I started this blog just over a year ago. My brother had been going on at me for ages to start one to salve my frustrations about not being a journalist. I also I had an important job interview looming, having been banjaxed by the MMC fiasco, and thought that it would make a tasty morsel to throw to my interviewers. It’s called ‘Frontier Psychiatrist’ after a song by a band called the Avalanches, who shone both brightly and briefly.

I had the job interview in February and, dressed in a smart suit, I mentioned this blog whenever I could. It seemed to do the trick as the interviewing panel seemed both interested in blogging and – usefully - entirely clueless about it. When there was even a minute or two left at the end of my first panel when they asked me to enlighten them further.

I got the job, and decided to continue the blog with dreams of eventual web stardom. Alas I’m not Raj Persaud yet, but then neither is he. As well as a chance to write, it’s a useful repository for information, a chance to air ideas and most importantly an opportunity to convene with people interested in mental health, who are not necessarily healthcare professionals. It’s quite time consuming, as each post takes me about two to three hours to write. If you’re interested in starting one yourself to supplement your income I must warn you that, for me, the returns have been poor; thus far I’ve made £25.86 out of 24 Amazon referrals and $11.07 out of something called text link ads. That was almost enough to take my girlfriend out for dinner, but I went too, so in a way I’ve actually lost money.

It would be easy to imagine that writing a blog is a bit like leaving a lot of leaflets in your local town hall, and that comments are like people calling you about them, but blogging is more subtle than this and much richer for it. Via the blog analytics applications, it’s possible to know who is visiting the here and why (don’t worry, there are no names involved). For instance 22 people have visited Frontier Psychiatrist following typing in the keyword ‘penile dysmorphic disorder’ into a search engine. They however spent only an average of 12 seconds on the site so I fear they were generally disappointed. In fact a lot of folk with an interest in the male member have been straying onto the site since I mentioned Mister Mark and his extreme cock.

Other search terms have caught my eye include ‘can someone have neurosyphilis after only 2 years’, for whom I remain concerned, and I will never know if the person who searched for ‘pretty doctor called Ruth’ was ultimately successful in his or her quest. Thus far I’ve had 21,330 visits, of whom 76% left again without looking at anything else. This is known as the ‘bounce rate’ and I find the idea of it quite distressing. The average time spent on the site has been 1 minute 43 seconds and the most visits I’ve had on a single day was 289 for a post I wrote about all round nice guy Joseph Fritzl. Most people find me via search engines, but some are also ‘referred’ when they find me via other blogs.

Mentioning celebrities always causes a spike in readership (were I doing this in a calculated fashion this would be called SEO, or search engine optimization), although disappointingly few comments. I find getting comments very exciting and I’d encourage anyone who reads any of my posts to leave one. I try and reply to any that require a reply, but sometimes don’t have the time. There have only been two or three nasties – surprising considering how much some people hate psychiatrists. I could delete them where I so inclined, but leave them on as a right of reply

The highlights thus far have been and my getting included on a list of top mental health blogs and Rufus May replying to my criticisms of his TV programme ‘The doctor who hears voices’. The lowlights are all the spam comments I get everyday; they say things like ‘hot+sexy+young+dancing+chicks!’ In general, they are efficiently hoovered up by a clever bit of software, but sometimes one sneaks through.

A ‘grand round’ is a term used by doctors to describe a large meeting were doctors who work at the same institution get together and talk about doctory things. Mostly this involves a presentation of an interesting patient, with subsequent discussion. For the habitually parsimonious there is also an added incentive of a free lunch.

I won’t bore you with the fine details of grand round I attended today, but suffice it to say that it concerned a patient with a long psychiatric history who had had several admissions to psychiatric hospital. She had had a very difficult upbringing and, at various times, a pretty broad selection of psychopathology.

Following the presentation, there was a long discussion as to how best to formulate this patient’s problems and with this in mind, how she should be treated. There were five or so experts on hand, and the interesting thing was that they all drew different conclusions from the same information; there was, variously, an animated debate about the possible existence of a personality disorder, a stout defense of the presence of psychosis and suggestion of an affective disorder. One member of the panel, a chaplain but one of only two people in the room who had met the patient, didn’t think that the patient was mentally ill at all; he said this so politely that I didn’t realise at first.

It’s not unusual for a patient with a long term problem with his or her mental health to attract a selection of psychiatric diagnoses over the years. The odd one or two seem quite pleased about this, but I’m sure for most patients and their families this must be quite confusing. A psychiatric diagnosis is made by the elicitation of recognized psychiatric symptoms by (hopefully) a trained professional. There are no tests available and if the constellation of symptoms with which a patient presents changes (the so called ‘clinical picture’) then the diagnosis can also be altered. Diagnoses themselves are standardized in two publications, namely the ICD-10 and DSM-IV. These standards envisage the possibility of patients being given more than one diagnosis at the same time. Which leads to the interesting idea that more than one mental illness can exist in a single brain simultaneously.

That there are no tests, and that psychiatrists themselves find it difficult to agree about individual patients, has often brought into question the validity of psychiatric diagnoses. I will limit myself to two very interesting points here, one a study and one unfortunate woman.

Martha Mitchell, the unfortunate woman and after whom the Martha Mitchell effect was named, was the wife of the attorney general in Nixon’s government. She was considered to have a psychiatric disorder following her allegations of impropriety in Nixon’s government. She was right, and psychiatrists were wrong.

Around the same time as Watergate, in 1973, David Rosenhan conducted a study consisting of two parts. The first involved the use of ‘pseudopatients’ who briefly simulated auditory hallucinations in an attempt to gain admission to 12 different psychiatric hospitals in five different states in the United States. The second involved asking staff at a psychiatric hospital to detect non-existent ‘fake’ patients. In the first case hospital staff failed to detect a single pseudopatient, in the second the staff falsely identified large numbers of genuine patients as impostors.

So what are the use of psychiatric diagnoses at all? Paul and me have been having a polite discussion about this, and despite his making some good points I cannot see the whithering of the ICD-10 yet. Psychiatric diagnoses earn their keep by:

Enabling effective communication between professionals.

Helping avoid unacceptable variations in diagnostic practice.

And allowing more accurate discussion of treatment and prognosis.

But on the other hand they are reductionistic and stigmatizing.

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Top tip: if you’ve attended a grand round solely to get the free lunch, then make sure you sit near the door, as the doughnuts go quickly.

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Links

Spurious precision: procedural validity of diagnostic assessment in psychotic disorders

Frontier Psychiatrist has been on holiday. Back soon.

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.

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

Cognitive dissonance is a psychological theory which was first described by Leon Festinger and, simply put, is the state of having two cognitions (ideas) that are mutually inconsistent.  It is held that the state of cognitive dissonance is a very unpleasant one, characterised by psychological tension and discomfort.  The theory holds that we are as motivated to change our behaviour due to cognitive dissonance as we might be to act to reduce hunger. 

An example of this might be a person who has always been very opposed to extra-marital affairs.  If he or she found themselves having such an affair, this would be inconsistent with this attitude causing cognitive dissonance. At this point he or she would have two choices: stop the affair, or justify the affair.  We are more likely to change our attitudes and justify our behaviour, than alter our behaviour.  

This makes sense from an evolutionary point of view as we are programmed to develop a set of beliefs to guide our lives.  It is not beneficial to be so open minded that we would be constantly changing our minds as this would make swift action difficult.  To avoid cognitive dissonance in the first place we are programmed to have an in built confirmation bias; this is where we notice, seek and remember information that confirms what we already believe and disregard or minimize information that conflicts with our world view. 

For a gentle introduction on this subject listen to this clip on cognitive dissonance on the Today Programme 

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Frontier Psychiatrist has just returned from the Hay Festival and in retrospect I can see confirmation bias at work in my choices of speaker meetings.  I almost entirely went to see people with whom I knew I already agreed, and justified this to myself on the basis that their ideas would useful as a source of further ammunition when arguing on the rare occasions when I get invited to parties. 

The only real exception to this was Cherie Blair,  wife of the former British Prime Minister, for whom I had a free ticket.  She makes me feel conflicted, which is hardly surprising as she’s rather conflicted herself.  She hates the press, but she wishes to use it to have her side of the story told.  She protects her privacy vigorously, but divulges cringing personal details in her autobiography.   She calls this autobiography ‘Speaking for Myself’ as if, as a highly successful barrister, she’s such a victim that she’s never had the chance before.  She’s a socialist, but she owns three houses.  And she makes her problems with being the wife of a head of state so painfully obvious; she publishes a book called ‘The Goldfish Bowl’ about previous spouses in Number 10.   Psychoanalysing this woman is too easy.  She also gave a really boring speech.

Elsewhere: 

I was looking forward to seeing Gore Vidal, but he left me not just cold, but feeling soiled, such was his constant negativity.  He criticized John McCain for not attempting to escape from a Vietcong POW camp.  I don’t think that Vidal has any experience of such scrapes, so should hold counsel until he’s tried himself.  My brother asked him whether he had any ‘words of advice for young people‘.  ‘Grow up’ said Vidal.  Perhaps it’s too late to take his own advice.

Much smaller fry was Mark E. Smith of The Fall.  The interviewer was Jon Gower. I’ve never heard of him either.  Early on during the interview Smith accused Gower of not having read this autobiography.  Gower had to admit that he hadn’t finished it, but to show he’d read what he had carefully, asked the most in depth and convoluted questions, most of which were answered by Smith with a simple ‘yeah’ followed by tittering from the audience.  I spent most of the interview wanting to jump on the stage and wrestle the microphone away from him.  Every psychiatrist knows - the best way to get someone’s story is to ask open questions.  A breath test for Smith and full refund to the audience wouldn’t have been out of place either. That was my question about the security guards.

Christopher Hitchens did nothing to quash allegations of a drink problem by coming to the stage with a glass of wine.  Apart from his rudeness towards a audience questioner, which boarded on bullying, we were in complete agreement.  Further agreement but slight boredom accompanied talks by Naomi Klein and Joseph Stiglitz.  It’s not always a good idea to read the corresponding books before seeing a talk, as the speakers just regurgitate the same facts you’ve already read.  Will Self as ever didn’t disappoint.  My brother got further coverage in the press by asking him about his love of long and seldom used words.

For us the festival ended with Rob Brydon.  Oliver James says that he’s rarely met a comedian who’s not personality disordered or depressed.  I hope he’s wrong in Mr Brydon’s case, as he seems so very nice and so very amusing.  

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

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

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

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

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

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

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

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

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

Guardian article about NHS apologies

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

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

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

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

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

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

It’s not easy doing night shifts.  When I was a medical student I used to think that they were a bit cool - the doctor, all alone, there to deal with whatever comes their way.  A sort of intrepid traveller travelling through the medical twilight, with nothing but his sharpened wits to see him through. 

Alas, the reality is somewhat different.  Tired and bored, nights lead to a very real personality deterioration.  I become rude, intolerant and I steal other people’s food from the fridge.  Work comes in dribs and drabs, a drug chart to write up here and a new patient to clerk in there.  Then occasionally it goes ballistic and I have four patients to see in Accident and Emergency and eight jobs to do on the wards.  This gives me a headache. 

I can tell I’m tired when I start to think that the patients are being sick deliberately to piss me off; and that colleagues are giving me work simply to vex me.  It also drives me crazy when people call me to sort out something as an emergency but it’s actually been a problem for three days, but no one has bothered to do anything about it.  This happens all the time.

My bed is a sofa that is four feet long;  I am six feet long.  I’m not meant to sleep on it anyway. And there’s an appalling collection of videos that I cannot stop myself watching. 

Yesterday for instance I reacquainted myself with ‘Dirty Dancing’.