People in the press have been playing one of my nasty habits - guess the diagnosis of someone you’ve never met.  In this case the beleaguered UK Prime Minister Gordon Brown.

For anyone who lives in a cave, Mr Brown came to be PM about a year ago having been the Chancellor of the Exchequer for ten years.  During this time he presided over unbroken economic growth and was well know for his prudent policies and dour demeanour.  Whilst his lack of easy charm and attention to detail made him apparently trustworthy as the head of the economy, they haven’t played out well as PM, especially as he is following the TV friendly and charismatic - but warmongering  - Tony Blair.  Incidentally, I met Brown’s private secretary, a rather attractive girl, at a party once and was thinking of trying to get off with her but regrettably she left before I could work any magic. 

Writing in The Times, GP Dr Thomas Stuttaford has speculated that Mr Brown has personality traits which might lead him to be diagnosed with a DSM-IV cluster A personality disorder.  He also says that Tony Blair would meet all the criteria for histrionic personality disorder

(If you need to brush up on personality disorders here’s a link to my previous post on the subject) 

BPS research digest disapproves

There are two issues here.  Is Dr Stuttaford proper to speculate in such a way?  Yes, in that we are in a free country, and it would be cheeky for me to say no when I have done similar myself*.  But he is very careless.  You can’t make these kind of diagnoses without meeting the patient, and it is sloppy to take a cursory glance at the DSM criteria and then imply that if someone possibly meets particular criteria and the diagnosis is likely.  He should at least have stated that what he is presenting is purely idle speculation.

Is he actually right?  Unlikely. With regards to Tony Blair, Dr Stuttaford can’t have looked very carefully at the DSM-IV histrionic personality disorder criteria.  Is he saying, for instance, that Tony Blair’s interactions with others are ‘often characterized by inappropriate sexually seductive or provocative behaviour’ or that he ‘consistently uses physical appearance to draw attention to (him)self’? (DSM IV criteria)

He says of Mr Brown:

‘He is likely to be demanding, self- absorbed, have difficulties in relationships with others, suffer discomfort in social situations with unfamiliar people, have vaguely unsettling inappropriate gestures or facial expressions and may be so focused that he finds it difficult to concentrate on subjects other than that which has caught his immediate attention’

I find it difficult to believe that anyone with these sort of characteristics could not only elevate himself to the job of PM(think of the political deals and alliances necessary), but also run the country for more than five minutes with this sort of personality.  ICD-10 states that a personality disorder is ‘usually accompanied with considerable personal and social disruption’ which sounds incompatible with any of Mr Brown’s achievements.   Dr Stuttaford is talking bollocks I fear. 

David Owen, former Labour minister and SDP leader, has written a book about illness suffered by heads of state, and has also coined a term ‘hubris syndrome’ which I think he is un-secretly hoping will pass into common parlance, if not into diagnostic manuals.  Rather less prestigiously, I wrote a post on a leaders and their drug problems, prompted by speculation that Moses was under the influence of psychedelic drugs. 

Other articles on this subject:

NHSBlogdoctor

*It would be hard to imagine that  Josef Fritzl is not  even a little bit anti-social though…

Just like when a physician sees a patient and looks for signs of physical illness, when a psychiatrist meets a patient they are looking for signs of psychiatric illness.  This is important because when people are suffering a deterioration in their mental health, they often describe similar experiences and these signs of mental illness are referred to as psychopathology.  When different psychopathological signs are identified and grouped together they can lead to the formation of a psychiatric diagnosis.

One of the most interesting psychopathology signs is formal thought disorder (FTD) which refers to the sort of disorganised speech which is a manifestation of psychosis. 

When people are describing a patient’s mental state they often write ‘no FTD’ when they wish to convey that the patient is coherent and can make themselves understood.  It’s a little bit more subtle than that; if a patient is intoxicated or delirious they will be incoherent but they will not necessarily be thought disordered.  Thought disorder refers to a particular set of language errors which are seen in psychosis. 

The name is rather strange.  Although it is called ‘formal thought disorder’ it actually refers to what a patient is saying.  The name is historical as when disorders of speech due to psychiatric illness were first being described (Bleuler, amongst others, was important in this), it was felt that disorders of thought form (disorganised speech) and content (delusions) should be considered separately.  Formal thought disorder therefore is a disorder of speech rather than content*.  

Normal human thinking has three characteristics

1. Content: what is being thought about - this would include delusions and obsessional thoughts

2. Form: in what manner, or shape, is the the thought about; abnormalities of the way thoughts are linked together

3. Stream or flow: how it is being thought about - the amount and speed of thinking

Different elements of formal thought disorder have been described. With his early work, Bleuler considered FTD to be when there was a loosening of associations which lead to fragmentary ideas being connected illogically.  This is seen clearly in the picture above.  Confusingly though, there appears to be no consensus about exactly what can be included formal thought disorder; it appears that most people would now use the term ‘thought disorder’ which refers to both errors of form and stream. Content is still considered separately.  

Disorder of stream of thought 

(I’ve split up these into disorder of thought form and stream, but several could be argued both ways)

Flight of ideas is when the content of speech moves quickly from one idea to another so that one train of thought is not carried to completion before another takes its place.  The normal logical sequence of ideas is generally preserved although ideas may be linked by distracting cues in the surroundings and from distractions from the words that have been spoken.  These verbal distractions may be of three kinds: clang associations, puns and rhymes.

Retardation of thinking is often seen in depression, the train of thought is slowed down, although still goal directed.  The opposite is pressure of speech and this is often seen in mania.

Peseveration is the persistent and inappropriate repetition of the same thoughts.  In reply to a question a person may give the correct answer to the first but continue to give the same answer inappropriately to subsequent questions.  This is especially seen in ‘organic’ brain disorders like dementia.

Disorders of thought form:

Overinclusion refers to a widening of the boundaries of concepts such that things are grouped together that are not often closely connected.

Loosening of associations denotes a loss of the normal structure of thinking.  The patient’s discourse seems muddled and illogical and does not become clearer with further questioning; there is a lack of general clarity, and the interviewer has the experience that the more he/she tries to clarify the patient’s thinking the less it is understood.  Loosening of associations occurs mostly in schizophrenia

Three kinds of loosening of association have been described:

Knight’s move thinking or derailment where there are odd tangential associations between ideas. 

Talking past the point (= vorbeireden) where the patient seems to get close to the point of discussion, but skirts around it and never actually reaches it

Verbigeration (= word salad = schizophasia = paraphrasia) where speech is reduced to a senseless repetition of sounds and phrases  (this is more of a disorder of thought form)

Circumstantiality is where thinking proceeds slowly with many unnecessary details and digressions, before returning to the point.  This is seen in epilepsy, learning difficulties and obsessional personalities 

Neologisms are words and phrases invented by the patient or a new meaning to a known word

Metonyms are word approximations e.g. paperskate for pen

Derailment (aka entgleisen) is where there is a change in the track of thoughts.  There is perserved, but misdirected determining of tendency/goal of thought)

With drivelling there is a disordered intermixture of the constituent parts of one complex thought

Fusion is where various thoughts are fused together, leading to a loss of goal direction.

Omission is where a thought or part of a thought it is senselessly omitted

Substitution is where one thought fills the gap for another appropriate more ‘fitting-in’ thought.

Concrete thinking is seen as a literalness of expression and understanding, with failed abstraction.  Can be tested by the use of proverbs.

Thought block  refers to the sudden arrest in the flow of thoughts.  The previous idea may then be taken up again or replaced by another thought.

As you can tell this is a big subject and I haven’t got onto the historical attempts to characterize schizophrenic thought processes (by Kraepelin, Bleuler, Goldstein, Cameron and Schneider) or the linguistic classification of speech abnormalities in psychosis. 

Further reading

Andreasen NC. Thought, language, and communication disorders. I. A Clinical assessment, definition of terms, and evaluation of their reliability. Archives of General Psychiatry 1979;36(12):1315-21

*Quite why they choose this name though it unclear to me, and if anyone else can shed more light on it I would be grateful. 

I’m doing some more nights shifts at the moment.  As regular readers of this blog will know, for me this involves a lot of grumbling, but it also involves seeing a lot of patients who are having problems with their mental health at times when most people are asleep.

Whenever I see a patient for the first time I interview them and ask a set of particular questions.  These questions add up to a ‘psychiatric history’.  The aim of the psychiatric history is to establish in a systematic way the problems that the patient is having, their chronicity, i.e. how long these problems have been going on, and any other influencing factors. 

If you ever fancy taking a psychiatric history from one of your friends then here’s how to go about it. 

Write the date and time a the top of the page and say who you are.  In my case ‘Psychiaty doctor on call’.  In general try and write down everything that you think is important.  This not just for when others may be reading the notes later, but also from a legal standpoint if there is no record in the notes then something will be considered not to have happened. 

The first part of the history is called the history of the presenting complaint (HPC).  It involves recent events which have lead to this particular visit to hospital.  These events could be over a few weeks or months or over a few days or hours. With a cooperative patient I often start with a list of the things that are bothering them.  This can be very illuminating and provide a guide as to the help the patient would like to receive.  I also find that this is a useful way of not medicalising a patient’s problems.  It is not unusual for a patient to be referred to me for depression, but to say to me that their problems are housing related, and that their husband keeps hitting them and to not mention any psychiatric symptoms at all.

An important thing to establish here is what brought the patient to hospital.  They may have been sent by their GP, or have been brought in by a family member, or have come in of their own volition.  They may also have been brought in by the police or an ambulance.  Although your patient is your primary ‘witness’ so to speak, don’t be shy of asking other people details like this.  This called taking a ‘collateral history’. 

The next section to cover is the past psychiatric history.  Here we must establish for how long the patient has had problems with their mental health.  This usually covers doctors seen, medications taken and admissions to hospital. 

Mental illness often runs in families, and it is important to probe about this.  This is called the family psychiatric history. If we know that there is mental illness already in someone’s family then this may lend weight to any diagnosis we may make, but it will also give us information about a patient’s background.  For instance if an adolescent is living with a depressed parent then this will make a big difference to their home environment. 

Some psychiatric problems may be caused by or interact with physical problems.  So the next section concerns medical history.  I usually split this up into family medical history and patient’s medical history.  It is far from unheard of for a psychiatric problem to actually be the result of an undiagnosed physical problem so psychiatrists have to be awake to this possibility.

One of the reasons that working in mental health is so interesting is that someone’s mental health is often very tied up with their social situation and the experiences they have had up to the point of presenting.  This is why a personal history is taken.  This will include details of childhood, with important questions about developmental delay, schooling, employment and relationships.  If time is short this is part of the history that can be left to a later time.

Drug use and particularly alcoholism is rife in our society and a careful drug and alcohol history is important.  I’m always amazed by how reluctant people are to tell me how much they drink.  The usual conversation: Me: how much alcohol do you drink?  Patient: not much.  Me: how much is not much?  Patient: much less than I used to.  Me: how much is that? Patient: one or two. Me: one or two what? Patient: well I don’t drink every night of the week…..  Cannabis use is also linked to the development of psychotic illness.

If writer’s cramp is holding off, then a forensic history, detailing brushes with the law and time spent in prison can be taken, and it is also useful to ask about premorbid personality whereby the patient or their relatives tell you how they used to be can give an idea as to how out of character a patients actions are and how sick they may be.

There are quite thick books written on the subject of the psychiatric interview and so I can’t hope but provide anything but a taster here.  Sometimes the patient is able to give you all the information you might need.  Sometimes they might be so disturbed that the entire history is from a a collateral source.  Often psychiatrists need to talk to several people.  At the same time as the history is being taken information for the mental state examination is also being noted - this is a posting for another day.

PS I have a theory that if someone without the appropriate qualifications, but with a bit of guile and a crash course in the right things to say, decided to pose as a psychiatrist then it would be quite some time before they were found out.  If anyone is interested in giving this a go, then take careful note, as the ability to take a ’psychiatric history’ will be an important part of your subterfuge

Catherine commented:

‘I disagree with the comment about bipolar and schizophrenia being chronic, remitting etc. There are a minority who are so badly affected that they never live independently, but the majority go on to either recover, or manage their illness very well, working, hobbies etc and have a good quality of life.’

The point I was making about the chronicity of schizophrenia/bipolar disorders is that in the film ‘Ruth’ is presented to us has having recovered from her mental health crisis with no mention of follow up.  For anyone who doesn’t know, it’s often common practice in healthcare for a patient to be seen by a doctor on at least a short term basis after a problem has resolved as there may be a chance of it coming back, and psychiatry is no exception to this. We know from the film that she already has a diagnosis of BPAD and so she must have had trouble before.  The episode presented to us is quite severe, so I would say that her chance of having another relapse is high, especially with bipolar disease

Schizophrenia is considered to have a wide variety in outcomes, that said, there are not millions of long term studies; here are the ones mentioned in the Shorter Oxford Textbook of Psychiatry:

Kraeplin Dementia praecox and paraphrenia 1919
Concluded that only 17% of his patients were socially well adjusted many years later

Mayer-Gross Die Schizophrenie in Bumke’s Handbuch der Geisteskrankheiten Vol 9 Springer Berlin 1932
Reported social recovery in 30% patients at 16 years all from the same clinic

Brown et al (1966) reported social recovery in 56% in Schizophrenia and social care Maudsley Monography 17 Oxford University Press  London

Manfred Bleuler (1972,1974) followed up 208 patients who had been admitted into hospital in Switzerland between 1942 and 1943.  Twenty years after admission 20% had complete remission of symptoms and 24% were severely disturbed. 

Ciompi did a larger study looking at 1642 records diagnosed as having schizophrenia between 1900 and 1962, with an average follow up of 37 years.  A third of patient were found to have good or fair social outcome.  Symptoms were often less severe in later life. 

Johnstone E.C. (1991) Disabilities and Circumstances in Schizophrenic patients: A follow up study British Journal of Psychiatry  159 supplement 13 5-46, did a 3-13 year follow up of patients with schizophrenia discharged from 1975 - 1985 and found that almost half had a good social outcome. 

Tsoi and Wong (1991) A fifteen year follow up of Chinese Schizophrenic patients Acta Psychiatrica Scandinavica 84 217-220  did a 15 year follow up of 330 patients with first admission Schizophrenia and in this found that almost one third recovered but 17% remained unable to function outside the hospital. 

Finally in the USA Carone et al (1991 - a busy year) found that only 15% of patients meeting DSM-III criteria for schizophrenia recovered after 5 years. 

Full admission: I haven’t read any of these papers/books, and for these papers to be comparable then they should all use similar definitions for schizophrenia and select similar patients - there would be no utility is comparing patients after their first admission and patients who have been admitted countless times.  With these caveats, it appears that prognosis has improved since schizophrenia was first studied.  In the earlier studies the patients would have had no access to modern pharmaceutical treatments 

Schizophrenia outcome is further discussed in  Schizophrenia Research Volume 1, Issue 6, November-December 1988, Pages 373-384

The factors associated with good prognosis in Schizophrenia:

Sudden onset; Short episode;No previous psychiatric history; Prominent affective symptoms; Paranoid type of illness; Older age of onset; Married; No personality disorder; Employed; Good social support; Good compliance with treatment

Poor prognosis is associated with:

Insidious onset; Long episode;Previous psychiatric history; Negative symptoms; Enlarged lateral ventricles; Male gender; Younger age of onset; Single/separated/widowed/divorced; Personality disorder; Poor work record; Social isolation; Poor complicance with treatment

If you’ve still got the strength, read on for outcome of bipolar affective disorder.  Again this is from the Shorter Oxford Textbook of Psychiatry:

The average length of a manic episode (treated or untreated) is six months

At least 90% of patients with mania experience further episodes of mood disturbance

Over a 25 year follow up on average bipolar patients experience 10 further episodes of mood disturbance

The interval between episodes becomes progressively shorter with both age and the number of episodes

Nearly all bipolar patients recover from acute episodes, but less than 20% of patients with this disorder achieve a period of 5 years of clinical stability with good social and occupational peformance

It is estimated that 10% of patient with unipolar depression will eventually turn out to have a bipolar illness.   

So, with both bipolar affective disorder and schizophrenia, I do think that if a patient has one episode they are likely to be troubled by the illness at a later date and this is what I meant by a chronic condition.       

I went to a talk today given by the widow of Jane Zito.  Jane is the widow of Jonathan Zito; Jonathan was killed in 1992 by Christopher Clunis who had a diagnosis of paranoid schizophrenia.  Following intense lobbying by Jane there was a public enquiry which examined how the healthcare system had failed Clunis in allowing him to murder Jonathan Zito, who was simply an unlucky bystander.  Since Jonathan’s death, Jane has set up the Zito Trust

During her speech and the subsequent questions Jane said several times how important she feels it is that, when something happens like in her case, someone contacts the victims family and says that they are sorry.  She said that this should happen even if nothing had been done wrong. 

I’ve been thinking since then about how important the word ’sorry’ and the power that it has as an expression and why we can be so reluctant to use it.

‘Sorry’ is many things, but above all it is the benchmark of contrition; you can make many expressions of apology, but until you’ve said ’sorry’ people will always come back asking for more.  As well as an expression of regret, it’s a sign of respect and an acknowledgement of the suffering of another person.  When an apology is felt to be lacking, people can feel that this absense can compound the original misdeed. 

‘Sorry’ in public and private life is often lacking.  People can feel that to say ’sorry’ is an admission of responsibility and a invite for disciplinary action.  Governments have failed to apologise for past crimes for fear of the possible financial consequences. 

Doctors and other healthcare staff make plenty of mistakes.  The NHS has a policy document about this which encourages people to apologise.  This is something that we’ve not been good at in the past.  Part of the problem perhaps is the responsibility is spread very thinly these days, and roles are blurred; it is not clear whom should be taking ultimate responsibility, who should be picking up the phone and saying ’sorry’.  Fear of being disciplined is ultimately destructive as people whose unsatisfactory treatment is not acknowledged are more likely to seek this recognition through litigation. 

It’s possible to go to far or to be insincere.  I used to work for a well known psychiatrist who was very keen, as we all are, on not attracting complaints.  He liked to tell a story about a meeting concerning a serious incident where he apologised so many times that an astute family member said ‘Dr X you’ve said ’sorry’ over 20 times during this meeting’.  To which the he replied ‘I’m sorry about that’.  It is also possible to say that you are ’sorry’ for the distress with which someone has been visited, without being sorry that about what caused it, which is something of a sleight of hand. 

There have been some famous ’sorries’ in recent times.  In November 2006 Tony Blair expressed ‘deep sorrow’ for the UK’s part in the slave trade.  This was considered by many to be inadequate.  In the following January he came out as being actually sorry.  In February 2008 the Prime Minister of Australia Kevin Rudd repeatedly said sorry for the stolen generation of aboriginal children.

The Apology Movement - although this may exist simply to sell books

Guardian article about NHS apologies

This is the first in an occasional series of posts examining aspects of psychiatric practice which have given shrinks a bad name. As always comments and suggestions are welcome and if you can think of a candidate then let me know.

Anyone who has seen the film ‘One Flew Over the Cuckoo’s Nest’ will remember McMurphy’s fate; having tried to strangle Nurse Ratched and subsequently restrained, he comes back to the ward where Chief Bromden discovers that he has been given a lobotomy. Previously sparky and defiant, he appears subdued and submissive.

Evidence for the use of surgical techniques, such as trepanation of the skull, in people has been found from skulls dating from the middle ages. Famously Phineas Gage underwent a non-surgical lobotomy following an accident during railroad construction. His subsequent personality change played a role in the understanding of the localisation of brain function.

Neurosurgery for psychiatric problems was introduced in modern times by the Portuguese neurologist Egas Moniz and his neurosurgical colleague Almeida Lima, when in 1935 they sought to damage connections to and from the frontal lobes in patients with symptoms of mental disorders. At this time there were no effective therapies for these conditions and the surgery was received positively, Moniz receiving the 1949 Nobel prize for medicine. Moniz’s technique was to drill holes in the skull and inject alcohol into the frontal lobes.

Walter Freeman and James Watts in America modified Moniz’s operative technique and introduced the standard prefrontal leucotomy, which is what we are normally referring to when we say ‘prefrontal lobotomy’. This however required trained neurosurgeons and Freeman was concerned that this restriction would mean that those patients who needed the procedure most, those in asylums, would not be able to access it. As a result he developed the transorbital lobotomy, a terrifying technique whereby a pick like instrument was driven through the thin bone at the top of the eye socket and into the brain at which stage it was blindly manipulated. This procedure could be undertaken anywhere, without surgical training; beforehand the patient was rendered unconscious by electroshock. Dr Freeman was a showman, who would occasionally like to show off in front of an audience of doctors by lobotomizing both sides of a patient at the same time. Dr Freeman alone peformed over 3,000 lobotomies during his career, the results of which, due to its imprecision, were very variable.

Overall between 1936 and 1961 50,000 patients underwent surgery in the United States and about 10,000 in the United Kingdom. No controlled studies were performed and many people who received this treatment did not have a mental health disorder. It is stated that about 20 per cent of patients with schizophrenia and between one-half and two-thirds of patients with affective disorder derived who underwent the procedure derived some benefit. There was a very high mortality (up to 4%), as well as severe abulia and amotivation (up to 4%), personality change (up to 60%), and postoperative epilepsy (up to 15% - all figures for success and side effects are from the Oxford Textbook of Psychiatry). Due to a lack of other effective treatments these were accepted by many psychiatrists as worthwhile risks.

The use of surgery declined rapidly following the introduction of antipsychotic and antidepressant medication during the late 1950s. Since then, neurosurgery has only been used for severe treatment-resistant affective, obsessional, and anxiety disorders. These operations are used only rarely there having been, on average, no more than 20 operations a year in the United Kingdom over the last 20 years.

Howard Dully, one of Dr Freeman’s youngest patients has written a book about his experiences called My Lobotomy (which I haven’t read), the subject of this Observer article

Dr Elliot Valenstein has written a book called Great and Desperate Cures!: Rise and Decline of Psychosurgery and other Radical Treatments for Mental Illness. (Which I haven’t read either)

Jack El-Hai has written a biography of Walter Freeman. I have read this, and it’s very interesting and detailed. It’s called The Lobotomist: A maverick medical genius and his tragic quest to rid the world of mental illness

I was meant to be seeing a patient this morning, but she’s not turned up.  In doctor speak she ‘DNA’d’ - did not attend.  

It’s not easy going to the doctor, especially when the doctor is a psychiatrist.  People think that going to a psychiatrist makes them ’mad’, and other members of their family may tell them not to go.  There’s also a strong association with psychiatrists and being ‘locked up’.  Worse still, when they do pluck up courage to go along to the appointment, they get asked all sorts of nosey questions, which can be taken in a way not intended.  This is particularly acute with child and family services where questions about parenting can be interpreted as accusatory. 

I’m pretty philosophical about all this; this sort of attitude is necessary to do a job where most of your patients don’t want to see you and some don’t even think that they have a problem.  But in less charitable moments I do find myself wishing that more of my patients would call to let me know that they’re unable to make it so that I could plan do to something else.  So many of my patients have DNA’d recently that I’m completely up to date with my paperwork, which is why I’m writing this post.

When I was a student and had nothing to do I’d sit around and do the crossword (the quick one).  Crucially for the NHS I was doing this for free, with the understanding that someone would give me a job at a later date.  That time has come, and tax payers are now paying for these missed appointments.  The most recent data that I can find on the total cost to the NHS is from an article in the Telegraph from 2005.  Which suggests that DNAs cost almost £200 million in 2004, and the total cost of missed appointments was £575 million.  Regrettably it doesn’t quote its sources and if anyone knows how I can get hold of this data please let me know.  MP Grant Shapps gave a speech on the subject in May 2006

The article says that in 2004 there were 5,707,288 missed appointments in the NHS.  Of these approximately one-third are ‘no shows’/DNAs, one third are cancelled by patients before the appointment and the remainer are cancelled by the hospital.  It seems that in two thirds of cases of DNAs patients simply forget about their appointments. A smaller percentage, roughly 25%, feel better and do not turn up, without informing the hospital.

It’s not an original point to make, but the ‘free at the point of delivery’ philosphy of the NHS is both its greatest strength but also its greatest weakness.  Things that are not paid for have no value. 

There’s news that Josef Fritzl, the man who imprisoned his daughter for 24 years in a dungeon of his own making, will plead insanity when his case goes to trial.  I also saw Glenn Wilson, who works at the IoP on TV speculating that Mr Fritzl is a psychopath.  

I’ve talked about personality disorders elsewhere; but in brief: your personality can be defined as ‘the characteristic, and to some extent predictable, behaviour-response patterns that each person evolves, but consciously and unconsciously as his or her style of life’ (Campbell’s Psychiatric Dictionary).  Personality disorders on the other hand relate to when the way in which an individual interacts is so rigid and fixed as to severely limit the likelihood of effective functioning and/or satisfying interpersonal relationships.  The point when a personality is sufficiently beyond the normal to warrant a personality disorder diagnosis is difficult and define and personality disorder is less a diagnosis and more a label of social non-conformity.  

Psychopathic personality disorder is synomymous with anti-social personality disorder (DSM-IV) and dissocial personality disorder (ICD-10) 

Back to Mr Fritzl.  Here’s the ICD-10 classification for dissocial personality disorder (DSPD)

F60.2 Dissocial personality disorder

Personality disorder, usually coming to attention because of a gross disparity between behaviour and the prevailing social norms and characterised by:

(a) callous unconcern for the feelings of other

(b) gross and persistent attitude of irresponsibility and disregard for social norms, rules and obligations

(c) incapacity to maintain enduring relationships; though having no difficulty in establishing them

(d) very low tolerance to frustration and a low threshold for discharge of aggression, including violence

(e) incapacity to experience guilt or to profit from experience, especially punishment

(f) marked proneness to blame others or to offer plausible rationalizations for the behaviour that has brought the patient into conflict with society

Mr Fritzl clearly has most of these in spades, so much so that it would not be entirely unreasonable if a whole new subtype of this personality disorder should be invented just for him.  People with DSPD are known to have a reduced ability to empathize with another person’s emotional state, or to recognise it from their face.  I remember a forensic psychiatrist explaining to me the response one of his patient gave when asked to name the emotion of the face of a person shown to him on a card (the emotion was fear)

‘I’m not sure what it’s called but that’s the way people look when I stick a knife in them’ 

Which still gives me the creeps. 

It’s also possible that Mr Fritzl is psychotic in some way, but this seems unlikely given how well he has been seen to function in society and how calculating and precise the planning for his deeds appear to have been. 

It will be brave psychiatrist who attempts to defend his insanity plea as an expert witness. 

***

I’ve also been very interested to learn of how Austrian society could let this sort of thing happen.  I’ve read in the press that people in general and institutions in particular are extremely reluctant to believe that anyone of social standing could do anything untoward.  Data protection laws are also weighed towards the criminal - any conviction is wiped after fifteen years, which means that the information relating to Mr Fritzl’s rape conviction was not available when he applied to adopt the children he had conceived with his daughter.  Austrian police also said almost immediately that Mrs Fritzl knew nothing of her husbands activities - more wishful thinking perhaps?

It would be easy to get snotty.  Here in the UK we’ve had our share of psychopaths whose crimes evaded the authorities for years.  Peter Sutcliff, who killed thirteen, was eventually caught because his car had false number plates.  Dennis Neilsen killed at least fifteen and was caught because his drain was blocked with flesh. 

***

And another thing, which no one else seems to be saying.  Mr Fritzl really looks like a pervert to me.  The supercilious smirk, the arched eyebrows with the right slightly higher as if in challenge.  Dogs and their owners eventually look the same people say.  Is it possible that psychopaths eventually look like their acts?