theguardian online today has a story on its main page which is titled ‘Why smiles are better than Prozac’

On closer inspection, it’s less an article, more an advertorial for a book called ‘Beating stress, anxiety and depression’ by Jane Plant and Janet Stephenson.  The  article says that the book is ‘new’ but the amazon.co.uk page says that it came out at the beginning of May this year.  I can only imagine that they were short of copy and rehashed a press release that they found knocking around the office.

Be this as it may, this is the sort of thing that catches my eye.  The introduction is available for perusal online, and Plant and Stephenson say some sensible things - like advising us to ignore celebrity culture - but I am concerned about some of the things they say particularly when they assert that levels of neurotransmitters should be assessed in patients suffering from depression.  The neurotransmitter hypothesis is problematic, as discussed by Badscience.net and Mindhacks.com, and this sort of test are likely to be more expensive than meaningful.

Daily Mail article on the same book title: ‘How the wrong drugs could be causing your depression’.

Best read it before I comment further.  If anyone has read it and would like leave a comment below I would be most grateful.

Also in the paper today Rachel Cooke has this to say about reality TV and meeting Jodie Marsh

What strikes you most about Marsh when you meet her is not her pleasure at the unexpected turn her life has taken, but her implacable anger…..(about four paragraphs)….I’ve lost count of the number of times youth workers and criminologists alike have made the connection, as they discuss knife crime, between low self-esteem and anger. Well, there is an awful lot of anger among those who participate in reality TV, the majority of which, it seems to me, is the result of low self-esteem, and Marsh is no exception.

BBC From our own correspondent ‘A shoulder to cry on in Baghdad’ - Psychiatrists in Baghdad 31 May 2008

(From our own correspondent homepage)

‘How Britons get high - drug users tell their stories’  Observer 20 July 2008

Anyone who thinks that psychiatrists are murders and psychopaths need look no further than Radovan Karadzic, who until yesterday was Europe’s most wanted man and is now awaiting trial for war crimes in The Hague.

Karadzic was born on June 19, 1945, in Petnjica, Montenegro. He studied medicine at the University of Sarajevo during the 1960s.  He also studied abroad researching neurotic disorders and depression at Næstved Hospital in Denmark in 1970, and during 1974 and 1975 he spent a year pursuing further medical training at Columbia University in New York.

After his return to Yugoslavia, he worked in the Koševo Hospital.  During this time it is said that he often supplemented his income by issuing fake medical and psychological evaluations to healthcare workers who wanted early retirement or to criminals, who tried to avoid punishment by pleading insanity.  Karadzic is married to a psychoanalyst, Ljiljana Zelen, the daughter of an established and wealthy Serb family. The couple have a daughter, and a son.

In 1983, Karadzic started working at a hospital in the Belgrade suburb of Voždovac. With his partner MomÄilo Krajišnik, then manager of a mining enterprise Energoinvest, he managed to get a loan from an agricultural-development fund and used it to build themselves houses in Pale, a Serb populated village above Sarajevo turned into ski resort for Communist establishment (future capital of Republika Srpska).  On 1 November 1984 the two were arrested for fraud and spent 11 months in detention before a friend managed to bail them out.  Due to lack of evidence, Karadzic was released and trial was brought to a halt.  The trial was revived and on 26 September 1985 Karadzic was sentenced to three years in prison for embezzlement and fraud. As he had already spent over a year in detention, Karadzic never had to serve this sentence.

During the 1970s and 1980s Karadzic worked at various medical posts, including the Zagreb Centre for Mental Health in Croatia, the Health Centre in Belgrade and as psychiatrist to the Sarajevo national soccer team. He also became a poet and fell under the influence of the Serbian writer Dobrica Cosic, who encouraged him to go into politics.

After working briefly for the Green Party, he helped set up the Serbian Democratic Party (SDS) in 1990 in response to the rise of nationalist and Croat parties in Bosnia, and dedicated to the goal of a Greater Serbia.

Less than two years later, as Bosnia-Hercegovina gained recognition as an independent state, he declared the creation of the independent Serbian Republic of Bosnia and Hercegovina (later renamed Republika Srpska) with its capital in Pale, a suburb of Sarajevo, and himself as head of state.  Mr Karadzic’s party, supported by Serbian leader Slobodan Milosevic, organised Serbs to fight against the Bosniaks and Croats in Bosnia.

The above text is cobbled together from a number of sources listed below; this next bit is solely from a BBC profile of Karadzic.

‘A vicious war ensued, in which Serbs besieged Sarajevo for 43 months, shelling Bosniak forces but also terrorising the civilian population with a relentless bombardment and sniper fire. Thousands of civilians died, many of them deliberately targeted.

Bosnian Serb forces - assisted by paramilitaries from Serbia proper - also expelled hundreds of thousands of Bosniaks and Croats from their homes in a brutal campaign of "ethnic cleansing". Numerous atrocities were documented, including the widespread rape of Bosniak women and girls.

Reporters also discovered Bosnian Serb punishment camps, where prisoners-of-war were starved and tortured.  War crimes were also committed against Serb civilians by the Bosnian Serbs’ foes in the bitter inter-ethnic war - Europe’s bloodiest since World War II.

Mr Karadzic was jointly indicted in 1995 along with the Bosnian Serb military leader, Ratko Mladic, for alleged war crimes they committed during the 1992-95 war.  He was obliged to step down as president of the SDS in 1996 as the West threatened sanctions against Republika Srpska, and later went into hiding. While on the run, he managed to get a book published in October 2004 by a former associate, Miroslav Toholj. Miraculous Chronicles of the Night, set in 1980s Yugoslavia, tells the story of a man jailed by mistake after the death of former Yugoslav strongman Josip Broz Tito.

In May 2005, investigators reported two separate sightings of Radovan Karadzic - allegedly with his wife Ljiljana in south-eastern Bosnia and then with his brother Luka in Belgrade - as his mother was dying of cancer in Niksic, Montenegro’

Before his arrest Karadzic was working as an alternative medical practitioner.  A blog in theguardian suggests that this is sufficient to discredit alternative medicine as a whole.  What rot! I’ve no time for alternative medicine, but damning it by association is unconvincing.

Further reading

‘The Edge of Madness’ Ed Vulliamy in theguardian 23 July 2008

Radovan Karadzic’s alternative medicine website 

For anyone interested in genocide in general the following books are excellent

Sources for above

Profile: Radovan Karadzic - poet, psychiatrist, war criminal The Times 22 July 2008 

Radovan Karadzic Wikipedia entry 

CNN: Karadzic: Psychiatrist-turned ‘Butcher of Bosnia’ 

moreorless : heroes & killers of the 20th century Radovan Karadzic profile (great site, but a pity it cites no sources)

Almost as if I asked them to, the Healthcare Commission have published a report today called ‘The pathway to recovery - A review of NHS acute inpatient mental health services’ which follows up very nicely my last posting, which was a review of Jeremy Laurance’s book Pure Madness.  

Link to full report / much more digestible press release

Today programme discussion 0850 23 July 2008 

Frontier Psychiatrist digest:

(I don’t think that much of this will come as a surprise to anyone who works in acute adult mental health.)

The report  assessed all 69 trusts providing acute adult mental health care in England.  This covered 554 wards providing almost 10,000 beds for patients between the ages of 18 and 65.  The press release says that they did the study as there was concern that recent focus on community mental health services meant that inpatient services do not always get the funding and attention they need.

Overall, eight trusts were rated as ‘excellent’ (accounting for 843 beds – 9%), 20 as good’ (2,808 beds – 28%), 30 as ‘fair’ (3,985 beds – 40%) and 11 as ‘weak’ (2,249 beds – 23%). The report says that while some trusts struggle to meet standards, there are a number of high-performing trusts ‘proving that it is possible to provide personalised, safe and good quality acute mental health care’. However no trust was scored as ‘excellent’ across all key criteria.

The higher performing trusts were those that ‘actively involved inpatients in their care, provided meaningful activities in a therapeutic environment and that planned care around the needs of the service users’. (That sounds like something I might memorize to say at a job interview)

But the report identified areas for action, in particular improving the involvement of patients in their care; despite guidelines to include patients’ views in their care plans, this occurred in only 50% of cases.

There were further concerns about:

one in nine trusts scoring ‘weak’ on criteria relating to safety, with high levels of violence - 45% of nurses and 15% of patients reporting that they were physically assaulted in 2007.

insufficient attention to the sexual safety of patients and overcrowding in some trusts

that, in a six-month period, patients detained under the Mental Health Act 1983 were absent from services without authorisation on 2,745 occasions.

Crisis resolution home treatment (CRHT) teams, which should be involved in deciding whether admission to hospital is the most appropriate course of action, were only involved in 61% of admissions.

Also, 6% of the time people spent in hospital was due to delays in finding accommodation or appropriate support to live within the community.

Anna Walker, the Commission’s Chief Executive, is quoted as saying

‘It is clear that it is possible to provide patients with excellent acute hospital care and that some organisations are doing exactly that.  It is also clear that these can be tough places to work and I pay tribute to the dedicated staff who face the challenges on a daily basis’

and 

There are cases where people are not always getting the personalised, safe, high quality care that they need. This is happening at a time of crisis in their lives and it cannot be ignored.’

I’m surprised that only 6% of beds are assessed as being blocked, as from my experience I would have guessed the number at much higher.  Or maybe it just feels that way.  There are some positive aspects to the report, which will doubtless be championed by politicos, but to my mind mental health care is still woefully underfunded in the UK and many psychiatrists would echo Dinesh Bhugra’s assertion that he would be unwilling to have a family member stay in some UK acute psychiatric wards. 

As usual the problems come down to a lack of investment both in staff training and facilities.

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I am forming a theory that, rather like a stew left in the fridge, the longer one leaves a book on a shelf, the better it becomes.  For instance I left Jonathan Coe’s ‘The Rotter’s Club’ on my shelf for four years before reading it and it turned out to be brilliant.  By contrast I acquired its sequel ‘The Closed Circle’ and read it without leaving it to languish at all, and it turned out to be most disappointing.

When clearing out an office at one of my placements eighteen months ago I requisitioned Jeremy Laurance’s book ‘Pure Madness’ and it’s been kicking around my flat ever since.  Subtitled ‘how fear drives the mental health system’ it’s a really interesting examination of the problems with the UK’s mental health system, and how these problems have come about.  Laurance is the health editor of the Independent newspaper and took nine months off to write the book.  A noble effort, considering that he can’t have been expecting to sell many copies. 

Throughout the book Laurance’s journalistic skills shine through, as the book is both informative and interesting, a not inconsiderable achievement given its potentially dry subject.  In large the book deals with current culture in the mental health field where the predominant concern is risk management rather than patient care and where the care of patients appears to lurch from crisis to crisis, with limited resources available for long term work.  Laurance also discusses that dissatisfaction that many people who use the service feel towards the care that they are offered. 

In chapter 11 ‘The new meaning of community care’ Laurance sets out the problems as he sees them:

‘In reality, over the past decade, mental heath services have been driven by public and political pressure to adopt the risk avoidance agenda.  Facing a chronic shortage of resources, community care has never been realised in its full scope and the services have been narrowly focused on securing the safety of the public rather than meeting the needs of the individuals.  The result is a service which:

Provides help in a crisis for people with mental health problems but offers little in the way of prevention to stop the crisis occurring, or support after it is over

Is medically driven and focused on drugs with little choice of other kinds of treatment

Relies on containment and compulsion with a 50% increase in the sectioning rather in the past ten years and increasing use of medication. 

Is strongly disliked by users and…

Has been heavily influenced by carers’ organisations

Is being driven to be more coercive and controlling by Government proposals for legistation which highlight dangerousness.’

How did this all start?  In terms of the risk model, Laurance identifies a turning point at which the debate about mental health treatment changed.  This turning point was the fatal attack by Martin Clunis, a man with a diagnosis of schizophrenia, on Jonathan Zito, a unfortunate bystander knifed at random.  Following this tragic incident, Laurance contends that, in terms of the care of those with mental health problems, concern for the welfare of the (non-violent) many was replaced by the fear of the risk posed by the few.  The result was an ‘inquiry culture’ and press frenzy.  Whist ignoring society’s most prominent cause of violence – that of people intoxicated by alcohol, suffering no mental illness – papers continually printed stories of unprovoked attacks of on strangers by ‘nutters on the loose’.

Clunis lived in the community, but fifty years earlier he would most likely have been in an asylum.  These places were more about containment than treatment and lead to the institutionalization of many people.  During the 1960s social and economic pressures, as well as the advent of anti-psychotic medication lead to their gradual closure.  At first this went smoothly – there were many people in hospital that shouldn’t have been there in the first place – but discharging patients with more severe problems proved more difficult and often the appropriate care for them in the community was lacking.  The money saved by closing asylums was diverted into physical medicine rather than being invested in mental health provision. 

In 1998 Frank Dobson, Health Secretary, stood up in front of the House of Commons and declared that ‘community care has failed’.  This view is disputed by Professors Graham Thornicroft and David Goldberg.  They contend that community care has only been half implemented and so this cannot be said to have happened.  The reduction of the number of psychiatric beds was achieved by closing the vast majority of long stay psychiatric beds but the number of acute beds has remained stable.  However no provision was made for the possibility of short term admissions for the previous long stay patients who are having a crisis.  The result is immense pressure on acute psychiatric wards, with occupancy rates often exceeding 100%. 

Community care is popular with patients, but standards are low with psychiatric wards being unpleasant places and community care without the resources for long term work and geared towards dealing with crises.  But the argument that community care has lead to increased risks to the public cannot be sustained; Laurance says that figures show that there has been no increase in killings by people with mental health problems in the forty years that mental hospitals have been emptying. 

The new president of the Royal College of Psychiatrists Dinesh Bhugra, was recently very critical of UK mental health provision.  Thornicroft would agree and is quoted in the book as saying: ‘There are ways in which the mental health services we have got used to wouldn’t be accepted in other forms of care’.  Laurance illustrates this schism whilst talking of suicides ‘imagine if cervical cancer patients, screened and treated on the NHS, were still dying at a rate of 300 a year with shortcomings in the service blamed for the deaths of a further 900?’

Very valuably, Laurance lends much of his book to providing reports as the feelings and wishes of people with mental health problems who use the service.  There is much dissent. 
‘the biggest change in the last decade has been the growing protests from people with mental health problems who use the service.  There is enormous dissatisfaction with the treatment offered with the emphasis on risk reduction and containment and the narrow focus on medication.  They dislike the heavy doses of antipsychotic and sedative drugs with their unpleasant side effects and a growing number reject the biomedical approach which defines their problems as illnesses to be medicated rather than as social or psychological difficulties to be resolved with other kinds of help’

With this in mind, we hear of Bradford consultant psychiatrists Phil Thomas and Pat Bracken who published a well known paper in 2001 entitled ‘Postpsychiatry: a new direction for mental health’.  Their attitudes are popular with user groups and Laurance finds them ‘prepared to take greater risks than many of their colleagues to protect the autonomy of people with mental health problems and are less in thrall to the ‘safety at all cost’ culture that dominates the profession’. 

This reminds me of Rufus May, who works in Bradford, and this site’s postings about his television programme ‘The doctor who hears voices’.  One of my major criticisms was that May did not manage the suicide risk of his patient adequately.  I still think that May took a big chance in the way he approached ‘Ruth’s’ treatment, but I can recognise here in my approach the effects of the culture in which I have been immersed. Like a creature of my training I was horrified at what I saw as May’s risky approach, whilst May took an approach that valued the autonomy of his patient over all else.  Rufus May features in the book, in a chapter in which Laurance details the ‘life stories’ of several people with mental health problems.  What stands out in all the stories are the difficulties people face in receiving the care that they might wish, but also the broad nature of the problems with which mental health services must deal. 

In conclusion Laurance reports that the Government has reacted to the problems of patient care and public safety with two opposing agendas: firstly they have identified mental health as one of its three health priorities, making new money available.  But they have also proposed more coercive laws to deliver a safer service.  Psychiatry has always had within it an element of social control, but the question is to how far these powers should extend. 
Laurance finishes:

‘The argument of this book is that the most effective way to increase satisfaction and at the same time improve public safety is to devise services that genuinely engage mentally ill people and meet their desire for greater involvement in their care so that they are encouraged to lead stable risk free lives.’ 

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I have been reading ‘Psychology A Very Short Introduction’ by Gillian Butler and Freda McManus.  It’s part of an interesting series published by Oxford University Press, which seek, via compact little books, to introduce readers to subjects as diverse as the fall of the Soviet Union and Indian philosophy. I’ve tried to tackle a few of them now, with varying levels of success.  The VSI books with which I’ve had the most success are the ones dealing with subjects with which I am most familiar and that I have chosen to read in order to brush up on my knowledge.  By contrast the VSI publication concerning fascism had defeated me by page 6.

‘Psychology A Very Short introduction’ starts off solidly: ‘What is psychology? How do you study it?’ is the title of the first chapter.  We are introduced to William James, American philosopher, physician and one of the founders of modern psychology who defined psychology as:

‘The science of mental life’

Early psychologists used introspection as a way to study psychological questions; James was unimpressed and displayed a talent for the epigram when he described this method as akin to ‘turning up the gas quickly to see how the darkness looks’.  In 1913 John Watson was even more sensible, when he stated that if psychology was to be treated as a science, the data on which its conclusions were based should be available for inspection. We’re taken through the methods used to study psychology and the main braches of the subject.  There’s a helpful bit on the difference between psychology and psychiatry which is quoted elsewhere on this site.

With this over the meat of the book starts with the subject ‘What gets into our minds? Perception’.  There’s a discussion of the Gestalt psychologists and some of those pictures that demonstrate their conclusions – the devil’s tuning fork, the Necker cube and Rubin’s vase.  Important to perception is attention and the discriminatory skills necessary to identify the things in which we are most interested and ignore the rest.

‘What Stays in the Mind Learning and Memory’ deals with what for many is the very embodiment of psychology: conditioning.  Classical conditioning, whereby associations are learnt between events was discovered by Pavlov.  Operant conditioning was first described by Skinner, who wrote about the role of reinforcement in learning.  Different flavours of memory such as short and long term memory are also dealt with.

‘How do we use what is in the mind? Thinking, Reasoning and Communicating’ is about no less a subject than how we ‘organize our perceptions so that they make sense, recall information when it is needed and use it to think, reason and communicate with, then we can make plans, have ideas, solve problems, imagine more or less fantastic possibilities and tell others about it’.  Discussed is different sorts of reasoning, alongside a number of tricky puzzles to illustrate concepts

The chapter entitled ‘Why do we do what we do? Motivation and Emotion’ concerns human drives and quickly mentions Maslow’s hierarchy of need before moving onto emotions, and the difficulties they present for psychologists. ‘Is there a set pattern? Developmental Psychology’ is concerned with psychological development and the way this is used to advise parents about the progress of their children.  Bowlby’s work is cited and there’s some inevitable talk about the effect of depriving monkeys.  The case of Genie gives some weight to the theory that there is a ‘critical period’ for language development.

‘How can we categorize people? Individual differences’ is concerned about ways in which psychologists seek to group people together in terms of their similarities and differences.  There’s intelligence and intelligence tests, and the problems inherent in these.  Also covered are assessments of personality, for example Eysenck’s personality types.

‘What happens when things go wrong? Abnormal psychology’ discusses what abnormal behaviour is and how we can classify it.  This is a thorny subject and several different approaches are mentioned.  This of the all chapters is the most psychiatric, and psychiatry’s attempts to classify abnormal behaviour using ICD-10 and DSM-IV are here.  Also covered is how psychodynamic and behavioural approaches both have their place in understanding and treating abnormal traits. ‘How do we influence each other? Social Psychology’ covers subjects like obedience/conformity and Miligram’s experiment, as well as whether ‘born leaders’ exist and the origins of prejudice.

Finally, the book ends with a chapter entitled ‘What is psychology for?’ Here we have a discussion of the many uses and abuses of psychology.  Clinical psychologists work in health care settings, whilst particular ire is reserved for those involved in corporate team building courses.  For this they quote:

‘Psychologists, past masters at convening conferences in order to state the obvious, have at last turned their attention to this most bizarre manifestation of late 20^th century corporate sadism’

Which makes me pleased that I don’t work in an office.  They finish with directions for possible psychological research and also a glossary of terms used in the book.

As you can tell from this quick run-through, this is an interesting little book which manages to cover a lot of ground over a relatively modest number pocket-sized pages.  For someone with a little bit of psychological knowledge it would be ideal consolidation material.  For a complete novice it is recommended, but there may be gentler introductions available.

Patrick McGrath has written a new novel ‘Trauma’ (Buy at  Waterstones Amazon) which has a psychiatrist narrator. McGrath probably knows quite a lot about psychiatric disorder as he grew up in the grounds of Broadmoor Prison, where his father worked.  Interviewed in theguardian Saturday July 12, McGrath said something interesting and flattering about why people might become psychiatrists.

‘It has seemed to me that for a long time the writer and the psychiatrist have been up to very similar things in terms of the exploration of human dysfunction. The writer wants to create forms of entertainment and to give pleasure, the psychiatrist is engaged in a therapeutic task. But we are both essentially engaged in the exploration of human nature.’

Tangentially, but with knowing how people end up as they do in mind, I came across this interesting analysis concerning how parents can cause behaviour problems in children in the book ‘Managing Children with Psychiatric problems’ Edited by M Elena Garralda and Caroline Hyde (Buy at Amazon Waterstones)

‘Analysis … has shown that the moment to moment responses of parents towards children have a powerful effect on their behaviour.  In families with difficulties, the children are often ignored when they are behaving reasonably, but criticized and shouted at when they are misbehaving.  The consequence is that, in order to gain attention, they must behave badly.  What is perhaps surprising is that they prefer negative attention to none at all, and are prepared to elicit often unpleasant and frankly painful reactions from their parents.  By contrast, children who receive a reasonable amount of positive attention within a family tend not to behave in a way that elicits negative attention.  All of this can be summarized as the ‘attention rule’ which states that children will behave in whatever way necessary to gain a reasonable amount of attention’

Frontier Psychiatrist has just been on holiday to the Outer Hebrides.  Anyone who reads this blog will know that I am a devotee of theguardian newspaper.  I normally read this online, but as a holiday treat whilst on the Isle of Harris-North Uist ferry I was reading a printed copy.  A normally relaxed gentleman, upon reading this article by Pamela Stephenson Connolly I came close to leaving the comfort of the ferry cabin to go onto the deck and shake my fist at the waves.

Stephenson Connolly writes a column for theguardian’s G2 section on a regular basis as a sort of sexual agony aunt.  Here was this week’s question:

‘My boyfriend is an outgoing type, always the life of the party. Even when we’re alone he wants to joke around. I love him, and sex with him is satisfying when we finish what we start. However, when we’re making love he is easily distracted. It could be the sound of someone moving around in the next flat, or noise outside, but pretty soon he loses his erection. Is this normal? How can I keep his mind on the job?’

To which Stephenson Connolly, ‘a clinical psychologist and psychotherapist who specialises in treating sexual disorders’, replies:

‘It is "normal" - for someone whose brain is wired in such a way that paying attention to one thing at a time is challenging. Your boyfriend may have Attention Deficit Hyperactivity Disorder (ADHD), meaning that he has difficulty filtering out sounds and other stimuli that are competing for his attention.

Don’t take it personally.

You should suggest he be evaluated and treated for ADHD, while remembering that he is probably a bright and creative person, who could do with your help in staying on-task.

Imagine what it’s like to be inside his head. Think carefully about your lovemaking environment and create a place with a minimum of stimuli. Consider darkening the room, eliminating telephones and TV and even installing sound-proofing or using noise-cancelling headphones. If thoughts begin to distract him, encourage him to let you know so you can help to bring him back with your voice, touch or whatever else may work. You will need to experiment a bit. Praise and reward his efforts to stay focused - you will reap the benefits.’

Although she almost says something sensible at the end, it’s hard to believe that someone who claims the expertise of Stephenson Connolly could write something like this (budding psychiatrists, write down your own reasons for Stephenson Connolly’s idiocy and then read the rest of the article - if you can think of any that I don’t mention then please add a comment).

(Those not familiar with ADHD could read this before continuing)

Stephenson Connolly is suggesting a diagnosis of ADHD on extremely flimsy evidence even for a newspaper column.  She should know that ADHD diagnostic guidelines  suggest that symptoms applicable to this sort of diagnosis should be present in  more than one situation, for instance at home and at school.  Our man has his distractability in only one very specific situation.  She should also know that distractability, which is the only symptom mentioned in the ‘letter’, is far from the only symptoms shown by ADHD sufferers.  ‘Always joking around’ hardly counts; what about disinhibition in social relationships, recklessness in situations involving some danger, and flouting of social rules, to name but three?  ADHD can be diagnosed de novo in adulthood, but she should at least mention the possibility of childhood symptoms.

But let’s be charitable and assume that, although unlikely, ADHD is a possibility here.  It’s certainly a Zebra:

Zebra (noun): a very unlikely diagnosis where a more common disease would be more likely to cause a patient’s symptoms - from the common admonition that "if you hear hoofbeats, think horses, not zebras"

Is it not rather more likely that the reason that this man is unable to complete sex with his girlfriend because he isn’t very sexually interested in her in the first place?  Or maybe he’s homosexual?  Is not Stephenson Connolly guilty of grossly medicalizing what is in fact a social problem? Why bring in mental health at all?  

Sometimes after days spent sorting out my patients’ housing problems or imparting common sense where seemingly there is none, I sometimes wonder what psychiatrists are for - but here’s one of the reasons, stopping people who don’t know what they’re talking about, but have a shiny new textbook and an over zealous approach, giving patients potentially stigmatizing diagnostic labels on very limited evidence.
 

Further reading:

Adult attention-deficit hyperactivity disorder: recognition and treatment in general adult psychiatry Asherson et al BJP (2007) 190: 4-5

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I’ve just finished reading Simon Singh and Edzard Ernst’s book on alternative medicine entitled ‘Trick or Treatment’.

Written by a best selling science author Singh, who boasts a PhD in particle physics, and Ernst, a professor in complementary therapy, and subtitled ‘alternative medicine on trial’ Singh and Ernst clearly hope to set a standard in the genre.  They set out their stall early, first by dedicating the book to the Prince of Wales, whose sympathetic views on alternative medicine are well known, and then by quoting Hippocrates as providing their guiding path:

‘There are, in fact, two things, science and opinion; the former begets knowledge, the latter ignorance.’

They themselves are not modest:

‘Although there are plenty of books that claim to tell you the truth about alternative medicine, we are confident that ours offers an unparalleled  level of rigour, authority and independence’

Any treatment which cannot stand up to the rigours of scientific enquiry, by which Singh and Ernst mean a well conducted controlled clinical trial, has no place calling itself medicine and is simply hocus-pocus with good PR.  At best such therapy is simply no better than placebo, at worse it is positively dangerous.  But even if it is harmless, it is far from costless, as the annual global spend on alternative medicine is in the region of £40 billion, money that could be spent on more fruitfully, should alternative therapies prove to be ineffective.

The authors say that the key theme running through their book is ‘truth’.  And not in any post-modern sense, but instead in the sense of the fundamental question: ‘is alternative medicine effective for treating disease?’.  With this in mind, the first chapter of the book is about how science establishes whether medical interventions are effective or not; that is, how the ‘evidence’ is put into ‘evidence-based medicine’.

To explain this, Singh and Ernst take a historical approach, building the notion of the clinical trial as the gold standard for evaluating medical interventions.  They start by telling us of one of the casualties of the ancien regime; on December 13 1799 former President George Washington awoke with the symptoms of a cold.  He thought nothing of it, but by the following night he was gasping for air.  Serious, but potentially survivable, until bloodletters drained Washington of half his blood in less than a day.  These men weren’t witchdoctors, but Washington’s personal physicians.  They thought that they were working in the great man’s best interests, but alas the medical profession had yet to work out how to distinguish interventions that worked from those that didn’t.

Typically, it was a British man who first came up with the randomized control trial, even more typically he then totally failed to capitalize upon his insight. The man was a naval surgeon called James Lind;  Britain at this time was the world’s greatest seafaring nation, but any journey lasting more than a few weeks was blighted by scurvy, a disease we now know is caused by a deficit in vitamin C. Lind split twelve scurvy sufferers into six pairs, and gave each a different treatment.  He also observed another group of sailors who received no treatment; these acted as a control.  As a shot in the dark, to one pair he gave oranges and lemons; this group made a miraculous recovery.  Alas, in part due to Lind’s diffidence, his findings remained almost totally ignored for 33 years.

Just as interesting, Singh and Ernst tell us about Florence Nightingale and her penchant for statistics.  Feeling a divine calling to become a nurse, Nightingale decided to work in the hospitals of the Crimean war, having read reports of the large numbers of soldiers dying there from cholera and malaria.  Upon her arrival at her chosen hospital she embarked on the mother of all spring cleans and within one week removed 215 handcarts of filth, had flushed the sewers nineteen times and buried the carcasses of two horses, a cow and four dogs all of which were found in the hospital grounds (I think that she had some help).  But, amazing to us now, the officers and doctors who were previously in charge felt that these changes were an insult to their professionalism.  Fortunately Nightingale also had a statistical education and used this to demonstrate that soldiers under her new order fared much better than those hospitalized in less salubrious conditions. By telling us of this Ernst and Singh also seek to demonstrate that, quite opposite to what alternative practitioners believe, scientists are willing to accept ideas which run contrary to the current received wisdom.  The clinical trail is such a strong instrument that it forces them to do so.

In the next four chapters of their book, the authors take four of the main branches of alternative medicine to task: Acupuncture, Homeopathy, Chiropractic therapy and Herbal Medicine.  They take us through the history of each approach, its theory of action and assess the evidence for its efficacy.

Acupuncture, is an ancient treatment, whereby the body’s ‘Ch’i', its vital energy or life force flows through our bodies in channels called meridans.  Illnesses are due to imbalances or blockages in the flow of Ch’i and the goal of acupuncture is to tap into the meridans at key points to rebalance or unblock the Ch’i.  Ernst and Singh cite the experience of James Reston, who was reporting on Nixon’s 1973 Chinese visit as key for acupuncture’s introduction into the west.  Whilst in China he suffered from appendicitis and was treated by acupuncture, bringing news of his treatment and recovery home. Unlike Reston, Ernst and Singh are unconvinced.  They demolish positive papers published by the WHO as having included too many trials, some of which used poor methodology, and conclude that the science behind acupuncture is implausible and totally without evidence.  They finish by saying that Acupuncture has inconsistent evidence to suggest that it has a use in pain and nausea control.

If acupuncture gets une point, then Homeopathy, gets null.   This was the work of a German physician Samuel Hahnemann at the end of the 18th century.  Hahnemann correctly realised that he and his medical colleagues knew nothing about how to treat people, but he then moved away from the then conventional medicine and contrived to establish his own brand of treatment.  Having taken quinine one morning he found himself having the same symptoms as if he had malaria.  From this he extrapolated a universal principle ‘that which can produce a set of symptoms in a healthy individual can treat a sick individual who is manifesting a similar set of symptoms’.  Even better, he went on to say that the potency of a cure could be greatly enhanced by diluting them.  Not just a little bit either; some homeopathic remedies are at the sort of concentration you might expect from putting a teabag in lake Superior.  Singh and Ernst find this all highly improbable, and put any positive effects attributed to this brand of alternative medicine down, amongst other things, to the body’s ability to heal itself.

The founders of chiropractic therapy argue that ill health in the body is due to subluxations, slight misalignments of vertebrae in the spine.  These subluxations interfere with the flow of innate intelligence (a bit like Ch’i).  They are corrected by spinal manipulation, whereby the practitioner flexes of extends the neck beyond its normal range of movement.  There are some chiropractors called ‘mixers’, who are basically back specialists, however their ’straight’ colleagues believe that their techniques can cure the body of ills seemingly unconnected with the bony structures.

My attitude to all this would be: not to my neck you don’t buddy.  And according to Ernst and Singh rightly so.  There is some evidence that chiropractors have a place in treating back pain.  This is something with which conventional medicine has struggled.  However in its treatment, chiropractors and conventional medicine come out as a dead heat, and a pack of ibuprofen is 35p in Sainsburys whereas a course of Chiropractic treatment costs a great deal more than this.  As worrying is that it is reported in the book that it is not unusual for chiropractors to spinally manipulate patients without their consent on their first appointment, and furthermore that this spinal manipulation has lead to vertebral artery dissections and death in patients.

Before their finger pointing and conclusions and an interesting section entitled ‘Why do smart people believe such odd things?’ Singh and Ernst take as their fourth case study Herbal Medicine.  This is a more tricky area for them, as unlike their previous three methodologies, some herbal remedies, for example St John’s Wort, actually work.  Here the problems are more subtle.  Imagine this:  in order to get onto the shelf in your pharmacy a mainstream medicine has been exhaustively evaluated in a process costing millions of pounds and will have been produced in a sophisticated process whereby a manufacturer will be sure exactly of the contents of the drug they are selling you.  With a herbal remedy on the other hand, you may be getting something, covered in dirt, from someone’s back garden and they probably didn’t even wash their hands as they picked it.  There’s worse too, as herbal remedies can interact with conventional drugs with unpredictable consequences and if they are taken in preference to conventional medicines they won’t get you very far, as the authors tell us was discovered by several unfortunate, but trusting, cancer victims.  And beware, some herbal remedies are effective because they actually contain conventional medicines.

So whose fault is this?  Ernst and Singh propose that most alternative remedies trade on being more natural, traditional and holistic, three ideas they quickly dispatch.  Uranium is natural, bloodletting was traditional, and holistic medicine is not a preserve of alternative practitioners - GPs regularly give lifestyle advice. They go onto blame celebrities for endorsing alternative treatments, universities for providing alternative medicine courses to make money and thus legitimizing alternative approaches, the media for inaccurately reporting the benefits of alternative therapies and many doctors for prescribing alternative medicine to get difficult patients out of their consulting rooms.

There should be warning messages on alternative medical treatments like cigarettes they say, accurately reflecting the current evidence.  For Homeopathy this would read

Warning: this product is a placebo.  It will work only if you believe in homeopathy and only for certain conditions, such as pain and depression.  Even then it is not likely to be as powerful as orthodox drugs.  You may get fewer side effects, from this treatment, than from a drug, but you will probably get less benefit.

At the end of their book a further 36 alternative therapies are critiqued including colonic irrigation and ear candles - the latter of which I could tell you is bollocks just from the name.

So, having written a much longer review than I initially intended, is this book any good?  It’s certainly pretty thorough.  The first chapter about scientific method is very interesting, but the next four chapters wherein the authors examine acupuncture, Homeopathy, Chiropractic therapy and Herbal Medicine are interesting in a lot of places, but often come across as a bit dry.  This book may attempt too much aiming to be both an entertaining popular science book and one offering balanced medical advice to those seeking treatment.

Mark Bostridge has written a new biography of Florence Nightingale:

Florence Nightingale: a woman and her legend

Guardian review

It’s psychopathology time again, here on planet Frontier Psychiatrist.  It’s been in the family as my brother recently  attempted the Fourteen Peaks Challenge will testify.  This is his story:

‘In June 2008 my friends and me decided to attempt the 14 Peaks Challenge. This involves scaling all 14 peaks in Wales which are in excess of 3000 ft and is a very long walk, taking up to 24 hours to complete.

After driving up from London, our party started walking at about 2am.  By around 4pm the next day I was starting to experience some quite peculiar visual effects.  Every time I looked at a stone, I could immediately pick out an image of a face or the shape of an animal (typically a crocodile).  Whereas normally it would take a conscious effort to see a pattern in an inert object, the comparisons were coming to me thick and fast.  At one point I picked up a piece of quartz convinced that it had the shape of an ancient Egyptian head.

I gave up the walk at around 6pm, having not slept for around 36 hours.  My tougher companions pushed on and walked for another 10 hours.  Their visual hallucinations apparently became much more vivid than mine with objects becoming actual animals and not just resembling them.’

Depending on your bent in life, this either sounds pretty cool, or pretty scary.  Plenty of people pay good money for similar nights out.

Psychiatrists have spent a lot of time classifying abnormal experiences; psychopathology is the study of this.  This is a big subject, so I’m going to gloss over a few bits.

As human beings we have a number of senses and sense organs and the brain interprets the sensory input from these.  Thus, perception consists of two parts - sensation (visual, auditory, tactile, gustatory, olfactory, kinasthetic and proprioceptive) and interpretation (the cognitive element).

But things can go wrong:

1. The stimulus can be perceived as the corresponding object, but not accurately.  For example an object could be perceived as being the wrong size; this is called micropsia or macropsia.

2. The stimulus is perceived as an object, but not corresponding to the source.  That is to say, both the stimulus and object are present, but different from each other.  This is an illusion

3. There is no stimulus, but a perception occurs.  This is a hallucination. 

4. There is a stimulus, but no perception occurs.  This is a negative hallucination.

So, my brother wasn’t hallucinating, but was seeing an illusion.  There are three major types of illusions:

1. Affect illusions:  here the person’s emotional state leads to misperceptions - perhaps being scared leads to the incorrect interpretation of a shadow.

2. Pareidolia: here a person perceives formed objects from ambiguous stimuli, for example seeing Elvis’s head in a cloud. 

3. Completion illusion: here, due to inattention, an incomplete object is perceived as complete.  For example, CCOK might be read as COOK.

Hallucinations

Hallucinations have several important qualities.  They take place in the same space and at the same time as other real perceptions - this is different from a fantasy or imagery, which take place in subjective space, or a dream, which has no real component;  they are experienced as sensations and have all the qualities of a real object from which they are indistinguishable. They are involuntary, so unlike imagery, they are not under conscious control.

Hallucinations can occur in any modality and there are many different types:

Elementary hallucinations are the simplest kind and they are unstructured hallucinations and bear no relation to anything in the natural world.  An example of this is whirring noises in the auditory modality.  In the visual modality, a person with elementary hallucinations might see multicoloured spots.  

Auditory hallucinations often occur with psychiatric illness, and auditory hallucinations of voices are one of the first rank symptoms of schizophrenia.  Visual hallucinations on the other hand are much more common with organic illness and are very uncommon in schizophrenia.  Organic causes for hallucinations include occipital lobe tumours, post concussional states, hepatic failure and dementia.  

Elderly patients with normal consciousness and no brain pathology, but with reduced visual acuity due to ocular problems experience vivid, distinct formed hallucinations, often of men wearing hats.  This is called Charles Bonnet syndrome.  Lilliputian hallucinations involve seeing tiny people or animals.  These can occur with alcohol withdrawal.  

Other sorts of hallucinations: 

Autoscopic hallucinations are the experience of seeing oneself.  This is different from an ‘out of body’ experience, as with the latter the person sees the world and his own body from a vantage point that is other than his physical body.  In autoscopy, the person ‘remains’ in their own body.

Extracampine hallucinations occur outside the field of normal perception.  An example of this would be hearing someone discussing you down the shops which are a mile away.   

Functional Hallucinations is where an external stimulus provokes hallucination, but both hallucination and stimulus are in the same modality but individually perceived.  An example of this would be hearing a voice when the tap is running.  On the other hand, Reflex hallucinations are when hallucinations in one modality are provoked by a stimulus in another modality.  An example would be seeing a elf whenever listening to music.

Formication is a type of haptic hallucination where there is the sensation of animals crawling under the skin.  This is seen in cocaine intoxication.  A character in the beginning of the film ‘A Scanner Darkly’ has a similar problem.

NB:

A pseudohallucination is like a hallucination, but lacks the quality of a perception.  It is a form of vivid imagery.  If someone feels that they are hearing voices in their head, this is a pseudohallucination as it does not have the same qualities as a normal perception. 

Synaesthesia is the perceiving of a stimulus in one modality in a different modality, for example, ‘hearing’ the colour red.  This can happen on taking LSD

Hypnagogic and hypnopompic hallucinations are hallucinations on falling asleep and waking up, respectively.  They may be normal phenomena and are particularly seen in narcolepsy 

Further reading:

Symptoms of the Mind by Femi Oyebode (Buy from Waterstones Amazon)