Foreword

Foreword by Professor Peter Liddle BSc, BMBCh, PhD, MRCPsych, Professor of Psychiatry, Queen's Medical Centre, Nottingham

This very interesting book makes a unique contribution to our understanding of serious mental illness. It is a first person account by an articulate young man of the severe psychotic illness which tormented him intermittently for nearly a decade. For long periods, his illness was dominated by delusions of alien influence and hallucinations. A plethora of incidental everyday events assumed extraordinary personal significance. These are the symptoms characteristic of schizophrenia. In addition, he experienced episodes of depression and episodes of manic excitement. He provides a graphic description not only of schizophrenic psychosis but also of depression and of mania. At one point he reports "my brain chemistry felt about as stable as a glass jug of water which was on the point of falling off the edge of the table". But, perhaps the key message of the book is that an individual who suffers from a schizophrenic illness is not defined by that illness, but rather by the range of interests, hopes and personal characteristics that shape him. Dr Labrador obtained a PhD in physics; rowed for his college and ran a marathon; embarked on a hair-raising journey across Africa; organised boat trips on the Thames to raise money for charity; founded a recording company that released two CDs, and was devastated by the breakdown of his relationship with the girlfriend he loved dearly. Indeed the announcement by his girlfriend, Amanda, that she did not wish to marry him was one of the factors precipitating his slide into illness. He describes schizophrenia as "partly an experience-derived illness". Later, he proposes "My main problem was that of heartbreak, which had gone undiagnosed by the NHS". Many chapters describe his chaotic travels through the length and breadth of Britain, Ireland and parts of Europe. At times his express purpose was to escape from psychiatric treatment, but many of his journeys lack any goal more explicit than an ill-defined odyssey of self-discovery. Never far below the surface, one feels, is his hopeless quest to recover the unattainable Amanda.

He is critical of the treatment he received from the psychiatric services (1). With some justification, he attributes two of his episodes of manic excitement to treatment with antidepressant medication. He is scathing about the effects of medication, especially the depression induced by these drugs (2). In fact the relationship between psychosis, depression and antipsychotic treatment is very complex. Depression is an integral part of schizophrenia. It can occur at any phase of the illness, and is especially prominent in the resolving phase of a psychotic episode. Under some circumstances, antipsychotic medication can help alleviate depression, but it can also contribute to depression. Stultifying sluggishness induced by blocking the natural energising effects of the brain chemical, dopamine, leaves the individual feeling like a zombie. More paradoxically, blockade of dopamine by antipsychotic medication can also produce extremely distressing restlessness. The complexity of the relationship between psychosis, depression and antipsychotic treatment can lead to apparent conflict between the subjective evidence based on the experience of an individual patient, and the purportedly objective scientific evidence derived from the careful observation of many patients. Dr Labrador's account brings home the importance of listening carefully to the individual's own reports of the effects of medication, and of adjusting medication to minimise the distressing side effects. However, in predicting the future consequences of treatment, it is equally important to take account of the evidence derived from careful observation of large numbers of patients. There is very strong evidence that continued use of antipsychotic medication reduces the risk of relapse over a time scale of several years. While antidepressant medication probably precipitated the acute manic agitation that led to his first two admissions to psychiatric hospitals, it is equally likely that discontinuation of antipsychotic medication predisposed him to his third relapse in the summer of 1997.

But this speculation brings us to a crucial issue raised by Dr Labrador. He reports that none of his doctors suggested the possibility that antipsychotic medication might ever be safely discontinued. The prospect of indefinite treatment with medication having such distressing side effects was intolerable to him. Unfortunately, on this issue there is a gaping hole in the scientific evidence. While an abundance of evidence demonstrates that antipsychotic medication reduces the risk of psychotic relapse over a time scale of several years, there is a paucity of good evidence regarding treatment in the longer term. Virtually all of the available evidence indicates that over a time scale of decades, between a third and a half of individuals suffering severe schizophrenia recover to the point where they no longer require antipsychotic medication. The mind and its brain have an amazing capacity to adapt to changing circumstances. It might be argued that the primary goal of psychiatry is to promote the circumstances that will maximise the likelihood that mind and brain adapt constructively rather than destructively. In individual cases, the prediction of the course of adaptive processes over a time scale of decades is fraught with difficulty. However, Dr Labrador exhibits several characteristics which bode well. While the intensity of his emotional responses is a source of torment in the short term, it also augurs well for a better outcome in the longer term. In addition, the intelligent way in which he grapples with the illness increases the likelihood of recovery. At one point he attempts to wrest back a sense of personal autonomy from the alien forces that appear to control him by a technique involving a random number generator. He is intelligent enough to realise that this provides only an illusion of autonomy, but this illusion is perhaps the crucial requirement. After all, what is free will? More pragmatically, his battle with the psychiatric services is an expression of his continuing determination to re-establish his autonomy. Perhaps the greatest tragedy in the delivery of psychiatric services to patients with psychotic illnesses is the failure to establish that collaboration might offer the best prospect for recovery of autonomy. In the face of the turmoil of psychosis, there is no easy prescription for achieving collaboration, but this book eloquently makes the point that the first step is engagement in dialogue. Professor Peter Liddle, August 2003

(1)As a result of medication-produced insight, I am more objective in my criticism than in the draft Professor Liddle read.
(2)However, see the postface "Happy Ending" written after Professor Liddle wrote his foreword.

London Marathon
2000

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Extract from Chapter 49.

I was allowed to go down to Coghurst Hall to see Emily for the weekend. The train journey was a nightmare and it was all I could do just to sit still and not fling myself through the slam door. It was the rush hour and the train was full. It was truly unbearable. But if I bided my time it should not be too long before I could get off this rubbish – the only problem being that the injection was slow release and it would be another four weeks at least before it cleared my system. Hell on Earth! I thought, nobody could conceive feeling this bad. I realised there must be worse still and in that condition, inferior to mine, lay the miserable little secrets of suicide which maybe even the coroner does not know or understand. Then again, maybe there was no worse. Maybe, in fact, I was now experiencing the worst psychiatric symptoms ever experienced by man. It was just that I was extremely resilient and was somehow, only just, able to cope with them. In order not to throw myself from the train I had to be extremely hard. But then how hard did I have to be to throw myself from it? It seemed that whatever I did I was the hardest man who ever lived! – extract from The Layman's Guide To Prince Charles's Dog


SMOKING IS EXTREMELY DANGEROUS, HIGHLY ADDICTIVE
AND MOST UNCOOL. DON'T START!
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Postface: Happy Ending

Following the end of this story I was sectioned a further four times, four more cycles of murderous(1) treatment. In March 2004, towards the end of my fourth spell of incarceration after this story, I found myself talking to a newly admitted patient in the bed next to me. He had never been in hospital before. I asked him what he was taking for his cannabis-induced psychosis and he told me saying he was getting no side effects. It did not need a genius to see that without medication I would almost certainly have been sectioned again before the year was out. So in May 2004, following my release and another cycle of drug-induced mysery (on Risperdal Consta), I bit the bullet and visited my GP. There was really only one drug left I had not tried, the one the other patient had been on: Olanzapine. I asked my GP to put me on a dosage of 5mg. After ten years of criminal(2), murderous and terrifying experiments I had finally found a drug I could take which did not leave me suicidal and was at last able to rebuild my life. Dr. C.H.Labrador, December 2004

(1)Murderous: "extremely arduous or unpleasant" – Concise Oxford Dictionary; "extremely difficult or unpleasant", "dangerous" –Penguin English Dictionary.
(2)Criminal: "deplorable", "scandalous" – Concise Oxford Dictionary, "disgraceful", "deplorable" – Penguin English Dictionary.

Portrait by a fellow patient
Fairfield Asylum 1999
(Asylum now closed)

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Clive Travis