Gin S. Malhi: A critical analysis of concepts in psychiatry.

Hector Warnes’ comment on Gin S. Malhi and Erica Bell’s Fake Views: Schizoaffective Disorder is not “SAD,” just bad

        Let me start off with a clinical case of a man in his 30s who had been showing ideas of reference, at times incoherent speech, social withdrawal, intermittent explosive behavior and ideas of worthlessness and inferiority.

        The psychotic state was insidious for several years and had been treated by several psychiatrists with anti-psychotics like olanzapine, quetiapine and haloperidol without apparent improvement. The patient was a rugby player with a good education who was able to tell me his story lucidly. He had no negative symptoms of schizophrenia nor had a family history of either disorder.

        I followed him up in psychotherapy and with pharmacological treatment for a period of four years until the family moved to another distant province. I was well aware of the depressive side effects of some "incisive" neuroleptics and in view of his self-depreciation I decided to continue with quetiapine, no more than 300 mg a day, and added Sertraline 50 mg to 100 mg a day. I was expecting a worsening of his schizophrenic symptoms but quite the contrary he felt better and started to improve to the point that was able to hold a job.

        The psychotherapeutic approach for these types of patients should not include a psychoanalytic approach nor any type of catharsis as was well pointed out by B. H. Lowy (1970). Occasionally I heard from the patient; he told me that he was on anti-psychotic agents and received no anti-depressants. I was concerned as well because his therapy was divided between a well-respected psychiatrist and a psychoanalytic oriented psychologist. My former patient could not establish a therapeutic alliance with either, but he told me that they were planning to stop giving him neuroleptics. His core depressive symptoms remained unabated. Because of the patient's fear of being considered a homosexual the psychotherapist fostered his acceptance of this alien or delusional idea. Two years after he moved to another province the response to treatment worsened and one evening he jumped from a seventh-floor window. (I learned this about my patient because a relative told me.) The patient was quite intelligent and could not accept the chronicity of his illness nor the fact of taking neuroleptics for life (as he was told). Evidently there was hopelessness as well in the final hours.

        Further I felt responsibly because I failed to call the psychiatrist in charge regarding the patient’s compus mentis and his suicidal trends. I did not want to interfere with his treatment though the psychiatrist knew perfectly well from my referral history that the patient was taking sertraline (which by the way did not worsen his psychotic symptoms, quite the contrary). I believe the pressure that the patient exercised on the psychiatrist to withdraw all medications was a reason to stop sertraline. I also felt bad because in one of his last calls a year before the fatal denouement he told me that he was pleased to take a minimal amount of medication and to see his psychiatrist once a month.

        I recalled a paper I wrote in 1968 on suicide in schizophrenics where I classified their motives for suicide. Imperative voices urging the patient to jump out a window or to shoot himself are not rare in this disorder. I wondered whether my former patient ever went through this type of experience. I found it strange that during the time I saw him on a weekly basis and at times twice a week his psychotic symptoms markedly diminished and he spoke normally.

        Genetic research has shown that there is a genetic overlap between schizophrenia and affective illness. This is clearly explained in an excellent paper by Craddock, O'Donovan and Owen (2009). The authors underline many research studies including those of Gershon and another of Angst in the 80s. The most complete study ever undertaken was that carried out in Sweden. Two million nuclear families of schizophrenic and bipolar disorder patients were identified from the Swedish population and the hospital discharge registers. It showed an increased risk for both schizophrenia and bipolar disorder in first degree relatives of probands with either disorder. It appears that both disorders share a common genetic etiology as the authors put it. Further they seem to suggest that there may be a schizoaffective spectrum or even two or more overlapping disease processes.

References:

Craddock N, O'Donovan MC, Owen MJ. Psychoses Genetics: Modeling the relationship between Schizophrenia, Bipolar Disorder and Mixed (Schizo-affective) Psychoses. Schizophr. Bull. 2009; 35(3):482-90.

Lowy FH. The abuse of abreaction: an unhappy legacy of Freud's cathartic method. Can. Psychiatric Assoc. J. 1970; 15(6):557-65.

Warnes H. Suicide in Schizophrenics. Dis. Nerv. System. 1968; 29(5):Suppl. 35-40.

May 7, 2020