Archive for the ‘Specific psychiatric disorders’ Category

Long term outcome in BPAD and Schizophrenia

Sunday, May 11th, 2008

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.       

Physical illness that cause psychiatric disease

Wednesday, April 23rd, 2008

 

Frontier Psychiatrist is sick today, and has been off work.  Ordinarily I might enjoy a day in front of the television working through a box set of Prison Break but I’ve been feeling really low all day.  I knew things weren’t right when I got up this morning and and simply stared at my toast rather than eating it. 

But what better time to examine physical illnesses (‘organic causes’) that cause psychiatric symptoms?

Psychiatry and physical medicine have a complicated relationship.  Psychiatric and physical disease can occur at the same time by chance or physical disease can cause psychiatric symptoms and vice versa. Psychiatric medications also have a large number of side effects.  

Whenever a patient comes into the hospital with psychiatric problems, a full ‘work-up’ should include looking for a physical cause for the problem.  Psychiatrists were a bit rubbish at doing this, but are getting better; the hospital where I work audits whether patients admitted have a physical examination whilst they are on the ward. Patients usually get blood tests and often a CT scan, especially if the presentation is atypical.

Depression has a lot of organic causes: cancer, infection, neurological disorders including dementia, diabetes, thyroid disease, Addisons disease, and systemic lupus erythematosis.  Just having one of these diseases in themselves may be a cause for depression as they can result in substantial disability.  Psychiatry blogger Lake Cocytus tells a tale of delayed diagnosis of metastatic breast cancer due to confusion with depression. 

Anxiety also has a number of organic causes: hyperthyroidism, hyperventilation, phaeochromocytoma, neurological disorders and drug withdrawal. 

Finally, psychosis may also be triggered by an organic cause and these include neurological conditions (e.g. epilepsy and strokes), metabolic conditions (e.g. porphyria), endocrine conditions (e.g. hyper- or hypothyroidism), renal failure, electrolyte imbalance (especially calcium), or autoimmune disorders.

Misidentification Syndromes

Sunday, March 30th, 2008

 

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…

 

 

Munchausen’s and friends

Thursday, March 13th, 2008

Psychiatric syndromes like hypochondriasis, somatization disorder and Munchausen’s disorder could be uncharitably characterized by the layman as ‘he’s making it up, innit’.  Not as simple as that alas, which one of the reason you have to train psychiatrists rather than pull them off the street.

Munchausen syndrome (also known as factitious disorder): the patient seeks medical attention by the intentional production or feigning of symptoms.  The motivation for this is considered not to be known to the patient and he/she keeps their stimulation or induction secret.  It was named (1) after Rudolf Raspe’s 1785 fictional German cavalry officer, Baron Karl von Munchausen, who always lied fantastically about his military exploits.  A classic case might have what is called a ‘grid iron’ stomach because of all the scars from numerous abdominal operations.  Also a feature is ‘perigrination’ where a patient will move from hospital to hospital seeking treatment, once rejected from a department.

Munchausen syndrome by proxy: This was first defined by Meadows (2) and has become controversial.  Defined as ‘the deliberate production or feigning of physical or psychological symptoms or signs in another person who is under that individual’s care’.  it is considered to be a form of child abuse.  It is also not unknown for healthcare workers to fabricate health crises in their patients so that they can ‘save’ them. 

Hypochondriasis: the patient is convinced that they have a life-threatening illness, despite evidence to the contrary.  They often misattribute normal bodily sensations as being pathological. 

Malingering: the patient knowingly fabricates a medical illness for known gain.  This is considered to be rare. 

Somatization disorder: With this a patient presents with multiple, medically unexplained symptoms. Originally described as Briquet’s syndrome in the 1960s.  Patients sometimes show a lack of concern for the nature and implications of their symptoms and the presentation may also be illogical for example, the patient may complain of intolerable pain, but still appear calm and composed.

So, in summary, if they’re doing it, but they don’t know why then it’s Munchausen’s syndrome; if they’re doing it to someone else and they don’t know why then that’s Munchausen’s by proxy; if they think they’re going to die and you can’t persuade them otherwise then that’s hypochondriasis; if they’re not doing it, but they feel unwell but are pretty vague about it then they’re somatizing and if they’re doing it, they know why and they want money for it then they’re malingering.  Clear?

Addendum: Jan-Michael has asked about how the above relate to conversion disorders, which is a good question.  Conversion disorders are presumed to be psychogenic in origin.  The patient experiences a conflict or trauma of some kind and the unpleasant affect is transformed (/converted) into symptoms.  Examples are dissociative amnesia, dissociative fugue, dissociative stupor, trance and possession disorders, dissociative disorders of movement and sensation and dissociative convulsions. 

In common with somatisation disorder, both involve physical symptoms and with both there is no evidence of a physical disorder that might explain these symptoms.  The difference is that to diagnose dissociative disorder there should be clear evidence of psychological causation for the symptoms, even if the patient denies it.  There is no need for this to make a somatisation disorder diagnosis.  Also with somatization disorder, the patient tends to present with a variety of vague symptoms whilst in a dissociate disorder the symptoms are more focused. 

In terms of classification, disorders with a predominantly physical or somatic mode of presentation are grouped together.  In ICD-10 F40-48 covers neurotic, stress related and somatoform disorders.  Within this F44 covers Dissociative [conversion] disorders and F45 covers somatoform disorders.  Somatoform disorder is classified within this as F45.0 and hypochondrical disorder is classified as F45.2.  Malingering is classified elsewhere as Z76.5 (Z0-Z99 Factors influencing health status and contact with health services) and Munchausen’s F68.1 ‘intentional production or feigning of symptoms or disabilities either physical or psychological [factitious disorder]‘ (F68 other disorders of adult personality and behaviour)

(1) Asher, R. (1951). Munchausen’s syndrome. Lancet, i, 339–41.

(2) Meadow, R. (1977). Munchausen syndrome by proxy: the hinterland of child abuse. Lancet, ii, 343–5.

SSRIs in the doghouse

Tuesday, February 26th, 2008

It’s a bad time to be an SSRI antidepressant.

Strike one:

In January a paper in the NEJM found that the evidence base for the use of these drugs was incomplete, with a large publication bias towards positive results.  When negative results had been published, it was in such a way as to give these results a positive skew.  This publication bias in itself does not mean that a drug is ineffective, but hardly instills confidence.  There have been rumblings about this sort of thing going on for a long time….

Strike two:

A paper published today in the Public Library of Science Medicine Journal entitled Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration collected (via the freedom of information act) what it believes to be all the trial data available before their licence was granted (published and unpublished, positive and negative) on Fluoxetine, Paroxetine, Venlafaxine and Nefazodone, and found via meta-analysis their effects for mild and moderate depression to have no clinical improvement over placebo. 

This raises a number of concerns for psychiatrists and the population at large, several million of whom were taking these medications at the last count.

  • Already not especially convincing, where does this leave the monoamine theory of depression?
  • Have pharmaceutical companies deliberately mislead the doctors and patients as to the effectiveness of their product, thereby costing health providers billions of pounds and subjecting millions to ineffective medication and unnecessary side effects?  If so, shouldn’t we take them to court or something?
  • What should we tell our patients?  There are plenty of people out there on the above medications for mild/moderate symptoms of depression.  See end of piece for a quick summary of how depression is categorized.  Doctors who prescribe antidepressants in these circumstances will be aware that it’s not the best treatment, but wouldn’t wish to give somethings that really doesn’t work at all.  If these antidepressants were working because of a placebo effect then, with all this publicity, they won’t be working now.
  • What are we going to do instead?  NICE already recommends that counselling/therapy is the most appropriate intervention in mild/moderate depression.  However waiting lists are very long and many people crave a quick fix to their problems, which in any case are more ingrained than that which is amenable to a course of cognitive behavioural therapy.

Classification of depression

Depression as an illness is somethings that’s talked about a lot these days.  The first thing to say is that the difference between ‘depression’ as an illness and simply feeling ‘gloomy’ is not qualitiative but quantitative.  There is also no test for depression, but rather a line in the sand that when (methaphroically) overstepped people say that you are depressed.  The diagnosis of depression is made on clinical grounds rather than via a test.  This is not unusual in medicine, epilepsy for instance is diagnosed in the same way.

When we as psychiatrists, (but also as lay people, but in a less formalised way) say that someone is depressed, what me mean is that they are displaying a number of symptoms that suggest to us that their main problem is of low mood.  In order to make diagnoses more consistent and also to aid in professional communication psychiatrists use diagnositic guidelines for their diagnoses.  In America these guidelines are called the Diagnostic and Statistical Manual edition IV and in Europe we mostly use the International Classification of Diseases edition 10. 

(I’m almost there.)

Although mood and hence depression exists on a dimension, i.e. there is a continum from ‘not depressed’ to ‘very depressed indeed’ with no breaks in between, we choose to draw further lines in the sand and make categorical diagnoses – this is where the mild/moderate/severe depression diagnoses come from. 

So, when the above study talks of ‘mild depression’ it’s saying that a person meets the criteria for either the DSM-IV or ICD-10 criteria for depression.  The ICD-10 criteria are:

F32.0 Mild Depressive Episode: Diagnostic Guidelines
Depressed mood, loss of interest and enjoyment, and increased fatiguability are usually regarded as the most typical symptoms of depression, and at least two of these, plus at least two of the other symptoms described above should usually be present for a definite diagnosis. None of the symptoms should be present to an intense degree. Minimum duration of the whole episode is about 2 weeks.
An individual with a mild depressive episode is usually distressed by the symptoms and has some difficulty in continuing with ordinary work and social activities, but will probably not cease to function completely.

If you’re interested in classification of depression then try this site

Roundup

Bad Science on SSRIs and criticism of media response to PLOS paper

Guardian articles on PloS paper: Ann Robinson – If the drugs don’t work; Allegra Stratton – A bitter pill; Sarah Boseley Prozac, used by 40m people does not work, say scientists; Mark Lawson Something for Nothing

 

 

Personality disorders

Monday, February 25th, 2008

I was interested to read an article in The Independent recently where psychologist Oliver James wrote that of comic peformers ‘most but not all – are either depressive or personality disordered’. 

James is a psychologist of some experience or, failing that, exposure.  Clearly it takes a particular sort of person to wish to earn their living by entertaining other people – and to subject themselves to the scrutiny this entails – but to make a blanket diagnosis of this nature cannot be right or fair.  Psychiatrists are often almost as guilty, it is a term often used in my by my colleagues to refer to patients or professionals we find difficult or do not like. 

Here’s an introduction to this difficult area.

Definitions

ICD-10 defines personality disorder as follows:

‘A severe disturbance in the character logical condition and behavioural tendencies of the individual, usually involving several areas of the personality, and nearly always associated with considerable personal and social disruption’

And DSM-IV:

‘an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment’

There are nine categories of ICD-10 personality disorder and ten of DSM-IV.  DSM-IV divides its personality disorder classifications into three ‘clusters’.

ICD-10 
(F60.) Specific personality disorders
(F60.0) Paranoid personality disorder
(F60.1) Schizoid personality disorder
(F60.2) Dissocial personality disorder
 (F60.3) Emotionally unstable personality disorder
 (F60.4) Histrionic personality disorder
(F60.5) Anankastic personality disorder
Obsessive-compulsive personality disorder
(F60.6) Anxious (avoidant) personality disorder
(F60.7) Dependent personality disorder
(F60.8) Other specific personality disorders 

DSM-IV
Cluster A (odd or eccentric disorders)
Paranoid personality disorder
Schizoid personality disorder
Schizotypal personality disorder

Cluster B (dramatic, emotional, or erratic disorders)
Antisocial personality disorder
Borderline personality disorder
Histrionic personality disorder
Narcissistic personality disorder

Cluster C (anxious or fearful disorders)
Avoidant personality disorder
Dependent personality disorder
Obsessive-compulsive personality disorder

Problems with the diagnosis

The diagnosis and treatment of people with personality disorder is one of the trickiest areas of psychiatric practice.  Although established as a diagnosis and enshrined in both the ICD-10 and DSM IV, there is not a consensus concerning to what extent behaviours of a negative social and moral value should be considered psychiatric disorders and as a diagnosis personality disorder has a number of problems. 

  • There is no definitive definition of ‘personality’ to be disordered, and it is at best a semi-technical term.  Most definitions are based on personality being an enduring combination of traits that serve to characterize an individual’s thoughts feelings and actions which are relatively consistent over a range of situations.  Some people would argue that personality is not a stable entity, but varies with time and situation. 
  • Few personality types would fit into a single category listed above.  With its three clusters, DSM-IV goes some way to address this.
  • There is an instability between raters when trying to diagnose personality disorder – this occurs even when rating scales are used.
  • There is a large overlap of the behaviour of people with personality disorders with those of ‘normal’ people.  ICD-10 and DSM-IV offer categorical diagnoses, whereas in fact personalities exist on a spectrum i.e. they are dimensional.
  • It is a hard area to conduct research into, partly due to the changing definitions of personality disorder over time and changing emphasis on personality traits not asked about on entry to the study.
  • There is a great deal of stigma attached to the diagnosis
  • This diagnosis allows significant deviance from societal norms, such as conscientious objection to a social regime, to be classified as a mental disorder. There is concern that this will be used to justify treatment of political dissidents as though they were psychologically disturbed.

Prevalence

Problems aside, people fitting the criteria for personality disorders are very prevalent in society, between 7 and 13 per cent in the general population and of 20 to 30 per cent in general medical practice.  It is also believed that 40% psychiatric outpatients and 50% inpatients would qualify for a personality disorder diagnosis.   Personality disorders rarely present to services in isolation and are associated with a high co-morbidity frequently being associated with alterations of eating behaviour, alcohol and substance abuse, other mental disorders, antisocial behaviour, and sexual promiscuity.  When someone meeting the criteria for personality disorder presents to health services an in-patient length of stay is likely to be longer and costs higher.

What causes Personality disorder?

As with a lot of mental illnesses, the answer to this question is not clear and genetic and social factors have been implicated.  There is evidence for the involvement of difficult upbringing with people having suffered physical or sexual abuse being over represented in personality disordered people.  Behaviour problems in childhood are also implicated, including severe aggression, disobedience, and repeated temper tantrums.

Treatment

It was felt for a long time that people with personality disorders were not treatable. There has been a perception that people with difficult personality traits can change themselves if they really wish and that it is therefore their fault if they do not. We therefore tend to blame people who have a personality disorder.  The tide has turned somewhat these days, and people are engaging those with a diagnosis of personality disorder in a number of ways.  These include trials of drug treatment, for example for comorbid depression, psychotherapy including dialectical behavioural therapy and therapeutic communities.

What research has been conducted suggests that over 10-30 years the outcome for people with personality disorders is generally favourable, with two-thirds improved at follow up with milder residual symptoms.  The severity of symptoms decreases with age and only one quarter would retain a diagnosis of boarderline personality disorder age 50.  Whilst employment is fairly common, marriage rates are half the average and odds of having children one quarter. 

 

Delusional?

Thursday, February 21st, 2008

Mohamed Al Fayed

Here’s a famous definition of delusion:

‘A belief held with unusual conviction that is unamenable to logic whose erroneousness is manifestly obvious to others’ – Jaspers (1959)

This came to mind the other day when I was reading about Mohamed Al Fayed’s peformance in court at the inquest into the death of Princess Diana.  Al Fayed spent time outlining the extent of the international conspiracy which had been involved her death and that of his son, stating that conspirators included Tony Blair, Robin Cook, MI5, MI6, the CIA, the French intelligence service and the French ambulance service, who drove to the hospital deliberately slowly so that she might die. 

This doesn’t strike me as very likely and this view appears to be shared by the inquiry’s coroner, who asked Mr Al Fayed: ‘Do you think that there is any possibility, however remote that your beliefs about conspiracies may be wrong and that the deaths of Dodi and Diana were in truth no more than a tragic accident?’

Fayed replied: ‘No way.  I am 100% certain’. 

I think this would count as ‘unusual conviction’.  In ICD-10, there is a diagnosis of ‘delusional disorder‘, which is defined by the presence of persistent, non bizarre, delusions.  A non-bizarre delusion is plausible; this is in contrast to a bizarre delusion which is not.  For instance a person who thinks that they are under survelliance by the security force may be delusional, but this does happen to a small number of people. This is non-bizarre; a person would hold a bizarre delusion if this had no chance of being true, for instance if they felt that there was a goat living on their head.  Delusions also need to be outside what is considered to be culturally accepted for instance, in isolation, some religious practices might be considered odd, but they are widely accepted and so not delusional. 

If you were to meet a person with a delusional disorder you might not notice anything obviously odd about them.  This is in contrast to someone who is suffering from a psychotic delusional disorder, when their behaviour may appear manifestly odd.  They are able to continue functioning normally, although may make some strange decisions based on their world view. 

Finally, sometimes people are labelled as being delusional, when in fact they are not.  This is called the Martha Mitchell Effect this is when a psychiatrist mistakes a patients perception of real events as delusional and misdiagnoses accordingly.  It is named after the wife of the attorney general in the Nixon administration who alleged that White House staff were engaged in illegal activities.  Her claims were attributed to mental illness, but the outcome of the Watergate scandal vindicated her. 

Psychosis at 30,000ft

Wednesday, January 30th, 2008

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. 

 

Heath Ledger

Sunday, January 27th, 2008

 http://www.411mania.com/game_screenshots/2014.jpg

Despite being very famous, Heath Ledger had somehow passed me by until a few weeks ago when I watched ‘Monster’s Ball’ and ‘Brokeback Mountain’ within a few weeks of each other.  It seems likely that his death was caused by an overdose of sleeping pills, either mistakenly or intentionally.  As a psychiatrist I was struck by something Ledger said in his last interview with Sarah Lyall, published in the Observer.

‘Last week, I probably slept an average of two hours a night,’ he said. ‘I couldn’t stop thinking. My body was exhausted and my mind was still going.’ One night, he took an Ambien sleeping pill, which didn’t work. He took a second one and fell into a stupor, only to wake up an hour later, his mind still racing

Obviously there’s not much to go on here, but I wonder if Ledger is suffering from hypomania, although I note that there is no mention of elevated mood in the article.  It is also worthy of note that Ledger had been flying between Manhattan and the UK, as he had been filming ‘The Imaginarium of Doctor Parnassus’ in London.  According to NICE guidelines, if a person has a predisposition towards bipolar disorder, relapses can be triggered by ‘night flying and flying across time zones, and routinely working excessively long hours, particularly for patients with a history of relapse related to poor sleep hygiene or irregular lifestyle’

There’s also been press speculation about Hedger’s history of drug use.  In 2006 he was the victim of a paparazzi sting operation during which time he was filmed admitting to smoking ‘five joints a day for twenty years’; in the background of the film were unidentified persons snorting what is presumably cocaine.  At the time the tape was not shown due to legal threats, but now Ledger is dead no such restriction aside, of course, from decency.