Stop press: celebrity says something sensible

I almost fell off my chair today whilst reading Scarlett Johansson’s article ‘Skinny’ in the Huffington post.  Appalled by tabloid stories that she had lost fifteen pounds in preparation for her role in Iron Man 2, Johansson hit back, and very sensibly and eloquently too, with no talk of the alien religions that so enamour some of her kinsmen:

Since dedicating myself to getting into “superhero shape,” several articles regarding my weight have been brought to my attention. Claims have been made that I’ve been on a strict workout routine regulated by co-stars, whipped into shape by trainers I’ve never met, eating sprouted grains I can’t pronounce and ultimately losing 14 pounds off my 5’3″ frame. Losing 14 pounds out of necessity in order to live a healthier life is a huge victory. I’m a petite person to begin with, so the idea of my losing this amount of weight is utter lunacy. If I were to lose 14 pounds, I’d have to part with both arms. And a foot. I’m frustrated with the irresponsibility of tabloid media who sell the public ideas about what we should look like and how we should get there.

Needless to say, right next to this article was a link for a posting for a magazine printing nude pictures of celebrities.  Please spread the word Miss Johansson, the world needs more people like you.

Update: I’ve been thinking about this (but mostly other people have been telling me) that although SJ may have written this article she still has a body shape that adheres to the Hollywood ideal and has also critically undermined her credibility by having appeared in Vanity Fair’s 2006 cover shoot which severely objectifies the female form .

What is mental illness, mental health, mental disorder?

A more difficult question to answer than one might think. As usual your definition depends on all or some of: your point of view, how deeply you wish to probe, how many people are sitting on your committee and how long you’ve got to write it before you break for lunch.

Before I get stuck in, it’s worth noting that the term ‘health’ is a non-exact term used loosely in everyday speech. Equally ‘mental health’, ‘mental illness’ and ‘mental disorder’ are used with an comparable lack of precision and the latter two most often interchangeably. In addition psychiatric health/illness/disorder are used synonymously with mental health/illness/disorder. A further problem with this concept is that there is no clear cut off point between mental disorder and mental health; indeed one person’s mental health, might be another’s mental disorder.

With this poverty of precision already built in, it is probably unfair to expect too much. For this posting I will be mostly using the phrase ‘mental disorder’. Whatever their definitions, common sense dictates that ‘mental health’ and ‘mental illness’ are at least related such that as one increases, the other decreases. There is no definition of mental disorder which is either entirely satisfactory or uniformly accepted.

For legal purposes, the UK’s Mental Health Act 2007 defines mental disorder succinctly and thusly:

‘Mental disorder’ means any disorder or disability of the mind (page 7)

It is clear here, even to the casual reader, is that there is a marked circularity to this statement. Verbose as ever the World Health Organisation makes the following submission:

Mental health can be conceptualized as a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.

Furthermore they state emphatically:

Mental health is more than the absence of mental disorders (read the rest)

Inspiration for the definition of mental disorder often comes from the world of general medicine. Whether or not a mental disorder can or should be considered in the same way as, say, a viral illness is a discussion for another day but it is a direction that modern psychiatry is wedded to. Looked at this way mental disorder can be:

An absence of mental health.
A stumbling block here is that health is at least as difficult to define as illness. Always willing to have a bash, the WHO have defined ‘health’ as ‘a state of complete physical, social and mental well-being and not merely an absence of disease or infirmity’.

A presence of significant psychopathology.
This is related to the definition ‘disease is what doctors treat’, in that psychopathology would be identified by a nominated professional (but with their own distinct gaze…). It is another rather circular argument which allows for expansion of the concept which it describes, as when treatments become available for a condition it is more likely to be considered a disease (think of depression).

Similar to defining mental disorder as the presence of psychopathology is the wish to define mental disorder as the ‘presence of suffering’. This defines the group of people most likely to consult doctors, or other health care professionals. However unlike the definition relying on psychopathology, it leaves out people with mental disorders whose main effect is not felt by the sufferer at the time, for example during the manic phase of bipolar disorder or schizophrenia without insight.

Finally depending on our agenda, we can also choose to define mental illness out of existence. Enter the philosopher and anti-psychiatrist Thomas Szasz who wished to define a disease purely in terms of its physical pathology. Since most mental disorders do not have any demonstrable physical pathology, they are by this yardstick not illnesses. Although not sunk, this view has come under considerable attack from research which suggests genetic and neurobiological processes are involved in the aetiology of mental illness.

Further reading:

There’s a chapters in this book
Clare AW (1997) in The Essentials of Postgraduate Psychiatry
and a section in
Shorter Oxford Textbook of Psychiatry

Also Wikipedia

I were hacked!

Sorry for anyone who came visiting and found something unexpected. It’s all over now, thanks Trev!

Jonestown Massacre

The PBS documentary Jonestown: the life and death of Peoples Temple

November 18 2008* marked the thirtieth anniversary of the Jonestown Massacre where over 900 followers of a cult led by the Reverend Jim Jones killed themselves at his behest in Jonestown in Guyana.

James Warren Jones was born in Indiana in 1931. It was here, during the 1950s, he started his own church, which was to become the ‘Peoples Temple’. In 1965, reportedly to protect its members against nuclear war, Jones moved the Peoples Temple to Northern California. This move eventually brought increased media scrutiny, and in 1977, with mounting accusations that Jones was illegally diverting the income of cult members for his own use, Jones and hundreds of his followers emigrated to Guyana and set up an agricultural commune, the narcissistic ‘Jonestown’.

The authors of Schizophrenia: a short introduction think that Jones was suffering from Schizophrenia:

Even more rarely a strong personality with psychotic delusions is able to impose them on a whole community. This seems to have been the case with the tragic ‘Jonestown massacre’

Jim Jones was the charismatic leader of a religious cult. He was almost certainly psychotic. He suffered from mysterious fainting spells, heeded advice from extraterrestrials, practised faith healing and experience visions of a nuclear holocaust. He lead his followers to a remote part of the jungle where they she up a community isolated from the rest of society. The community lived in fear of an unnamed enemy and destroyer who would descent upon them and kill them mercilessly.**

Rather than being devout, Jones was a communist and his interest in worship was to achieve social and political goals. With this in mind, it is not surprising that Jonestown was more reminiscent of a Stalinist state than a religious community, and Jones more megalomaniac Marxist than deranged religious leader. Preaching social equality, Jones had recruited mostly lower income African-Americans into his church, inviting them to become part of creating a utopia. They found a regime directly by North Korea of eight hours of work followed by a further eight of study. Witnesses report that they were instilled with a pervasive sense of being under attack. Just like during the worse days of the Cultural revolution members would turn each other in as potentially enemies to the common cause. No one was allowed to leave the settlement and beatings were administered to dissenters at group meetings.

Jones himself was reportedly obsessed with his personal safety, and recruited two Temple members to place themselves between himself and an assassin’s bullet, should the need arise. He is described as becoming increasingly paranoid through the 1970s aided, no doubt by abuse of LSD and marijuana as well as other drugs. At his post mortem, enough Phenobarbital was found in his body to kill someone who had not developed considerable tolerance. Jones was often noticed by his follower as having slurred speech which he put down to his nurse giving him the incorrect medication.

Jones would rehearse mass suicide in order to test his subjects’ loyalty. This presumably came in useful following the chain of events that started on November 14, 1978. On this day US Congressman Leo Ryan arrived in Guyana with a group of newsmen and relatives of Jonestown residents to conduct an unofficial investigation of alleged abuses of Temple members. Four days later, as Ryan’s party and 14 defectors prepared to leave from a nearby airstrip, Jones ordered the group assassinated. Ryan and four others were killed but when Jones learnt that others had escaped and would likely bring in Guyanese authorities, he commanded his followers to drink cyanide adulterated punch; Jones himself died of a gunshot wound in the head. Guyanese troops reached Jonestown the next day, and the Jonestown death toll was eventually placed at 913 (including 276 children).

Jones was clearly disturbed, but for my money rather than schizophrenia, I favour Jones suffering a schizotypal personality disorder, which is classed under F20-29 Schizophrenia, schizotypal and other delusional disorders in ICD-10. It seems unlikely to me that Jones would have been able to achieve the foundation of a church and ultimately that of a substantial settlement if he had been severely affected by schizophrenia, whereas People with schizotypal disorder whilst not have a full blown schizophrenia type picture can display odd beliefs, unusual perceptual experiences, suspiciousness and paranoid ideation. Under stress this can deteriorate into psychosis, which, with the tragic end of Jonestown would fit the picture.

Another interesting question is why nearly a thousand of Jones’s followers apparently allowed themselves to become part of a massive suicide pact. The Jonestown film suggests that there was a great deal of coercion involved in this, but by settling in Jonestown its inhabitants were self selected to be susceptible to Jones’s will and people whose utopia has just collapsed might be a desperate bunch. Jonestown’s inhabitants had been living in an atmosphere of paranoia the veracity of which appeared to be aptly illustrated by the visit of Congressman Ryan. Their worries, channelled through a disturbed but charismatic man, were ultimately fateful.

The Brian Jonestown Massacre – The Ballad of Jim Jones

PBS documentary website

A rather disturbing tape recording made as the Jonestown inhabitants debated whether to commit suicide

Jim Jones biography

Rt Rev. Tom Butler said something sensible about this on Radio 4 thought for the day 18 November 2008


*The day I started to write this post.

** These are the own two paragraphs on the subject, which leads to the suspicion that they didn’t give the matter in depth consideration.

Psychiatry book club: proposal

As I sat my exam on Tuesday, I’ve got a lot more time for this blog, and I would like to try an experiment in reader participation. Every month or so I’ll nominate a book which a few of us can read and then comment upon. A bit like a book club, but without the red wine or sexual tension.

Nothing too difficult, and obviously I’m very open to suggestions.

This month I thought that we could start with The Bell Jar by Sylvia Plath. I read this about ten years ago and loved it beyond reason; this was before I became a psychiatrist so I’m interested to know what I think of it now. In brief, it’s an autobiographical novel of a young woman who, about when about to break into the world of writing, has a mental breakdown. The real story is well known and Plath committed suicide a month after its publication.

It occurs to me that people might think that I’m doing this to encourage people to buy books through this site. Of course you can, but worldcat lets you know which libraries have a copy of the book near to you.

Christmas Psychiatry

Sorry I’ve not written anything for ages, I’ve been revising for MRCPsych paper 3, which seems to be taking all my time.  I’ll be back in the New Year!


Here are some mildly amusing psychiatry epigrams  shamelessly stolen from Therapist in a Box – a lightweight psychoanalytical stocking-filler.  Unpacking the context and tacit meanings of each of the below are posts in themselves – some other time perhaps.   That some of the below were said with serious intent is worthy of note.

‘A neurotic is man who builds a castle in the sky.  A psychotic is the man who lives in it.  A psychiatrist is the man who charges them both rent’ – Jerome Lawrence, playwright

‘If you talk to God, you are praying.  If God talks to you, you have schizophrenia’ – Thomas Szasz M.D. psychiatrist

‘The aim of psychoanalysis is to relieve people of their neurotic unhappiness so that they can be normally unhappy’ – Sigmund Freud

‘A Freudian slip is when you say one thing, but mean your mother’ – author unknown

‘Men will always be mad, and those that cure them are the maddest of them all’ – Voltaire

‘Show me a sane man and I will cure him for you’ – Carl Jung

‘The Statistics on sanity are that one out of every four Americans is suffering from some form of a mental illness.  Think of your three best friends.  If they are okay, then it’s you’ – Rita Mae Brown, American author and playwright

‘A psychiatrist asks a lot of expensive questions that your wife will ask for free’ – Joey Adams, American comedian author columist

‘There never was a genius without a tincture of madness’ – Aristotle

‘They called me mad, and I called them mad, and damn them, they outvoted me’ – Nathaniel Lee, English dramatist (on being consigned to a mental institution circa c.17)

Season’s greetings! FP

Frontier Psychiatrist is one year old

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.

Grand rounds and psychiatric diagnoses

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.


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.



Spurious precision: procedural validity of diagnostic assessment in psychotic disorders

Why has psychiatry become so dominant in mental health services?

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….