Treatment and recovery in mental health NICE guidelines and service user perspectives Katherine Darton

outline Standard diagnosis and treatment in psychiatry Schizophrenia as an example - symptoms - treatments - alternative ways of understanding - alternative approaches to treatment CAMs – possible place?

Diagnosis based on ICD-10 (WHO) and DSM-IV (APA) criteria mood disorders – depression anxiety psychotic disorders crucial for access to treatment

NICE guidelines Depression – mild to moderate; severe Anxiety – + panic disorder, OCD & BDD Self-harm Eating disorders PTSD Bipolar disorder Schizophrenia Personality disorders – antisocial; dangerous and severe; borderline Plus guidelines on specific treatments

Schizophrenia - symptoms Positive symptoms Hallucinations – voices, things seen, etc. Delusions – being controlled by outside force; paranoia; thought insertion; thoughts being heard; magic powers Lack of insight Increased salience (dopamine)

Schizophrenia - symptoms Negative symptoms Self neglect Lack of emotional response Absence of thoughts Apathy

Schizophrenia - treatments Medication – antipsychotics Talking treatments – CBT Arts therapies – art, drama, music, dance

Medication Antipsychotics – neuroleptic; ataraxic [ataraxy – detachment; indifference – distinct from sedation] Block dopamine – and other neurotransmitters

Dopamine Brain neurotransmitter Salience – the importance attached to things associated with psychosis Voluntary movement Prolactin Effects on other neurotransmitters

synapse Photomicrograph of synapse

Synapse - diagram

Antipsychotics – adverse effects Parkinsonism Other movement disorders - tics, spasms, tardive dyskinesia, loss of fine control Akathisia Prolactin – breast development; lactation sexual side effects Heart effects – disturbances of heart rhythm

Antipsychotics – adverse effects Metabolic syndrome – weight gain, increased blood fats, diabetes Blood disorders Antimuscarinic effects Constipation Life-limiting not worth the candle?

Antipsychotics – and talking Reduce salience – hence some psychotic symptoms Do not change beliefs or past experiences need CBT or other talking therapy to unlearn things wrongly attributed and come to terms with damaging events (Human Givens therapy) Arts therapies – may help deal with bad memories; park difficult ideas.

Schizophrenia – controversies a scientific delusion – subjective diagnosis An unhelpful label – stigmatising; implies deterioration No evidence for discrete condition 4% of population hear voices – only a minority are bothered by them

Alternative approaches Formulation vs diagnosis (sense-making) Other cultures Hearing Voices Network – a new approach to symptoms (the voices have a message – need to translate it) Narrative approaches (tree of life) Group therapy – helps people know themselves

Recovery Process rather than outcome Person rather than symptoms/diagnosis Hope The end of untreatability (unheilbarkeit) Self-determination Allow people to tell their story Come off medication (hi-jacked by professionals)

Medication withdrawal Psychoactive substances Consequences of long-term medication – receptor changes Abrupt withdrawal Slow withdrawal – dose reduction switch to drug with longer half-life

Alternative therapies Help with adverse effects Help with withdrawal help with symptoms? Acceptance as treatment Need for evidence of efficacy - scientific studies in peer-reviewed journals Personalisation – an opportunity?

Resources Books Gail Hornstein – Agness jacket Marius Romme and Sandra Escher – Accepting voices Jim Read – Psychiatric drugs: key issues and service user perspectives South Somerset Mind – Art of recovery Websites