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Problems when antipsychotics interfere with the ability to anticipate threat

Richard Bentall, in his book Doctoring the Mind: Is our current treatment of mental illness really any good? describes how researchers first noticed and tested the properties of the medications that later became known as “antipsychotic.”  The procedure was fairly simple.  They first exposed rats to an electric shock applied to the floor of their cage, accompanied by a sound.  The rats quickly learned to climb a rope to get away from the floor of the cage whenever they heard the sound:  this is what is called “conditioned avoidance.”  Then they gave the rats the new medications, and noticed that the medicated rats no longer showed the conditioned avoidance – that is, they no longer climbed the rope in response to the sound.

That this effect exists is not surprising given what we now know about the function of dopamine in the brain, and the role of antipsychotic medication in blocking dopamine.  Dopamine nerve cells are involved in anticipating threats, and that animals that have been repeatedly exposed to threats show increased sensitization of their dopamine system (in other words, their dopamine system is more reactive).  And since antipsychotic medications block dopamine, it follows that they reduce threat anticipation.

People who are diagnosed with psychosis are often misperceiving people or events as threatening when they are not.  Often, such misperceptions cause chaos in a person’s life (especially if the person takes action to fight off threats that are unreal, actions which may create real threats.)  So, medications that reduce “conditioned avoidance” reduce reactivity to perceived threats, and this is helpful at least some of the time.  But isn’t it also possible that such reduced anticipation of threat can go too far, and result in people on medication being less likely to protect themselves from many real threats that may exist?

Some threats worth considering:

  1. Research shows that people diagnosed with serious mental disorders are much more likely to be victimized by assault than the average person.  What is the effect when people at increased risk of such crimes are given medications which make them less inclined to anticipate risks and to act to avoid it? 


  1. Antipsychotic medications are increasingly being given to soldiers involved in warfare.  What effect will this have on their ability to protect themselves?


  1. There are risks associated with treatment, such as the risk of death from medication side effects, of obesity, of permanent movement disorders, as well as psychological problems resulting from over-reliance on medication to solve mental and emotional issues.  But if the medication itself interferes with the ability to perceive and respond to risk, how can people on antipsychotic medications be sufficiently vigilant in protecting themselves from excess treatment related risks? 


  1. People are threatened not just by external threats, but by the consequences of their own behavior.  For example, if we initiate a particular behavior or particular line of thinking, but then perceive it as potentially threatening to ourselves, we may alter it to avoid the threat.  But what happens when an antipsychotic medication makes a person less able to show conditioned avoidance and so anticipate threats?  That person may persist in the behavior or line of thinking that otherwise might have been avoided.  So, while the medication may make a person “less psychotic” in the present, by reducing mistaken or exaggerated fears in the present, it also may make them less capable of learning how to not be psychotic in the future.  This sort of effect may account for evidence that suggests that medication use leads to lower rates of full recovery:  the increased obliviousness to threat may make it harder for people to learn to change their thinking and behavioral habits in constructive ways. 

It often is helpful for people to be less reactive to anticipating threat, especially, people who have a tendency to over-anticipate threat.  But taking a medication to achieve such an effect does not allow for the sorts of fine tuned distinctions that can be achieved by a person who learns over time how to adjust his or her own anticipation of threat, how to think things through.  Instead, the person using medications to be reduce anticipation of threat is at risk of under-responding when future threats are likely, and this under-responding can be very detrimental.

A few more comments on dopamine and threat:

It is known that children form bonds even with people who severely abuse them.  It turns out that when this happens, dopamine is apparently suppressed, at least in one area of the brain, in order to allow this bonding.  This suppression of risk perception in the interest of bonding makes sense from an evolutionary perspective, since children typically have little ability to survive without strong bonds with adults, even if those adults are sometimes traumatizing.  Later, when the person moves toward adulthood, it becomes necessary for the person to become more active in anticipating risk, rather than relying on caretakers.  This accounts for why the dopamine system would become more active (and possibly hyperactive at times) in younger adults. 

When such individuals are given antipsychotic medications to suppress their dopamine activity, they are being pushed back into a style of functioning more appropriate for childhood, and not for becoming an independent adult.  From this perspective, giving antipsychotic medications can be seen as an attempt to instill a state of permanent childhood, rather than allow the person to learn to self-regulate the activity of his or her own dopamine system, which includes anticipation of threat. 

Dopamine is also involved in reward anticipation.  So when antipsychotics suppress dopamine, they also suppress a person’s ability to anticipate rewards.  This comes off as helpful when it keeps a person from spending time and energy believing in and pursuing truly “crazy ideas.”  But it also interferes with recovery when it flattens a person’s sense of anticipation of reward sufficiently that the person fails to find it interesting enough to work toward rebuilding a life or to carry out other steps toward recovery.

A mental health system that acknowledged the above concerns would find it has yet another reason to seek to use antipsychotic medications only as a last resort after other options were tried, and would seek to make any such use be as temporary as possible.

23 comments… add one
  • Absolutely possible, even probable, I’d say. One such real threat is the mh system itself. Both the “treatments” and the messages are dangerous. Why people, to start with, often reject them. People may not be consciously aware of it, but I think their “gut feeling” tells them very clearly: ‘this is going to harm you, your body as well as your psyche’, triggering an instinctive fight, flight or freeze response. Why the mh system regards rejection of, and/or non-adherence to, “treatment” (“non-compliance”) and the messages (“lack of insight”) as an indicator for more “treatment” to be necessary. In most cases, at some point the drugs do their “magic”, and the rats stop climbing the rope, and become “compliant” and “insightful”.

    I’ve usually thought of this phenomenon as a kind of Stockholm syndrome, a mere psychological effect. The drugs chemically suppressing a natural instinct , adds another dimension to it.

    I don’t know, if I’d talk about “mis perceptions”. It somehow gives the impression, that the perception is entirely wrong. I remember seeing a person on TV several years ago, while I still was in crisis to an extent. I reacted to seeing this person with extreme fear and an urge to switch off the TV, or simply leave the room (=flight), although this person had never harmed me, although she didn’t know me, didn’t even know I existed, and thus had no chance to ever harm me, and although we’re not talking a serial killer, but simply a mother, making her case on TV for AOT-laws, and for labelled people to have their ID taken away, after her “schizophrenic” daughter had been killed in an accident in Spain while on the run from both the system and her mother. Analyzing my reaction, I found that what I’d reacted to was first and foremost the mother’s patronizing, dehumanizing attitude towards her daughter, and labelled people in general, and the harsh bitterness in her voice. I recognized all these elements and some more as having been very real threats to me in my dim and distant past. So, it was not a misperception. It’s only that I initially failed to separate past from present, and this particular woman from the person who’d actually threatened me in the past. The threat was real enough, but my situation had changed. I wasn’t the dependent victim anymore, but free to choose not to take the threat personally.

  • Thanks Marian, for pointing out that the messages from the mental health system, as well as the treatments, are dangerous! I think people sometimes resist the messages, and then are defined as “lacking insight” while other times they just buy the messages, such as “I have a biological illness,” without being aware that they will likely be later hurt by this message as it will make them feel hopeless about learning to manage their life. The drugs may make people less able to anticipate that the messages may be harmful.
    I think you are right that when there is a problem with someone’s perceptions, it is often the case that the perception is not completely wrong, only partially wrong. These are the sorts of things that people can evolve to get better at sorting out, especially if both the person and others who talk to the person have an openness to noticing both what may be right and what may be wrong about particular perceptions. Ultimately, we need to develop both our ability to anticipate threat, and our ability to sort out when we may be getting carried away and actually putting ourselves at risk by anticipating more threat than actually exists. This capacity cannot fully evolve while we are taking drugs to numb out our capacity to anticipate threat.

  • Hello,
    I found this a very interesting and on many levels, a thought-provoking post. Also, I enjoyed that it is an easy read instead of so much technical stuff about chemistry that my brain fog renders me unable to process it.
    I want to help someone who is suffering and I don’t know how to help. I am extremely sad about this.
    I think you are right, that sometimes, in a psychotic crisis, for a lack of a better term, a low dose of an antipsychotic is useful. Sigh… A mental health system that acknowledges this is not here in America is it? Is it anywhere?
    I see the person I love suffer. It feels like it is killing me. Truly. Inside it is killing my spirit and will to live, that’s how bad it hurts. How the hell is someone to know what to do to help? My loved ones pulls on his fingers, and says he is purposefully hurting himself. Then, ten minutes later denies it. It isn’t like a cut and what if it was? What if the damage being done to his joints and connective tissue was so visible? Mental health workers could do all they seem to know how to do, which is sign a commitment paper!
    I think these, ACT teams, could do so much, if… if we were on another planet. Here they ACT when a patient continues not to take antipsychotics, and they deem it time to once again commit the person.
    No psychologist to talk to. No therapy. A few minutes here and there they see my son, maybe 15 minutes if that much. He says he is fine and that is his “treatment” —
    I truly wish I knew real things to do, real things I can do that would really help, other than suggest antipsychotics.
    Not some philosophy, not that I found that here, but I need something tangible, realistic, attainable —
    I’ve visited websites, like the one with the fire burning and that is all good, all the pretty words and ideas, but that does not stop my son, nor me, from suffering.
    I appreciate the space to share. Thank you.

  • This article is as good as I have ever seen (or written) with respect to explaining what occurs psychologically and biologically with regards to the manifestation of psychosis. I agree that the administration of neuroleptic drugs retards the emotional, and no doubt cognitive, maturation of the individual receiving the drugs.

    Dogkisses…I have been exactly where you are presently and appreciate your frustration. The fact that you are broadening your horizons and are looking for alternatives is an excellent indication that you will help guide your loved one to recovery. I appreciate that at the moment you probably don’t understand where to turn and lack confidence in your ability to provide meaningful assistance to your loved one. I suggest you hold the belief that your loved one can and will recover. The most important thing you can do is nurture a trusting, loving, non judgmental relationship with him in order to start the process and continue to educate yourself. Don’t do anything rash with the medication as abrupt withdrawl can have significant adverse effects. The mental health system will advocate that the only hope is antipsychotic drugs. This is a myth.

    While we are inclined to seek therapists and psychotherapy for our children what they need, and what the therapist provides when the parent has failed to do so, is a relationship; one that nature intends to occur between parent and child. Examine how this has been functional, or dysfunctional, and alter who you have been in the relationship and the child (including the adult child) will alter their interpretations that have left them unrelated to other people and to the occurring world.

  • dogkisses:(WordPress obviously doesn’t like lots of links, so I have to post this in two or three parts) 1. You’ve probably already checked for it, but are there any peer-run self help groups in the area where you live? There’s a movement in Europe, the Hearing Voices Network, with a growing number of local self help groups, especially in Britain. As of lately, the movement is about to become more known in the U.S. too, and I know that there is a group in Portland, Oregon. If this is not an option, there are some online resources that may be of help. One is Tamasin Knight’s book Beyond Belief that can be downloaded for free at the website.

  • 2. Personally, I found it extremely helpful to read and listen to survivor accounts, interviews, etc. where I could recognize myself, my own experience, find my view of it confirmed, and get inspiration to further investigate into the meaning of it. Madness Radio has a lot of such accounts/interviews in its archives. Also I can recommend Leo Regan’s documentary The Doctor Who Hears Voices, and Daniel Mackler’s Take These Broken Wings. The latter unfortunately is only available as a DVD, though. Not, as some people assume, because Daniel Mackler wants to earn a fortune by selling it, but simply because he has to pay back the loan he took to produce it.

  • 3. Last but not least, there are some web communities that are worth checking out. The Icarus Project for instance. But beware, there are also a lot of online “support” groups that are not very supportive. Maybe the most known of them is I’ve been there. You don’t want to go there!

  • Hello,
    I apologize for my absence here after commenting. Wow, what great information, along with support and encouragement!
    Marain, thank you for the links. I know about — it is a place to push drugs.
    I have not had much luck so far finding help my son could afford. We live in NC. He has insurance and lives on disability income, so we do not have much money.
    He has signed up for a Martial Arts school, which is expensive, but it is the only thing I knew that he might do and that might help him. I think it is helping.
    He does not usually take antipsychotics, and is not taking them now. He will take a small dose when he chooses, which is rare, but only when he is really suffering and needs a break. He has never taken them for long. He has had to take them to get out of hospitals but he stops when they let him out. Oh yes! Everyone cries “No insight” and “Non-compliance” and God only knows what these same people think of me.

    I’ve taken criticism from both sides of the fence. I’m tired of that. I am an open minded individual. I do not throw out the baby with the bath water. For instance, I believe in God and evolution, which many people think you cannot believe in both, but I do, although I must admit I understand evolution better.
    I lost a few “friends” when I agreed that my son needed modern medical help at age 19. I still believe he needed that help. I just don’t think he needed it for the rest of his life. I’ve also lost a few “friends” when I said I did not want medication forced on him and believe that there are other ways to heal.
    Today he cooked for me. Today he is fine. Today he may be better than I am. Tomorrow, I have no clue about.
    I am scared. I am scared to take sides. I try to remain open-minded. I question what I read. I question advice I am given.
    One thing I must say is that psychiatrists do not blame me. People need to stop blaming parents. Maybe that is part of the reason parents do listen to psychiatrists sometimes. Because we don’t get blamed. I know they blame it on a chemical imbalance and this is lacking in scientific evidence. But the one thing they do right when it comes to an adult child, and I think this is different than a young child, is that they don’t blame us for not being like Mother Theresa!
    I do not think it is right, fair or helpful to blame parents when an adult child has a mental breakdown — and that phrase most likely means something quite different to me than other people.
    I blame myself for many things but I refuse to let other people blame me. I do it enough all by myself. I raised my son the best I could. I think I was a good mother. I did a better job than my parents did. Yet I have cried more tears than any person should ever have to when I lie in bed at night and think of a thousand reasons it might be my fault.
    Alan: I like very much what you shared. I honestly do — but I must question last part of your comment:
    “While we are inclined to seek therapists and psychotherapy for our children what they need, and what the therapist provides when the parent has failed to do so, is a relationship; one that nature intends to occur between parent and child. Examine how this has been functional, or dysfunctional, and alter who you have been in the relationship and the child (including the adult child) will alter their interpretations that have left them unrelated to other people and to the occurring world.”
    I have read it a couple of times. I honestly do not understand what you mean.
    Did I provide a “relationship” with my son? You bet I did! Have I ever been dysfunctional? You bet I have!
    I don’t know many parents who were all perfect. I know some parents who were extremely “dysfunctional” and their kids are in Harvard and other such institutions of higher education.
    Who have I been in my relationship with my son? I’ve been myself doing the very best I can with the knowledge I have in the moment. I’ve been the best I’ve known how to be.
    I’m going to post an image on my blog soon that an artist recently drew for me. I told her how I felt about ways to help my son. It is a wonderful image titled “FenceSitter.”
    Thank you for the space here to share my feelings. I like this site. I like being able to have discussions. I need to be able to be completely honest and maybe one day I will not be sitting on that fence.
    I invite you to visit my blog. I invite your honest responses to what I have written here.
    Thank you again, very much.

    • Hi to dogkisses,

      I appreciate that you are sensitive to having the relationship with your son apparently questioned by another commenter. And of course, when something goes wrong with a child’s mental health, it’s natural for parents to wonder if they contributed something to the problem, and I think this sort of wondering is even healthy, as long as it is kept in a reasonable perspective. (Psychiatrists often go to an extreme in not blaming parents: they deny any possible role of trauma in causing psychosis or schizophrenia, even in cases of serious abuse!)

      No one parents a child perfectly. As you point out, many of us are lucky enough that our children make it through our imperfections, even very serious ones, and go on to achievments that make us look good. For others of us, and sometimes even when our parenting was better than average, our children run into serious problems with their mental health. Some possible explanations:

      There is much more to growing up than interacting with parents. Children can be traumatized by other adults, by their peers, or even by toxic aspects of a culture to which they are especially sensitive. And children don’t just passively receive the experiences to which they are exposed: they are always busy constructing views and perspectives on what they experience, and sometimes something goes wrong in the way the child makes sense of the world. And these errors are even more likely for those children who are naturally creative, and who tend to think up their own ways of making sense of things rather than just buy into standard viewpoints (this creativity can be an asset when well directed but can be a real problem when mistakes are made.)

      So I think we can just try to understand what made things difficult for the particular person we are trying to help, and what misunderstandings there might have been, and then try to help the person reorganize in a way that makes sense for them. It sounds like you are willing to be there for your son, and that sounds great. By the way, I always suggest for families the Windhorse Family Guide

  • dogkisses: I agree with Ron that it can be very useful for family members to have a look in the mirror, and children tend to, primarily, mirror their parents – though not only their parents, as Ron suggests. IMO, the problem is the word “blame”. Usually it is perceived as meaning “accuse”, “point fingers at”, judging the one who is blamed a “bad” person. And this is, btw, how I see you feel. Originally though, “blame” doesn’t mean anything else but to hold accountable. To my conviction, we are all responsible for our actions. Personal responsibility is the flip side of personal freedom.

    There’s a qualitative difference between blaming you as in accusing you, telling you it’s all your fault, you’re a “bad” parent, etc., on the one hand, and “blaming” you as in holding you accountable, asking you about your own traumas, which you, unintentionally, might have passed on to your son, on the other. If it’s done right, the latter opens up for you to explore your own “stuff”, without having you feel overwhelmingly guilty. It actually opens up for you to become more aware and conscious. While the first usually results in massive feelings of guilt, and, consequently, resistance, or even denial.

    I think, it is crucial that family as well as others whom the person in crisis has a relation with, take responsibility. In some cases, it has led to a spontaneous recovery when “family secrets” were revealed, admitted and talked about openly. I’ve just read a paper about a study looking at how staff dealt with the implementation of certain elements from the Open Dialog approach at an outpatient clinic here in Denmark. Everyone except the doctors was over-the-top enthusiastic about it. The doctors didn’t like the idea that they had to pass some of their godlike power over into the hands of others. Especially when it were the “patient’s” hands… Well, I’ve been critical of the “meciless” family involvement of Open Dialog. So are these doctors. Just not for the same reasons as I am. They argue that relatives usually already are sufficiently stressed with having to cope with a “mentally ill” family member, that they already bring enormous sacrifices, and that they shouldn’t be burdened with feelings of guilt on top of that. I fully acknowledge that it is not easy having to deal with a person in acute emotional distress, but if being asked to take responsibility, to have a look in the mirror, to face one’s own “demons” means that one’s relative has a chance to recover, I’d definitely say it’s worth it. No matter how frightful the truths that may be revealed. “To make a mistake doesn’t mean the end of the world. But to make a mistake, and then to claim it was the right thing to do, although you know it was a mistake, is unforgivable.” Ewa Jälmbrant. And it means, among a lot of other, individually very varying, and often seemingly insignificant factors, the difference between going to Harvard, or going to a psych ward.

    We all make mistakes. We’re all dysfunctional, more or less, every now and then. The important thing is to be aware of it, to accept it, and not to feel guilty and ashamed of it, and, as a defence mechanism against guilt and shame, to deny it. It is actually incredibly liberating to be able to admit that, yes, I messed up, I made a mistake. And, in addition, it disarms others. You no longer have to fear that they come after you and blame you, because there’s nothing they could blame you of. And mistakes aren’t restricted to the really big and obvious ones, like physical/sexual abuse and the like. Some of the most devastating mistakes actually look exactly like “normality”. The only way we can recognize them as mistakes is indeed by others’ reaction to them. Personally, I wasn’t able to put a finger on any of all the “normality” that charcterized my upbringing before I saw the reaction of my therapist when I told her about it.

  • Hi,
    I feel that after reading the two responses, and thinking them through, that I should not comment anymore on this site.
    I simply do not agree. So what good would it do either of us for me to continue?
    I would like to remark on one thing: Are you a parent? If so has your son or daughter had any “mental” challenges? Are parents “asked to take responsibility,” for a child with other problems? Because I believe people who are not parents who give advice on parenting simply are not equipped.

    With that said, I sincerely appreciate your thoughtful — yet personal opinions on the subject.
    Thank you for taking the time to offer me links, two of which I found quite interesting and possibly will be helpful to me in my journey.
    Thanks again for your time.

    • Hi to Dogkisses,

      I would be sad to see you give up on contributing your perspective, especially since I think the conflict you are experiencing with Marian and I may not be as deep as you perceive!

      I heard you say that you do think through what you may have done imperfectly and what blame you might have, sometimes in a way that is too hard on yourself, but you don’t like others to blame you. I imagine you don’t like others to blame you because then you are even harder on yourself.

      While you ask “Are parents “asked to take responsibility,” for a child with other problems?” in a way that implies you think they aren’t, I actually think parents naturally do have to sort out how much responsibility they have for other problems as well. If a child is raped, or even just ends up failing a class or getting a minor injury, parents wonder what they might have been able to do to prevent it.

      The greater the tragedy though, the more highly charged this sorting out of responsibility becomes, and the more likely parents will be too extreme in the way they approach it. So the parents might blame themselves too much, or too little. The trick is to try to understand objectively what happened and face it squarely, neither being too hard nor too soft on oneself, and then figure out how to make the best of what is still possible.

      I agree with Marian that children as well as parents have something to say about parenting. My daughter (an adult now) has been very helpful in bringing to my attention some of the imperfections in my own parenting! Not to say that I agree with all of her perspectives though. The dialog is good, and we can support different sides of the dialog, even though no one has a complete perspective.

      While my daughter has relatively good mental health, many of my younger siblings have had very serious mental health problems, including the suicide of one brother. I have looked through how various actions and inactions of mine possibly contributed at various points to their problems (including how the fact that I mostly cut off my family for a decade, while I knew the younger brother who eventually committed suicide was facing extensive abuse at home, and might have had a different life outcome had I stayed in the area and provided some kind of support.) And there are other ways I more actively contributed to misguiding my younger siblings. I have had to figure out how to face stuff like that objectively, without condemning myself or being too hard on myself.

      Anyway, those are some of my thoughts. Hope you find a way to let your son’s story be complex (not just a “biochemical balance” that has nothing to do with what happened to him) while also not being unfairly harsh in your judgment of your own actions or inactions.

  • dogkisses: No, I don’t have children. But I am someone’s child, so I have my first-hand experiences with parent-child relationships. Which, I think, allows me to voice my two cents about them. Sad to hear that you perceived this voice from the perspective of a child as a personal attack. It was certainly not meant that way.

  • Hi Ron

    Can you quote som litterature on dopamine being involved in the anticipation of reward?

    Best regards

  • Hi Jonas,

    There’s a lot out on this, but I’ll just draw attention to a couple items. One article that mentions the connection – “Dopamine (DA) has been shown to be involved in reward-related (incentive) learning but not stimulus-stimulus (s-s) associative learning” has an abstract available at This article also points to evidence that antipsychotics impair reward learning because they block dopamine.

    A more recent article on the role of dopamine in anticipating reward is at

  • Ron,

    I read the comment you made for D.J. Jaffe on the Huffington Post article…

    You called him on his deception, and what was obvliously an attempt to smear the alternatives conference, and the personal decision of many to taper off psychiatric medications…..

    There is far too much fear-mongering out there, especially among “advocates,” and it was refreshing to see a professional such as yourself lay out the facts, with confidence.

    Thank you. sir!


  • The thing I did not find in this post and the replies is that the chemical imbalance theory of mental illness is slowly being proven wrong. There have been admissions that it is a metaphor to explain mental illness to the public and an argument to get patients to take medications.

    If that is true then the medications based on chemical imbalance cannot be helping anyone.

    There is a simpler explanation discovered when it caused mental breaks for office workers, Subliminal Distraction exposure. No one has investigated it since it was discovered in the 1960’s.

    • Robert Whitaker has reported that many experts dismissed the “biochemical imbalance” theory of mental illness decades ago as lacking evidence, and it was just trotted out to the public because it sounds good and like you said, gets people to take medications.

      But just because mental health issues are not simple biochemical imbalances, that doesn’t mean that medications that alter biochemical balances could never help. Psychiatrist Joanna Moncrieff describes what they do as creating a “drugged state” which may or may not prove to be helpful. What they don’t do is restore any kind of balance.

      I think there are lots of explanations as to the cause of mental disorders – and it may be that, like various forms of accidents, a wide number of possible causes may exist.

  • I am going to tell you I personally experienced this. I have become completely attached to a man who pretty much raped me while on antipsychotics. I did not try to get away, instead I was in love with him and went out seeking him all the time.