Tuesday 25 September 2012

Classifying psychiatric drugs: Corrective, Symptomatic, Counter-pathological


The major psychiatric drugs fall into three categories: Corrective, symptomatic and counter-pathological.

Corrective drugs (when they work) tend to correct the underlying pathology; symptomatic drugs (when they work) do not affect the underlying pathology but relieve troublesome symptoms; while counter-pathological drugs create an alternative pathology that (in some way) tends to counter troublesome symptoms.

1. Corrective

An example are the psychostimulant drugs, such as amphetamines or methylphenidate ('Ritalin'). These are drugs which increase central dopaminergic activity - and are generally used in people where dopaminergic activity is low or deficient.

Some tranquillizers such as benzodiazepines (or the earlier 'Miltown'/ meprobamate) act to diminish anxiety states, probably by damping-down the same brain systems which cause anxiety - and could perhaps be regarded as corrective.  

I would place electroshock/ electroconvulsive therapy (ECT) in the corrective category. It probably works partly by normalizing the coordination of the brain (as seen in the 'brainwaves' of the EEG) and breaking a positive feedback loop of sleep disturbance leading to behavioural change which perpetuates sleep disturbance - as happens in ECT treatment of severe melancholia with psychosis, in mania and acute schizophrenia. The therapeutic effect of ECT on, for example Parkinson's disease and Catatonia, also suggests that dopaminergic deficiency states are corrected.


2. Symptomatic

Tricyclic antidepressants such as Imipramine and Amitriptyline can be used to treat moderately severe 'endogenous' depression, where they probably act as analgesics/ pain killers to treat symptoms of malaise (fatigue, aches and pains, 'feeling ill'), treat insomnia and reduced appetite/ weight loss.

Hypnotics, or sleeping drugs (strong sedatives) are used to treat insomnia, and also the psychotic results of sleep disturbance and deprivation. 


3. Counter-pathology

Neuroleptic/ antipsychotic drugs cause symptoms of Parkinson's disease, and this pathology may counteract the symptoms of psychotic illness such as agitation - the demotivation which comes with Parkinsonism tends to make people docile, stops them listening to hallucinatory voices, stops them acting upon delusional ideas.  

Lithium also produces the counter-pathology of emotional blunting - and this can be used to treat mania; and to prevent manic or depressive breakdowns.

SSRIs when used to treat anxiety and mild depression produce a milder version of the demotivation and emotional blunting of neuroleptics (because SSRIs are chemically related to neuroleptics, being derived from the same antihistamines as are neuroleptics). Thus people with emotional instability, anxiety, panic, phobias, shyness etc. - may have these symptoms implores by the counter-pathology of emotional blunting.


There is a hierarchy implicit in this classification system: the most effective treatments (potentially) are corrective (although they may have other problems, such as addiction); while the worst treatments are counter-pathological - since even when effective on the target problems these will always have significant 'side effects' because the core 'side effects' are in fact the counter-pathology caused by treatment. 



Thursday said...

If you are correct about lithium and SSRIs then they really might tend to diminish genius, or at least artistic genius. However, I wonder if they still might in some circumstances actually help a genius produce more and better work, if his emotional instability is getting in the way of actually getting the work done.

Bruce Charlton said...

@The - yes, I agree.

But it was significant that SSRIs are the characteristic drugs of the present era of bureaucratic conformity. Although there are signs that neuroleptic/ antipsychotics are taking-over - being given increasingly to children and teens, and they are dependence producing.

This is seriously sinister since these were the drugs given to Soviet dissidents; because they demotivate people and make them placidly compliant (and less productive). The perfect Leftist drugs, in fact...

dearieme said...

Is addiction necessarily much of a problem? If you expected to need a drug for the rest of your life, would it matter that you might become addicted to it?
(I ask from profound ignorance of this whole field.)

Bruce Charlton said...

@d - no not necessarily, under the circumstances you outline and so long as the side effects are not worse than the problem being treated.

Indeed almost all drugs create dependence to some extent (the higher doe for longer period the greater the dependence) - and all psychoactive drugs without exception create dependence.

Luckily many/ most people can get through the withdrawal process OK (especially if they are expecting it) and come off the drugs if necessary or beneficial to do so.

But many psychiatric problems are self-limiting (e.g. most cases of mania and endogenous depression, and many cases of catatonia and apparent schizophrenia - although these may be permanent with or without treatment) and some drugs - like the neuroleptics/ antipsychotics - make people feel bad.

Probably hundreds of thousands/ millions of people who suffered an acute, one-off, short-term, psychotic breakdown have been made permanently dependent on neuroleptics which make them feel bad, look bad (blank face, tremor, tardive dyskinesia etc) and function badly - but which they cannot stop taking without proking a psychotic break.

Indeed, nowadays the situation may be worse, since these are being given to children, teens and non-psychotic people under the pretense that they are preventive of more serious problems in the future - but actually creating innumerable impaired lifetime clients for Big Pharma who are the only beneficiaries of the process.

CHris said...

Bruce, you really need to go and read the current work from the Australians on neuroglial pathways and neurogenesis.

It explains some clinical findings, such as why antidepressants and antipsychotics do not work for a week to fortnight (they hit steady state and alter receptor saturation within a day or so).

And it blows your classification to smithereens.

dearieme said...

That sounds very gloomy. Whenever my wife sees appalling driving, be it recklessness or incompetence, she wonders out loud about the driver being on drugs. Must we now wonder whether they are on prescribed drugs?

dearieme said...

A long shot but: the short-tempered cabinet minister who ranted at the policemen the other day - would it be legitimate to wonder what he's on, or is "he's always been a twat" explanation enough?

Bruce Charlton said...

@d - not sure about these particular examples - but some of the out-of-the-blue suicides (e.g of famous people) will probably due to SSRIs; and some of the weirdly horribly violent explosive murders we see in the news are probably due to anabolic steroids (which are extraordinarily widely used, illegally).

@CHris - but antidepressants begin to work in hours or a few days (i.e. after they have been absorbed, or when they later reach therapeutic levels), not after a few weeks - so there is nothing to explain.

(There is no drug which takes weeks to start working - the slowest are probably drugs that affect cell turnover like cytotoxics - but even they work in days.)

(Look at my (online) book Psychiatry and the Human Condition - http://www.hedweb.com/bgcharlton/
for a discussion of this point.)

You must understand that almost all modern medical research is corrupt, and systematically dishonest - rotten from top to bottom. The people involved are not even trying to be honest - surely you have heardthem speaking?

It is a matter of working from a few sources of evidence that can be trusted.

FHL said...

I have a quick question: can psychoactive drugs permanently alter thinking patterns? I'm not talking about the simple effect of withdrawal and addiction. I mean: can taking a psychoactive drug change the way a person processes reality and logic in such a way that his thinking is permanently altered even after the drug has completely left his system, even years later- possibly for the rest of the person's life? Would/could this change personality? Can certain drugs reroute neurons?

Bruce Charlton said...

@FHL - Not usually. But yes, they could. And not just psychoactive drugs, but various agents.

Neurotoxicity is one mechanism - poisoning nerve cells so that they are permanently impaired or killed. It happens with a number of agents - for example Alchohol, Carbon monoxide; and from trauma (e.g. punch drunk syndrome) - as well as drugs.

The fact that some drugs have such a different effect in first dose from ever after implies that some changes may occur with the first dose and last a lifetime.

Bruce Charlton said...


Rather a lot of "it probably works by...."

...and in conjunction with your comment-

"You must understand that almost all modern medical research is corrupt, and systematically dishonest"

makes me wonder about the efficacy of pills as panaceas. Does anybody really understand how these pills work.

I asked my doctor what effect my levetiracetam tablets would have on my body if I didn't need them and she replied 'probably none'
There's that word again - probably. Makes me nervous hearing words like that.

Do I need them?
I sometimes wonder if there isn't a better way.
By the way, I didn't know you had been 'sacked' - the internet is a strange world with a mind of its own :)
John Douglas

Ariston said...

Where would you place the use of the anticonvulsant lamotrigine in this classification? It seems (by comparison to lithium, at least) that it would be placed in category three, but testimony has given me the idea that it does not result in the blunting effects lithium or SSRIs tend to.

It strikes me that one of the biggest problems with drug regimens is the desire to create easily definable classes rather than analyzing particular cases and allowing the patient (if intelligent enough) to self–experiment with differing psychopharma to a degree. I worked as a technician in a pharmacy during college, and the amount of persons on SSRIs was terrifying— especially among women over 35.

(Even more terrifying is the wide use of anti–psychotics amongst children from families poor enough to be on the free governmental health care in the US— obviously the successor to amphetamines in attempting to deal with their behavior.)

Bruce Charlton said...
This comment has been removed by the author.
Ariston said...

The link you sent me was dead, but I found it here. Very interesting. I've noticed that European (including the UK) doctors tend to be more bullish on St John's Wort than American ones; a friend of mine doing her residency says the negative interactions are very emphasized in medical school. I know a number of persons who take it, but mostly for SAD.

It's interesting that you call lamotrigine an antipsychotic; most of what I've seen on it has defined it as an atypical antidepressant, but that has not jived with my impression the phenomenal side of the literature describing patient response. (I'm a hobbyist reader of medical literature— a strange way to pass time, I know.) I have wondered if its description as such has been to make it more palpable to patients; it's a lot easier to sell to a patient that they need an atypical antidepressant than an antipsychotic.

Bruce Charlton said...


Thanks for pointing out my slip of the pen with Lamotrigine - I meant anticonvulsant (*not* antipsychotic).

From a psychiatry point of view - Lamotrigine is promoted as a 'mood stabilizer' - but that concept is bogus.

Lamotrigine may - apparently - have uses as an antidepressant (in line with what you say above). It may have stimulant properties (increasing energy and motivation, rather like amphetamine).

I agree that people seem to like taking L. - whereas they dislike most of the other anticonvulsants, unless they appreciate sedation.

I have deleted my comment, to avoid propagating error - which does make you comment in response look rather strange - sorry!