“What is Schizophrenia?”

Someone asked me this at a party recently. It’s a difficult question to answer in a single sentence.

For a start, schizophrenia is not a single disorder. According to the ICD-10 it is a group of disorders, classified under F20 in a chapter called ‘Schizophrenia, schizotypal and delusional disorders’.

F20 is split into the following sub-classifications:

F20.0 Paranoid schizophrenia

F20.1 Hebephrenic schizophrenic schizophrenia

F20.2 Catatonic schizophrenic schizophrenia

F20.3 Undifferentiated schizophrenia

F20.4 Post-schizophrenia depression

F20.5 Residual schizophrenia

F20.6 Simple schizophrenia

F20.8 Other schizophrenia

F20.9 Schizophrenia, unspecified

(I can’t immediately find out what happened to F20.7 – maybe it suffered the same fate as floor number 13 in New York skyscrapers)

The aetiology of schizophrenia is unknown; as this is the case we are forced to define schizophrenia on the basis of a number of symptoms which appear together sufficiently frequently to merit a grouping. In this way schizophrenia is a syndrome rather than a disease. A disease is a disorder with a specific cause and recognizable signs and symptoms whereas a syndrome is combination of signs and/or symptoms that form a distinct clinical picture. The ICD-10 classification system deliberately avoids including aetiology in its definition.

Schizophrenia is a disorder which covers a wide range of cognitive, emotional and behavioural disturbances; there is disintegration in the process of thinking, of contact with reality and a pattern of emotional unresponsiveness.

ICD-10 puts it nicely:

The schizophrenia disorders are characterized in general by fundamental and characteristic distortions of thinking and perception and by inappropriate or blunted affect.

There is no one sign that ‘guarantees’ a diagnosis of schizophrenia. For instance many of the characteristic symptoms of schizophrenia can occur during a manic phase of bipolar disorder or during psychotic depression. However the following ‘fundamental and characteristic disorders of thinking and perception’ are considered to have special importance in the diagnosis of schizophrenia. They are based on Schneider’s first rank symptoms, proposed in 1959 and are:

a) thought echo, thought insertion or withdrawal, and thought broadcasting;

(b) delusions of control, influence, or passivity, clearly referred to body or limb movements or specific thoughts, actions, or sensations; delusional perception;

(c) hallucinatory voices giving a running commentary on the patient’s behaviour, or discussing the patient among themselves, or other types of hallucinatory voices coming from some part of the body;

(d) persistent delusions of other kinds that are culturally inappropriate and completely impossible, such as religious or political identity, or superhuman powers and abilities (e.g. being able to control the weather, or being in communication with aliens from another world);

(e) persistent hallucinations in any modality, when accompanied either by fleeting or half-formed delusions without clear affective content, or by persistent over-valued ideas, or when occurring every day for weeks or months on end;

(f) breaks or interpolations in the train of thought, resulting in incoherence or irrelevant speech, or neologisms;

(g) catatonic behaviour, such as excitement, posturing, or waxy flexibility, negativism, mutism, and stupor;

(h) “negative” symptoms such as marked apathy, paucity of speech, and blunting or incongruity of emotional responses, usually resulting in social withdrawal and lowering of social performance; it must be clear that these are not due to depression or to neuroleptic medication;

(i) a significant and consistent change in the overall quality of some aspects of personal behaviour, manifest as loss of interest, aimlessness, idleness, a self-absorbed attitude, and social withdrawal.

(Source of (a)-(i) ICD-10)

The final thing to say is that the conception of schizophrenia is to a certain extent historical and many textbooks choose to explain schizophrenia as a disorder with reference to the history of its classification. The term itself was Bleuler introduced the term in his 1911 book ‘Dementia praecox or the group of schizophrenias’

Stop Press:
Discussion (and speculation) about Olympic doping including 100m/200m results
Science of Sport
Steroid Nation

I was listening on the radio just now about UK medal hopes at the Beijing Olympics. It seems we’re doing quite well. Unfortunately I have an anti-talent at sports; at primary school I would only be picked second last if my brother beat me to the wooden spoon. Many years later I lived with a girl and she would watch football on our ancient TV, whilst I sat in my room with the door shut reading ‘The Road to Wigan Pier’.

What’s more my bag is the speculation about the scale of abuse of performance enhancing drugs and their psychiatric sequelae. There are a number of substances used by athletes in order to improve performance. and of these the most common are anabolic steroids.

In the UK anabolic steroids are class C drugs and can be sold only by pharmacists with a doctor’s prescription (most often for hypogonadism). It’s legal to possess or import steroids as long as they’re for personal use, but possession or importing with intent to supply is illegal and could lead to 14 years in prison and an unlimited fine. A UK government source states that in 2003 300,000 steroid tablets were seized.

Use of anabolic steroids in the UK is suspected to be widespread and is not just the preserve of elite athletes; in a survey of 687 students at a British college the overall rate of current or previous use was 2.8% (4.4% in males, 1.0% in females) and, of these, 56% had first used anabolic steroids at the age of 15 or younger. A BMA report in 2002 found that as many as half of the members of dedicated bodybuilding gyms admitted to taking anabolic agents, and that steroid use ran as high as 13% even in some high street fitness centres.

Anabolic steroids are synthetic derivates of the hormone testosterone and allow the user to increase both the frequency and intensity of workouts, in addition to increasing muscle capacity, reducing body fat, increasing strength and endurance, and hastening recovery from injury. Users have varied aims. The majority may wish to enhance their physical appearance in order to achieve a ‘perfect body’, whilst a smaller proportion have experienced physical or sexual abuse, and are trying to increase their muscle size to protect themselves. A further group (possibly between 5 and 10%) includes people who have a form of body dysmorphic disorder (sometimes called ‘reverse anorexia nervosa’), in which they believe that they look small and weak, even if they are large and muscular (Brower et al, 1991).

The steroids are taken orally, or by intramuscular injection and according to a number of regimes – ‘stacking’, ‘cycling’ and ‘pyramiding’.

Misusers of anabolic steroids subjectively report significantly more fights, verbal aggression and violence towards their significant others during periods of use compared with periods of nonuse. Other work has suggested that adolescents who abuse anabolic steroids have nearly triple the incidence of violent behaviour. Clinical presentations include grandiose and paranoid delusional states that often occur in the context of a psychotic or manic episode. Symptoms usually resolve in a few weeks if steroid use is discontinued, although may persist for as long as a month even if adequately treated with antipsychotics.

Steroid users have been shown to have a higher prevalence of cluster B (histrionic, narcissistic, antisocial and borderline) personality traits than community controls . Self report questionnaires and informant histories have been used to retrospectively assess the personality type of anabolic steroid misusers before their first use. Such work suggests that they start out with personalities similar to those of non-using bodybuilders, but develop abnormal personality traits that could be attributed to steroid misuse.

A study involving 41 steroid-using bodybuilders used structured interviews to measure affective symptoms according to DSM–III–R criteria. They identified 5 participants (12.2%) who met the criteria for a manic episode during steroid exposure; a further 8 (19.5%) only narrowly missed the diagnosis. Significantly more participants developed a full affective syndrome during periods of steroid exposure (22%) than non-exposure (5%), and 10 were ‘stacking’ when they experienced manic symptoms.
Symptoms of steroid withdrawal include mood disorders (with suicidal depression as the most life threatening complication), apathy, feelings of anxiety, difficulty in concentrating, insomnia, anorexia, decreased libido, fatigue, headache, and muscle and joint pain. It is difficult to distinguish symptoms that may be physical in origin from those more psychological. Observing oneself to lose muscle mass, strength, performance and confidence after cessation of steroid use has a powerful negative effect on mood, and this may lead to a strong desire to take steroids again.

So, you’re all asking yourself, what’s FP’s advice? Listen to Noam Chomsky:

‘Take, say, sports — that’s another crucial example of the indoctrination system, in my view. For one thing because it … offers people something to pay attention to that’s of no importance; that keeps them from worrying about things that matter to their lives that they might have some idea of doing something about. And in fact it’s striking to see the intelligence that’s used by ordinary people in [discussions of] sports [as opposed to political and social issues

***

Sources for this posting:

General

I have leant very heavily on Anabolic androgenic steroids: what the psychiatrist needs to know

This BBC Ethics page has a concise summary of the arguments for and against use of performance enhancing drugs in sport

The talk to Frank site anabolic steroids page

News reports:

Steroids a dangerous new trend BBC February 2 2004

BBC 8 June 2006 Body builder misuse alarm

BBC 11 April 2002 Steroid misuse widespread

Radio programmes (I can’t get these to work, but perhaps you can…)

BBC Radio 4 Diet and Drugs 24 April 2002

BBC Radio 4 The Long View 14 October 2003

Woman’s hour East German doping 7 November 2005

Background
What’s it like Man?
Drawbacks
Khat and the Psychiatrist
Socio-economics
What to do?
In the UK
Khat and The Frontier Psychiatrist
Links

Yemen has been in the news recently, due to its deteriorating security situation. I’ve long had a fascination with the Middle East, and this country is known not just for its fantastic architecture, but also for its people’s fondness for chewing khat.

Background

Khat (Catha edulis) is a slow growing evergreen shrub that grows wild in countries bordering the Red Sea and along the East coast of Africa. Its appeal is that chewing its fresh leaves and tops leads the user toward a state of amphetamine-like euphoria and stimulation. There are several names for the plant, depending on its origin: chat, qat, qaad, jaad, miraa, mairungi, cat and catha. In most of the Western literature, and this posting, it is referred to as khat.

The habit of khat chewing probably predates the use of coffee, but it has become increasingly popular of late and it is estimated that three quarters of Yemeni adults chew the leaves each afternoon, with a similar social role to that of tea, cigarettes or alcohol. Khat chewing commands a dominant place in social functions and its use so widespread that withdrawal from khat can result in social isolation.

What’s it like Man?

Yemeni homes are constructed specially to provide a warm reception room for khat chewing. For the urban chewer, khat sessions usually begin soon after lunch with men and women meeting separately; the habit is mostly practiced by males.
Drs Wijdan Luqman and T. S. Danowski describe the drug’s effects:

The chewing session starts with slightly euphoric behaviour and a friendly sense of humour. The leaves are plucked off the twigs, chewed, and stored against one or the other cheek. The mixture of saliva and extract from the leaves is swallowed. As new leaves are taken, the cheek bulges out. The euphoric effects appear shortly after the chewing begins ….. The session and the friendly atmosphere last about 2 h. These are followed by a mood of zeal that lasts another 2 h, and during this interval current subjects and problems are discussed. This in turn is supplanted by a serious mood and may be accompanied by irritability.

They also note:

The act of communal chewing promotes interpersonal interactions. For example, as passengers on public transport we observed spontaneous eruptions of group conversations among previously-mute Yemenis once khat chews began.

Writing in the guardian in 2001 Brian Whitaker is a bit more poetic

As you approach cruising altitude, the brain slips into overdrive and you discover that you’re one of the most intelligent and articulate people in the world. Thoughts have never been so clear, nor have ideas flowed so freely. No matter how difficult the problem, by the end of the session you will have either dreamed up a solution or decided that it’s not worth bothering about.

And writing in his book ‘Eating the flowers of paradise’ (buy Amazon Waterstones), Kevin Rushby makes the experience sound positively transcendental:

I passed the hours listening to the gentle lubalub of the hookah and whispered conversations about dead poets and fine deeds. In Sana’a, khat governs. Each day at three, climbing the steps to a smoky room with a bundle under the arm; then closing the door to the outside world, choosing the leaves, gently crushing them with the teeth and waiting for the drug to take effect. No rush, just a silky transition, scarcely noticed, and then the room casts loose its moorings.

In rural areas the chewing of khat starts soon after breakfast, and continues throughout the day, with the children also participating. The stimulant effect is said to lighten the daily tasks. In these poorer regions food may be lacking and the khat decreases the need for meals; on the other hand such is the appeal of the plant that people will sometimes forgo buying food for khat.

Drawbacks

Yemem’s people can spend about one-quarter to one-third of their cash income on the plant. This report has a teacher spending 44% of his salary on khat. As discussed in the Yemen Times the cultivation of khat is extremely widespread, and there is concern due to 80% of Yemen’s water being used for khat growing. One reason for khat’s popularity with farmers is the high income it provides, which can be five times that of that from growing coffee or fruit. A wikipedia source states that increasing demand has lead to the area on which khat is cultivated growing from 8,000 hectares to 103,000 hectares from 1970 to 2000.

Chronic khat chewing can cause hypertension in young adults, with a spontaneous regression once consumption ceases. Khat’s tannins may lead to gastritis, stomatitis, oesophagitis, and peridontal disease. The tannic acids produced are also thought to be hepatotoxic. There are also concerns about the pesticides used in khat cultivation.

Khat and the Psychiatrist

There is debate as to whether khat is able to produce dependence with some researchers saying that the dependence effects are psychological. There is also debate as to whether a withdrawal syndrome exists. Physical withdrawal symptoms have been documented and may consist of lethargy, mild depression, slight trembling and recurrent bad dreams. Discontinuation results in improvement of sleep and appetite, and fewer constipation problems.

According to the WHO expert committee on drug dependence khat chewing can induce two kinds of psychotic reactions. First, a manic illness with grandiose delusions and second, a schizophreniform psychosis with persecutory delusions associated with mainly auditory hallucinations, fear and anxiety, resembling amphetamine psychosis.

Psychotic reactions to chewing khat are rare, probably due to the physical limits of leaf chewing. When seen they are related to chewing large amounts. Symptoms resolve when the khat is withdrawn and anti-psychotics are not usually needed. Khat psychosis may be accompanied by depressive symptoms and sometimes by violent reactions. It has been argued that khat chewing might exacerbate symptoms in patients with pre-existing psychiatric disorder.

Socio-economic effects

The habit of Khat chewing does manifest a number of socio-economic problems. Khat chewing leads to loss of work hours, decreased economic production, malnutrition and diversion of money in order to buy further khat. Family life is harmed because of neglect, dissipation of family income and inappropriate behaviour and khat is quoted as a factor in one in two divorces in Djibouti. Acquisition of funds to pay for khat may lead to criminal behaviour and even prostitution.

On the other hand there are a lot of benefits from the Yemeni’s love of khat and a lot of people clearly enjoy its use. The crop generates wealth for its cultivators and the need for a rural workforce has stabilized the rate of rural to urban migration. It has positive psychological effects too and many people report that it leads them to be more creative. Its energizing effects benefit the elderly especially and it serves as a medium for social discourse.

What to do?

Attempts have been made to control the use of the drug but with little success. In 1957 the Adeni political party instigated a ban, but such was the political turmoil over this issue that the party collapsed the following year. Many people complain that Yemeni authorities are not committed to combating the use of khat because the crop is such a moneymaker for senior officials and influential tribal leaders.

In contrast to Yemen, in Saudi Arabia use of the plant is completely banned and there are harsh penalties in place. One less severe approach would be to treat khat like tobacco in the West, with information campaigns about its drawbacks and restrictions on its use.

In the UK

In recent years as a result of air transport, the consumption of fresh khat leaves has expanded considerably and khat is readily and legally available in the UK. It has been estimated that about 7000 kg of khat pass through Heathrow Airport each week from where it is distributed into the UK and into other European countries.

There have been calls for it to be banned and the BBC reported Faisa Mohammed, chair of the Bromley-based Somali Well Women Project, saying that the abuse of khat was damaging many Somali families in Britain.

Back home the men were the breadwinners but they came to Britain without jobs and took up khat, which has become an addiction. They chew all night and during the day they can’t do anything.

Your correspondent’s humbling experience

As khat is legal in the UK I thought that it might make for a distracting afternoon to try to purchase some. Living near Whitechapel, as I do, I hung outside a semi-reputable Somali shop until I plucked up the courage to go in.

‘Hello, I was wondering if you sold khat’ I said. ‘You know, that plant you can chew’

‘No we don’t and I don’t approve of it’.

I panicked and told the shop keeper that I was a medical student doing a project on khat and I was trying to buy some for ‘research purposes’

Then the shopkeeper’s friend came in and starting to tell me about all the bad things that have happened to the Somali society in the UK thanks to khat, chiefly men ignoring their families and jobs in order to chew the stuff. He thought it should be banned.

Duely chastened I left.

***

Links for this article:

Adverse effects of khat: A review Advances in Psychiatric Treatment (2003), vol. 9, 456–463 - a really great review - full text available for free!

The impact of qat chewing on health: A re-evaluation by Nageeb Hassan, Abdullah Gunaid and Iain Murray-Lyon British-Yemini Society

Al-Bab.com qat page
Pages about the Middle East run by the Guardian’s Middle East Editor Brian Whitaker

The Curse of Yemen Ian Black Guardian August 12 2008

Here’s Kevin Rushby’s book again:

Also:

Lonely Plant Yemen page

High in hell An Esquire article by Kevin Fedarko September 1 2006

That darned khat Village Voice article 14 November 2006

The Curse of Yemen Guardian 12 August 2008

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)… 

Catherine commented:

‘I disagree with the comment about bipolar and schizophrenia being chronic, remitting etc. There are a minority who are so badly affected that they never live independently, but the majority go on to either recover, or manage their illness very well, working, hobbies etc and have a good quality of life.’

The point I was making about the chronicity of schizophrenia/bipolar disorders is that in the film ‘Ruth’ is presented to us has having recovered from her mental health crisis with no mention of follow up.  For anyone who doesn’t know, it’s often common practice in healthcare for a patient to be seen by a doctor on at least a short term basis after a problem has resolved as there may be a chance of it coming back, and psychiatry is no exception to this. We know from the film that she already has a diagnosis of BPAD and so she must have had trouble before.  The episode presented to us is quite severe, so I would say that her chance of having another relapse is high, especially with bipolar disease

Schizophrenia is considered to have a wide variety in outcomes, that said, there are not millions of long term studies; here are the ones mentioned in the Shorter Oxford Textbook of Psychiatry:

Kraeplin Dementia praecox and paraphrenia 1919
Concluded that only 17% of his patients were socially well adjusted many years later

Mayer-Gross Die Schizophrenie in Bumke’s Handbuch der Geisteskrankheiten Vol 9 Springer Berlin 1932
Reported social recovery in 30% patients at 16 years all from the same clinic

Brown et al (1966) reported social recovery in 56% in Schizophrenia and social care Maudsley Monography 17 Oxford University Press  London

Manfred Bleuler (1972,1974) followed up 208 patients who had been admitted into hospital in Switzerland between 1942 and 1943.  Twenty years after admission 20% had complete remission of symptoms and 24% were severely disturbed. 

Ciompi did a larger study looking at 1642 records diagnosed as having schizophrenia between 1900 and 1962, with an average follow up of 37 years.  A third of patient were found to have good or fair social outcome.  Symptoms were often less severe in later life. 

Johnstone E.C. (1991) Disabilities and Circumstances in Schizophrenic patients: A follow up study British Journal of Psychiatry  159 supplement 13 5-46, did a 3-13 year follow up of patients with schizophrenia discharged from 1975 - 1985 and found that almost half had a good social outcome. 

Tsoi and Wong (1991) A fifteen year follow up of Chinese Schizophrenic patients Acta Psychiatrica Scandinavica 84 217-220  did a 15 year follow up of 330 patients with first admission Schizophrenia and in this found that almost one third recovered but 17% remained unable to function outside the hospital. 

Finally in the USA Carone et al (1991 - a busy year) found that only 15% of patients meeting DSM-III criteria for schizophrenia recovered after 5 years. 

Full admission: I haven’t read any of these papers/books, and for these papers to be comparable then they should all use similar definitions for schizophrenia and select similar patients - there would be no utility is comparing patients after their first admission and patients who have been admitted countless times.  With these caveats, it appears that prognosis has improved since schizophrenia was first studied.  In the earlier studies the patients would have had no access to modern pharmaceutical treatments 

Schizophrenia outcome is further discussed in  Schizophrenia Research Volume 1, Issue 6, November-December 1988, Pages 373-384

The factors associated with good prognosis in Schizophrenia:

Sudden onset; Short episode;No previous psychiatric history; Prominent affective symptoms; Paranoid type of illness; Older age of onset; Married; No personality disorder; Employed; Good social support; Good compliance with treatment

Poor prognosis is associated with:

Insidious onset; Long episode;Previous psychiatric history; Negative symptoms; Enlarged lateral ventricles; Male gender; Younger age of onset; Single/separated/widowed/divorced; Personality disorder; Poor work record; Social isolation; Poor complicance with treatment

If you’ve still got the strength, read on for outcome of bipolar affective disorder.  Again this is from the Shorter Oxford Textbook of Psychiatry:

The average length of a manic episode (treated or untreated) is six months

At least 90% of patients with mania experience further episodes of mood disturbance

Over a 25 year follow up on average bipolar patients experience 10 further episodes of mood disturbance

The interval between episodes becomes progressively shorter with both age and the number of episodes

Nearly all bipolar patients recover from acute episodes, but less than 20% of patients with this disorder achieve a period of 5 years of clinical stability with good social and occupational peformance

It is estimated that 10% of patient with unipolar depression will eventually turn out to have a bipolar illness.   

So, with both bipolar affective disorder and schizophrenia, I do think that if a patient has one episode they are likely to be troubled by the illness at a later date and this is what I meant by a chronic condition.       

I wrote a post about this the other day before I’d actually seen it and I’ve watched it now.

For anyone who didn’t see it, ‘The Doctor Who Hears Voices‘ was a film shown during the past few days on Channel 4. It concerns a doctor called ‘Ruth’ – her identity has been changed, but we are told that the documentary is a mix of film of Dr May taken throughout the actual treatment, spliced with reenactments of Dr May’s sessions with ‘Ruth’ with Ruth being played by actress Ruth Wilson.  Ruth has no wish to take psychiatric medications and is currently off work with depression; she has a diagnosis of bipolar disorder.  She is sure that if she tells her work that she is ‘hearing voices’ then she will be sacked and sectioned.

I thought that I’d start this post by listing the things that I liked about the documentary.  So far I’ve only been able to think of one – that it’s good that mental health issues are being given airtime by a major television channel.

There were lots of things I found objectionable about the film. 

1. The subject’s suitability was questionable:

Was it really suitable to film a documentary over a seven month period of a vulnerable patient having a mental health crisis?  I cannot believe that this helped in her recovery, and I suspect that it simply served to raise Dr May’s profile.  Sure, she must have consented before broadcast, but by then the damage could have been done.

2. The film is misleading

Dr May is described as a doctor – whilst this is strictly true, he has a doctorate, most people would interpret this as meaning that he is a medical doctor.  He is not, he is a psychologist.

The film implies that people who have voices are always sectioned, this is not the case.  The film also gives the impression that were ‘Ruth’ to admit to be suffering auditory hallucinations, then she would be sacked and sectioned on the spot.  In fact her dismissal would have to be sanctioned under employment law, and if she were to be sectioned, this would require two independent doctors and an appropriately qualified social worker. 

No attempt is made in the film to put the treatment of this patient in context.  All that one can legitimately say about this film is that Dr May’s interaction with this patient coincided with partial recovery for this patient during one of her relapses.  Many people will leave this film thinking that because of Dr May’s limited ‘success’ that current mental health treatment is all wrong.  This cannot be concluded on basis of one case. 

3. The film is unrepresentative and unrealistic:

‘Ruth’ is not a particularly representative patient.  She is above average intelligence, and I cannot help but notice, is played by a young and beautiful actress.  I wonder if this film would have been made if its subject matter was a typical London inner city patient.

Whilst Ruth Wilson played the role believably, her depiction was not challenging to the viewer.  The most chaotic thing she does is put her head under a stream and walk out in front of a slow moving lorry.  She remains coherent and well turned-out throughout.  What if she did other things less palatable to the body beautiful: neglected personal care, started to have sex with (unattractive) strangers or lived in a filthy house?  Let’s consider how much publicity a conventional psychiatrist, offering medications to a patient who would go home much better the following week, would muster – not much I expect. 

Early on, we are told that Dr May sees Ruth in an unofficial capacity in addition to his NHS work.  Even if it worked, about which I remain dubious, there is simply not the capacity within the health service to allow all patients with serious mental health problems this sort of intensive input. 

At the end of the film, we are encouraged to think that ‘Ruth’ has managed to return to work successfully, despite continuing to have auditory hallucinations.  It is implied that this is because Dr May and ‘Ruth’ manage to pinpoint the identity of the voice which is troubling her; this is over simplistic.  We are told nothing of the long term outcome of this case.  Remember that both bipolar affective disorder and schizophrenia (the two terms are used interchangeably during the film) are chronic disorders of a relapsing and remitting nature. 

4. Dr May is deeply unprofessional:

Dr May shows a total distain for other professionals working in the psychiatric field.  Informed by his own experiences, he says that people who work on psychiatric wards consider their patients to be ‘degenerate’.  Psychiatric wards are not nice places, but they are staffed in the main by caring people who do an extremely difficult job with very difficult patients.  It is insulting to suggest that, to a person, they all consider patients with mental health problems in this way.   

Dr May’s relationship with ‘Ruth’ seriously blurs the boundary between patient and professional.  Ruth is seen to stay with his family and there is no mention of any other important relationships in Ruth’s life, for instance the support which might be available from parents or friends.  Instead, Dr May positions himself as a svengali character and it appears that his professional zeal for alternative psychiatric treatment may be an expression of his own personal distaste for the psychiatric profession with Ruth as a unwitting pawn.

Ruth is an extremely vulnerable patient.  The programme takes place over the course of seven months, during which time who, if anyone if managing the risks she poses to herself and others?  At one stage Dr May admits that she has been told by the voice that she hears that she should kill her parents.  He simply considers this to be ‘useful’.  At another Ruth goes missing and Dr May is concerned that she may have committed suicide.  When asked about why he is reluctant to talk to camera about this he admits that he is reluctant, in our risk adverse age, to implicate himself on camera, perhaps realising how far out on a limb he has gone. He is also described as using a technique which many psychiatrists think ‘irresponsible and dangerous’.  Imagine if your surgeon told you he wanted to try a procedure on you that other surgeons thought ‘irresponsible and dangerous’ – you would not be impressed, and neither should we be. 

In discouraging Ruth from seeking any professional advice but his own, Dr May steers her away from evidence based (but I grant, imperfect) methods of treating mental illness, towards his own paradigm.  In the film she is portrayed as manic for in excess of six months, and would have been unlikely to have been so were she on appropriate medication.  In addition to not seeing a psychiatrist, in isolating her, Ruth would also not be helped by the array of other professionals who work in community mental health.  We see her at the end, apparently recovered, but where on earth is her follow-up?

Dr May has a professional case to answer in his attitude to the panel that is to decide whether Ruth is safe to be practicing as a doctor.  This panel is not there simply to get in Ruth’s way, but to make sure that vulnerable patients are to be treated safely by competent doctors.  Whilst being aware that Ruth has symptoms of serious mental illness, Dr May encourages Ruth to lie to the panel and also coaches her to do so. 

This is in direct contradiction to the GMC good practice guidelines which state:

‘If you know that you have, or think that you might have, a serious condition that you could pass on to patients, or if your judgement or performance could be affected by a condition or its treatment, you must consult a suitably qualified colleague. You must ask for and follow their advice about investigations, treatment and changes to your practice that they consider necessary. You must not rely on your own assessment of the risk you pose to patients.’  (my italics)

I don’t doubt that a lot of patients are not keen on taking antipsychotic medications.  It’s widely known that people with mental health problems have trouble finding and keeping employment.  If Dr May’s work aims to help people with their mental health problems get back into employment and deal more effectively with their illness, they we’re on the same side.  And perhaps there’s a four hour version of this film which would clear up all of the above concerns.  But this film is unbalanced and unhelpful.

Here’s a guardian review of the TV show and some interesting comments.

Kathryn Flett in the Observer didn’t like it much either 

Addendum: Dr May has kindly commented on this piece below.  There’s a BMJ review of TDWHV available on his website, which raises some interesting points. 

Addendum: I’ve now seen this film and it annoyed me so much that I’ve written another post about it 

Tonight there’s what may be quite an interesting programme on television - Channel 4 2200.  I can’t watch it as I don’t have a TV, but here’s the blurb:

‘The Doctor Who Hears Voices tells the true story of Ruth, a junior doctor, who has begun to hear a male voice telling her to kill herself. Suspended from her job, she turns to clinical psychologist Rufus May who is known for his unconventional approach to treating people with severe mental health problems.

Although she admitted feeling depressed and suicidal to her employers, Ruth knows they would have sacked her immediately if she had told them about the voice.’

Furthermore:

‘Rufus May is a maverick psychologist. He believes there is no such thing as schizophrenia, that medication can destroy lives and that there’s nothing wrong with hearing voices. Rufus is an authority on the subject. He was diagnosed with acute schizophrenia aged 18.’

I hadn’t heard of Rufus May until this evening; I’ve now looked at his website so I’m getting clued up.  He’s a little bit more circumspect than the Channel 4 would have him:

‘I am not against people using psychiatric medication I just would like people to be able to make informed choices and have the chance if they so wish to try out other approaches to their mental health problems.’

Which sounds a little more balanced, but also less exciting.

It’s rather a poor show to criticize a TV programme I haven’t seen, although this never stops politicians.  I’ve got quite a lot of sympathy for people who say that schizophrenia doesn’t exist.  In a way it sort of doesn’t, in that our understanding of its aetiology is patchy and it could easily be a number of similar diseases based on different genetic defects.  If he is helping people to deal with their psychosis with means other than medication, this is also to be applauded. 

As usual though what’s necessary for the highest level of evidence for May’s methods is a controlled trial and I can’t see him having been involved in one of those.  If he chooses the patients he treats, he can thus pick the ones he would expect to have a better outcome - those that have a higher intelligence and better social support.  There are a lot of patients out there with psychosis and May has treated but a few of them.  Twenty % of schizophrenia patients make a full recovery without any psychiatric intervention.

As a final thought, if the doctor in question had a serious psychosis then you could also argue that he would have had a duty of care to reporting her to the GMC.  

Like I say, I’d better watch it. Here’s Rufus May’s Bradford page

PS. There’s an interesting transcript on the Rufus May website of a debate entitled ‘Psychiatric drugs do more harm than good’ For: Dr Peter Breggin, seconded by Dr Joanna Moncrieff.  Against: Dr Mark Salter, seconded by Dr Trevor Turner 

If you had a cough and were expectorating  lots of green phlegm then you might think that something was amiss; if you broke a bone in your foot, it might hurt to walk.  Either way, if I suggested to you that you had a problem with your health you’d probably agree with me.  With mental illness it is possible to be very severely ill and believe yourself to be well; in fact, on the contrary, you might believe yourself to be at the top of your game.  This ability, or inability, to recognise illness is called ‘insight’ and psychiatrists talk about it a lot. 

Loss of insight is a symptom of severe mental illness and is seen with diagnoses such as schizophrenia and bipolar affective disorder. 

It has been proposed that insight consists of three overlapping dimensions

1. The ability to relabel unusual mental events as pathological
2. The recognition that one has a mental illness
3. Compliance with treatment

Rather than just being an indicator of the severity of other symptoms, lack of insight is thought to be a distinct phenomonological feature in its own right, being similar to anosognosia where a patient shows an unawareness of neurological symptoms.  This is associated with lesions to the frontal lobes and the right parietal lobes.  

It’s important to note that insight is not an all or nothing thing.  Someone with complete lack of insight may deny that anything at all is amiss.  Sometimes though we describe a patient as having ‘partial insight’.  An example of this might be someone who thinks that MI5 is passing messages to  him/her via messages written on Tescos carrier bags.  He or she might concede that this was rather a strange thing to be happening, but would insist on its veracity nevertheless.  With recovery of full insight he or she might say that now they realise that the messages on carrier bags were a function of their illness. 

Loss of insight is also important because it has prognostic implications.  As you might expect, if you don’t think that you have a problem, you’re likely to carry on as before, and won’t be opening the door to health care professionals.  As well as this it is linked to poorer functioning across all areas of a patient’s life.  

Misidentification syndromes are some of the most fascinating psychiatric disorders around.  I would say ‘cool’ but I’m sure that suffering from one can be very dispiriting, and will continue to use this adjective for trainers and indie bands only.  They involve a disturbance in the judgement of uniqueness of certain events.

First up, there’s Capgras Syndrome; also known as I’illusion de sosies (Illusion of doubles).  Here, a person is under the impression that someone close to them has been removed and replaced by an identical looking impostor.  It is named after Joseph Capgras, a French psychiatrist, who described this in a paper published in 1923.

Capgras Syndrome is associated with schizophrenia in more than half the cases. The theory behind it runs like this: when the eye sees a face, the brain processes the information in two parallel streams, which can be damaged independently.  Faces are at once explicitly identified via the temporal cortex and also more rapidly though the amygdala, which is involved with the limbic - emotional processing - system.  We can see an example of this rapid processing if we were to find ourselves running away from something without fully understanding what it is. 

If the temporal cortex path is damaged, the brain will have difficulty in recognising a face.  However, via extra-visual clues, emotional responses to familiar faces are preserved.  Therefore someone with prosopagnosia (inability to recognise faces) will still have an emotional response to the faces of people they know.  If the amygdala path is compromised then the person will still recognise the face, but the expected emotional response will be absent.  This could lead the feeling that a familiar face is ‘not quite right’ and to the erroneous conclusion that his is because of an impostor.

Subtly different is Fregoli Syndrome.  Rather than named after a pioneering psychiatrist, this disorder was named after Leopold Fregoli (1867-1936) who was an Italian actor and the greatest quick change artist of this day.  He was famous for his ability in impersonations and his quickness in exchanging roles, so much so that at times rumours spread that his act was in fact performed by more than one person.  This is also known as the illusion of a negative double, and the suffer believes that various people he or she meets is actually the same person in disguise.  This often has a paranoid flavour, with the sufferer believing that that are pursued by a someone that assumes different identities. 

A sort of combination of Capgras Syndrome and Fregoli syndrome is intermetamorphosis syndrome, first described by P Courbon and J. Tusques (1932); in this, the subject develops the delusional conviction that various people have been transformed physically and psychologically into other people.  This disorder involves false physical resemblance and false recognition. 

Almost there.  Reduplicative paramnesia was described by Pick in 1903 and is often seen in post traumatic brain injuries. With this, there is a belief that a familiar person, place, object or body part has been duplicated. For example, a person may believe that they are in fact not in the hospital to which they were admitted, but an identical-looking hospital in a different part of the country. 

Finally, there’s delusion of subjective doubles, in which a person believes there is a doppleganger or double accompanying the self.  Apparently meetings with doubles were a popular theme of 19th century romantic literature (see Dostoyevsky’s The Double).  It was believed that we each have a doppleganger who normally remains unseen; if we see our doppelganger then death is imminent…

Several newspapers including The Guardian and The Irish Independent have reported have reported over the past few days that an Air Canada 767 bound for London Heathrow had to divert to Dublin Shannon following one of the co-pilots suffering from ‘nervous breakdown’. 

The Irish Independent reports that the co-pilot had been ‘acting in a peculiar manner and was talking loudly to himself’ during the transatlantic crossing and the crew had become concerned.  From The Guardian we learn that he was restrained after yelling and "invoking God" while at the controls of the plane.  The Guardian continues by quoting one of the passengers on board, who said that the co-pilot was carried into the cabin with his hands and ankles cuffed after being restrained by, amongst others, an off-duty Canadian soldier.  He was subsequently handcuffed to a seat as his captain requested permission to land from Irish air traffic authorities.

I read of what sound like quite severe psychotic symptoms: ‘His voice was clear, he didn’t sound like he was drunk or anything, but he was swearing and asking for God. He specifically said he wants to talk to God’. When the plane landed in Dublin, he was met by a medical team who assessed him at the scene before transferring him to a psychiatric unit in Ennis.  

It’s hard to imagine a more difficult situation for any of the people involved in this incident.  It must have been terrifying for the passengers on board the aircraft as well as extremely distressing for the crew to have to restrain one of their colleagues. We should reserve some of our sympathy for the co-pilot too.  A previously high functioning individual, when he recovers he will have to come to terms with what has happened as well as facing the end of his flying career.  

A search of the Canadian Civil Aviation authority website suggests that anyone with a history of psychotic illness is not permitted to fly aircraft. It is therefore likely that this is a first presentation of psychiatric illness for this pilot, or possibly he has in some way concealed any problems he has had in order to maintain his chosen career ultimately putting passengers at risk. 

A recent article in the New Scientist is about antidepressant use amongst pilots.  It tells us that most aviation authorities do not allow pilots on antidepressants to fly.  The Australian Civil Aviation Authority is one of the few that do and a study there suggested that pilots on antidepressants were not at greater risk of accidents.  It also suggests that banning pilots from flying who are taking antidepressants may actually increase accidents by discouraging depressed pilots from seeking treatment.  Perhaps this pilot did not seek help until it was too late with very nearly devastating consequences.