Crying on the inside

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.

Health Care Commission Report

 

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

Link to full report / much more digestible press release

Today programme discussion 0850 23 July 2008 

Frontier Psychiatrist digest:

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

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

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

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

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

There were further concerns about:

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

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

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

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

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

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

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

and 

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

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

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

General paralysis of the insane* and psychiatry’s only Nobel Prize

 

General paralysis of the insane, a syndrome of mental disorder and weakness occurring in tertiary syphilis, is also known as dementia paralytica, Bayle disease, parenchymal syphilis and symptomatic neurosyphilis.  It is a rare disease in western general adult psychiatry these days but, at the height of its powers, it is thought that it accounted for up to 20% of patients in asylums.  

In brief: syphilis is a chronic sexually transmitted disease, caused by the bacterium Treponema pallidum, resulting in the formation of lesions throughout the body.  As well as being sexually transmitted the infection can also be transmitted from mother to the developing fetus (congenital syphilis). 

The primary symptom is a hard ulcer (chancre) at the site of infection (i.e the penis or vagina) and this forms 2-4 weeks following exposure.  Secondary symptoms develop about two months after this infection and include fever, malaise general enlargement of lymph nodes and a faint red rash on the chest.  Then, after a period of time somewhere between some months to many years the disease enters its tertiary phase with widespread formation of tumour like masses (gummas).  These can cause serious damage to the heart or blood vessels (cardiovascular syphilis) or to the brain (neurosyphilis) resulting in tabes dorsalis, blindness and general paralysis of the insane. 

The onset of GPI is usually gradual with depression as the dominant symptom.  There is then a slowly progressive memory and intellectual impairment.  Frontal lobes are particularly involved, resulting in characteristic personality change with disinhibition, uncontrolled excitement and over activity which may be mistaken for hypomania.  Grandiose delusions are present in 10%.  Physically there is slurred speech, a tremor of the lips and tongue, and Argyll Robinson pupil** in 50%.  As the condition progresses there is increased leg weakness leading to spastic paralysis. Patients become completely incapacitated, bedridden, and die, the process taking about three to five years on average.

The first clearly identified examples of paresis among the insane were described in Paris after the Napoleonic wars and general paresis of the insane was first described as a distinct disease in 1822 by Antoine Laurent Jesse Bayle.  Originally, the cause was (charitably) believed to be an inherent weakness of character or constitution.  While Esmarch and Jessen had asserted as early as 1857 that syphilis caused general paresis, progress toward the general acceptance by the medical community of this idea was only accomplished later by Alfred Fournier. In 1913 all doubt about the syphilitic nature of paresis was finally eliminated when Noguchi and Moore demonstrated the syphillitic spirochaetes in the brains of paretics.

In 1927 Julius Wagner-Jauregg was given the first and only Nobel Prize awarded to a psychiatrist.  This was for work done in 1917 by which time he had been selflessly studying the the relationship between fever and psychosis 30 years.  Wagner-Jauregg had exposed three neurosyphilitic patients to malaria drawn from the blood of a wounded soldier.  The resulting high fever killed the syphilis spirochetes, leading to their recovery (the fate of the soldier is not recorded).  Given that there were few cures for anything in 1917, Wagner-Jauregg’s achievement was a milestone in psychiatric and medical science.  There was now a reliable, albeit risky, cure for neurosyphilis.

After WWII the use of penicillin to treat syphilis has made general paresis a rarity and now even patients manifesting early symptoms of actual general paresis are capable of full recovery with a course of penicillin. The disorder is now virtually unknown outside  third world countries, although it has been reported in western HIV sufferers.   I was recently told by someone who should know about these things, that it is no longer routine to test for syphilis in sufferers of dementia. 

If you can get hold of it Hare (1959) has written an interesting historical analysis

Trivia: 
Murderous Ugandan dictator Idi Amin is thought to have died from neurosyphilis

Also check out:
Tuskegee Syphilis Study – a clinical study, conducted between 1932 and 1972 in Tuskegee Alabama in which 399 poor and mostly illiterate African Americans were studied to observe the natural progression of the syphilis if left untreated.  Wikipedia page / List Universe: Top ten evil human experiments #3

 

* I’ve always thought this is an extremely evocative name for a disease (although I grant the use of the word ‘insane’ is archaic and potentially un-PC)

** non medics – these are known, rather tastelessly, as prostitute’s pupils as they accommodate, but don’t react (to light)… 

 

Cognitive dissonance or a psychiatrist at Hay

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 

*** 

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 BrydonOliver 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.  

The Power of Sorry

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

DNA

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. 

Night shifts – the time of my life

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’.

Psychiatrist vs. Psychologist

Judging by how often I’m asked this question, there is a lot of confusion out there about the differences between psychiatrists and psychologists. For a lot of people the two professions are synonymous.

There is overlap between the two roles, and both professions deal with a similar group of patients; we both work for the well being of patients who have problems concerning their mental health or behaviour (or both). There are however a large number of differences.

Firstly, psychologists and psychiatrists have different training. A psychiatrist goes to medical school and, in the UK , will have spent at least a year working in physical medicine. A psychologist starts their training with a psychology degree, going on to higher degrees and has no medical background.

This leads us to the really big difference: psychiatrists can prescribe medications for patients (as ever there are exceptions to this – nurses can take a prescribing course, but their remit would mostly be restricted to commonplace short term medication, for example night sedation) and psychologists do not. Psychiatrists therefore spend a lot of their time initiating and monitoring pharmaceutical treatments and assessing patients’ mental state in the light of this.

In contrast to the psychiatrists’ focus on medication as a treatment for mental illness, a psychologist’s approach focuses extensively on psychotherapy and treating emotional and mental suffering in patients with behavioral interventions. This might involve problem solving techniques or identifying and tackling dysfunctional behavioural patterns perhaps via psychological therapy such as CBT. Psychologists are also qualified to conduct psychological testing, which is important in assessing a person’s mental state and determining the most effective course of treatment.

One final difference is that psychiatrists are also involved in involuntarily detaining patients on psychiatric wards when it is felt that a patient is at risk to themselves and/or others and cannot be treated in the community; this is not part of psychologist’s remit.

So, as a simple example, let’s say that a person is referred to a mental health team because of severe anxiety. Their psychiatrist would consider prescribing them anti-anxiety medication. A psychologist will be more focused on behavioural intervention. This might involve CBT or, with a phobia, graded exposure.

People also mix up the role of psychiatrists and psychologists with that of psychotherapists/psychoanalysts. Again there is overlap between this profession and psychiatry – but it’s a story for another day.

Added 14 June 2008

Here’s what ‘Psychology: A Very Short Introduction’ has to say on the subject.

‘There are some fields with which psychology is frequently confused – and indeed there are good reasons for the confusion. First, psychology is not psychiatry. Psychiatry is a branch of medicine which specialises in helping people to overcome mental disorders. It therefore concentrates on what happens when things go wrong: on mental illness and mental distress. Psychologists also apply their skills in the clinic, but they are not medical doctors and combine with their focus on psychological problems and distress a wide knowledge of normal psychological processes and development. They are not usually able to prescribe drugs; rather they specialise in helping people to understand control or modify their thoughts or behaviour in order to reduce their suffering and distress’

Added 13 August 2008

And in 1980 under Mao psychology was condemned as being

‘90% useless’ and ‘10% distorted and bourgeois phoney science’

Source: Bond M.H. 1995 Beyond the Chinese Face: Insights from Psychology

Via Affluenza by Oliver James page 128

Added 25 December 2008 (that’s right – nothing on television)

From Madness Explained Richard Bentall pp. 3 quoting Medicine balls Too pp. 78-9

‘Rob Buckman, doctor and humourist has characterised the difference between psychologists and psychiatrists in the following way: ‘According to psychologists, a psychologist is a scientist how has trained in various aspects of experiment psychology, neuropsychology, operant conditioning and interpersonal dynamics, whereas a psychiatrist is a doctor who couldn’t keep up the payments on his stethoscope. Psychiatrists on the other hand tend to view the schism in a more allegorical style. Thus according to a very senior psychiatrist, ‘neurotics are people who build castles in the air, psychotics are people who live in them, while psychiatrists are people who charge the rent, and psychologists are like men from the council who come round once in a blue moon, talk incomprehensible crap and do damn all”

Added 19 August 2009

Another viewpoint from Guide to Psychology

Sectioning and the ‘Bournewood Gap’

I was seeing a patient the other day.  A fairly young bloke, he’d had a bit of stress at work, and subsequently what he’d called a nervous breakdown, and what I’d call an acute stress reaction.  He’d gone to this local A&E and had been seen by the psychiatrist on call and had spend a few days in hospital. 

The next thing he said struck me:

‘I didn’t think that I needed to come into hospital, but they told me that they thought that I did and if I didn’t come in voluntarily then they would think about making me come in’

This sort of thing happens all the time.  No one likes to bring a patient into hospital against their will (sectioning).  It doesn’t feel like a nice thing to do and psychiatrists like to think that they’re nice people.  A lot of patients would rather not be sectioned either, as this is seen as a very stigmatising thing by a lot of people you might meet.  So people come into the ward ‘informally’ i.e. not under section.

So, what’s the problem with that?  I’m not saying that all patients who are admitted to a psychiatric ward should be under section.  There is a place for informal admissions.  However if a patient is being informally admitted then a question should be asked: if this patient tries to leave will we let them?  If the answer to this is ‘no’ then a section should be considered. 

To my mind if an informal patient will be sectioned if they try to leave then they’re actually not there informally at all, but under a defacto section.  Worse still,  being under defacto section means that there is no legal protection; if you are on a section you are entitled by law to reviews of your status under the Mental Health Act, if you are an informal patient you receive no such protection. 

There have been similar, but not identical, concerns the context of patients with learning difficulties as a result of the Crown vs. HL. This case involved Bournewood Hospital in Surrey where the hospital’s authority to keep a person in hospital and give treatment, when they have neither actively consented nor refused, was challenged. 

Because of this case a situation where there is an issue of the rights of mental health inpatients who lack the capacity to make decisions for themselves and therefore cannot consent to their treatment has come to be known as the "Bournewood Gap".  Many such patients are given hospital treatment informally because they accept hospitalisation and treatment ‘compliantly’.  You can read more about the mental health charity Mind’s concerns about this here