Post traumatic Stress Disorder – two views

Orthodox view:

In the ICD-10 PTSD is listed under ICD-10 as F43.1; here find a summary of the PTSD information available on the Royal College of Psychiatrists website:

In our everyday lives, any of us can have an experience that is overwhelming, frightening, and beyond our control. We could find ourselves in a car crash, the victim of an assault, or see an accident. Police, fire brigade or ambulance workers are more likely to have such experiences – they often have to deal with horrifying scenes. Soldiers may be shot or blown up, and see friends killed or injured.
Most people, in time, get over experiences like this without needing help. In some people though, traumatic experiences set off a reaction that can last for many months or years. This is called Post-Traumatic Stress Disorder (PTSD).

PTSD can start after any traumatic event. A traumatic event is one where we can see that we are in danger, our life is threatened, or where we see other people dying or being injured. Some typical traumatic events would be military combat or a serious road accident or being taken hostage or being diagnosed with a life threatening illness.  Even hearing about the unexpected injury or violent death of a family member or close friend* can start PTSD.

The symptoms of PTSD can start after a delay of weeks, or even months. They usually appear within 6 months of a traumatic event.  Many people feel grief-stricken, depressed, anxious, guilty and angry. As well as these understandable emotional reactions, there are three main types of symptoms produced by such an experience:

  • Flashbacks & Nightmares – where people find themselves reliving an event again and again.  Ordinary things can trigger ‘flashbacks’.
  • Avoidance & Numbing – where sufferers avoid places and people that remind you of the trauma, and try not to talk about it.  Numbing is where people deal with the pain of their feelings by trying to feel nothing at all.
  • Hypervigilance – this is like being “on guard” all the time.

These symptoms can be accompanied by: muscle aches and pains, diarrhoea, irregular heartbeats, headaches, feelings of panic and fear, depression, drinking too much alcohol and using drugs.
Traumatic events are so shocking as they undermine our sense that life is fair, reasonably safe, and that we are secure. The symptoms of PTSD are part of a normal reaction to narrowly avoided death.  However not everyone will get PTSD after a traumatic experience.  Over a few weeks, most people slowly come to terms with what has happened, and their stress symptoms start to disappear.  However about 1 in 3 people will find that their symptoms just carry on and that they can’t come to terms with what has happened.  The more disturbing the experience, the more likely you are to develop PTSD.

Possible explanations for why PTSD occurs:
The first of these is psychological.  When we are frightened, we remember things very clearly. Although it can be distressing to remember these things, it can help us to understand what happened and, in the long run, help us to survive.  The flashbacks, or replays, force us to think about what has happened; we can decide what to do if it happens again. After a while, we learn to think about it without becoming upset.  Being ‘on guard’ means that we can react quickly if another crisis happens.
In terms of the body and its mechanisms, adrenaline is a hormone our bodies produce when we are under stress. It ‘pumps up’ the body to prepare it for action.  When the stress disappears, the level of adrenaline should go back to normal.  In PTSD, it may be that the vivid memories of the trauma keep the levels of adrenaline high.  This will make a person tense, irritable, and unable to relax or sleep well.

The hippocampus is a part of the brain that processes memories. High levels of stress hormones, like adrenaline, can stop it from working properly – like ‘blowing a fuse’. This means that flashbacks and nightmares continue because the memories of the trauma can’t be processed. If the stress goes away and the adrenaline levels get back to normal, the brain is able to repair the damage itself, like other natural healing processes in the body. The disturbing memories can then be processed and the flashbacks and nightmares will slowly disappear.

PTSD Critical view:

Rather than being something with an objective existence, whether identified by psychiatrists or not, the origins of PTSD are actually grounded in the political and social, emerging as it did during the fallout from the Vietnam War.  At this time returning American soldiers found themselves pilloried and marginalised.  The new diagnosis of PTSD shifted the emphasis from the brutal actions of soldiers towards the essentially traumatic experience of war.  The diagnosis bestowed victimhood and thereby moral exculpation.  Originally envisaged as being appropriate for application to only extreme and unlikely experiences, the diagnosis has come to encompass relatively common, albeit unfortunate, events (see * above).  Vulnerability, rather than resilience is now considered to be the norm.

Modern western culture has taken a direction whereby a nation is judged as an economy rather than as a society and where great disparities of wealth are tolerated and even argued necessary.  ‘Psychological thinking’, individualism and personal rights are increasingly prominent.  Grievances for life’s injustices under such circumstances are common and individuals largely tailor their behaviour to fit expectations.   In this way PTSD allows compensation to be granted in a socially acceptable way.
PTSD is also weak as a diagnostic category.  A psychiatric disorder is not necessarily a disease, but rather a way of seeing; throughout history people have had disturbing recollections and despair, but the idea of traumatic memory as a fixed, circumscribed, pathological entity separate from other varieties of psychological distress is recent.  Rather than representing, as one might expect from its separate categorisation , a entirely independent disease process, PTSD is grounded in phenomena which are shared by other psychiatric disorders.  It also lacks specificity as it fails to distinguish what is ‘pathological’ from ordinary distress.  Furthermore, its conception that the condition’s aetiology involves a single traumatic event from which all else follows is dubious given the influence that other factors must have over the development of the disorder, for example coping styles and previous psychiatric history.

PTSD is made rather than discovered, but once invented, it is hard to uninvent; each time a diagnosis of PTSD is made its existence is further solidified.


Further reading:

The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category BMJ 2001;322:95-98

PTSD: a critical appraisal

Article on Dr Pat Bracken and his book Trauma: Culture, meaning and philosophy

On the concept of trauma BMJ2009;339:B4577 – access restricted

‘One in four’

One in four of us have a mental health disorder. Ruby says it (and Stephen Fry too), so then it must be true. But has one in four people I pass in the street really got a diagnosable mental health problem? If this sounds like rather a lot, then it is: 15 243 750 people from the last estimate of the UK population.

I emailed the Time to Change Campaign to ask them where they got their numbers from and, seemingly unable to provide any hard evidence themselves, they pointed me toward the webpages of Mind, the Royal College of Psychiatrists and the Institute of Psychiatry. Pause for a minute to consider that a campaign that is happily promulgating ‘one in four’ via television advertisements and on London-wide posters is unable to produce simple evidence for it to an interested party on request. Of the three websites, that of Mind is the most helpful and points towards two surveys, the references of which are below. Both of them use population surveys to come their conclusions.

But before I get to that, think about this; in his book Blink: the power of thinking without thinking the eloquent Malcolm Gladwell essentially posits the following thesis: if you are faced with something and your first reaction is ‘that’s bollocks’ (my phraseology) then this inner voice should not be ignored; it well might be correct. I put it to you that ‘one in four’ statistic is just such instinctual bollocks and it is only because it is told to us by ‘experts’ and written all over our world that it is accepted as fact.

Because anyone like me who’s in the business of identifying mental health disorders knows one thing. Sometimes it’s very difficult to do and untangling symptoms of reasonable distress from those of functional mental illness is more often than not utterly impossible. I’ve written before about people whose ‘career’ as psychiatric patients involves being given a number of different classifications on which any two psychiatrists often disagree. What hope then for surveys whose aim is to tease out these same symptoms with scant regard to the whole person whose reasons meanings and circumstance will be complex and opaque? Thus ‘one in four’ is a vast overestimate reached in part as life is hard and distress but not ‘mental illness’ is widespread.

Sadly the more something is repeated, the more it is accepted as fact. And this is true doubly if it is coming from the mouth of a celebrity. But soberingly: even if these numbers are not real, they may be real in their consequences and in a world where 25% of the population is mentally ill, we get what we deserve. In the UK 2.5 million working age people are claiming disability benefits, and only 20% of people claiming these benefits will return to work within the next five years. This amounts to massive waste of potential and one which doctors are expected to police, despite often not even having received ten seconds tuition on the matter whilst at medical school or since.

Yes there is a significant number of people in the population with serious problems in their mental health, and yes, Time for Change’s aim to reduce mental health stigma is laudable. But their ‘one in four’ slogan is an untruth sold to them by foolish psychiatrists. Time for change indeed…


From the MInd site:

ONS 2000, Psychiatric morbidity among adults living in private households in Great Britain,
States that the number of people with a mental health disorder in the UK at any one time is 1 in 6 people. This number represents those with ‘significant’ mental health problems.

Goldberg, D. & Huxley Common mental disorders a bio-social model which uses a wider definition of mental illness and correspondingly provides us with a ‘one in four’


Derek Summerfield has written about similar especially with regard to the Layard proposals


Addendum 27 May 2009 The excellent Neuroskeptic has begun looking into this.  In his first posting he looks into the basis of the ‘one in four’ claim, and was unable to find the basis of the claim

What is mental illness, mental health, mental disorder?

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

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

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

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

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

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

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

Furthermore they state emphatically:

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

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

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

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

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

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

Further reading:

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

Also Wikipedia

Internet addiction? Bollocks more like

‘Internet addiction’ is in the news this week, as the authorities in China are threatening to recognize it as a clinical syndrome. It has steadily been accruing column inches of late having received a substantial profile boost in March when Dr Jerald Block suggested in an editorial American Journal of Psychiatry that it is a ‘common disorder’ and deserving of a place in the upcoming DSM-V.

It’s telling that internet addiction disorder (IAD) was originally proposed as a joke. In 1995 New York Psychiatrist Dr Ivan Goldberg decided to parody the complexities of DSM-IV by means of a disorder of his own invention, and was surprised when his bleary-eyed colleagues stepped forward as sufferers and asked him for help. Ironically in response Goldberg set up an online internet addiction support group. This apart, he remains a less than committed advocate. Here he is, talking to the New Yorker:

IAD is a very unfortunate term. It makes it sound as if one were dealing with heroin, a truly addicting substance that can alter almost every cell in the body. To medicalize every behavior by putting it into psychiatric nomenclature is ridiculous. If you expand the concept of addiction to include everything people can overdo, then you must talk about people being addicted to books, addicted to jogging, addicted to other people.

Although the rise and rise of the World Wide Web and its possible misuse is worthy of study and debate, I disagree with the classification of internet overuse as an ‘addiction disorder’. The concept contains so many holes, you could use it to strain pasta.

In a psychiatric sense ‘addiction’ is best applied to the use of psychoactive substances where it is described in terms of dependence syndrome. In brief: in order to keep us alive, the brain has evolved reward pathways which make us feel better about fundamental things that are in our interest, such as eating and sex. The trick that drugs such as heroin pull is to reward us in the same way for an activity that has no intrinsic value. Thus, for an individual, the taking of heroin then takes on a much higher priority than other behaviours, which once had a greater value. The presence of a withdrawal syndrome is also important.

An obsession with the internet shares few characteristics with a dependence syndrome. But this is only a small part of the folly of IAD. Framing overuse of the internet as a psychiatric condition, medicalises it and leads to us thinking about its treatment in terms of psychiatric interventions where more prosaic ones might be more appropriate. Here’s Block again, pen in one hand and in this other his prescription pad and section papers.

South Korea considers Internet addiction one of its most serious public health issues. Using data from 2006, the South Korean government estimates that approximately 210,000 South Korean children (2.1%; ages 6–19) are afflicted and require treatment About 80% of those needing treatment may need psychotropic medications, and perhaps 20% to 24% require hospitalization Am J Psychiatry 165:306-307, March 2008

You can almost hear the ambulance sirens. If something is sufficiently hazardous to require 1.6% of South Korea’s population of 6-19 year olds to take psychotropic medication, surely the authorities should think about banning it? And should we believe these figures? Block cites various symposia and reports, but little in the way of peer reviewed research. Any attempt to understand the natural history of internet overuse goes unmentioned.

Some of the strongest advocates for the IAD model are involved with selling addiction treatments and so cannot be regarded as unbiased. Dr Block owns a patent on technology that can restrict computer access. If we heed their advice mental health services will again recruit mildly dysfunctional people, for whom it can offer little help. More appropriate action would require looking into why some people appear more comfortable convening with a computer screen to the expense of other arguably more wholesome activities. I would not be at all surprised if provision for alternative activities in relentlessly urban Beijing or Seoul are lacking. Or that China’s brave new world requires many families to live apart and where their only communication is via the internet. For the totalitarian minded, It’s also a useful excuse for limiting internet access.

And even if none of the above objections were valid, the internet is not simply one thing to be addicted to, but rather a portal to allow a wide range of activities. As a media it can be no more addictive than a book, or as part of the social milieu it can no more be addictive than the air to breathe (that is, it is a category error – see comment below). And the question must be asked of how much additional information is convey in an IAD diagnosis, when the behaviour could more usefully be described in terms of more established diagnoses.



Wikipedia: Internet addiction disorder


The Times 11 November 2008 Internet addiction made an official disorder in China

China Daily 10 November 2008 Internet addiction ‘not just a bad habit’

BBC health 29 September 1999: Internet addicts ‘need help’

In support of IAD

Addiction Inbox: Internet addiction: A novel disease

Centre for internet addiction recovery

Criticism of IAD

PsychCentral 10 November 2008: China declares internet addiction, imprisons addicts

PsychCentral 18 March 2008: What’s that smell? Internet addiction disorder in the news

Mindhacks 20 August 2007 Why there is no such thing as internet addiction 16 December 2008 ‘Internet Addiction’ built on foundations of sand (thanks to Paul for this link)


Internet Addiction: Metasynthesis of 1996–2006 Quantitative Research

Online Information, Extreme Communities and Internet Therapy: Is the Internet Good for Our Mental Health?

Addendum 24 July 2009:

When we say something is real, it becomes real in its consequences:
Case study: Electric shock therapy in China for internet ‘addiction’
China bans electric shock treatment to cure internet ‘addiction’

Grand rounds and psychiatric diagnoses

A ‘grand round’ is a term used by doctors to describe a large meeting were doctors who work at the same institution get together and talk about doctory things. Mostly this involves a presentation of an interesting patient, with subsequent discussion. For the habitually parsimonious there is also an added incentive of a free lunch.

I won’t bore you with the fine details of grand round I attended today, but suffice it to say that it concerned a patient with a long psychiatric history who had had several admissions to psychiatric hospital. She had had a very difficult upbringing and, at various times, a pretty broad selection of psychopathology.

Following the presentation, there was a long discussion as to how best to formulate this patient’s problems and with this in mind, how she should be treated. There were five or so experts on hand, and the interesting thing was that they all drew different conclusions from the same information; there was, variously, an animated debate about the possible existence of a personality disorder, a stout defense of the presence of psychosis and suggestion of an affective disorder. One member of the panel, a chaplain but one of only two people in the room who had met the patient, didn’t think that the patient was mentally ill at all; he said this so politely that I didn’t realise at first.

It’s not unusual for a patient with a long term problem with his or her mental health to attract a selection of psychiatric diagnoses over the years. The odd one or two seem quite pleased about this, but I’m sure for most patients and their families this must be quite confusing. A psychiatric diagnosis is made by the elicitation of recognized psychiatric symptoms by (hopefully) a trained professional. There are no tests available and if the constellation of symptoms with which a patient presents changes (the so called ‘clinical picture’) then the diagnosis can also be altered. Diagnoses themselves are standardized in two publications, namely the ICD-10 and DSM-IV. These standards envisage the possibility of patients being given more than one diagnosis at the same time. Which leads to the interesting idea that more than one mental illness can exist in a single brain simultaneously.

That there are no tests, and that psychiatrists themselves find it difficult to agree about individual patients, has often brought into question the validity of psychiatric diagnoses. I will limit myself to two very interesting points here, one a study and one unfortunate woman.

Martha Mitchell, the unfortunate woman and after whom the Martha Mitchell effect was named, was the wife of the attorney general in Nixon’s government. She was considered to have a psychiatric disorder following her allegations of impropriety in Nixon’s government. She was right, and psychiatrists were wrong.

Around the same time as Watergate, in 1973, David Rosenhan conducted a study consisting of two parts. The first involved the use of ‘pseudopatients’ who briefly simulated auditory hallucinations in an attempt to gain admission to 12 different psychiatric hospitals in five different states in the United States. The second involved asking staff at a psychiatric hospital to detect non-existent ‘fake’ patients. In the first case hospital staff failed to detect a single pseudopatient, in the second the staff falsely identified large numbers of genuine patients as impostors.

So what are the use of psychiatric diagnoses at all? Paul and me have been having a polite discussion about this, and despite his making some good points I cannot see the whithering of the ICD-10 yet. Psychiatric diagnoses earn their keep by:

Enabling effective communication between professionals.

Helping avoid unacceptable variations in diagnostic practice.

And allowing more accurate discussion of treatment and prognosis.

But on the other hand they are reductionistic and stigmatizing.


Top tip: if you’ve attended a grand round solely to get the free lunch, then make sure you sit near the door, as the doughnuts go quickly.



Spurious precision: procedural validity of diagnostic assessment in psychotic disorders

Why has psychiatry become so dominant in mental health services?

Although psychiatrists cannot claim to ‘run’ mental health services, as things stand they take ultimate responsibility for the individual care of most patients in the mental health system. But good practice in mental health care involves more than just psychiatrists, and other professions such as psychologists and mental health nurses, could also make a valid claim to be in charge of patient care.*

The status of doctors in the treatment of mental health is actually historic. At the time of the establishment of asylums there were no effective treatments on offer for psychiatric disorders so doctors’ medical qualifications were irrelevant. However doctors’ social standing and accountability meant it was felt that they would be effective guardians of against abuse of patients.

One argument for the continuing prominence of psychiatry is the overlap between mental and physical diseases. For instance, thyroid problems can mimic depression and the argument runs that a psychiatrist should be on hand to identify these instances. This argument is not especially solid, as although physical problems are occasionally picked up by psychiatrists, general practitioners should sift these problems out before referring to psychiatrists.

A second argument is that ‘medical model’ of psychiatry is successful at treating mental illness. This is not just simply prescribing drugs for patients, as this could be done by doctors without their current status, but also that a doctor brings to the table a pragmatic approach to the treatment of patients that draws on scientific method. Although the medical model is much maligned, as being too narrow and too dominant, it also entails a benign paternalism and a willingness to accept responsibility, which some, but of course not all, in their time of sickness may welcome.

Consultation by a doctor is often valued by patients and staff alike despite the fact that a lot of patients are seen by psychiatrists do not have problems related to anything that could be characterized as an ‘illness’. Why this should be so has societal roots beyond the scope of this piece. It has not been unusual for me to be asked to give a ‘doctor’s opinion’ on matters of importance when there is no obvious reason for why I should be qualified to do this, except a willingness to stick my neck out. When working in the community I have often felt that, as many people with mental health problems often have very unsatisfactory social situations, patients would be better off seeing a social worker once a month who could then refer onto me if necessary rather than the current situation which is the other way around.

* I am aware the situation is more nuanced than this paragraph portrays. In a CMHT, many patients will go nowhere near a psychiatrist; furthermore the new mental health act contains provision for other professions to become patient RMOs.

Someone who doesn’t agree with this post….

ADHD, Pamela Stephenson Connolly and what are psychiatrists for?


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



I was at a course the other day and someone piped up from the back:

‘In an ideal world everyone needs a counsellor, that they can talk to every week about their problems’.

I expect that quite a lot of people would agree with this statement, but not me.

Different psychotherapies (‘talking therapies’) are easily confused and I’m not talking about directed therapies such as cognitive behavioural therapy, family therapy or behavioural therapy.  These therapies are aimed at specific psychiatric conditions, are goal directed and administered by trained practitioners.  

Counselling on the other hand is difficult to define, and tends to be performed by those with limited training and aimed at people without strictly classifiable mental health problems.  As such it seriously encroaches on normal experience and the implication of the statement above is that people going about their everyday life need professional help to deal with common problems of everyday living.   

There is little evidence that counselling helps, and some evidence that it actually makes people worse.  There is a danger that attending a counsellor for a problem will introduce the expectation of experiencing distress and in some way validate it.  Some people regard simply attending counselling as a mentally healthy thing, but is airing your problems suitable for everyone, and could it be that people attend counselling as a proxy for real action?  Counselling is popular and this is given as justification for it continuing to be available, but what people want and what’s in their best interests is not always the same thing. 

An argument could be made that the counsellor is taking the place of the parish priest in these godless times.  With many of my patients I feel that what they really need is some good friends, who can offer support, sympathy and real world feedback.  Friends are also a lot cheaper.

From Will Self