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