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?