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

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

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

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

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

More reading:

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

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

I did swear to myself recently that I wouldn’t write any more posts about celebrities and their mental health problems, but then David Duchovny started saying he’s a sex addict and I have a problem with this.

The word ‘addiction’ hasn’t an exact or agreed definition either within common or medical usage, but is normally applied to the use of psychoactive substances, and, called dependence syndrome; its use in psychiatry implies:

A cluster of psychological, behavioural and cognitive phenomena in which the use of a substance or a class of substances takes on a much higher priority for a given individual than other behaviours which once had a greater value.

For the diagnosis to be robust there needs to be accompanying evidence of difficulties in controlling behaviour despite clear evidence of consequences, and increased tolerance to the substance, a withdrawal syndrome and progressive neglect of alternative pleasures. A good example would be someone who is dependent upon alcohol; you can readily observe the effects, a complete deterioration of self control in pursuit of drunkenness, on a street near you.

An obsession with sex shares few of these characteristics, and its classification as a disorder offers a comforting cushion for those whose behaviour has landed them into trouble. With this narrative, wherein greedy behaviour is rebranded as a disorder, the afflicted can neatly sidestep responsibility and jump straight into the sick role.

Regrettably the more this line is trotted out by popular press, supported by some psychiatrist and psychologists, the more the approach is normalized and what develops is a popular narrative and language for describing behaviour in pseudo-medical terms that which would once have been viewed as an issue of self control and personal failing.

Wikipedia page

BBC Magazine - Does sex addiction exist?

Addictions.co.uk (sponsored by the Priory)

Here’s the Oxford English Dictionary on ‘men in white coats’:

men in white coats n. (a) medical or laboratory staff, esp. doctors; (b) psychiatrists or psychiatric workers, usually (with humorous exaggeration) referred to in order to imply a person’s supposedly imbalanced or deluded state of mind.

The dictionary has this to say about the first use of the phrase:

1961 W. FENNELL Dexter gets Point 135, I think I’d better phone the man in the white coat.] 1967 L. ANDREWS Hosp. Circles ii. 33 He did not wake when the usual procession of night sisters and men in white coats came in and out. 1968 D. HELWIG in Sat. Night Mar. 37/3 They’re going to put you in jail, do you know that? Or they’re going to send the men in white coats for you.

Of these the third by Helwig would be the most recognizable in the vernacular.  I’ve no idea who he or she is or was.

A famous use of white coat in reference to mental health was by ‘Napoleon XIV‘ in the popular 60s novelty hit ‘They’re Coming To Take Me Away, Ha-Haaa!‘ which includes the lyrics:

They’re coming to take me away ho ho hee hee ha haaa!
To the funny farm,
Where life is beautiful all the time.
And I’ll be happy to see those nice young men
In their clean white coats,
And they’re coming to take me away ha haaa!

I’ve actually never worn a white coat as a doctor, although I was forced to wear one as a student.  More socially, I did wear one on the 2007 RemedyUK London March and made it onto the background of a report on Channel 4 news to other people’s hilarity.  This aside,  they’re uncomfortable, hot and unless changed every day, potentially rather dirty.  I suspect that doctors used to wear them to give themselves an air of professional expertise and that their demise has been as much about fashion and the breaking down of barriers between healthcare professions as much anything else.

If anyone knows any more about the use of white coats in psychiatry, then please comment below.

The other night I tried to get a cup of tea in Hoxton at nine thirty pm only to be told to piss off by a spotty barman who was so rushed off his feet that he could barely be bothered to look up from his fashion magazine. There was no end of exotic cocktails on offer, but seemingly no demand or no desire to serve me something less intoxicating.

It often seems to me in London that we don’t like non or even moderate drinkers. On at least one occasion I’ve taken to hiding pints of beer under my seat, bought for me despite my protestations that I didn’t want a fourth a fifth or a sixth. We’re suspicious of the sober as if they don’t they want to have fun. Or perhaps jealous of how they can have fun without the lubricant we need? Save tea, there’s nothing else which glues British society together like alcohol. New addition to the family: let’s wet the babies head; someone died: let’s drown our sorrows. Any excuse will do. As Reverend Sidney Smith said:

What two ideas are more inseparable than beer and Britannica?

I am not, of course, against having fun. But with alcohol we’ve been sold a sort of fun without due consideration for the harm it does to the individual or wider society. There appears to be no objective appraisal of the dangers of drinking large amounts of alcohol, and a blindness to the sheer horror of town centres rendered no-go areas to families every night of the week due to alcohol fuelled antics. When it comes to alcohol, threats are downplayed and benefits lauded.

Indeed, next time someone boasts to you ‘I was so drunk that I could hardly stand’, take a step back and think about what a bizarre statement this really is, and how we can arrived at a place where this is regarded as an achievement. Generally people like to boast about their abilities like how many hot dogs they can eat, or Munroes they’ve bagged, yet with alcohol it’s the opposite – how much you can’t do. And we all laugh along. It’s clear that excess drinking isn’t just about the behaviour of individuals, but occurs within a social and economic context.

Supermarkets are selling alcoholic drinks at prices cheaper than bottled water. Bars are vertical drinking establishments, intoxicating people to the point of unconsciousness, before ejecting them (sometimes rather forcefully in my experience) onto the street for the ambulances to scrape up. The Government finds itself conflicted – it makes money from taxes on alcoholic drinks but also finances the NHS. Famously, before the 2001 election the Labour Government sent out a text message to its young supporters encouraging them to vote Labour on the basis of a relaxation of the licensing laws. In a way so are psychiatrists; if you guys didn’t drink so much booze quite few of us wouldn’t be needed….

Here are some facts, gleaned from Institute of Alcohol Studies factsheets:

• There are significantly more premises licensed to sell alcohol than 20 years ago. The licensed capacity of premises in the centre of Manchester increased by 242% between 1996 and 1999. This expansion has led to more competition,including heavy discounting, which is associated with binge drinking and increased drunkenness.
  (Interim Analytical Report. Strategy Unit Alcohol Harm Reduction Project. Strategy Unit 2003)
• Between 1980 and 2003 the price of alcohol increased by 24% more than prices generally. However, households’ disposable income increased by 91% in real terms over the same period, making alcohol 54% more affordable in 2003 than in 1980 (Statistics on alcohol: England, 2004. Department of Health. Office for National Statistics Statistical Bulletin, 17 September 2004)
• In 2001, £36,636,000,000 was spent on alcohol, equivalent to 5.8% of all consumer expenditure.
• Britons spend around £17 billion in pubs each year. In 2002, the nightclub market was worth £1.7 billion.
• In comparison, Britons spent £7.2 billion on activities such as going to the cinema, theatre, museum and bingo combined. £7.4 billion was spent on gambling in 2002.
  Source for above three
• The Strategy Unit calculated that for England and Wales the costs of some but not all adverse consequences of alcohol consumption to be in the region of £20 billion.
  Strategy Unit: Alcohol Misuse: How much does it cost? September 2003
• Of the 580 deaths in drink drive accidents in 1996, 59 per cent were drivers or riders over the limit and 41per cent were innocent victims.
  (Tomorrow’s roads: safer for everyone. The Government’s road safety strategy and casualty reduction targets for 2010. DETR March 2000)
• Up to 1,000 young people a week suffer serious facial injuries as a result of drunken assaults. 18,000 young people are scarred for life each year.
  (D Campbell. Name Your Poison. The Guardian 8 June 1998. Cited in ‘Taking Stock:What do we know about violence? ESRC Violence Research Programme HMSO 1998)

And I haven’t even touched here on the damage done to individual families and health by dependence and overconsumption.

I’m rather hoping that someone is going to do something about this soon. There’s a lot that can be addressed if the Government and local councils have the stomach for it. Reining back the number of licensed premises, reducing the duty free allowance are two. An important step one was illustrated to my way home on the tube the other week (my bike is broken), when I saw this advertisement:

Advertising’s aim is to sell more alcoholic drinks. Otherwise producers would spend their money on something else. You can see that is says in very small letters that we are recommended to drink responsibly. In much bigger letters the advertisement wishes to plant in our minds that drinking Gordon’s Gin is for the exceptional and those aspiring to greatness. Other advertisements for other drinks show attractive people leading desirable lifestyles. There has been concern that these advertisements disproportionately influence the young.

It’s hard to miss the parallels with the advertisement of tobacco products, which have been banned for the past few years. Alcohol advertisements should be banned also.

More information:

Today Programme report - 0814 23 July 2008 - UK hospital admissions due to alcohol have increased markedly compared to 13 years ago.

Alcohol: The world’s favourite drug Griffith Edwards

.

“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’

Buy on Amazon

Notes:

1. Anyone who reads this blog regularly may have noticed that I’ve been reading a lot of books recently; I am allergic to the summer you see and am on a quest to read every book ever written about psychiatry ever…
2. If you can’t be bothered to read this long review there’s a summary paragraph at the end. (But make sure to read the quote about Nixon)
3. I’ve not found any other psychiatrists’ reviews of this book. If you know of any please add a comment!

Medically trained and Foreign Secretary to the Callaghan Government, David Owen must have felt born to write this book, an exploration into the ailments of heads of governments during the past hundred years. It’s part insiders’ guide, part medical sleuthing and Owen admits to playing his own version of ‘guess-the-disease-of-the-person-opposite-on-the-bus’:

In February 1984 when attending Andropov’s funeral and after shaking hands with the new President, Konstantin Chernenko, at a reception in the Kremlin, I mentioned to a journalist that it was clear to me that Chernenko, then seventy three, had emphysema. The aside was soon flashed around the world, somewhat to my embarrassment.

‘In sickness and in power’ breaks down four ways. There are two round-up chapters detailing the problems of leaders 1901-1953 and 1953-2007 respectively, four in-depth case studies where Owen judges that leaders’ ailments may have landed them in particularly hot water, a detailed breakdown of the events surrounding the war in Iraq and finally Owen’s recommendations for the future.

The first two chapters are strongest. Did you know for instance that some American psychiatrists consider it highly likely that 26th US President Theodore Roosevelt suffered from bipolar affective disorder? Or that Ronald Regan was showing early signs of Alzhemier’s disease whilst still President? In the 1901-1953 chapter we learn of France’s clearly mentally deteriorating President Paul Deschanel:

Soon after his election … rumours of extravagant behaviour started circulating. He surprised crowds, for instance, by enthusiastically kissing the mouth of a First World War Soldier who had a severely mutilated face. Then, on 23 May, Deschanel disappeared from his presidential train while travelling from Paris during the night. He had either fallen from an open window … He ended up in this night clothes and with blood on his face in a gatekeeper’s house at a railway crossing. His assertions that he was the President of the Republic and had fallen off the train were met with hilarious incredulity until a doctor, who was called in, recognised him.

Around the same time 28th US President Woodrow Wilson had a stroke leading him to develop a paralysis of the left side of his body and a neglect syndrome. Rather than standing down, the obvious thing to do for a man who was subsequently unable to hold a cabinet meeting for seven months, Wilson’s personal physician informed his colleagues that he was simply suffering ‘nervous breakdown, indigestion and a depleted nervous system’. Owen speculates as to the consequences of this action; thinking that, had Wilson resigned, his healthier Vice-President may have been able to persuade Congress to ratify the treaty establishing the League of Nations and that this in turn might have helped prevent the Second World War.

The Nixon in Owen’s book appears dangerously unhinged; here’s Owen quoting journalist James Reston:

Between 9.22pm on 8 May and 4.22am on 9 May 1970, Nixon made 51 telephone calls to members of his Cabinet, his staff, magazine editors, Foreign Service Officers, newspaper reporters, repeating calls to one or the other, talking about his family, his grandparents, the civil war – sort of a sleepless, compulsive nightmare of a talk – after which, to the consternation of the Secret Service, he got into his car at dawn and drove to the Lincoln Memorial to argue with the startled young people who had come to Washington to demonstrate against the invasion of Cambodia.

The case histories are of Anthony Eden’s illness during the Suez Crisis, US President John F Kennedy’s Addison’s disease, leukaemia affecting the Shah of Iran and President Mitterrand’s prostate cancer. In all four cases the voters were unaware of the state of their leader’s health.

For Eden a botched cholecystectomy lead to severe pain and he was hospitalized with a high fever at the height of the Suez crisis. JFK was taking cortisol replacement for adrenal insufficiency, strong analgesia for chronic back pain and had a rather shady doctor who provided him with amphetamine on demand. Owen makes a direct connection between JFK’s shambolic medical treatment and the Bay of Pigs fiasco, and contrasts this to his much more measured performance during the Cuban Missile Crisis, when his care was much improved.

The Shah of Iran was diagnosed with leukaemia in 1974, but this was only known to a very small number of people for the next five years. Bringing in a personal dimension, Owen states that as British Foreign secretary from 1977-79 he would have encouraged the Shah to stand down had he known of his condition. He links the Shah’s inability to handle events to the Islamic Revolution, and thereon a potentially avoidable government that has contributed to the continuing instability of the Middle East.

Mitterrand gained the French Presidency on the understanding that there would be full transparency regarding this health. Of course ‘transparency’ as others might know it and ‘transparency’ to a man who had a secret second family who followed him around in a second plane on state visits, proved to be two different things. ‘The Sphinx’ managed to get his personal physician to sign a clean bill of health, presented to the French people, for many years before coming clean.

Part three is called ‘The intoxication of power’ and there’s a chapter on Iraq, which is a distillation of Owen’s other book The Hubris Syndrome. Here Owen painstakingly charts the discussions and resolutions of major players in the run up to the conflict. This was rather dull, full of the minutiae of the interactions of diplomats and politicians. In this chapter as well as throughout the book, Owen is not content merely to document events and maladies but instead proposes his own syndrome – ‘Hubris Syndrome’. A half way house between a medical condition and a rhetorical device, from the man who almost called the SDP ‘New Labour’. Hubris syndrome is all about people in positions of great power getting too big for their boots. In the introduction Owen gives us a list of symptoms which characterise this. Here are the first four:

A narcissistic propensity to see the world primarily as an arena in which they can exercise power and seek glory rather than as a place with problems that need approaching in a pragmatic and non-self-referential manner

A predisposition to take actions which seem likely to cast them in a good light – i.e. in order to change their image

A disproportionate concern with image and presentation

A messianic manner of talking about what they are doing and a tendency to exaltation.

There was something about Hubris Syndrome, which every time it was mentioned almost compelled me to throw ‘In sickness and in power’ out of the window, or at least turn to the person next to me in the bus for solace. I don’t doubt that powerful politicians may act in particular ways. I, for instance, might start to think I was superhuman if, like Tony Blair, I didn’t have to wait at a traffic light for ten years. I do not think that his counts as a disease, as to make a convincing case any proposed illness should have (at least a stab at) an aetiology, an incidence, and a population distribution to name but three. Owen makes almost no attempt to frame hubris syndrome in this way and, irritatingly, always refers to it as if it were something that had an existence outside the confines of his book.

The book finishes on some sensible and interesting points on how illness in heads of government can be protected against by the use of independent medical assessments and, in the case of hubris syndrome, strengthening democratic checks and balances.

So, if you’ve read the first two paragraphs and are now skipping to the end: This book has some fascinating chapters about illnesses suffered by heads of state and the effects their maladies had on themselves and on their governments. Towards the conclusion it loses its way and has a very boring chapter on Iraq. Throughout Owen compares his protagonists for signs of a set of behaviours he calls ‘Hubris Syndrome’. I am not convinced that he makes a strong case for this being a disease.

Margaret Cook review A Doctor in the House in The Guardian 5 April 2008

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

theguardian online today has a story on its main page which is titled ‘Why smiles are better than Prozac’

On closer inspection, it’s less an article, more an advertorial for a book called ‘Beating stress, anxiety and depression’ by Jane Plant and Janet Stephenson.  The  article says that the book is ‘new’ but the amazon.co.uk page says that it came out at the beginning of May this year.  I can only imagine that they were short of copy and rehashed a press release that they found knocking around the office.

Be this as it may, this is the sort of thing that catches my eye.  The introduction is available for perusal online, and Plant and Stephenson say some sensible things - like advising us to ignore celebrity culture - but I am concerned about some of the things they say particularly when they assert that levels of neurotransmitters should be assessed in patients suffering from depression.  The neurotransmitter hypothesis is problematic, as discussed by Badscience.net and Mindhacks.com, and this sort of test are likely to be more expensive than meaningful.

Daily Mail article on the same book title: ‘How the wrong drugs could be causing your depression’.

Best read it before I comment further.  If anyone has read it and would like leave a comment below I would be most grateful.

Also in the paper today Rachel Cooke has this to say about reality TV and meeting Jodie Marsh

What strikes you most about Marsh when you meet her is not her pleasure at the unexpected turn her life has taken, but her implacable anger…..(about four paragraphs)….I’ve lost count of the number of times youth workers and criminologists alike have made the connection, as they discuss knife crime, between low self-esteem and anger. Well, there is an awful lot of anger among those who participate in reality TV, the majority of which, it seems to me, is the result of low self-esteem, and Marsh is no exception.

BBC From our own correspondent ‘A shoulder to cry on in Baghdad’ - Psychiatrists in Baghdad 31 May 2008

(From our own correspondent homepage)

‘How Britons get high - drug users tell their stories’  Observer 20 July 2008