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)

Kirstin Davis has been annoying me this morning.  The doctors’ on call room here is full of celebrity magazines; they’re always a few weeks old and these ones have a lot about the new Sex and the City movie.  Here are some of the headlines:

Now Magazine 26 May 2008

Kristin: ‘I’m a recovering alcoholic’

Q: You admitted to suffering from alcoholism in your twenties.  Is there any truth in the rumours that you relapsed and went back to rehab?
A: I haven’t had a drink for 20 years now.  I haven’t kept it a secret but people don’t really know about it*

{nb the other four headlines were Cynthia: ‘I’ll wed my lesbian lover’, SJP: ‘I’ll miss Carrie’ and Kim ‘My tomboy keeps me young’}

Reveal Magazine 24 - 30 May 2008

‘I’m not ashamed to be an alcoholic’

‘Her co-stars may be toasting the release of the new Sex and the city movie with champagne, but Kristin Davis won’t be joining them
The star, who plays Charlotte in the New York-based sitcom, hasn’t drunk alcohol in more than 20 years because she had a drink problem.
She says ‘I’m an alcoholic, but I haven’t kept it a secret.  I’ve been sober for a really long time now’

She certainly doesn’t look like an alcoholic to me.  Davis is 43, and since you can legally drink at 21 in the USA this didn’t provide her with much of a window of opportunity to get really stuck in.  Neither article gives us much in the way of details as to what Davis got up to whilst she was a boozing. 

Some more digging revealed this interview from the Guardian in 2002:

‘To the outside world, I was a good girl. But I drank a lot, which was rebellious because my parents didn’t drink at all. In the South, pretty much everybody drinks. There was always lots of alcohol, lots of access to alcohol, people sitting around every night with a Mint Julep, or whatever.’ …. At high school, it was just crazy. We’d all be behind the gym drinking, about 20 people passing around bourbon or whatever.’

Throughout our conversation, Davis has been sipping water, but she refuses my offer of wine: ‘No, I’ve been sober a long time.’ Did she end up having problems with alcohol? ‘Oh yes.’ I didn’t know that. ‘Not many people do. There’s this whole thing in America about talking about all your addictions and problems and I’m not really into that**. But it’s not like I want to keep it a secret either.’ What happened? ‘Oh, nothing that bad. I just realised that drinking was counterproductive to what I was trying to do. Acting is very difficult in weird ways. You’d have to get to class by 8am, work all day, rehearse all night, and it’s not really good to do when you’re hung over. I’d wanted to be an actress my whole life, that was my goal, that was all I cared about. Something had to go, so I chose drinking to go.’ Has it been difficult? ‘Oh yeah. Sometimes it would be nice to just have some red wine with dinner, but it’s not worth the risk. I have a great life, a great situation. Why would I want to risk self-destructive behaviour? Even though I might not, I might , do you know what I’m saying? You just never know.’

So, in summary Davis drank a lot whilst she was a rebellious student but then she realized that hangovers weren’t compatible with having a career and making something of yourself.  So she stopped.  Um, I did that too (without actually stopping mind).  Does that mean that I’m an alcoholic too?  ’Alcoholic’ is a poorly defined term, and this is where the confusion may lie.  But if by alcoholic Davis means ‘alcohol dependent’ she’s stretching it rather thin.  If a psychiatrist were to do this, this would be an example of criterion or diagnostic creep, where a previously well defined syndrome widens to include experiences that were previously thought to be a part of normal experience.  Has Davis actually seen a doctor, or is she a self-appointed recovering alcoholic?  PTSD is often accused of criterion creep and this can occur easily for psychiatric syndromes, where the aetiology is unknown. 

Why has Davis appropriated the language of psychiatry and addiction to explain her own reaction to what many people would consider a normal stage of many people’s lives?  Perhaps as a way to draw attention to herself, to explain other failings in her life about which we know nothing, or so that she may permanently have one foot in Parsons‘ sick role.  My esteemed colleague, on call with me today, ‘Dr Cynic’ is proposing that Davis is so boring that her alcoholic ploy is a way to spice herself up in the eyes of her public. 

For what it’s worth, ICD-10 requires that three of the following criteria be experienced or exhibited at some time during the last year for a diagnosis of dependence:

A strong desire or sense of compulsion to take the substance

Difficulties in controlling substance-taking behaviour in terms of its onset, termination, or levels of use

Physiological withdrawal state when substance use has ceased or been reduced, as evidenced by either of the following: the characteristic withdrawal syndrome for the substance or use of the same (or closely related) substance with the intention of relieving or avoiding withdrawal symptoms

Evidence of tolerance, such that increased doses of psychoactive substance are required to achieve effects originally produced by lower doses

Progressive neglect of alternative pleasures or interests because of psychoactive substance use and increased amount of time necessary to obtain or take the substance or to recover from its effects.

Persisting with substance use despite clear evidence of overly harmful consequences (physical or mental)

For an interesting account of the effect of alcohol and other drugs on society try the following two books by Griffith Edwards:

Matters of Substance - Why Everyone’s a User   Amazon  Waterstones

Alcohol: the World’s favourite drug

*It’s certainly out of the bag now - I don’t think that talking to NOW magazine is a very effective way of keeping a low profile on this one.

** So what are you doing talking about it here then?

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…

John Prescott has come out in the papers today as saying that he was suffering from bulimia nervosa whilst he was Deputy Prime Minister.

With two jags, an affair, some punches and a poorly timed croquet game and now a psychiatric illness, I’m impressed with how much mileage John Prescott has provided the red tops with other the past few years.  Bulimia is quite something for someone who was right at the top of the political pile to admit to.  Food’s a difficult thing - if you have a problem with it, eating too much or too little, you can’t just stay away from it.  And everywhere there are pictures of perfect bodies reproving you for not being just like them.   

Here’s a bit about eating disorders for the curious: 

The International Classification of diseases recognises a number of eating disorders, of which are two major flavours identified - anorexia nervosa (F50.0) and bulimina nervosa (F50.2).  If someone presents with a difficulty with their eating which doesn’t fit into either of these patterns then they are classified as having an eating disorder, unspecified (F50.9) 

Anorexia Nervosa is characterised by deliberate weight loss resulting from under-nutrition with associated with endocrine and metabolic disturbance. It occurs most commonly in adolescent girls and young women with males of the same age affected rarely.  For a definitive diagnosis:

• Body weight must be maintained at 15% below that expected
• weight loss is maintained by the avoidance of ‘fattening’ foods
• There need be body-image distortion, where dread of fatness persists as an intrusive overvalued idea. 
• Amenorrhoea (lack of periods) in women and loss of libido in men. 
• Delay or arrest of puberty.

In contrast bulimia nervosa is characterised by repeated bouts of overeating and an excessive preoccupation with the control of body weight.  The age and sex distribution is similar to AN, with the age of onset being slightly later.  Bulimic patients often have a history of anorexia nervosa.  For a definitive diagnosis:

• There is a persistent preoccupation with eating and a craving for food; the patient binges
• The patient attempts to counteract the ‘fattening’ effects of the food by vomiting, but could also attempt control by purgative abuse or use of appetite suppressants. 
• There is a morbid dread of fatness

There are two subtypes of BN - purging (with regular use of vomiting/laxatives etc.) and non purging (where compensating behaviours are exercise or fasting). 

Both these diseases are serious.  The death rate for suffers of AN is twelve times that of the general population, the worst of any psychiatric disorder.  Suicide rates for those with AN are two hundred times that of the general population.  The two conditions are also often associated with other psychiatric difficulties such as depression, personality disturbance and alcohol abuse. 

Given his age and presentation Mr Prescott’s case is atypical and and it will be interesting to read about it in his forthcoming biography (this can’t have done his sales any harm) 

Addenda

Here’s a Guardian article by Decca Aitkenhead about Prescott

NHSblogdoc is rather less charitable than I am

There’s an Israeli academic who is speculating that the Old Testament’s Moses may have been under the influence of psychadelic drugs at the time of his writing the 10 commandments.  Benny Shanon is a professor of cognitive psychology at the Hebrew University of Jerusalem, says that these formed an integral part of the religious rites of Israelites in biblical times.  The article is in the Time and Mind journal of philosophy (I can’t find a link for this)

Given how speculative this is, it’s hardly worthy of comment and it’s more likely been said to get a bit of publicity and piss off a few religious leaders.  More interesting is the articles in the press about which of our current and former world leaders have been fond of recreational substances. 

In no particular order:

Boris Yeltsin - Distilled in 1938 Most celebrated incident was his failure to disembark from a plane to meet Albert Reynolds in Shannon Airport

Winston Churchill - The Winston Churchill Centre maintains that he was not an alcoholic but ‘dependent’, two states between which to differentiate would require a very fine pair of scales.  Probably wins the prize for the most quoted about the benefits of alcohol.  Try to Bessie Braddock, socialist member of parliament

George W. Bush - the current president has been arrested for driving under the influence and there is also speculation about his other drug use

Bill Clinton - "When I was in England, I experimented with marijuana a time or two, and I didn’t like it. I didn’t inhale and never tried it again."  Also known for his fondness of cigars…

David Cameron - Not strictly a leader, but he has been pressed at times to come clean about his drug use in the past.  He has refused to do so. 

Anthony Eden - British Prime Minister Anthony Eden was prescribed Benzedrine an amphetamine following damage to his bile duct during a gallstone operation.  It is widely reported across the internet that he ‘lived on benzedrine’ during the Suez crisis, but I can find no citation for this. 

John F Kennedy - is now known to have suffered from adrenal insufficiency.  His medical records have been made public and have detailed his use of hydrocortisone, testosterone, codeine, methadone, Ritalin, antihistamines, anti-anxiety drugs, barbiturates, and regular injections of Procaine to ease his back. Kennedy is described as being in almost constant pain in his last years by some sources, which seems in conflict with stories of his sexual adventures.  This article also suggests the the President smoked cannabis and took LSD

Adolf Hitler - said to have received daily amphetamine injections from his personal physician. 

I’ve also written about the drug use of the current UK home secretary Jacqui Smith

How should we judge the behaviour of these men.  I would argue that if our leaders seek to leglisate against the public’s use of recreational drugs, then the hyprocrisy evident in their own use is very relevant, and cause for public interest.  We also have a right to be concerned if decisions being taken on our behalves are being taken by people who may be comprimized.  However maybe if we wish a great leader (I’m not counting Hitler here), we must appreciate that their greatness may come hand in hand with their flaws.

Here’s an interesting article on celebrity drug use.  If anyone has other examples of similar leaders please let me know.

I was interested to read an article in The Independent recently where psychologist Oliver James wrote that of comic peformers ‘most but not all - are either depressive or personality disordered’. 

James is a psychologist of some experience or, failing that, exposure.  Clearly it takes a particular sort of person to wish to earn their living by entertaining other people – and to subject themselves to the scrutiny this entails – but to make a blanket diagnosis of this nature cannot be right or fair.  Psychiatrists are often almost as guilty, it is a term often used in my by my colleagues to refer to patients or professionals we find difficult or do not like. 

Here’s an introduction to this difficult area.

Definitions

ICD-10 defines personality disorder as follows:

‘A severe disturbance in the character logical condition and behavioural tendencies of the individual, usually involving several areas of the personality, and nearly always associated with considerable personal and social disruption’

And DSM-IV:

‘an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment’

There are nine categories of ICD-10 personality disorder and ten of DSM-IV.  DSM-IV divides its personality disorder classifications into three ‘clusters’.

ICD-10 
(F60.) Specific personality disorders
(F60.0) Paranoid personality disorder
(F60.1) Schizoid personality disorder
(F60.2) Dissocial personality disorder
 (F60.3) Emotionally unstable personality disorder
 (F60.4) Histrionic personality disorder
(F60.5) Anankastic personality disorder
Obsessive-compulsive personality disorder
(F60.6) Anxious (avoidant) personality disorder
(F60.7) Dependent personality disorder
(F60.8) Other specific personality disorders 

DSM-IV
Cluster A (odd or eccentric disorders)
Paranoid personality disorder
Schizoid personality disorder
Schizotypal personality disorder

Cluster B (dramatic, emotional, or erratic disorders)
Antisocial personality disorder
Borderline personality disorder
Histrionic personality disorder
Narcissistic personality disorder

Cluster C (anxious or fearful disorders)
Avoidant personality disorder
Dependent personality disorder
Obsessive-compulsive personality disorder

Problems with the diagnosis

The diagnosis and treatment of people with personality disorder is one of the trickiest areas of psychiatric practice.  Although established as a diagnosis and enshrined in both the ICD-10 and DSM IV, there is not a consensus concerning to what extent behaviours of a negative social and moral value should be considered psychiatric disorders and as a diagnosis personality disorder has a number of problems. 

• There is no definitive definition of ‘personality’ to be disordered, and it is at best a semi-technical term.  Most definitions are based on personality being an enduring combination of traits that serve to characterize an individual’s thoughts feelings and actions which are relatively consistent over a range of situations.  Some people would argue that personality is not a stable entity, but varies with time and situation. 
• Few personality types would fit into a single category listed above.  With its three clusters, DSM-IV goes some way to address this.
• There is an instability between raters when trying to diagnose personality disorder - this occurs even when rating scales are used.
• There is a large overlap of the behaviour of people with personality disorders with those of ‘normal’ people.  ICD-10 and DSM-IV offer categorical diagnoses, whereas in fact personalities exist on a spectrum i.e. they are dimensional.
• It is a hard area to conduct research into, partly due to the changing definitions of personality disorder over time and changing emphasis on personality traits not asked about on entry to the study.
• There is a great deal of stigma attached to the diagnosis
• This diagnosis allows significant deviance from societal norms, such as conscientious objection to a social regime, to be classified as a mental disorder. There is concern that this will be used to justify treatment of political dissidents as though they were psychologically disturbed.

Prevalence

Problems aside, people fitting the criteria for personality disorders are very prevalent in society, between 7 and 13 per cent in the general population and of 20 to 30 per cent in general medical practice.  It is also believed that 40% psychiatric outpatients and 50% inpatients would qualify for a personality disorder diagnosis.   Personality disorders rarely present to services in isolation and are associated with a high co-morbidity frequently being associated with alterations of eating behaviour, alcohol and substance abuse, other mental disorders, antisocial behaviour, and sexual promiscuity.  When someone meeting the criteria for personality disorder presents to health services an in-patient length of stay is likely to be longer and costs higher.

What causes Personality disorder?

As with a lot of mental illnesses, the answer to this question is not clear and genetic and social factors have been implicated.  There is evidence for the involvement of difficult upbringing with people having suffered physical or sexual abuse being over represented in personality disordered people.  Behaviour problems in childhood are also implicated, including severe aggression, disobedience, and repeated temper tantrums.

Treatment

It was felt for a long time that people with personality disorders were not treatable. There has been a perception that people with difficult personality traits can change themselves if they really wish and that it is therefore their fault if they do not. We therefore tend to blame people who have a personality disorder.  The tide has turned somewhat these days, and people are engaging those with a diagnosis of personality disorder in a number of ways.  These include trials of drug treatment, for example for comorbid depression, psychotherapy including dialectical behavioural therapy and therapeutic communities.

What research has been conducted suggests that over 10-30 years the outcome for people with personality disorders is generally favourable, with two-thirds improved at follow up with milder residual symptoms.  The severity of symptoms decreases with age and only one quarter would retain a diagnosis of boarderline personality disorder age 50.  Whilst employment is fairly common, marriage rates are half the average and odds of having children one quarter. 

Paul Gascoigne detained under the mental health act 

Here’s a famous definition of delusion:

‘A belief held with unusual conviction that is unamenable to logic whose erroneousness is manifestly obvious to others’ - Jaspers (1959)

This came to mind the other day when I was reading about Mohamed Al Fayed’s peformance in court at the inquest into the death of Princess Diana.  Al Fayed spent time outlining the extent of the international conspiracy which had been involved her death and that of his son, stating that conspirators included Tony Blair, Robin Cook, MI5, MI6, the CIA, the French intelligence service and the French ambulance service, who drove to the hospital deliberately slowly so that she might die. 

This doesn’t strike me as very likely and this view appears to be shared by the inquiry’s coroner, who asked Mr Al Fayed: ‘Do you think that there is any possibility, however remote that your beliefs about conspiracies may be wrong and that the deaths of Dodi and Diana were in truth no more than a tragic accident?’

Fayed replied: ‘No way.  I am 100% certain’. 

I think this would count as ‘unusual conviction’.  In ICD-10, there is a diagnosis of ‘delusional disorder‘, which is defined by the presence of persistent, non bizarre, delusions.  A non-bizarre delusion is plausible; this is in contrast to a bizarre delusion which is not.  For instance a person who thinks that they are under survelliance by the security force may be delusional, but this does happen to a small number of people. This is non-bizarre; a person would hold a bizarre delusion if this had no chance of being true, for instance if they felt that there was a goat living on their head.  Delusions also need to be outside what is considered to be culturally accepted for instance, in isolation, some religious practices might be considered odd, but they are widely accepted and so not delusional. 

If you were to meet a person with a delusional disorder you might not notice anything obviously odd about them.  This is in contrast to someone who is suffering from a psychotic delusional disorder, when their behaviour may appear manifestly odd.  They are able to continue functioning normally, although may make some strange decisions based on their world view. 

Finally, sometimes people are labelled as being delusional, when in fact they are not.  This is called the Martha Mitchell Effect this is when a psychiatrist mistakes a patients perception of real events as delusional and misdiagnoses accordingly.  It is named after the wife of the attorney general in the Nixon administration who alleged that White House staff were engaged in illegal activities.  Her claims were attributed to mental illness, but the outcome of the Watergate scandal vindicated her. 

I’ve written a previous post about celebrity lives and why they predispose people towards problems with their mental health.  In it I mention Britney Spears, who has been regularly described in the press as ‘troubled’ for some time now.  Things took an altogether more serious turn when on Thursday she was taken to a psychiatric hospital under a 72-hour detention.  This was the second time she has been taken to hospital in recent weeks, the first was after she refused to relinquish her children  who were to be taken into the care of her ex-husband.  On this occasion, in a pantomime show some 30 cars trailed her ambulance, twelve of them belonging to the police.  By way of contrast, here in London it can take a week to get one police car to attend a section.

Recent news is that Ms Spears period of involuntary stay in hospital has been extended to 14 days.  Not that I have given it a great deal of thought, but I’d always considered that Spears’ problems were likely to be personality based, that is to say as the result of learned behaviour, rather than because of a serious mental illness.  Even if I am right, it appears that her problems have become much more severe than just throwing her toys around when someone refuses to pick out the blue M&Ms. 

Her behaviour certainly has been bizarre, Associated press report that

Since her breakup with Federline, Spears has been seen at public events in short skirts and without underwear, has shaved her head bald, run over a photographer’s foot with her car, left the scene of a fender bender, flogged another car with an umbrella and abandoned a car in traffic when it had a flat tire. Recently, she was seen sitting on a sidewalk, holding her pet dog and crying

elsewhere it is said that before she was admitted she had not slept for five days.

It’s impossible from this vantage point to know what’s wrong with Spears.  The diagnosis of mental illness requires a period of assessment and often is only settled with response to treatment.  Emma Forrest writing in the Guardian seems to have decided that she’s got bipolar disorder and writes an article sympathetic to Spears detailing her own experiences.  Biopolar has become quite a fashionable diagnosis these days - I’ve been toying with the idea of doing a survey where I ask people whether they think it’s okay to be bipolar now that Stephen Fry says that he has it. 

Let me finish on a confession: I’m more than a bit disgusted with myself for writing a post about Britney Spears when the best medicine for her is for us all to leave her alone.  But that won’t happen. 

Britney’s perfume still selling well - Britney and the Sweet Smell of Distress Laura Barton Guardian 25 February 2008

Lisa Appignanesi’s Out of Control Guardian 10 March 2008 - an excellent article discussing her mental health problems in the context of how differently she would have been treated were she a man.

Despite being very famous, Heath Ledger had somehow passed me by until a few weeks ago when I watched ‘Monster’s Ball’ and ‘Brokeback Mountain’ within a few weeks of each other.  It seems likely that his death was caused by an overdose of sleeping pills, either mistakenly or intentionally.  As a psychiatrist I was struck by something Ledger said in his last interview with Sarah Lyall, published in the Observer.

‘Last week, I probably slept an average of two hours a night,’ he said. ‘I couldn’t stop thinking. My body was exhausted and my mind was still going.’ One night, he took an Ambien sleeping pill, which didn’t work. He took a second one and fell into a stupor, only to wake up an hour later, his mind still racing

Obviously there’s not much to go on here, but I wonder if Ledger is suffering from hypomania, although I note that there is no mention of elevated mood in the article.  It is also worthy of note that Ledger had been flying between Manhattan and the UK, as he had been filming ‘The Imaginarium of Doctor Parnassus’ in London.  According to NICE guidelines, if a person has a predisposition towards bipolar disorder, relapses can be triggered by ‘night flying and flying across time zones, and routinely working excessively long hours, particularly for patients with a history of relapse related to poor sleep hygiene or irregular lifestyle’

There’s also been press speculation about Hedger’s history of drug use.  In 2006 he was the victim of a paparazzi sting operation during which time he was filmed admitting to smoking ‘five joints a day for twenty years’; in the background of the film were unidentified persons snorting what is presumably cocaine.  At the time the tape was not shown due to legal threats, but now Ledger is dead no such restriction aside, of course, from decency.