19 February 1994

A SIMPLE THEORY OF MENTAL ILLNESS.

by

Dr. Errol B Cahoon.

Having read Dr. Sigmund Freud's books for 6 months in 1945, I decided that I did not agree with him, as I could see no proof of his statements.

This has made me somewhat unpopular in the Toronto area, because soon after Dr. Aldwyn B. Stokes arrived and brought about 40 psychoanalysts of various disciplines into the Toronto area, and gave them all good jobs.

I remained at St. Joseph's Hospital from 1950 to the present, and treated many patients with EST and medication. They seemed to improve fairly well, and I continued on this way.

I had gone to the Montreal Neurological Institute, and the Queen Mary Veterans Hospital for 2 months training in Electroencephalography. I set up the EEG laboratory in Sunnybrook Hospital on my return and stayed in charge of it till 1968. I continued on from 1962 to 1987 in charge of the EEG laboratory in St. Joseph's Hospital. During this time I gradually decided that all mental illness occurred in the brain by electro-chemical means. I decided that patients became upset with some problem (or stress-the new word), and as a result became depressed in their mood to a greater or lesser degree.

This was apparently quite devastating to some people, as the depression lasted, and as they did not know how to get rid of it, their reaction varied.

It appeared that at several times in their lives they had to make decisions as to how they would assess the other persons reaction to themselves, and how they must relate to other people. Today they seem to want to relate to teens only. This, I regard as a great disadvantage, as they do not talk to people of all ages and listen to them, and as a result develop only an early teen age philosophy toward life.--consisting of music with 2 or 3 sentences in very loud monotonous sound, and suggesting the use of alcohol, drugs, sex, and fun. They have not realized that satisfaction in life comes from doing something or making something, and getting satisfaction from the accomplishment. This does not occur from entertainment or fun, which most of the time has no accomplishment and therefore no satisfaction, resulting in no contentment.

1. I concluded that they were more depressed with this monotony, and had to decide how to get rid of the depression. Some patients became a little frightened of the continuing symptoms of depression, and then became tense and shaky--resulting in the diagnosis of Anxiety States, or Neuroses.

2. Some of them found that activity lessened the shakiness, and used it every time they became tense and shaky. They then developed an Obsessive Compulsive Disorder. Some of them just had the depression fade away, and they were much better adjusted after, paid more attention to school, and learned something. (This is a very lofty logical idea that I can understand).

3. Some of them made a decision, that the depression was too painful, and the best way to get rid of it was to feel some other emotion instead. These as a result, had inappropriate feeling in situations, with accompanying inappropriate thinking, and then inappropriate behaviour--depending on which emotion they substituted for the depression. Their diagnosis became Schizophrenia.

a: If they chose humour, instead of depression, then they would laugh at sad stories and situations, and be diagnosed Hebephrenic or Simple Schizophrenics.

4. Others made a decision that the best way to stop the depressed hurting, was to stop having feelings at all. Does this relate to the necessity today to be "real cool"? The word "cool" in the 1950's & 1960's seemed to mean that one should not be emotionally affected by anything that happened to them. Thus it is easy to be "real cool" if there are no feelings to be affected.

When they have no feelings, and as a result, are left with no joy, and have to get along with physiological excitement--hitting the baseball over the fence, or other exciting activity, some of them ending up kicking policemen in the head.

They get into a great deal of trouble, and it never seems to bother them, as they continue to go on and on, doing the same things over and over in their behaviour. These are the Psychopathic Personalities, Borderline Personalities, Personality Disorders.

It was my opinion that this list is in ascending order of difficulty in treatment of the patients.

I described this to the Professor of Psychiatry Dr. A. B. Stokes in 1961. At the end of this short discourse, he said "You are leaving yourself open to criticism"! I replied "Who isn't"?. He never answered this, and I guess he didn't think much of my theory, as he never offered me any job at the Toronto Psychiatric Hospital then or after.

I had seen Dr. Wilder Penfield operating on one of his epileptic patients in 1947, using the EEG for electrocorticography to locate the focus of electrical abnormality in the cortex, and to remove it and to relieve the patients' seizures. He stimulated the cortex, in different places, using electricity, in small amounts under local anaesthesia, and could produce movement in various parts of the body, and sounds, music, scenes, etc. This persuaded me that the brain is organized, to store the memories, and functions in some way. This also showed me that some of the localities for these functions seemed to be in different places in different patients.

This must be so, or we would be all clones of each other, and one must at some time in life realize that every person thinks differently, and that men and women think even more differently.

I have always regarded the fact that women think differently as an advantage, and that when one talks to them about a problem, one gets a set of differing thoughts which can be put with one's own thinking, and perhaps then one can make a better decision on that subject.

Treatment:

In 1945 I had used the hot tub treatment at the Toronto Psychiatric Hospital for the manic patients. It didn't seem to work very well. Sedation using barbiturates, HMCs#1's (Hyoscine, Morphine & Cactoid) seemed to work to stop agitation temporarily, but didn't last very long, and patients were given EST in small numbers, Insulin Shock was used for the Schizophrenic patients, and Modified Insulin was used for the Chronic Anxiety States. Sodium Amytal 1gr. was used tid, and 3grs qhs., or phenobarb, 1/4 gr tid, and 1 ½ grs qhs. These seemed to be quite effective, in spite of all the furore at the present time about them being so dangerous, as they were used until the mid 1950s, when the phenothiazines were put on the market and the antidepressants followed. These latter were touted at relieving 67-87% of depressions. I added up the effects of Marsilid (Iproniazid) in 100 patients, and compared them to 114 patients on Tofranil (Imipramine) in 1958. The improvement was 37% for Marsilid and 42% for Tofranil. The side effects were 33% and 9% respectively, in these series. At that time Geigy had a meeting at the Allen Memorial Hospital. There were 30 Psychiatrists reporting 17 to 27 patients. They stated that 67-87% showed improvement on Tofranil. I thought that I had 5 times as many patients, and probably knew 5 times as much as they did.

New drugs today are advertised as having 70% improvement. The ones I try on my patients never add up to that much. Would this be because I talk to my patients and ask them question about the pills and the effects they find when they take them? I do not know what the researchers do about their numbers and %'s. The advertising and the detail ladies cannot tell me. After I try the new pills out on a few patients, and tell the detail ladies that the improvement numbers are about 30-40%, the ladies never return. I guess the truth hurts.

I have found that many patients do not seem to know how to express their feelings, and many have tried to "Give it all they have" as in the old song in the 1920's. This of course leads to over expression and getting themselves into difficulty with others, especially as they do this at inappropriate times. I gradually formulated the idea that people who over expressed their emotions, should learn to express them in small amounts, which would not require as much energy, and might just be diplomatic in nature,and not upset the person listening as much either. I suggested that they might repeat it if necessary, and if not, let the listener go home and think about it by themselves, and maybe they could figure out what the patient meant, without taking the listener by the ears and pounding his head on the cement until he said "UNCLE".

At one time I asked questions to get out of the patient all the description of what happened with various emotions, joy, love, depression, fear, and anger.This always took a very long time, and finally today I just describe the situations relating to these emotions.

1. To express joy, one laughs, dances, and sings. The people who are celebrators have to have a champagne party because they finished work and they are living for excitement. Others have an attitude of "sour grapes" or "sweet lemons" and may say that someone out on the dance floor or elsewhere is "making a fool of himself". We know that these people, will probably never engage in this behaviour, and are worried how their expression of joy is received. They seem to wish to control other people's reception of their expression. This causes less difficulty for them than the expression of love.

One cannot control the other person's reception of any emotion, therefore one must not give the other person permission to overreact by over expressing one's own emotion. This might be called "prevention" (a very popular word in medicine today among planners and politicians).

2. To express affection, all one has to do is listen, and answer the questions appropriately. The person listening then knows he was listened too. This is likely called "communication". The "celebrators" of affection, are the people who have to touch one, as they do not believe that you can recognize they are being affectionate without the touching. Some, the "Not here, John" girls, and the "Not here, Mary" boys, are unable to receive affection. They cannot hold hand in public, or kiss each other goodbye in Union Station--someone might be looking. Some are not able to express affection, and they when asked by their spouse if the spouse loves them, they say, "I go to work, I bring home the bacon, I darn your socks, I get your meals, etc, etc.", but never say the simple work "Yes". One might think that is the answer the questioner wishes to hear, and might satisfy them much better than the semi-put-off answer. One thinks that this way of expressing love, is because the answerer if afraid of how it will be received, and wants it received his way. This will never happen in all likelihood, and one must learn to accept the way the others receive our expression of emotion, as we cannot control others reception of emotion. Some people think there is some obligation in affection, and when they are invited out for a cup of coffee or whatever, they fight over the check. They feel that they have to reciprocate later, and do not want to, and so cannot receive the gift. I try to get these to realize, that gifts are freely given, and all they have to do is say "thanks". Gifts not freely given, are the responsibility of the giver, not the receiver. All one has to do to express affection in "teaspoonfuls instead of buckets" is to listen with interest.

3. To express depression, one has to feel depressed. With small amounts this should probably last 5 minutes of thinking how bad something is; and then one should get up and do something else. If there is a tragedy in life, then one has to grieve over it for 2-3 days, and then go on living. One cannot live other's problems, their tragedies, etc. One can only sympathize, or give some other form of help or advice, but one cannot live the tragedy. I tell these people they would be great psychiatrists, as they would be as sick as their first patient, and never get to see the second one. One of my colleagues, a family doctor, 44 years ago, said to me that he couldn't do my work as it would bother him. I asked him what he would do if he had a patient with a fractured leg. He replied "Fix it". I asked him what he did next, and he replied, "See the next patient". I then asked him why he didn't go out and kick the bumper of his car with his shin to fracture it? He asked, "Why?". I said then you could have all the feeling the same as the patient. He said, "I don't understand". So I replied that I don't live all my patients' bent emotions, I try to help them the same as he fixed the fracture. He still did not understand.

4. Before one expresses fear, one has to decide whether to run or stay in any fearful situation. At that time the body has to prepare for the escape, which it does very quickly and more or less efficiently. The action of running away or attack, reduces the tension in the body. However when one has to get up on the stage and give a speech, one has similar feelings if one is not prepared. Therefore one should prepare the speech, even to the point of having to read it. I find it better to prepare also the description of the slides and not talk about the slide without some definite preparation, as one lengthens the presentation, past the time allowable. When one gets up to speak, there is some tension; but after the first sentence is out, this lessens, due to one's interest in the subject, and the activity of presenting. Many years ago, I presented a talk on EEGs at St. Joseph's Hospital to the Medical Staff. I had lantern slides, and 35 mm slides to demonstrate what EEGs looked like. The projectors were nowhere to be found. I had to go to the blackboard and make drawings of the EEGs. The lectern was several feet away, and I could not see the notes. I decided that I knew what I was going to talk about and the audience didn't, as this was a new subject for most of them, so I talked and drew the pictures, without notes. This seemed to work very well, and I did not feel tense during the presentation after my decision. The expression of fear consists of action, and making decisions as to the course of that action.

5. Anger seems to be the most difficult for people to express in teaspoonfuls. There is annoyance, resentment, hostility, anger, and rage. All that makes one annoyed in the beginning is that someone disagrees with one's valuable opinion. To express one's disagreement, one disagrees right back. This can be done by saying, "I never heard that before; Isn't that interesting; I'm glad you told me". Then you can go away, having found an new thought to possibly help you make a better decision of the subject. One big problem with this is the fact that many young people have made the decision, that when someone gives them some advice, they are "Being told what to do, and no one must ever do that". this attitude, means that the person with it is going to invent "Square Wheels", as he is not going to listen to some method others have used for many years to do the same thing.

The advantage of expressing one's emotions in teaspoonfuls instead of buckets, is that the emotion goes away, if one lets that amount of expressions be sufficient. The advantage for the Narcoleptic patient is that his emotion never gets so great in amount that he does not get cataplexy, with its attendant complicating confusion in thinking, and attendant muscle weakness, which have affected his behaviour most of his life. My patients find that this is so, although it takes practice, and some time and numerous mistakes along the way.

I also give them antidepressants, tricyclics, MAOI drugs, and the newer antidepressants, whether of either type. Some patients can take none of them, due to side effects of the pills. Due to the hysteria of the regulators one is unable to try out the alerting drugs. Appetite suppressants sometimes work very well, but the rule of only being able to give a 300 lb. person an appetite suppressant for one month in a life time is laughable. One of my patients could take 6 Preludin a day and be alert, but requires 30+ a day of Ionamin. She can get the Preludin in Texas where her sister lives, but it was taken off the market in Canada in 1973. Why, I do not know.

I note in a recent issue of the Medical Post that some one is using the EEG in biofeedback to get patients to see on the computer screen the level of tension, and teaching them (how it is not stated) to learn to change their thinking to reduce the level of tension.

I think my method is easier to apply and cheaper, and does not involve any machinery. This of course does not prove anything as my method is not validated on paper. What a shame! What I think I have proved, is that the criteria for the diagnosis of Narcolepsy is too narrow and restrictive, and interferes with the treatment of my 1340 patients over the last 13 years.

25 April 1994

In the time for discussion, one gentleman asked my if I had a reference for my statement that all mental illness was a part of the electro-chemical system of the brain.

I answered him stating that I had no reference, and that I had thought this up myself on the basis of the work I had done in Electroencephalography, and my observation of Dr. Wilder Penfield at an operation when he was stimulating the brain of a patient, and his writings on the stimulation of the brain in his operations for the relief of epilepsy. I further stated that as time has gone on, I can only see that the research in the workings of the brain only prove what I was thinking in the late 1950's.

No one asked any further questions.

I have given this to a number of doctors, and patients. The doctors have not responded to my asking them for their opinions of it. Several patients think it is useful to them to help them understand their problems a little better.

Dr. Errol B Cahoon