Csikszentmihalyi240

Patients suffering from chronic and ‘functional’ disorders are stuck—literally and metaphorically. The experience of being trapped by a body and mind that no longer perform naturally or follow orders can be overwhelmingly debilitating.

With many of the conditions eluding diagnosis and effective treatment, the frustration experienced by the patient often infects the practitioner, with demoralizing results.

Subjective ‘stuckness’ is easily demonstrated. If the sub-modalities of either patient or practitioner are examined, we will almost certainly see that they lack movement: stills or snapshots, rather than movies, full of color and movement. Their representations of the problem lack process and action. Their sensory representations are restricted, or loop continuously in a self-maintaining cycle of failure. The successful resolution of a problem will always be accompanied by a shift from ‘still’ to ‘moving’.

Healing, whether or not it involves a ‘cure’, is a return to optimal experience, or ‘flow’.

We are often asked by hopeful newcomers to Medical NLP for ‘the’ cure for depression (or anxiety, chronic pain, post-traumatic stress disorder, etc). Our reply is always, ‘It depends on the patient.’ The pre-supposition that the prescriptive approach of Western medicine can be applied to all patients suffering from superficially similar disorders misses the essential point. Medical NLP holds that the patient who has the condition is the key to relieving the condition that has the patient.

Therefore, even though in this chapter we review the underlying structure and process of three components commonly encountered in complex, chronic conditions—depression, anxiety, and pain—these are not intended to be applied prescriptively.

Rather, we urge you to remember always to return to basics—structure, process, purpose, and intention—and then to develop approaches out of the principles and techniques outlined earlier in this book. In the following chapter, we will present a number of patterns that can be used as templates for further interventions. Avoid being too constrained by formal diagnoses. Although all clinical guidelines categorize conditions and make specific recommendations, these are evaluative statements and cannot accurately reflect the fullness of the patient’s experience.

Do not confuse text with context, the patient with his symptom, the diagnosis with the disease itself. Therefore, the headings we give to the following sections are intended as general, not definitive, descriptors.

Note: Since we regard allostatic load as an underlying cause or component of all ‘functional’ disorders, we suggest encouraging patients to adopt a regular program designed to evoke the Relaxation Response, the psychophysiological counter-balance to the fight-or-flight response (see Appendix A, pages 357 to 360). The Relaxation Response has been demonstrated to have a regulatory effect on many disorders classed as ‘functional’ or ‘somatoform’, possibly by restoring hemispheric balance.241,242,243 The simple technique outlined in the Appendix also introduces the essence of ‘mindfulness meditation’, the practice now being embraced by Western medicine, without an unnecessarily long learning curve.

Depression and the myth of chemical imbalance

If you’ve ever sought help from the mainstream medical profession for depression (or, for that matter, schizophrenia, attentional deficit, or bipolar disorders, social phobia, and, even, restless legs), the chances are you would have been offered a psychoactive drug, as first-line treatment.

Equally likely is the fact that you were probably told by your doctor or psychiatrist, or may already have read or heard somewhere, that your problem was a ‘chemical imbalance’ in the brain.

The shift in the approach to mental illness over the past two or three decades has been profound. Where once social and family were considered to be the likeliest causes of emotional disturbance, now it is a failure of your neurochemicals to order themselves correctly.

It’s a seductive theory, and one which both doctors and patients have embraced. First, it gives permission to administer medication, the treatment they know best; second, it removes from the patient and her family any suggestion of responsibility or blame.

As we see it, there are two serious problems with this approach: how can a patient suffering chronic disturbances of any kind be treated in isolation from the context in which she exists—and, how can anyone claim the existence of a ‘chemically unbalanced brain’, when there is absolutely no evidence as to what a ‘chemically balanced’ brain might be?

Furthermore, there is

In fact, even David Kupfer, overseer of the Diagnostic and Statistical Manual of Mental Disorders (DSM) Fifth Edition, the American Psychiatric Association’s diagnostic and prescriptive ‘bible’, admits in the press release of the publication’s latest edition, ‘We’ve been telling patients for several decades that we are waiting for biomarkers. We’re still waiting.’

This astonishing admission does nothing to rein in the taxonomic enthusiasm of DSM-5’s contributors, who have created even more ‘psychiatric disorders’, all ‘treatable’ with medication. These range from ‘disruptive mood dysregulation disorder’ (severe and frequent temper tantrums); ‘binge-eating disorder’ (over-eating 12 times in three months); ‘oppositional defiant disorder’ (children who won’t listen to their parents); and ‘hoarding disorder’ (difficulty in discarding possessions regardless of value).246

But, rather than finding themselves united by a global description of drug-treatable mental illnesses, some psychiatrists on both sides of the Atlantic have challenged the validity of the 100-page volume and what one source calls its ‘diagnostic hyper-inflation’.

Even more dramatically, the Division of Clinical Psychology of Britain’s distinguished Psychological Society met publication of DSM-5 by calling for the abandonment of all psychiatric diagnosis and the development, in its stead, of alternatives which do not use the language of ‘illness’ or ‘disorder’.

Diagnoses such as schizophrenia, bipolar disorder, personality disorder, attention deficit hyperactivity disorder, conduct disorders, etc, are of ‘limited reliability and questionable validity’.247 Instead of assuming a physiological basis for mental illness—as yet unproven—they point to socio-economic factors as being far more accurate predictors of emotional distress.

The theory of biochemical imbalance remains so well entrenched that it has seldom been questioned. The response of the pharmaceutical industry has been to launch thousands of psychotropic drugs costing billions of dollars in the ‘war’ against mental disease. The promise continues to be an effortless chemical ‘tweak’ and an end to behavioral problems and mental suffering. However, in the case of many mental illnesses, the outlook remains bleak. In fact, the long-term condition of some sufferers, notably schizophrenics, has actually worsened since the early- to mid-20th century, when treatments ranged from camphor injections; electro-convulsive therapy; deliberate infection with malaria; to insulin-induced comas; ice-water showers; and lobotomy.248

Astonishingly, according to two major studies by the World Health Organization, if you suffered a psychotic episode in a poor country, such as India or Nigeria, you’d probably be more or less back to normal in a couple of years, whereas if you were unfortunate enough to be a citizen of one of the developed countries, you would, in all likelihood, end up chronically ill. Meta-analyzes of the outcome literature reveals that clinical and social outcomes are significantly better for patients in ‘Third World’ countries than for those being treated in the West.249,250 Explanations for this apparent anomaly include greater familial and social integration in these two countries, and, paradoxically, little or no medication.

These findings, reviewed in detail in Robert Whitaker’s highly readable (and disturbing) book, Mad in America: Bad Science, Bad Medicine, and  the Enduring Mistreatment of the Mentally Ill,251 have been greeted with almost as much disparagement and anger from some psychiatrists as did Robert Rosenhan’s iconoclastic ‘thud’ report.252 And, yet, both the theory and the problems it causes persist.

Moods (and probably the levels of certain neurochemicals, including serotonin) may doubtless be affected by certain activities and triggers, such as exercise, sunlight, and sex. However, some people might regard it is cavalier, not to say dangerous, to administer profoundly mind-altering drugs based on the assumption that two or three neurochemicals, out of the 100 or more that have been identified, are out of whack.

Resistance to change

Resistance to changing tack in the way certain drugs, antidepressants in particular, are prescribed is high. So entrenched is it, that even doctors in general practice are allowed to prescribe highly psycho-active drugs—sometimes on the flimsiest of diagnostic criteria. Even though research suggesting most of the leading SSRIs are of little use to anyone—except, possibly, people with extremely severe depression, as has been widely publicized—prescriptions, at the time of writing, continue to be issued at a rate of nearly 200-million a year in the United States,253 and nearly 40-million in the UK.254

Understandably, pharmaceutical companies embrace the chemical imbalance theory with enthusiasm. Almost all the major brands suggest in their publicity material that chemical imbalance in the brain ‘may’ be the cause of depression.

Also, while certain drugs may have a place as a response to acute mental problems, the model of chemical imbalance has been extended across the board to cover the widest possible range of conditions, from major psychotic incidents and florid hallucinatory experiences to the breakup of a teenager’s relationship, or worry about incipient changes in the work-place. As we’ve remarked elsewhere (see page 219), life experiences that would have been considered normal a few years ago are becoming pathologized, with scant proof that pharmacological intervention is in the subject’s real interests. Aside from the risk of side-effects, including habituation and addiction, our concern is that such a response does little to improve the patient’s ability to respond appropriately to life’s vagaries.

The theory of chemical imbalance affecting the ‘normal’ functioning of the nervous system has a lot in common with that which underlay the Victorian concept of ‘neurasthenia’, a term first coined by psychiatrist George Beard in 1869. This diagnosis, describing a nebulous condition marked by mental and physical fatigue, listlessness, and medically unexplained aches and pains, dominated medical thinking for more than a century.

The term was dropped from DSM in 1969…but the concept is neither dead nor buried.

Diseases related to neurochemical imbalance were unknown in Japan. However, as soon as Western pharmaceutical companies invented and imported the concept of nerves and electrical nerve-impulse into the country, using the analogy of trolley-buses derailed from their power sources (something to which the Japanese could relate), the country began to suffer from a near-epidemic of what became known locally as shinkeisuijaku (Figure 19.1).

Figure 19.1 Shinkeisuijaku

Given the high-achieving, time-poor, and over-crowded world in which many millions of Japanese live and work, it was readily accepted as an ‘explanation’ of the country’s widespread but inchoate sense of anxiety and stress—what we would call ‘allostatic load’.

Some observers, including cultural analyst Junko Kitanaka, see the introduction and acceptance of shinkeisuijaku as the first psychological ‘disease’ of the common man, and the first instance of large-scale medicalization of everyday distress in Japan. It also serves as a particularly graphic example of how the ruling WEIRD (Western, Educated, Industrialized, Rich, and Democratic) paradigm is being deliberately extended far beyond its source. This is what writer and commentator Ethan Watters eloquently calls ‘the globalization of the Western mind’.255

The pharmaceutical industry’s infomercials are no more scientific when preaching to domestic audiences. For example, one slick advertising video for Zoloft® (sertraline), one of America’s top-selling brands, suggests that feeling sad, lonely, or that ‘things’ don’t feel the way they used to, is ‘depression’, a condition that ‘may’ be caused by a failure to produce enough serotonin, and which requires medication.

No life-event is mentioned as a possible cause of depression; no suggestion is made that behavioral and dietary change may help. Your friends and family are irrelevant. The fact that your mother, or a beloved pet, might have died, doesn’t rate a mention. Instead, a highly simplified animation shows how the drug turns a sparse trickle of serotonin into a positive flood of feel-good chemicals leaping across the nerve-endings in the brain, resulting in an almost immediate existence of sunshine, clear skies, flowers, and birds.256

So how can a dictum as shaky as the chemical imbalance explanation continue to survive in the face of such scientific challenge?

Eliott Valenstein, author of a meticulously researched and well argued book on the subject, Blaming the Brain, views it starkly. ‘A fallacious theory,’ he says, ‘is regarded as preferable to admitting ignorance.’

Valenstein traces the medical profession’s commitment back to the 1950s when the accidental discovery of some mood-altering drugs opened the door to the belief that psychopharmacology would mean an end to mental illness. The result has been worldwide reliance on drugs to treat depression, and massive profits for the pharmaceutical companies involved.257

Many doctors still argue that patients report positive results after using SSRIs. We have no way at the moment of establishing how much of this is a placebo response and how much has to do with the fact that the patient is able to experience some ‘difference’, even though it may not be the happiness or wellbeing implied by the drug companies’ marketing copy.

Dr. Joanna Moncrieff of University College in London believes this is the explanation for how psychotropic drugs used to treat ‘psychiatric conditions’ really affect people with depression and other emotional ‘disorders’. She argues that the effects reported by patients may result from the drugs’ psychoactive qualities—in much the same way as alcohol, cannabis, and cocaine can alter the user’s mood. Some drugs dampen down thoughts and emotions; others create a pleasant soporific effect. The fact that patients are put into an altered mental and physical state does not mean that the drugs have effectively treated their condition, she says, but may simply have suppressed or masked their feelings. Or, the patient may simply feel ‘different’.

None of this is intended to suggest that there is no role for medication in certain cases of depression, particularly when acute. But we agree with Dr. Moncrieff, who urges her colleagues to give patients true ‘informed consent’ by telling them that the prescribed drug may simply make them feel different and could suppress thoughts and feelings. We suspect that many people would reject such drugs, while some, particularly those who have been severely distressed over a period of time, may welcome these effects as preferable, at least for a time.258

For the most part, though, we prefer patients who consult us because they are feeling low to explore some of the suggestions in this book, as well as to try exercise (where possible), diet, and the support and love of family and friends. From experience, we know that depression is caused or deepened among people who: lose structure to their days; eat badly; don’t get any exercise, and avoid social contact.

These alternative ‘treatments’ are not as strange as they might at first sound. Britain’s Mental Health Foundation lists a number of benefits of exercise for sufferers of depression, including:

Furthermore, side-effects (supposing the exercise regime is geared to the individual’s capabilities and needs) are non-existent.

Few, if any, drugs can make these claims in good conscience.

Diet has been associated with mood fluctuations, as well as several mental diseases and behavioral problems—including attention-deficit hyperactivity disorder (ADHD), autism, and even schizophrenia.260 Some studies suggest that a diet high in B vitamins, omega-3 oils, and plenty of vegetables—the so-called Mediterranean diet—may be useful in helping to control depression.261

There is no doubt that considerable damage has been done to both the patient’s capacity for self-efficacy and the healer’s ‘art’ by the current belief that depression is exclusively a biochemical disorder. As we have mentioned elsewhere (see page 120), where diagnostic criteria exclude the events and experiences surrounding the offending condition, and seek only to tackle the symptom itself, the patient is deprived of important healing resources. The ‘brain flaw’ explanation is not only the source of even greater problems, including stigmatization, reduced proactivity, and, in some cases, chemical dependence, but it creates an extraordinary new and unsettling phenomenon—experience stripped of meaning.

If anything makes humans human, it’s our experience and the meaning we attach to it. To act as if our life experiences are irrelevant and our problems reducible to a malfunction as perfunctory as a leaky valve or derailed trolley bus, is to drag us even more deeply into the mechanistic, reductionist mire which can create more problems than it solves.

Process, as we repeat many times, needs to be restored to the experience and description of depression, as well as of many, if not all, of the complex, chronic conditions that prompted us to write this book. Since English has no verb to describe the process of ‘depress-ing’, we urge you always to remember that it is not a ‘thing’, but a behavior or response.

The structure of depression

Patients suffering from feelings of depression often:

Developing interventions

Consider:

We also suggest that the practitioner explores and addresses the following:

Not only do these problems surface when a patient becomes depressed, but serious disruption of any or all of them may actually trigger a depressive response.

Anxiety

Anxiety should always be regarded (and reframed) as a protective response that is either overactive or de-contextualized. Anxious patients are usually trapped in:

Developing interventions

Consider:

Note: Post-traumatic stress disorder has a similar structure to anxiety disorders and panic attacks. It may be approached as suggested above.

We emphasize the need to incorporate coping strategies into all outcomes, rather than simply ‘blowing out’ the behavior. This not only inoculates against the problem regenerating, but also increases the patient’s sense of self-efficacy.

Case history: Duncan presented with chronic neck pain, anxiety, and retrograde amnesia (inability to recall events immediately preceding a trauma) following a car crash at an intersection late at night. A motorist Duncan failed to see shot a red light and smashed into the side of Duncan’s car.

Of all his symptoms, the inability to remember what happened seemed to bother Duncan most. He said, ‘It’s like part of my life has been taken away from me. The harder I try, the more confused I become.’

Retrograde amnesia is usually self-limiting (that is, memory returns without further treatment after a while), but since Duncan was becoming increasingly distressed at his lack of improvement, he sought further help from one of the authors. He believed knowing what had happened would help him recover more quickly from the injuries he had received.

The practitioner began by identifying the last thing Duncan remembered before the accident, and the first things he recalled after the event. He invited Duncan to lay these events out like a movie clip with a blank stretch that corresponded with his amnesia.

Then, step by step, Duncan added new frames in response to the questions, ‘What is the most likely thing to have happened immediately after the last thing you remember?’, and, ‘What is the most likely thing to have happened immediately before the frame in which your memory returned?’

Painstakingly, Duncan and the practitioner reconstructed the events according to both what seemed probable, and what Duncan had been told by witnesses. Throughout, he was reassured by the practitioner that, since he had survived the crash, any protective need for the amnesia was no longer necessary. Likewise, if he uncovered some purpose or learning he could derive from the experience, it was likely the effect of the trauma could be reduced.

Suddenly, it was as if his brain realized what was required of it, and the remaining frames of his ‘movie’ filled in spontaneously. After examining the sequence closely, Duncan was convinced that it represented a true memory of his experience.

Also, he said, he realized that he couldn’t rely on green lights when he was driving, but needed to stay alert for other motorists who were not obeying the traffic signals.

At that point, finer details from his memory started flooding back and Duncan felt he could relax and put all his attention on healing his body.

Pain

Pain is one of the greatest, most enduring, mysteries of medical science and the human condition. While the most common medical description is ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage’, chronic pain, as experienced by millions of sufferers, continues to resist the most advanced pharmacological and remedial treatment available.262 It is also one of the most widely reported reasons for primary care attendance. According to a World Health Organization 15-country study, pain is the main reason for 22% of patients seeking medical assistance.263

Chronic pain can affect all areas of a patient’s life. A report in the In Practice journal series outlined the problem. ‘Chronic pain detrimentally affects all aspects of physical health, not only those directly related to the underlying cause. It is associated with significant disability, unemployment and loss of other physical roles. These produce social and financial problems, which include reduced earning capacity, family disharmony and isolation.’264

Other psychological consequences include reduced self-esteem, anxiety, and sleep disturbance. Recent research has suggested a higher mortality rate, particularly from cancer, among people with widespread pain.265

Running parallel to the challenge faced by the victim of chronic pain is the fact that the medical care system is severely taxed by the demands placed on it. As the In Practice report adds, ‘It stimulates a huge number of prescriptions, investigations and referrals, causes frustration in its resistance to treatment, and leaves patients and doctors with low expectations of successful outcomes.’

The categorization of pain continues to challenge the medical profession. Some sub-groups of ‘medically unexplained’ pain include:

Victims in any of these three categories are often frustrated and depressed by the failure of the medical profession to diagnose and treat what is to them a very real and distressing problem. Counseling or psychiatric intervention improves the situation for few people. The inference, that their pain is not ‘real’, may not be verbalized by the attending clinician, but it is often sensed by the patient.

What makes pain different?

The failure of most cognitive approaches to medically unexplained pain may derive from the failure to recognize how it differs from other affective disorders.

Emotions such as fear, lust, rage, and attachment may all be responsive to rational challenge, as with the cognitive behavioral therapies, since each of them has both an identifiable affect center in the brain and an easily identifiable external ‘cause’. People fear something specific that has happened or might happen, or desire something or someone relatively easily identifiable. A subject-object (internal-external) relationship exists, and that relationship is the focus of treatment.

However, no affect center for chronic, medically unexplained pain has been identified, and a specific, easily identifiable, external ‘cause’ is usually absent. Therefore, no subject-object relationship exists, and the pain ‘just is’.268

Treatment that suggests the patient’s problem is the way he is thinking about the pain, rather than the pain itself, is, understandably, a frequent cause of added distress. The pain is real. Medical NLP approaches the problem somewhat differently. Before proceeding with any intervention, it is necessary to elicit a representation of the pain at the Object level, and then externalize it so there can be a relationship with which to work.

Revealing the glyph

At various points in the book, we have suggested using questions such as ‘What’s it like?’, ‘What else is it like?’, and ‘How does it happen?’ in order to elicit the structure and process of an experience. We are looking for sensory-based descriptions (size, shape, color, movement, etc), rather than evaluative statements such as ‘awful’, ‘terrible’, ‘bad’, etc.

The patient will often report his experience as a three-dimensional object—for example, ‘a sharp knife’, ‘a hot red ball’, ‘a bright burning ribbon, like a magnesium strip’. In Medical NLP, such a representation is called a ‘glyph’ (from ‘hieroglyph’, meaning a carved object that represents more than itself), and, for therapeutic purposes, it is treated as ‘real’.

This creates a subject-object relationship that the practitioner now seeks to restructure by exploring sub-modality changes, especially those involving the restoration of movement. We offer several ways to work with the glyph later in the book (see pages 284 to 291).

Patients suffering from chronic pain are often:

Developing interventions

Useful approaches include:

Case study: Sean, a 28-year-old man, whose foot had been blown off by a landmine 25 years before, presented with low back and leg pain having had lumbar surgery six years previously. Drug and physical therapies had failed. He was insistent that the explosion was not in any way a problem, and that he was simply seeking to find relief from his chronic pain, which he rated as 7 on the Subjective Measure of Comfort Scale (SMCS).

While he was talking, the practitioner paced and led him into a more relaxed state before briefly introducing him to a technique to activate the Relaxation Response (see Appendix A, pages 357 to 360). When describing the pain, he used metaphors, such as a ‘pestle’ being pushed into and moved up and down the lumbar scar.

He experienced the pain as ‘burning, red pressure’. The practitioner invited him to transfer the image to a PC monitor. The patient exhibited considerable V r and V c eye-movement behind closed lids (characteristic of vivid visualization) and then reported that he had been successful. The monitor—an old green and black model—was situated in his lower, left visual field.

He repeated the process, but this time created a more desirable state. He chose ‘the best screen available’, large and flat, on which he projected himself as healthy, active and pain-free, using vibrant colors. He reported a feeling of comfort spreading through his body.

Under the guidance of the practitioner, Sean repeatedly ‘swished’ from the small, dark screen to the larger one, until he could no longer easily recover the trigger image. He reported that his level of pain had reduced to 3 on the SMC Scale. The practitioner continued the consultation using a variety of embedded suggestions of comfort and coping abilities to help the patient build a model of future experience and behavior.

At the second consultation, two weeks later, Sean reported that the effect had faded and that his own attempts to practice the Swish Pattern had failed. The practitioner responded by suggesting that trying to overcome pain might increase its intensity, and coached the patient into sitting back, dissociating, and ‘simply observing’.

The kinesthetic spontaneously began to expand and move, and changed color to ‘flame’ (a sub-modality shift to visual). The flame moved up Sean’s body and back, finally separating out and moving away, to become a source of warmth ‘like the sun’. He finished the consultation in a smiling, relaxed state, engaged and interested in the process. He was keen to continue practicing these methods at home, if required.

Cross-lateralization

Anecdotal evidence suggesting a strong relationship between hemispheric lateralization and a wide range of chronic disorders is gaining increasing support from researchers in various fields. Simply put, homolateralized brain activity (abnormally favoring one hemisphere over another) has been implicated in conditions as wide-ranging as dyslexia, certain ‘learning disorders’, obsessive compulsive disorder, depression, medically unexplained pain, anxiety, psychosis, and even immunological disorders.269

For this reason, we often use ‘whole-brain’ exercises adjunctively with other interventions. Since the body-brain system operates bidirectionally (brain function influencing body-function and vice versa) and is cross-lateralized (each hemisphere directing and being directed by the opposite side of the body), it follows that interventions that reduce homolateralization and increase whole-brain activity deserve attention.

A number of Medical NLP approaches have been developed and/or adapted from this premise. These include breathing, meditative and physical techniques and are further discussed in Appendix B (pages 361 to 362).

Also, see Appendix C, pages 363 to 365, for the Medical NLP algorithm for managing pain.

EXERCISES

Glyphing

1. Glyphing—use the glyph question (‘What’s it like?’) with every client in your next client session. Make a note of any glyph responses you elicit.

2. When that occurs ask the second glyph question (‘So, what’s happening now?’)

3. The third glyph question, the transformative enquiry (‘What needs to happen for it to be with you differently?’) suggests an intervention. Avoid authoritarian, directive approaches. Simply say, ‘So, let’s find out what happens when you let that [the answer to Question 3] happen…’

Notes

240. Mihaly Csikszentmihalyi (new ed. 2002) Flow: The Psychology of Happiness. The Classic Work on How to Achieve Happiness. London: Rider.

241. Ornstein R (1972) The Psychology of Consciousness. San Francisco: WH Freeman.

242. Benson H (1996) Timeless Healing. New York: Scribner.

243. Benson H, Stuart E (eds) (1992) The Wellness Book. New York: Fireside.

244. http://www.themoralliberal.com/blog/2010/12/20/the-illegitimacy-of-the-%E2%80%9Cpsychiatric-bible%E2%80%9D/.

245. Kirsch I (2009) The Emperor’s New Drugs: Exploding the Anti-Depressant Myth. London: Bodley Head.

246. Diagnostic and Statistical Manual of Mental Disorders (DSM), Fifth Edition (May 2013), Arlington VS: American Psychiatric Publishing.

247. Medicine’s big new battleground: does mental illness really exist? (May 12, 2013) The Observer, London.

248. Hegarty J (1994) 100 Years of Schizophrenia: A Meta-analysis of the Outcome Literature, American Journal of Psychiatry 151:1409-1416.

249. Leff J (1992) The International Pilot Study of Schizophrenia, Psychological Medicine 22: 131-145.

250. Jablensky A (1992) Schizophrenia: Manifestations, Incidents, and Course in Difference Cultures, Psychological Medicine, supplement 20: 1-95.

251. Whitaker R (2010) Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill. New York: Basic Books.

252. Rosenhan DL (January 1973) ‘On being sane in insane places’. Science 179 (4070): 250-8.

253. http://www.cbsnews.com/stories/2006/12/13/fyi/
main2255769.shtml.

254. http://www.theguardian.com/society/2010/jun/11/
antidepressant-prescriptions-rise-nhs-recession

255. Watters E (2010) Crazy Like Us: The Globalization of the Western Mind. London:Robinson.

256. http://www.youtube.com/watch?v=hu0ONl8aSGU

257. Valenstein ES (1998) Blaming the Brain: The Truth about Drugs and Mental Health. New York: The Free Press.

258. Moncrieff J (2009) The Myth of the Chemical Cure: A Critique of Psychiatric Drug Treatment. Basingstoke, Hampshire: Palgrave MacMillan.

259. http://www.healthnewstrack.com/health-news-668.html

260. Van de Weller C (2005) Changing diets, changing minds: how food affects mental well being and behavior. In: Longfield J, Ryrie I, Cornah D, eds. Feeding Minds: The Impact of Food on Mental Health. London: Sustain, Mental Health Foundation and Food Commision.

261. Sánchez-Villegas A, Henríquez P, Bes-Rastrollo M, Doreste J (2006) Mediterranean diet and depression, Public Health Nutrition 9(8A): 1104-1109.

262. Perskey H (1979) Pain terms: a list of definitions and notes on usage recommendations by the IASP subcommittee on taxonom. Pain 6: 249-52.

263. Gureje O, Von Korff M, Simon GE, Gater R (1998) Persistent pain and wellbeing. A World Health Organization study in primary care. JAMA 280: 147-51.

264. Smith Blair H (September 2002) Chronic pain: a primary care condition. In Practice (ARC) 9: 1-5.

265. Mcfarlane M, McBeth J, Silman AJ (2001) Widespread body pain and mortality: prospective population based study. BMJ 323: 662-4.

266. Melzack R, Wall PD (1982) The Challenge of Pain London: Penguin.

267. Loeser JD (1994) Tic douloureaux and atypical face pain. In Wall PD, Melzack R (eds) Textbook of Pain, 3rd edn. Edinburgh: Churchill Livingstone.

268. Scarry E (1985) The Body in Pain. New York: Oxford University Press.

269. Evans P, Hucklebridge F, Clow A (2000) Mind, Immunity and Health: The Science of Psychoneuroimmunology. London: Free Association Books.