The Hidden Psychology of Pain

clinic questions

  1. Do i need a referral?

      No, but if you get a referral from your GP under a Mental Health Care Plan, you will be entitled to 6 consultations over a 12 month period which attract a Medicare rebate. This can be increased to 10 by an additional 4 sessions with a re-referral from the GP.  Dr Alexander generally charges a gap fee (depending upon people's ability to pay). For income earners, the gap fee is $30-40. For those on Centrelink benefits, the gap fee is $15-20. You can seek his services without a referral form a GP, however no Medicare subsidy will apply.  Additional fees may apply if Skype services are provided out of normal work hours.

  2. Can i receive services via my employer, if i have been injured at work, or if i have been the victim of a crime?

      Yes. Some employers have free counselling available for their employees via an EAP Counselling scheme, which Dr Alexander can provide services under. If you have been injured at work (either physical or psychological injuries), discuss a referral with your WorkCover nominated treating doctor, and the insurance company may pay for psychological services. If you have been the victim of a crime in NSW, the Victims of Crime Tribunal may pay for required counselling- ring them on 1800633063.

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methods questions

  1. What approaches does Dr Alexander use to help people?

    Being a psychologist, Dr Alexander relies on non-drug treatments to assist people with a range of problems. In treating depression and anxiety, he utilises a range of approaches, including Coherence Therapy, and Solutions Fosused Brief Therapy. When problems like depression and anxiety are resulting from trauma, he utilises EMDR- a psychological therapy for trauma which has the highest evidence base. He also teaches EFT, as this can be very helpul for anxiety and sleep problems, amongst other issues such as pain and trauma. He uses the Hidden Psychology of Pain when treating chronic pain (book released in 2012). He instructs people in the use of healing guided imagery for a range of problems, and is able to use hypnosis where appropriate. When people have decided for themselves that they want to undergo drug withdrawal (either illicit or prescription drugs), he provides assistance and support in their withdrawal programs. Dr Alexander is also very familiar with pharmacogenetics, and is able to advise people in regards to whether the relevant genetic tests would make sense for them; and if so, how to obtain such a test. Dr Alexander is also a trained mediator, and is able to conduct couples and family therapy using 'systems' approaches. All of his interventions are conducted from a stance of finding and developing strengths within his clients. The home page will give you a more detailed idea of his ways of working with various issues.

  2. What is EMDR?

    Eye Movement Desensitization and Reprocessing (EMDR) was devised by American psychologist, Dr Francine Shapiro. It is an approach which entails a desensitization process aimed at reducing the level of physiological arousal associated with the traumatic event, in combination with cognitive restructuring. EMDR has undergone more empirical testing than any other approach in the psychological treatment of trauma; and it has more evidence supporting its efficacy than any other psychological treatment of trauma, including CBT.

    During EMDR the client is guided to deliberately bring into conscious awareness the sensory memory, their thoughts, and the accompanying emotions and bodily sensations. Clients need to be willing to experience the emotions and body sensations that accompany the recall of a distressing memory and associated thoughts. Then by following the moving fingers of the therapist, the client's eyes move rapidly for a brief period of around 30 seconds or so.This produces a distinctive and naturally occurring pattern of electrical activity in the brain (similar to what the brain is doing while we dream), which causes the stored trauma memory to change and move. This process can at times occur very quickly, and at other times at a slower rate requiring many more sessions of eye movements. The exact mechanism in the brain which causes the stored trauma memory to change has not yet been confirmed, but the regions of thebrain involved with sensory storage, emotional activation and reasoning all become more active with changed patterns of nerve cell firing, leading to resolution.

    During the eye movement, the therapist talks very little and rarely offers suggestions. The client is instructed to not try and change any aspect of the memory, but is asked to just notice their emotions, bodily sensations and thoughts. At the end of each set of eye movements, the client is then asked to report their present experience. It may be that the sensory memory becomes less detailed or vivid, and clients often report that the memory has become quite distant. Commonly, the emotional or bodily sensations reduce in intensity quite quickly, and at other times it may take longer. The goal isto arrive at no emotional or physical distress relating to the memory.

    The EMDR process is complete when a new, more positive perspective about the incident feels true, even when the old memory is recalled. The entire process with any one memory may take as little as ten minutes, or as long as a full session- at times, more than one session on a resilient memory is required. Where there are several different experiences underlying the client's difficulties, it usually takes a series of sessions to fully resolve them- six to as many as twenty sessions may be needed.

    EMDR is not suitable for all clients. Some people will need additional help in managing and reducing emotional arousal before the process can be attempted, if at all. Whilst EMDR looks and sounds simple, there are many important procedural steps for the therapist to follow before the eye movements are commenced. It takes over 50 hours of closely supervised instruction to fully train already experienced psychologists and mental healthworkers to become EMDR therapists. There have been over 100,000 professionals trained in this approach around the world over the last 20 years, and millions of people have benefited from it as clients. EMDR incorporates much of the best that psychology has developed over the last hundred years, and continues to evolve in response to rigorous scientific research and observations about what works best in addressing human problems.

    EMDR is endorsed as an evidence based therapy by:

    The World Health Organisation (2013); The Australian Centre for Posttraumatic Mental Health (approved by the National Health and Medical Research Council) - 2007 American Psychiatric Association - 2004; US Department of Veterans Affairs and Department of Defense - 2004Northern Ireland Department of Health - 2003 Dutch Guidelines of Mental Health Care - 2003 Israel National Council for Mental Health - 2002 Clinical Division of the American Psychological Association - 1998.

     See Chapter 16 of The Hidden Psychology of Pain for more discussion on EMDR.

    See also the EMDR button on the Home Page for more information and links to EMDR resources.

    see a brief You Tube interview with neurologist Dr Robert Scaer, a brain/trauma specialist, on the neurological effects of EMDR.


    Read some of the evidence demonstrating the effects of EMDR, presented by its originator, Dr Francine Shapiro who answers dozens of questions put to her about this unique psychotherapy.




    Hear aninformative interview with Dr Francine Shapiro about EMDR by clicking on the following link.


    (acknowledgments to Graham Taylor & Chris Lee for some of the above material)


  3. What is EFT?

    Emotional Freedom Techniques (EFT) is a form of 'energy psychology', and can be thought of as 'psychological acupuncture' utilizing taps on acupuncture points rather than needles. It is often applied to psychological issues, but can equally be applied to physical issues. The application of acupuncture to emotional issues was aided by chiropractor George Goodheart who, in the early in 1960s developed what he referred to as “Applied Kinesiology.” Goodheart discovered that he could get equally impressive results by stimulating the acupuncture points with either pressure or tapping. The next step in the development of what ultimately became EFT was the work of psychiatrist John Diamond, who in the 1970s created what he referred to as “Behavioral Kinesiology.” Diamond applied Goodheart’s approach to emotional difficulties, having his patients repeat affirmations while stimulating specific acupuncture points. This became a forerunner to what has since been called energy psychology.

    In the early1980s, as a psychologist specializing in the treatment of anxiety states, Roger Callahan had undergone training in behavioral kinesiology as well asacupuncture. He treated a woman who experienced an extreme phobia to water, so much so that even seeing water on TV would lead to a large anxiety response. As part of his treatment, Callahan was attempting to desensitize her to water by having her sit on the edge of a swimming pool. When the woman complained of stomach pains whilst attempting this, he suggested that she tap a point on her cheekbone which corresponds with the “stomach meridian.” The woman reported that not only did her stomach pain quickly go away, but so did her phobia of water. In fact, she began joyously splashing it on her face. None of the other standard psychological approaches to reducing her anxiety over the previous two years of treatment had helped this woman at all.

    Callahan investigated and researched the potentials of this discovery further, arriving at a process which he called Thought Field Therapy (TFT). This involved tapping on a range of acupuncture points whilst mentally focusing on specific thoughts. Gary Craig, a minister of religion who studied TFT under Callahan, concluded that the process was unnecessarily complicated and convoluted. While learning these procedures, he observed many occasions when the person administering the taps accidentally did it out of the supposedly correct sequence, however the person’s symptoms still improved. From these observations, he decided to modify TFT into a more simple sequence of taps which could be applied to a very wide range of presenting problems.

    Craig titled this reworking of Callahan’s approach “Emotional Freedom Techniques,” and created an extremely thorough website dedicated to it in which he gave EFT away for free. More than a million people have downloaded the beginners’ manual for EFT, and have benefited from the enormous archive of reports which have accumulated over the years in which both health professionals and sufferers of various conditions have reported their findings. I have had clients report an almost immediate departure of persistent pain when they have undertaken the simple and brief EFT procedure, and there are scores of such accounts on the EFT website.

    As I have no training in either Traditional Chinese Medicine or behavioral kinesiology, such energy psychology theories are simply not the language that I use to make sense of how EFT works. However, as a treating psychologist, I do have a need to understand these remarkable outcomes, especially as I often introduce the process to clients. Whilst not a neurologist, I am more able to develop some understanding of what may be happening with EFT from a very basic neuro-psychological point of view. As such, my way of making senseof EFT has less to do with Chinese medicine, meridians or life-energy, and more to do with conventional psychology and neurology.

    While neuroscience has developed rapidly in the last couple of decades, and produced some remarkable insights in the process, one is still left with the impression that we know relatively little of what goes on inside our black box of a brain. However, there are neurological observations from studies which pinpoint specific brain changes that occur as a result of actions and experiences. Where the knowledge is incomplete, we are able to hypothesize about the possible neuro-psychological components of the changes that have been observed from processes like EFT. It is still somewhat speculative in that, despite recent advances, there are few absolute certainties when dealing with the human brain.The interested reader can find more extensive examples of this psycho-neurological understanding of EFT on the Net.

    Acupuncture has been demonstrated in scientific research to change the electromagnetic field ofthe skin surface. Other forms of sufficient stimulation, such as the application of heat, mild electrical current, pressing or tapping, also impact on the surface of the skin. Through an elaborate system of sensory nerves, our mind/brain is highly aware of changes in the skin caused by different forms of stimuli. Put your hand in either cold or hot water, and the part of your brain which processes sensory input from your hand will become electro-chemically activated in order to make sense of the nerve experience. The same is true for other forms of stimulation to your skin as skin tissue is being manipulated, including the insertion of acupuncture needles, or the sensations derived from tapping, pressing or massage. Change the stimuli experienced by your hand, and you will also change the corresponding parts of your brain (sensory cortex) in their attempt to make sense of the physical experience. A possible mechanism of EFT is that it creates changes in the brain, while the person is focused on a psychological issue, via the nerve stimulation of tapping. See The Hidden Psychology of Pain, Chapter 12 for a more detailed discussion of this possibility.

    Research has found EFT to be effective for a range of conditions including anxiety, athletic performance, depression, pain and physical symptoms, phobias, PTSD andweight loss. Despite the research, as well as the abundance of anecdotal reports of positive outcomes, it has not been around for long enough or attracted enough research interest to yet reach a critical mass of positive findings that allow it to qualify as a “Well-Established Treatment.”Research which does testify to the effectiveness of EFT is presented in 'The Hidden Psychology of Pain', along with a detailed explanation as how to use it for a range of issues.

    EFT Universe is a fantastic website which contains more information about EFT than one could possibly get through- and its all free. You will find countless articles written by both health professionals as well as by those using EFT about how to use it on a multitude of conditions. You will find research which demonstrates its usefulness on a range of conditions, as well as papers discussing its possible mechanisms. You will also find a free 'Getting Started' download which explains how to use the procedure.



    excellent article discussing some of the science behind EFT


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The Hidden Psychology of Pain

  1. Chronic Pain Myths

    Faulty ideas can play a very large role in exacerbating and maintaining pain as well as creating a high level of disability. If you are able to manage the incorrect ideas, beliefs and myths, then you have an excellent chance of gradually emerging from pain when the stressful situation has sufficiently changed either by its own accord, or as a result of your problem solving. Pain cognitions, or your beliefs about the pain, are extremely important and powerful. Some beliefs have the power to help you overcome pain,and some beliefs will only make the pain worse by deeply entrenching it.

    The following are common myths about chronic pain which are adhered to and promoted by both clinicians and sufferers alike. None of them are an accurate reflection of the current state of knowledge.

    1.    Chronic pain isthe result of damage

    The reality is that highly sophisticated imaging studies are generally unable to locate specific forms of structural damage which is responsible for chronic pain. This is further demonstrated by the regular finding that structural abnormalities which are often believed to be causing the chronic pain are usually found in high proportions amongst the pain-free population. Mos tpeople have structural pathology, but no chronic pain.

    2.    Chronic pain is evidence of spinal/body weakness & vulnerability

    Your spine is your body’s core strength. It is rarely seriously damaged, even by those who participate in highly physical contact sports. The fact that superbly fit and strong athletes can also experience chronic pain is evidence against the notion of vulnerability via weakness.

    3.    Chronic pain is only likely to get worse with time

    With the right type of information and recovery program, there is no reason for most cases of chronic pain to get worse with time. In fact, given the right intervention, most will actually improve with time. The rates of chronic pain in the population decrease as age increases. This suggests a connection between the “years of responsibility” and chronic pain, and not a relationship between increasing years and increasing chronic pain.

    4.    Chronic pain isultimately crippling

    While many people experiencing bouts of chronic pain can be somewhat “crippled” by it, there is nothing inevitable about this. The fact that many sufferers are able to overcome the pain and decrease their level of disability, suggests that ultimately others can overcome it too. Professor Alan House in the UK has demonstrated that when similar factors produce “hysterical” paralysis, people are still able to overcome the condition and learn how to walk again.

    5.    Chronic painprecludes independence or the ability to earn

    Many people who have suffered from serious chronic pain, to the extent that they have lost their jobs as well as their independence, have managed to rebound from this to lead full and happy lives again. Such people have returned to pre-pain employment and recreational activities. I regularly see this happening in my work, and this observation is echoed by other like-mindedtherapists.


  2. 'The Hidden Psychology of Pain' chapters

    ·       Chapter 1 provides an overview of the role which psychology can play in both the causation and the cure of chronic pain.

    ·       Chapter 2 looks more closely at the medical treatment of chronic pain. Confusion between and amongst health professionals have added to the current epidemic of chronic pain. It is important to understand the guiding philosophy underlying the medical treatment of this condition, as gaining such an understanding is part of the treatment process—knowledge is power. Conventional medical treatments of chronic pain will also be discussed, as well as the new understanding of pain which is developing within medicine.

    ·       Chapter 3 introduces a more expanded model of medicine, which incorporates both psychological and social, as well as physical factors. This bio-psycho-social approach to medicine is viewed as an important development, and is in essence entirely compatible with The Hidden Psychology of Pain.

    ·       Chapter 4 discusses the range of misunderstandings which abound with chronic pain. These misunderstandings are not simply benign, but play an important role in creating and perpetuating the current epidemic.

    ·       Chapter 5 introduces some of the biological pathways, triggered by psychological issues, which can result in chronic pain. Some basic physiology, in relation to parts of the anatomy which are vulnerable to chronic pain, is presented.

    ·       Chapter 6 discusses the unconscious psychological factors which can trigger chronic pain in more detail. By virtue of being unconscious, these are often not the most obvious ones.

    ·       Chapter 7 presents more in-depth discussion of unconscious psychological factors, which range from childhood experiences to broad cultural issues.

    ·       Chapter 8 discusses many of the strategies and changes in thought that are required to overcome chronic pain. You will be taught to ‘tune into’ what your experience is telling you as a tool to helping you in your recovery.

    ·       Chapter 9 begins the presentation of self-help strategies. It will come as no surprise that these are psychological. Many of the helpful activities can be done by you at home with no professional help.

    ·       Chapter 10 involves a discussion about depression, as this is a common experience for people in chronic pain. Again, how we make sense of this experience has a major role to play in regards to what we do about it, and the subsequent likelihood of recovery. Unfortunately, our culture provides as many blind-alleys with depression as it does with chronic pain, so being a well-informed consumer of health services is vital.

    ·       Chapter 11 examines the healing potential which dreams hold. Learning how to harness their healing potential will take your further on the path of physical and emotional recovery.

    ·       Chapter 12 presents an approach to ‘energy psychology’ (EFT) which I have seen work wonders for many sufferers. It can be thought of as ‘psychological acupuncture’, although a more neurological explanation aids in the understanding of how it achieves results. As it is a self-help strategy, you can begin using it on a range of issues as soon as possible.

    ·       Chapter 13 addresses another common problem for people in chronic pain—the inability to sleep well. A range of strategies to improve sleep are presented, and you will be taught how to use EFT to assist in overcoming this problem.

    ·       Chapter 14 discusses the application of EFT to stress and anxiety. Most people who suffer chronic pain feel stressed by the condition, and will often be highly anxious in regards to flare-ups, or actions associated with the pain. EFT is a very useful means of reigning in these anxieties.

    ·       The value of psychotherapy in the treatment of chronic pain is discussed in chapter 15. Like any other health service, psychotherapy is a market place of ideas and differing approaches. Some types of psychotherapy are especially useful for treating chronic pain, while others can offer little.

    ·       Chapter 16 presents a particular type of psychotherapy, EMDR, which is especially effective in dealing with both trauma and chronic pain.

    ·       Chapter 17 discusses the importance of finding greater acceptance of chronic pain. Thisis deliberately left as the final chapter. The basic thesis of this book is that there is much you can do to radically decrease your experience of chronic pain. However, cultivating an attitude of acceptance towards all challenges allows you to minimise your stress response to the pain. You will learn thatemotional pain, such as ‘stress’, is highly related to the experience of physical pain, so decreasing one is likely to have a flow-on effect to the other.


    Appendix1: Pain Questionnaires (I)

    Appendix2: A neurological understanding.

    Appendix3: Anatomy of the spine .

    Appendix4: Standard medical treatments for chronic back pain.

    Appendix5: The value of physical therapies?

    Appendix6: The evolution of psychology.

    Appendix7: Sample of research demonstrating structural pathology in pain-free populations.

    Appendix8: EFT on a Page.

    Appendix9: Process for staying in the present moment.

    Appendix10: Testimonials from the Hidden Psychology of Pain clients.

    Appendix11: Pain Questionnaire (II).

    Appendix12: Placebo treatment?  


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Psychiatric drugs

  1. what are your views on psychiatry and drugs?

    Firstly, it needs to be noted here that I am a psychologist, not a medical practitioner. If the reader is wanting a medical or psychiatric view of psychiatric drugs, then this is not the place to find it. As with physicians, my views are likely to be coloured by my profession and training- my bias is towards psychology, psychotherapy and other non-medical approaches to helping people overcome problems in living. I respect people's rights to use any approach to overcoming their problems which makes sense to them- even pharmaceutical options. I have never talked anyone into or out of using any drugs. I do make it clear to people that they have a choice in what substances to put into their system, unless that choice has been legally taken away from them. When it comes to psychiatric drugs, I am pro-choice and informed consent. This is predicated on the requirement that people are actually well informed so as to be able to exercise informed consent- and this applies to all interventions, psychological and pharmaceutical.

    Our culture still has a particular impression of psychiatry as a profession, although this view is now more an aspect of popular imagination and very old films in which we see psychiatrists conducting psychoanalysis, often complete with the traditional couch. Contemporary movies still perpetuate this stereotype as well. This image of psychiatry is maintained, in part, because while very few psychiatrists are also psychoanalysts, most psychoanalysts are psychiatrists. Despite the stereotype, the current reality is that psychoanalytic psychiatrists (those following Freud’s psychological approach) constitute only very small proportion of contemporary psychiatry, where they used to be prevalent.

    Psychiatrists are mental health professionals who have undergone firstly a medical degree, followed by specialist training in psychiatry. As with psychology, different parts of the world have different pathways to becoming a psychiatrist, however, they all begin their careers with a medical degree.

    While the situation is slowly changing, there is still very little psychology taught in most medical degrees. This is understandable as the amount of information required to educate a student about the physical functioning of the body alone is phenomenal. As such, an aspiring psychiatrist has very little exposure to psychology until she or he is undertaking their training in psychiatry following the completion of their medical degree. In the past, this may have been an opportunity for them to learn about psychology. However, in recent decades, this training in psychiatry has become primarily focused on learning the psychiatric classification system of mental disorders, and which drugs to apply to which label. This is not a psychological enterprise, nor is it informed by psychological science. As such, it has become the norm for contemporary psychiatrists to have little training in or awareness of psychology, Freudian or otherwise. As the originator of CBT, Aaron Beck is a psychiatrist, if contemporary psychiatrists show an interest in psychotherapyat all, it is often CBT.

    If you consult a psychiatrist, he or she is more likely to be interested in prescribing drugs for you than delving into your background. There are some notable exceptions to this, with some psychiatrists seeking out a thorough training in psychology, but by and large, contemporary psychiatry is essentially a biochemical enterprise. As such, most contemporary psychiatrists are not interested in psychology, and view it as subservient to biological theories of mental disorders. As an example, some psychiatrists proudly boast that they have no interest in their patient’s thoughts, feelings or experiences, as these are all irrelevant to their biochemistry and the endeavor to change it with drugs.

    Amongst the psychiatrists who have rejected this overwhelming redefinition of their own profession, from being psychology focused to biochemistry focused, are peoiple like Peter Breggin, Daniel Siegel, Bessel van der Kalk, and Norman Doidge in America; David Healy, Joanna Moncreiff, and Allan House in the U.K; John Juredini, and Yolande Lucire in Australia. As well as having an interest in psychology, they often also practice an authentic neuro-psychiatry, exploring the role of brain functions in human problems; as well as the problems which introduced chemicals can create in the brain/mind . Such notable practitioners and authors have aroused great interest in the public because of their sophisticated theories and approaches-usually quite different to the simplistic biochemical theories espoused by drug companies and the psychiatrists they employ for marketing.

    Biochemical theories of psychological problems, like any other, are valid as theories. The problem is that these psychiatric theories have been promoted to the status of established fact, especially where the pharmaceutical industry has developed a drug treatment which follows on from the theory. If human problems in living prove one day to be reducible to aberrant brain chemicals, then they would be added to the list of neurological disorders.As a result, the list of psychiatric disorders would decrease. Where neurology investigates actual brain conditions, such as neurological illnesses and injuries, psychiatry studies presumed brain conditions, for which there is no neurological evidence.

    There is no doubt that depressed emotion and delusional beliefs exist, and that these can reach an extreme level in some people. However, it is another thing again to suggest that such conditions exist because of a chemical imbalance in the brain. I refer to chemical imbalances as a “pseudo” condition, as there is simply no consistent and convincing evidence from neurology that such any chemical imbalances exist which relate to experiences such as depression, schizophrenia, bi-polar, anxiety disorders,etc. In fact, the evidence that does exist often argues against such chemical imbalance theories.(listen to the audio interview with Dr Peter Breggin- see the link).

    The biological reductionist approach is akin to watching TheTitanic and explaining the emotional impact of it in terms of the actions of various brain chemicals. No doubt, watching this film will have a different biological impact than watching a comedy—there are likely to be more stress hormones in your blood supply after watching The Titanic, for instance. But, does it actually explain anything to refer to the different actions of chemicals as a way of making sense of the experience of watching the different movies? Does the increase of stress hormones cause the emotional impact of watching The Titanic; or does the movie itself produce the emotional impact as well as the change in brainchemicals? Are the changes in brain chemistry causing the emotional response,or are they merely correlated to the emotional response?

    Different life experiences will result in different biological realities in our bodies. These are perhaps best viewed as facts that simply go together (correlates), rather than as relationships of A causing B. The evidence of biological possibilities in depression is really just a collection of working hypotheses. The research is inconsistent and inconclusive, with much of it contradicting other findings. Yes, we are biological beings as much as we are psychological and social beings. There are no doubt biological correlates for all of our experiences, including depressed mood. However, with the current state of scientific knowledge, these observed correlations do not establish causal relationships. From both philosophical and common sense perspectives, it is doubtful whether they ever will.

    The following link details the perilous state which psychiatry has placed itself in with dubious theories and claims in the last 35 years.


    The following website, Coming Off Psychiatric Medications, provides an excellent harm reduction guide to withdrawing from these drugs. 


    Hear an insightful interview with psychiatrist Dr Peter Breggin, who has maintained a sustained critique of psychiatric drugs with reference to scientific evidence for more than 40 years.


    Read what the Citizens Commission on Human Rights have to say about psychiatry.



  2. What is Pharmacogenetics?

    Some people enthusiastically report that going on to an antidepressant has been the best thing for them, while others report that their depression radically worsened as a result, bringing them to the point of suicidal despair. These widely different responses to psychiatric drugs are in some part attributable to differences in liver enzymes which are now detectable with genetic testing. I became aware of the science of pharmacogenetics (aka pharmacogenomics) several years ago from an ABC Radio National Health Report program- listen to this program from the following link:-


    All substances which we put in our body need to be metabolized in order that the chemicals be expelled from our system. If this process does not occur, we become poisoned by an accumulation of the chemicals. Many drugs also require bioactivation to form the active compound and desired effect within our body. Pharmacogenetics is the scientific study of inherited variations in the ability to metabolize different drugs via specific liver enzymes.

    One family ofliver enzymes play a large role in the metabolizing of antidepressants: the CYPs. The existence and amount of these particular liver enzymes in any individual, seen in the cytochrome CYP450, derives from our genetic inheritance. We usually have two copies of each gene, but if one or both copies of the gene don’t function properly, then the drug will be processed too slowly. The blood concentration will then be higher than normal, as the rate of excretion from the body is too slow. With antidepressants, this can lead to side effects such as worsening depression; increased anxiety, panic and agitation; increased suicidal ideation; and a raft of physical adverse effects.

    If a person has both CYP450 genes that do not work properly, s/he is referred to as a poor metabolizer. The person who only has one of the genes working for that enzyme (referred to as an intermediate metabolizer) processes the drug more slowly than normal, but not as slowly as a poor metabolizer. A person who has both genes working is called an extensive metabolizer (i.e. “normal”;). And people who have more than two relevant genes are referred to as ultrarapid metabolizers.

    These genetic differences have a very large role to play in how our body reacts to drugs, however they do not explain everything—there are other relevant factors. Genetic factors appear to explain around 75% of the different outcomes which people can experience from the same drug, with the remaining 25% being explained by such factors as exposure to environmental toxins. People who are lacking in the cytochrome CYP450 system are likely to be the ones who experience the most adverse side effects from antidepressants currently being prescribed. A poor metabolizer is likely to experience the onset of adverse side effects soon after taking the antidepressant, whereas an intermediate metabolizer may experience side effects over a period of time, as the chemicals from the antidepressant slowly accumulate in their system—this may take months or even years. Extensive metabolizers are less likely to experience problems with antidepressants at the recommended dosage levels; and ultrarapid metabolizersare the least likely to experience side effects, as their system is able to quickly metabolize and expel the chemicals.

    These differences in genetic inheritance go a long way to explain the wide range of responses that people can have to antidepressants. As the cytochrome CYP450 system is also responsible for the metabolism of alcohol, cannabis, nicotine and amphetamines, the combined use of these substances with antidepressants or other psychiatric drugs can cause additional problems. This is due to the metabolic pathway already being busy or "stressed" with the psychiatric drug when the additional substances are added. The body becomes even less able to expel the chemicals, due to the pathway being overloaded, and more problematic side-effects can be experienced due to a build up of chemicals in the body.

    Many other drugs will also increase or decrease the activity levels of various CYP enzymes, either by directly inhibiting the activity of the enzyme, or inducing the biosynthesis of enzymes. This can cause dangerous interaction effects between drugs as changes in the CYP enzyme activity may affect the metabolism and clearance of other drugs. As such, if one drug inhibits the metabolism of another drug, the latter drug may accumulate in the body and reach toxic levels. This is particularly relevant for people who are taking both antidepressants and pain killers, as many analgesics are metabolized by the same enzymes as are antidepressants (e.g. CYP2D6). Some high profile celebrity drug deaths in the last few years could be explained by this phenomenon. Sudden changes in dosage levels of one of the drugs can lead to unanticipated problems in metabolizing and clearing the other drugs.

    Another example of a contributing substance is the herbal depression remedy, St. John’s Wort, which acts as an inducer of CYP3A4, but as an inhibitor of CYPA1, CYP1B1, CYP2D6 and CYP3A4. Bioactive compounds in seemingly innocuous grapefruit juice can also inhibit CYP3A4 mediated metabolism of certain medications, leading to an increased possibility of overdosing because of the increased bio-availability of the substance which the juice creates.

    For these reasons, it is advisable that people on combinations of medical and recreational drugs consult with a pharmacist who is aware of the role of liver enzymes and different interaction effects, prior to making any changes in dosage levels.

    See a You Tube conference presentation by Dr Yolande Lucire on her research in pharmacogenetics, discussing the genetics and biology of adverse side effects to psychiatric drugs.


    If you decide that you would like to withdraw from psychiatric drugs, a very useful resource is the Harm Reduction Guide to Coming off Psychiatric Drugs, published by the Icarus Project and the Freedom Center. This extensive manual is available via a free download from the webpage comingoff.com, and is recommended by arange of services, including the British Department of Health.

    The genetic test referred to above can be conducted in Australia by HealthScope pathology, using blood samples. For more information, go to their webpage: http://www.healthscopepathology.com.au/index.php/advanced-pathology/pharmacogenomics/brochures/

    and download the brochures titled CYP450 Drug table, as well as DNAdose (general info and patient brochure). 

    GenesFX (geneticists who work in association with Healthscope) also conduct pharmacogenetic testing- you can request a sample pack, take the sample yourself (a swab of your inside cheek) and send back to them for analysis and a report. This is cheaper (at $195) than the blood test which Healthscope offer (around $290), but results in the same type of report which can then be used to based prescriptions on. It can be ordered (without a GP request) from GenesFX on:-


     The GenesFX site (http://www.genesfx.com.au/) also has valuable information regarding different drugs, and which liver enzymes are required to metabolise which drugs.

  3. The problem with pills

    Firstly, it needs to be noted here that I am a psychologist, not a medical practitioner. If the reader is wanting a medical or psychiatric view of psychiatric drugs, then this is not the place to find it. As with physicians, my views are likely to be coloured by my profession and training- my bias is towards psychology, psychotherapy and other non-medical approaches to helping people overcome problems in living. I respect people's rights to use any approach to overcoming their problems which makes sense to them- even pharmaceutical options. I have never talked anyone into or out of using any drugs. I do make it clear to people that they have a choice in what substances to put into their system, unless that choice has been legally taken away from them. When it comes to psychiatric drugs, I am pro-choice and informed consent. This is predicated on the requirement that people are actually well informed so as to be able to exercise informed consent- and this applies to all interventions, psychological and pharmaceutical.

    The Citizens Commission on Human Rights  have an excellent site which presents psychiatric drug side effects from official sources.


    Recent reports have highlighted that more Americans now die from medically prescribed pain killers than from car accidents. This trend, event especially in the last 10 years, is being followed by other developed countries such as Australia. The Victorian Coronor recently reported that the last decade has seen 50 times more pain killing drugs being prescribed, resulting in a 15 fold increase in the amount of deaths from prescription drugs. This amounts to more deaths from prescription drugs than from heroin. It is time that we, as a culture, recognised that asking a GP for pain killing medication is not a great option- it wont eliminate the pain, and can radically increase the risk of accidental death. The prescription of antidepressants, also constantly on the rise, is an equally concerning scenario.

    My involvement with GPs dramatically rose with the introduction of Medicare rebates for psychologists introduced in November 2006. Suddenly, more than hal fof my private practice case load were GP referrals, as GPs are the ‘gate-keepers’to these rebates via mental health care plans. Prior to this, most of my clients were either self-referred, or referred by Employee Assistance Programs as part of employee entitlements. This increase in GP referrals has given me more experience in what appears to be conventional medical responses to such issues as depression and anxiety. It has also given me the opportunity to work more closely with many GPs and to see that for the most part, these are caring professionals who are genuinely well intentioned. This has created something ofa dilemma for me in that it would be easier to take a critical stance of medical responses to mental health issues were I able to disregard the motivesof physicians as being paternalistic power plays- my experiences have helped me to sincerely believe that this is not the case. What, then is going on?

    While not maintaining any statistics on the issue, my estimate is that around 50% of people referred to me by GPs come already having been placed on antidepressants, usually SSRIs, and often benzodiazepines or mood stabilizers in addition. Many of these people present with symptoms which clearly suggest negative side effects. Naturally, I am aware that I see a biased sample, i.e those whose distress is resistant enough to medical treatment to justify a psychology referral. My assumption, based on the occasional client that I see as well as figures presented by David Healy, Professor of Psychiatry at Cardiff University, is that a portion of the population either appear to do well on SSRIs, or at least they are doing no worse. For the most part, I do not get to meet these people. Around 60% of people placed on antidepressants find the side effects so intolerable that they do not continue on them beyond the initial few weeks (Healy 2004). The other 40% fit the category of doing well on these drugs, or at least no worse- or they continue with the medications even though their lives are spiraling downwards. It is common for me to see this latter group of people in my practice. They typically present with many of the following symptoms:- worsening depression; anxiety and panic attacks; increases in suicidal ideation, and sometimes self-harming behaviour; psychological as well as physical agitation, and often increases in substance use to counter this; mania and hypomania, reflected in reports of ‘out of control’ behavour that ‘just isn’t me’; sexual dysfunctions; insomnia as well as lethargy; nightmares and terrors; electric shock like sensations in the head, as well as a myriad ofother odd physical sensations, including new chronic pains (medicallyinexplicable); nausea; dizziness; headaches; tinnitus; bowel and digestive system abnormalities.

    The people that I meet who have been suffering symptoms from this list, sometimes for years, generally lack the confidence to defy their physicians recommendations and withdraw. This lack of confidence is usually bolstered by experiences of failed attempts to withdraw themselves, often ‘cold turkey’ or at least too quickly, resulting in terrifying withdrawal effects. To compound the problem for these sufferers, they tend often to respond to medical cues and invitations to view the symptoms as resulting from a worsening of their condition, eg.depression, rather than attribute the symptoms to the drugs. When a sincere and respected physician authoritatively tells a patient that the drugs can’t be creating these symptoms, a significant part of the population are likely to believe them. People who are suffering tend to be vulnerable to the influence of those in credible positions of authority, even just out of sheer desperation. The greater the suffering ,the greater the vulnerability to this influence. As such, the sense of despair and hopelessness deepens and a vicious downward spiral can be created.

    If this is apparent to me as a psychologist, why is it not so apparent to intelligent and conscientious GP’s? This question has puzzled me greatly. To date, I have settled on the explanation that when many of the current crop of mid-career physicians were embarking on their careers in medicine, the SSRIs were being heralded as the new ‘wonder drug’. Commencing my own career in psychology during the same era, I remember wondering if I had not just been made redundant by this advance in pharmaceuticals. This concern was only stemmed by my reading of Peter Breggin’s (1983) critical book on psychiatric drugs. The marketing of the SSRIs drugs in the late 1980s was so effective that few members of the public could have remained ignorant of them, and they had not yet been around for long enough for the industry claims of ‘no SSRI side-effects’ to have been proven false. The promise of relief from emotional suffering was now as close as the doctor’s prescription pad. Due to the effective marketing and the plethora of ‘good news stories’ in popular media, the placebo effect (most recently demonstrated yet again by Kirsch, Deacon, Huedo-Medina, Scoboria, Moor& Johnson (2008) was in full force. This merely reinforced everyone’s confidence, especially the prescribing doctors confidence, that the ultimate answer had been found in a pill.

    Placebo effects are one matter, with the evidence in regards to the SSRIs calling into question the legitimacy of the very term antidepressant. Were the SSRI story to end there, merely with the placebo findings, one may conclude that they were relatively harmless. The issue of psychological and physiological damage is quite another matter however. It can take years for reports of adverse reactions to filter through to authorities in such numbers that demand attention. On a clinical level, it appears that some physicians (even those who both I and their patients view as being the most caring and attentive) are more attached to the promise of SSRI safety and effectiveness than they are to an open minded receptiveness to their patients reports of deterioration of their condition. This appears to be a psychological need of these physicians. It is an anomaly that I can only understand in relation to the marketing successes of pharmaceutical companies and the construction of depression as a medical illness. My view is that depression and anxiety are not illnesses requiring medical attention. Our culture used to have a term which covered most of these experiences- it was called life. Some experiences in life can be entirely problematic –Professor of Psychiatry, Thomas Szasz wisely referred to them as ‘problems inliving’. Fortunately, most of the problems in living which are currently being treated with SSRIs and other antidepressants tend to be resolvable with: genuine care, concern and support from professionals or friends; problem solving strategies (perhaps involving legal, economic, social and interpersonal solutions); and with brains that are not being further compromised with introduced neurotoxins in the form of drugs, either illicit or medically prescribed. And this is perhaps the most tragic part of the situation to me- that so much of the potential damage to people with the mass prescribing of such substances is unnecessary. Viable alternatives exist, and are now financially accessible via Medicare rebates.

    Clearly, there are viable alternatives to psychiatric drugs. See:-


    I have seen Professor Healy’s (2000 SSRI withdrawal protocol to be an extremely effective approach for people to restore some balance and sanity in their lives (see http://www.seroxatusergroup.org.uk/David%20Healy%20Withdrawal%20Protocol%202009.pdf); however I would prefer to be spending my time helping people with problems that were not iatragenic in nature. The public maintains a healthy skepticism towards such wonder drugs. My observation is that there seems to be as many psychologists, nurses and social workers unaware of potential adverse effects of antidepressants as there are physicians. When will health professionals of all types catch up with the inherent sense of the general public who we are meant to be serving? Surely, listening to people when they report adverse side effects or worsening of their problems post-drugging is a sensible starting point.


    Breggin, P (1983) Psychiatric Drugs: Hazards to the Brain.Springer, NY.

    Healy, D(2000) http://www.seroxatusergroup.org.uk/David%20Healy%20Withdrawal%20Protocol%202009.pdf

    Healy, D(2004) Let Them Eat prozac: The Unhealthy Relationship between the PharmaceuticalIndustry and Depression. New York University Press, NY.

    Kirsch I,Deacon B, Huedo-Medina TB, Scoboria A, MoorE TJ & Johnson B(2008) InitialSeverity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to theFood and Drug Administration. PLoS Med 5(2): e45doi:10.1371/journal.pmed.0050045


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