Barry Blackwell: The Lithium Controversy - Barry Blackwell’s reply to Hector Warnes’ response

I thank Hector for an informative and knowledgeable comment on our three areas of dialog.

First, he correctly notes that I chose to extend the existing Oxford English Dictionary (OED) definition of agnosia as opposed to the two alternatives he advocates.  I shun the terms “loss of reality, lack of reality and lack of insight” because they imply the fault lies in the psychological make-up of the victim of bipolar disorder although the defect is clearly in the biochemical pathology of the brain. This is important because the patient is given a false and futile message that the problem is theirs to fix, either alone or (presumably) with psychological assistance. Until the advent of chlorpromazine, then lithium, psychoanalysts followed this totally ineffective line of reasoning with attempts to uncover imagined repression, denial or ignorance. It is also incorrect to parse inability to see oneself as sick as a “neurosis” when the problem is a symptom of manic psychosis that disappears immediately with effective treatment, a claim no therapist, however determined or diligent, can make.

The same difficulties emerge with the word “anosognosia” found in the Psychiatric Dictionary but not the lay one (although both are published by the Oxford Press). Again the semantics are dismissive; it is alleged to be “a tendency to suppress all knowledge of the disability” or as “a protective mechanism.” In contrast agnosia is “typically a result of brain damage” (OED).

Secondly, Hector acknowledges we are in full agreement that a scientist’s conclusions must be based on the integrity of how they are discerned and their validity. But to reinforce his opinion, he cites two examples that make a different point. They concern Daniel Gajdusek and Martin Heidegger, whose scientific and philosophical accomplishments were, he alleges, blemished by moral and ethical, not scientific, shortcomings. These are two distinct domains held to different standards.

Our third disagreement remains moot. I do not believe, as Hector asserts, that lithium acts as an antidepressant in bipolar disorder to reduce suicide. I, like thousands of psychiatrists, have experienced the frustration of attempting to treat the depressive component of bipolar disorder without success. We agree that further evidence and research is needed to resolve this enigmatic claim.

Barry Blackwell
December 31, 2015