When Howard Hughes died on April 5 1976, the state of his body compelled the FBI to resort to fingerprints for identification. Severely malnourished, he weighted 40kg and his hair, beard, fingernails and toenails had grown grossly long. X-rays revealed broken-off hypodermic needles still embedded in his arms.

A strange way for one of the world’s richest man to go, and not what Hugh Hefner has in mind. During his life, Howard was known as a film maker, industrialist, and aviator. At various points in his life he owned an international and two regional airlines, a major motion picture studio, mining properties, a tool company, gambling casinos in Las Vegas, a medical research institute, a vast amount of real estate; had built and flown the world’s largest airplane; and had produced and directed the movie ‘Hell’s Angels’ – a Hollywood film classic. However it is perhaps for the psychiatric disorder of his final years that he is best known.

His father was the wildcatter Howard Robard Hughes, his mother the Dallas heiress Allene Gano. When Hughes was four years old, his father patented a rotary drill bit able to penetrate thick rock, which revolutionizing oil drilling. He shrewdly decided to commercialize this himself thereby creating start-up capital for Howard Jr’s subsequent vast empire. Howard Jr. showed engineering ability himself, setting up Houston’s first wireless broadcast system when he was eleven years old.

Hughes’ early life was shaped by his mother doting on him with excessive concern about his health, his teeth and his bowels. Hughes appears to have been introverted from an early age, characteristics that were exacerbated by this mother’s worries. She is said to have disapproved of the young Hughes making friends in the belief that other people were disease carriers, thereby giving him an excuse to escape social pressures. When Howard wanted to attend summer camp his parents requested assurances that their son would be protected from contracting polio. When this was not forthcoming, it was decided to keep him home. After attending camp another summer, Hughes avoided the next year’s camp by complaining about headaches and bad dreams. Later, on the verge of adolescence, Howard became ill and was kept out of school for almost a year. He developed a form of paralysis which disappeared several months later

When Hughes was 16 his mother died during surgery, his father died two years later. As a result, at the age of eighteen, Hughes took control of his father’s company. Soon afterwards he became enamoured with the motion picture industry and moved to Los Angeles.

Hughes was married for the first time in 1925 to Ella Rice, a Houston socialite. By 1927 this marriage was failing, no doubt in part as he kept her at home isolated for weeks at a time. Following this he was linked romantically variously to Jean Harlow, Bette Davis, Katharine Hepburn, Ava Gardner, Jane Greer, Lana Turner, Rita Hayworth and Janet Leigh; there were also rumours of homosexual affairs, but evidence for this is equivocal.

Hughes wrote and directed ‘Hells Angels’, a film about First World War RAF pilots, in 1930 and during this production he cemented a lifelong passion for aviation. By the 1940s Hughes’ obsessive tendencies were becoming apparent and during the production of ‘The Outlaw’, which featured the barely covered breasts of its star Jane Russell, Hughes was obsessed with a minor flaw in one of Russell’s blouses, and wrote a detailed memorandum on how to fix the problem. He contended that fabric bunched up two seams, giving the distressing appearance of two nipples on each of Russell’s breasts. To remedy this he designed a complicated cantilevered bra; Russell never wore it.

During the last thirty years of Hughes’ life, his story becomes more incredible and his behaviour more erratic and bizzare. In 1946, while test-piloting the XF-11 photo reconnaissance plane, Hughes crashed the in Beverly Hills and wasn’t expected to live. The multiple fractures he sustained lead to the liberal administration of morphine and the beginning of a lifelong addiction to opiates.

In 1952 Hughes purchased RKO Studios and immediately cut the staff there from 2,500 to 600. His management over the next two years, which involved shutting down productions for weeks at a time to try to control dust, or to check the staff’s credentials to sift out communists, eventually lead to the studio’s downfall in 1955. In 1957 he married Jean Peters, who was 22 years younger than him. Their marriage lasted until 1971. During this time he was probably a bigamist as following his death his estate came to an out of court settlement with Terry Moore who claimed to have married him in 1949.

In 1966 Hughes became one of the richest men in the world when he was forced to sell his shares in TWA making him $547 million. In the same year Hughes and Peters moved to Las Vegas, although by this time, due to Hughes’ phobias, they tended to communicate by notes rather than by meeting. On arrival in the city, having reserved the top two storeys of the Desert Inn for 10 days, Hughes then refused to leave. The matter was finally resolved by Hughes buying the hotel for twice its valuation price.

In 1968 Hughes was still living in the Desert Inn, where he is reported to have seldom slept, instead spending the night watching old movies. Occasionally, he would nod off and missed parts of the film being screened. In the age before video recorders, he bought the Las Vegas KLAS-TV so that he could have the chunks he had missed rebroadcast.

Towards the end of this life, Hughes’ business holdings were overseen by a small panel dubbed ‘The Mormon Mafia’ because of the many Latter-day Saints on the committee. Although Hughes was not a member of the church, he considered them trustworthy. In addition to supervising day-to-day business operations and Hughes’ health, they also went to great pains to satisfy Hughes’ every whim. Remaining financially canny, Hughes moved hotels every 180 days to avoid personal income tax and during a visit to London Hughes Hughes fractured his hip during a nocturnal bathroom run. He refused to accept specialist advice that he exercise to get better, instead opting to remain bedridden, which led to his living in increasing squalor and filth.

Several doctors were kept in the house, but Hughes rarely saw them and usually refused to follow their advice; likewise despite having a barber on call he only had his nails cut once a year. In 1976 a 70-year-old Hughes, who had already been in a coma for three days, died at 1.27pm, en route by private jet from Acapulco in Mexico to a hospital in Houston. The official cause of death was chronic kidney disease, but it is just as likely to have been from dehydration, malnutrition and neglect.

Much of the strange behaviour that Hughes demonstrated in later life is attributed by some biographers to tertiary stage syphilis. This strikes me as rather unlikely. It very possible that brain injuries caused by numerous air crashes also played a part. Any psychiatric formulation would have to consider the possibilities of some or all of a severe obsessive compulsive disorder, a personality which was allowed to deteriorate due to the indulgence of his acolytes, dementia, and schizophrenia. It is clear that there was a failure of proper care towards the end of Hughes’ life, no doubt caused in part because of the great power he wielded in spite of his psychological incapacity.

Sources for this posting:

Channel 4 Howard Hughes a chronology

Howard Hughes psychological autopsy

Wikipedia

BBC ‘on this day’ death of Howard Hughes

Howard Hughes biography

Another biography

Although psychiatrists cannot claim to ‘run’ mental health services, as things stand they take ultimate responsibility for the individual care of most patients in the mental health system. But good practice in mental health care involves more than just psychiatrists, and other professions such as psychologists and mental health nurses, could also make a valid claim to be in charge of patient care.*

The status of doctors in the treatment of mental health is actually historic. At the time of the establishment of asylums there were no effective treatments on offer for psychiatric disorders so doctors’ medical qualifications were irrelevant. However doctors’ social standing and accountability meant it was felt that they would be effective guardians of against abuse of patients.

One argument for the continuing prominence of psychiatry is the overlap between mental and physical diseases. For instance, thyroid problems can mimic depression and the argument runs that a psychiatrist should be on hand to identify these instances. This argument is not especially solid, as although physical problems are occasionally picked up by psychiatrists, general practitioners should sift these problems out before referring to psychiatrists.

A second argument is that ‘medical model’ of psychiatry is successful at treating mental illness. This is not just simply prescribing drugs for patients, as this could be done by doctors without their current status, but also that a doctor brings to the table a pragmatic approach to the treatment of patients that draws on scientific method. Although the medical model is much maligned, as being too narrow and too dominant, it also entails a benign paternalism and a willingness to accept responsibility, which some, but of course not all, in their time of sickness may welcome.

Consultation by a doctor is often valued by patients and staff alike despite the fact that a lot of patients are seen by psychiatrists do not have problems related to anything that could be characterized as an ‘illness’. Why this should be so has societal roots beyond the scope of this piece. It has not been unusual for me to be asked to give a ‘doctor’s opinion’ on matters of importance when there is no obvious reason for why I should be qualified to do this, except a willingness to stick my neck out. When working in the community I have often felt that, as many people with mental health problems often have very unsatisfactory social situations, patients would be better off seeing a social worker once a month who could then refer onto me if necessary rather than the current situation which is the other way around.

* I am aware the situation is more nuanced than this paragraph portrays. In a CMHT, many patients will go nowhere near a psychiatrist; furthermore the new mental health act contains provision for other professions to become patient RMOs.

Someone who doesn’t agree with this post….

You recall perhaps a post I wrote on Oliver James and the article he wrote following the news of the end of John Cleese’s marriage. In it he said:

‘Most – but not all [comedians] – are either depressive or suffer from personality disorders … having done in-depth TV interviews with seven leading comics and having met many others, I feel that it must be acknowledged that misery is a necessary condition for great humour in the vast majority of cases.

I’ve just been reading The Naked Jape by comedian Jimmy Carr and Lucy Greeves. I’m not going to review it for this site, but it is an interesting and thoughtful discussion of jokes, jokers and their societal context. In the book Carr and Greeves discuss the ’sad clown stereotype’ and basically disagree with it. They quote a 1992 study by psychologist James Rotton which found that comedians were actually no more prone to suicidal depression than any other group.

Assuming that we buy the line that childhood trauma or hardship can, in some cases, spur individuals on to high-profile achievements, it’s not surprising that many successful and famous jokers have less than Walton-esque family backgrounds. But would you find any fewer damaged individuals if you were to look at rock musicians, or actors, or any other deeply competitive profession where the stakes are high, your personality is exposed to harsh public criticism and you have a bit too much time on your hands?

Apparently the Rotton study also compared the longevity of comedians with that of other entertainers and non-entertainers. The entertainers died younger, but there was no difference between the life expectancy of a comedian and any other sorts of entertainers.

I’ve been searching for this paper (the book gives no reference) and can’t find it on either pubmed.org or Google scholar so I don’t know how robust it is (I’ve emailed the publishers). We can poke holes in both viewpoints. James has anecdote on his side and also personal experience, and in interviewing leading comics he essentially presents case studies. But it is a big leap that the comedians he has met, who are themselves self selecting, represent leading comedians in general. Carr and Greeves present evidence to the contrary, but commit the heinous sin of not referencing their work, which makes it difficult to research the basis of their assertions. You could argue that Carr, as a professional comedian, is not an impartial researcher. Indeed, there is at least one skeleton in his cupboard.

Beating stress, anxiety and depression by Jane Plant and Janet Stephenson

Previous posting on this book

This is a self help guide for people with anxiety and depression which grandly purports to offer ‘ground-breaking ways to make you feel better’. Its authors Plant, a professor in earth sciences, and Stephenson, a psychologist, have both had problems with their mental health and are keen to share their insights.

It’s a strange journey, with very broad subject matter, so much so that every chapter rightly requires a critique of its own. The book is at once curious display of scientific partisanship - once their personal stories are over, Plant and Stephenson dive into a detailed account of how mood disorders can be localized to particular parts of the brain a contentious assertion – coupled with a paean to alternative therapies. Later on, like two meddling aunts, the authors turn their attentions to UK housing policy and their dislike of ‘so called intellectuals’ who have the gall to suggest that God is a delusion.

In all this, psychiatrists are only worth consulting if they also have a qualification in neurology and are willing make available functional MRI scanning to their patients. Antidepressants are equally acceptable, but only in conjunction with laboratory tests, undertaken in private laboratories, which inform which neurotransmitters are lacking in the brain. If only clinics were so simple, and the research in this area so concrete. There are long sections on ECT and neurosurgery, the latter of which I can only imagine is included in the book specifically to scare people.

Following this mad scientist part of the book, Plant and Stephenson put on their hair shirts. There’s much talk of detoxing, which includes staying away from cut flowers, homeopathy and biofeedback, all presented as if scientific certainties rather than highly contentious and based on questionable studies. Indeed often when flicking to the references the source is not a peer-reviewed paper from a major journal, but a book, or even a newspaper article.

To be fair, there is quite a lot of sensible advice on lifestyle, and a reasonable account of psychological therapies. For a book which is somewhat hostile to conventional medicine, no consideration is given to encouraging a patient to consider their problems using a non-mental health framework. Indeed the orthodox mental health classification system is not just accepted, but expanded with an assertion that post traumatic stress disorder can be caused by a difficult relationship split. Not recommended

Book review full disclosure page

Affluenza by Oliver James

Observing that there is an inverse correlation between the psychological health of a population and the magnitude of the gulf between its highest and lowest paid, television psychologist Oliver James contends that many people living in the western world have been infected by the ‘Affluenza virus’. This virus is a set of values that leaves us at increased risk of emotional distress and entails placing a high value on acquiring money and possessions, looking good in the eyes of others and wanting to be famous.

To prove his point, James sets out on a quest across industrialized nations, whereupon he is disgusted by the unrestricted greed of a New York banker, and then bats away tears engendered by the purity of the Nigerian taxi driver who drives him home. After America he seeks out equally polarized people in Russia, Singapore and Australia. Global infection proven, James then seeks to construct us ‘vaccines’ against our temptations and finally demands our genuflection as he bestows on us a ‘blunt unsparing statement of what needs to change’.

‘Affluenza’ is then part travelogue, part psychological profile and part self-help guide. I don’t disagree with the, rather unoriginal, central premise but the problem is that this is a dull, turgid and overlong book. ‘Affluenza’ is a great title, but the neatness of this neologism is restrictive, as the analogy with a virus is actually very limited, necessitating tedious semantic work-arounds whereby people are, for instance, pardoned if they have ‘virus goals’ without the dreaded ‘virus motives’. James also stretches indulgence by referring to ‘Affluenza’ throughout as if this rhetorical construct had an independent life of its own beyond his work.

His ‘vaccines’ are banal, such as ‘consume what you need, (not what advertisers want you to want)’, and the insights of this book do not justify its 500 page length. In the final gloves off section, James contends that 75% of us require dynamic psychotherapy to examine our childhoods, an experience which seems to have failed to improve the psychological health of the rich New Yorkers he happily disparages earlier in the book.

It’s not entirely without merit; James’s strength is in psychological analysis and he does provide some neat interpretations of the behaviour of his subjects. But within the book’s sweeping scope, encompassing all of modernity, he fails in bringing convincing analysis to the societies over whom he places his microscope, the problems of whom are as much to do with barely examined gender-politics and socio-economics as psychology.

Affluenza reviewed in The Times

More Oliver James: A psychological diagnosis of the banking crisis theguardian 18 September 2008. I don’t wish to turn this site into a OliverJameswatch site, but I don’t think that you can categorize the failure of government to regulate banks effectively as evidence of psychopathology in our leader and members of his cabinet. The current crisis is the result of a complex and widely based web of motivations, the identifications of the origins of which need not draw on the language of mental disorders.

Book review full disclosure page

Brainwash – the secret history of mind control by Dominic Streatfield

Following the Soviet show trials of the 1940s and early 1950s, during which prisoners had apparently become powerless to resist interrogation, American and British intelligence embarked on a remarkable search to harness, for their own ends, the powers of psychotropic drugs and disorientating interrogation techniques. They hoped the use of their discoveries on their own and enemy operatives would gain them advantage in a psychological arms war.

Dominic Streatfield’s book on the subject is amusing and tragic in equal measures. Unburdened by consideration of the moral and ethical morass into which they were casting themselves, and in the name of security, agents drugged the unwitting with sodium amytal, killed an elephant with a dart containing a massive dose of LSD and tried out violent hypnosis techniques on unwilling subjects.

Psychiatry doesn’t emerge well and many of the techniques are referred to as belonging to ‘Black Psychiatry’. In the USA psychiatrist Dr Ewen Cameron formed the opinion that his psychiatric patients would fare best if their personalities were wiped clean by ECT and sensory depravation; an objective shared for different reasons by the CIA, who funded his research. In the UK Dr William Sargent, who work for MI6, believed that modified narcosis, where patients were put to sleep with barbiturates for months at a time, was an effective treatment for mental disorder.

Streatfield himself should be shot if he failed to make an interesting book out of such rich material and he guides us through events entertainingly. Curiously he devotes little space to our current preoccupation with recruitment to fanaticism, but does give space to the coercion techniques used to recruit and perpetuate membership of religious cults.

In the end the effectiveness of ‘Brainwashing’, is illustrated by the fate of Yuri Nosenko, who died last week. A would be Soviet defector, he was imprisoned whilst his American interrogators threw every mind-warping technique they had at him in order to extract any information he might have possessed concerning the suspected Soviet involvement with JFK’s murder. Three years later they were still no closer to the truth.

Book review full disclosure page

Here’s a line from The Dark Knight script written by Christopher Nolan and David Goyer. To set the scene, good guy Harvey Dent has one of the Joker’s henchmen and is roughing him up. The Batman appears and suggests that he might like to act more responsibly (’You’re the symbol of hope I could never be’ etc). During this exchange Batman reflects upon the mental health of the Joker’s man:

His name’s Shiff, Thomas. He’s a paranoid schizophrenic, a former patient at Arkham. The kind of man the joker attracts script page 82

This sort of casual unthinking prejudice and stigmatization I cannot let pass without comment. Someone who suffers from schizophrenia is a not simply a ’schizophrenic’ but a person. Although many people suffering from schizophrenia, as well as other disorders of mental health, are vulnerable, it does not follow that they would be easily perverted in this way. You may think that I am being needlessly pedantic, but this has been an extremely popular film and this scene will influence many people’s perceptions of what it is to have a serious mental illness.

Stigma has been found to be highly prevalent among people with a serious mental health problem living in the community. Due to exchanges like the above both former psychiatric patients and members of the general population internalise negative cultural conceptions and attitudes about people who have been diagnosed with a mental illness. This results in discrimination, leading to to people who have been labelled mentally ill being denied important life opportunities. For example, people with mental illness are frequently unable to obtain good jobs or find suitable housing because of the attitudes of key members of their community such as employers and landlords.

As a result, many psychiatric patients form a negative self-concept emerges from both their primary disorder and from the cumulative reaction of others. Social rejection is an ongoing and recursive experience in the community setting and a persistent form of social stress.

More reading:

How stigma interferes with mental health care Patrick Corrigan American Psychologist 2004

4th International stigma conference - 21 - 23 January 2009 IoP London -  looks interesting if you’ve got £260 to spare

I did swear to myself recently that I wouldn’t write any more posts about celebrities and their mental health problems, but then David Duchovny started saying he’s a sex addict and I have a problem with this.

The word ‘addiction’ hasn’t an exact or agreed definition either within common or medical usage, but is normally applied to the use of psychoactive substances, and, called dependence syndrome; its use in psychiatry implies:

A cluster of psychological, behavioural and cognitive phenomena in which the use of a substance or a class of substances takes on a much higher priority for a given individual than other behaviours which once had a greater value.

For the diagnosis to be robust there needs to be accompanying evidence of difficulties in controlling behaviour despite clear evidence of consequences, and increased tolerance to the substance, a withdrawal syndrome and progressive neglect of alternative pleasures. A good example would be someone who is dependent upon alcohol; you can readily observe the effects, a complete deterioration of self control in pursuit of drunkenness, on a street near you.

An obsession with sex shares few of these characteristics, and its classification as a disorder offers a comforting cushion for those whose behaviour has landed them into trouble. With this narrative, wherein greedy behaviour is rebranded as a disorder, the afflicted can neatly sidestep responsibility and jump straight into the sick role.

Regrettably the more this line is trotted out by popular press, supported by some psychiatrist and psychologists, the more the approach is normalized and what develops is a popular narrative and language for describing behaviour in pseudo-medical terms that which would once have been viewed as an issue of self control and personal failing.

Wikipedia page

BBC Magazine - Does sex addiction exist?

Addictions.co.uk (sponsored by the Priory)