Psichiatria

Meteore psichiatriche: la sparizione delle diagnosi

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L’assassinio di Marat

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Monoaniaco

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monomaniaca

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Monomaniaco

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Pinel libera i malati di mente dalla prigione

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Entrance Philippe Pinel (1745-1826) releasing the lunatics from their chains at the Salpêtrière Hospital in 1795.

Nella storia della psichiatria le malattie appaiono e scompaiono come meteore. Agli inizi del secolo diciannovesimo Pinel coniò il termine mania ragionante o follia parziale , Esquirol quello di monomania omicida. Per Etienne Jean Georget allievo di Esquirol la follia parziale escludeva l’idea di azione criminale e di colpa oltre che quella di responsabilità della condotta. Il concetto originariamente autonomo di monomania, legato all’ipotesi di due differenti sedi organiche della follia l’epigastrio ed il cervello, alimentò un acceso dibattito nel corso del XIX secolo, basato su argomentazioni spesso risibili sulle quali ironizza Dostoevskij nel “ I fratelli Kamarazov”. Nel romanzo tre medici cercano di stabilire se l’imputato di omicidio fosse o meno “monomaniaco” basandosi sull’osservazione della direzione del suo sguardo all’ingresso del tribunale.

A partire dalla seconda metà dell’Ottocento prevalse l’idea che che la “follia ragionante” altro non fosse che un raggruppamento provvisorio ed artificiale di fenomeni diversi e che pertanto non si potesse considerare un’entità nosografica a se stante. Si affermò il concetto di moral insanity coniato da Prichard (1835) che si agganciava alla teoria della degenerazione di Morel e Magnan. Dopo Kraepelin i vari casi di monomania furono ascritti alle psicopatie, alla paranoia, alle psicosi organiche e dopo Eugen Bleuler alle varie forme di schizofrenia o psicopatia . La monomania scomparve perché non aveva un fondamento psicopatologico ed era facile obiettare che la psiche è un tutto in cui intelletto, affetti ed impulsi agiscono unitariamente. La monomania omicida era un concetto frutto di una visione intellettualistica e filosofica della mente umana. Le passioni e gli affetti, considerati irrazionali, per una lesione della volontà che lasciava indenne l’intelligenza avrebbero determinato l’impulso irresistibile e criminale. Non si comprendeva che poteva essere la razionalità lucida solo apparentemente integra ma in realtà anaffettiva a determinare l’agire delittuoso ed omicida.

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L’ipnotizzatore e l’isterica

Anche per l’Isteria è successo un qualcosa di analogo. A partire dal DSMIII non si trova più una categoria diagnostica riconducible al sostantivo isteria ma neppure troviamo l’aggettivo isterico sostituito da istrionico. L’istrione è il mentitore ed il commediante: l’isterico, nell’aggettivo sostantivato, diventa sinonimo di simulatore di cui il medico diffida perché può indurre in gravi errori diagnostici.

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Isterica della Salpetrière

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Hysterical yawnings.” Three photos in a series showing a hysterical woman screaming.

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A Clinical Lesson with Doctor Charcot at the Salpêtrière.
Painting by André Brouillet, 1887. Lyon, Hôpital Neurologique. Il dipinto di André Brouillet mostra Blanche Witmann prima di una crisi. Dietro Charcot il suo famoso allievo Joseph Babinsky

SHAH-GRAND-HYSTERIA-CATALEPSY

Il declino dell’ Isteria ha inizio con Charcot ma anche con Breuer e Freud. Ciò che Charcot denominava isteria era una coorte composta dalle più disparate malattie. Le isteriche della Salpetrière agivano come attrici consumate abituate a mettere in scena un copione ben preciso secondo le aspettative dell’autoritario direttore. suo uso attuale il termine ‘isteria’ non ha praticamente alcun rapporto con il suo significato originario. Perché non si riferisce più a un disturbo legato all’utero od alla sessualità come si era ritenuto a partire da Ippocrate. È invece utilizzato per riferirsi a qualsiasi sintomo o qualsiasi modello di comportamento anomalo per cui non esiste patologia organica ed esso è pertanto ritenuto un prodotto di stress emotivo, ansia o qualche altra causa psicologica. Se tutti i pazienti che sembrano essere affetti da sintomi fisici, ma che non hanno alcuna patologia organica rilevabile dovessero essere soprannominati ‘isterici’, il concetto di isteria diverrebbe così ampio e così vago da essere del tutto privo di significato. Hysteria, in effetti, cessa di essere l’entità nosografica molto particolare che si è sempre storicamente considerata, e diventa semplicemente un’ affermazione negativa sulla natura di alcuni sintomi. L’aggettivo isterico ‘viene oggi utilizzato come se fosse un sinonimo di ‘non biologico’ o ‘psicogeno’.

Jose-Breuer

joseph Breuer

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Anna O- Bertha Pappenheim

Quando Breuer cominciò il trattamento di AnnaO- Bertha Pappenheim nel 1880 e fece diagnosi di Hysteria si riferiva alla natura psicogena della tosse,delle contratture, delle paralisi , dei disturbi del linguaggio e della diplopia : egli escluse per es. la possibilità di una meningite tubercolare.
E’ stato suggerito però da Mikkel Borch Jacobsen nel suo libro “Remembering Anna O. A century of mystification” (1996) che il quadro sintomatologico complessivo cui il famoso medico si trovò di fronte sia stato un’abile messa in scena attraverso la quale la giovane ebrea confermava la diagnosi di Breuer , ma fondamentalmente lo teneva in scacco. Si sarebbe trattato di una simulazione isterica od autoipnotica, che avveniva ad un livello preconscio e non di una menzogna intenzionale e pienamente cosciente. Massimo Fagioli nella sua magistrale premessa al libro “La storia di Anna O di Lucy Freeman” (L’asino d’oro” 2013) afferma che Breuer pur utilizando una volta il termine inconscio in realtà preferiva parlare di un “doppio stato di coscienza” od un’Io cattivo”: quest’ultimo potrebbe aver agito come un’abile simulatore . L’inganno riusciva perché Breuer non andava oltre i sintomi e la rievocazione dei ricordi o l’abreazione nel linguaggio degli affetti rimossi che in quanto tali erano stati un tempo coscienti. Joseph Breuer brillante neurofisiologo, rimaneva nell’ambito dell’approcio razionale alla malattia e sbagliò in partenza la diagnosi. Non collegò l’isteria alla presenza di un nucleo psicopatologico “inconscio”, nel senso di mai venuto prima alla coscienza, che si celava dietro il teatro privato della paziente ; l’anaffettività e la pulsione di annullamento non producevano manifestazioni visibili nascondendosi indisturbate dietro una teatralità vuota ed a tratti manierata.

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George Gershwin muore per un tumore cerebrale scambiato per isteria da Gregory Zilboorg

Freud sfruttò cinicamente la malattia di AnnaO e la sua messa in scena in quanto legata alla fama ed alla credibilità di Breuer . Indusse quest’ultimo a dichiarare il falso a proposito dell’efficacia del metodo catartico nel trattamento dell’isteria per poi procedere a demolirne l’ immagine. Già nella corrispondenza con la fidanzata Freud appare particolarmente invidioso del rapporto fra Breuer ed AnnaO, che viene descritta come molto avvenente, tanto da accennare all’infelicità ed alla gelosia della moglie del collega, Mathilde. Non sappiamo quanto risponda al vero la famosa storia della gravidanza e del parto isterico di Bertha Pappeheim messa in giro dal padre della psicoanalisi : di certo è falso che Breuer concepì la figlia Dora dopo l’interruzione del trattamento e il ricovero in ospedale della giovane. Dora Breuer nacque ben tre mesi prima la fine della cura . Ciò rende inquietante un’altra comunicazione che Freud fece a Marie Bonaparte nel 1925: a causa del coinvolgimento del marito con Anna O-Bertha Pappenehim, Mathilde Breuer avrebbe tentato addirittura il suicidio durante l’allattamento della figlia Dora . Quest’ultima circostanza, se vera, testimonierebbe a favore di una grave forma di depressione .

Jacobsen, nel libro prima citato,  riferisce che lo psiconalista Peter Swales ebbe modo di leggere i “Diari” di Marie Bonaparte nei quali veniva riportata una confidenza di Freud

<<Confronted by Breuer almost obsessional discussing of Anna O. all the time, his wife Mathilde made a suicide attempt. Breuer broke off the treatment. But the same night he was called back and Anna confessed to him she was pregnant by him.>>

Freud ovviamente non è attendibile sia sul piano teorico né umano per cui quanto comunicò a Marie Bonaparte va preso con beneficio di inventario:  resta il fatto che l’aver scelto l’isteria come suo cavallo di battaglia può aver influito  sul declino dell’isteria come entità nosografica autonoma. La psicoanalisi proprio in America dove si è più largamente diffusa nel novecento, ha invalidato la credibilità della diagnosi come ha affermato a più riprese lo psichiatra Allen Frances, il padre del DSMIII e IV. Emblematico il caso George Gerschwin. Lo storico della psichiatria , il russo Gregory Zilboorg emigrato negli USA e diventato psicoanalista freudiano con credenziali false, curava il musicista per mal di testa e anosmie ritenuti sintomi isterici ma in realtà espressione di un tumore cerebrale con esito mortale . Questo errore fa parte integrante della tradizione freudiana.9 MARZO2

Storicamente anche Freud, del tutto in malafede aveva confuso sintomi organici con sintomi psichici . Egli, proprio nel 1895 pochi mesi prima della pubblicazione degli “Studi sull’Isteria” firmati insieme a Breuer, convinse una sua paziente isterica Emma Eckstein a sottoporsi ad un intervento al naso in base alla teoria delirante di Fliess secondo la quale la masturbazione provocava un’alterazione dei turbinati che poteva essere risolta chirurgicamente. Fliess che per la prima volta si cimentava in un’operazione del genere, lasciò mezzo metro di garza nel naso della paziente. Freud interpretava i sintomi di un’infezione che si era sviluppata come se fossero sintomi isterici. Jeffey Moussaieff Masson ha fornito un resoconto dettagliato e completo di questo episodio nel suo libro “Assalto alla verità” (1984) . La paziente costretta ad altri interventi chirurgici si salvò ma rimase per sempre sfigurata nel volto. Mentre Bertha Pappenheim- Anna O , durante la malattia, non si riconosceva allo specchio Emma Ekstein fu resa irriconoscibile. A quanto pare Freud mentre pubblicava nel 1895 gli studi in cui ribadiva la natura traumatica e psicogena dell’Isteria contemporaneamente caldeggiava l’idea che essa fosse dovuta a cause organiche dando credito all’amico berlinese, che fu a suo tempo accusato dal figlio Robert, diventato anche egli psicoanalista, di aver abusato di lui da bambino.

Quindi né Joseph Breuer nel 1880 né Freud nel 1895 avevano la minima idea di cosa fosse l’Hysteria. Breuer si trovò del tutto impreparato ad affrontare un quadro psicopatologico complesso in cui i sintomi isterici erano solo la sovrastruttura di un nucleo psicotico e dissociativo mentre Freud si limitava a ripetere le formule di Charcot sull’origine traumatica dell’isteria dedotta dall’osservazione degli effetti psichici dei primi incidenti ferroviari nell’Ottocento.

Le vicissitudini del concetto di monomania omicida e di isteria parlano di forme di razionalità diagnostica differenti. L’approccio illuministico di Pinel ed Esquirol racconta dell’illusione di una ragione integra, senza delirio che potrebbe convivere con affetti ed una volontà malate nell’impulso irresitibile dell’agire criminale. Breuer testimonia lo scacco, personalmente sofferto, di un progetto di diagnosi e cura razionale di fronte all’immagine femminile oppressa e sofferente: il caso di Anna O rappresenta un punto di crisi e un un’occasione mancata di passaggio ad una nuova psichiatria. In Freud la razionalità è strumentale piegandosi a diventare mezzo per il perseguimento di un’utile personale, la fama ed il denaro, che non rifugge ma anzi integra in sé la logica dell’agire falso e criminale che oltre a diffamare produce lesioni e morti.

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Adam Lanza imita Anders Breivik

I manuali diagnostici del terzo millenio, improntati a criteri apparentemente ateoretici ed operativi, eliminando la soggettività della valutazione medica , segnalano un’ulteriore evoluzione verso sistemi classificatori che si espandono proporzionalmente all’espansione del mercato delle case farmaceutiche . In quanto prodotto di una psichiatria disfunzionale ed acefala, che ha perso ogni riferimento alla ricerca sulla psicopatologia e sull’inconscio, essi concorrono a generare nuovi modelli di patologia mentale. Entità tradizionali come l’isteria, ma oggi anche la schizofrenia e la psicopatia, si ibridano e scavano percorsi carsici scomparendo. Quando tali entità non riconosciute riemergono alla superficie della vita sociale innescano fenomeni drammatici ed inquietanti all’interno delle quali la bizzaria dei deliri e dell’acting out criminale come nel mass shooting , si coniuga con fenomeni isterico-imitativi che contagiano una moltitudine di persone.Come scrive Allen Frances oggi

“Psychiatry is rapidly expanding and normal is shrinking”

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Psichiatria

LA PAZZIA DIETRO LE SBARRE: il carcere come manicomio

 

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La legge Basaglia non ha risolto il  problema della segregazione manicomiale ma , togliendo credibilità alla psichiatria, ha favorito il ritorno alla concezione moralistico-punitiva della malattia  mentale.

Domenico Fargnoli

L’opinione pubblica non ha la percezione esatta dell’emergenza psichiatrica in atto in Italia che ha legami  con  una situazione più generale.

Scrive Amanda Pustilnik ( University of Maryland)

” Oggi i nostri ospedali psichiatrici più grandi sono le prigioni.(…) Le prigioni di Stato spendono circa 5 miliardi di dollari per incarcerare detenuti affetti da patologie mentali che non sono violenti. Stando a quanto afferma il Dipartimento di Giustizia 1,3 milioni di individui con malattie mentali sono incarcerati nelle prigioni di stato e  federali  a fronte di soli 70.000 individui  assistiti negli ospedali psichiatrici”

Si viene messi in carcere solo per essere afflitti da malattie mentali  e per aver disturbato l’ordine pubblico e non perché si siano commessi reati penalmente rilevanti. Nel luglio del 2004 The House Comitte on Governement Reform ha pubblicato uno studio dal  quale  risulta che negli USA  vengono incarcerati bambini  (anche di sette anni) con gravi patologie mentali senza che essi siano responsabili di condotte criminali .

Rispetto agli ideali illumunistici che hanno ispirato   la Costituzione americana la situazione sopra descritta è paradossale per il venire meno della fondamentale distinzione operata da Pinel durante la Rivoluzione francese:i malati di mente  furono separati, dalla fine del 700, dai criminali e liberati dalle catene. Nasceva così una nuova branca della medicina : la psichiatria .

A distanza di di più di due secoli notiamo una inversione di tendenza,: si ritorna alla confusione fra criminalità e pazzia, al prevalere della logica della segregazione  e della punizione .Il ritorno  ad orientamenti preilluministici   è dovuto  al significato sociale che ha assunto la malattia concepita come un  cedimento colpevole, una  mancanza di cntrolloe  e del senso di responsabilità personale.  E’ la vecchia idea cristiana della pazzia  come influenza  demoniaca, come complicità con il male, la quale  riappare in una forma secolarizzata.goya

Dalla mentalità religiosa deriva l’approccio punitivo,  che ha prevalso negli USA, alla  malattia mentale. La punizione dovrebbere rinforzare l’adesione all’ etica su cui è fondata la società e garantire , tramite la severità della pena, il rispetto delle norme.  Per la   concezione moralistico-punitiva le persone con  malattie mentali avrebbero  difetti della volontà o del carattere che li rendono incapaci  di controllarsi: imporre loro criteri restrittivi aiuterebbe  ad ottenere comportamenti accettabili ed aumentare  il senso di responsabilità. Il giudice si sostituisce allo psichiatra poiché  quest’ultimo considerando le malattie semplici “disturbi” od opinabili convenzioni diagnostiche , non è in grado di fornire criteri certi e non manipolabili di non imputabilità. Pertanto l’essere psichicamente malati anche gravemente  non garantisce di solito negli USA, l’impunità rispetto ai crimini violenti.

In Europa Anders  Breivik  è stato dichiarato sano di mente con  criteri diagnostici del  DSMIV  in un  processo  nel quale si è affermata la  tendenza alla punizione piuttosto che alla cura.

Ed in Italia? Il caso di Erika ed Omar  a Novi Ligure ,   quello di  Franzoni  a  Cogne  o dei coniugi  pluriassassini di Erba hanno visto prevalere una logica punitiva estranea alla psichiatria.

Perché ci troviamo di fronte a  questa tendenza?

La Prof. Amanda C. Pustilink non chiarisce il punto essenziale cioè  il ruolo avuto dalle istituzioni psichiatriche nel permettere che il modello moralistico- punitivo della malattia mentale si affermasse: cento anni di freudismo hanno lasciato il segno . Proprio in USA , comunque,  i media  a partire daglii  anni 90 hanno denunciato   il fallimento della psicoanalisi mentre la psichiatria organicistica, subentrata al freudismo, si prepara ad un clamoroso “disastro “, dovuto alla mancanza di scientificità,   con l’edizione del nuovo DSMV nel Maggio 2013.

I medici  americani sono  impegnati a distribuire psicofarmaci ad una popolazione di soggetti “normali” sempre più vasta , utilizzando  diagnosi che sembrano create ad hoc per favorire gli interessi delle case farmaceutiche. I casi più gravi  sono sottoposti a terapie,come l’iloperidone assunto da Adam Lanza ( l’autore della strage nella scuola di Newport), che possono amplificare la tendenza alla violenza.

Le carceri funzionano da contenitori per ogni sorta di patologie mentali   che, in un  regime di inaudita violenza e perversione, subiscono un aggravamento. Gli effetti sono devastanti sui singoli e sulla società. In Italia, patria di Cesare Beccaria che voleva la pena commisurata razionalmente al delitto  e che era contro la tortura,  si sta verificando qualcosa di analogo a quanto avviene in USA: l’adesione acritica ai modelli  diagnostici americani, l’abuso  degli psicofarmaci, il ricorso alla TEC (Terapia elettroconvulsivante), toglie credibilità alla psichiatria e favorisce l’affermazione del modello moralistico-punitivo della malattia mentale. Dato che i medici appaiono  incapaci di prevenire e curare le patologie psichiche la gestione di queste ultime è demandata, ai giudici ed ai tribunali. La legge Orsini -Basaglia  ha vuotato i manicomi di  circa centomila degenti negli ultimi decenni  ma , nello stesso lasso di tempo, si sono riempite in un modo inverosimile le carceri.

C’è  un’emergenza psichiatrica nelle prigioni : secondo un’indagine epidemiologica dell’Agenzia Regionale di Sanità i detenuti con “disturbi psichiatrici” sono 1137 ,il 33.4% ,nella  sola Toscana. Il carcere funziona come contenitore di patologie psichiche, che  non entrano nel circuito dei servizi psichiatrici . Con la chiusura dei manicomi non sempre sono state create strutture alternative  cosicchè molti soggetti sono rimasti senza controllo o rete di protezione  e sono finiti nelle maglie della giustizia. Le prigioni sono gironi infernali. Prendono il sopravvento l’idea di rovina, il vuoto affettivo, l’umiliazione e l’ emarginazione:  le varie patologie  diventano manifeste e si aggravano. I quadri  psicopatologici  si  strutturano  in forme  croniche, difficilmente curabili. L’identità sessuale, in un contesto di violenza e  promiscuità forzata,  subisce spesso una destrutturazione irreversibile. Il suicidio è un’esito drammatico la cui frequenza , anche più di venti volte la norma, è in diretta relazione al sovraffollamento ed agli abusi.

Come far fronte a tale situazione ? Il 31 Marzo in seguito alla legge Marino è prevista la chiusura degli OPG : l’ evento  ha un forte significato simbolico anche se interessa 1400 persone, su un totale di 66.721 detenuti italiani.  Gli OPG sono stati l’emblema della schizofrenia istituzionale : individui affetti da vizio totale o parziale di mente e quindi non imputabili sono stati sottoposti ad un regime carcerario in condizioni di degrado inimmaginabili. Per non dire delle torture fisiche e psicologiche .E’ necessario che questa chiusura sia occasione non solo per proporre strutture di intervento alternative  ma  per un ripensamento della psichiatria nel suo insieme . Andrea Zampi, il pluriomicida-suicida  di Perugia è stato sottoposto l’anno scorso  a Pisa a due cicli di  8 TEC: un intervento “terapeutico” od un a prassi senza alcuna base scientifica che ha aggravato le condizioni del paziente? Oggi gli psichiatri non hanno competenze adeguate ad affrontare la psicosi con il metodo della psicoterapia: lo psicofarmaco o la TEC sono inefficaci e  alla lunga pericolosi.

La psichiatria deve allora  fare un salto culturale  e metodologico dotandosi di nuovi criteri scientifici e formativi. L’esperienza dell’ Analisi collettiva che fa capo alla teoria della nascita di Massimo Fagioli, costituisce un’esperienza pilota : quasi quarant’anni   di cura, formazione e ricerca unica nel suo genere a cui hanno partecipato migliaia di persone e centinaia di psichiatri, impegnati ad approfondire la conoscenza della realtà psichica  oltre il riduzionismo organicista ed il moralismo della ragione e della religione. Come scrive Adriana Pannitteri  in “La pazzia dimenticata” (L’Asino d’oro 2013)”

<<(…) la malattia mentale non si risolve semplicemente buttando giù i muri dei manicomi, ma in maniera più solida cercando di sapere cosa c’è dentro la psiche di chi è ammalato>>


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Adan Lanza ha agito sotto gli effetti di psicofarmaci

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DECEMBER 21, 2012

Adam Lanza Taking Antipsychotics

Via Business Insider, hat tip  SBY News:

The Antipsychotic Prescribed To Adam Lanza Has A Troubled History All Its Own:

By now the whole country is fully embroiled in the Gun Control debate, spurred by the grisly murder of 27 people, mostly kids, at the Sandy Hook Elementary school last Friday.Fanapt

Guns might not be the only problem though.

New York Magazine wrote a pieceabout shooter Adam Lanza’s supposed “aspergers” syndrome as a “red herring” meant to distract from the real problem (guns, of course, the subject goes without mentioning).

Inside the piece though they report the boy was prescribed Fanapt, a controversial anti-psychotic medicine.

The article uses the term “controversial” to describe Fanapt, one generic name used for the drug Iloperidone which is an atypical antipsychotic  medication that works by changing the effects of chemicals in the brain.  Fanapt is used to treat schizophrenia andmay also be used for purposes not listed in the medication guide.

From Wikipedia:

Iloperidone, also known as FanaptFanapta, and previously known as Zomaril, … It was approved by the U.S. Food and Drug Administration (FDA) for use in the United States on May 6, 2009.
As most people know, the medication guides are written by lawyers and included with all medications these days.  They list every possible side affect that could ever happen even to a tiny percent of those taking the medication. The medication guide is more of a ‘cover your butt’ for the drug companies than it is a caution for the consumer.  It does say that thoughts about suicide or hurting yourself can be a side affect of Iloperidone.

Drugs.com also reports:

 Psychiatric side effects including restlessness, aggression, and delusion have been reported frequently. Hostility, decreased libido, paranoia, anorgasmia, confusional state, mania, catatonia, mood swings, panic attack, obsessive-compulsive disorder, bulimia nervosa, delirium, polydipsia psychogenic, impulse-control disorder, and major depression have been reported infrequently. (hat tip Economic Policy Journal)

InfoWars writes:
As the except from CCHR below demonstrates, anti-psychotic drugs are a hallmark of mass shooters, but you won’t see any call in the mainstream media to see them banned, …

What caused Adam Lanza to shoot his mother in the face, to shoot 20 innocent young children and 6 innocent adults and then shoot himself?  We may never know.  To blame it on a prescription alone that was supposed to help him is wrong; or to blame it on video games alone is wrong;  to blame it on his mental condition alone is wrong.  To blame the 27 deaths on a a gun that on it’s own can do nothing, is certainly wrong.

Lanza had problems, his mother was apparently trying to get him into a facility that could help him, and he did not want to go, according to some reports.  Other reports have the mother trying to push him out of the house to get a job or attend college.

We may never really know the truth.

Back to the drug from Business Insider:

Fanapt was the subject of a Bloomberg report when it passed regulators, after previously getting the “nonapproval” stamp. Why wasn’t it approved, you might ask?

There are many reasons, some of which have to do with competing entities in a competitive market.

The main cited reason for the rejection was that it caused severe heart problems in enough patients to cause a stir.

Maybe more importantly, though, Fanapt is one of a many drugs the FDA pumped out with an ability to exact the opposite desired effect on people: that is, you know, inducing rather than inhibiting psychosis and aggressive behavior.

[snip]

In fact, Fanapt was dropped by its first producer, picked up by another, initially rejected by the FDA, then later picked up and mass produced. The adverse side-effect is said to be “infrequent,” but still it exists, and can’t be ignored.

The reaction invoked by the drug in some people is reminiscent of the Jeffrey R. MacDonald case, where a Green Beret slaughtered his entire family and then fabricated a story about a marauding troop of “hopped up hippies”.

MacDonald though, had Eskatrol in his system, a weight-loss amphetamine that’s since been banned in part for its side effects of psychotic behavior and aggression.

These drugs are not the only ones that can cause the opposite of their desired effect. Several anti-depressant medications are also restricted to adults, for the depression they inspire in kids rather than eliminate.

Fanapt (iloperidone)

Side Effect Search
Underlined words or phrases provide helpful links to information in wikipedia.org and when moused over often give helpful definitions of the medical terms. Keywords
Fanapt may cause aggressive/violent behavior (frequent).This drug may also cause the following symptoms that are related to aggressive/violent behavior:

Medical Source Information
Yellow highlights indicate symptoms related to aggressive/violent behavior.Psychiatric side effects including restlessnessaggression, and delusion have been reported frequently. Hostilitydecreased libidoparanoiaanorgasmiaconfusional statemania,catatoniamood swingspanic attackobsessive-compulsive disorderbulimia nervosa,deliriumpolydipsia psychogenic, impulse-control disorder, and major depression have been reported infrequently.Nervous system side effects including dizziness (up to 20%), somnolence (up to 15%),extrapyramidal disorder (up to 5%), tremor (3%), and lethargy (up to 3%) have been reported.Paraesthesia, psychomotor hyperactivity, restlessnessamnesia, and nystagmus have been reported infrequently. Restless legs syndrome has been reported rarely.

Side Effects to Watch
Watch closely for the following side effects and notify your physician immediately should any of these develop:
  • Abnormal heart rate, fluttering in the chest, weakness, faintness, dizziness or loss of consciousness (signs of a serious condition called “torsade de pointe or QT prolongation” in which irregular heartbeats occur)
Lab and Diagnostic Tests
If certain symptoms develop, ask your physician whether you need the following lab tests or other diagnostic tests (if you’ve not already had them):
  • Monitor white blood cell count, complete blood count and complete blood count
  • Blood tests to assess normal clotting – in people who develop signs of bleeding such as abnormal bruising or signs of bleeding including bleeding from the gums, nose, digestive tract, vagina (females), faintness, dizziness, loss of consciousness, or rash
  • EKG – if abnormal heartbeats (rapid slow or irregular) develop
  • electrolytes, magnesium, potassium and glucose – check before starting treatment and then periodically
References
  1. Product Information. Fanapt (iloperidone). Anonymous Vanda Pharmaceuticals Inc, Rockville, MD.


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Psichiatria

Dsm, la rivolta dei medici

NEWS_91336Articolo interessante, come documentazione storica del problema del DSM.

Interessante è la cricostanza per la quale il DSMIV fu pubblicato nel 1994. L’anno prima c’era stata in America una campagna stampa, mi ricordo una copertina del “Times” dal titolo Freud è morto, che decretava la fine della psicoanalisi freudiana naufragata sotto il peso della sua inconsistenza terapeutica, delle critiche epistemologiche di Grunbaum,Assalto_alla_Verit_pagina_1_di_69_grunbaum
documente della pubblicazione dei carteggi del padre della psicoanalisi. Tutti questi elementi concorrevano a dare della psicanalisi un’immagine molto lontana dalla agiografie edulcorate fra le quali spiccava quella di Ernst Jones e più vicina a quella di un gigantesco imbroglio sostenuto da un’intero apparato istituzionale  e ideologico.images Il DSM si inseriva tempestivamente nel vuoto lasciato dalla” morte di Freud” (morte ovviamente simbolica) che Fritz Lang fin dal 1933 aveva rappresentato come un ipnotizzatore criminale che cercava di imporre ad una intera civiltà il diktat “si prega di chiudere gli occhi”. Già Freud nel 1938 nel suo “Compendio di Psicoanalisi” aveva auspicato l’avvento dell’era farmacologica: la psichiatria organistica nel suo sviluppo a partire dagli anni 80-90 si situa in una linea di continuità con il freudismo con cui condivide l’idea di una incurabilità della malattia mentale. Le corporazioni degli psichiatri cercavano, in quegli anni,  un consenso ed una amalgama  facendo quadrato sul DSM come fosse un manifesto politico piuttosto che un un testo che derivava da approfondite e motivate riflessioni teoriche.

Attualmente il disastro del DSMV coincide con la planetaria crisi economica innescata dalle banche e dalla bolla  del  mercato immobiliare americano: come se la crisi del modello liberista si ripercuotesse sugli aspetti sovrastrutturali della società americana, in particolar modo della psichiatria, incapace  di offrire strumenti di contenimento dell’enorme  malessere sociale ed economico delle fasce di popolazione più deboli negli Usa. Le guerre ingiuste ed inique combattute dagli  States su scala planetaria, in difesa dei loro interessi legati al controllo delle fonti energetiche, hanno indebolito sul piano non solo dell’economia  ma anche dell’immagine il paese. Gli psicofarmaci, come si è scoperto negli ultimi decenni, non solo non possono essere un ‘intervento a lungo termine sulla malattia mentale senza provocare danni iatrogeni rilevanti ma  neppure possono essere somministrati  in modo irresponsabile  ai bambini piccolissimi  senza alterare i processi di sviluppo ed incidere pesantemente sulla realtà psichica di questi ultimi costituendo il punto di innesco di veri e propri episodi psicotici.

S

Allen Frances, classe 1942, è un pezzo di storia della psichiatria. Ha presieduto i lavori del comitato scientifico di quel l’American Psychiatric Association (Apa) che, nel 1994, partorì la quarta edizione del Manuale diagnostico e statistico dei disturbi mentali (Dsm-IV): 886 pagine, 297 disturbi. Oggi, capelli bianchi e abbronzatura alla Robert Redford, Frances è un professore emerito che vorrebbe godersi la pensione in California. Invece, è reduce da un giro di conferenze, anche in Italia, dal titolo «Usi e abusi della diagnosi in psichiatria». Oggetto della sua preoccupazione, e delle sue critiche severe, sono i criteri proposti (li trovate su http://www.dsm5.org) per la quinta edizione del Dsm, la cui uscita è prevista nel maggio 2013. Del Dsm-5 (da romana la numerazione è diventata araba, quindi Dsm-5), ha parlato su queste pagine Gilberto Corbellini più di un anno fa («Disturbi mentali, il catalogo è questo», 22 marzo 2010), raccontandone costi e ricavi ed elencando le principali novità: maggior attenzione agli aspetti dimensionali della diagnosi (cioè non solo la presenza/assenza di un sintomo o di un disturbo, ma anche la sua intensità), semplificazione di diagnosi “complesse” quali schizofrenia e autismo, riduzione del numero dei disturbi di personalità, revisione del quadro nosografico delle “dipendenze”, con introduzione di nuove dipendenze comportamentali, per esempio da internet.
Ma cosa preoccupa Frances, al punto da invitare l’intera comunità dei professionisti della salute mentale a firmare una petizione (www.ipetitions.com/petition/Dsm5) e perorare una users’revolt, una ribellione degli utenti del Dsm? Petizione a cui l’Apa, proprio in questi giorni, ha fornito risposte tese più ad appiattire i contrasti che ad affrontare le critiche, attraverso quelle che lo stesso Frances ha definito «formule bizantine» che sostanzialmente ignorano il problema.
Un punto di partenza per descrivere questa rivolta fantapsichiatrica potrebbe essere il mancato coinvolgimento degli psicologi come comunità professionale nella stesura del Dsm-5. La marginalizzazione degli psicologi è un problema delicato dato che questi non solo applicano il Dsm nella pratica clinica, ma conducono anche ricerche sulla base delle sue categorie diagnostiche. Le critiche contenute nella petizione anti Dsm-5 sono infatti sottoscritte da un lungo elenco di divisions dell’American Psychological Association. Poco prima si era mossa in modo simile la British Psychological Society. L’anno scorso, un autorevole cartello di esperti (Shedler, Beck, Fonagy, Gabbard, Gunderson, Kernberg, Michels e Westen) aveva lanciato un allarme sul futuro diagnostico dei disturbi di personalità, una delle diagnosi più importanti nel campo della salute mentale (basti pensare al loro ruolo in ambito forense). In particolare suscitò scalpore, tra noi addetti ai lavori, l’esclusione dal Manuale di alcuni importanti disturbi di personalità, quali il paranoide, lo schizoide, l’istrionico, il dipendente e soprattutto il narcisistico. Tanto che, nel giugno 2011, l’American Psychiatric Association si sentì costretta a reinserire tra le diagnosi almeno quest’ultimo, accogliendo così in parte le osservazioni dei molti clinici che vedevano nella sua eliminazione l’affacciarsi di una pericolosa scollatura tra la realtà clinica e le categorie diagnostiche, oltre che la preoccupante eliminazione di tutte le manifestazioni psicopatologiche non immediatamente riducibili a meccanismi di tipo biologico. Ma il dissenso era ormai diffuso e, proprio dalle pagine dell’American Journal of Psychiatry, questi clinici internazionalmente noti definivano la diagnostica di personalità targata Dsm-5 «un agglomerato poco maneggevole di modelli disparati e male assortiti, che rischia di trovare pochi clinici disposti ad avere la pazienza e la costanza di farne effettivamente uso nella loro pratica». Anche in Italia si è mosso qualcosa: un gruppo di clinici e ricercatori di diversa formazione (Lingiardi, Ammaniti, Dazzi, Del Corno, Liotti, Maffei, Mancini, Migone, Rossi Monti, Semerari, Zennaro) ha voluto inviare all’Apa una lettera con le proprie perplessità sul tema. E anche l’ultima Newsletter dell’Ordine degli psicologi del Lazio presenta un analogo documento critico.
Ricordo che il Dsm è probabilmente il sistema diagnostico in psichiatria più usato al mondo. Se i suoi meriti sono noti, primo tra tutti il tentativo di creare una lingua comune e principi condivisi per descrivere i disturbi mentali, i punti di debolezza dell’imminente Dsm-5 sono sotto i riflettori. Proviamo a riassumerli: 1. «abbassamento delle soglie diagnostiche» col conseguente accresciuto rischio di falsi positivi (viene diagnosticato un disturbo mentale che non c’è) e relativa medicalizzazione (psicofarmaci compresi) di soggetti non clinici; 2. «inserimento di nuove categorie diagnostiche» dubbie, come la «sindrome psicotica attenuata», che sembra peraltro avere un basso potere predittivo rispetto allo sviluppo successivo di una sindrome psicotica vera e propria, e il «disturbo neurocognitivo lieve», diagnosticabile nella maggior parte degli anziani; oppure l’eliminazione del precedente criterio che impedisce di far diagnosi di «depressione maggiore» in presenza di un lutto (per cui sarà più facile diagnosticare come sindromi depressive, e quindi medicalizzare, alcune reazioni di lutto normali); 3. «minore attenzione al peso dei fattori psicologici, sociali e culturali» nella genesi e nell’espressione dei disturbi mentali; 4. «eccessiva polarizzazione medico-organicista», dal punto di vista sia teorico sia clinico

Unknown

Secondo Gilberto Corbellini nel DSMV verrà abolita la dizione “schizofrenia paranoide”. Con il gruppo di psichiatri “Progetto psichiatria” abbiamo ultimato in questi giorni un articolo “Breivik e la diagnosi di schizofrenia paranoide” che secondo noi non solo esiste ma ha caratteristiche peculiari che la distinguono dalle altre forme della classica quadripartizione di Eugene Bleuler.

DSM-5

Da Il Sole 24 Ore del 22-03-2010, di Gilberto Corbellini

Articolo: Disturbi mentali, il catalogo è questo

Verso il nuovo manuale. L’associazione psichiatrica americana ha investito 25 milioni di dollari coinvolgendo 600 specialisti per ridisegnare la mappa delle patologie. Siamo vicini al varo finale. L’uscita prevista nel 2013

USA. Dopo undici anni di discussioni e un certo numero di falsi annunci dell’imminente pubblicazione, finalmente la fumata bianca.
Habemus DSM-V. o, quantomeno, si sa verso quali modifiche sono orientati i componenti della task force e dei 13 gruppi che lavorano, coordinati da David Kupfer e finanziati dalla American Association of Psychiatry (Apa), sulle categorie fondamentali delle diagnosi psichiatriche. Il 10 febbraio l’Apa ha pubblicato un draft del DSM-V richiedendo commenti e critiche da parte di tutti gli interessati entro il 20 aprile prossimo. Quindi nei prossimi tre anni, saranno organizzate tre fasi cliniche per testare la validità delle revisioni proposte e l’edizione definitiva sarà acquistabile nel maggio del 2013.
Il DSM o Diagnostic and Statistical Manual of Mental Disorders, è il più diffuso e influente testo di psichiatria nel mondo occidentale. Sulla base di questo strumento, edito dall’Apa, si battezzano e si classificano le malattie mentali, ma soprattutto gli psichiatri e i neurologi diagnosticano e trattano i loro pazienti. Inoltre, le case farmaceutiche progettano e finanziano le sperimentazioni cliniche dei farmaci, e gli enti di ricerca pubblici decidono quali ricerche finanziare.

Ultimo, ma non per importanza, i sistemi sanitari o le compagnie di assicurazione pagano le cure che sono indicate come appropriate. Rappresentando la larghissima diffusione del DSM una fonte di incalcolabile guadagno economico per l’Apa, si comprende l’ingente investimento di 25 milioni di dollari per effettuare la revisione, a cui hanno concorso 600 psichiatri, e anche la decisione di pubblicare un’edizione che probabilmente lascerà insoddisfatti molti, ma che lancia nondimeno una serie di segnali inequivocabili sul cammino che sta percorrendo la psichiatria.
La storia del DSM, dall’I al V, è uno dei capitoli più affascinanti della storia della psichiatria, anzi della storia della medicina del Novecento in generale. Non solo perché è intellettualmente intrigante analizzare i ragionamenti che hanno portato dalle 106 malattie mentali descritte nelle 106 pagine del DSM-1 del 1952 ai 293 disturbi descritti in 886 pagine del DSM-IV del 1994. Ma per il fatto che si tratta di una finestra storica unica sulle difficoltà e i problemi, sia teorici sia pratici, che hanno incontrato i tentativi di fornire alla psichiatria una base scientifica. Cioè una metodologia diagnostica basata sull’eziologia del disturbo clinicamente rilevante, come è nel caso delle definizioni di malattia sviluppate dopo l’avvento della medicina sperimentale o scientifica. […]

L’unico trattamento efficace per superare una condizione di precarietà di natura epistemologica di cui soffre la psichiatria forse sarebbe un salutare pluralismo epistemologico, ispirato però da una rigorosa concezione naturalistica della malattia mentale. Gli avanzamenti delle neuroscienze stanno muovendo in questa direzione, consentendo di tornare a sfruttare euristicamente le teorie per ricondurre i disturbi del comportamento a quello che sono. Cioè alterazioni del funzionamento del cervello.
Dal DSM-IV al DSM-V
– Eliminazione di una serie di sottotipi di schizofrenia (paranoide, disorganizzata, catatonica, eccetera) e maggiore attenzione ai sintomi comuni come allucinazioni e disturbi del pensiero, nonché alla durata e gravità di tali sintomi, nella diagnosi dei disturbi psicotici.
– Introduzione di una diagnosi di depressione ansiosa mista.
– Riduzione da 12 a 5 dei disturbi della personalità. Sono rimasti: borderline, schizotipica, evitante, ossessivo-compulsiva e psicopatica/antisociale.
– Introduzione della categoria di sindromi di rischio, in modo da consentire agli psichiatri di identificare gli stadi precoci di gravi disturbi mentali, come le demenze o le psicosi. […]
– Introduzione della singola categoria diagnostica dei “disturbi autistici” in sostituzione delle attuali diagnosi alquanto indefinite di malattia autistica, malattia di Asperger, disturbo disintegrativo dell’infanzia, e disturbo pervasivo dello sviluppo.
– Introduzione della nuova categoria dei disturbi da dipendenza e simili, in sostituzione della categoria di dipendenza e abuso di sostante.
Questa opzione consente di differenziare il comportamento compulsivo di ricerca della droga dovuto alla dipendenza dalle risposte normali di tolleranzae astinenza.
– Introduzione della categoria delle dipendenze comportamentali, che al momento include solo il gioco d’azzardo, ma dove alcuni vorrebbero includere la dipendenza da internet.
– Aggiunta di una valutazione dimensionale della diagnosi, rispetto al criterio basato solo sulla presenza o assenza di un sintomo, per consentire agli psichiatri di valutare la gravità dei sintomi.

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Psichiatria

Brain-DisablingTreatments in Psychiatry by Peter Breggin

694940094001_1409784734001_640-brain

Peter Breggin indubbiamente rivela alcuni aspetti negativi del trattamenti farmacologici che non sempre vengono propagandati con la stessa enfasi di quelli positivi, ammesso e non concesso che questi ultimi esistano in un trattamento a lungo termine: in questo senso ciò che dice è degno di essere preso in considerazione ed attentamente valutato. Dove personalmente non seguo Breggin è nel trasformare la sua battaglia contro gli psicofarmaci in uno scontro ideologico che si avvicina molto alle posizioni di Scientology.  in un suo intervento del 2005 egli ringraziava Tom Cruise  di cui  egli condivideva le opinioni e  difendeva l’appartenenza  alla setta.Lo psichiatra americano assomiglia a Beppe Grillo. Egli  si scaglia a testa bassa contro le case farmaceutiche denunciando  giustamente degli abusi ma non propone niente di seriamente alternativo. Le sue proposte sul piano della psicoterapia ad essere gentili sono inconsistenti dato che  secondo lui le malattie nascono da problemi “spirituali”.  La realtà non materiale umana non è ovviamente “spirito” da contrapporre al corpo, salvo non riproporre, in un modo più o meno larvato, un’impostazione fideistica  che si vorrebbe  superare. Il vero nemico da combattere è l’ideologia religiosa  che impedisce alla psichiatria di sviluppare una capacità ed una mentalità atta ad affrontare sul piano della relazione interumana la malattia mentale. Non si possono demonizzare i farmaci e non combattere con altrettanto vigore tanto per fare un esempio  contro le concezioni freudiane infiltrate nella pratica della psicologia e psicoterapia americana. La polemica, peraltro giusta in molte circostanze, contro il trattamento farmacologico è un terreno facile,aperto al sensazionalismo,  che fa leva su componenti persecutorie , come la paura di essere avvelenati o di subire lesioni da parte di medici incompetenti. Rimane la domanda se sia più dannosa una psicoterapia fatta male od un trattamento a base di benzodiazepine od antidepressivi somministrato da uno psichiatra che crede che quella veramente  sia la cura della malattia mentale.

Brain-DisablingTreatmentsi n Psychiatry

DRUGS, ELECTROSHOCI(, AND THE ROLE OF THE FDA

Peter R. Breggin, MD

/7). /;ltj1 LY~

[~I Springer Publishing Company

Contents

Introduction and Acknowledgments …………………………………………….. xi

  1. 1  The Brain-Disabling Principlesof Psychiatric Treatment ……………………………………………………… 1
  2. 2  Deactivation Syndrome (Chemical Lobotomy)Caused by Neuroleptics ……………………………………………………… 14
  3. 3  Neuroleptic-Induced Anguish, Including Agitation,Despair, and Depression …………………………………………………….. 25
  4. 4  Neuroleptic Malignant Syndrome, Tardive Dyskinesia,Tardive Dystonia, and Tardive Akathisia ………………………….. 35
  5. 5  Neuroleptic-Induced Brain Damage, PersistentCognitive Deficits, Dementia, and Psychosis ………………………. 53
  6. 6  Antidepressants, Including Prozac-Induced Violenceand Suicide ………………………………………………………………………… 77
  7. 7  Lithium and Other Drugs for Bipolar Disorder ……………….. III
  8. 8  Electroshock for Depression …………………………………………….. 129
  9. 9  Stimulants and Other Drugs for Children, Including
    an Analysis of Attention-Deficit Hyperactivity Disorder …… 157
  10. 10  Antianxiety Drugs, Including Behavioral Abnormalities

Caused by Xanax and Halcion ., …… ………………………………….. 184

ix

x Contents
11 Drug Companies and the Food and Drug

Administration: Failed Mandates …………………………………….. 208 Bibliography …………………………………………………………………………… 234 Index ……………………………………………………………………………………… 295

CHAPTER 4

Neuroleptic Malignant Syndrome, Tardive Dyskinesia, Tardive Dystonia, and
Tardive Akathisia

This chapter focuses on two well-known neurological disorders caused by the neuroleptics-tardive dyskinesia (TD) and neuroleptic malignant syndrome (NMS), with emphasis on their frequency and their destructive impact on the physical and emotional life of the individual. It also discusses neuroleptic withdrawal syndrome. The next chapter will explore irrevers- ible damage to the brain that primarily affects mental functioning, includ- ing tardive psychosis and tardive dementia. However, as products of neuroleptic neurotoxicity, all these drug-induced abnormalities are clini- cally and neurologically interrelated.

TARDIVE DYSKINESIA

Within a few years after the development of the first neuroleptic, it became obvious that many patients were not recovering from their drug-induced neurologic disorders even after termination of the therapy. Reports were made in the late 1950s. Delay and Deniker (1968) date their awareness

35

36 Neuroleptic Malignant Syndrome and Relnted Disorders

of irreversible neurological syndromes to 1959. By 1968 they were able to provide a vivid review of several varieties, including buccolingual, tnmcal, and variable choreic movements. In 1964 Faurbye (Faurbye, Rasch, Petersen, & Brandborg, 1964) named the disorder tardive dyski- nesia.

As if governed by one mind, psychiatry as a profession refused to give any official recognition to this potential tragedy. Then Crane made it a personal crusade to gain the profession’s recognition of the problem (1973). The American College of Neuropsychopharmacology/Food and Drug Administration Task Force (1973) described the syndrome in a special report. Following 1973, everyone in the profession should have been alerted to the dangers of TD; but too many psychiatrists have contin- ued to act as if it hardly exists.

In 1980, the American Psychiatric Association (APA) published a task force report on TD. In 1985 the FDA took the unusual step of setting specifically worded requirements for a class warning in association with all neuroleptic labeling and advertising (“Neuroleptics,” 1985). In a wholly unprecedented move, in the same year the APA sent out a warning letter about the dangers of tardive dyskinesia to its entire membership (see chapter 11 for further discussion of the FDA’s role).

TD often begins with uncontrolled movements of the face, including the eyes (blinking), tongue, lips, mouth, and cheeks; but it can start with almost any group of muscles. The most common early sign is a quivering or curling of the tongue. Tongue protrusions and chewing movements are also common, and can become serious enough to harm teeth and impair chewing and swallowing. The hands and feet arms and legs, neck, back, and torso can be involved.

The movements displayed are highly variable, and include writhing contortions, tics, spasms, and tremors. The person’s gait can be badly impaired. More subtle functions can be affected and are easily overlooked: respiration (involving the diaphragm), swallowing (involving the pharyn-

and esophageal musculature), the gag reflex, and speech (Yassa & Jones, 1985).

The movements usually disappear during sleep, although I have seen exceptions. They sometimes can be partially suppressed by willpower; frequently are made worse by anxiety; and can vary from time to time (see below).

Many cases of TD appear to be relatively mild, often limited to move- ments of the tongue, mouth, jaw, face, or eyelids. Nonetheless, they are

frequently disfiguring and often embarrassing. Patients have been known to commit suicide (Yassa & Jones, 1985).

The abnormal movements can sometimes become totally disabling. Turner (1971) describes patients who cannot eat and must have their teeth removed in order to facilitate the entry of food into their mouths. He also describes patients who cannot keep shoes on their feet because they wear them out while sitting with the constant foot-shuft1ing activity. I have evaluated a number of cases in which the tardive dyskinesia was wholly disabling, including massive distortions of the position of the neck or body, rocking and swaying, shoulder shrugging, and rotary or thrnsting movements of the pelvis, as well as disturbances of respiration, such as periodic rapid breathing, irregular breathing, and grunting.

Ironically, the disease makes the patient look “very crazy” because of the seemingly bizarre facial and bodily movements. Tragically, this has often led to patients being treated more vigorously with neuroleptics, ultimately worsening their TD.

As in other neurological disorders, the patient may attempt to hide the disorder by adding voluntary movements to the involuntary ones in order to disguise them. For example, to cover up a tendency to move the arms continually, the patient may make grooming movements around the face and hair. This can make it seem as if the individual suffers from a psychological compulsion instead of a neurological disorder. Or the patient may clasp his arms together in order to control the movements, making it seem as if he is trying to psychologically “hold onto himself.”

All the neuroleptics (see chapter 2 for a list) can cause tardive dyskine- sia, including the atypical neuroleptics clozapine (Weller & Kornhuber, 1993) and risperidone (Addington, Toews, & Addington, 1995). The overall adverse effects of the atypical neuroleptics are summarized in chapter 5.

Masking the Symptoms of TD with Continued Neuroleptic Treatment

The symptoms of tardive dyskinesia are masked or suppressed by these drugs, so that the disease symptoms do not fully appear until the patient has been removed from the treatment. For this reason, in addition to using the smallest possible dose for the shortest possible time, whenever possible patients should periodically be removed from their neuroleptics, if only

38 Neuroleptic Malignant Syndrome and Related Disorders

for a short period, to determine if they are developing tardive dyskinesia. Permanent removal from the neuroleptics is a more difficult matter, often requiring many months of gradual withdrawal for the hrain to adjust to the drug-free environment.

Harold Klawans has discussed the dangerousness of trying to control or treat TD with the causative agent. He asserts (in the discussion following Goetz et al., 1980): “Treatment of tardive dyskinesia with neuroleptics themselves is clearly treatment with the presumed offending agent and should be avoided.” He calls it “short-sighted” to use the neuroleptics in the treatment of tardive dyskinesia, and concludes that the therapy “serves to aggravate its pathogenesis.” Unhappily, Klawans himself in the same article too readily recommends reserpine as a helpful agent in the treatment of TD, when it too can cause the disorder.

Nonetheless, I have seen cases of TD that were so disabling that the only recourse seemed to be treatment with a neuroleptic. But two points must be borne in mind about these cases. First, in each instance, the case became so severe because physicians failed to detect the disorder when it first appeared and continued neuroleptic treatment long after it should have been terminated. This has been true in nearly all the most disabling cases I have examined. Second, the individuals in question were overcome with suffering and rendered wholly unable to function by the TD. They and their families made informed decisions to continue the offending agent because the TD was making life unbearable for the patient.

The anticholinergic drugs typically used to ameliorate the symptoms of drug-induced parkinsonism also may aggravate the symptoms of TD (Yassa et al., 1992). They include benztropine (Cogentin), biperiden (Aki- neton), and trihexyphenidyl (Artane, Tremin). These agents are known to worsen similar symptoms in Huntington’s chorea (Hunter, Blackwood, Smith, & Cumings, 1968; Klawans, 1973). At present the role of these drugs in the development or exacerbation of tardive dyskinesia is contro- versial and undetermined, but caution is required in giving them to patients on neuroleptics. Their adverse effects are discussed in chapter 2. These agents are often used to treat acute extrapyramidal symptoms and may be mistakenly prescribed for TD.

Rates of TD

In 1980 the APA produced a detailed analysis of the disease in its Task Force Report: Tardive Dyskinesia. It made clear that TD is a serious,

Brain-Disabling Treatments in Psychiatry 39

usually irreversible, untreatable, and highly prevalent disease resulting from therapy with the neuroleptics. The task force estimated the prevalence rate for TD in routine treatment (several months to 2 years) as at least 10%-20% for more than minimal disease. For long-term exposure to neuroleptics, the rate was at least 40% for more than minimal disease.

Even after the publication of the 1980 task force report and a mountain of confirmatory evidence, some biologically oriented psychiatrists, such as Nancy Andreasen (1984), in The Broken Brain: The Biological Revolu- tion in Psychiatry, continued to misinform the public that tardive dyskine- sia is “infrequent” (p. 210) and occurs in “a few patients” (p. 211).

The more recent APA task force (1992) report cites a rate of 5% per year, cumulative over the first several years of treatment. Jeste and Caligi- uri (1993) estimate the annual incidence rate among young adults at 4%- 5%.

In a recent prospective project emanating from Yale, Glazer, Morgen- stern, and Doucette (1993) reported a long-term evaluation of 362 outpa- tient psychiatric patients who were free of TD at baseline and who were being maintained on neuroleptics. For patients who are starting neurolep- tics, according to projections from their data, the risk of tardive dyskinesia will be 31.8% after 5 years of exposure-a rate of slightly over 6% per year. The risk is 49.4% after 10 years, 56.7% after 15 years, 64.7% after 20 years, and 68.4% after 25 years.

Chouinard, Annable, Mercier, & Ross-Chouinard (1986) followed a group of 136 persons who had already been receiving neuroleptics but had not manifested TD. Over 5 years, 35%-a rate of 7% per year- developed the disorder.

Overall, in relatively young and healthy patients, the cumulative risk of contracting TD when exposed to neuroleptic~ ranges from 4%-7% per year during the first several years o f treatment. Approximately one-third of the patients will develop this largely irreversible disorder within the

first five years of treatment. This represents an astronomical risk for patients and should become part of the awareness of all mental health professionals, their patients, and their patients’ families. Furthermore, we shall find that TD brings with it the additional risk of irreversible cognitive dysfunction and dementia (chapter 5).

There is evidence that rates for tardive dyskinesia are increasing. It may be caused by the growing tendency to use drugs with seemingly more toxic effects on the extrapyramidal system, such as Haldol and Prolixin (see Jeste & Wyatt, 1981). These drugs also come in long-acting

40 Neuroleptic Malignant Syndrome and Related Disorders

intramuscular preparations that do not permit patients to independently lower their own dosages by taking fewer pills than prescribed.

It is unusual for TD to develop in less than 3-6 months’ treatment and standard texts suggest that TD which develops earlier requires special investigation. However, it is not possible to place too much emphasis on one point that has been mentioned by Tepper and Haas (1979) and others (for example, Hollister. 1976): tardive dyskinesia can develop in low-dose, short-tenn treatment. DeVeaugh-Geiss (1979) has seen cases develop in a matter of weeks. I have seen several cases develop at around 3 months of treatment. One patient developed tardive dyskinesia after 1 month of recent exposure, with a history of 2 months’ prior exposure several years earlier. One case which developed in 3 months of constant exposure had a probable history of prior head injury from childhood. In the elderly, many cases may develop within a few weeks (see below).

THE ELDERLY AND
OTHER VULNERABLE POPULATIONS

It is important to remember that medications in general are more likely to cause dysfunction in the elderly (Nolan & O’Malley, 1988). Nowhere is this demonstrated more tragically than in regard to TD.

A study of elderly nursing home patients by Yassa, Nastase, Camille, and Belzile (1988) found that 41 % developed tardive dyskinesia over a period of only 24 months and that none fully recovered. While long-term studies have found a spontaneous dyskinesia prevalence of 1%-5% in the elderly, none of the non-drug-treated controls developed spontaneous dyskinesias during the 2 years. Yassa, Iskander, and Ally (1988) found TD in 45% of an outpatient clinic population with a mean age of 60.

In a more recent study, Yassa, Nastase, Dupont, and Thibeau (1992) followed up patients from a geriatric psychiatric unit who had received neuroleptics for the first time during the hospitalization. Out of 99 patients, 35 (35.4%) had developed TD after a mean exposure of 20.7 months. Of these 35, 21 had moderate TD and 3 had severe. Some had tardive dystonia (see below).

Saltz and his colleagues (1991) found the incidence of TD was 31 % following 43 weeks of cumulative neuroleptic treatment in the elderly. The incidence was higher among patients who had previous electroshock

Brain-Disabling Treatments in Psychiatry 41

treatment. Patients with early signs of parkinsonism developed TD at a faster rate. Of great importance, in this older population, the mean cumula- tive time while taking neuroleptics was very brief, a mere 22.7 weeks. One patient developed TD at 2 weeks.

Jeste, Lacro, Gilbert, Kline, and Kline (1993), in an ongoing prospective study, found that 26% of middle-aged and elderly patients developed TD after 12 months. The authors also reviewed the literature on neuroleptic withdrawal and found “that almost 60 percent of the patients withdrawn from neuroleptics did not relapse over a mean period of 6 months.” They concluded, “it seems feasible to discontinue neuroleptic medication from a select population of older schizophrenic patients, if it is done carefully with adequate monitoring and follow up.” They also experimented with brief 2-week placebo-substituted withdrawal in their own group of pa- tients, both younger and older subjects, and found it relatively benign: none relapsed or required resumption of neuroleptics. They concluded, “Given the heightened risk of TD in older patients, it seems that a trial of neuroleptic withdrawal is warranted in this population.”

Jeste et aI. (1993) emphasize that “The potential seriousness of neuro- leptic-induced TD warrants obtaining competent, informed consent to treatment from patients or guardians.” They recommended that consent be periodically renewed and cited other sources to confirm their position.

In addition to age, prior brain damage probably increases the risk of TD (Breggin, 1983; Chouinard, Annable, Ross-Chouinard, & Nestoros, 1979), although studies are contradictory and not conclusive. McKeith, Fairbairn, Perry, Thompson, and Perry (1992) found that 13 of 16 patients with Lewy body type dementia showed deterioration on neuroleptics, including the development of extrapyramidal features. The authors con- clude, “Severe, and often fatal, neuroleptic sensitivity may occur in elderly patients with confusion, dementia, or behavioral disturbance. Its occur- rence may indicate senile dementia of the Lewy body type . . . ” Pourcher, Cohen, Cohen, Baruch, and Bouchard (1993) found a correlation between TD and prior organic brain disorder.

Relapse, Exacerbation, and Delayed Onset after Termination

TD typically waxes and wanes, both in the course of a day and in the course of weeks or months. Especially in the elderly, both partial remissions and relapses are common (Lacro et aI., 1994).

42 Neuroleptic Malignant Syndrome and Related Disorders

As in many neurological disorders, the manifestations ofTD can worsen during stress and can be somewhat calmed with sedation (Jeste & Caligiuri, 1993). In my experience, anxiety, exhaustion, and other general stresses to the mind and body can temporarily exacerbate the symptoms, while relaxation, when possible, can temporarily reduce them.

With great effort, patients can sometimes suppress some of their symp~ toms for a short time. They can also integrate their movements into more natural-looking actions, such as grooming or smiling, in order to disguise them. One patient with whom I consulted would hide her involuntary facial grimaces by trying to smile. The effect was to make her look even more strange to the casual observer.

Neither the fact that TD waxes and wanes, sometimes in response to stress, nor the patient’s ability to partially suppress it with an exertion of will, should mislead observers into believing that it is psychological or emotional in origin. Too often the early signs of TD are overlooked, denied, or dismissed by physicians on these mistaken grounds.

Christensen, Moller, and Faurbye (1970) have documented that a signif- icant percentage of TD cases may not show up at all until many months or even several years after discontinuation of the treatment. They believe that the symptoms are brought on by the interaction between the damage caused by the drugs and by the aging process. If this is true, then a tragic reality may develop as we observe the evolution of TD in aging populations. I have on occasion seen cases that did not become apparent until several months or more after termination of treatment.

Reversibility Is Rare

In the vast majority of cases, TD is irreversible and there is no effective treatment. One repOlt indicates that among patients with persistent TD, followed for a period of 5 years, 82% showed no overall significant change, 11% improved, and 7% became worse (Bergen et aI., 1989).

Another study followed 49 outpatient tardive dyskinesia cases for a mean of 40 weeks (range 1-59 months) after discontinuation of medication (Glazer, Morgenstern, Schooler, Berkman, & Moore, 1990). Many patients showed noticeable improvement in their movements within the ftrst year after stopping neuroleptics, but only 2% showed complete and persistent recovery. The authors conclude, “A major finding of this study is that complete reversal of TD following neuroleptic discontinuation in chroni- cally treated patients was rare.”

44 Neuroleptic Malignant Syndrome and Related Disorders

underestimated. I therefore reviewed the subject in detail. Fortunately, this is no longer necessary, since it is now well-recognized that children are susceptible to TD at rates no less than adults, and that the disorder is often more virulent in children, because it frequently affects the torso, including posture and locomotion (Breggin, 1983a; Gualtieri & Barnhill, 1988; Gualtieri, Quade, Hicks, Mayo, & Schroeder, 1984; Gualtieri, Schroeder, Hicks, & Quade, 1986). A high percentage of neuroleptic- treated children also develop a permanent worsening oftheir emotional and behavioral problems, psychoses, or dementia (see chapter 5). Physicians should not use neuroleptics for behavioral control in children.

TARDIVE DYSTONIA

It is now apparent that there are at least two related variants of TD, tardive dystonia and tardive akathisia. In a 1988 review of tardive dystonia, Burke and Kang found 21 reports describing 131 patients (for reviews, also see Greenberg & Gujavarty, 1985, and Kane & Lieberman, 1992).

Tardive dystonia involves’ ‘sustained involuntary twisting movements, generally slow, which may affect the limbs, trunk, neck, or face” (Burke et al., 1982, p. 1335). The face and neck are by far the most frequently affected areas of the body. Severe deformities of the neck (torticollis) can cause extreme pain and disability. r have seen several cases affecting the orbital muscles of the eyes (blepharospasm) to the degree that the individual’s vision was impaired, requiring botulin injections to paralyze the muscles. I’ve also seen respiratory and abdominal muscles affected in a painful and debilitating manner.

Tardive dystonia can produce cramplike, painful spasms that temporar- ily prevent the individual from carrying out normal activities. Sometimes the spasms are so continuous that the individual is largely disabled. Dam- age to the joint and skeleton system, including fractures, can occur (Burke & Kang, 1988). The pain and muscle tension, as well as the eff01i to compensate for the spasms, can be exhausting and demoralizing.

The torsions can be worsened by other bodily movements, such as attempts to write or to walk. Sometimes they can be relieved by particular movements, such as touching the chin to relieve torticollis or touching the brow to relieve blepharospasm.

Brain-Disabling Treatments in Psychiatry 43 Physician and Patient Denial of TD

Physicians understandably find it painful to face the damaging effects of their treatments. Sometimes it is difficult for them to confront the damage done to patients by other physicians as well. In addition, physicians may consciously seek to protect themselves or their colleagues by failing to acknowledge or to record obvious symptoms of tardive dyskinesia. I have seen many hospital and outpatient records in which obvious, severe cases of tardive dyskinesia have gone either unrecognized or undocumented, sometimes by several physicians in succession. For example, the nurse’s notes may make clear that the patient is in constant motion, yet the doctor’s physical examination or progress notes will give no indication of the disorder. Even official discharge summaries may fail to record TD in patients who have been demonstrating the disorder throughout the period of hospital or clinic treatment. This denial of the obvious is mirrored within the profession itself, which has been very remiss in recognizing or emphasizing the seriousness of the problem (for an analysis of this history, see Breggin, 1983a; Brown & Funk, 1986; Cohen & McCubbin, 1990; Wolf & Brown, 1987).

Psychiatrists sometimes accuse patients of exaggerating their tardive dyskinesia. In reality, most patients tend to deny the existence or severity of their TD. As discussed in detail in chapter 5, patient denial is caused in part by neuroleptic-induced lobotomy effects and in part by denial associated with brain damage. The mutual denial of TD by physician and patient is an aspect of iatrogenic helplessness and denial-the use of brain-disabling treatments in psychiatry to enforce the patient’s denial of both his personal problems and his iatrogenic brain dysfunction and dam- age (chapter 1).

The Size of the Epidemic

It is difficult to determine the total number of TD cases. Van Putten (see Lund, 1989) estimated 400,000-1,000,000 in the United States. My own earlier estimate is higher, ranging in the several millions (Breggin, 1983). It is no exaggeration to call tardive dyskinesia a widespread epidemic and possibly the worst medically induced catastrophe in history.

Children and TD

When I reviewed the subject in 1983, I was among the first to state that the rate and severity of tardive dyskinesia in children was being vastly

Brain-Disabling Treatments in P5ychiatry 45

As Burke and Kang (1988) point out, tardive dystonia can be mistakenly dismissed as a manifestation of hysteria, psychological in origin: “In this regard it is important to realize that dystonia, like many other neurological disorders, can be influenced transiently by suggestion, placebo, or sedation (e.g., during an amobarbital interview) and such maneuvers cannot exclude a true dystonia.” Also, like many other neurological disorders, it can sometimes be partially controlled by extreme exertions of will.

Tardive dystonia can make an individual appear unsympathetic or bizarre, especially to the uninformed observer who equates the facial grimaces or neck distortions with being “crazy.” As in all the drug- induced dyskinesias, the individual may try to cover up for the disorder with additional movements that make the disorder seem voluntary, and therefore not a product of mental illness. The result can be very confusing or distressing to the observer.

TARDIVE AKATHISIA

Tardive akathisia involves a feeling of inner tension or anxiety that drives the individual into restless activity, such as pacing (see chapter 3 for details). The first report of tardive akathisia I have located in the literature was published by Walter Kruse in 1960. He described three cases of muscular restlessness that persisted at least 3 months after discontinuation of treatment with fluphenazine and trit1upromazine. The “akathisic syn- drome … consisted of inability to sit still, pacing the floor all day, jerky movements of arms and shoulders.” Once again Delay and Deniker (1968) were also among the first clinicians to notice the disorder. In discussing “syndromes persisting after cessation of medication,” they mention “hy- perkinetic” ones. As early as 1977, Simpson more definitively made an association between tardive dyskinesia and akathisia that would not re- spond to treatment.

Gualtieri and Sovner (1989) reviewed the subject of tardive akathisia, cited studies with prevalence rates of 13%-18%, and called it “a signifi- cant public health issue.” Nonetheless, the drug companies have ignored it in the labeling of their products.

The anguish associated with akathisia should not be minimized. Con- sider Van Putten’s (1974) description of a mild, temporary akathisia or hyperkinesia: “Patient feels ‘all nerved up,’ ‘squirmy inside,’ ‘uptight,’

46 Neuroleptic Malignant Syndrome and Related Disorders

‘nervous,’ ‘tense,’ ‘uncomfortable,’ ‘impatient’…. Subjective feeling of ill-being may be accompanied by restless changes in posture.”

One reason that so little attention has been given to the mental disruption associated with the dyskinesias is the tendency to blame the mental compo- nent on the mental illness of the patient. Indeed, it has been commonplace to blame the obvious motor disturbances on the mental illness as well, often resulting in increased treatment, and a worsening of the symptoms, until immobility sets in, masking the entire process.

It takes no great imagination to grasp the suffering of a patient con- demned to a relatively mild tardive akathisia for a lifetime. I have seen cases of this kind that were previously mistaken for severe anxiety or agitated depression. Chapter 3 reviewed research indicating that acute akathisia can drive a patient into psychosis, and to violence and/or suicide. Considering the millions of patients subjected to this torment, the problem takes on epidemic proportions.

Tardive akathisia can be subtle. A woman in her mid-sixties consulted me because of seemingly bizarre feelings that other doctors attributed to her depression and to somatic delusions or hallucinations. She had a feeling of “electricity” going in periodic bursts throughout her body. Although she sat quietly in the office, she spoke of feeling fidgety and driven to move about.

Her hospital and clinic charts disclosed that 2 years earlier she had been treated for approximately 6 months with neuroleptics. The sensation she was describing had first been noted while she was taking the medica- tion. I concluded that she probably had tardive akathisia, a subtle case that did not actually force her to move about. However, because she didn’t show external signs of the disorder, other physicians were reluctant to make the diagnosis. The patient felt “driven to distraction” and even to suicide by the disorder; but after my probable diagnosis, she actually felt somewhat relieved. At least she was being taken seriously.

In 1993, Gualtieri wrote:

In telms of clinical treatment and the public health, however, TDAK [tardive akathisia] is a fact, not a question. It is one more serious side effect of neuroleptic treatment, like TD and the Neuroleptic Malignant Syndrome. Taken together, they define neuroleptic treatment as a necessary evil, a treatment that should be administered with care and caution, and reserved for patients who have no other recourse.

Brain-Disabling Treatments in Psychiatry 47 RESPONSES TO TARDIVE DISORDERS

Physical Exhaustion

Fatigue to the point of exhaustion almost always accompanies tardive disorders of any severity. The patient can be exhausted by the movements themselves, by the effort to hide them, and by increased effort required to cany out daily activities. The primary impact on the brain itself may also produce fatigue. Although the disorders tend to disappear in sleep, they can make it difficult to fall asleep, adding to the exhaustion. Having to contend with the physical pain associated with tardive akathisia (inner torment) and \vith tardive dystonia (muscle spasms) can also wear a person down.

Psychological Suffering

Commonly, patients experience shame and humiliation, often leading to social withdrawal. Even a seemingly mild dyskinesia that affects facial expression can be sufficiently humiliating to cause a person to withdraw from society. So can a speech abnormality that makes a person seem to “talk funny.”

The experience of constant pain from dystonia or inner torture from akathisia can drive a person to suicidal despair. The physical disabilities associated with disorders can also become very depressing to patients.

In a clinical report from the Mayo Clinic by Rosenbaum (1979), depres- sion was found closely linked to tardive dyskinesia. Rosenbaum states, “Almost all patients in our series had depressive symptoms accompanying the onset of tardive dyskinesia,” and he cites other studies confirming his observation.

Tardive dyskinesia patients often feel very betrayed by the doctors who prescribed the medication or who later failed to detect the disorder or to tell the patient about it. Too frequently, perhaps in a self-protective stance toward their colleagues, several psychiatrists in a row will fail to inform the patient or family about the obvious iatrogenic disorder. This can leave patients feeling that they cannot trust psychiatrists. In the extreme, it can create an understandable distrust of doctors in general.

Even a slight or minimal de!,’Tee of tardive disorder can end up seriously impairing an individual’s quality of life.

48 Neuroleptic Malignant Syndrome and Related Disorders

NEUROLEPTIC \VITHDRAWAL SYNDROME

Withdrawal frequently causes a worsening mental state. including tension and anxiety. With those drugs that produce potent anticholinergic effects. such as Thorazine and MeHaril, a cholinergic withdrawal syndrome (cho- linergic rebound) may develop that mimics the flu, including emotional upset, insomnia, nausea and vomiting, diarrhea, anorexia and weight loss, and muscle aches.

Withdrawal symptoms can also include a temporary worsening of dyski- netic effects, both painful and frightening.

While classic addiction to these substances has not been demonstrated, the drugs should be considered addictive in the sense that withdrawal symptoms can make it impossible for patients to stop taking them. For this reason, I have suggested viewing these drugs as addictive (Breggin, 1989a, 1989b).

Because of the withdrawal symptoms, it is often necessary to reduce these drugs at a very slow rate. Sometimes withdrawal seems to be impossible. I have described the principles of withdrawing from psychiat- ric drugs in Talking Back to Prozac.

NEUROLEPTIC-INDUCED PSYCHOSIS AND DEMENTIA

The following chapter will describe irreversible psychosis and dementia associated with the neuroleptics. These may first become obvious as withdrawal effects that make it seemingly impossible to stop the drug therapy.

OTHER NEUROLEPTIC-INDUCED NEUROLOGICAL IMPAIRMENTS

The neuroleptics can produce a variety of other symptoms of central nervous system dysfunction, including abnormal electroencephalogram (EEG) findings, an increased frequency of seizures, respiratory depression, and disturbances of body temperature control (Davis, 1980; Davis & Cole,

Brain-Disabling Treatments in Psychiatry 49

1975). Endocrine disorders, especially in females, may also be of central nervous system origin (Davis, 1980). There is some evidence that auto- nomic dysfunction can become irreversible (tardive autonomic disorders).

NEUROLEPTIC MALIGNANT SYNDROME (NMS)

This devastating disorder was seemingly so bizarre, unexpected, and inex- plicable that physicians for years literally refused to believe their eyes. Seven years after the introduction of the drugs into North America, Leo Hollister (1961) reviewed their side effects for “Medical Intelligence” in the New England Journal of Medicine. In two separate places, he referred to syndromes that probably were NMS. He described a “bizarre” dystonic syndrome that can b e ‘ ‘confused with hysteria, tetanus, encephali- tis or other acute nervous-system disorders; a rare fatality may occur.” Later he mentioned that “other clinical syndromes attributed to central- nervous-system effects of these drugs have resembled acute encephalitis, myasthenia gravis, bulbar palsy or pseudotabes.”

Although NMS was identified in an English-language publication by Delay and Deniker as early as 1968, physicians continued to be reluctant to recognize the syndrome. Delay and Deniker declared it was caused by the neuroleptics, specifically including haloperidol (Haldol) and t1uphen- azine (Prolixin). Any neuroleptic can cause NMS. However, clinicians have found an increased danger with long-acting injectable neuroleptics.

Delay and Deniker were already able to identify many of the compo- nents of NMS, including pallor, hyperthermia, a severe psychomotor syndrome with akinesia and stupor or hypertonicity with varying dyskine- sias. They warn that, at the first suspicion, “one must stop medication immediately and completely.” They were already aware of fatalities. That the syndrome was named and definitively identified in English in 1968 is most remarkable in light of the failure of drug companies to give it formal recognition until compelled to do so by the FDA almost 20 years later (see chapter 11 for further discussion).

Neuroleptic malignant syndrome is characterized by “such symptoms as severe dyskinesia or akinesia, temperature elevation, tachycardia, blood pressure t1uctuations, diaphoresis, dyspnea, dysphagia, and urinary incon- tinence” (Coons, Hillman, & Marshall, 1982). If unrecognized, as too often happens, it can be fatal in morc than 20% of cases. The syndrome

50 Neuroleptic Malignant Syndrome and Related Disorders

frequently leaves the patient with permanent dyskinesias and dementia (see chapter 5).

Most cases develop within the first few weeks of treatment (even within 45 minutes!), but some develop after months or years, or after increased dosage (Gratz, Levinson, & Simpson, 1992).

Estimates for rates of neuroleptic malignant syndrome vary widely but studies indicate that they are very high. Pope, Keck, and McElroy (1986) surveyed 500 patients admitted during a I-year period to a large psychiatric hospital and found a rate of 1.4%. The cumulative rate for patients would be much higher. Addonizio, Susman, and Roth (1986) carried out a retro- spective review of 82 charts of male inpatients and found that prevalence for the diagnosed syndrome was 2.4%. Again, the cumulative rate over repeated hospitalizations or years of treatment would be much higher.

Although it is sometimes called’ ‘rare,” NMS should be described as common or frequent 0/100 is common by FDA standards).

The rates for neuroleptic malignant syndrome, as well as its potential severity and lethality, make it an extreme risk for patients receiving antipsychotic drugs. A risk of this size would probably result in most drugs in general medicine being removed from the market.

I have reviewed cases in which several physicians at a time missed making the correct diagnosis in what seemed, from my retrospective analysis, like an obvious case of NMS. The failure to stop the neuroleptic and to institute proper treatment resulted in severe, permanent impair- ments, or death. The mistaken idea that NMS is rare may contribute to these errors in judgment.

After reviewing episodes of NMS in 20 patients, Rosebush and Stewart (1989) found that most cases fit the following cluster of symptoms: delir- ium, a high fever with diaphoresis, unstable cardiovascular signs, an elevated respiratory rate, and an array of dyskinesias, including tremors, rigidity, dystonia, and chorea.

Patients spoke little during the acute illness and later reported that they had found themselves unable to express their anxiety and feelings of doom. Almost all patients were agitated shOltly before developing NMS, suggesting to the authors that they were undergoing akathisia. The white blood cell count was elevated in all cases, dehydration was common, and lab tests showed a broad spectrum of enzymatic abnormalities, including indications of muscle breakdown.

There is little or nothing about acute NMS to distinguish it from an acute, severe episode of encephalitis, especially lethargic encephalitis

Brain-Disabling Treatments in Psychiatry 51

(also called von Economo’s disease), except for the fact of exposure to neuroleptic therapy. I have previously compared neuroleptic toxicity and lethargic encephalitis in detail (Breggin, 1993; also see chapter 5).

Although Rosebush and Stewart provide insufficient data to draw exact parallels, their NMS patients also suffered chronic impairments similar to those reported in lethargic encephalitis patients. Of the 20 patients, 14 continued to have “extrapyramidal symptoms or mild abnormalities of vitals signs and muscle enzymes at the time of discharge” (p. 721); but we are not told how many of the 14 specifically had persistent extrapyrami- dal signs. In a striking parallel with lethargic encephalitis, three patients displayed persistent parkinsonian symptoms until they were lost to follow- up. One patient, who had mild cognitive impairment prior to NMS, devel- oped a persistent worsening of her dementia.

Neuroleptic malignant syndrome has also been reported with the atypi- cal neuroleptics, clozapine (Anderson & Powers, 1991; DasGupta & Young, 1991) and risperidone (Dave, 1995; Mahendra, 1995; Raitasuo, Vataga, & Elomaa, 1994; Singer, Colette, & Boland, 1995).

NEUROLOGICAL MECHANISMS OF PARKINSONISM AND TD

Drug-induced parkinsonism apparently develops in part, but not wholly, from blockade of dopamine receptors in the basal ganglia, specifically the striatal region or striatum (the caudate and putamen), producing motor retardation, rigidity, and other symptoms. Damage and degeneration in the pigmented neurons of the substantia nigra play a key role. These neurons terminate in the striatum, where, when they are functioning nor- mally, they release dopamine to act on striatal dopamine receptors.

Tardive dyskinesia is a more delayed reaction, probably based on the development of reactive supersensitivity or hyperactivity in these same striatal dopamine receptors following continuous blockade (see American Psychiatric Association, 1980; Fann, Smith, Davis, & Domino, 1980; Klawans, 1973; and chapter 5 in this volume). This supersensitivity of the dopamine receptors becomes most obvious when the drug is reduced or eliminated, terminating the blockade. The overactive, unblocked receptors produce the tardive dyskinesia symptoms. Undoubtedly a great deal more must be learned about the neuropathology of both these drug-induced

52 Neuroleptic Malignant Syndrome and Related Disorders

diseases, which probably involve multiple neurotransmitter system abnor- malities.

CONCLUSION

The widespread use of neuroleptics has unleashed an epidemic of neuro- logic disease on the world. Even if tardive dyskinesia were the only permanent disability produced by these drugs, this would be among the worst medically induced disasters in history. Meltzer (1995) has urged that attempts be made to remove long-term patients from neuroleptics and has attempted to demonstrate its feasibility. Gualtieri (1993), warning about the extreme dangers, has suggested neuroleptics be viewed as a therapy of last resort. I believe the profession should make every possible effort to avoid prescribing them. Although beyond the scope of this book, it is worth ending with a reminder that there is strong evidence that psychosocial alternatives can be more effective in the treatment of both acute and chronic patients labeled schizophrenic (Breggin, 1991a; Breg- gin& Stern, 1996; Karon & Vandenbos, 1981; McCready, 1995; Mosher & Burti, 1989).

Standard
Psichiatria

Dsm V: a disaster for American psychiatry


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Dsm V: a disaster for American psychiatry

The catastrophic terror, evoked all the time, seems to be the sticking point of the collective psychology in the United States. And there are people who earn inventing diseases

 


Domenico Fargnoli
giovedì 17 gennaio 2013 13:01

Allen J. Frances, Professor Emeritus of Psychiatry at the Duke University and coordinator of the team of experts that in 1994 created the DSM IV (Diagnostic and Statistical Manual of Mental Disorders), regarding the soon to be published new version, the 5th, talked about “a disaster”. With respect to its etymology, the term “disaster” (dis-aster) refers to a calamity, as it could have been the end of the world proposed by the Maya, caused by negative astral influence. The DSM manual, now considered in its various editions a true Bible for psychiatry, has been conceived and written by real people, with real names: on those real people must fall the enormous responsibility for the incalculable damages that the practical applications of DSM criteria – completely devoid of any scientific basis – could cause to the mental health of millions or even billions of people. To exorcize or cancel the sense of guilt about the possible iatrogenic damage, I think that it’s not enough to simply exchange a human event with a natural event, just as schizophrenic patients use to do; or to lose the research of the real causes by referring to horoscopes, destiny and alignment of planets. As the use of particular terms reveals, a catastrophic sense has silently and unnoticeably entered, just like the Trojan Horse, the secret citadels of the powerful lobbies of the A.P.A., pointing out a dangerous flaw in their ideological pseudo-truths. The subject is very present. Freus’d “death” has left, in America, a heavy heritage that negatively influenced psychiatry. Catastrophic fantasies and daydreaming form part of the connective tissue of North American imagination: from the famous 1938 radio show in which Orson Welles announced the war of the worlds and the Earth attacked by Martians, causing a wave of uncontrolled and general panic; to cinema productions like “The Invasion of the Body Snatchers” (Don Siegel, 1956), or like more recent ones: “The Day After Tomorrow” (Roland Emmerich, 2004), “2012” (Roland Emmerich, 2009), the catastrophic terror, perennially evoked and exorcised, seems to be the sensible, aching spot of collective American psychology. Surely Osama Bin Laden had well understood this aspect, when planning the attack to the Twin Towers: a scene that, seen on television, seemed to be taken from a Sci-Fi movie. Sometimes nightmares, or what psychiatrists could define as “socially shared deliriums” are transformed by someone in reality with an enormous amplification of the terrifying effect.

In May 2013 the new edition, revised and corrected, of the DSM, the famous Diagnostic and Statistic Manual of Mental Disorders will be published: even without referring to astrology, it’s been anticipated that for American psychiatry it will represent a true announced catastrophe. According to Allen J. Frances, the present moment – that exactly matches the final approval and the imminent release of the manual – is the worst moment in his multi-decennial activity of study, teaching and clinical research in psychiatry: he encourages patients, physicians, media and naturally psychiatrists to refuse credit to a publication that, in his opinion, has no scientific credibility and that could lead to many and very serious diagnostic mistakes, extremely dangerous for patients due to completely useless prescriptions for drugs. These new diagnoses in psychiatry could well be more dangerous than the medicines, because they deeply affect the circumstance that millions of people could be prescribed psychotropic drugs often by general practitioners and after a very short interview. The introduction of new diagnoses should be done with the same attention that is dedicated to the patients’ health when introducing on the market new drugs. All the new diagnostic categories introduced in the DSMV – from those regarding alimentary abuse (basically everyone who loves eating and good food could be diagnosed with Binge Eating Disorder), to addictions (millions of youths could be diagnosed with Internet Use Gaming Disorder), to autism spectrum (Autism Spectrum Disorder, in which from now on will be included the Asperger Syndrome, that used to be a separate and autonomous diagnosis) – extend the limits of pathology by the tendency to codify many symptoms that are dangerously close to “normality”. There are many other extremely controversial aspects in the DSMV, like the adoption of the definition “Pedophilic Disorder”. The word “disorder” can not, in any case, give a correct idea of the seriousness of this pathology, that in this new edition is considered in such a manner only when the sexual fantasies and impulses create a sense of clinically significant “discomfort” (sic!) or the impairment of working or social activity, as it was already stated in the DSMIV. This definition has a very important consequence: only those who perceive a sense of “discomfort”, a sense of guilt, that is, could be diagnosed as pedophiles, while those with a much more serious illness, those that are completely unemotional could be considered normal because they do not feel any guilt or discomfort, because they maintain an equilibrium. This tendency to identify “normal” and “unemotional” can be found also in the decision – that could also appear in the DSMV, unless last minute changes are adopted – of confusing the pain caused by the loss of someone close, with a clinical depression. Grief excluded depression in the DSMIV, while in the new edition these two situation could coincide. Regardless of the final conclusion of this controversy, that has risen due to many protests from many columnists and important scientific publications, it clearly speaks well about the ideological foundation of American psychiatrists, that consider schizoids, those that are completely unemotional, as perfectly normal and balanced people. The repercussions of this conception are important: every year 2,5 millions of people in the United Stated die, leaving many more people, relatives and friends, in a state of sorrow and grief; if this condition goes on for more than two weeks, these people could easily be diagnosed, especially by general practitioners, a depression – this with great satisfaction, economical also, for pharmaceutical industries. In everyday’s medical practice the false positives of depression diagnoses after a loss, cause absurd situations and clearly show, just by common sense, an admission of complete incompetence.

American psychiatry is absolutely unable to face extremely serious psychotic situations such as Adam Lanza’s mass murdering: in this case schizophrenia hasn’t been diagnosed and aptly treated. A normal and physiological state of grief is considered pathologic and a clear psychotic state isn’t detected. The so called “mass shooting” has become almost epidemic, a sort of unconsciously repeated dramatization of the idea of a violent and hyper rational society (62.000 deaths in just a few years by firearms) that historically has been erected on racism and systematic extermination of native populations. The same war ideology that makes the United States so present in many unfair and useless conflicts, is the origin of a psychiatric emergency in the armed forces: 295 soldiers took their lives just in 2012. The only given response to this dramatic situation is a manual that’s been created with the aim of reinforcing the academic status quo, that is very far from real life and whose main interest is to obtain an economic profit for pharmaceutical sector. According to Frances the motivations that lead to the new edition of the DSM aren’t just of economic nature, tied to a very simple conflict of interests among various researchers paid by different pharmaceutical industries; this conflict, for the scientist, is a lot more of “intellectual” nature: these highly specialized researchers have the natural tendency to value their personal guidelines and ideas, to expand their sectors of study regardless of the practical clinical consequences for the unfortunate patients. It must not be underestimated that A.P.A. invested 25 millions in DSMV, and given that the previous edition has been a worldwide bestseller, a similar result is expected for this new edition as well, not only in terms of profits from the sells, but also in terms of increased popularity and prestige for the researchers – popularity and prestige that can be cashed in on as well. Even if Professor Frances’ critiques appear to be somehow well motivated, they do not decrease his personal responsibility in this announced disaster.

He has been, indeed, the first creator of DSMIV, starting what now appears to be a true psychiatric apocalypse: it must be remembered that the 1994 edition of the manual was labeled as “trash science” in an international survey of experts carried on in England in 2001, as well as being voted as one of the ten worse psychiatric publications of the millennium. It’s false, therefore, to say that there’s a substantial difference between DSMIII and IV, because in the latter, already, it was introduced a clear loss of effectiveness of the diagnosis in favor of its reliability: a group of psychiatrists finds an agreement on a series of atypical behaviours and on the fact that they found a mental disease. The creation of new categories becomes, therefore, a sort of cultural and intellectual game completely devoid of any scientific validity despite its – supposed – reliability that comes from the simple fact of being shared by a large number of experts: this procedure, applied to the real world of clinical practice is a fraud tout court. As it shows, not only Allen J. Frances appears be to be unreliable when not only declaring his non-theoreticism, but also when claiming to have overcome the confusion of diagnoses that ruled psychiatry before the DSMIV; a confusion largely due to the massive presence of Freudian psychoanalysis in America. There’s a precise historical and ideological continuity between the Freudian fraud – submitting patients to analysis without wanting and without being able to be a cure – and DSM in its various versions – proposing diagnostic criteria based on pseudo-scientific assumptions, as those regarding the affirmed genetic nature of schizophrenia, just as an example, very useful to be paid by medical insurances.

Just as Freudians considered all human beings as potential carriers of mental illness, for the fact that in everyone there would be a naturally perverse subconscious and a schizophrenic ideation as the one in dreams; so the A.P.A. now with DSMV sees in normality a state of potential illness: for the psychoanalysis, mental illness, omnipresent in every human being, was latent in the subconscious; at present moment, on the other hand, mental illness is found in the conscious and in the behaviour of so-called normal people that, for example, have the misfortune of losing a relative, therefore getting trapped in the knots of the diagnostic categories of DSM. Personally I will comply with Allen J. Frances advices: I will boycott in every possible way the DSMV, adding that I’ve done exactly the same with III and IV. Just as I did not believe to Mayas’ prophecy about the end of the world, so I don’t believe that the failure of DSMV is a particularly meaningful event in the history of contemporary psychiatry, despite all the hype in the mass media. According to my experience and formation, the true game regarding the future of psychiatry is played on another field: in my professional practice I will keep on using the classification of illnesses that was already present from the start of 20th century in the great theoretical production of the psychopathologists, with the likes of Jaspers, Eugen Bleuler, Minkowsky, Kurt Schneider, Barison.

To my advice, only the critical revision of those diagnostic categories with a psychopathologic derivation, carried on for more than sixty years by Massimo Fagioli, allows us to correctly identify and focus the nature of the pathogenetic processes that we have to face in the practice of psychotherapy. Fagioli’s “Teoria della Nascita” (“Birth Theory”) completely transformed all traditional theoretical views regarding the genesis of mental illness. Starting with Esquirol, throughout 19th and 20th centuries to the present (the last example being Rita Levi Montalcini), it’s been thought that mental illness is tied to a rationality deficit and to a diminished ability to draw together by the conscience. Regression, therefore, would set the subconscious automatisms free, taking into light an irrational ideation that was considered naturally psychotic. Today, though, we know that the generating nucleus of the illness does not reside in conscience, but in a specific unconscious activity, the “Pulsione di Annullamento” (“Annulment Drive”), that was historically discovered by Fagioli: the “Pulsione di Annullamento” is not a natural characteristic with which each human being was born; to the contrary, it derives from a failure in the relations with other human beings. Originally the “Pulsione di Annullamento” comes from an inadequacy in the relation between mother and child: this inadequacy – no matter how we conceive it – affects the child’s vitality right from birth. Only by identifying the generating nucleus responsible for the specific form that mental illness takes, we can get also what is not immediately visible and understandable by the conscience, thus formulating diagnoses that are not only reliable, but also motivated and true. Many other internationally known researchers, such as American Louis A. Sass and Joseph Parnas from Copenhagen University, share this same view, although in a different theoretical reference frame; according to Parnas, only by improving our psychopathologic knowledge, we can fight the reification of the diagnostic categories that is carried on in the various editions of the DSM, the Bible of American psychiatry.

Domenico Fargnoli, psychiatrist

Translation: Dr. Lorenzo Frusteri

Italian version

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cosa c’è dietro la strage degli innocenti di domenico fargnoli



  • di domenico fargnoli

    Cosa c’è dietro la strage degli innocenti

    Quella del killer della Sandy Hook è l’imitazione manierata di un militare dei corpi speciali. Le vittime, nel suo delirio, “viste” come bersagli inanimati [Domenico Fargnoli]

    Domenico Fargnoli*
    domenica 16 dicembre 2012 17:29

    Matteo di Giovanni, Strage degli Innocenti, pavimento del Duomo di Siena

    Matteo di Giovanni, Strage degli Innocenti, pavimento del Duomo di Siena

    Adam Lanza, il ventenne americano che venerdì scorso, nel Connecticut, ha ucciso 26 persone fra cui 20 bambini di età compresa fra cinque e dieci anni, per poi suicidarsi, appartiene alla categoria di omicidi che i criminologi in epoca recente hanno denominato “Pseudocommando”. Di essa fanno parte soggetti che equipaggiati con armi da guerra e giubbotti antiproiettile, come se appartenessero a truppe d’elite, assaltano e uccidono a caso e in un breve lasso di tempo un gran numero di persone inermi. Negli Stati Uniti, nel 2012, quasi ogni mese si è verificato un episodio in cui moltissime persone, per lo più giovani e studenti, hanno perso la vita per l’azione imprevedibile di individui di cui nessuno sospettava la pericolosità. Ciò che colpisce è la ripetizione, in tali delitti, del copione del gesto eroico, alla Rambo, dell’omicida suicida: un uomo solo spara contro un gruppo, una massa anonima per motivi che appaiono incomprensibili alla comunità. Il primo interrogativo è: come può la mostruosità della strage balzare fuori dalla sonnacchiosa normalità della vita di provincia americana? Forse solo apparentemente era “normale” la madre di Lanza, la prima vittima sfigurata con un colpo al volto, quando pur dedicando la sua vita ai bambini, coltivava la passione delle armi da guerra con cui si esercitava regolarmente con i figli al poligono. Forse non è normale per nessuno trovare divertente o compiacersi del possesso di un moderno fucile d’assalto come quello sottratto dal giovane alla madre, pensato e progettato per seminare la morte.

    Un mitragliatore non è una semplice arma di difesa personale che è legittimo detenere in base al secondo emendamento americano, ma è un oggetto concepito per compiere una strage, per determinare il rapido annientamento di una moltitudine di eventuali assalitori. Se alla fine del settecento era una necessità reagire contro l’esercito spagnolo e inglese, nel territorio statunitense oggi non è in corso nessuna operazione bellica. La legalità della detenzione di armi e di armi da guerra in particolare è pertanto immotivata sia dal punto di vista della società in generale che dell’individuo. Si può ipotizzare che dietro il comportamento socialmente e legalmente ineccepibile della madre dell’omicida e la sua “normale” passione per pistole e fucili si sarebbero potute celare fantasticherie megalomaniache e persecutorie, più o meno coscienti. Nella relazione profondamente malata con il figlio, non provvisto di una identità solida e definita, stando ai racconti di chi lo conosceva, esse avrebbero potuto contribuire a innescare in lui l’idea della strage. Bisogna mettere in evidenza il fatto che il cosiddetto “Pseudocommando mass murderer” fa solo l’imitazione manierata di un militare dei corpi speciali (vedi anche a questo proposito il caso del norvegese Anders Breivik) perché i soggetti colpiti del tutto incapaci di difendersi non sono terroristi o sequestratori armati e pericolosi. Le vittime inoltre vengono completamente disumanizzate nel delirio: Adam Lanza ha sparato sui bambini “vedendoli” come se fossero i bersagli inanimati del poligono di tiro.

    Nell’esecuzione fredda e calcolata di una strage così efferata nessun dimensione emotiva può entrare in gioco: se un qualunque “affetto” fosse presente, consentirebbe un riconoscimento dell’altro come essere umano e bloccherebbe la mano dell’assalitore. La vera motivazione del mass murderer è pertanto da cercare nella realizzazione di una totale anaffettività e disumanizzazione che sfocia prima nell’annullamento e poi nell’annientamento fisico di un gruppo di individui e di se stesso. Alla massa per lui amorfa ed indistinta, l’omicida si contrappone come un assolutamente altro, un “Anders”, che con un atto estremo di violenza distruttiva ratifica il proprio totale fallimento umano. La ritualità manierata degli omicidi eseguiti con una vestizione e un armamentario particolare, l’anaffettività che fa percepire all’assassino le vittime come entità non umane, la presenza del delirio implicita nella progettazione della strage esclude sia motivazioni immediatamente comprensibili che “l’impeto passionale” di gelosia evocato da Vittorino Andreoli nel Corriere della Sera. L’idea di un impulso omicida irresistibile dovuto a uno stato emotivo abnorme ricorda la “monomania omicida” di Esquirol e Georget nei primi decenni dell’Ottocento che è stata ampiamente superata e criticata dalla psichiatria attuale. Anche l’altra affermazione dello psichiatra veronese secondo cui il giovane statunitense avrebbe uno sviluppo mentale di un bambino di quattro anni è molto discutibile: da quando in qua i bambini dell’asilo fantasticano omicidi di massa? Le considerazioni precedentemente esposte fanno propendere la diagnosi dello psichiatra, per ciò che riguarda il ventenne americano, per una forma di schizofrenia.

    A proposito del caso Breivik che si discosta da Adam Lanza per l’assenza di una vera intenzionalità suicidaria e per la presenza di una motivazione pseudoterroristica, ecco cosa scrive sul settimanaleleft lo psichiatra Massimo Fagioli: «Udii, un anno fa, l’assassino freddo dei 77 ragazzi di Utoya. Reagii scrivendo deciso: schizofrenia paranoidea ma, forse, ebbi nelle parole un po’ di razionalità perché.il freddo sentito era invisibile. Fu detto: pazzo criminale.
 Ora le parole che vengono sono: “Ho ucciso settantasette formiche; chiedo perdono ai fobici per non averne uccise di più”. Ero disturbato dai loro morsi che sembravano punture di spillo.
Forse so interpretare ciò che ho scritto. Scrivere togliendo al parlare ogni realtà di rapporto interumano. 77 ragazzi, 77 formiche. Viene pensato uguale, come se fosse uguale». Nell’agosto del 2012 sempre sulla sua rubrica settimanale “Trasformazione”, Fagioli ha parlato a proposito del ragazzo di Denver che aveva ucciso senza motivo 12 persone in un cinema, di stolidità e di schizofrenia semplice. Del ventenne del Connecticut sappiamo molto poco: da ciò che trapela dai media americani e italiani sembra fosse ritenuto affetto da una sindrome di Asperger, con problemi importanti nella socializzazione, e da una personalità schizoide. Ora la diagnosi di sindrome di Asperger è quanto mai fumosa e controversa tanto che si parla del fatto che nel nuovo DSM V (in uscita nel 2013) essa non sarà più presente, con tutti le controversie assicurative che ciò comporterà, per una totale revisione che verrà effettuata nel nuovo manuale diagnostico del concetto di autismo. Inoltre non esiste una letteratura che propenda a favore di una correlazione certa, come hanno fatto notare le associazioni di familiari dei malati mobilitatisi in questi giorni sulla stampa, fra le varie forme di autismo, comunque lo si voglia definire e l’acting out violento.

    Per quello che riguarda la diagnosi di personalità schizoide sappiamo che in essa oggi viene inclusa quella che Eugen Bleuler, a partire dal 1913, denominava “schizofrenia simplex” in cui non si hanno deliri o allucinazioni o altri sintomi accessori. La personalità schizoide, secondo Kurt Schneider, è una struttura della personalità caratterizzata da una povertà dei legami affettivi. Essa resta per lo più invariata nel tempo, mentre la schizofrenia semplice è un vero e proprio quadro psicotico che può rimanere allo stato latente come può anche evolvere verso le altre forme di schizofrenia e, anche se in un numero limitato di casi, sfociare in condotte violente. Adam Lanza sicuramente è andato incontro a un improvviso peggioramento del suo quadro psicopatologico con un esito catastrofico come avviene nella schizofrenia. In assenza di una diagnosi corretta e motivata e di un intervento psichiatrico adeguato il giovane è stato lasciato a se stesso e al rapporto con la madre sicuramente molto patologico in una pressoché totale assenza del padre, risposatosi dopo la separazione nel 2008, e del fratello Ryan che viveva da tempo lontano da casa. Da questa tragica e dolorosissima vicenda, soprattutto per le famiglie dei bambini e delle persone uccise, emerge la responsabilità ovvia della lobby delle armi che specula sulla paranoia delle cosiddette persone normali, ma anche della psichiatria americana che ancora una volta appare del tutto inadeguata, con le sue categorie diagnostiche e con i suoi interventi farmacologici finalizzati soprattutto al lucro delle case farmaceutiche, ad affrontare l’inquietante problema della malattia mentale.

    Domenico Fargnoli, psichiatra e psicoterapeuta

  • Monday 17 December 2012

    Connecticut school shooting: Adam Lanza’s mother was preparing for disaster

    The mother of the gunman who killed 20 children and seven adults in America’s worst school massacre, was a gun-proud “survivalist” preparing for economic collapse, it has emerged.

    Connecticut school shooting: Adam Lanza's mother was preparing for disaster

    A police officer wipes her eyes, Adam Lanza and his victims

    By , Connecticut and Peter Foster in Washington

    9:45PM GMT 16 Dec 2012

    Nancy Lanza, whose gun collection was raided by her son Adam for Friday’s massacre at Sandy Hook school, was part of the “prepper” movement, which urges readiness for social chaos by hoarding supplies and training with weapons.

    “She prepared for the worst,” her sister-in-law Marsha Lanza told reporters. “Last time we visited her in person, we talked about prepping – are you ready for what could happen down the line, when the economy collapses?”

    It also emerged that Mrs Lanza had spoken of her fears less than a week before the attack that she was “losing” her son. “She said it was getting worse. She was having trouble reaching him,” said a friend of Mrs Lanza who did not want to be named.

    Adam Lanza, third from the right, posing for a group photo of the technology club which appeared in the Newtown High School yearbook

    Police disclosed that the 52-year-old had five legally registered guns – at least three of which her 20-year-old son carried with him. Most victims were shot with an assault rifle, while Lanza also carried two handguns and left a shotgun in his car.

    President Barack Obama was in Connecticut to comfort families of the victims, amid mounting pressure for political action in Washington on gun control.

    Democrats are preparing to introduce a new bill to ban assault rifles, but the difficulty of achieving any consensus was well illustrated after one Republican congressman said staff at the school should have been armed to protect themselves.

    Fresh details emerged of the massacre which has caused shock across America as well as internationally.


    Nancy Lanza, who was killed by her son with her own gun (Reuters)

    Lanza was reported to have wiped out one complete class of six and seven-year-olds along with their teacher. Dr H Wayne Carver, Connecticut’s chief medical examiner, said the injuries were the worst he had seen in his career with some of the children shot 11 times.

    One of the victims, six-year-old Dylan Hockley, was the British-born son of a couple who moved their family to Connecticut from Hampshire two years ago.

    His mother, Nicole, had described the area as “a wonderful place to live”, with “incredible” neighbours and “amazing” schools”.

    Dannel Malloy, the Connecticut governor, said the death toll might have been much greater and Lanza may have planned to kill even more.

    “We surmise that… he heard responders coming and apparently at that, decided to take his own life,” Mr Malloy said.

    Candlelit vigils were held over the weekend for the victims.

    One was for Victoria Soto, a 27-year-old teacher who was killed after telling Lanza the children were in another room, allowing some of the children to escape. “She was selfless – selfless,” Jessica Zrallack, a former schoolmate, told The Daily Telegraph.

    Newtown’s residents were forced to endure fresh anguish yesterday, when a Roman Catholic church that has become a centre of support for the grieving, was evacuated following a telephoned-in security threat. St Rose of Lima was later given the all-clear.

    Mr Obama was in the town last night in order to comfort the families of those killed and speak at an interfaith vigil.

    The president, who failed to deliver on a 2008 election promise to reinstate an assault weapons ban, is now under mounting pressure from within his own party to throw his political weight behind new laws.

    (Top row from left) Charlotte Bacon, Daniel Barden, Olivia Engel, Josephine Gay, Ana Marquez-Green. (Middle row from left) Dylan Hockley, Catherine Hubbard, Chase Kowalski, Jesse Lewis, James Mattioli. (Bottom row from left) Grace McDonnell, Emilie Parker, Noah Pozner, Caroline Previdi, Jessica Rekos

    Despite the outpouring of national grief, the Bill is likely to be highly divisive; Congress has not passed significant gun legislation for almost 20 years, amid partisan gridlock.

    A poll by CNN in August found that 57 per cent of Americans favour a ban on semi-automatic assault weapons, while 60 per cent favour outlawing high-capacity ammunition clips.

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