Barry Blackwell: Lithium Controversy - Barry Blackwell’s response to Hector Warne’s reply
Hector’s rapid response is an extremely erudite analysis of the semantic, historical, neurological and psychological roots of our difference of opinion that I am not sure we truly have. To this dense intellectual debate I plead ‘no contest’!
My opinions are based on limited clinical experience rather than an encyclopedic knowledge of the literature. The core of my opinion resides in observing that the most difficult manic psychoses to treat were psychiatrists who, despite their professional training, remained oblivious to being sick or in need of treatment and deaf to any or all psychological feedback or interpretations they “lacked insight” or “reality testing.” But they rapidly regained an ability to view themselves as needing treatment after they benefited from medication, which they often stubbornly refused. See Xavier Amador’s book, “I’m not sick and I don’t need treatment”, for his dissection of this problem in a psychotic brother suffering from schizophrenia, with advice about how to manage it via negotiation rather than confrontation or interpretation (Amador, 2010)
I was a contemporary of Alwyn Lishman at the Maudsley, where his knowledge of organic psychiatry was widely respected by faculty and fellow registrars (residents). Alwyn’s presentation to Aubrey Lewis at a Journal Club was responded to by spontaneous applause, an unprecedented occurrence.
But Hector’s citations from Alwyn’s textbook do get to the semantic basis of our disagreement. My preference for extending and preferring the meaning of “agnosia” (Oxford English Dictionary, OED) over anosognosia (Psychiatric Dictionary) is based on the fact that the former is defined as due to organic pathology, whilst the latter carries with it seemingly psychological explanations. Lishman is quoted as agreeing with Freud that agnosia is “a defect of perception”, while anosognosia implies “lack of awareness of disease”, for which Alwyn gives a physical example (hemiplegia).
But according to the OED, “perception” is “developing a state of awareness.” If the two words are, indeed, synonyms how can they have different etiologic implications?
The practical basis for this disagreement is in the therapeutic approach. To imply that the defect is psychological risks alienating the patient (I’m making this up) and suggests taking a drug is illogical. To overcome this obstacle requires negotiating acquiescence to medication. Perhaps, an agreed on short trial of lithium in return for something the patient wants, such as a pass home, accompanied by a trusted escort, or participation in a desired ward activity? Assisting this dialog may be kindly and tactfully drawing attention to life threatening, sexual, economic, and humiliating or risk taking behaviors the patient is aware of.
Perhaps Hector and I can agree that the INHN dictionary of technical terms would benefit from a carefully crafted definition of the two terms we are debating, agnosia and anosognosia, as they apply to psychiatric diagnosis and its treatment.
Amador X. I Am Not Sick, I Don’t Need Help! How To Help Someone With Mental Illness Accept Treatment. New York: Vida Press; 2010 (10th. Anniversary Edition).
January 14, 2016