary during remission in bipolar disorder type II – see Dr. Fieve’s recent book, “Bipolar II: Enhance Your Highs, Boost Your Creativity, and Escape the Cycles of Recurrent Depression.” If I state that I don’t need meds when I’m in remission, that is a treatment decision, not the symptom of a cognitive deficit.
5. The milder forms of bipolar disorder occur far more that the severe forms. That is, most bipolars never experience psychosis. I suspect that there is a missing qualifier throughout the article – a description of what population exactly they mean. That is, do the authors include the milder forms of bipolar in their 40% statistic, or is the article strictly based on their experience with the sickest of the sick, the ones who wound up in-patient? If this is so, then the authors are stigmatizing most of the bipolar population based on a very biased sample. I suspect that the sample of bipolars in the article are folks who have never been educated as to the symptoms of their illness. Education alone makes a big difference in our ability to manage the illness.
6. The horrible possibility that we aren’t aware of our symptoms is devastating to the self-esteem of even the most intelligent and self-aware mentally ill person. Am I acting out? Should I speak up or will my words betray my condition? I feel good today – maybe that’s just a mania talking? I disagree what what X is saying – am I delusional?
7. This article opens the mentally ill to victimization by society and especially by the medical profession. The word “Anosognosia” gives society the pretense of a valid reason to marginalize the mentally ill, to victimize, to force-medicate, to control us. It enables our families, friends and employers to shrug off our ideas and opinions for no other reason than that we have been diagnosed and they haven’t.
8. Why exactly is it that a heart patient is allowed to request that further treatment be withheld, yet a mentally ill person can be hospitalized against his will? Are we monsters?

For all its talk about stigma busters, NAMI has shown with this single document exactly what they are all about. I am not an animal. Mental illness is not a crime. And NAMI is not advocating for us.

UPDATE 4/15/2007:
Sylvia Caras of People Who accepted this post for inclusion on her own site. Stop over to People Who and check out the tremendous amount of excellent mental health advocacy information she offers.

If someone figures out how to “cure” genetics, let me know. You can’t exactly pick up a bottle of Grecian Formula for Brain at the local pharmacy.

Remission is another thing altogether. That simply means that you are having an extended symptom-free period. Given that the DSM-IV bipolar criteria only require that the patient have ONE episode of mania or hypomania, some folks may remain in remission for the rest of their lives even without meds.

Science *is* empiricism. I would like to suggest that a large percentage doctors are not particularly careful in their application of the science of medicine. If they were scientific, they’d test and retest the bipolar patient’s continued need for meds instead of following the bizarre rule of thumb that once you’re on meds you need them forever. The killer is that as long as the illness is masked by drugs, it is impossible to practice “evidence-based medicine” as they disparagingly call it.

None of us on meds is being treated in an scientific manner. It isn’t scientifically valid to say that bipolar disorder causes cognitive deficits if a large percentage of the patients in the study were on meds. Antipsychotics have been *proven* to reduce the IQ by affecting the short-term memory. They aren’t the only drug to cause cognitive deficits. Lithium makes you feel as if your brain is wrapped in cotton wool.

I don’t believe that it is scientifically valid to say that bipolars must be on meds for life. If the patient stops the meds and experiences a return of symptoms… well, you’ve rewired the brain. The drugs themselves create a continued need for themselves by reconfiguring the brain’s neurons to need higher levels of serotonin in the synapses. The symptoms are bound to return, and much worse than before the drug did its damage.

Another thing about remission is that so many things besides bipolar disorder cause mood swings. Bipolar disorder has periods of remission. Things like the personality disorders, schizophrenia, schizoaffective disorder, PTSD and any of a hundred organic illness all cause mood swings. But they don’t necessarily have periods of remission, and in many cases remission just doesn’t occur.

Here – this is my particular manifestation of bipolar disorder. Three-year cycles. They come no matter what, but fortunately the meds attentuate the episodes. On the other hand, until I was on meds the cycles didn’t seriously impact my salary.

I think that it’s important, if a bipolar isn’t having remissions, to figure out why. Ultra-rapid cycling could be caused by an antidepressant, particularly in women. Newly-diagnosed bipolars often experience a great deal of fear or anxiety that might be better treated with therapy than with additional meds. Antipsychotics may ruin the patient’s ability to effectively manage the illness by dumbing them down. Sometimes it isn’t the illness, it is the meds that make bipolars disabled.

Are your drugs masking periods of remission?

Sometimes I get tired of the reverse stigma that I get for taking fewer meds so that I can continue to have a life. Isn’t that the purpose of treatment? If not, what is?

Most bipolars have the so-called milder varieties of the illness, and many of them are unfairly overmedicated and isolated from society for no good reason. It is unbearably sad to see that happening. So if I can tolerate psychosis instead of trying to medicate away every little nuance of mood or emotion, does that make me somehow inferior? I don’t f*cking think so. It isn’t pathological until it has a negative effect on my life.