Review of ‘The Greatest Silence: Rape in Congo’ screened at the RSM Global Health film club 28 March 2012

April 27th, 2012

The author Philip Gourevitch once wrote: “Oh Congo, what a wreck. It hurts to look and listen. It hurts to turn away”. Exploited and misruled for much of its modern history, this country has spent more than a decade in a state of semi-permanent civil war.  5.4m people have died, mostly from disease and starvation, and Congo’s abundant mineral resources bring nothing but the worst kind of exploitation.

Directed in 2006 by Lisa F Jackson, and shown recently at the RSM’s global health film club, The Greatest Silence: Rape in the Congo concerns a further tragic facet of this conflict: the systematic rape of Congolese women.  “Rape” is actually a rather mild term for the violations suffered.  Many of the women subsequently require surgery for fistulas, having been deliberately mutilated and 30% will be HIV positive.  This gender violence is not a consequence of the war, but a key mechanism in its execution: both as a demonstration of power and a form of social control.  Raped women are likely to be abandoned by their partners and ostracised by their communities; children born as a result of rapes carry their own stigma.  Jackson has a connection with this subject that no one would wish on themselves: she was gang-raped herself in 1976, an experience she shares with the women she interviews.

Filming takes place in South Kivu province, 3572sqkm and 141000 in population.  It is part of the ‘red zone’ and has known incessant fighting during the conflict.  Healthcare services are often poorly equipped and serving the area are twenty-seven health centres and Panzi hospital.  The gynaecologist there, Denis Mukwege, works eighteen hour days repairing severely damaged genitalia.  Some of the women may also be doubly incontinent and require multiple operations.

During and after the screening, this question is with me: who are these men who commit these acts, and how can they act in this way?  I refuse to believe that Congolese people are any different to any of the rest of us, but some of their number act in ways that are cruel and barbaric beyond expression.  In the film, and with rather more disregard for her personal safety than I can muster, Jackson ventures into the bush and meets some of them.  From behind scarves and dark glasses they admit their crimes, but otherwise give little away.

Perhaps their casually brandished weaponry reveals more.  During the post screening discussion one of the panellists explains that many of the soldiers will have joined the militia in their early teens.  Initiations whereby they will have killed their families and raped their own mothers are not uncommon.  With a weak central government, Congo is unable to protect its citizens and the brutalisation of its people stretches back several centuries.  This is a thoughtful and powerful film, and I hope that someday the Congolese will be able to make films of their own.

Books about Congo:

Dancing in the glory of monsters: The collapse of Congo and the great war of Africa – Jason Stearns (there’s a free copy on Scribd here, which I don’t supposed he’s very happy about) is interesting and comprehensive

Blood River – Tim Butcher.  Butcher sets off to navigate the Congo river and reports on what has become of the DRC

The state of Africa – Martin Meredith.  A riveting history of Africa post independence.

This also published on BMJ blogs

Can incarceration be thought of as disease?

April 19th, 2012

This review by me in the BMJ

It’s fashionable to treat social problems as if they were diseases. Stephen Ginn reflects on a book that considers an epidemiological solution to the huge and rapidly rising prison population in the United States

Among its many marvels, some things about the United States of America are stubbornly unfathomable. The persistent, widespread opposition to socialised medicine is one of them. And despite a murder rate impressive for all the wrong reasons, US gun laws remain unreformed.

Add to this America’s prisons. This is not an area in which the United Kingdom basks in glory, but the American dedication to incarcerating its citizens remains without rival. “If this population had their own city, it would be the second largest in the country,” dryly remarks author Ernest Drucker.

The numbers tell the story: of a population of 310 million, 7.3 million people are under the control of the US criminal justice system. Of these, 2.3 million are imprisoned, 800?000 are on parole, and 4.2 million are on probation. The US has 5% of the world’s people but 25% of its prisoners. This section of the US population grew fivefold between 1970 and 2009.

Drucker, an epidemiologist, sees this increase as a plague and amenable to examination using the tools of his trade. Although imprisonment is not usually considered a disease, this framing isn’t meant to be metaphorical. The American fondness for imprisoning its citizens meets all the key criteria for an epidemic: its growth rate is rapid, its scale large, and it shows self sustaining properties.

During London’s 1854 outbreak of cholera, John Snow’s insight famously led to the removal of the handle of the Broad Street water pump. Soho’s residents could no longer drink its contaminated water. What is the pump filling America’s prisons, and is it possible for the handle to be removed? Drucker shows how in one state­­—New York—the rate of incarceration clearly surged from the 1970s. This coincides with the introduction of the state’s so called Rockefeller drug laws: punitive legislation introduced in response to a rise in heroin use in the 1960s. These laws made it possible for those caught in possession of even small amounts of illegal drugs to receive the same sentences as imposed for violent crime. Similar legislation would be enacted throughout the country.

Most of New York City’s prison population comes from just six neighbourhoods. This echoes the distribution of deaths on the Titanic, which reveal the rigid social structure of the Edwardian era. On the Titanic, those in the highest social class were more than twice as likely to survive as those in the lowest social class. In New York some areas are plunged into near anarchy by the so called war on drugs being waged on their streets, while others are almost untouched.

Incarceration also causes disability, just like disease, and is passed on to future generations, just like disease. The children of families where a member is incarcerated have a lower life expectancy and are six to seven times more likely to go to prison themselves.

The notion of applying an analysis to social problems that is more conventionally used to understand disease has gained recent cultural currency. The Interrupters, a 2011 feature length documentary, focused on CeaseFire, a Chicago antiviolence programme that deploys street workers as mediators between factions during incipient street conflict. It was founded by Gary Slutkin, another US epidemiologist, who considers violence to be primarily a public health issue. Slutkin has publicly encouraged David Cameron to adopt CeaseFire’s approach in London.

Something must be done about prisons, but is this the way ahead? Labelling people as victims of a plague has never been a good way to rehabilitate them back into society. No matter how neatly it may fit a disease model, bringing epidemiological theory to bear on the problem of prisons reframes that problem as something dispassionate and treatable, when in fact it is intensely political. Drug laws may be America’s prison pump but behind those laws lies the willingness of lawmakers and politicians to treat marginalised groups and their problems within a punitive criminal justice framework. If drug laws are reformed then opprobrium for other misdemeanours may take their place. Some US schools now use police to enforce school discipline, for example, and increasing numbers of children are being convicted via this route.

This criticism is unacknowledged by Drucker, but to his credit, the public health response he offers to high levels of incarceration is more radical than might be expected. It’s no surprise that he writes that, as primary prevention, drug laws like the Rockefeller laws have to go. Secondary prevention involves prison reform. But as tertiary prevention, and to address the “great task of healing to be done on both sides of crime and punishment,” he proposes a programme of restorative justice in a shape of a formal peace process, not unlike South Africa’s Truth and Reconciliation Commission.

In a time when public inquiries are not in short supply, it’s easy to be cynical about such a suggestion, as it is about Drucker’s approach in general. But this book is accessible and persuasive. Prisons on both sides of the Atlantic represent an immense waste of human potential and financial resources. The questions of what to do about them need to be asked more often. This analysis has much relevance beyond US borders; British incarceration rates are lower, but the UK has one of the highest rates of imprisonment in Europe. Successive recent governments have presided over a steadily increasing UK prison population that has doubled in 20 years.

Interview with writer Will Self part 2

April 16th, 2012

Will Self interview by Prof Femi Oyebode (part 1 with me found here) in November 2010

WS: I’ve been very interested in the psychiatric profession and though out my fiction and my nonfiction and have written on visions related to psychiatry, so in a way when it comes to reading to you I’m presented with an embarrassment of riches. So I’m going to confine myself to my latest book, available in all good bookshops at the seductive price of £17.99. No one, not even the most exalted mental health professionals would see this for a second as being in any way analogous to £18 but will see it as significantly cheaper. It’s called Walking to Hollywood and it’s a sort of fictionalized memoir which in itself arouses some interesting questions about relationships between mental states and what philosophers call ontology, the nature of reality in a wider sense.

Just by way of an introduction to a couple of short readings, as it’s a fictionalized memoir and the ‘I’ in the fictionalized text and me are the same person.

(Reading – I’ve not transcribed this for copyright reasons, but extracts are legitimately  available here and here)

FO: Thank you very much for that Will. One of the intriguing things about that reading was how it is both fiction and autobiography, and I was wondering how far the fiction had in it ‘real life’.

WS: Well my grandfather was a relentless autodidactic who, whist working as civil servant gained eight degrees by studying during his daily train commute to London. He did write a thesis called ‘The Divine Indwelling’, which was an attempt to reconcile Existentialism, Christianity and Western science. That’s true.

I was prescribed those drugs; I did decide not to take them and tied a knot in the bag and threw them on top of a shelf. Indeed they were up there until I wrote that passage, when I finally got them down and disposed of them in a suitably irresponsible fashion.

FO: And Dr Busner?

WS: Dr Busner doesn’t really exist but is a character who exists in a number of my different narratives. He’s a consultant psychiatrist in a place called Health hospital which doesn’t exist either, although it’s quite easy to guess which hospital it might be modelled on. He doesn’t exist, but he acquires an existence by being present in different narratives appearing in my novels and short stories; I think that gives him perhaps a greater level of reality than a lot of fictional characters.

He’s based to some parts on R D Laing and the anti-psychiatrists of the 1960s. I was very influenced by books like Thomas Szasz’s the Myth of mental illness and Laing’s The Divided Self and most specifically by Szasz’s concept of the ‘therapeutic state’ and the idea of the psychiatric profession being responsible in our culture for policing behaviour in ways that perhaps neither the profession itself nor the wider society are actively aware of. He’s also based in some other aspects on the neurologist Oliver Sacks as well as people I’ve known over the years. Busner is a way for me to examine in fictional terms the role of the psychiatrist in our culture and what the psychiatrist represents. He’s described in one of my books as a kind of almost religious figure, almost like some kind of shaman or witch doctor.

FO: Can I draw you out a little bit about the question of characterisation. One of the things I find wonderful in your writing is the way in which you create these very strong characters. They could easily be in plays and I was thinking of Ibsen, for example, saying that when he is writing a play, he thinks during the first draft that he knows his characters like he might someone he has met once. When he writes the second draft he feels like he’s spent a month with them on his farm. Then when he writes the third draft, he thinks that he knows him as well as he knows his friends.

With characters like Shiva Mukti and Zac Busner, how do you create them? Because they do feel real. I know they are fiction, but there is a sense in which you feel that they are real.

WS: Shiva Mukti is a protagonist in a novella I wrote called Dr Mukti. The second protagonist in that novella is Dr Zac Busner and these two psychiatrists find themselves engaged in a duel – or at any rate Shiva Mukti thinks they are engaged in a duel – where they attack each other using psychotic patients as weapons, whom they send to each other for diagnoses, with the knowledge that having appended falsities in the case notes, their colleague may well make a mistake in terms of diagnosis and then reap the consequences which could potentially be fatal. It’s in many ways an engaging – or non-engaging – fantasia, but it’s based in reality like of a lot of what I write.

It’s interesting that you should pick on Shiva Mukti as a character. I don’t think of myself as a writer of character in particular at all. I would say that he’s probably one of the few characters I’ve created who has a more or less conventional depth psychology. I don’t know how many of you here today read much fiction. There are certain assumptions in naturalistic fiction about how and what you can convey in prose narrative of individual psychology.

What you said Femi about Ibsen, though he’s a playwright, applies to what conventional writers of fiction at times do. I’m not a naturalisitic writer and the reason I think that most people, if they read a lot of fiction, find characters in fiction believable as people is because they have constructed their own persona from reading fiction. In other words I think it’s a self-fulfilling prophecy. However in that particular novella I needed a character to contrast with Zac Busner. We never really know Dr Busner in Dr Mukti except through Shiva Mukti’s perception and it becomes clear, without giving too much away, that Shiva Mukti is himself mentally ill. I needed him to have that kind of naturalistic humanity in that way. And how did I construct the character? I think that all fictional characters are kind of ‘us’. They are usually based on a number of people the writer knows, their characteristics cut up and sewn together into some sort of Frankensteinian figure.

FO: There’s a theme in your work where psychiatrists, I suppose through their patients, themselves have pathology in them. That’s quite an interesting way in which you’ve got the patients in the asylum but you’ve also created the similar problems in the psychiatrists I was wondering why you were doing that?

WS: Well, in terms of iatrogenic disease, psychiatry is well ahead of the pack. The phrase in the pharmaceutical industry I believe now is ‘conditioned branding’ whereby a certain psychiatric pathology is devised or defined in order to provide a market for a certain neuropharmaceutical product. That is an iatrogenic disease. This is going on all the time and it goes on more in psychiatry than arguably in any other branch of medicine. So in seeking to establish that the psychiatrists themselves are afflicted with a pathology I’m making a comment on the iatrogenic propensity of psychiatry itself. Primarily my use of psychiatry is supposed to establish what psychiatry is doing in our society which neither its practitioners nor the wider society may be aware of and then to satirise it.

Question from floor: You mentioned about Zac Busner that he can be a tool for exploring the role of psychiatrists in society today and their ‘policing’ of social behaviour, but what should be the role of psychiatrists be in society today?

WS: That’s a very interesting question. I started off at some point saying that when I was a young man I was very much influenced by RD Laing’s writings and very much viewed psychosis as a radical lifestyle choice. And then as a result of that I put my money where my mouth was and found myself living in my own version of Laing’s Kingsley Hall with a group of psychotic outpatients in a mental hospital and rapidly reached the understanding that in fact psychosis is not a lifestyle choice at all, it’s a mental illness. So don’t get me wrong. I’m not one of those people who say that there shouldn’t be psychiatrists or that mental illness doesn’t exist, I know it does. I think the job of psychiatrists is to treat mental illness, pure and simple. Far be it from me to tell you your job in its practical application but I think that the criteria used and the way in which we understand what mental illness is is in question. And nor do I think that the psychiatric profession necessarily are the worst offenders of the problem we have in understanding what mental illness is. If you’ll forgive the extended pun, there’s a folie à deux between the wider society and the psychiatric profession in regard to that and that’s where the problem is and where I think the confusion sets in.

Let’s not forget that this is an evolving thing. In the 1950’s and 60’s there were 120 000 people in this country in total institutions in one kind or another. So we have changed in our attitudes and we continue to change our attitudes. I don’t want to demonize the psychiatric profession because in a way you get loaded with society’s dirty work. But put simply psychiatry’s job is to treat mental illness, nothing more and nothing less.

Question from floor: Critiques about medicalisation of normal life leave psychiatrists between a rock and hard place and in our culture. On the one hand we are criticized if we are paternalistic. On the other hand if we don’t attempt to define the diseases we treat then patients are given the ‘keys to the shop’, which also has its problems. Where do we draw the line?

WS: There have been some colossal howlers within living memory in your profession. There are many many thousands of people with extra-pyramidal side effects who were classed as catatonic schizophrenics and held in total institutions for many years. Nobody is responsible for that except for paternalistic psychiatrists.

You could argue that medical science had not advanced far enough for the diagnosis to be made, that’s not actually true. You could also argue that society wished for a total institution programme to exist. I’m not sure. Of course when you come to people who are, to use probably an expression that is outmoded in the profession, engaged in inadequate reality testing and to actually hand over to them the keys to their own sins on the face of it is an absolutely mad thing to be doing. But on the other hand I’m very concerned and have been concerned throughout my writing career with kinds of collusion that particularly affect who are placed in positions of professional expertise. I don’t think that the psychiatric profession is by any means unique in this but I do think that all professions need to be very alive to these tendencies. The tendencies to create forms of arcane knowledge that are not accessible to lay people and to hide behind that. In as much as I agree with you that there is a real difference of kind between serious mental illness and what could be regarded epiphenomenal forms of that: neuroses of various kinds. I think again there is an unconscious collusion between the profession and the wider society to allow the profession to police that boundary.

Question from floor: Medicine generally is responsible for some ‘real howlers’ in the past – and psychiatry as well – and will continue to do so to a large extent because of the relationship we have with society as doctors. One of the problems is that the brain should be an organ that gets diseased as well, it shouldn’t be protected but it’s not the liver and it’s not the kidneys, it’s who we are, it’s our very essence, it’s the human condition. We all find it a problem when it goes wrong and I think one of the bigger problems is that none of us, especially lay persons, are clear about what constitutes a mental illness and what constitutes the rough and tumble of normal life and we in a sense sup with the devil on that one because there are some psychiatrists who are willing to go down that route and profess to make comments about all sorts of human endeavours, activities and behaviours as if they’re psychiatric conditions. If you ask a cardiologist on something that’s got nothing about cardiology he’ll say ‘I can’t answer that as a professional, but I’ll answer it as a lay person’. But many psychiatrists are unwilling to do that and they medicalize all of human behaviour. My concern with psychiatry is around the areas of depravation of liberty and the perceptions of dangerousness which is primarily driven by the public and by commentators. Those are the areas that worry me because that determines how we work.

WS: Yes I would agree with where you paint the problem. Interestingly that’s another aspect of my psychiatrist Zac Busner; he’s a kind of media doctor. So that is exactly what I was satirizing. But it’s easy to understand as well why, that of all things psychiatry is seen to be the right profession to be doing that. Here you are, the people qualified in science but you’re treating not of the brain but of the mind, so you seem to represent the interface between the mechanistic, physical explanation of the world and whatever other meanings we wish to ascribe to our existence. So it’s very easy to understand that if one of your kind goes to the dark side it’s going to be that much more dangerous than it might be for a cardiologist or a podiatrist.

The other thing that I’ve been most concerned is about, and I’ve written about a lot in my fiction, is the impact of neuropharmacology. That concerns me a great deal. I don’t necessarily think – and I’m aware that I’m in a room full of psychiatrists and I’m not looking to make a swift exit out the back – that psychiatrists are the worst offenders in terms of what we described as ‘conditioned branding’, I actually think that the foot soldiers in that tendency are General Practitioners. And also what can you do when we have now reached the situation where the public collectively now know how to approach a dispensing doctor in such a way as to solicit an anxiolytic medication of some kind or another? I think we need to maintain a very critical view of all of this, and I think the profession in and of itself, and maybe goaded on by people like me, needs to be involved in a continuous and evolving discourse.

Question from floor: I think that it’s interesting the shift you made from writing fiction where you can be in control of your characters and be quite sheltered to then a fictionized memoir in which you leave yourself open and reveal a lot about yourself, but still retain the power to change whatever elements you like because it’s fictionalized. I just wondered what made you choose to do that? And I think it’s interesting given what Ruby Wax was saying before, talking about stigma, and making herself a poster person for mental illness. She said that she didn’t volunteer to be a face for Time for Change.

WS: What pathology does Ruby Wax cleave to? I only ask this as a point of information.

Floor: She was talking about her experience of bipolar disorder.

WS: Bipolar, that’s a corker isn’t it? There was a very good article in the London Review of books’ last issue on bipolar disorder. I mean again following on from what you were saying: this idea that there are, these quite dangerous people from the profession who adopt this role of medicalizing conditions that are just part of the hurley-burley of life. The celebrity authorities are equally dangerous for almost exactly the same reason. One thinks immediately of Alastair Campbell as I do – on waking – with the feeling of deep and numbing rage – or indeed Stephen Fry who can make me feel quite nauseous at almost any hour of the day. People who witting – or not – are doing exactly the same thing, they are placing expectations on you as a profession that you will be able to provide some sort of pill for every ill.

I’m not really answering your question because the answer is inadvertent in a sense. I wanted to write about various things and I found I couldn’t write about them within the established rubric of factuality. So, like a lot of things I write it was a form as on-the-job experimentation using my own psyche as the test bed. So I didn’t set out to reveal or not reveal particular things about myself. It’s actually on the public record anyway some of the things I’ve said about my own history of either what you might call ‘mental illness’ or of being diagnosed with mental illness. I’ve written about it and spoken about it before, so that wasn’t why I choose to use myself as the protagonist.

There’s a connection with a film I recently saw called Hancock. It’s about a superhero living in modern LA, and there were some scenes in that, as there are in quite a lot of contemporary Hollywood films, I thought were psychotic, that they were like people’s experience of psychosis must be. They had a sense of great believability and you could suspend disbelief in them but in fact what was happening in these scenes was suspension of all kinds of natural laws and so on and so forth. So it was an interesting exercise to write from a protagonist’s point of view about experiencing that. So as mental health professionals next time you see one of these extravagant CGI sequences in a Hollywood blockbuster try and think about it as really happening and what that might be like and then snapping back to reality. That might be quite a good way into the mental states of some of your patients. And of course that’s something one can only do fictionally.

FO: I wanted to finish with one or two words. Will Self’s writing is absolutely incredible and I think we ended on what is quite so important about his writing from a psychiatrist’s point of view. Of course he’s commenting on the world we inhabit, on a day to day basis, as psychiatrists and commenting on the hospital environment, commenting on people’s emotional experiences and commenting how people might depart from their sense of reality that we all take for granted.

But he does something else we haven’t talked about today which is that he bends language so that he to express the world that he’s created for that particular story, or for that particular novel. And of course as psychiatrists we also have a day to day contact with patients who use language in an awkward, novel, original kind of a way. So I think there’s a lot to learn from what Will Self does and it’s been marvelous listening to him talk with his exposition and also for him to challenge us in his usual subtle way.

“One in four”: the anatomy of a statistic

February 24th, 2012

(From a bus stop Archway – if you look carefully you can see the reflection of me and my bike)

This written by me and Jamie Horder published this week in the BMJ

Despite a lack of supporting evidence, the claim that one in four people will have a mental health problem at some point in their lives is a popular one. Where does this figure come from, and why does it persist, ask Stephen Ginn and Jamie Horder


“It’s time to talk” is a campaign currently being promoted by Time to Change, a charity whose aim is to change attitudes to people with mental ill health. On the charity’s website a banner tells us:

“1 in 4 of us will experience a mental health problem at some point in our lives, but we still don’t talk about it. What are we afraid of?”

This “one in four” figure has also appeared in government speeches(1) and NHS publications.(2) It is the name of a short film and the title of a mental health magazine.

Yet it is not always clear to what the figure refers. Time to Change seems to be referring to lifetime prevalence, while a 2010 advertising campaign by Islington Primary Care Trust stated, “One in four people will experience mental health problems each year.” A statement on the Royal College of Psychiatrists’ website reads, “One in four people has a mental health problem,” implying point prevalence.

The evidence base

The number’s origin is unclear. When one of us (SG) contacted a selection of organisations that use “one in four” in their literature, they cited a number of different sources. The earliest seems to be a 2001 World Health Organization report, Mental Health: New Understanding New Hope, which stated, “During their entire lifetime, more than 25% of individuals develop one or more mental or behavioural disorders (Regier et al 1988; Wells et al 1989; Almeida-Filho et al 1997).”(3)

However, none of the three papers cited contains an estimate of 25% lifetime risk. One did not report on lifetime prevalence at all,(4) and the two that did provide a lifetime figure of rather more than 25% (66% for “all [mental] disorders” in New Zealand and 31-51% in Brazil).(5, 6)

Lifetime prevalence of mental disorder seems never to have been estimated in the United Kingdom. In 2007 the annual psychiatric morbidity survey (APMS) estimated a UK prevalence of 23% in the past week.(7) In numerous other countries lifetime estimates are reported as being in the region of 50%.(8)

We are unaware of any evidence that straightforwardly supports a UK lifetime prevalence of 25%. The APMS past week prevalence most robustly supports one in four as a statement of the UK’s 12 month prevalence,(7) but in this case the UK lifetime prevalence would be expected to be much higher.

Counting cases

A 2005 meta-analysis estimated a yearly prevalence of 27% for the European Union (including the UK),(9) but a 2010 update of this work revised this to 38% a year,10 as a result of including more disorders such as insomnia and attention-deficit/hyperactivity disorder. This highlights the fact that over the years the consensus on what constitutes mental disorder has often changed.

Different population surveys adopt different definitions, and there is no agreement about whether to treat, for example, a phobia such as arachnophobia as “mental illness.” No major study has considered nicotine dependence or male erectile disorder in their calculations, despite these disorders being widespread and listed in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Nicotine dependence is perhaps responsible for more deaths than any other psychiatric disorder.

Furthermore, surveys such as the APMS establish diagnosis in a very different way from how it is discerned clinically. In the clinic, a doctor works from a patient’s presenting complaint, through their history, and on to mental state examination. By contrast the APMS recruited a large representative sample and used a structured diagnostic interview to screen each participant for a range of disorders. Structured interviews involve a patient answering a fixed series of questions taken from published criteria.

Systematic checking of a symptom inventory in this way lacks the benefit of clinical judgment and simultaneously creates a risk of both over-diagnosis and under-diagnosis. Taken literally, the DSM-IV criteria for major depressive disorder would deem many people depressed after bereavement or the end of a relationship. Conversely, a patient’s imperfect recall or lack of insight into their own psychopathology could lead to under-reporting.

The popularity of “one in four”

Despite these drawbacks, why has this figure proved so popular? We would like to suggest some reasons.

Demonstrating relevance: For journalists, quoting a high prevalence of mental disorder helps illustrate the newsworthiness of stories about mental health.

Fighting stigma: The one in four statistic has been used extensively by charities to advocate the interests of people with mental illness. Much of their recent campaigning has focused on attempting to combat stigma and prejudice through providing a more inclusive vision of mental disorder—one in which it is nothing unusual and a threat to everyone.

Not too big, not too small: If the intent is to raise awareness of the burden of mental illness, why do organisations not cite the even higher, and better supported, figures of one in three or one in two lifetime prevalence? We suggest that one in four is high enough to gain people’s attention but not so high that it provokes incredulity, as claims that over 50% of people have had a mental illness indeed have.

Conclusion

The one in four figure for mental illness prevalence is widely quoted, related variously to lifetime, yearly, or point prevalence. The evidence indicates that it is best supported as an estimate of yearly prevalence. However, estimates of the population prevalence of mental disorder should be approached with caution, as the methods used often have shortcomings. It is important that people know that mental illness is common and that treatment of mental disorder is essential, but it is not clear that championing a poorly supported prevalence figure is the way to achieve this.

References

  1. Johnson A. Psychological therapies in the NHS: science, practice and policy (speech to the New Savoy Partnership Annual Conference). Department of Health, 2008.
  2. Tavistock and Portman NHS Foundation Trust. Mental health myths. 2011. www.tavistockandportman.nhs.uk/mentalhealth/myths.
  3. World Health Organization. Mental health: new understanding, new hope. WHO, 2001:23.
  4. Regier DA, Boyd JH, Burke JD Jr, Rae DS, Myers JK, Kramer M. One-month prevalence of mental disorders in the United States. Based on five epidemiologic catchment area sites. Arch Gen Psychiatry1988;45:977-86.
  5. Wells JE, Bushnell JA, Hornblow AR, Joyce PR, Oakley-Browne MA. Christchurch psychiatric epidemiology study, part I: methodology and lifetime prevalence for specific psychiatric disorders. Aust N Z J Psychiatry1989;23:315-26.
  6. Almeida-Filho, Mari Jde J, Coutinho E, França JF, Fernandes J, Andreoli SB, et al. Brazilian multicentric study of psychiatric morbidity: methodological features and prevalence estimates. Br J Psychiatry1997;171:524-9.
  7. Weich S, Brugha T, King M, McManus S, Bebbington P, Jenkins R, et al. Mental well-being and mental illness: findings from the adult psychiatric morbidity survey for England 2007. Br J Psychiatry2011;199:23-8.
  8. Kessler, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the national comorbidity survey replication. Arch Gen Psychiatry2005;62:617-27.
  9. Wittchen HU, Jacobi F. Size and burden of mental disorders in Europe: a critical review and appraisal of 27 studies. Eur Neuropsychopharmacol2005;15:357-76.
  10. Wittchen HU, Jacobi F, Rehm J, Gustavsson A, Svensson M, Jönsson B, et al. The size and burden of mental disorders and other disorders of the brain in Europe 2010. Eur Neuropsychopharmacol2011;21:655-79.

Art of psychiatry: Richard Dadd

February 18th, 2012

Richard Dadd (1 August 1817 – 7 January 1886) was an English painter of the Victorian era. Following a long tour of the Middle East in the early 1840s he succumbed to a schizophrenia-type illness, following which he murdered his father and fled to France where he attacked another traveller. After his return to England he spent over forty years in the Bethlem and Broadmoor, during which period most of the works for which he is best known were created.

Dadd’s painting The Fairy Feller’s Master Stroke is featured on the cover of a recent British Journal of Psychiatry. Nicholas Tromans, a Senior Lecturer at London’s Kingston University, is widely published on the subject of 19th century art and is author of Richard Dadd: the Artist and the Asylum. He came to talk to The art of psychiatry society (with which I am involved) about Dadd’s life and mental illness:

AoP: As a young man, how did Dadd go about establishing himself as a painter in London?

NT: It seems that Richard owed a great deal to his father, who had been a high-street chemist in Kent but who, when Richard was a teenager, took over a gilding business in central London which must have had many professional artists among its clients. Dadd’s own beginnings as a professional artist were really entirely conventional. He became a student at the Royal Academy (virtually next door to his father’s shop) and made studies after the sculptures at the British Museum. He appears to have been extraordinarily self-confident, and was soon sending his pictures to exhibitions in London and in places like Birmingham and Manchester. He managed to attract the patronage of both London aristocrats and the self-made men of the industrial cities – as well as the support of some influential critics. By the time he left for his tour of the East in 1842 he was one of the risng stars of the London art scene.

AoP: What do we know about how and why he killed his father?

NT: Towards the end of his tour of the Mediterranean, in the Spring of 1843, Richard began to suffer from delusions – that there were people trying to harm him, perhaps that he could see the devil in human forms. Many of those who had known him were worried by his unusual behaviour after his return to London, and his father consulted a psychiatrist at St Luke’s – Alexander Sutherland – who recommended hospitalisation. Possibly in response to this suggestion, Richard carefully planned a knife attack on his father, which succeeded in killing him. Richard was soon afterwards arrested and eventually sent to Bethlem Hospital in Lambeth. Later Dadd explained that the killing had been required of him by the Ancient Egyptian god of the dead, Osiris, and that although Richard approved of the destruction of the imposter who claimed to be his father, he was in effect only an instrument in the hands of the deity. It was a fantastic delusion, but one in keeping with Richard’s larger set of beliefs about the continuing truth and relevance of the philosophies of ancient cultures.

AoP: What do we know about how he was as a patient?

With regard to his time at Bethlem (1844-64) – not a lot. There are really only two entries in his casenotes, and the first of these dates from as late as 1854. This entry describes how violent Dadd was considered when first admitted, and how he would suddenly strike another patient without provocation (and then immediately apologise). The formal designation of ‘dangerous’ was applied to Dadd even during the last years of his time at Bethlem. I infer from the lack of detail in the notes, however, that he was by and large not an especially troublesome patient – not one who required strategies to manage. That he painted ambitious pictures for the two senior managers of Bethlem – paintings which he worked on for years – suggests some kind of relationship between patient and staff, although certainly not an uncomplicatedly collaborative one.

AoP: Why was he transferred to Broadmoor?

Dadd was admitted to Bethlem as a Criminal Lunatic – someone too unwell to be punished for a crime, or (from the 1840s) one too unwell to stand trial at all. This meant being placed in a special wing of the hospital in very cramped, minimally furnished, high-security conditions. It was obvious to the authorities that something needed to be done with this novel legal category of prisoner/patient, and a dedicated new hospital was made possible by an Act of Parliament in the early 1860s. This was to be Broadmoor near Reading, to which Dadd was transferred along with his fellow male Criminal Lunatics, in 1864, and where he died and is buried. There were those – among them the Superintendent of Bethlem – who feared that gathering together these cases out in the countryside would produce “a bastile of lunacy”, feared and resented by the public. These critics were to be proved at least partly right, but for Dadd the change brought improvements. By any common-sense criteria of well-being, his life got better: he was able to see more, to move about more; he took an interest in cricket and chess; and the range of media in which he himself worked expanded.

AoP: How has Dadd’s legacy been regarded after his death?

Dadd’s meticulous watercolours never entirely went off the radar of the art market. Collectors were able to buy them as they left Bethlem and Broadmoor by one route or another. The V&A and the British Museum both acquired watercolours by Dadd while he was still living at Broadmoor. But after his death there were really only a series of false starts when it came to retrieving his biography and reconstructing his oeuvre. Various people had a go, but there was just too little to go on. Things changed only in the 1960s when the Fairy Feller arrived at the Tate and when Bethlem acquired a dynamic and imaginative archivist who was in a position to become Dadd’s first proper biographer. This all coincided of course with the passionate debates generated by the so-called anti-psychiatry movement, and Dadd – in the guise of heroic ‘survivor’ of the Victorian asylum – seemed suddenly of acute cultural significance. Interest in him has calmed down since. As I say in the preface to my own book on Dadd, I have not tried to resurrect him as a hero of any kind: I have tried to understand him as a wonderful artist – one of the most exciting of the Victorian age in my opinion – who happened to spend his career in unusual circumstances.

AoP: Despite his situation, Dadd’s pictures seem untouched by the content of his delusion and he never addressed asylum life in paint. Can you reflect on this?”

Well, “sane” Victorian artists rarely painted the streets on which they lived, or pictures which sought to sum up their philosophies of history. They were typically more interested in the same kinds of things on which Dadd remained fixed, that is, the topography of exotic places filtered through the memory, portraits, and illustrations to literature. Dadd had never been a Realist — on the contrary he was from the start of his career a painter of poetic imagination. And in any case, one reason for spending so much time thinking back, visually, over his time abroad in the early 1840s must surely have been a need to escape from the very limited environment in which he had to live.

AoP: And where can interested people see Dadd’s stuff?

NT: Not a lot of oil paintings in public collections (the watercolours can only be shown periodically of course because of their vulnerability to light).

The Scottish National Portrait Gallery have Dadd’s wonderful portrait of Dr. Alexander Morison:

Tate Britain Dadd collection

And just last year, the Harris Museum and Art Gallery in Preston acquired the early fairy subject Puck which had been in a Preston collection in the nineteenth century

The best place to head is however Bethlem Hospital itself where a substantial number of Dadd’s works can be seen in a context which helps make sense of them.

A small collection of Richard Dadd’s paintings is being exhibited Feb – April 2012 in the Bethlem Hospital museum – details.

Links:

Richard Dadd: The artist and the asylum on Amazon.co.uk

This clip of a Richard Dadd painting being discovered on Antiques Roadshow is worth a watch (starts at 4:24)

Tate channel: Richard Dadd the artist and the asylum (recommended)

Wikipedia

Richard Dadd: Masterpieces of the asylum Independent 2011

Richard Dadd: Madness and Beauty Telegraph 2008

Review of Artist and the asylum:
Guardian A S Byatt September 2011
Telegraph Nicholas Shakespeare July 2011

A surgeon for life: Pioneer in robotic enhanced and minimal access surgery

February 17th, 2012

An interview I did for Student BMJ

Biography

Roberto Casula studied at Padua medical school in Italy, graduating in 1989. He came to the UK in 1993 and has worked in Glasgow, Cambridge, and London. He has a European qualification in cardiac and thoracic surgery and is a fellow of the Royal College of Surgeons. He is a consultant cardiothoracic surgeon and honorary senior lecturer at Imperial College London and a UK pioneer of minimal access and robotic cardiac surgery.

What first attracted you to cardiac surgery?

As a child I was told about the first heart transplant. This never left my mind and I was fascinated by the whole story. Since then I never considered any other path in life apart from studying medicine and then training in cardiac surgery.

What do you value about your job?

You hear about successful people being bored with their highly remunerated job after 10 years. I don’t think that this will happen in a specialty like mine. The technical improvements and technological refinements in cardiac surgery continue to stimulate me and remain challenging on a daily basis.

It is also rewarding to see that we can provide somebody’s problems with a solution and hear from them about how much they have improved after surgery and minimal invasive procedures.

What’s different about cardiac surgery compared with other sorts of surgery?

Dealing with the heart is challenging and fascinating: having to stop it and then restart it and—even more challenging—sometimes having to operate it while it’s moving. Performing microsurgery on a beating heart requires dexterity and skills that have developed in cardiac surgery to a high level.

What’s a normal day like for you?

There are days when I spend most of the time in the operating theatre. This is usually physically demanding. In a day I typically do one, two, or three operations and I often organise my meetings and do paperwork in between cases.

Some days I attend multidisciplinary team meetings or see outpatients. Regardless of the extensive use of technology in my clinical practice I enjoy talking and listening to my [out] patients because it allows me to ensure they continue to progress to our expectations.

I also spend some of my time reading, reviewing, or writing academic papers.

What does robotic enhanced minimal access surgery involve?

When we say “robotic enhanced” obviously it is not an independent intelligence that performs the operation. The system is guided by a surgeon, and moves pencil sized surgical effectors inside the chest that are positioned at the beginning of the operation.

The operation takes place through small incisions. This avoids opening the sternum, which is always required with traditional surgery, and this is what we mean by “minimal access.” The advantage is that we can reproduce traditional surgical techniques with reduced surgical trauma. We also do not use the cardiopulmonary bypass machine, and therefore we do not expose these patients to side effects [associated with the machine].

Usually patients treated with less invasive or robotic surgical techniques recover faster and return to their normal daily and professional activities sooner than the traditional patient.

What sort of operations are you doing using these techniques that other people are doing via traditional surgery?

The most common operation performed with robotic technology is a single bypass to a blocked coronary artery. We also undertake mitral valve repairs. Several other minimal access procedures are routinely performed to change or repair the aortic valve, remove heart tumours, or reset the normal sinus rhythm in patients with atrial fibrillation. These do not necessarily require robotic technology.

Why are so few surgeons offering robotic cardiac surgery in the UK?

The techniques are time consuming and require specific training. The set of skills needed for robotic surgery are different from those acquired when training for traditional cardiac surgery.

Another limitation is that several medical specialties offer treatments for cardiac disease. As a result, we don’t treat a sufficient number of patients surgically to reproduce robotic technology in large volumes.

What’s the best way to choose the most appropriate treatment for a patient with a cardiac problem?

In an ideal world the specialists discussing the case would be a conventional cardiologist who can do an angioplasty, a non-interventional cardiologist who is untrained in either angioplasty or robotic surgery, and a cardiac surgeon capable of performing minimal access/invasive surgery. This is what is suggested by European guidelines. Between the three of them they will be able to reach the best decision for the patient.

What innovations do you think we’ll see in cardiac surgery in the future?

I would like to see better integration between present technologies with better collaboration between groups of specialists. The best treatment is “hybrid treatment,” which means being able to offer a bespoke treatment to a patient according to his or her needs. An example of this might be a patient with multivessel coronary artery disease who has a robotic operation on the most important vessel, such as the left anterior descending, and angioplasty to a further vessel of lesser importance.

What advice would you give a student thinking of training to be a cardiac surgeon?

The best approach is to arrange to visit an operating room and watch an operation. If possible they should also see a minimal access operation, and perhaps even a robotic operation. If they are caught by this bug that caught me many years ago I think they will never regret entering into a career in cardiac surgery.

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Interview with writer Will self part 1

January 12th, 2012

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. 

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Mobile phones: the future of health

January 5th, 2012

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

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Disability and the Military

December 28th, 2011

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

Psychiatric eponyms: Fregoli delusion

December 14th, 2011

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