The writer Will Self came to talk at a conference I organised in November 2010.  Here is a transcript of a conversation we had.  I started off by asking him about the Quantity Theory of Insanity, which was one of his first published works. 

SG: What was the inspiration for your short story the Quantity Theory of Insanity?

WS: Well, it’s a long time ago…

SG: Eighteen years ago?

WS: The story was written in 1990, more like twenty years ago.  All sorts of things came together in that story, but the most significant things were an exposure to the psychiatric ward at the Royal Free hospital in the 1980s.  At that time one of the consultants there was the father of somebody I’d been to school with. When I was growing up there was a psychiatrist who lived in the house behind ours and her son had a flamboyant psychotic breakdown when I was in my teens.  And I grew up around – this was the Hampstead Garden Surburb – the fringes of mental health professionals of various sorts and kinds and so had an awareness of the wider culture surrounding that. 

It struck me as an interesting conceit, that a lot of – but I‘m thinking more of another story in the collection called Ward 9 in which a ward in the hospital – it’s called ‘Health hospital’ in the books, but it’s based on the Royal Free hospital – in which a psychiatric ward in the hospital is full of the children of mental health professionals.  That relates to the Quantity of Insanity which in a way is an aggressive synthesis of RD Laing and Milton Freedman. 

There’s a classic study of suicide in Sweden, that some people have said seemed to conform to some of the outlines of the Quantity theory of insanity although I hadn’t read it and I didn’t know about it when I wrote the story.  The Quantity theory of insanity states that there’s only a given quantity of mental ill health to go around or a given quantity of sanity in any given society or societal group at any given time.  So if you palliate one group of mentally ill people inevitably a different mental illness will crop or up or maybe the same one in a different cohort of the population. 

My inspiration for that was more Milton Friedman’s work on the classical quantity theory of money, which was something that was very much in the air at that time because monetarism was one of the keystones of the second Thatcher government.  So it was a kind of unholy miscegenation between economics and some of the more radical theories about mental health propagated by some of the 1960s anti-psychiatrists.  So that was the intellectual and personal background to the story. 

SG: I got the feeling reading the story that you’d actually done quite a lot of reading on how psychiatric research is conducted.  Is that something you picked up by osmosis? 

WS: Yes I picked it up by osmosis.  I certainly knew how a scientific trial is conducted and my closest friend at school went on to become a psychiatrist and is now a consultant.  He’s helped me with my stuff over the years.  And I’m reasonably well read on some of the literature but not exhaustively, because one doesn’t as a layperson. 

SG: The interested difference between our viewpoints is that we’re very directed in terms of what we read about psychiatry and we’re moulded by our profession, whereas you as an outsider looking in, but nevertheless an interested one, would have a different viewpoint and be freer to come to your own conclusions

WS: A bit is not the right qualifier there! It’s not only the psychiatric profession that is guilty of a degree of professional closure, not only in terms of what it’s allowed to treat but also in the sense of mental closure.  All other professions are engaged in the kind of canalization and a certain blinkered view of what it is they do. 

The advantage of being a novelist is that we’re interested in everything, so by definition we shouldn’t be blinkered in that way.  And I think that psychiatry is increasingly interesting because of various things that have happened in our society over the twentieth century, the way in which we have come to regard mental ill health and the increasing specialization and pathologization of certain kinds of conduct and that’s what got me interested in it from the get-go. 

I studied philosophy in university and I come to psychiatry from Nietzsche rather than from medicine.

SG: It’s interested you should say that because generally speaking a psychiatrist doesn’t read much philosophy.  It’s often a very medical role of identifying symptoms, putting them into symptom clusters and then moving onto treatments.  Your view of psychiatry is quite different in that it’s very much from first principles.

WS: Yes, I was reading an account written by two doctors about a mental hospital in north London.  They make the observation – this is a book written in the 70’s – that in that era a psychiatrist wouldn’t physically examine a patient.  My impression is this still often happens.  The psychiatrist, although qualified as a medical doctor, has moved into psychiatry to stop laying on hands. 

If you say then “I’m interested in first principles”, I’m not just interested in looking at sets of symptoms and getting them to conform or not conform to pathologies. I’m interested in what psychiatry is in the wider sense.  What it is that psychiatrists are doing and how they relate to the other healing professions and how they relate to society’s expectation of itself.  Society’s own self regard.

SG: In your book Junk Mail you met Thomas Szasz, I’d love to meet him.  Although with his age it’s becoming increasingly unlikely. 

WS: He’s still very active.

SG: How was your meeting with him?

WS: it was a long time ago, seventeen years ago.  I wrote to him.  He had a book out called Our right to drugs and I went and interviewed him for the Times in Syracuse where he was attached to the medical centre there.  I’d read the Myth of mental illness before that and others of his books and was interested in him as a sort of Hungarian/Viennese/ American version of Ronnie Laing.  With the Myth of Mental illness perhaps standing in some relation to The Divided Self.

I wrote in my latest book (Walking to Hollywood) about meeting Szasz.  If you’re interested in my thinking about psychiatry over the years a lot that it is worked into this book.  It’s a fictionalized memoir so some of it’s fictionalized and some of it is not.  The meeting with Szasz is a mixture of fiction and fact.

SG: Does he appear in that book as a character?

WS: He does.  I’ve always had a character Zac Busner.  He appeared initially in the Quantity Theory and he’s in a lot of my books.  He’s a psychiatrist and he is the most consistent fictional character in my work overall.  He’s like a sort of practical philosopher he has a shape shifting quality, I suppose to express my view of the psychiatric profession as being our equivalent in secular society of a priesthood.  He has a shape shifting and hieratic character to stand for these different things.  Sometimes he seems more based on the neurologist Oliver Sacks and sometimes he appears more like Ronnie Laing.

SG: Why do you equate Psychiatrists with priests?  A lot of people equate GPs with vicars, why do you see psychiatrists as more in this vein?

WS: I think because in a sense Freudianism has been so successful in the West.  It really has, what’s interesting is that even psychiatrists who feel themselves to come from a hard scientific background, and feel themselves to have no truck with the ‘talking cures’, nonetheless are unable to evade Freudianism in all sorts of ways and are unable to evade the presumption that there is a sliding scale between relatively minor neurotic symptoms and major psychoses. And that means that psychiatrists stand – whether they acknowledge it themselves and whether people collectively acknowledge it- at the threshold between happiness and sadness and between sanity and madness, between the particular and quotidian and the transcendent.  This is a priestly role.  You might say that a GP occupies a ‘vicar function’ and but I’m thinking more of the old religion, in terms of priests who manage the transition from the phenomenal to the numinal.

SG: Almost as if we stand at the gateway, saying “you’re normal, but you’re supernatural”.   And we hold the key to that.

WS: Yes, whilst neurosis is in some ways rejected and stigmatized, in many other ways it’s embraced.  We have a culture of ‘compliant neurosis’.  These two readings which are sometimes directly contrary to one another are quite present in our culture.  In some ways psychosis is revered.  It’s our version of ecstasy.  There are all forms of experience that either are genuinely psychotic or verge on the psychosis.  They are revealing.

SG: One last question, if you had one piece of advice to psychiatrists what would this be?

WS: I’m very concerned about the prescription of SSRIs to everyone in our society.  It’s just the latest, pill fad.  They occupy the same role as baribituates did in the 1950s or benzodiazepines did in the 1960’s and 1970’s or tricyclics did in the 1980s and into the 1990s.  But I see so many people who are suffering from long-term SSRI use for all sorts of reasons.  Because of the very fact that they work on what used to be considered ‘exogenous depression’ – in other words they work to alleviate the subjective experience of unhappiness which should be felt – that they represent a very dangerous evolution in neuro-pharmacology. 

I don’t actually think that psychiatrists are usually responsible for writing too many prescriptions for SSRIs, I think that GPs are more to blame.  If I were a member of the psychiatric profession I would make it an imperative to open a conversation in society about the use of these drugs. 

Photo credit

Also published on BMJ blogs

I learnt some interesting facts about mobile phones the other day. For instance, there are 59 countries where mobile phones outnumber people. This refers to mobile phones actually in use, rather than forgotten ones in drawers, under sofas, or in the glove compartment of your car.  Worldwide there are six trillion texts sent a day, about which unexceptional Western teens are exceptionally keen as they send/receive an impressive 3,400 per month.  The average user of a mobile phone looks at it 150 times a day.  That’s every 6 minutes 30 seconds. 

We’ve known for while that mobile phones, and their newer, cleverer brethren “smart phones” are really going places.  They’ve become essential to our lives, supplanting other objects in our affections, as observed (tearfully?) by Jeff Hazlett, former CMO of Kodak. 

“Photographs used to be the item people would run into a burning building to go retrieve; today a mobile phone has replaced that”

Even a fairly humdrum smart phone now packs a terrific amount of computing power. Beyond making voice calls the initial uses of these phones were fairly unimaginative.  Since then a combination of advancing phone functionality and imaginative third party “apps” points to a future where mobile phones are not only ubiquitous but will be increasingly relied upon to help us to interact with, and make sense of, the world.  They also have a potential to substantially alter the practice and potential of healthcare. 

Key to this transformation is that smart phones can interact with the world around them. The first generation of mobile phones received input solely through a keypad. Today, just like me, my phone can see and hear, and can detect motion and direction.  Using an app like Layar I can overlay digital information onto my phone’s field of vision. Using SoundHound, it can tell me which song is playing on the radio. My maps app means I never get lost. 

So far, so useful, but my phone can also communicate with other devices wirelessly–something that exceeds my human capabilities.  This is already allowing smart phones to subsume the function of a credit card or a set of keys.  Using the same technology in the near future the world has the potential to become an “internet of things,” a huge network of interconnected devices. 

Imagine your ever smarter handset telling you that you have a window left open at home and asking you whether you wish to switch off your heating, or reminding you that your car is short on fuel. From here it’s almost no leap at to see a patient with coeliac disease scanning every item in a supermarket before purchase to ensure it’s compatible with their diet. Or to imagine a world where wearable sensors, that will allow us to routinely monitor our wellbeing, are commonplace.  If your heart beat rises unexpectedly, your phone will ask you if you’re stressed and advise you to take a break.

In many ways this all sounds fantastic, as it offers opportunities for the early detection of disease and for promotion of healthy living. I’m not sure I personally welcome a coming world where my phone moonlights as my super-ego, or where my body is viewed as simply being a more intimate extension of my social network. However even I can see it would be useful if my running shoes could tell me when they’re worn out.

Interesting link:  the future of health

Photo credit

Image credit

War may not be good for much, but it has proved to be an effective incubator for innovation. I’m not just talking about the Slinky: the development of nylon, polythene, and aerosol sprays also benefitted from conflict.

The urgency of war has also lead to many of the most important innovations in medicine. It was the battlefield surgeon Ambroise Paré who in the 16th century introduced the ligature of arteries (instead of cauterization) during amputation. An effective treatment for leukaemia emerged from nitrogen mustard’s use as a poisonous gas and Dwight Harken operated on wounded D-Day soldiers and demonstrated that shrapnel could successfully be removed via open surgery to the heart. 

A recent Royal College of Surgeon’s event, “Disability and the military,” discussed medical progress emerging from more recent conflicts. Most notably the chance of surviving an injury during combat is now much improved. During the Second World War wounded soldiers had a one in three chance of dying. Today this figure in Afghanistan is less than one in ten. 

Speaking at the event orthopaedic registrar Major Arul Ramasamy attributes this improvement to a variety of factors. Body armour plays an important role, as have improved helmets and ocular protection. The “continuum of care” is also vital. Treatment now starts the moment an injury is sustained, as all deployed troops are trained in battlefield first aid and carry tourniquets and haemostatic dressings. “We’re bringing some of the stuff that was always left to the hospital out to the battlefield,” said Major Ramasamy. 

The injured are evacuated quickly and soldiers receive medical attention, including blood transfusions, on the evacuation helicopter. On arrival at Camp Bastion the team aim for rapid surgical decision making. “The fastest time I’ve seen from a patient arriving to them being operated on is 45 seconds” said Major Ramasamy. To a psychiatrist like me, even thinking about this sort of speed makes my head swim. 

Soldiers are now living with injuries that five years ago were considered unsurvivable, such as the loss of two or even three limbs. This brings its own challenges and physically surviving such injuries is only the beginning of a long period of recovery. 

David Richmond, an army colonel wounded in Afghanistan, also spoke at the event about his own recovery and that faced by others. The majority of the injured are very young and “under different circumstances they would be in the 6th form at school” he said. “To have your life tipped upside down at that point of your life when you haven’t really worked out who you are in the first place is much more a battle of mind than it is a battle against injury.” 

Much of the provision for long term rehabilitation comes from the charitable sector with the Royal British Legion and Help for Heroes providing facilities such as Tedworth House. Colonel Richmond was keen to stress that injured soldiers are capable of much, including outdoor activities, and that one of the challenges of rehabilitation is persuading them of this. 

It remains to be seen how far the advances in treating battlefield injuries will translate into improved civilian trauma treatment as the advanced continuum of care the military can offer is unlikely to be replicable on civvy street.  Few civilian casualties, for instance, find themselves injured whilst standing next to friend trained in first aid.

Also published on BMJ blogs

Fregoli delusion is a delusional misidentification syndrome which describes an individual’s mistaken belief that different people are in fact the same person in disguise who is able to change their appearance.  Misidentification syndromes all involve a belief that the identity of a person, object or place has somehow changed or has been altered.

The Fregoli delusion was first described in 1927 in the paper Syndrome d’illusion de Frégoli et schizophrénie.  In it the authors described a case of a 27-year-old woman living in London who believed she was being persecuted by two actors she often saw at the theatre. She believed these people pursued her, taking the form of people she knew or met. 

The Fregoli of the delusion’s title refers not to the authors, but more modestly to an Italian actor, Leopoldo Fregoli, who was renowned for his ability to make quick changes of appearance during his stage act.  In the Fregoli delusion the sufferer often thinks that they are being persecuted by the misidentified person. 

Whereas the similar Capgras syndrome involves an under-identification of people and places and it has been postulated that this syndrome results from the inability to match current experience to autobiographical memories.  Fregoli delusion conversely involves over-identification and a seeming confabulation of resemblances between the misidentified entity and the original, so this explanation is not as satisfactory. 

I found this paper offers which offers half an explanation:

A partial answer … may come from Rapcsak and colleagues  who described a patient without prosopagnosia who displayed false recognition (over-identification) of faces following the surgical removal of a right pre-frontal lesion. They attributed the patient’s pattern of impairment to an intact reflexive face-recognition system but an impaired reflective or strategic face-processing system, leading this patient to mistake an unknown face for one in memory. This kind of defect might explain some instances of visual over-identification of faces. This account still does not explain selectivity, refractoriness, delusional nature, or multimodality.

Links:

Case Report: Fregoli Syndrome: An Underrecognized Risk Factor  for Aggression in Treatment Settings

A case of ’subjective’ Fregoli syndrome

Fregoli syndrome

This was originally published on BMJ Blogs

Established on 15 October outside St Paul’s and watched over by a statue of Queen Victoria, the Occupy London Stock Exchange (LSX) camp continues its controversial settlement in central London. 

Paul, a doctor whose day job is as a sexual health specialist in South London, shows me around.  For a movement with no apparent leadership, lurking somewhere must nevertheless be an effective organising team. The camp is clean and alongside the accommodation are larger tents with information, welfare, first-aid, and “university” roles. 

Paul tells me of the chaotic establishment of the camp: “The police were stopping us from going into Paternoster Square,” he says. Corralled, the protestors’ current spot was chosen by default.  “There were a lot of police,” he continues. “When I woke up in the morning, I was really surprised we were still here.” The police eventually withdrew the following morning. 

We drop into the university tent where Professor Ted Honderich, UCL professor emeritus of the philosophy of mind and logic, is hosting a discussion; an erudite debate is underway concerning the nature of capitalism. Immediately outside the disparate aims of the Occupy movement are clear from the posters that now adorn the pillars facing M&S on the north side of the camp. “More to life than money,” reads one, whilst others variously call for defence of public services, Julian Assange’s release, as well as more niche concerns. 

Defending the NHS is a motivating factor for some protestors for whom the recent takeover of Hinchingbrooke hospital by Circle augurs future unacceptable developments. David stays in the camp, doing his job remotely via a laptop from the nearby Starbucks.  He’s also first aid trained and works shifts in the camp’s first aid tent. “I’m here to put pressure on the government to look seriously at the Robin Hood (aka Tobin) tax,” he says. “I’m concerned about the cuts in public services and especially the NHS.” He sees the Tobin tax as avoiding cuts that would otherwise be inevitable.

A large sign outside the mediation tent reads “No drugs” and suggests concern that some camp visitors might mistake Occupy LSX for the Glastonbury Festival. “There’s a problem about having a thing like this in the centre of a city,” explains Paul. “It attracts people who are homeless or have addiction problems.”

As a consequence, a welfare tent was established with the involvement of two consultant psychiatrists. Paul says this required some consideration. “There was part of me that said we are not about caring for people, we’re here for a political purpose,” he says. The welfare tent’s presence is not entirely altruistic to my mind. The camp’s continued existence remains precarious, and a responsible, civic-minded community is harder to demonise and evict.  Asides medical involvement in the welfare tent, a medical team also wrote a report on site safety, hygiene, and sanitation. 

In Starbucks I meet Simon, a part time nurse also involved with the first aid tent. A target at past protests, Starbucks is in fact warmly regarded by all I meet at Occupy LSX. As well as Occupy’s de facto common room, early on the café allowed the protestors use their toilet before alternative portable ones were sourced.

“We do have two facets to the organisation. There’s the progressive widespread attempt to verbalise certain issues and get them fed into the media, and then there’s the occupation and the collaboration of people living together and trying to maintain a site,” says Simon. By chance at an Arab Spring protest earlier in the year, Simon had been impressed by the protestor’s medical facilities and sought to bring similar facilities to Occupy LSX.  

These from scratch facilities may be laudable, but what is the actual message of the camp? “It’s pro-activism here” says Simon. “There are very few groups that are excluded. I’ve yet to meet anyone down here who thinks that we shouldn’t make our corporations pay more tax or that services should be cut over sourcing additional sources of income.”

What I hear the loudest from the protestors is that Occupy LSX is about creating a space for people to articulate arguments about the government’s economic policy and its consequences:  unemployment, increasingly expensive education, and the privatisation of the NHS.  The vague sense of unease many of us feel is here, amplified and expressed. 

The criticisms are obvious.  The camp has no manifesto and articulates no alternative. In focussing on bankers it victimises a small part of society, when the true causes of the current crisis are less straightforward. Contrary to their claims, the activists have no mandate to represent the “99%.”

But I’m inclined to be generous. Expecting protestors to have a fully developed alternative before they raise their voices represents an unrealistically high expectation. But whatever I think, they have no inclination to pack up their tents yet. At the time of writing a third camp is forming in an abandoned UBS building in the City. 

Paternoster Square remains closed indefinitely. When I stood by the security barrier peering in, armed only with an iPhone, a security guard approaches menacingly. Curiously, here’s a press release from Mitsubishi Estate – Paternoster Square’s owners – describing the square as a “public space.”

Some names and identifying details in this post are changed by request.

Letter by me in the BMJ this week:

Inglis contends that the BMJ’s print run and thus carbon footprint can be reduced by a combination of increased reader sharing of print issues and greater embrace of digital distribution.

The whole picture is less straightforward. The BMJ is a commercial publication, albeit not an aggressively capitalist one, and it must pay its way. Part of its funding comes from print advertising, and advertisers remain reluctant to pay for online and iPad advertisements. Were the BMJ to make the transition to an online only publication, with most printed copies communally read in institutions, its business could prove unsustainable. “So what?” some might say, but unexamined healthcare is also wasteful inefficient healthcare.

The idea that a move from printed to digital distribution will automatically lower the BMJ’s carbon footprint is not a foregone conclusion. At least one comparison of the environmental impact of print, online, and tablet based consumption has been attempted and comes out only hesitantly for tablets.

A comparison of print and digital distribution must include all stages. A digital journal is free from the physical print and distribution costs of a print journal but data storage—“cloud computing”—and device manufacture/disposal must be considered. Greenpeace’s recent report on cloud computing data centres voices concern that many rely on “cheap but dirty” coal power stations.

Ultimately many factors determining an electronic journal’s environmental impact are down to reader behaviour. The fewer tablets, laptops, and smart phones we buy the lower our carbon footprint. Yet most of us own several devices with overlapping functionality, which we regularly replace. Few of us switch them off as often as we should.
Notes

Competing interests: SG is employed by the BMJ as editorial registrar.

(Picture credit – taken with a tilt shift lens – looks like a model…)

It’s widely accepted that individuals can be disturbed or troubled of mind.  What is controversial is how we should understand this. 

Asides psychiatrists, many professional disciplines work and research in the field of mental disorder.  Each discipline approaches the subject from their own viewpoint, using their own conceptual model to explain what they find before them. 

Alas there is no single model that has complete explanatory power.  To fully understand an individual’s difficulties it is often necessary to borrow from several.  This would be the favoured approach from an eclectic practitioner.  In practice it’s easy to favour a pet model which most closely fits one’s world view and defend this against those supported by others. 

The on-going debate about the merits of drug treatments versus talking therapy can be viewed as a clash of models: biological versus psychodynamic/cognitive.

The disease or biological model

This model holds that any dysfunction that effects mental functioning can be regarded as ‘disease’ in a similar way to dysfunction that affects other parts of the body.

In the disease model, a disorder affecting mental functioning is assumed to be a consequence of physical and chemical changes which take place primarily in the brain.  Just like any other disease a mental disease can be recognised by specific and consistent signs, symptoms and test results.  These distinguish it from other diseases. 

Psychiatrists who adhere to the disease model are often referred to as ‘biological psychiatrists’ (as in ‘he’s very biological’).
With a biological approach comes a preference for physical treatment methods, primarily drugs, but also ECT. 

This model best applies to schizophrenia

The psychodynamic model

The central tenet of the psychodynamic model is that a patient’s feelings have lead to problematic thinking and behaviour.  These feelings may be unknown to the patient and have formed during critical times in their life, due to interpersonal relationships. 

These unknown (or unconscious) feelings are uncovered during therapy.  Therapy can take place over a large number of sessions and over a time period of a year and beyond. 

During therapy a relationship builds up between therapist and patient.  The emotions that the patient attaches to the therapist are collectively known as ‘transference’, and those the therapist attaches to the patient collectively as ‘counter transference’.  By understanding these feelings a patient may gain an understanding that they can take with them to future relationships. 
This model is applied broadly, but has limited applicability to the most severe mental disorders. 

The behavioural model

The behavioural model understands mental dysfunction in terms theory emerging from experimental psychology.

Symptoms, as understood by the behavioural model, are a patient’s behaviour.  This behaviour has come about by a process of learning, or conditioning.  Most learning is useful as it helps us to adapt to our environment, for example by learning new skills.  However some learning is maladaptive and behaviour therapy aims to reverse this learning (counter conditioning). 

This model best applies to phobias.

The cognitive model

The cognitive model understands mental disorder as being a result of errors or biases in thinking.  Our view of the world is determined by our thinking, and dysfunctional thinking can lead to mental disorder.  Therefore to correct mental disorder, what is necessary is a change in thinking. 

This model will be familiar to anyone who has trained or undergone cognitive behavioural therapy (CBT).  CBT aims to identify and correct ‘errors’ in thinking.  In this way, unlike psychodynamic therapy, it takes little interest in a patient’s past. 
This model is widely used, but classically applies to depression and anxiety.

The social model.

The social model regards social forces as the most important determinants of mental disorder.  The social model takes a broader view of psychiatric disorder than any other model.  It regards a patient’s environment and their behaviour as being intrinsically linked. 

In some ways it is like the psychodynamic model, which also sees patients as moulded by external events.  However whereas the psychodynamic model sees mental disorder as highly personalized and its determinants not immediately recognizable, the social model sees mental disorder as based on general theories of groups and caused by observable environmental factors. 

Example

For someone who develops persistent depression following the death of a close relative :

“This can be perceived in several ways by psychiatrists.  One sees the depression as a pathological event that is directly due to the biochemical changes occurring in the brain of someone who is predisposed to pathological depression through an accident of illness.  Another sees the depression as a reactivation of unresolved childhood conflicts over an early loss.  Another regards the depression as part of the normal mourning process that has got out of control because the person’s thoughts become fixed in a negative set which sees everything in the most pessimistic light.  Yet others conclude that the mourning response has been exaggerated primarily by society or see it as an abnormal form of learning which is no longer appropriate for the situation but is receiving encouragement from some quarter (positive reinforcement)”

From Models for mental disorder

French, translation: beautiful indifference

The apparent lack of concern shown by an individual towards their physical symptoms in dissociative or conversion disorder. 

The term was first used by the French psychiatrist Pierre Janet

Link

The free dictionary

Abreaction

A psychoanalytical term for when a repressed painful memory is recalled together with emotional release. 

Links:

Wikipedia

The free dictionary

Note: if time allows this will become part of an online psychiatric dictionary.  Please help by adding corrections below.

I wrote this for the student BMJ (Sorry about the dreadful photo above)

Identifying mental illness in historical figures is a favourite hobby of psychiatric sleuths. Particular scrutiny has been paid to the lives of painter Vincent van Gogh and composer Robert Schumann. Both spent time in asylums, but their correct diagnoses remain in dispute. Similarly, descriptions of symptoms of mental disorder have been identified in creative works dating as far back as Shakespeare in the 16th and 17th centuries and the playwright Sophocles in ancient Greece.

Until recently depiction of mental disorders in comics (also known as graphic novels) has attracted less interest. This may be because of their historic association with younger readers, but comics are now read by people of all ages and are gaining more attention, particularly in healthcare. Long running series such as Batman have multiple characters who display symptoms of mental disorder, and works such as Couch Fiction and Psychiatric Tales have storylines specifically about mental health issues.

Looking at the psychopathology of comic book characters is an interesting diagnostic challenge and also a newly used approach to medical education. A comic book convention earlier this year was held to educate the public about psychiatric conditions. Various comics were studied, with Batman being heavily scrutinised.

Batman

Mental illness is ubiquitous in Batman’s Gotham city. “Over the years, the stories of the Batman comics have been intensely psychological,” says psychologist, writer, and visiting senior research fellow at the Institute of Psychiatry, Vaughan Bell.

The longevity and popularity of Batman comics and films make it one of the best known representations of mental illness. Arkham Asylum, Gotham’s sanatorium for the “criminally insane,” towers both literally and metaphorically over the city. Many of Batman’s adversaries have either escaped from there, or are destined to return there.

In Batman, “the fictional explanations of what causes madness tend to be particularly detailed,” says Dr Bell. The disorders often bear little relation to those seen in clinical practice, however. In Batman comics “two main themes are used to explain the development of madness,” says Dr Bell. “The influence of trauma and the pursuit of forbidden knowledge.”

The personas of Batman and his arch enemy the Joker are both trauma-induced. Batman’s crusade against crime begins with witnessing the death of his parents. The Joker becomes a villain when, as told in The Killing Joke, he falls into a toxic river shortly after the death of his wife.

Batman’s response to his traumatic experience is to become a masked vigilante. Objectively this is unusual behaviour, but not in Gotham city, where spandex-clad criminals are the norm. In contrast, the Joker is unable to show such a “mature” response and turns to crime. Both can be considered madness owing to trauma.

On the other hand, it is those who seek to know who also suffer. For example, being a psychiatrist in Gotham city’s Arkham Asylum is a particular “risk factor” for mental ill health. “A remarkable number of Arkham inmates are former psychiatrists who have been driven to madness as a result of their work as investigators of the human mind,” says Dr Bell. “Rarely are psychiatrists, psychologists, or neuroscientists portrayed as anything except figures of fear.”

Harley Quinn is an example of a disturbed psychiatrist, although her presentation has little resemblance to an established psychiatric disorder.

Quinn, originally Dr Harleen Quinzel, is an Arkham psychiatric intern who becomes fascinated with the Joker and offers to psychoanalyse him. During treatment, the Joker’s influence causes her to abandon her previous life and personality. She falls in love with him and helps him escape on several occasions.

Accuracy

The portrayals of mental disorder in the Batman characters such as the Joker and Harley Quinn are often highly inaccurate. This has been of interest to American psychiatrists Eric Bender, Praveen Kambam, and Vasilis Pozios.

“In the real world we don’t necessarily see someone either becoming a hero or a villain following a single traumatic event,” says Dr Bender, questioning the verisimilitude of the back stories of Batman and the Joker.

Dr Bender also says that the term “criminally insane,” although liberally used in the Batman stories, is not a term that is used either legally or in psychiatry.

Batman storylines often combine syndromes, and sometimes the use of terminology is just plain incorrect.

“The Joker is the character who is most commonly referred to as ‘psychotic’,” says Dr Kambam, “but in over 70 years of stories you’d be hard pressed to find evidence of actual psychosis depicted.” Classically, the definition of psychosis is a mental state seen in serious mental disorders such as schizophrenia, when a patient has disorganised behaviour and thinking.

“What the Joker actually displays more of is psychopathic traits,” says Dr Kambam. Psychopathic traits include manipulativeness and a lack of empathy.

Reaching out

Drs Bender, Kambam and Pozios are using the depictions of mental states in Batman as a way to talk to the general public about psychiatric disorders. The histories of comic book characters are well known and, unlike other public figures, can be discussed without fear of impropriety.

Pioneering this form of medical education, they held a seminar at Comic Con, a large comic convention held in San Diego in July 2011.

“We looked at whether the character of Bruce Wayne [Batman] displays any symptoms of post-traumatic stress disorder (PTSD) in the film Batman Begins,” says Dr Pozios. During the seminar they explored the nature of PTSD and the challenges in making a diagnosis. They felt that Batman had symptoms of PTSD but does not meet the full diagnostic criteria.

Audience questions also provided an opportunity to correct misperceptions. One audience question was, “If Batman doesn’t have PTSD then is it better to say that he has schizophrenia?” This refers to the common misunderstanding that schizophrenia means split personality.

“That’s not correct,” says Dr Bender, “schizophrenia is a psychotic illness.” PTSD is an anxiety disorder.

Beyond the bat cave

Many other comic book characters are amenable to psychiatric scrutiny. Could we diagnose the Hulk with an impulse control disorder? And how has Superman been affected by being the last survivor of his planet?

Mental disorder is also depicted in characters who are not superheroes. “The examination of mental illness in comic form goes well beyond that seen in genre comics,” says Ian Williams, a general practitioner and comics artist. “Batman comics primarily aim to entertain, and their interest in mental disorder is second to this. Other more thoughtful works address the subtleties of mental disorder directly, and aim for a more realistic depiction,” says Dr Williams. “Comics are able to convey an immediate visceral understanding in a way that conventional texts cannot.”

“The handling of mental disorder is particularly effective in The Long Road Home by G B Trudeau,” says Dr Williams.

G B Trudeau draws the well known newspaper comic strip Doonesbury. In The Long Road Home he examines the life of a Doonesbury character following active duty in Iraq.

“The comic documents how the character’s life changes after he loses a limb traumatically,” says Dr Williams. “The author spent time in rehabilitation centres in order to make the approach more realistic.” The character develops PTSD, becomes withdrawn, and has constant flashbacks.

Another comic, Depresso, by Brick, examines depression. “The visual metaphors in Depresso are very powerful,” says Dr Williams. “Especially when he likens depression to being entombed in wet shrinking concrete.”

Brick’s approach to doctors is interesting. “Brick takes a deliberately provocative point of view to his medical care,” says Dr Williams. “He is by nature suspicious, and this influences his view of the psychiatrists who treat him.”

Dr Williams also recommends Psychiatric Tales. This is a collection of 11 strips about psychiatric illness, which was published to acclaim in 2010. Its author, Darryl Cunningham, worked as a healthcare assistant on psychiatric wards and also had his own problems with mental illness.

“Psychiatric Tales is patient centred and humane as Cunningham has experienced mental illness from both sides,” says Dr Williams. “Despite the seriousness of the subject he has a light touch and the book is funny and informative.”

Rich medium

Comics are very accessible as they are quick and easy to read. Their ability to juxtapose image and text means that they are a rich medium for both storytelling and documenting.

Established comics such as Batman have featured mental disorder for many years. Although the characters’ disorders in Batman often display a high degree of artistic licence, they can still be used as a teaching aid and may engage an audience who would otherwise lack interest.

Non-fiction comics such as Psychiatric Tales are often more realistic and can provide us with valuable insights into the lives of psychiatric patients.