Monday, October 22, 2012

Has psychiatry over-reacted to psychosis?

Yesterday, I sat down with my son to discuss his recent difficulties that resulted in his going back on medication, the warning signs - will he be able to recognize them in future? - and observations about what we can do in the meantime to avert future episodes.

I'll get to the title of this post after I meander through the events of this past summer and how they are informing some current thoughts about Chris's troubles of the past ten years.

The latest mini-crisis may have started in June with Chris complaining about not sleeping well. He had finally come off the Abilify in April or May, having tapered over the course of one year from 5 mg down to nothing. His lack of sleep could have been related to going off the drug, and/or, lack of sleep could be something that he always needs to guard against. (Even as a toddler, he put himself to bed, early, which was kind of unusual, I would say.)

To be honest I didn't give the latest professed lack of sleep too much thought, for several reasons. One is that Chris didn't look or act like someone who wasn't sleeping well. He got up early every day like clockwork, he went to bed at a reasonable hour each night, he didn't have bags under his eyes. In September, when he again complained about not sleeping well (there were periods in between when he said he was getting a good night's sleep), I suggested that he ask Dr. Stern for a sleeping pill. The rest is history. Dr. Stern put him back on an antipsychotic within two weeks of his asking for help sleeping.

If lack of sleep is the cause of this latest drama, then Chris's growing lack of self-confidence that I DID observe in September, is a possible by-product. He was becoming downright weepy and talked of himself in very self-deprecating terms. Lack of sleep will do that for some people. For other people, lack of sleep will make them hostile, aggressive, or paranoid. Prolonged lack of sleep can eventually lead to hallucinations.

If you haven't listened to Will Hall's presentation in front of the American Psychiatric Association, please do. Will knows the territory of psychosis very well. In his speech he makes reference to lack of sleep as an under-recognized/under-treated factor in psychosis. Many people claim that they became psychotic following a period of intense sleeplessness. That fact I know well, but then it gets complicated. As Chris pointed out, the psychiatrists when he was first hospitalized talked about the importance of sleep in the recovery process, but they didn't relate it to a possible reason for his becoming psychotic in the first place.
Chris started to go psychotic during his last year of high school, a time of intense academic pressure. He tells me that he drank coffee to keep himself awake into the early hours of the morning. For many people staying up late wouldn't be a problem, but perhaps for Chris, who put himself to bed voluntarily as a toddler, lack of sleep for him means more than just being tired the next day.

My latest effort to help improve Chris's resilience (help him get better sleep to avoid psychosis) was to move him into a bedroom that is much darker and quieter at night, and to keep him supplied with Dr. Hoffer's niacin combination, which also aids sleep.

Perhaps if his psychiatrists at the hospital had focused on lack of sleep as a possible primary cause of his psychosis, rather than merely one of many symptoms of psychosis, his recovery to date would have been more straightforward. Why couldn't he have been treated with a sedative at night, like Joanne Greenberg (author of I Never Promised You a Rose Garden)  was given when she was a patient at Chestnut Lodge in the late 1950s? I suspect the answer may be that today's patients are given antipsychotics during the day (which have a sedating effect), and sent home quickly in order to avoid costly hospital stays. Hospitals are not prepared to be Soterias. Joanne Greenberg spent three years at Chestnut Lodge, where she wandered the hospital during the day conversing with other patients, and saw her psychiatrist once a week. She was unmedicated and quite psychotic, but presumably got a good night's sleep. After three years, she was released from hospital.

I am deliberately hedging my bets here about putting too much emphasis on sleep deprivation as a cause of Chris's psychosis, but I do think it is an area that psychiatry has put too little emphasis on as a possible causative factor for some individuals. Sleeplessness in most people leads to anxiety, lack of self-esteem, aggression, and, in a certain segment of people, to hallucinations, all of which are considered symptoms of psychosis. Why not begin with aggressively treating sleeplessness through the more conventional means of sedatives at night and preparing the proper sleep environment?


  1. I agree sleep is critical, but given that the most commonly prescribed drugs for sleep are benzos and the related z-drugs, it's not as simple as handing out just never is. As many of your readers may know benzodiazepines potentially have the worst withdrawal profile of all the psychiatric drugs and because they're so effective in the short-term people often like's risky business being that they're so addictive.

    One can do many things to aid sleep...including many daily and nutrition, exercise and meditation all have an important role as well...

    I know I'm not telling you anything new here, Rossa...I'm making the comment simply to add to the conversation for others.

    when up against a wall pharmaceutical sleep aids may be all one can resort to, I have no issue with that, but I know folks who have severe withdrawal reactions to benzos after being on them for as short of a time as a couple of weeks (even among those with no psychiatric history ie: given the drug for a muscle pain or something), so again...caution is always warranted.

    1. Thanks for your in-depth comment. I'm not familiar with the term z-drugs. Can you fill me in? There are other natural sleep supplements - Chris tried those, too, in the past - but what we are lacking here is a concerted effort by psychiatry to tackle the sleep problem in the least invasive way.

    2. z-drugs are the drugs like lunesta, ambien, sonata and zoplicone...they're very closely related to benzos and people can have really nasty withdrawals from them...

      but I agree with you...bottom line psychiatry needs to learn about holistic wellbeing...that EVERYTHING in your life contributes to your health and also your ability to sleep...until that is embraced and pursued we get no's much better to go elsewhere for that information at this time (in general anyway...)

  2. Ms. Forbes,

    I had a terrible time getting to sleep when I was manic and I was greatly helped by a drug called trazodone. It's a generic, old-school antidepressant that people rarely take for its original purpose anymore, largely because it is so sedating.

    I stil take it and it still works very well at the same dose I've been on for years--it's not one of the drugs I've developed the kind of tolerance for that makes me want more and more.

    Trazodone is old, dirt-cheap and safer and less addictive than benzos or "z-drugs." However, there is one potential side effect for men that women do not have to worry about--it is similar to a potential side effct of Viagra.

    (I'm trying to be discreet yet get the point across, so please forgive me if I sound a bit goofy.)

    I personally have not experinced any negative side effects from Trazodone but Chris should read up on them if he ever considers taking it.

    I take melatonin as well. Chris might also want to try another natural supplement called 5-HTP (tryptophan), but of course he should talk to his doctor first to make sure that any drugs he should take will not interact badly.

    Most people don't understand how vital sleep can be for some of us. If I go too long without sleep, I will kick myself right into a manic episode which will in turn cause more sleeplessness and possibly psychosis.

    It is a horrible cycle and I will do anything I can to avoid triggering it, though sometimes it still happens despite my best efforts.

    I know you have a preference for natural supplements, so you might want to ask Chris if he'd like to try melatonin and/or 5-HTP first and file away the information about trazodone in case they are not effective enough.

    Sleep deprivation can indeed cause psychosis, but like you, I am not at all sure that it caused my illness to take root in te first place. In fact, I rather doubt it.

    In any case, as always, I wish you and Chris the best of luck.

  3. Thanks for your helpful input, Anonymous. Like you said, I am still rather doubtful that sleep alone would have fixed his recent crisis, but I try to keep an open mind. Chris, when he was working with the holistic psychiatrist, was on melatonin and trytophan (present in turkey!)and a huge amount of other supplements, and yet he still relapsed. There is a huge puzzle to be solved. What some say works for them, won't be replicated in others.

  4. I am anonymous 2. Too much caffeine and not enough sleep while cramming for exams were definitely the cause which drove me into psychosis. I reached a point after a while where I just could not sleep no matter how hard I tried. It is well known that caffeine and not sleeping enough have the effect of increasing dopamine in the brain.Not being able to sleep made me anxious and unable to concentrate and think clearly which in turn made me depressed and feel like a failure.My mother talked me into taking valerian pills for a month and it helped, calmed me down and reestablished my sleep pattern. I became wise, never pushed myself in this terrible way again and never experienced psychosis again. I am 70 years old.

    1. Thanks for this great story. It reinforces the connection between caffeine, exam stress and psychosis.

    2. I wonder how many young people experience their first "psychotic break" due to both sleep deprivation and "caffeine allergy" -


  5. Rossa,

    In fairness, Dr. Pfeiffer *does* mention *sleep deprivation* as a cause - Deprivation

    Re: "Has psychiatry over-reacted to psychosis?"
    Answer: Is the Pope Catholic?

    Be well,


    1. More on sleep disorders -

      Resources for sleep -


  6. Duane,
    You are right! How did I miss number 8 on the list? I'll correct what I said in the blog. Now, if the past ten years were simply a matter of Chris not getting enough sleep, then there has been a definite over-reaction going on.
    Thanks so much for the link. I'll check it out.

    1. Rossa,

      I miss stuff all the time.
      Thanks for all you do with your website!

      Your family is in my prayers.


  7. Rossa,

    What Dr. Pfeiffer prescribed for the insomnia was the aminoacid tryptophan and the vitamin inositol. I take tryptophan 500 mg. only if needed, not in a daily pattern. If I required, instead one capsule 500mg, I could take until 8 capsules of 500 mg. during the night. It should be noted that beside I follow an orthomolecular treatment during the rest of the day. I don´t know if the tryptophan alone could be effective. The orthomolecular doctors said that its treatments works like a concert with all the nutrients interacting each other. Dr. Pfeiffer distinguished his patients mainly by their histamine (high or low), krytopyrrole, cerebral allergy and others characteristics that may overlap each other. with different treatments, as appropiate

    Inositol has a very relaxing effect and mimic the valium and the like. I take two 650 mg capsules each night

    One thing that it is necesary to take into account is that the quality of the sleep with antipsycotics and/or benzodiazepines is very poor (the important REM phase of sleep is invalidated or diminished). There were manifest signs particularly during the day. Dr. William C. Dement wrote about the importance of the sleep phases in his book “The Promise of Sleep”. He says that the REM phase was essential for a good quality of life, memory and learning amongst other things.

    If for whatever reasons, usually something that for me is stressful, I sleep less than four or three hours per night, I start taken 1 gram of vitamin C and 650 mg of inositol each hour or an hour and a half during one or two days, normally that´s enough, until the anomalies dissapear.

  8. Many thanks for this useful information. Niacin hexanicotinate is flushless niacin, I believe. Dr. Hoffer favored niacin or niacinimide over flushless niacin for treating schizophrenia, but I assume that all three kinds of niacin have sleep benefits. I'll start taking my niacin closer to bedtime, rather than in the morning as I have been doing.


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