Monday, November 18, 2013

Are all psychiatric drugs just avoidance that make the problems worse?

Nils Nilsen Clinical Psychologist

In working with anxiety patients, I see that there is one element that is behind all anxiety problems: Avoidance of psychological distress. The typical case is a person who feels anxious going to shops. She gets Valium or another benzodiazepine and takes this in order to do her shopping.

She avoids the anxiety by taking the drug. She never goes to the shop without taking the drug, so she has no opportunity to see that she would have been able to do it, and that she would get better every time she tried.

So she ends up not being able to go to the shop, and after a while other places (avoidance always spreads) and in addition she is physically dependent on a drug with many side effects.

In anxiety treatment it is fairly accepted that medical treatment to avoid discomcfort makes the problem worse.
Could it be the same in depression?
A person is depressed because she feels she is unhappy in her marriage. She has all the clinical/diagnostic signs required to be diagnosed, and gets an antidepressant from her doctor.

Is this avoidance in the same way that the benzo is avoidance in anxiety. Depression is an unpleasant state, and is often difficult to distinguish from anxiety. She avoids the feeling by taking a pill. Since the feeling is no longer there to motivate her to do something to get it away, e.g. get couples counseling, we have an avoicance situation. She does not learn what she is supposed to learn: that something can be done with the problem or the thoughts about the problem (CBT).

So she is now addicted to a medication that is very difficult to stop, and nothing has been done with the problem the emotion signaled.

How about psychotic symptoms? Can antipsychotics be an avoidance solution that makes things worse?
Let us take a classical example of a man who starts thinking the FBI is after him. All around him see that this is not the case and that it gives him a psychologically unpleasant state. We give a second generation antipsychotic, and after some days, he says that even if he still thinks the FBI is after him, he doesn’t really care. It is not so important. Actually nothing is important apart from food. The unpleasant feeling decreases, and it seems like the problem is solved.

But what actually happens? The man no longer has any motivation to find out if the FBI really was after him, and may uncritically accept other strange thoughts since he has not learned to check out the validity of thoughts. We all may have strange thoughts from time to time (exemplified in the Bud Light superstition commercials), but we usually have a strong motivation to check their validity. This motivation is often taken away with antipsychotic drugs, since they take away most motivation, e.g. for personal hygiene.

So medicating away a problem may be like peeing in your pants on a winter day. It is very nice and warm for a little while, but then the situation becomes worse than before.

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