Amanda passed this infuriating article on to me. It tells the story of 17-year-old Nia, hospitalized with schizophrenia, and the psychiatrist who treats her — a psychiatrist who found it so alarming that she was gaining weight from the medication that finally and completely dealt with her symptoms that he took her off the medication.
It also tells another story about the authors of the piece, the deputy editor of the magazine and a psychiatrist — namely, that they don’t seem to find anything wrong with the treating shrink’s decision to compromise his patient’s treatment to save her willowy looks, but they sure can’t understand why she’s not bothered by the weight gain — unless she’s still mentally ill.
Here’s what Nia’s psychosis was doing to her:
Then, as she turned 17, Nia’s teenage behaviour began to become something else. She started crying out, shouting at invisible persecutors who came into her room. Her parents didn’t know what to do. They were a close family and at first avoided the thought of doctors. They tried to love her more. It wasn’t until Nia stopped going to school altogether that they broached the subject with their GP. He immediately referred her to a psychiatrist.
Nia had revealed little to her parents of what was really going on inside her head. But the soft-spoken psychiatrist at the local adolescent mental health centre won her confidence and she began to tell him about the trains. A railway line ran a few hundred yards past the bottom of their garden, far enough away for the family to ignore it. Nevertheless, Nia said she could hear people talking about her inside the painted steel carriages. In the clank of heavy rolling stock she could pick out snatches of conversations about her—derogatory insinuations that crept into her room through the plastic veneer of the double-glazing. She also told him that she had seen things on television. The newsreaders had begun looking at her. In the corners of their eyes she began to read signs. They were sending her messages; messages that linked up with the voices on the trains.
Got that? Auditory hallucinations. So severe that they’re impairing her ability to function. I don’t know if you’ve ever known anyone who suffers from hallucinations, but it’s pretty scary to watch them. I once worked with a woman who fell asleep a lot at work. When she was talked to about it, she said she didn’t sleep at night because her apartment was filled with demons that wouldn’t let her onto her own bed. She was fine at work except for the falling-asleep bit, because the demons stayed in the apartment. But one day, some of them hitched a ride in her hair, and we found her screaming among the files, beating at her head with her hands.
Nia told the psychiatrist all the things that she had kept secret from her parents. But by the end of the session she began to doubt the wisdom of doing so. She glanced at him with suspicion. He too was insinuating something. There were meanings to be found everywhere in her world. The psychiatrist gave Nia a prescription, which her parents collected from the chemist. She refused to touch it.
On the day before her admission to hospital, Nia had stood at her parents’ front door, unmoving, for five hours. They could get no explanation out of her. There seemed to be no explanation for any of this. Nia was dishevelled, and had stopped paying attention to her appearance, but that still couldn’t disguise her beauty. At their wits’ end, her parents agreed to her being forced to accept treatment.
Five hours. She stood stock-still at the front door for FIVE HOURS. And the authors, one a psychiatrist, are concerned about her appearance? But it’s okay, because she’s still beautiful.
Sitting in one of the interview rooms opposite the new arrival, the junior psychiatrist was struck by the patient’s beauty: shoulder-length brown hair, slender in hipster jeans and a fitted T-shirt. Apart from her distracted eyes she didn’t look unwell. He felt himself giving her more time than usual, fascinated by the experiences she related. Third-person auditory hallucinations, delusions of reference, ambitendency—it was as if this teenager had read a psychiatry textbook.
After a period of observation (apparently to make sure that her psychosis was not cannabis-related), she started getting worse and the doctors started considering treatment:
In fact she got worse. She wouldn’t talk to the staff and her meals were brought to her room. For hours on end she lay with her head under the pillow, the radio quietly on. The clinical team was now faced with the difficult decision of which medication to prescribe…. It is known that antipsychotics can block D2, one of the five dopamine receptors in the brain, and that this has an effect. Very often, the main effect is beneficial. Equally often, the side-effects are troubling.
The consultant favoured Olanzapine for Nia; he had found the drug to work well in her age group despite concerns about weight gain and diabetes. Other modern choices include Quetiapine, though many clinicians think it a weaker drug, and Risperidone, which can also cause weight gain and stiffness. The older drugs like Chlorpromazine and Haloperidol were felt to be “dirtier” and to have worse side effects, including the irreversible lip-smacking and protruding tongue movements of tardive dyskinesia. Seasoned sceptics argue that not much, fundamentally, has changed since the 1950s, apart from refining the choice of side-effects. The young psychiatrist wrote Nia up for Olanzapine—10mg, the regular dose. The drug being a sedative, Nia took it at night. She began to sleep.
The treatment proved successful and the young shrink patted himself on the back:
Not much changed for five days. Then, one morning, Nia was transformed. She left her bedroom, came to meals, had normal conversations with staff. Her face filled out with ordinary human expressions. A day later she was even laughing. A young woman, an intelligent teenager, had reappeared; the psychosis seemed to have left her. To see a patient respond to a drug in this way made the young psychiatrist feel like a real doctor. Almost ashamed of himself for feeling this, he noticed that he felt grateful towards Nia—for getting better.
Then, the side effects:
What the staff didn’t pick up immediately was Nia’s hunger. The nurses were so encouraged by her regular appearance in the dining room that they didn’t question the heap of beans and potatoes. But soon it became apparent that insanity had been replaced by appetite. Within three weeks she put on three stone.
Three stone is 42 pounds, which indeed is a hell of a lot of weight to put on in three weeks. And remember, one of the potential side effects of the drug prescribed is diabetes. But are the doctors concerned about her health? They are not. It’s all about her looks.
Now, for the first time, Nia’s features were being corrupted. She started to take on the shape of many of the chronically mentally ill. Her jawline collapsed below puffed-out cheeks. Her stomach sagged above her jeans. Even the consultant found the contrast alarming. “Get a dietician to see her; tell the staff to watch what she eats; change her to Quetiapine.”
I don’t really have a problem with the decision to switch her meds, per se. After all, she did gain an alarming amount of weight in a very short period of time and I have no idea if the effect of the original meds subside over time, or if the patient will continue to gain at this rate. But this whole focus on her looks rather than her health as the reason to switch is, I think, appalling. In any event, the next medication didn’t work so well and Nia was back to square one:
The Olanzapine leached out of the tissue of Nia’s central nervous system and made way for the new compound, Quetiapine. But now the illness began to resurface. She was eating less, but the paranoia had returned. “Put up the dose,” said the consultant. “Quetiapine hardly ever works below 750mg.”
Despite a month-long trial on the highest dose, the relapse of Nia’s psychosis was untouched. She became so vulnerable that one-to-one nursing became necessary. Isolated in her room, the voices tormented her.
So they decided to go back to the original medication, the one that worked. Pay attention, however, to what the shrink was concerned about:
The young psychiatrist’s early optimism collapsed under the grinding reality of Nia’s dilemma. The first drug had worked. But the change in her appearance seemed intolerable—and potentially devastating for the self-esteem of a 17-year-old girl. The second drug hadn’t made her fat, but nor had it treated her illness. The consultant felt there was no option but to put her back on the Olanzapine. Again, it worked. The terrors of persecution vanished, the voices quietened down. Even her parents said that this was the old Nia. They cried over her.
Got that? Here’s a young woman who’s been hearing voices in her head, who hasn’t been able to leave her bed for months, who was so tormented by her illness that she could no longer function — and the shrink is worried about the blow to her self-esteem if she walks out of the hospital free of the voices but fat? The authors certainly seem to buy into this as well — note how they set up the equivalence between psychosis and weight gain.
Oh, but here’s where it gets really good and the fatphobic attitudes of the psychiatrist and the authors come out:
The desire to experiment further with her medication left the consultant and the young psychiatrist. It was likely that the weight gain associated with Olanzapine would be very difficult to treat and that Nia would be fat, if not obese. But more disconcerting to the young psychiatrist was Nia’s apparent indifference to her predicament. While those around her worried about the beauty she had lost, she seemed unconcerned. Was she really as well as her family suggested? Had she really rejoined the image-conscious world of her peers? The dieticians came and went to little effect.
For a while the young psychiatrist worried about the consequences of the choices they had made in treating her. They had removed a stigma of the mind and replaced it with a stigma of the body. It struck him as strange that the patient had been the only one not to worry about a loss that the team around her found so tragic. Perhaps it didn’t matter. Perhaps, in fact, this was a merciful side-effect of medication, or even of the disorder itself; one that liberated Nia from the need to live up to the standards of an image-obsessed world.
The young psychiatrist wasn’t sure. The treatment had reversed a Faustian pact in which Nia had been beautiful and mad, and replaced it with another—in which she was fat and sane. But was it really a blessing that Nia seemed to have no conception of what she had lost?
She couldn’t possibly be sane, because if she were, she’d be bothered by the weight gain! Doesn’t she know she’s supposed to feel ashamed of being fat, instead of maybe thinking that being fat and sane is preferable to being thin and tormented by voices?
Cripes. None of these people seem to be able to comprehend that they’re putting their own issues on her, that while they’re mourning the loss of something pretty to look at, Nia’s got her freakin’ sanity back. She’s probably well aware of what she’s lost, but maybe, just maybe, she considers what she’s gained to be of more importance.
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