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

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

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

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

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

More reading:

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

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

Frontier Psychiatrist has just been on holiday to the Outer Hebrides.  Anyone who reads this blog will know that I am a devotee of theguardian newspaper.  I normally read this online, but as a holiday treat whilst on the Isle of Harris-North Uist ferry I was reading a printed copy.  A normally relaxed gentleman, upon reading this article by Pamela Stephenson Connolly I came close to leaving the comfort of the ferry cabin to go onto the deck and shake my fist at the waves.

Stephenson Connolly writes a column for theguardian’s G2 section on a regular basis as a sort of sexual agony aunt.  Here was this week’s question:

‘My boyfriend is an outgoing type, always the life of the party. Even when we’re alone he wants to joke around. I love him, and sex with him is satisfying when we finish what we start. However, when we’re making love he is easily distracted. It could be the sound of someone moving around in the next flat, or noise outside, but pretty soon he loses his erection. Is this normal? How can I keep his mind on the job?’

To which Stephenson Connolly, ‘a clinical psychologist and psychotherapist who specialises in treating sexual disorders’, replies:

‘It is "normal" - for someone whose brain is wired in such a way that paying attention to one thing at a time is challenging. Your boyfriend may have Attention Deficit Hyperactivity Disorder (ADHD), meaning that he has difficulty filtering out sounds and other stimuli that are competing for his attention.

Don’t take it personally.

You should suggest he be evaluated and treated for ADHD, while remembering that he is probably a bright and creative person, who could do with your help in staying on-task.

Imagine what it’s like to be inside his head. Think carefully about your lovemaking environment and create a place with a minimum of stimuli. Consider darkening the room, eliminating telephones and TV and even installing sound-proofing or using noise-cancelling headphones. If thoughts begin to distract him, encourage him to let you know so you can help to bring him back with your voice, touch or whatever else may work. You will need to experiment a bit. Praise and reward his efforts to stay focused - you will reap the benefits.’

Although she almost says something sensible at the end, it’s hard to believe that someone who claims the expertise of Stephenson Connolly could write something like this (budding psychiatrists, write down your own reasons for Stephenson Connolly’s idiocy and then read the rest of the article - if you can think of any that I don’t mention then please add a comment).

(Those not familiar with ADHD could read this before continuing)

Stephenson Connolly is suggesting a diagnosis of ADHD on extremely flimsy evidence even for a newspaper column.  She should know that ADHD diagnostic guidelines  suggest that symptoms applicable to this sort of diagnosis should be present in  more than one situation, for instance at home and at school.  Our man has his distractability in only one very specific situation.  She should also know that distractability, which is the only symptom mentioned in the ‘letter’, is far from the only symptoms shown by ADHD sufferers.  ‘Always joking around’ hardly counts; what about disinhibition in social relationships, recklessness in situations involving some danger, and flouting of social rules, to name but three?  ADHD can be diagnosed de novo in adulthood, but she should at least mention the possibility of childhood symptoms.

But let’s be charitable and assume that, although unlikely, ADHD is a possibility here.  It’s certainly a Zebra:

Zebra (noun): a very unlikely diagnosis where a more common disease would be more likely to cause a patient’s symptoms - from the common admonition that "if you hear hoofbeats, think horses, not zebras"

Is it not rather more likely that the reason that this man is unable to complete sex with his girlfriend because he isn’t very sexually interested in her in the first place?  Or maybe he’s homosexual?  Is not Stephenson Connolly guilty of grossly medicalizing what is in fact a social problem? Why bring in mental health at all?  

Sometimes after days spent sorting out my patients’ housing problems or imparting common sense where seemingly there is none, I sometimes wonder what psychiatrists are for - but here’s one of the reasons, stopping people who don’t know what they’re talking about, but have a shiny new textbook and an over zealous approach, giving patients potentially stigmatizing diagnostic labels on very limited evidence.
 

Further reading:

Adult attention-deficit hyperactivity disorder: recognition and treatment in general adult psychiatry Asherson et al BJP (2007) 190: 4-5