Dr. Sohom Das2013-05-24T09:31:05-04:00Dr. Sohom Dashttp://www.huffingtonpost.co.uk/author/index.php?author=dr-sohom-dasCopyright 2008, HuffingtonPost.com, Inc.HuffingtonPost Blogger Feed for Dr. Sohom DasGood old fashioned elbow grease.French Psychiatrists Convicted of Manslaughter Because Her Patient Killed: Is This Fair?tag:www.huffingtonpost.com,2013:/theblog//3.25280922013-01-23T19:00:00-05:002013-03-25T05:12:01-04:00Dr. Sohom Dashttp://www.huffingtonpost.com/dr-sohom-das/ given a one-year suspended sentence and a £7,000 fine because one of her patients with paranoid schizophrenia, Mr Gaillard, killed somebody.
I've been reading various blogs surrounding this issue with interest. As far as I understand, the doctor had sectioned this man several times in the past against his will. However on this occasion, he had apparently escaped during a consultation. Despite the doctor's attempt to resolve the situation by contacting the police, Mr Gaillard killed his grandmother's 80-year-old partner with an axe around three weeks later. He was thought to be psychotic at the time, not responsible for his actions, and therefore exonerated. I believe the French courts found that Dr Canarelli had been negligent by underestimating the risk, by not taking into account previous episodes of violence.
I do not personally feel that I know enough of the details about this case to make a decent judgement about accountability. Clearly many people who have contributed to the various blogs don't share this burden. What a luxury it must be to not allow insignificant, menial things like facts, to hinder one's ability to be judgemental.
My first reaction was that if Dr Canarelli informed the police that Mr Gaillard had escaped, then realistically, what more else could she have done? Even if she had underestimated the risk profile of this man, if the police were not able to physically find him, would it have been possible for anybody to prevent his egregious crime? I suppose the counter argument could be that if she had explicated exactly how potentially dangerous Mr Gaillard is, the police may have utilised more resources, thereby increasing the chances of apprehending him.
In the various newspaper articles I've read, it does not appear that Dr Canarelli is a forensic psychiatrist. This is the specialty of psychiatry that I work within on a daily basis; we are supposedly experts in the assessment and treatment of people with mental illnesses, who potentially pose a risk to others. It's possible that Dr Canarelli did not have the experience or virtuosity to deal with this cohort of patients. Perhaps her incompetence was in not seeking an expert opinion.
In this particular case, apparently Dr Canarelli had not taken into account the views of other colleagues, and hadn't fully considered his previous history of violence. Perhaps there were short-comings in her treatment. However, we must understand that in many other cases, as unpalatable as it may be, the risk is not always predictable; even experts can't prognosticate the future. Signs or behaviours that are a harbinger to future violence are not always apparent. It would be completely inhumane, insensible and unacceptable to indefinitely or permanently detain somebody who has committed violence just because they suffer from a mental illness.
Therefore, the best that we can do is to treat symptoms as far as possible and rehabilitate patients by utilising a variety of medications and psychological therapy. First the patient's mental state has been optimised, and then their risk to other people has to be tested gradually using extended periods of escorted and unescorted leave, and allowing increasing independence. Eventually, a decision about discharge needs to be made.
I got an uneasy feeling in some of the blogs that I have read, that some people feel in the above scenario, regarding the French psychiatrist, that somebody deserves to suffer; either patient or the doctor. I think this is a very dangerous way to think and would admonish against it. Sometimes when people are plagued by mental illness, they are not in control of their thoughts and actions. They often can commit actions that are completely out of character for them. They need to be treated and rehabilitated. It is archaic and barbaric to automatically wish to punish them, without first looking at the circumstances and try to improve them. I wonder if the bloggers who are so quick to advocate castigation would feel the same if a member of their family committed an uncharacteristic act of violence whilst not in control of their actions due to mental illness.
"Men are only clever at shifting blame from their own shoulders onto others" - Titus Livitius, Roman historian.
If the French court's ruling set a precedent, then I fear that we have troubled times ahead. If psychiatrists (and other doctors for that matter) are forced to act in such a defensive manner to avoid incarceration, there is a real risk that we have to act in an extremely overcautious manner; e.g. not letting patients with a history of violence ever have a chance at having leave, being independent, being discharged, and having freedom. This means that hospitals would become replete with patients that we would be too worried about discharging. Without extra resources, we would be depriving other non-forensic patients from having the psychiatric care and input they need and deserve. This is already happening to a degree in the UK due to a lack of funding, and due to an enforced shift for patients to be in the community rather than in hospital. It could force us to be more punitive, and less caring. And how would patients feel knowing that their doctor would be forced to prioritise their own impunity ahead of treating others?
Having said all that, I can understand why the people would want some accountability for lax psychiatrists who allow dangerous events to occur through incompetence. I just think that it is dangerous to assume that all violence is predictable and preventable. In England we have a very thorough system of forensic psychiatry. Patients are assessed carefully and cautiously over a long period of time. A high level of support and rehabilitation is offered during admission, as well as follow-up afterwards. Decisions about discharge not taken lightly, and usually involve many different healthcare professionals that know the patient well. Patients' families are often involved in the process. Organisations, such as the General Medical Council (GMC), whose role it is to weed out and punish doctors' incompetent practice are already extant. They commit to this role zealously, and can initiate legal proceedings if necessary. Do we really need the heavy hand of the law to intervene as well?
The blogosphere is reminiscent of an angry mob from ye olden days. It's easy to bay for blood and gesticulate with verbal pitchforks and sticks.
It's a shame; by simplifying these very intricate issues, instead of creating a forum to discuss so many complexities, these commentators invalidate their own points, some of which are actually quite reasonable.]]>Re-Branding Schizophrenia - Would Changing the Name Make a Difference?tag:www.huffingtonpost.com,2012:/theblog//3.21943532012-11-27T19:00:00-05:002013-01-27T05:12:01-05:00Dr. Sohom Dashttp://www.huffingtonpost.com/dr-sohom-das/
I have read with interest the recent report published by the Schizophrenia Commission, sponsored by 'Rethink Mental Illness', which analysed the current state of the treatment of schizophrenia in the UK.
Below is an interesting extract, relating to the term 'schizophrenia' and debating whether it should be replaced:
"We recognise that many people given the diagnosis of schizophrenia and indeed many working in the services would prefer a less stigmatising alternative to the current term. Indeed, we heard from many who believe that there is so much misconception associated with the term schizophrenia that it has lost its usefulness. We empathise with this view and share the sense of disempowerment resulting from the term's unfortunate and inappropriate connotations... However, the call to abolish the term schizophrenia is not unanimous. This is both because not everyone feels so negatively about the term... without greater consensus on an agreed alternative, and a better understanding of causes and remedies, a new term will not in itself deliver an improvement in attitudes."
The report itself highlights that opinions are polarised. I suppose I was initially sceptical.
I thought it was a simplistic way to approach an intricate issue. If some people judge, distain or demur at those who suffer from this tragic disorder, it's probably their own ignorance and attitude that needs to be addressed. I'm not sure that changing the appellation would resolve this. Those who cringe at the S-word I suspect would eventually discover its successor (probably from reading the Daily Mail), and react similarly to the new name. In the same way, a homophobic person's pathology lives within them. I doubt changing in the terminology would improve their attitudes. Bigots are bigots.
Only education can combat ignorance, and only exposure can combat attitudes.
It amazes me that some Philistines still believe that schizophrenia is 'split personalities'. If you subscribe to that egregious fallacy, please read my prediction at the end of this blog ("What is that schizophrenia?"), and let's never speak of this again ...
I was impressed by the report's novel suggestion of focusing on mental health education in the school curriculum; this could reduce inchoate ignorance and stigma. Influencing the malleable minds of the young is easier than for us ignorant adults. Hopefully it will instil confidence within these kids to seek help if necessary, for themselves and for their loved ones in the future. I'm glad to hear from my wife (enthusiastic psychology teacher daily, reluctant blog editor occasionally) that 'Rethink Mental Illness', the very charity that sponsored the report, have been distributing information leaflets at her college.
"Mental illness is nothing to be ashamed of, but stigma and bias shames us all" - Bill Clinton
Though many people (45% according to the report; higher than previously promulgated) recover after one episode, tragically, it burdens a significant cohort for their entire lives, and is classically described as "remitting and relapsing". What must it be like to have the salubrious misfortune of paradoxically losing touch with reality, of being hospitalised, of having your family, personal and professional life, ripped off its trajectory and thrown into turmoil? What must it be like to have to take medication, with potentially unbearable side-effects? What must it be like to have to witness this happening to a loved one? Personally, I imagine that after surviving all that, I'd feel patronised if an authority tried to rename my experience, and suggest that this would palliate it. Pain that is not called pain still hurts.
I've recently spoken to a few patients who have schizophrenia. One young man's words were particularly poignant; he told me that the very word spurts painful and embarrassing memories of rueful events. He said it sent shivers down his spine. He relayed to me that he acknowledges that rebranding schizophrenia won't to change his past vicissitudes, or make his future any easier. But it would help him feel like he has been given a clean slate. Some of my colleagues (psychiatrists and otherwise) feel that a different name can afford patients a more positive framework, to focus on their recovery.
I must admit, I'm not fully convinced either way. But I think a chat with my patients swayed me somewhat. I felt humbled by their attitude. After all, they have lived it. Life trumps observations every time.
What Is Schizophrenia?
Schizophrenia is often mistaken for 'Multiple personality disorder' (also known as 'dissociative identity disorder', or more colloquially as 'split personality'). The latter does exist as an entity, but is extremely rare. Most psychiatrists don't see one of these in their career. I've only ever seen one (or two, whether you see it from my or his point of view).
The term Schizophrenia (literally "split mind") was coined by Bleuler around a century ago. It is not one disease; it's more of a syndrome, with several disparate, complex incarnations. It occurs in 0.5 to 1% of the population, and usually presents around late teens or early 20s. It has obvious symptoms (known as positive symptoms) which include hallucinations (most commonly hearing voices) and delusions (often paranoid in nature, such as a strong belief that others want to hurt you).
Less distinctive symptoms relate to social withdrawal and lack of motivation (known as negative symptoms). There are other rarer symptoms, such as 'thought disorder' (a disconnection in the flow of thoughts, making speech jumbled, confused and random). There may also be an 'affective component' related to mood (e.g. a depressed mood, or irritability, or uncontrollable excitement). The combination of symptoms vary between people. As does the impact it has on their lives.]]>Antidepressants - Can They Help? (Tom Cruise Doesn't Think So)tag:www.huffingtonpost.com,2012:/theblog//3.16671382012-07-12T19:00:00-04:002012-09-11T05:12:10-04:00Dr. Sohom Dashttp://www.huffingtonpost.com/dr-sohom-das/this video.
I'm not going to speak out against Scientology. I've seen the Panorama documentary - I'm not crazy.
However, I thought I might use my experience to depict a balanced portrayal of antidepressants and relevant issues around them. I have been a doctor for nine years and specialised in psychiatry for six of them. In this time I have prescribed hundreds of tablets, including antidepressants.
"There is no such thing as a chemical imbalance... antidepressants - all it does is mask the problems. There's ways, there's vitamins, there's exercise" - Tom Cruise
"Rigorous, published, peer-reviewed research clearly demonstrates that treatment works. Medications can be an important and even life-saving part of a comprehensive and individualized treatment plan." - Brooke Shields
In essence there are three main groups of antidepressant. The oldest type, called monoamine oxidase inhibitors are very rarely used any more, because they have serious side-effects such as extremely high blood pressure after eating certain foods.
Nowadays it is much more common for doctors to prescribe SSRIs (serotonin specific reuptake inhibitors). Fluoxetine, which is known as Prozac is the Tom Cruise of antidepressants. Citalopram is less well known, but popular nonetheless. There are another four licenced for use in the UK.
In addition there are also tricyclic antidepressants, which were more popular in the past, but nowadays tend to be used when SSRIs haven't worked.
How do antidepressants work?
To paraphrase a shampoo advert... here comes the science.
It's quite complicated, and we don't fully understand all of their actions.
There are chemicals in the brain, called monoamine neurotransmitters - monoamine describes their structure, and neurotransmitter is the name given to any substance within the brain and within nerves that affects their function. These are distributed between cells in the brain, which are called neurones.
There are three main chemicals that travel between these cells that are thought to have an effect on mood. These are noradrenaline, serotonin and dopamine. After they are transported from one cell to another, they are broken down in the gaps between cells (called synapses) and recycled. SSRIs and tricyclic antidepressants affect the way these chemicals are absorbed back into cells. This results in a higher concentration of the chemicals in the gaps between cells, and as a result, this can reverse some of the symptoms of depression. Monoamine oxidase inhibitors also increase the amount of these chemicals available in the brain, but they actually work inside the brain cells, rather than in the gaps between them.
When these chemicals are passed from one cell to another, they travel via receptors on the outside of the cells. Receptors are basically gates. In addition to altering chemical levels, antidepressants also affects the number of receptors that grow on the outside of brain cells. They do this in ways we do not fully understand, though this may be an explanation as to why antidepressants take several weeks to work.
Are antidepressants exclusively used in the treatment of depression?
Nope. They are used to treat a number of mental disorders, including obsessive-compulsive disorder (OCD), and anxiety disorders. They're even occasionally used in other less common disorders such as anorexia.
In addition, it's important to bear in mind that antidepressants are not appropriate for all cases of depression, especially milder forms.
So if somebody feels depressed, that doesn't automatically mean they should start taking antidepressants?
That's right. First of all, it's vital to make sure the diagnosis is correct. Depression isn't just a feeling of low mood. I think it's important not to pathologise normal feelings. I'm sure Mr Cruise would indict all psychiatrists of this practice. Everybody has periods of low mood. Depression is something more. It's accompanied by other symptoms such as a lack of energy and interest or pleasure in activities. Sometimes it's associated with weight loss, poor sleep and poor appetite.
In some situations low mood is normal, such as bereavement or adjusting to a major life event. Sometimes, physical causes such as hormonal problems can cause low mood. In these cases antidepressants might not be appropriate. This is why people who think they might be depressed should see their GP's first.
You mentioned that antidepressants shouldn't be used in milder forms of depression.
That's right, I did. Guidance suggests that for mild depression a better option is to watch and wait, as the depression might resolve by itself. People can also use cognitive behaviour therapy (CBT). In this form of therapy, people look at their negative thoughts, feelings and behaviour, recognise the triggers that cause them, and try to change them. There are other tactics for dealing with mild depression, such as exercise and also St John's wort.
However, in stronger forms of depression, like moderate or severe depression, these other treatments are not likely to be enough. In these cases, antidepressants can be helpful.
Do they work quickly?
No. One of the salient problems, is that people have unrealistic expectations of this timeframe. Perhaps doctors need to explain this more thoroughly. Some people might take antidepressants for a few days and feel no improvement. They then prematurely stop taking them, which is a shame, because they could be missing out on the benefits. It usually takes around 4 to 6 weeks for antidepressants to work. They need to be taken on a daily basis within this time. Each individual tablet won't lift somebody's mood.
Do all antidepressants work after if taken for this period of time?
Unfortunately not. Trials have shown that they work for around half to two-thirds of people. Around a third of people are treatment resistant, which means it might take them several trials to find an antidepressant that works, and even then they may not be successful.
I remember once treating an elderly gentleman with depression, who was previously a very cheerful, sociable man. He had to try out seven different types of antidepressants before he found one that restored his quality of life to a level he found acceptable.
And they all have side-effects?
Unfortunately they do. However the extent to which people are bothered by them can vary significantly. Some people barely notice any, and benefit from treatment. Other people find side-effects intolerable, and feel that they prefer not to be on medication. In this case, it is best to work with a doctor and try a different type of antidepressants, or a different dose to see if that's any better.
What are the common side effects that someone should expect?
Common general side effects include insomnia, nausea, dry mouth, sweating, and problems getting an erection. There are more specific side effects for specific medications as well.
Sounds like a lot.
Yeah, fair enough. Though you should bear in mind that these are all possible side effects. That's not to say that people get them all - or any in fact. Some people are lucky enough not to get any. It's impossible to predict, so people need to try medications out.
Like most things in life, taking antidepressants has its advantages as well as downfalls. I think it's unethical and harmful to pretend that they can help everybody. It's also naive to think that they cannot help anybody. People should be given information and options, so they can make their own decisions.
I have plenty more to say on this topic, including addiction, withdrawal symptoms, safety in overdose, and the disparate experiences of patients I have treated. However, I will express this in a separate blog. My unofficial editor (my official wife) tells me that my blogs are too long.
I very much doubt Tom Cruise will be reading this. If you are, Tom, I just like to say that I accept that trying to pacify the war of the worlds between Scientology and psychiatry is mission impossible. I know psychiatry has its shortcomings. Antidepressants are not perfect by any means. But by focusing only on a minority report of poor outcomes, you're keeping your eyes wide shut. In the same way, skewing data by promulgating only the work of a few good men is risky business.
What about you, dear Huffington Post UK readers ?
What are your experiences with antidepressants?
Terrible? Lifesaving? Neither?
Are there any questions you would like me to address in the second part of my blog? ]]>Being Admitted to a Psychiatric Ward - The Experience and the Processtag:www.huffingtonpost.com,2012:/theblog//3.15350412012-05-23T19:00:00-04:002012-07-23T05:12:05-04:00Dr. Sohom Dashttp://www.huffingtonpost.com/dr-sohom-das/
Both of them. (Hi Mum, by the way).
I've worked on five different general adult psychiatric wards, six months in each, including two in Sydney, and have been summoned onto around 20 more whilst doing on-call out of hour shifts. There are of course specialists wards too - I've worked on Learning Disability wards, old age wards and currently work on forensics wards - with mentally disordered offenders.
As with all public services, the layout of the ward, the quality of care and the ward routine varies significantly between disparate wards. As does the atmosphere.
How do people end up on these psychiatric wards?
Good question.
In essence, a psychiatric doctor (often a trainee) has to make the final decision to admit a patient, though this could be brought to attention by another professional (e.g. a social worker or a Registered Mental Nurse), a family member, or even by the patient themself. There are numerous forms of mental state deterioration that can raise concerns. For example, somebody could be severely depressed with thoughts of suicide, or lacking the volition to eat. Someone could be very paranoid to the extent that they are uncharacteristically aggressive or pugnacious. Somebody could be suffering from dementia, and wondering onto the streets with no regard for their own safety.
Despite numerous presentations of mental illness, the avenues of contact with psychiatric services in any given area, actually depends more on the healthcare facilities available in that area.
In psychiatric hospitals that I have worked in, the majority of patients are directed from Accident and Emergency departments, with the next most common routes of admission being via their GP, or the local Community Mental Health Team, who may have seen the patient in an outpatient clinic or at their home. Some hospitals have a kind of 'drop-in centre' where patients or family members can turn up, if they are worried about a person's thoughts or behaviour. That person is then triaged; spaces are scarce and are in high demand, and so a professional (usually a trainee psychiatrist) has to do a thorough assessment and prioritise who needs to be admitted. If they are not deemed to need treatment inside a hospital, they can be linked In with various other services in the community.
Aren't all the people there against their will?
Contrary to what most films depict; no.
In my experience, around half of inpatients are 'sectioned' - i.e. they are detained under the provisions of the Mental Health Act (first written in 1983, but recently revised in 2007). The others are there as a voluntary 'informal' admission, which means they have the right to leave or refuse treatment.
I've been involved in several situations where a voluntary patient has wanted to leave against medical advice. Sometimes staff are worried about them (e.g. because there is suicide risk or because the patient is vulnerable). In such an event, a psychiatric doctor usually does a thorough assessment of the patients mental state at the time. If they are deemed to be safe, they can go, and will hopefully be offered follow-up. If there are concerns, then an emergency Mental Health Act assessment is arranged, and is conducted by two senior doctors and a social worker. People under a section are essentially there against their will, or are so unwell they lack the capacity to make the decisions about their treatment.
What does being sectioned involved?
No men in white coats. No straight jackets. No big van. Lots of paperwork.
Detaining somebody under the provisions of the Mental Health Act is a serious, detailed and time-consuming process. It is never done flippantly. Stringent procedures follows strict guidelines. The people involved and the documents are highly scrutinised. The assessment must be carried out by two senior doctors, who are independent of each other as well as an experienced social worker. Of the two doctors, at least one has to be in a special position of authority - i.e. "approved under Section 12 of the Mental Health Act". To achieve this, they have to undergo rigorous training, assessments and have references. To pass, they need an in depth knowledge of the Act, and when it is applicable and appropriate. I did this training myself around two years ago. Likewise, the social worker is a senior professional with specialist training and qualifications.
It's not enough that the professionals want to detain the patient in order to treat them. They must prove that they believe the patient needs to stay in hospital for their own health, or their own safety or because someone else's safety would be under threat if they were released. Indeed, there are hundreds of people with active symptoms of mental illness, who are not a danger to anybody. They survive perfectly well without their freedom being restricted. And rightly so.
For professionals to 'section' people who are more unwell, they must also prove that the patient would not recover without this enforced treatment, and that there isn't a less restrictive option. This must all be documented thoroughly. There are various legal safeguards to ensure this process is not abused, including scrutiny by hospital managers, lawyers and sometimes judges.
The nuances of the Mental Health Act and the difference sections it encompasses are intricate and specific. I think they deserve a blog of their own.
Maybe I'll write one...
What kind of mental illnesses do people on these wards have?
In my experience, the majority of patients suffer from schizophrenia or a mood disorder such as severe depression or mania (when people with a bipolar illness are in a 'high' phase). However, I've also been involved with treating patients with more unusual psychiatric diseases such as catatonia (a severe psychosis which can render the patient completely mute and sedentary, as if paralysed), and AIDS-related early dementia.
What are the patients like? Are they disturbed?
That's like asking "what are humans like?"
As with other people, there is a huge variety of presentations amongst patients in psychiatric wards, and even amongst patients who have the same disorder. On the worst end of the spectrum, some people with schizophrenia can be extremely disturbed, suffering from hallucinations (such as hearing voices) or delusions (such as very strong paranoid beliefs) and some people with depression can lack the drive to do much or say much. But to assume that all patients are like this would be a misdemeanour. Some people have recovered fully and are in a long process of incipient rehabilitation. They may present identically to before their mental illness took hold of them, have long periods of leave and live with a high level of ability and independence.
It can occasionally be quite an intense and intimidating environment. I've been spat at, shouted at, threatened and even hit. As have other staff working in the mental health arena. If you speak to somebody working in this setting who isn't faced with some form of regular confrontation - then maybe they need to leave their office a bit more.
However, the majority of patients are friendly and interact in the same way as the average person on the street. Additionally, the staff are usually very well equipped and experienced to deal with disturbed behaviour and can perform miracles in terms of placating, de-escalating, and most importantly listening to unwell patients. Nurses are particularly adroit. All staff should have been trained in safety procedures - e.g. carrying alarms, and knowing where people are and what they are doing on the ward.
It annoys me to see the portrayals of psychiatric patients in most films. They are usually completely crazy, and out of touch with reality, or dribbling wrecks, rocking in a corner. To show people in that state and to suggest that they are all that disturbed is unfair and immoral in my opinion.
Perhaps more importantly - it's inaccurate.
Like all hospitals, psychiatric ones are places of healing. Depending on the profile and of the patients and the quality of the staff members, some wards can be peaceful therapeutic places. I've witnessed tremendous compassion and support between patients. Sometimes the most mentally unwell people find solace amongst those in similar positions.
So, what happens on psychiatric wards?
People live there, and gradually recover.
More modern facilities tend to have individual rooms and other entertainment such as TVs, video games and a pool table. Older places tend to have draconian dormitories. Patients live together, and some integrate well and support each other. Others may value their privacy and choose to isolate themselves more. This could be down to mental illness leading to paranoid or negative thoughts. Equally, it could just be down to personality.
There are nurses on site, 24 hours a day. I've worked in places with really well motivated and caring nurses who engage patients in conversation and activities every day. Unfortunately, I've also worked in places where this doesn't happen.
Every patient has assigned to them a Consultant Psychiatrist - the boss. They are ultimately responsible for salient decisions such as medication, leave and discharge, though a good consultant will liaise with and seek counsel from the nurses and the rest of the team. They have many other duties outside of the ward, such as outpatient appointments, home visits, and writing psychiatric reports. Therefore they tend not to be on the ward on a daily basis, but instead usually have weekly "ward rounds". Here, each patient is invited to discuss their progress and any issues. There are also junior doctors on the ward, who review the patients regularly and feed back to their consultants. They themselves are usually in training to become consultants one day, and only years of clinical experience, and a plethora of gruelling exams and assessments are in their way.
Patients are given three meals a day. Most are given medication once or twice a day, though occasionally are offered some extra if they become particularly distressed. Therapeutic activities should be offered throughout the day, and other members of the multidisciplinary team (see later) make appointments, and visit patients to spend some time with them.
Is it true that people are locked up for years?
Rarely. Length of admission varies significantly and depends on the situation.
I've treated patients who have literally stayed for one night only; I remember a young woman who became psychotic after taking a cocktail of methamphetamine and ecstasy while celebrating her 18th birthday. She returned back to an embarrassing lucid sobriety the next day, after the substances had left her system. An extreme introduction to adulthood!
Conversely I've know of people with puissant mental illnesses who lack insight or are unlucky enough to need several trials of medication before they find one that works effectively . They can have admission is that last several months, or even years.
There are many other factors which affect length of treatment and hospital stay. Again, this merits its own blog, if anybody is interested ...
Isn't everybody just doped up?
Not at all.
From working abroad I've seen some places where the ethos is to medicate people immediately with high doses. In England the approach is much more... softly, softly, catchy monkey.
With new patients when the extent and type of illness is unknown, there tends to be a period of observation for several days or even weeks before a decision is made on what medication should be used, if at all. Ultimately these decisions are down to the treating consultant, but good practice is to start at low doses and increase gradually depending on response. The benefits and side effects of any "psychotropic" (i.e. psychiatric) medication varies significantly between patients, and are unpredictable. There is no right or wrong answer. Decisions are made from years of clinical experience. Treating mental illness is an art form as well as science.
In an ideal world, there should be other staff members that can contribute to recovery. These include psychologists who can meet patients individually or in groups and use talking therapy and thinking exercises to help nurture the patients' insight and ability to reflect on their mental illness, personality and behaviour. Occupational Therapists help provide activities including sports and art therapy and assess people's ability to carry out tasks of daily living that other people may take for granted. They can also help patients find work that is appropriate yet challenging, both inside the hospital, and in the long-term, after discharge. Social Workers help with a variety of issues such as communicating with and educating family members, managing benefits and finances and finding appropriate accommodation after patients leaves hospital. All of this is available in an ideal world.
But I've only ever worked in the real world, where some patients have to wait for month after recovery to have their accommodation sorted and some people never see a psychologist even though it would be of great benefit. Underfunded and under-resourced services lack basic necessities. This can make reintegration back into society much more of an uphill struggle for some people.
What is the patient experience of being on a psychiatric ward?
In my career I've talked to many many patients about this, both whilst they were in patients and also afterwards. Their experience and their opinions vary dramatically.
This is a complex, important and vast issue, which I have a lot to say about. Again, I think it deserves its own blog.
What about you, Dear readers?
Have any of you had experiences of either yourselves or loved ones being on a psychiatric ward? If so, how did you find the whole episode? Were you happy with the quality of care you received? If not, what could have been done better?
The film was Sucker Punch, by the way.
I wouldn't recommend it, unless you're suffering from insomnia, or have a particularly horrible shirt that you want to dribble upon.]]>Mental Illness and Stigma - Interpretations of a Recent TV Adverttag:www.huffingtonpost.com,2012:/theblog//3.12432842012-01-31T19:00:00-05:002012-04-01T05:12:01-04:00Dr. Sohom Dashttp://www.huffingtonpost.com/dr-sohom-das/new TV advert by MIND / Rethink, called "It's time to talk. It's time to change", with my colleagues at the psychiatric inpatient unit where I work. You know the one - where Dave (from accounts) has come back to work after some time off with a mental illness, and his colleague is contemplating whether or not to ask him how he has been.
It really seems to polarise opinions amongst the folk at my work. Many thought it was funny and interesting, but a couple of people felt it was demeaning to people with mental health issues, by portraying Dave (from accounts) as unpredictable, chaotic, impulsive and... well, a bit nuts, really (sorry for the psychiatric jargon). I respectfully disagreed, because my interpretation (the advert is ambiguous, perhaps intentionally) was that the bizarre behaviour (e.g. crawling into a photocopier, turning into dust, and guzzling down a model building) was the other person's imaginary fear of how the conversation could go. Also, I pointed out that at the very least, it has people talking about the advert, and by proxy thinking about mental illness.
I'd be interested to know what you Huffington Post UK readers think, and would be much obliged if you could enlighten me.
One of my colleagues made a comparison to the Vinnie Jones recent resus advert, noting that this also tackles a grave medical situation (near death), which is no laughing matter, in a... well, laughing matter. I pointed out that there was a pertinent difference - unconscious people who are in immediate need of life-saving treatment are not stigmatised like some psychiatric patients. They are not vilified and unfairly judged by many or arbitrarily presumed to be violent.
Hell, nowadays, even Vinnie Jones isn't vilified and unfairly judged by many or arbitrarily presumed to be violent.
Of course, Jones himself promulgated his battle with depression, in a recent BBC documentary - a laudable, brave and progressive step.
I do not have the temerity to attempt to deconstruct the intricate and multiple reasons for such stigma in a blog. But I would say that ignorance is a salient factor. Whoever said it was bliss clearly doesn't sympathise with victims of such backward, archaic, hillbilly thinking. The media hasn't helped, with depictions of the mentally ill, as demonstrated by the unfounded language frequently found in newspaper articles, especially in tabloids. You only have to look back at the Sun's egregious gaff - the headline "Bonkers Bruno locked up", for an example. I wonder how the authors of these types of articles would react to equivalent epithets when being described themselves; such as "sensationalist, greedy, oafish tabloid journalist" or "insensitive, callous, attention-seeking, horrible, immoral reporter."
Too much? Sorry.
"Mental illness is nothing to be ashamed of, but stigma and bias shame us all" - Bill Clinton
The very same day of the discussion about the TV advert, I reviewed an outpatient who had recently been discharged after a long stay in our secure Forensic Unit. He was telling me his woeful experience of returning back home, and trying to reintegrate himself against all the prejudice and stigma he had to face.
Although very psychiatrically unwell at the time of his index offence (he assaulted a stranger, while suffering from paranoid delusions), he had since turned his life around. It took medication, psychology sessions and a lot of therapy, but most of all it took motivation, effort and dedication on his part. He is able to look after his day-to-day living, and elude the temptation of drugs and the company of old, nefarious associates. He exercises every day, is actively interacted with his community, and is trying to look for work.
Now, either I am watching too much Jeremy Kyle, or there is actually a significant proportion of our society, for whom the same cannot be said. But because of this invisible, yet heavy label hanging around his neck, he has felt stigmatisation all around him. When it came to looking for a job, speaking to old friends from his neighbourhood, and even spending time with his family, he sensed their fears and insecurities behind the looks they gave him, and hidden within the words they spoke.
I've been around many people with mental illnesses in my career. Some can be challenging and difficult, but the majority are friendly, pleasant and thoughtful. I've also been around many more people without mental illnesses in my life. It is the same.
I've been able to draw my own conclusions from my experiences, but struggled to construe how some people can be so judgemental and narrow-minded. More than a quarter of the population suffers from a mental disorder at one time in their life. And very, very few of those people crawl into photocopiers, turn into dust, or guzzle down model buildings. This means that the only way someone can realistically reach the corollary of mental illness always equating to unpredictable bizarre behaviour, is if they locked themselves in a cave, and barely interacted with anybody at all.]]>Personality Disorder - What Is it, and What Does Diagnosis Mean?tag:www.huffingtonpost.com,2012:/theblog//3.12083282012-01-17T19:00:00-05:002012-03-18T05:12:01-04:00Dr. Sohom Dashttp://www.huffingtonpost.com/dr-sohom-das/"The meeting of two personalities is like the contact of two chemical substances; if there is any reaction, both are transformed." - Carl Jung
Know somebody that you just cannot get on with? Does their behaviour irritate and confuse you? Are they generally a massive pain in the distal digestive tract? There is always the possibility that they have a personality disorder. If, however, everybody you know seems like this...maybe you do!
So, what is a personality disorder?
Good question.
The ICD 10 (the Bible of psychiatry favoured in the UK) defines it as: "[a condition that comprises] deeply ingrained and enduring behavioural patterns, manifesting themselves as inflexible responses to a broad range of personal and social situations. They represent either extreme or severe deviations from the way the average individual in a given culture perceives, thinks, feels, and particularly relates to others. Such behaviour patterns tend to be stable and to encompass multiple domains of behaviour and psychological functioning. They are frequently, but not always, associated with various degrees of subjective distress and problems in social functioning and performance."
Sorry. I dozed off then. What did you say?
Yeah, fair enough. It's a bit wordy, isn't it? For the layman - in essence, a personality disorder is when a person has deeply ingrained, pervasive flaws in their personality. It develops from adolescence, and to varying extents, it is there for life. It affects almost all aspects of their lives and relationships. It can lead to repeated problems at work, and turbulent, strained interactions with friends, partners and relatives. The sufferer may lack insight, but the "average individual" (ICD 10's words, not mine) would find severe faults in their character. Usually, people close to the sufferers suffer themselves. They may avoid contact, or may only have difficult, fractious interactions.
So, is it a mental illness?
Absolutely not! Whereas a mental illness is a change in somebody's normal state, personality disorders are ingrained. They dwell in the very fibre of that person's essence. Potentially mental illnesses can be reversed (though rarely cured) with medication, therapy and care. Ideally with a combination. A tablet that can change a person's personality is about is feasible as a tablet that can solve world poverty. Co-morbid anxiety or depression might be relieved by medication, but the personality disorder itself will always be there. Therapy and time might help sufferers mellow out. I'm sure that age has also mellowed out many an anarchistic punk rocker, or a moody sarcastic goth into...your average, tubby, middle-aged bank manager.
Is it really that important?
Is what?
The distinction between mental illness and personality disorder.
Absolutely. Without it, psychiatrists such as myself could be inadvertently medicating, treating, and even more egregiously, detaining somebody for the wrong reasons. Many times in my career, I've seen people incorrectly being treated for depression, anxiety, and even schizophrenia when they had a personality disorder. However, it was not necessarily incompetence that led to misdiagnosis - inevitably symptoms relating to feelings, emotions, reactions, beliefs, thoughts and behaviours, can be extremely difficult to assess, especially if the patient is particularly agitated, pugnacious or deceitful. You'd be surprised at how many people fake symptoms of psychosis for medication or for hospitalisation. It can take months, even years, of observation and assessments to reach the final corollary of a diagnosis of personality disorder.
Treating somebody for a mental illness, when they actually have a personality disorder, not only gives doctor and patient false hopes and unrealistic expectations, but wastes valuable time that could have been used in therapy, teaching the patient how to adapt their behaviour for their own benefit, as well as for the benefit of people close to them.
Sounds like a diagnosis of personality disorder is pretty serious
Yep. Sadly, the label of "personality disorder" can be used by lazy or inexperienced health-care professionals as an alternative moniker for "difficult patient" when communicating with other lazy or inexperienced health-care professionals. This can lead to people assuming that people with personality disorders are demanding, aggressive, malingering, or time wasting. It can lead to patients who are in crisis to be ignored or discharged prematurely.
One could argue that the label is detrimental to the person's health. My view is that it can be, potentially, but not if it is discussed and explained to the patient, the condition is monitored, and treatment is offered. Treatment should never be forced, but always offered - it is morally wrong to insist somebody needs to change who they are. The exception to this would be life-threatening situations, such as a high risk of suicide.
Despite this, to my surprise I found out that the diagnosis of personality disorder can actually be enlightening and useful for some people. I remember seeing a young woman as an outpatient when I worked in Australia. She had a very chaotic and turbulent lifestyle, and frequent explosive altercations with family members. She would drink excessively, and cut herself. Over several hours, she described her life story, previous stressors, and current problems. She became quite animated and angry when discussing certain topics, including her intense dissatisfaction with the medical profession for repeatedly fobbing her off.
I must admit, at times I was scared. Fascinated, but scared. At the end of the consultation, after undertaking a thorough assessment using a personality measurement tool, I gave her my tentative diagnosis - reiterating of course, that I couldn't confirm my conjecture in one meeting, and that it would have to be reassessed over a long period of time.
I timorously told her that I thought she had Borderline Personality Disorder (whose features include impulsivity, fear of abandonment, chronically low mood, a feeling of emptiness, unclear identity and unstable relationships). She was a...feisty person (when I say feisty, I actually mean intimidating), but surprisingly, she seemed grateful for the diagnosis and explanation. She was relieved. Firstly that she had a recognised disorder, and that she was "not the only one". Secondly, that she did not have schizophrenia, which had ruined the life of her cousin.
"I have an unfortunate personality" - Orson Welles
You ain't the only one, Orson. It is estimated that 10% of the population has a personality disorder (usually younger people, and more often male than female), though the truth is, many more people may never be diagnosed. There are several defined types (nine or 10, depending on which classification system you use), that all have very different characteristics. Aggression and confrontational attitudes are present in very few, though these are the ones that tend to come to the attention of psychiatric services e.g. Borderline Personality Disorder. This is because sufferers are more likely to have symptoms and behaviours that are relevant to mental health interventions - i.e. self harm, an explosive temper and a low mood.
In comparison, people with Narcissistic Personality Disorder (whose features include a grandiosity, and lack of empathy, as well as the need for admiration) are far less likely to want or need help.
Antisocial Personality Disorder (whose features include a callous lack of concern for others, irresponsibility, aggression, and a disregard for others' rights) is very common in the prison population (about 10 times higher than the rest of society), and in my line of work - Forensic Psychiatry.
The different types of personality disorder are beyond the scope of this blog entry, but I may write another one about them if people are interested.
Is it the person's fault?
Now that is a tricky question, which I cannot answer with confidence, or without awkwardness.
Sorry.
That's okay. I don't think there's a straight answer. A person with a personality disorder is in full control of their actions and behaviours, just like the rest of us. Of course they are - their personality disorder is them. Somebody with a mental illness may not have full responsibility of their actions, if they are particularly unwell at the time. For example, somebody with schizophrenia may be out of touch with reality, or somebody with severe depression might lose their motivation or their judgement.
However, people do not choose to have a personality disorder, and they cannot simply just "snap out of it". So I guess they cannot control the way they are, but they can control what they do.
This guy at work is really obnoxious and argumentative. I bet he's got a personality disorder.
Now hold your horses. I appreciate your zealous absorption of this information. But let's be clear.
The majority of people who are unpopular, fractious, irritating and impulsive do not have a personality disorder. This diagnosis is especially unlikely if they get on with others, without rubbing them up the wrong way. It is also rarely compatible with a high level of functioning. Although there are tools (personality inventories) and other indications in somebody's background (e.g. a childhood of emotional privation) it's very easy to misdiagnose.
Psychologists and psychiatrists should only make such a diagnosis after a thorough assessment. This isn't because we like to feel intellectually superior, and utilise our jargon. Okay, maybe it is a tiny bit.
But mainly, it's down to experience. Even a person who veraciously reads textbooks (or perhaps an informative, well written, concise blog) cannot acquire the nuances of sensing how a personality disordered person makes them feel (known as "transference").
So, all you Armchair Psychiatrists; beware. Only by seeing and assessing hundreds of normal people, and dozens of people with a personality disorder, can a professional recognise the latter with confidence.
Help does exist, and people do improve.
So, you never know, with encouragement and guidance, that person you loathe could potentially become your best friend...]]>Mass Hysteria at Kim Jong Il's Death - Normal Vs Abnormal Grieftag:www.huffingtonpost.com,2011:/theblog//3.11739242011-12-29T19:00:00-05:002012-02-28T05:12:02-05:00Dr. Sohom Dashttp://www.huffingtonpost.com/dr-sohom-das/
No, not the Boxing Day sales. I'm talking about the mass grieving of the people of North Korea, for their recently deceased, supposedly exalted leader, Kim Jong Il. I noted some performances that may contend for the 2012 Oscars.
To them, he was a generous and inspiring leader. Apparently.
The rest of the world may remember him as a brutal dictator, obsessed with the development of nuclear weapons. Either that, or the butt of a mildly-racist, but superbly-funny joke in Team America.
"I'm so Ron-rey!" - Kim Jong Il
I'm surprised that North Korea has been so open about his demise. Their more typical coverage of such an event would have been reports that he had "entered a long-term sleeping contest, and is so far doing remarkably well."The histrionic commotion made me think about the different ways that grief can manifest itself in our intricate, unfathomable, unpredictable human minds. Different ways, not just between individuals, but between cultures as well.
In psychiatry, we make a distinction between "normal" grief and "abnormal" grief. The latter condition has other aliases such as "pathological grief" or "morbid grief". Should psychiatrists meddle in such a natural human reaction?
I have read the prose of numerous anti-psychiatry bloggers and commentators, always opinionated, often absurd, on this website and other internet forums. Their colourful statements and conspiracy theories entertain me. No doubt, they would answer the above question thusly:
"Psychiatrists are funded by drug companies to invent illnesses to sell pills", or: "Psychiatrists want to make a normal people looked crazy, so they can lock them up, to keep themselves in business", or: "There is no such thing as mental illness," or: "Aliens impregnated my cat." Okay, so maybe not so much the last one ...
I personally feel that there is a role for healthcare professionals when it comes to grief. The primary role, often undertaken by GPs, is to offer support, and promulgate its availability to those who may wish to use it. Some people, after all, do not have the luxury of loved ones with whom to share the burden.
"Grief can take care of itself, but to gain the full value of joy, you must have someone to divide it with." - Mark Twain.
Thanks, Mark, but that kind of invalidates the point I'm trying to make.
The secondary, and often vital role, is the vigilance to detect exceptional cases where people's grief crosses the dark line from normality to mental illness. These cases need to be treated before something tragic occurs.
Several years ago, one of my patient's grief at losing his daughter was so profound that he stopped eating and sleeping. In fact, he stopped doing anything and became almost catatonic. He was found in his flat emaciated and starved, hours away from death. Only after several months of treatment for psychotic depression on a psychiatric ward, did his quality of life improve, until he was eventually discharged home. Of course, this was an extremely unusual case. However, I can't help wonder if his prognosis and outcome would have significantly improved with earlier psychiatric intervention.
"I measure every grief I meet with narrow, probing eyes - I wonder if it weighs like mine - or has an easier size." - Emily Dickinson, American poet.
Normal grief consists of a range of typical symptoms, such as: sadness, denial, emotional numbness, shock, anger and guilt. Often these symptoms are worse for complex or ambivalent relationships between the griever and deceased. Frequently bursting into tears and poor sleep and appetite are also recognised features. However, additionally there are some other, more unexpected symptoms, such as weight loss, hearing the voice or seeing simple images of the deceased, or even obsessional thoughts about the method of death. This state of grief usually lasts up to a year (though the average is half his time). Grief that is more persistent should be monitored closely, lest it slip into the murky world of a deep depression.
Abnormal grief is not just a more intense or prolonged version of the above, but can also entailed more sinister symptoms, like a morbid preoccupation with death or thoughts of suicide. Excessive guilt or a total apathy are also indicators. Sufferers can refuse to interact with others, and sometimes even refuse to leave the house. They can become reclusive or even catatonic, like my ex-patient. Complex or systematic hallucinations, or belief that the deceased still live, are other worrying symptoms, as is a newfound uncharacteristic pugnacity, that leads to the breakdown of relationships.
However, the one most significant element of abnormal grief that trumps all the others is the breakdown of day-to-day functioning.
Regular support and high-intensity bereavement counselling from an experienced specialist can help. Medication can be given if, and only if, co-morbid depressive or anxiety disorders coexist. In short, treatment is available.
Whereas I agree in principle that normal grief should not be medicalised, I also believe that pathological suffering should not be normalised, and swept under the carpet.
Anyway ... Happy New Year!
Apologies for the macabre topic.
Rest in peace, Kim Jong Il. Thanks for all the funny memories!]]>Norwegian Massacre Man Breivik Diagnosed With Paranoid Schizophrenia. Is This Reasonable? What Does the Voice of the Internet Say?tag:www.huffingtonpost.com,2011:/theblog//3.11445332011-12-13T19:00:00-05:002012-02-12T05:12:01-05:00Dr. Sohom Dashttp://www.huffingtonpost.com/dr-sohom-das/"What's the difference between Andres Breivik and the Yorkshire Ripper?"
I know this sounds like the setup of a scurrilous, distasteful joke from Sikipedia, but bear with me; there is a point to this.
I was very interested to hear about Breivik's diagnosis of paranoid schizophrenia and the suggestion from experts that he should be sent to hospital, not prison. I am a Specialist Registrar in Forensic Psychiatry. I regularly deal with people with mental illnesses (including schizophrenia) who have perpetrated serious crimes (including homicide) and often submit recommendations to courts and judges about appropriate placements.
So as a professional, this story is right up my proverbial street.
However, as a blogger, I was more interested in the opinions and comments made about him, and his case on this website, and others.
Now, I must stress I absolutely sympathise with the horrific suffering the loved ones of Beivik's 77 victims must have endured. Clearly, his actions and beliefs are abhorrent. I'm merely examining the situation objectively from a psychiatric perspective.
I'm also making an observation. And that observation is that many people speaking on the internet seem to hold one of three strong beliefs.
1) Of course he is mentally ill, stupid! All murderers, fascists and hate-mongers of this intensity must be.
2) He cannot be diagnosed with paranoid schizophrenia, because he meticulously planned this massacre, and a mentally ill person would not be able to do that.
3) By being sent to hospital, he's been given an "easy option".
1 is not compatible with 2, and 2 and 3 complement each other.
I politely (and I hope not too smugly) dispute all three.
Let's get to the crux of the matter.
What is insanity? What is evil?
Well, one could literally write a library's worth on each topic and still not answer either question.
Being malicious, hateful, and having hurtful, pernicious ideologies, and carrying out atrocious actions by itself is not indicative of mental illness. One could postulate that the subject's personality and character are warped. Sure. The diagnosis of a Personality Disorder could be made. There are many, but a Dis-social Personality Disorder is the most likely, which features include a callous lack of empathy for others and a violation of their rights. A diagnosis of psychopathy could even be made (check out my blog about what psychopaths are like). Personality disorders, by definition are ingrained and on some levels unchangeable. They are not mental illnesses, as the latter must be a change of one's normal mental state.
The vast majority of people who hurt, kill and hate are in control of their thoughts and actions.
Was Breivik?
Psychiatrically, having extreme views or ideas, however bizarre or unpalatable they may be to the rest of us, is not in itself indicative of a delusion. For example, Isaac Newton, stuck a needle into the back of his eye as an experiment. Maybe it was concussion from that apple, yet the man undoubtedly was a certified genius.
Delusions, by definition, are un-understandable, fixed ideas that are out of keeping with one's cultural background, and most importantly they must originate from a false, inexplicable source. He reportedly believed he was chosen (literally, not metaphorically) by a supreme power to decide who has the rights to live or die. This could potentially be a delusion, if the source of this idea was outside the realms of reality - e.g. from aliens, or a message from the television. This is one possible symptom of paranoid schizophrenia. Others include hallucinations (classically, hearing voices) and thought disorder (where one's mind is unable to sustain one topic without jumping to another vaguely related one). Breivik apparently spoke in 'neologisms', the vocal demonstration of thought disorder.
Some people with schizophrenia, especially with a chronic disease that has been under-medicated, may have a low level of functioning, but exceptions do occur. This was sensibly pointed out by Dr Rygnestad, the head of the panel of the Norwegian Board of Forensic Medicine, who reviewed the assessment. It is possible for people with this disorder, as well as other related psychoses such as delusional disorder, to be highly functioning. In theory, it is possible that someone who is psychotic could have the cognitive ability to write detailed manifestos and meticulously plan a massacre like Breivik did. Unusual, but possible. But then again, many things about this case are unusual. With paranoid schizophrenia, killing one person, let alone almost 80, is unusual. The majority of sufferers of schizophrenia are not violent, despite how they are often portrayed. In fact, the risk of self harm is higher than the risk to other people. Additionally, over 90% of violent crime is carried out by people without a history of a psychotic disorder.
Ultimately, I can't really comment with certainty on whether Breivik's diagnosis is correct without assessing him personally. Nobody can. I'm merely trying to keep an open mind. What I would say is that a diagnosis in such a high-profile case would not have been made lightly. I'm sure the forensic psychiatrists involved would have been experienced experts and would have looked at a plethora of other relevant factors, such as family history, previous psychiatric contact, and the presence of the prodrome (a prolonged unusual mental state, that's usually a harbinger of schizophrenia). A frivolous perfunctory conclusion for such a notorious patient, under such scrutiny is potentially career ending.
Given the easy option?
There is no doubt that Breivik will go to a high secure forensic hospital (the Norwegian version of Broadmoor). These can be very tense and dangerous places, that house some very ill people. All too often, assaults, bullying and a hierarchy of status occurs. I am reminded of the case of Peter Bryan, who murdered Richard Loudwell, due to the latter's offence (murdering an 82-year old lady), whilst they were both patients at Broadmoor Hospital.
Of course the ethos of hospital is to treat and rehabilitate. Their ethos of prison is to punish, hopefully rehabilitate. Care vs retribution. Patient vs Prisoner. They may sound different on paper, but in reality the lines are blurred (check out my blog on the criminal code of prisoners). I don't think this is an easy option, as such.
As many bloggers and commentators have pointed out, there is a maximum tariff for Norwegian prisoners, whereas in the psychiatric system, the client is not discharged until it is proven that they risk has decreased. For Breivik, this will be at the educated discretion of the forensic psychiatrists treating him, and is largely influenced by how his symptoms respond to medication and how his ideas and attitudes respond to intense and challenging therapy. If the system over there reflects the English one, my guess would be that he would not be released for several decades, if ever. If he does get leave, it certainly would be extremely gradual, and under heavy supervision.
If I was his doctor (which I'm not), I would want to at least attempt to rehabilitate him. If I was a relative of one of his victims (which I'm even more not), I would want him to suffer. Thinking about it now, I don't know which is right. Neither? Both?
The Yorkshire Ripper, Peter Sutcliffe, was convicted in 1981 for murdering 13 women, and attacking seven others. A confident diagnosis of paranoid schizophrenia was made, but due to the high demand of the public baying for blood, the judge ignored professional opinions of four psychiatrists, and sentenced him as a 'normal person'. He went to prison, against the doctors' recommendations. It seems Breivik probably will not. Sutcliffe's was a political decision, I fear, rather than a medical or logical one. Despite this, he was eventually transferred to Broadmoor Hospital nevertheless, though not before being horrifically attacked and cut across the face.
I'm sure that there is a significant cohort of opinionated people who feel vindicated by Sutcliffe's fate, and share this sentiment about Breivik. The internet is your platform. Feel free to rant abuse towards them. Perhaps you could admonish me for the audacity to question automatic brutality towards these men. If you're struggling to concoct material, please help yourself to any of the following stereotyped responses that I have taken the trouble to write on your behalf:
"I don't need a degree or any of that so-called 'training' to know he must be a raving lunatic."
"The guy is a monster. I hope he rots in hell."
"Bring back hanging."
And my personal favourite: "It is political correctness gone mad." ]]>Woman Spends £4000 on 100 Lip Injections to Look Like Jessica Rabbit - Could This be Body Dysmorphic Disorder?tag:www.huffingtonpost.com,2011:/theblog//3.11269502011-12-04T19:00:00-05:002012-02-03T05:12:01-05:00Dr. Sohom Dashttp://www.huffingtonpost.com/dr-sohom-das/"Woman Spends £4000 on 100 Lip Injections to Look Like Jessica Rabbit". My first thought was "Sorry love, you don't look like Jessica Rabbit". Perhaps a healthier choice would be a role model that is a) not imaginary and b) predominantly human. Maybe I'm prejudiced.
My second thought was "This seems oddly familiar."
I think I know what this is and I think I've seen it before.
Obviously, it would be presumptuous of me (though instinctive as a psychiatrist) to diagnose somebody I've never met, but she draws strong parallels to a previous patient of mine with a body dysmorphic disorder (aka body dysmorphic syndrome). The main feature is a powerful, pervasive preoccupation with one particular element of the sufferer's appearance, that other people do not necessarily see. I guess it's akin to the obsession with being overweight in anorexia (though this bears the burden of its own unique problematic, dangerous behaviour). My previous patient, 'Mr N', was obsessed with his nose. It's classified within the 2 bibles of Psychiatry; ICD-10 and DSM-IV. In other words, it may be weird and wonderful, but it's also an official psychiatric disorder.
It's just as common in men and women, and effects about 1% of the population. It tends to run in families, and there's a 60% risk of major depression, and a whole host of other psychiatric baggage. For example, sufferers often have social phobia (ie too scared to go out in public lest people recoil at their supposed 'disfigurement'), and also suicide rates can be 50 times higher than the rest of the population. That's pretty shocking to me.
I was a little disheartened by the negative judgements and insults made towards her on the comment section of the post (shame on you!) and it saddens me to hear her report that strangers make hurtful comments to her when she's out and about. In my opinion, people who suffer from this disorder, like any other psychiatric or medical disease should be treated with dignity and respect. I guess that's the age-old issue with psychiatric disorders and stigma. However, if you refute my psychological proposition, and think this is all about attention-seeking, then I guess it's only natural to judge her. Maybe in the same way you'd judge a man showing off his physique by going topless in an urban, non-beach environment when it's not sunny - "I bet he's a tool".
Sufferers very often go for repeated plastic surgery, and I think any surgeon who provides this service when it clearly isn't necessary must be prioritising money over morals. As a wise man once said: "Quality care makes the world go round - I'm pretty sure they don't reach that at business school."
Despite surgery, any satisfaction afterwards is short-lived. It can be treated with high doses of anti-depressants (specifically a class called SSRIs - Selective Serotonin Re-uptake Inhibitors) or even anti-psychotics, such as those used in schizophrenia. But here lies the problem - if a sufferer has no insight, then what motivation do they have to acquiesce to a pesky doctor, who's offering medication instead of surgery for their nose? Cognitive Behaviour Therapy (CBT - where your ideas, beliefs and behaviours are discussed, tested, challenged, and hopefully adapted) is the best therapy. But again, this is difficult to initiate without some degree of insight.
It usually becomes a monstrous preoccupation, and impinges on one's day-to-day living, with people constantly checking mirrors, avoiding social contact, and even picking and scratching at their particular apparent anatomical anomaly. For more serious psychiatric disorders, like severe depression, in exceptional circumstances some people are detained and treated against their will under the Mental Health Act, 1983 (amended 2007), though for this to happen, the disorder must be "of a nature or degree to affect their own health or safety or the protection of others". One could argue that body dysmorphic syndrome does cause long-term psychological damage, though equally one could argue that the sufferer understands the risks and benefits of repeated cosmetic surgery, and so has the capacity to make that decision.
I vividly remember my consultations with Mr N. The entire time, he sat with his head tilted downwards, and pretended to have an itchy eye, and would rub it, just to cover up his nose with his hand. It was really frustrating, and as a fairly naive junior doctor at the time, I couldn't help but try to convince him that his nose was of a normal size. We ended up in a surreal, circular polite argument!
At times, I just wanted to step out of my role as a psychiatrist, reach over the table, shake him vigorously and shout "There's nothing wrong with your frickin' nose! Please stop going on about it!" I even used to feel like he was wasting time and resources, that could have been used to treat people with 'proper' mental illnesses. Looking back at it, I regret my attitude (shame on me!) He was suffering from a genuine disorder, and my difficulty in handling the lack of tangible problem was my problem, not his.
As it happens, Mr N's case was very unusual - his preoccupations crossed the dark line into delusion. Worryingly, he actually had intentions to carry out his own 'surgery' using a stanley knife. He had even done some research, and had meticulous plans. Only after thorough, persistent investigation by my consultant did Mr N disclose these morbid thoughts. I hadn't revealed them because I hadn't given him the time he deserved. I shudder to think what would have happened if my consultant hadn't been there as my safety net. It was an invaluable life-long lesson for me.
We decided that he did need to be detained under the Mental Health Act for treatment against his will (which is very unusual with this condition) as the risk of self-harm was so high. He had a long, arduous, hospital admission, and his insight did improve slightly with a great deal of effort, encouragement, and CBT from a diligent psychologist. He was not 'cured' and still believed his nose was oversized, but was able to distract himself from the obsession, and able to put things in perspective far more rationally. He was able to go outside - a mini-victory in itself.
I find it interesting how keen we are to vilify 'freaks', and define them by their eccentricities. Yet often when the outcome is something as serious as a suicide, or a breakdown, then we quickly do a U-turn. We deem the case 'tragic' and retrospectively show pity.
Obviously, I think everybody is entitled to their own opinion. I just feel that instead of being so quick to judge and chastise people like Miss Rei, it's more helpful to take a step back and try to objectively analyse why she has these thoughts. That way, if her ideas are seen as pathological, at least help rather than criticism, can be offered.
(PS. I must confess I was tempted to make some kind of pun about Mr N 'spiting his face' but I did manage to refrain!)]]>The New Health and Social Care Bill - My Concernstag:www.huffingtonpost.com,2011:/theblog//3.11028092011-11-24T19:00:00-05:002012-01-24T05:12:02-05:00Dr. Sohom Dashttp://www.huffingtonpost.com/dr-sohom-das/Sky. It involved much more frustrating, mundane drudgery than I expected. Forget 'Believe in better' - I was left not even believing in mediocre. The catalogue of errors included Love Digital, who signed me up, neglecting to inform me that there would be a six-week delay in my phone-line being connected. But why let such minutiae get in the way of a sale? When I finally did manage to agree a date (after several phone calls to people whose enthusiasm outweighed their English, Sky customer service operators), I took the day off work, ready to be connected.
At the last minute Openreach, texted me the "good news" that an engineer was not needed, and I should be up and running in a few days. I wasn't. After a plethora of irritating phone calls, an engineer did come round, and I was finally connected. I'm not just ostensibly bitching about my bad experience here. Bear with me - I'm making a (somewhat convoluted) point ...
Earlier this year, in January, our coalition government introduced the Health and Social Care Bill to Parliament. It was passed through the House of Commons and is currently being considered by the House of Lords. There was an uproar from the medical profession for many reasons, and a tirade of negativity was thrown at Andrew Lansley (including, bizarrely a 'diss-rap' - see YouTube).
Although some doctors agreed with the principles of the Bill, the consensus was that it was bulldozing through Parliament far too quickly and with an inconsiderate temerity, ignoring public and professional opinion - especially as it had not even been mentioned in any election manifestoes in 2010. This chorus of complaints was appeased to a certain degree when David Cameron put the plans on hold for a "listening exercise" in April (though allegedly some actions had already been irreversibly implemented at this point).
I can only blog from the point of view of a psychiatrist, though of course all the specialties of medicine are affected, not least GPs, who through the abolition of Primary Care Trusts have to carry the financial burden of commissioning. This of course is closely accompanied by the burden of blame, if it does fail. A slippery way, cynics may say, for the government to relinquish responsibility.
Like my peers, I have many concerns about the proposals. Here are some of them:
Say we have an imaginary person, Stephen, with very real mental health problems. Stephen develops schizophrenia in his early 20s. His insidious negative symptoms (withdrawal, inertia) are followed months later by positive symptoms (paranoia, hearing voices). Eventually, his family become so worried they seek professional help. His GP start him on an antipsychotic medication, and introduces him to the Early Intervention Service (a specialist psychiatric team that proactively treats and monitor initial presentations of psychosis, as this improves prognosis). He gets better initially, but has a relapse due to the stress of falling behind at college.
His local Crisis Resolution Team (psychiatric team dealing with mental health sufferers in crisis) see him daily and give him support, but unfortunately one night he is particularly unwell and distressed. The voices torture him to the point that he needs admission. He is taken to Accident and Emergency, where the doctor refers him to a Liaison Psychiatrist, who recommends voluntary admission to a psychiatric ward.
With a stronger dose of medication, supplied by hospital pharmacist, and several weeks of structured activity, support and encouragement from nurses, he improves. Whilst on the in-patient ward, he sees an Occupational Therapist who helps assess his skills and engages him in various groups, assisted by a Social Therapist. A Social Worker helps him sort out his income support, and arranges accommodation after discharge, in a specialist psychiatric hostel with round-the-clock supervision and staff support. A Psychologist administers talking therapy, and as well as a Psychiatric Consultant, there's also a junior doctor on the team who monitors his progress every few days. He is given increasing periods of leave, and feedback from the hostel workers is positive. On discharge, Stephen is reviewed regularly by a Community Mental Health Team, which is made up of a different Psychiatrist, Social Worker and Community Psychiatric Nurse.
This is a typical journey through the mental health services. I count around 17 health-care workers, belonging to 12 different specialities, in a variety of settings. Currently, they all work together as a well oiled machine. They all work for the NHS (except maybe the hostel worker), which ensures that there are regular communications. Clearly, efficient interface is needed.
According to the new Bill's proposals, funding and commissioning will no longer be handled by Primary Care Trusts (local healthcare organisations who have an elected board of directors, and hold open, accountable public meetings) but by GP consortiums (made up of probably well-meaning, but economically naive GPs), who are encouraged to outsource services to "any willing provider".
The problem is, this opens the doors to private companies, many of whom are big and powerful enough to undercut current NHS services, and bully them into bankruptcy. The GP consortiums themselves could crumble under their financial inexperience, and inefficient budgeting can culminate in their own bankruptcy. Unfairly pessimistic? Perhaps not - there are numerous similar examples in the US for the past couple of decades.
Even if economically viable services are set up, they might all be from different companies, with different structures, styles of working, priorities and codes of ethics. Hell, who's to say they even have a code of ethics? They are ultimately private companies, striving for profits, in contrast to the ethos of the NHS. Saving money is in their interests of survival, as competing contract-seekers could be nipping at their proverbial heels. They might not agree that Stephen needs follow up quite so regularly, or could provide a watered-down service, or employ cheaper, less experienced clinicians.
Let's say Stephen's psychologist is concerned about another resident in a hostel intimidating him and using peer pressure to bully him into taking drugs. She may want to address this problem with his social worker and hostel manager. Currently, the social worker might be in the office next door, and even if he is busy this morning, our heroic psychologist can catch him at the end of the day at the Team Meeting, during which every patient problem is discussed. If there is a failure of care, or any concerns, they can be raised then and dealt with. But if these professionals all worked for different companies, in different buildings, how can we be sure that smooth communication is possible? If the problem is too complex, it's easy for people to shrug off responsibility, and pass the buck - especially if your boss is talking to you about profits, rather than quality of care.
What if I'm wrong? What if the company that is commissioned to provide follow-up actually does so to a decent standard, by not cutting corners? Without a minimum contract, they could be undercut and replaced at any moment by a competitor, leaving Stephen with the uncomfortable process of having to trawl through his history, problems and issues again. With strangers.
Don't get me wrong, in theory I can see how competition promotes quality and efficiency, and of course I acknowledge that the NHS has finite resources that must be distributed fairly. But are GPs prepared and able to handle such responsibility? I would not expect them to have in-depth knowledge of all the specialist treatments needed in psychiatry. Why would they? They spend little or no time in their careers working on psychiatric wards or for Community Mental Health Teams. Just as I have limited understanding of medicine outside mental health.
Other specialists such as surgeons shared this concern about the expectations put on GPs making commissioning decisions without experienced and knowledgeable input from specialists. Additionally, many GPs that I personally know don't want to be pressurised into this position. The original Health and Social Care Bill proposals overlooked this issue, though apparently it'll now be taken into consideration.
If the aforementioned well-oiled machine is disintegrated into several individual, privately-funded, cogs, what happens if some of the components don't pull their weight? Psychiatric services contain some of the most vulnerable patients. Would somebody with severe depression, or negative symptoms of schizophrenia necessarily realise if they are being short-changed, or have the motivation to speak up and proactively resolve the situation?
Stephen's case is fairly typical. But what if it was more complex? What if he had comorbid substance abuse issues, or learning disabilities? This would fragment his care even further, amongst more profit-driven companies. If he drained too many resources, he could be passed around services just like the proverbial buck. The danger is that companies might even see him as a financial liability, and not treat him at all.
What of patients with other complex psychiatric disorders, that are challenging to treat? Like Borderline Personality Disorder or anorexia. Might private services find them economically unviable, and so few in number, that they may simply feel they are not worth spending money on?
When I complained to Sky about shoddy service, they replied with an apology, but explained they could not be responsible for the actions and failures of Love Digital or Openreach. I really hope this marriage of inconvenience doesn't occur within the management of the future NHS. (See, I told you earlier that there was a point in my moaning).
Like many other doctors, I am not against the principles of the Health and Social Care Bill or against the theoretical restructuring of the NHS. What worries me is the potentially misguided and hasty way it is being proposed. One only has to look at the outcome of the privatisation of rail services - dire quality and ever inflating fares. Whilst fat cats at the top get fatter.
"Quality care makes the world go round" - I'm pretty sure they don't teach that at business school.
In a perfect world, companies might prioritise patient welfare over money. In a perfect world, competition might inspire service providers to work and budget more efficiently.
The problem is, I don't live in a perfect world.
Do you?]]>The Criminal Code of Prisonerstag:www.huffingtonpost.com,2011:/theblog//3.10908372011-11-13T19:00:00-05:002012-01-13T05:12:01-05:00Dr. Sohom Dashttp://www.huffingtonpost.com/dr-sohom-das/
I worked in a prison earlier this year, as a detox doctor, prescribing methadone to heroin addicts, and other medications to alcoholics, who had just arrived at prison, in withdrawal. They would demand obscene doses of medication, which I was not allowed to prescribe for safety reasons - you can die from a methadone overdose, but not from opiate withdrawal. I used to think I had reasonable levels of charm and charisma, but even Sean Connery would struggle to tame this demographic of people. I don't imagine many criminal drug addicts were taught the best of manners.
But one thing that really struck me from getting to know the prisoners there was the moral code they lived by. It's also rife within forensic psychiatry wards that I have subsequently worked in, which is unsurprising, as many of these particular patients have spent time behind bars. The code seemed bizarre and contradictory to a naive yet inquisitive man like me. Some staff members called it the "con code".
"We judge others by their behaviour. We judge ourselves by our actions" - Ian Percy, motivational speaker.
For example, in the prison I worked for, sex offenders are segregated in a separate "vulnerable prisoners' wing", in fear of retribution from the other inmates. I have been to such a wing and far from the debauchered, nefarious hellhole I imagined (I told you I was naive), it looked identical to any other wing. Its inhabitants looked and acted no differently to the other inmates, many of whom would gladly take the opportunity to inflict their own style of physical retribution on them.
Similarly, there was one prolific sex offender, Mr C, who was resident in a medium secure forensic unit I worked in, who was bullied, spat at, insulted and disdained because of his crime. But who were the perpetrators?
They were all men with a long history of violent assaults, who in their own way caused profound physical and psychological traumas on many innocent people. What made them feel they needed to act so righteously? Why did they consider themselves to be morally superior?
It reminded me of the case of Peter Bryan, who murdered a fellow Broadmoor patient, Richard Loudwell in 2004, in cold blood, because the latter's Index Offence was the rape and murder of an 82-year-old lady. Apparently all the other patients knew what was about to happen, and some even helped orchestrate the incident. But Peter Bryan himself had killed two people; the first of whom was a random, innocent 20-year-old female shop assistant, and the latter was a friend, whose brain he proceeded to eat. He was hardly a man of the moral calibre to judge another criminal!
Don't get me wrong, of course I believe that sexual offending and paedophilia are heinous crimes (call me old-fashioned!), and of course I believe perpetrators should be castigated. However, I also believe in rehabilitation for these, and any offender that will eventually be released into the community, contrary to the beliefs of many others (usually old-fashioned!) Not doing so, in order to take the moral high ground, in my opinion is naive and above all dangerous in terms of risk management and public protection in the future.
I'm not a robot. In my work, of course I have private thoughts and judgements about individuals, but I would never allow them to interfere with my professional duties. My job is to identify, consider, and treat individuals' risk factors, including personality traits and mental illnesses. I do not confuse my role of a doctor for that of a judge.
But, I guess it's not really surprising that prisoners adopt this mind-set. It's only a reflection of what is thought in wider society, when some crimes and cases are judged and punished much more harshly than other similar ones. Look at the London Riots.
I wonder if these prisoners project the parts of themselves that they hate onto sex offenders, as it is easier to attack another under the shadow of the false morality than to have to accept it in themselves. The latter option would require introspection, insight, but above all the acceptance of guilt. Perhaps that is too painful for a fragile psyche to cope with.
"Everything that irritates us about others can lead us to an understanding of ourselves." - Carl Jung
Well put, Mr Jung. Thanks for backing me up.
This inability to accept guilt was particularly apparent in one of my patients, Mr B, who resided on the same ward as Mr C. He was a career drug dealer, who in his line of work often ran into the occasional...difference of opinions - much more than even traffic wardens and prison detox doctors. He inevitably found himself in the midst of brutal turf conflicts, and used to brag to staff and patients about how he was well respected, and that he "only ever hurt scumbags who deserved it". However, looking at his records, I know that he has a prolific history of robbing dozens of innocent people at knifepoint in his earlier days - some of whom were lone women. Yet he genuinely holds a distorted view of committing only "honourable violence". I find it all remarkable.
As it happens, despite Mr B's past, he was actually a friendly, charming young man (no Sean Connery, though), but when I heard conversations between him and his peers about their past criminality, and their current disdain towards Mr C, I found it exasperating. Their code of honour did not conjure up images of a classic criminal fraternity such as the mafioso in the Godfather. Far from it. It's reminded me of a bunch of sniggering kids, calling another kid names behind his back.
They say there is honour amongst thieves. Maybe. But in my experience, when it comes to many violent criminals, there's a lot more bullcrap.]]>What are Psychopaths Like in Real Life?tag:www.huffingtonpost.com,2011:/theblog//3.10791642011-11-07T18:00:00-05:002012-01-07T05:12:01-05:00Dr. Sohom Dashttp://www.huffingtonpost.com/dr-sohom-das/I'd Like to Talk About Kevin
I've just seen that film, We Need to Talk About Kevin. Wow!
I really enjoyed it. The acting was outstanding and I was especially impressed with how effortlessly sinister and chillingly-vile the small child was. Even if I was the biggest bully at his school, I think I'd still give him my lunch money.
Like many films, this one succeeded in depicting violence, and a spine-tingling coldness. But in real life, true psychopaths have many other character traits. In forensic psychiatry, it is our business to diagnose and treat psychopathy as well as a range of other personality disorders and mental illnesses.
The term "psychopath" or rather "psychopathic disorder" was in fact originally a legal term, not a medical or psychiatric term. It was described in the Mental Health Act, originally in 1959, as: "A persistent disorder or disability of the mind that results in abnormally aggressive or seriously irresponsible conduct on the part of the person concerned." Sounds a bit more official than "creepy teenager who'd shoved his sister's hamster down a garbage disposal unit to upset his mom" - doesn't it? (Apologies if you haven't seen the film).
Character Traits of Your Typical Psychopath
Films can easily depict savage cruelty and a lust for violence, but as well as this, a true psychopath has a unique way of relating to other people, feeling emotions, and also makes well-recognised lifestyle choices. I have had the questionable honour of treating many psychopaths within in-patient medium security psychiatric wards during my career.
The aim is to try to decrease their risk in the future, in order to push them towards discharge, and integrate them back into the community they once wrecked havoc upon. One particular patient, Mr E, has embedded himself into my memory, as he was a textbook case - ticking almost all the boxes in terms of how a psychopath is defined.
Unlike Kevin in the film, life wasn't easy for Mr E. He was physically abused and severely emotionally bullied by his father - he actually thought his first name was 'Bastard' until the age of four. Yet he did fairly well at school, gaining five GCSE's, until he was pushed off the rails by alcohol and drugs. He often got into trouble at school for fighting, and with the police for dealing drugs. Psychopaths have turbulent upbringings and early behavioural problems with juvenile delinquency.
His index offence that landed him in prison, before he was diverted to a hospital, was a brutal assault on an elderly pensioner, who disturbed him as he burgled her house. Even though he appeared to superficially show remorse for this malicious crime, when I really challenged him, he did not accept responsibility, blaming his behaviour on intoxication.
This, as well as a lack of guilt and empathy, are typical traits of a psychopath. Inevitably, on the psychiatric ward that he resided on there were frequent arguments and occasional fights between the other patients, many of whom had a long history of violent crimes and personality disorders. Mr E seemed to take a perverse pleasure in stirring trouble, and would often chuckle to himself when he saw others fight.
Psychopaths are cunning, manipulative, and often convincing liars. Mr E exhibited these traits to escape arrest for several crimes in the past - a typical psychopath is criminally versatile, and Mr E had his proverbial fingers in many illegal pies, working as a pimp and a conman for several years.
He would bully less intelligent, vulnerable patients to sneak drugs on to the ward, and procure them with threats of disclosure rather than money. Psychopaths are typically parasitic, and Mr E demonstrated this by borrowing money from the less popular, marginalised patients on the ward by pretending to be their friends - but a psychopath cannot feel true warmth towards another human. They don't regard people as friends - only as opportunities. Any supposed loyalty is feigned. This, combined with sexual promiscuity, often leads to frequent infidelity and repeated, but loveless relationships. They also tend to feel permanently bored and empty, and any pleasure they experience is fleeting.
Mr E showed impulsivity, and an inability to control his behaviour, which manifested itself not only in the past by him breaching his parole conditions by using drugs, but also once when he attended hospital for an emergency whilst he was a prisoner, and ran away.
What are Psychopaths Actually Like?
Glad you asked!
Although their lack of empathy and their propensity for violence make psychopaths dangerous people, as previously mentioned, they are cunning and manipulative. Psychopaths I have treated in the past may have been indifferent to me as a person, but as their treating psychiatrist, it was in their interests to make me like them. This characteristic, combined with the grandiosity that comes across as confidence, usually makes them quite charming.
Mr E had a powerful presence, and easily slotted in at the top of the ward hierarchy. He was complimentary, friendly and flirtatious with staff, and could easily give you the impression, that although he looked down on most people, he valued your opinion. The weird thing was; even though I knew this, I couldn't help but be drawn into his personality.
The Hare Psychopathy Checklist
A Canadian Criminal Psychologist named Robert Hare created a list of 20 elements that define psychopathy, many of which I've talked about here. This checklist is the gold standard for diagnosis, though its interpretation should only be undertaken by professionals with experience in this field.
"With great power comes great responsibility", as Spiderman once said.
Being a psychopath is not just about anger. It's about all these other traits that Hollywood may not have the inclination to research or portray. Maybe that's because they are not really that glamorous. So for now, it can just carry on its representation of (admittedly very well acted) disturbed teenagers slaughtering innocent hamsters.]]>Misconceptions About Psychiatriststag:www.huffingtonpost.com,2011:/theblog//3.10734712011-11-03T19:00:00-04:002012-01-03T05:12:02-05:00Dr. Sohom Dashttp://www.huffingtonpost.com/dr-sohom-das/
I've lost count of the number of times that I've been met with the phrase "Can you read my mind?", when I've told people what I do for a living. Recently in a phone shop I replied, "Yes, I can. It seems to me...you're an idiot!" (To myself, in my head).
In my defence - he was.
But of course, to him, I said "No, I'm afraid I can't."
Maybe it's my over-inflated ego and my grandiosity about working within this particular field, but to me it seems remarkable how little the general public knows about psychiatry and psychiatrists. They say one in four people will suffer from a mental disorder within their lifetime. Only a miniscule proportion of the population need cardiac surgery in their lifetime, but everybody knows what a heart surgeon does. Right?
There are several thousand psychiatrists and trainees working in the UK today, yet their function seems to remain ambiguous and mysterious.
Here are some misconceptions which, like they bother me, probably get on their nerves.
We Are Posh, Old And Have Beards
Cheers Frasier!
Not only do I personally feel this show is dull and over-acted, with obvious and predictable jokes, but it has dented the image of a generation of psychiatrists. Other films, such as Good Will Hunting also reinforce this stereotype. Very few of us are pompous, bespectacled and sloppy. A trainee psychiatrist can be as young as 25. Amongst my colleagues, facial hair is sparse, and well-kempt. I also refute the claim that as a professional body, psychiatrists are boring. Within my career I've worked along side colleagues with a range of personalities and interests including a novelist, columnist, a stand-up comic, a part-time rapper and a lead singer of a punk-rock band.
We Tell You To Lie On A Couch And Ask You About Your Mother
This Draconian image is outdated. I think part of the problem is that the distinction between psychotherapists, psychologists and psychiatrists is ambiguous. Psychotherapists specialise in long-term, regular-talking therapies, which occasionally may examine patients' childhood and impact of early experiences. Psychologists also analyse personality traits, and use talking therapy, but often in psychiatric wards, and usually are more flexible in their format.
Psychiatrists are medical doctors, who specialise in treating mental illnesses after medical school. Unlike psychotherapists and psychologists, they can prescribe medication, treat physical complications, and in extreme circumstances, detain people against their will.
Generally, psychiatrists oversee more people than the other two professions, and therefore have less time to spend with each individual patient, and may have to delegate to a Multi Disciplinary Team (which may consist of junior budding psychiatrists, nurses, social workers, and psychologists).
If my office was big enough for a couch, and I managed to stealthily bypass the Health and Safety hurdles, I would use it solely for taking siestas.
We like To Lock People Up
No. Men in white coats don't try to take you away.
For a start, doctors rarely wear white coats nowadays, due to infection control protocols. Psychiatrists certainly don't. Yes, of course people do need to be detained in some circumstances. In contrast to what used to happen historically, this action is never undertaken flippantly.
A psychiatrist has to have several years of experience, two good professional references, and meet other specific qualification-based criteria before they can be "Section 12 approved". Only then can they apply for somebody to be detained. After this application is made, a completely independent senior Social Worker who works for the borough must assess the patient in the company of their own independent Section 12 doctor, to uphold the section under the Mental Health Act (created in 1983, but recently updated in 2007).
It must be proven that the patient has a mental disorder and detention is necessary to alleviate suffering or prevent deterioration of health, and/or for the safety of themselves or others. In principle, patients should be admitted into the least restrictive environment, and their views and wishes should be accommodated as far as is feasible. There are other safeguards within this process, including reviews by independent tribunal (consisting of a psychiatrist, a solicitor and a layperson), during which patients and their relatives are invited to present their case to the tribunal, who have to decide whether or not to uphold the section.
Basically, it is a long intricate process, which patients are invited to appeal against, and independent experts, some of whom are non-psychiatrists, have to review to make sure it's fair.
Psychiatrists Drug People Up
I'm not proud to say that in yesteryear the treatment of some mentally ill patients was barbaric. But then again, history is polluted with other such atrocities within institutions, as we all know. Psychiatry has learned its lessons and moved on. People used to be locked up, medicated and even displayed in zoo-like asylums for entertainment. Over-sedation was a tactic used to control unusual or unacceptable behaviour.
Yes, of course some medication is necessary to control various symptoms like severe depression, hallucinations and delusions. This can relieve thoughts and feelings that torture sufferers. It can keep them and those around them safe by quashing violent impulses. In extreme circumstances, patients can lack insight or be too confused to consent to treatment, so these medications are given against their will. This is done to improve their quality of life.
However, far more frequently, patients are involved in the decision-making process and informed about medications in advance of taking them. A good psychiatrist should regularly discuss medication with patients and review dosages, the type of medications prescribed and potential side-effects to optimise treatment.
"I Bet You're Analysing Me Right Now."
I bet I'm not.
I've been told this many times along with "I'd better be careful what I say around you." I usually shrug and smile back inanely. I'm probably thinking to myself, "Sorry mate, you're not really that interesting."
My speciality is Forensic Psychiatry. Many of my patients have had horrific childhoods, been involved in high levels of lifelong criminality, had severe mental illnesses, have serious drug and alcohol problems, and have committed several violent offences, including murder. After analysing and dealing with these characters all day, it's unlikely I'm going to be stimulated by Average Joe, his mundane background, and his mediocre chat.
Also, if I was an accountant, I would not automatically try to calculate a person's tax return after meeting them in the first time, socially. If I was a dentist, I wouldn't be voraciously eager to examine a stranger's mouth. If I was a gynaecologist...well, you get what I'm trying to say, right?
Anyways.
I like my job. The vast majority of patients have fascinating background and intricate psychopathology (that's clever-talk for psychiatric symptoms). It's still a job, though. It's doesn't permeate into every level of my life. But for every interesting patient I encounter, there's a presumptuous buffoon who has no idea what psychiatry entails and what we do.
But maybe I'm being harsh. Maybe it's the profession's fault for not explaining and advertising ourselves and our roles well. (Though the media hasn't exactly portrayed us in a positive light).
Maybe I can make a small difference. I can start with these blogs. I could write about psychiatry for days on end, and I have plenty more to say. It's all about communication.
Which reminds me - I never did figure out why the guy in that phone shop gave me a tariff that was so much higher than other people I know on a similar contract. Maybe he could read my mind...]]>