I’ve just finished reading Simon Singh and Edzard Ernst’s book on alternative medicine entitled ‘Trick or Treatment’. 

Written by a best selling science author Singh, who boasts a PhD in particle physics, and Ernst, a professor in complementary therapy, and subtitled ‘alternative medicine on trial’ Singh and Ernst clearly hope to set a standard in the genre.  They set out their stall early, first by dedicating the book to the Prince of Wales, whose sympathetic views on alternative medicine are well known, and then by quoting Hippocrates as providing their guiding path:

‘There are, in fact, two things, science and opinion; the former begets knowledge, the latter ignorance.’

They themselves are not modest:

‘Although there are plenty of books that claim to tell you the truth about alternative medicine, we are confident that ours offers an unparalleled  level of rigour, authority and independence’

Any treatment which cannot stand up to the rigours of scientific enquiry, by which Singh and Ernst mean a well conducted controlled clinical trial, has no place calling itself medicine and is simply hocus-pocus with good PR.  At best such therapy is simply no better than placebo, at worse it is positively dangerous.  But even if it is harmless, it is far from costless, as the annual global spend on alternative medicine is in the region of £40 billion, money that could be spent on more fruitfully, should alternative therapies prove to be ineffective.

The authors say that the key theme running through their book is ‘truth’.  And not in any post-modern sense, but instead in the sense of the fundamental question: ‘is alternative medicine effective for treating disease?’.  With this in mind, the first chapter of the book is about how science establishes whether medical interventions are effective or not; that is, how the ‘evidence’ is put into ‘evidence-based medicine’. 

To explain this, Singh and Ernst take a historical approach, building the notion of the clinical trial as the gold standard for evaluating medical interventions.  They start by telling us of one of the casualties of the ancien regime; on December 13 1799 former President George Washington awoke with the symptoms of a cold.  He thought nothing of it, but by the following night he was gasping for air.  Serious, but potentially survivable, until bloodletters drained Washington of half his blood in less than a day.  These men weren’t witchdoctors, but Washington’s personal physicians.  They thought that they were working in the great man’s best interests, but alas the medical profession had yet to work out how to distinguish interventions that worked from those that didn’t. 

Typically, it was a British man who first came up with the randomized control trial, even more typically he then totally failed to capitalize upon his insight.  The man was a naval surgeon called James Lind;  Britain at this time was the world’s greatest seafaring nation, but any journey lasting more than a few weeks was blighted by scurvy, a disease we now know is caused by a deficit in vitamin C. Lind split twelve scurvy sufferers into six pairs, and gave each a different treatment.  He also observed another group of sailors who received no treatment; these acted as a control.  As a shot in the dark, to one pair he gave oranges and lemons; this group made a miraculous recovery.  Alas, in part due to Lind’s diffidence, his findings remained almost totally ignored for 33 years. 

Just as interesting, Singh and Ernst tell us about Florence Nightingale and her penchant for statistics.  Feeling a divine calling to become a nurse, Nightingale decided to work in the hospitals of the Crimean war, having read reports of the large numbers of soldiers dying there from cholera and malaria.  Upon her arrival at her chosen hospital she embarked on the mother of all spring cleans and within one week removed 215 handcarts of filth, had flushed the sewers nineteen times and buried the carcasses of two horses, a cow and four dogs all of which were found in the hospital grounds (I think that she had some help).  But, amazing to us now, the officers and doctors who were previously in charge felt that these changes were an insult to their professionalism.  Fortunately Nightingale also had a statistical education and used this to demonstrate that soldiers under her new order fared much better than those hospitalized in less salubrious conditions. By telling us of this Ernst and Singh also seek to demonstrate that, quite opposite to what alternative practitioners believe, scientists are willing to accept ideas which run contrary to the current received wisdom.  The clinical trail is such a strong instrument that it forces them to do so. 

In the next four chapters of their book, the authors take four of the main branches of alternative medicine to task: Acupuncture, Homeopathy, Chiropractic therapy and Herbal Medicine.  They take us through the history of each approach, its theory of action and assess the evidence for its efficacy.  

Acupuncture, is an ancient treatment, whereby the body’s ‘Ch’i', its vital energy or life force flows through our bodies in channels called meridans.  Illnesses are due to imbalances or blockages in the flow of Ch’i and the goal of acupuncture is to tap into the meridans at key points to rebalance or unblock the Ch’i.  Ernst and Singh cite the experience of James Reston, who was reporting on Nixon’s 1973 Chinese visit as key for acupuncture’s introduction into the west.  Whilst in China he suffered from appendicitis and was treated by acupuncture, bringing news of his treatment and recovery home. Unlike Reston, Ernst and Singh are unconvinced.  They demolish positive papers published by the WHO as having included too many trials, some of which used poor methodology, and conclude that the science behind acupuncture is implausible and totally without evidence.  They finish by saying that Acupuncture has inconsistent evidence to suggest that it has a use in pain and nausea control.

If acupuncture gets une point, then Homeopathy, gets null.   This was the work of a German physician Samuel Hahnemann at the end of the 18th century.  Hahnemann correctly realised that he and his medical colleagues knew nothing about how to treat people, but he then moved away from the then conventional medicine and contrived to establish his own brand of treatment.  Having taken quinine one morning he found himself having the same symptoms as if he had malaria.  From this he extrapolated a universal principle ‘that which can produce a set of symptoms in a healthy individual can treat a sick individual who is manifesting a similar set of symptoms’.  Even better, he went on to say that the potency of a cure could be greatly enhanced by diluting them.  Not just a little bit either; some homeopathic remedies are at the sort of concentration you might expect from putting a teabag in lake Superior.  Singh and Ernst find this all highly improbable, and put any positive effects attributed to this brand of alternative medicine down, amongst other things, to the body’s ability to heal itself. 

The founders of chiropractic therapy argue that ill health in the body is due to subluxations, slight misalignments of vertebrae in the spine.  These subluxations interfere with the flow of innate intelligence (a bit like Ch’i).  They are corrected by spinal manipulation, whereby the practitioner flexes of extends the neck beyond its normal range of movement.  There are some chiropractors called ‘mixers’, who are basically back specialists, however their ’straight’ colleagues believe that their techniques can cure the body of ills seemingly unconnected with the bony structures. 

My attitude to all this would be: not to my neck you don’t buddy.  And according to Ernst and Singh rightly so.  There is some evidence that chiropractors have a place in treating back pain.  This is something with which conventional medicine has struggled.  However in its treatment, chiropractors and conventional medicine come out as a dead heat, and a pack of ibuprofen is 35p in Sainsburys whereas a course of Chiropractic treatment costs a great deal more than this.  As worrying is that it is reported in the book that it is not unusual for chiropractors to spinally manipulate patients without their consent on their first appointment, and furthermore that this spinal manipulation has lead to vertebral artery dissections and death in patients.  

Before their finger pointing and conclusions and an interesting section entitled ‘Why do smart people believe such odd things?’ Singh and Ernst take as their fourth case study Herbal Medicine.  This is a more tricky area for them, as unlike their previous three methodologies, some herbal remedies, for example St John’s Wort, actually work.  Here the problems are more subtle.  Imagine this:  in order to get onto the shelf in your pharmacy a mainstream medicine has been exhaustively evaluated in a process costing millions of pounds and will have been produced in a sophisticated process whereby a manufacturer will be sure exactly of the contents of the drug they are selling you.  With a herbal remedy on the other hand, you may be getting something, covered in dirt, from someone’s back garden and they probably didn’t even wash their hands as they picked it.  There’s worse too, as herbal remedies can interact with conventional drugs with unpredictable consequences and if they are taken in preference to conventional medicines they won’t get you very far, as the authors tell us was discovered by several unfortunate, but trusting, cancer victims.  And beware, some herbal remedies are effective because they actually contain conventional medicines.

So whose fault is this?  Ernst and Singh propose that most alternative remedies trade on being more natural, traditional and holistic, three ideas they quickly dispatch.  Uranium is natural, bloodletting was traditional, and holistic medicine is not a preserve of alternative practitioners - GPs regularly give lifestyle advice. They go onto blame celebrities for endorsing alternative treatments, universities for providing alternative medicine courses to make money and thus legitimizing alternative approaches, the media for inaccurately reporting the benefits of alternative therapies and many doctors for prescribing alternative medicine to get difficult patients out of their consulting rooms.

There should be warning messages on alternative medical treatments like cigarettes they say, accurately reflecting the current evidence.  For Homeopathy this would read

Warning: this product is a placebo.  It will work only if you believe in homeopathy and only for certain conditions, such as pain and depression.  Even then it is not likely to be as powerful as orthodox drugs.  You may get fewer side effects, from this treatment, than from a drug, but you will probably get less benefit.

At the end of their book a further 36 alternative therapies are critiqued including colonic irrigation and ear candles - the latter of which I could tell you is bollocks just from the name.

So, having written a much longer review than I initially intended, is this book any good?  It’s certainly pretty thorough.  The first chapter about scientific method is very interesting, but the next four chapters wherein the authors examine acupuncture, Homeopathy, Chiropractic therapy and Herbal Medicine are interesting in a lot of places, but often come across as a bit dry.  This book may attempt too much aiming to be both an entertaining popular science book and one offering balanced medical advice to those seeking treatment. 

It’s psychopathology time again, here on planet Frontier Psychiatrist.  It’s been in the family as my brother recently  attempted the Fourteen Peaks Challenge will testify.  This is his story:

‘In June 2008 my friends and me decided to attempt the 14 Peaks Challenge. This involves scaling all 14 peaks in Wales which are in excess of 3000 ft and is a very long walk, taking up to 24 hours to complete.

After driving up from London, our party started walking at about 2am.  By around 4pm the next day I was starting to experience some quite peculiar visual effects.  Every time I looked at a stone, I could immediately pick out an image of a face or the shape of an animal (typically a crocodile).  Whereas normally it would take a conscious effort to see a pattern in an inert object, the comparisons were coming to me thick and fast.  At one point I picked up a piece of quartz convinced that it had the shape of an ancient Egyptian head.

I gave up the walk at around 6pm, having not slept for around 36 hours.  My tougher companions pushed on and walked for another 10 hours.  Their visual hallucinations apparently became much more vivid than mine with objects becoming actual animals and not just resembling them.’

Depending on your bent in life, this either sounds pretty cool, or pretty scary.  Plenty of people pay good money for similar nights out.

Psychiatrists have spent a lot of time classifying abnormal experiences; psychopathology is the study of this.  This is a big subject, so I’m going to gloss over a few bits.

As human beings we have a number of senses and sense organs and the brain interprets the sensory input from these.  Thus, perception consists of two parts - sensation (visual, auditory, tactile, gustatory, olfactory, kinasthetic and proprioceptive) and interpretation (the cognitive element).

But things can go wrong:

1. The stimulus can be perceived as the corresponding object, but not accurately.  For example an object could be perceived as being the wrong size; this is called micropsia or macropsia.

2. The stimulus is perceived as an object, but not corresponding to the source.  That is to say, both the stimulus and object are present, but different from each other.  This is an illusion

3. There is no stimulus, but a perception occurs.  This is a hallucination. 

4. There is a stimulus, but no perception occurs.  This is a negative hallucination.

So, my brother wasn’t hallucinating, but was seeing an illusion.  There are three major types of illusions:

1. Affect illusions:  here the person’s emotional state leads to misperceptions - perhaps being scared leads to the incorrect interpretation of a shadow.

2. Pareidolia: here a person perceives formed objects from ambiguous stimuli, for example seeing Elvis’s head in a cloud. 

3. Completion illusion: here, due to inattention, an incomplete object is perceived as complete.  For example, CCOK might be read as COOK.

Hallucinations

Hallucinations have several important qualities.  They take place in the same space and at the same time as other real perceptions - this is different from a fantasy or imagery, which take place in subjective space, or a dream, which has no real component;  they are experienced as sensations and have all the qualities of a real object from which they are indistinguishable. They are involuntary, so unlike imagery, they are not under conscious control.

Hallucinations can occur in any modality and there are many different types:

Elementary hallucinations are the simplest kind and they are unstructured hallucinations and bear no relation to anything in the natural world.  An example of this is whirring noises in the auditory modality.  In the visual modality, a person with elementary hallucinations might see multicoloured spots.  

Auditory hallucinations often occur with psychiatric illness, and auditory hallucinations of voices are one of the first rank symptoms of schizophrenia.  Visual hallucinations on the other hand are much more common with organic illness and are very uncommon in schizophrenia.  Organic causes for hallucinations include occipital lobe tumours, post concussional states, hepatic failure and dementia.  

Elderly patients with normal consciousness and no brain pathology, but with reduced visual acuity due to ocular problems experience vivid, distinct formed hallucinations, often of men wearing hats.  This is called Charles Bonnet syndrome.  Lilliputian hallucinations involve seeing tiny people or animals.  These can occur with alcohol withdrawal.  

Other sorts of hallucinations: 

Autoscopic hallucinations are the experience of seeing oneself.  This is different from an ‘out of body’ experience, as with the latter the person sees the world and his own body from a vantage point that is other than his physical body.  In autoscopy, the person ‘remains’ in their own body.

Extracampine hallucinations occur outside the field of normal perception.  An example of this would be hearing someone discussing you down the shops which are a mile away.   

Functional Hallucinations is where an external stimulus provokes hallucination, but both hallucination and stimulus are in the same modality but individually perceived.  An example of this would be hearing a voice when the tap is running.  On the other hand, Reflex hallucinations are when hallucinations in one modality are provoked by a stimulus in another modality.  An example would be seeing a elf whenever listening to music.

Formication is a type of haptic hallucination where there is the sensation of animals crawling under the skin.  This is seen in cocaine intoxication.  A character in the beginning of the film ‘A Scanner Darkly’ has a similar problem.

NB:

A pseudohallucination is like a hallucination, but lacks the quality of a perception.  It is a form of vivid imagery.  If someone feels that they are hearing voices in their head, this is a pseudohallucination as it does not have the same qualities as a normal perception. 

Synaesthesia is the perceiving of a stimulus in one modality in a different modality, for example, ‘hearing’ the colour red.  This can happen on taking LSD

Hypnagogic and hypnopompic hallucinations are hallucinations on falling asleep and waking up, respectively.  They may be normal phenomena and are particularly seen in narcolepsy 

Further reading:

Symptoms of the Mind by Femi Oyebode (Buy from Waterstones Amazon)

Regular readers of this blog beware, this is about as close as I get to gossiping.

General Medical Council’s fitness to practise panel starring TV psychiatrist Raj Persaud has, to paraphrase the late Japanse Emperor Hirohito, developed not necessarily to Dr Persaud’s advantage.

The panel’s ruling is not reported on the GMC website, but has been carried by Reuters and the Guardian.

Initially the GMC choose to dance around Dr Persaud, setting him up for a fall:

‘You are an eminent psychiatrist with a distinguished academic record who has combined a clinical career as a consultant psychiatrist with work in the media and journalism"

Before poking him in the eye:

‘The panel is of the view that you must have known that your actions in allowing the work of others to be seen as though it was your own would be considered dishonest by ordinary people*‘

And then delivering the knock-out blow:

‘The panel has therefore determined that your actions were dishonest in accordance with the accepted definition of dishonesty in these proceedings.’

So, true to my title, Persaud is giving psychiatry a bad name.  We’ll find out whether he’s also down for the count when the panel rules whether this impacts on Persaud’s fitness to practice and what sanctions to impose on him.  He could be struck off the medical register. 

The most interesting question is why a man such as Persaud could score such a spectacular own goal.  One of my regular comment contributors has been nudging me towards giving Persaud a psychiatric diagnosis; this would be amusing, but alas won’t get us very far, and worse could be a bogus simplification of complex motivations of which even Persaud himself may not be aware. Former New Labour wonk turned psychotherapist Derek Draper has done some armchair psychoanalysis of Persaud in the Guardian today. 

Persaud himself has said that he was under a great deal of stress and the pressure of his commitments lead to his behaviour.  This reasoning has a plea of insanity and diminished responsibility whiff about it and for me is a little too neat.  Stress certainly can make people act strangely, but the general opinion of where I work is that Persaud is a narcissist and the reported misdemeanors are just the tip of a much bigger plagiarism iceberg below the surface.

If Persaud liked to be seen as a man of great erudition, this would of course require a lot of ideas and simply regurgitating other people’s isn’t nearly as satisfying as thinking them up yourself.  It is however difficult to be original whilst you’re also writing two books and holding down a full time job as well as doing private practice.  Whether stupidly, or wilfully (and one of the witnesses in this case Professor Richard Bentall, can’t make up his mind on this) one solution to this quandary is pass off other people’s ideas as your own.  One of the articles which has caused all this stink has been subsequently amended with the correct attribution of text.  But by doing so, Persaud appears no better than someone reading out of a book in front of a class, something he might clearly wish to avoid.  He tried to blame his plagiarism on sub-editors, an action that looks nearly as bad as the plagiarism itself. 

Perhaps, as Draper aruges, Persaud was seized by a evangelical zeal, and wished to bring psychiatry to the masses.  In the pursuit of this greater good, does it really matter who wrote the words, so long as people read them?  Or maybe it is all narcissism as my colleagues contend.  Persaud was simply to famous to bother with what the little people do: ‘fess up when someone has had a better idea than us.  He didn’t believe in credit where credit is due, but would rather have all the glory for himself.

But none of this explains why it was so ineptly executed.  Exhausted by the same driving ambition that had made him so successful, perhaps he subconsciously wanted a way out, a way to return to being an ordinary doctor again.  Alas his actions have put this modest wish into jeopardy. 

Or he was simply lazy and couldn’t bothered.  I’m sure that he’d have chastised a medical student for that.

But what use all this speculating: Dr Persaud, Richard and Judy’s couch beckons you.  Lie down, close your eyes and tell us why.

In the press

Persaud’s plagiarism was dishonesty rules medical Council Guardian 19 June 2008

Persaud’s blatant cribs were flabbergasting, professor tells tribunal Guardian 18 June 2008

TV psychiatrist found guilty of disrepute Reuters 19 June 2008

Media Psychiatrist fights for his job Guardian 17 June 2008

* ‘Ordinary people’ - that’s me and you kids.  Dr Persaud is a ‘celebrity’

Raj Persaud who, since the death of Anthony Clare, is probably the UK’s most prominent psychiatrist, has spent the day batting on rather sticky wicket.  Many news sources, including the guardian and BBC report that in a Manchester GMC hearing today Persaud admitted to having plagiarised material in a book and several newspaper articles and medical journals.

He did admit that this plagiarism was inappropriate and misleading, but denied that his actions were dishonest or were liable to bring the medical profession into disrepute.  This latter claim may need some justification. 

(this next bit has parts pinched from Persaud’s wikipedia page, but that’s okay isn’t it?  I’ve substantially rewritten also added some new bits.  Anyway I’m anonymous!)

Persaud’s troubles started in 2005 and concern claims, now substantiated by Persaud, that he passed off the work of other academics as his own in several publications and books. 

Thomas Blass, professor of psychology at the University of Maryland, complained that a large proportion of Persaud’s article in Progress in Neurology and Psychiatry (Volume 9, Issue 2) had been taken verbatim from Blass’s work on Milgram’s experiments, as had an earlier article of Persaud’s in the Times Educational Supplement. Persaud claimed this had been due to an error, and offered to apologise for not crediting Blass.

In the BMJ Persaud appeared to have reviewed a book of Blass’s by simply quoting large chunks of it, but without using quotation marks.  The BMJ subsequently withdrew the piece. Persaud blamed the BMJ’s editing of his original article, a claim that the BMJ refuted.  This Guardian article has further details and a comparision of the relevant texts.

A June 2005 article about Scientology in The Independent is said to have used parts of a publication of the Canadian Professor Stephen A. Kent without attribution.  Around 300 words of the 685-word piece are almost identical to a a paper by Kent titled The Globalization of Scientology, Influence, Control, and Opposition in Transnational Markets.
(a particularly perspicacious discussion of a similar subject can be found here). The paper blamed a ‘production error’ and altered the article in its web archives to properly attribute Kent.

An investigation in 2006 by the South London and Maudsley trust, where Persaud is a consultant, found that parts of his book, From The Edge Of The Couch, appeared also to have been copied.  Persaud admitted that his book had not been adequately sourced and said that he had made these mistakes after overcommitting himself

As a result of these embarrassments Persaud resigned as host of the BBC Radio 4 programme All In The Mind in April 2006 because of the controversy, but returned in April 2007.  He also relinquished an honorary position at the Centre for Public Engagement in  Mental Health Sciences. 

At the extreme the GMC have the power to strike doctors off the medical register, although I think that this would be unlikely (and harsh) in this case.  Punishment not withstanding, Persaud has done his reputation enormous damage.  It is hard to imagine that all these occasions can be the result of errors, as the omissions of citations are too many and too blatant.  Persaud is an clever and able man; can it be that he started to believe his own publicity machine and considered that in order to maintain his omniscient image he had to appear to have to originated all the wisdom that he imparted? 

And if he is chastised, will he bear his soul on Richard and Judy to regain the public’s trust?  I do hope so.

It starts early: UCAS finds that 800 prospective medical students plagiarised their medical school application forms BBC

Is It Plagiarism… Or Is It Wikipedia-Like Collaboration?  - a slightly connected article I happened across.

More On Raj Persaud: 

‘Psychiatrist to face plagiarism charges at GMC hearing’ Guardian 4 December 2007

Raj Persaud: TV Psychiatrist admits Plagiarism Guardian 16 June 2008

‘He took paragraphs from my work, word for word’ - psychiatrist faces plagiarism charge Guardian November 7 2005

Raj Persaud BBC Profile

Plagiarism Row dogs radio doctor BBC News 3 April 2006

Kirstin Davis has been annoying me this morning.  The doctors’ on call room here is full of celebrity magazines; they’re always a few weeks old and these ones have a lot about the new Sex and the City movie.  Here are some of the headlines:

Now Magazine 26 May 2008

Kristin: ‘I’m a recovering alcoholic’

Q: You admitted to suffering from alcoholism in your twenties.  Is there any truth in the rumours that you relapsed and went back to rehab?
A: I haven’t had a drink for 20 years now.  I haven’t kept it a secret but people don’t really know about it*

{nb the other four headlines were Cynthia: ‘I’ll wed my lesbian lover’, SJP: ‘I’ll miss Carrie’ and Kim ‘My tomboy keeps me young’}

Reveal Magazine 24 - 30 May 2008

‘I’m not ashamed to be an alcoholic’

‘Her co-stars may be toasting the release of the new Sex and the city movie with champagne, but Kristin Davis won’t be joining them
The star, who plays Charlotte in the New York-based sitcom, hasn’t drunk alcohol in more than 20 years because she had a drink problem.
She says ‘I’m an alcoholic, but I haven’t kept it a secret.  I’ve been sober for a really long time now’

She certainly doesn’t look like an alcoholic to me.  Davis is 43, and since you can legally drink at 21 in the USA this didn’t provide her with much of a window of opportunity to get really stuck in.  Neither article gives us much in the way of details as to what Davis got up to whilst she was a boozing. 

Some more digging revealed this interview from the Guardian in 2002:

‘To the outside world, I was a good girl. But I drank a lot, which was rebellious because my parents didn’t drink at all. In the South, pretty much everybody drinks. There was always lots of alcohol, lots of access to alcohol, people sitting around every night with a Mint Julep, or whatever.’ …. At high school, it was just crazy. We’d all be behind the gym drinking, about 20 people passing around bourbon or whatever.’

Throughout our conversation, Davis has been sipping water, but she refuses my offer of wine: ‘No, I’ve been sober a long time.’ Did she end up having problems with alcohol? ‘Oh yes.’ I didn’t know that. ‘Not many people do. There’s this whole thing in America about talking about all your addictions and problems and I’m not really into that**. But it’s not like I want to keep it a secret either.’ What happened? ‘Oh, nothing that bad. I just realised that drinking was counterproductive to what I was trying to do. Acting is very difficult in weird ways. You’d have to get to class by 8am, work all day, rehearse all night, and it’s not really good to do when you’re hung over. I’d wanted to be an actress my whole life, that was my goal, that was all I cared about. Something had to go, so I chose drinking to go.’ Has it been difficult? ‘Oh yeah. Sometimes it would be nice to just have some red wine with dinner, but it’s not worth the risk. I have a great life, a great situation. Why would I want to risk self-destructive behaviour? Even though I might not, I might , do you know what I’m saying? You just never know.’

So, in summary Davis drank a lot whilst she was a rebellious student but then she realized that hangovers weren’t compatible with having a career and making something of yourself.  So she stopped.  Um, I did that too (without actually stopping mind).  Does that mean that I’m an alcoholic too?  ’Alcoholic’ is a poorly defined term, and this is where the confusion may lie.  But if by alcoholic Davis means ‘alcohol dependent’ she’s stretching it rather thin.  If a psychiatrist were to do this, this would be an example of criterion or diagnostic creep, where a previously well defined syndrome widens to include experiences that were previously thought to be a part of normal experience.  Has Davis actually seen a doctor, or is she a self-appointed recovering alcoholic?  PTSD is often accused of criterion creep and this can occur easily for psychiatric syndromes, where the aetiology is unknown. 

Why has Davis appropriated the language of psychiatry and addiction to explain her own reaction to what many people would consider a normal stage of many people’s lives?  Perhaps as a way to draw attention to herself, to explain other failings in her life about which we know nothing, or so that she may permanently have one foot in Parsons‘ sick role.  My esteemed colleague, on call with me today, ‘Dr Cynic’ is proposing that Davis is so boring that her alcoholic ploy is a way to spice herself up in the eyes of her public. 

For what it’s worth, ICD-10 requires that three of the following criteria be experienced or exhibited at some time during the last year for a diagnosis of dependence:

A strong desire or sense of compulsion to take the substance

Difficulties in controlling substance-taking behaviour in terms of its onset, termination, or levels of use

Physiological withdrawal state when substance use has ceased or been reduced, as evidenced by either of the following: the characteristic withdrawal syndrome for the substance or use of the same (or closely related) substance with the intention of relieving or avoiding withdrawal symptoms

Evidence of tolerance, such that increased doses of psychoactive substance are required to achieve effects originally produced by lower doses

Progressive neglect of alternative pleasures or interests because of psychoactive substance use and increased amount of time necessary to obtain or take the substance or to recover from its effects.

Persisting with substance use despite clear evidence of overly harmful consequences (physical or mental)

For an interesting account of the effect of alcohol and other drugs on society try the following two books by Griffith Edwards:

Matters of Substance - Why Everyone’s a User   Amazon  Waterstones

Alcohol: the World’s favourite drug

*It’s certainly out of the bag now - I don’t think that talking to NOW magazine is a very effective way of keeping a low profile on this one.

** So what are you doing talking about it here then?

Insulin is a hormone produced in the body by the pancreas; its main role is to cause cells to take up glucose from the blood thus regulating its level. The history of the discovery of insulin is an interesting one, albeit involving the death of a pack dogs.

In 1889, the physicians Oscar Minowski and Joseph von Mering removed the pancreas from a dog to test its assumed role in digestion. Several days after the dog’s pancreas was removed, it was noticed that there was a swarm of flies feeding on the dog’s urine. On testing the urine they found that there was an unusually high sugar content, establishing for the first time a relationship between the pancreas and diabetes mellitus.  In 1901, it was established that the diabetes was caused by the destruction of a part of the pancreas called the Islets of Langerhans. These islets had been identified by Paul Langerhans whilst a medical student in 1869. 

We now know that what the islets were producing was insulin, but this proved difficult to isolate. Nicolae Paulescu a professor of physiology in Bucharest was the first one to succeed and published his work in 1921. Use of his techniques was patented in Romania , but no clinical use resulted.  At almost the same time, Canadian Frederick Banting hypothesised that the reason for the difficulties was that some of the other products of the pancreas, digestive enzymes, were destroying the islet secretions before they could be extracted.  In the summer of 1921 he was supplied with a laboratory, Charles Best, a medical student assistant, and ten more dogs.  The idea was to ligate the dog’s pancreatic ducts; the pancreatic secretions would then pool in the pancreas, but the digestive elements would be reabsorbed leaving the islets.  It was found that an extract from these islets was able to keep a pancreatectomized dog alive all summer as the extract lowered the level of sugar in the blood. 

Efforts continued by Banting and Best to purify the extracted insulin enough to allow administration to humans, which was underway by late 1921; commercial quantities were available by 1923.  Banting received the Nobel Prize for his work, although controversially Paulescu was not recognised.

******

In the sadly now departed spirit of have-a-go experimentalism, the newly discovered insulin was then tried out on patients suffering with illnesses for which no treatment was known. In Berlin , between 1928 and 1931, Dr. Manfred Sakel used insulin to reduce the unpleasant symptoms of patients undergoing opiate withdrawal. With insulin, they became calm, gained weight, and were much more cooperative.  When the dose of insulin was high, the patient went into stupor; after such events, the patients were less argumentative, less hostile, and less aggressive. 

Noting these results, Sakel moved to Vienna , and was assigned to treat patients with schizophrenia.  He further investigated the benefits of insulin, and reported that when the patients developed stupor or coma, they lost their psychotic thoughts.  His experience was reported to the Vienna Medical Society in January 1933, and by May 1936, favorable reports of the benefits of insulin coma therapy in schizophrenia from 22 countries were presented at a major meeting of the Swiss Psychiatric Society.

The German name for the treatment was ‘Insulin-shock-behandlung’. Translated into English, the phrase became ‘insulin-shock-treatment’.  Sakel interpolated the word ‘shock’ to emphasize his belief that the essential element of ICT was the lowered blood pressure, sweating, increased heart rate, and increased breathing rate that resulted from the stresses produced.  It was later understood that, that the medical shock aspects were not important to the treatment results, and any benefit was mostly likely due to the insulin induced coma.  Insulin coma therapy was regarded as a specific treatment for schizophrenia, and was probably the first in this regard.

Essentially the treatment involved a large dose of insulin which lowered the patient’s blood glucose enough to produce a coma.  This would be maintained for one to three hours and terminated by either tube feeding or intravenous glucose.  A course of treatment could include up to 60 comas.  Serious side effects were common, and a mortality of at 1-10% could be expected depending on the standard of the clinic and physical state of the patient.  Epileptic seizures could occur during the beginning stages of treatment, roughly 45–100 minutes into the procedure, but before the onset of the comatose state.  Seizures occurring during the coma were more dangerous, requiring immediate interruption of the procedure and coma termination, and were often followed by delayed recovery or severe hypotension.  Complications would also occur from the unconsciousness reaching excessive depths and that the coma would not end despite the administration of feeding or glucose.   Administrators would monitor the patient’s vital signs, to determine the level of danger.   

Despite these risks, insulin coma treatment was rapidly taken up throughout Europe and many specialized treatment units were built.  It is worth remembering that at this time there were no effective treatments for psychotic disorders and that the physical effects of prolonged psychosis were also severe, such that it was felt at the time that the risks were worth taking.  Indeed there was a great improvement in the morale of patients and staff because of the belief that this dramatic treatment could cure symptoms of the most serous psychiatric disorders. 

There were always some doctors who doubted the efficacy of insulin coma treatment.  Their doubts were reinforced by a controlled trial by Acker and Oldham (1962) who found that, in patients with schizophrenia, insulin coma was no more effective than a similar period of unconsciousness induced by barbituates.  It may be that the treatment had a tranquillising effect on patients by inducing brain damage through the prolonged deprivation of the brain cells of glucose, as suggested in a journalist Robert Whitaker’s book Mad in America*. It was also a very dramatic procedure, with patients being put into a long coma, and then re-awoken quite suddenly by the injection of glucose. This raises the possibility that coma therapy may have owed its perceived effect to a placebo effect, and a result of the drama of the whole procedure.

The Acker and Oldham study was published about the same time that chlorpromazine was introduced and both factors lead to a rapid decline in the use of insulin coma treatment.  It should be said though that some controlled studies did not exclude the efficacy of insulin treatment in certain circumstances and a number of workers continued to maintain that it was effective**.  Recent experimental studies have shown that insulin administration causes changes in the release of monoamine neurotransmitters, suggesting a possible mechanism of action**.

Links:

The Insulin Treatment of Schizophrenia From An Introduction to Physical Methods of Treatment in Psychiatry (First Edition) by William Sargant and Eliot Slater (1944, Edinburgh, E & S Livingstone).

A History of Shock Therapy in Psychiatry by Renato M.E. Sabbatini, director of the Center for Biomedical Informatics and Chairman of Medical Informatics of the Medical School of the State University of Campinas Brazil

Drug Treatments in Modern Psychiatry: A History of Delusion Dr Joanna Moncrieff Senior lecturer UCL UK

A Brilliant Madness PBS minisite about Nobel Prize winning schizophrenia sufferer John Nash.  In the same site Dr. Max Fink, the head of the insulin coma unit at the Hillside Hospital in Glen Oaks, Queens, New York from 1952 to 1958 writes about the treatment

Wikipedia on insulin shock therapy

* I haven’t read this, Joanna Moncrieff, Senior Lecturer in Social and Community Psychiatry UCL and chair of the Critical Psychiatry Network cites it in the above presentation.  He’s a journalist though, so I can’t shake the suspicion that he’s making it up.

**Source Shorter Oxford Textbook of Psychiatry by Michael Gelder, Richard Mayou and Philip Cohen Oxford 2001 pg 648.  They don’t cite a source.

I got home from the pub the other night and was casually scanning through the TV channels, when I happened across the second half of a curiously compelling documentary.  ‘The Perfect Penis‘ was about an American psychology student who was paying $4000 to have his penis lengthened.  This is not my area of expertise, but apparently this involves cutting a ligament located in the pubis.  A lot of the penis is actually in the body and cutting this lets a bit more of it protrude. 

The next bit sounds worse: to complete the job, the gentleman must then hang a weight off his member for no less than eight hours a day for several weeks after the op.  As well as sounding painful and unbelievably tedious, the results appear barely worth the trouble, with Wikipedia quoting an increase in penis length of 2-3cm and netdoctor stating that the only study available suggested that average increase in length was 0.5cm.  

The chap who was having it done actually seemed pretty normal, although my suspicions of obsessive/narcissistic personality traits were raised by his buff physique.  I didn’t catch all the programme so I didn’t see if he had a psychiatric evaluation.  I suspect not, as it might have spoilt things and there was a bit where he was talking to this psychology supervisor, who said sensible things which were completely ignored.  We got to have a look at the ‘inadequate’ equipment towards the end of the show and it looked perfectly fine to me.  We were also told at the end of the show that the penis surgeon had recently bought a new house in which to keep his four rollers;  I couldn’t help thinking our poor boy had been done. 

Leaving no grotesque stone unturned, the documentary makers included an interview with ‘Mister Mark’.  Mark is a gentleman who has injected enough silicon in his testicles and penis to make his scrotum 1ft in circumference.  He was appeared pleased as punch about this, and even has a website called ‘extremecock.org’ dedicated to his enlarged genitals (full admission: in the spirit of ‘frontier psychiatry’ I did visit this website, but I really wouldn’t recommend it to anyone of an even slightly queasy disposition).  

If I was trying to drum up business for myself, I’d be concerned if the psychology student was suffering from body dysmorphic disorder; Mister Mark is a subject for another day.  At the end of the show it was revealed that he was unwell and that he may be suffering from a silicon embolis.

Body dysmorphic disorder (Also known as dymorphophobia) was first described by Morselli in 1886:

‘A subjective description of ugliness and physical defect which the patient feels is noticable to others, although the appearance is within normal limits.  The dysmorphophobic patient is really miserable in the middle of his daily routines, everywhere and at any time, he is caught by the doubt of deformity’

Typically the patient is convinced that some part of his/her body is too large, too small or misshapen.  This is usually a part of the face, but can be any body part.  To other people the appearance is normal or there may be some slight abnormality.  The patient may be constantly preoccupied and tormented by his/her mistaken belief;  he/she may blame all his other difficulties on it.  For instance they may think that if only their nose were a better shape then they might have a better life or job. 

There may be time consuming behaviours.  I once had a patient who was constantly late for work as he used to spend hours examining his nose in the mirror. There is substantial overlap with other psychiatric disorders, especially depression and social phobia.  At its extreme the BDD may be very disabling and may leave the patient housebound and unemployed.  In the absence of corrective operations, people have been known to take matters into their own hands, for instance using a clothes iron to remove wrinkles on their face.

The prevalence is 1% in the community. The treatment is often difficult and  surgery is usually contraindicated.  Patients usually will have unrealistic expectations and once the operation is complete their concern may transfer to another part of the body. 

Dr David Veale’s site has a BDD reference page which is worth a look.

General paralysis of the insane, a syndrome of mental disorder and weakness occurring in tertiary syphilis, is also known as dementia paralytica, Bayle disease, parenchymal syphilis and symptomatic neurosyphilis.  It is a rare disease in western general adult psychiatry these days but, at the height of its powers, it is thought that it accounted for up to 20% of patients in asylums.  

In brief: syphilis is a chronic sexually transmitted disease, caused by the bacterium Treponema pallidum, resulting in the formation of lesions throughout the body.  As well as being sexually transmitted the infection can also be transmitted from mother to the developing fetus (congenital syphilis). 

The primary symptom is a hard ulcer (chancre) at the site of infection (i.e the penis or vagina) and this forms 2-4 weeks following exposure.  Secondary symptoms develop about two months after this infection and include fever, malaise general enlargement of lymph nodes and a faint red rash on the chest.  Then, after a period of time somewhere between some months to many years the disease enters its tertiary phase with widespread formation of tumour like masses (gummas).  These can cause serious damage to the heart or blood vessels (cardiovascular syphilis) or to the brain (neurosyphilis) resulting in tabes dorsalis, blindness and general paralysis of the insane. 

The onset of GPI is usually gradual with depression as the dominant symptom.  There is then a slowly progressive memory and intellectual impairment.  Frontal lobes are particularly involved, resulting in characteristic personality change with disinhibition, uncontrolled excitement and over activity which may be mistaken for hypomania.  Grandiose delusions are present in 10%.  Physically there is slurred speech, a tremor of the lips and tongue, and Argyll Robinson pupil** in 50%.  As the condition progresses there is increased leg weakness leading to spastic paralysis. Patients become completely incapacitated, bedridden, and die, the process taking about three to five years on average.

The first clearly identified examples of paresis among the insane were described in Paris after the Napoleonic wars and general paresis of the insane was first described as a distinct disease in 1822 by Antoine Laurent Jesse Bayle.  Originally, the cause was (charitably) believed to be an inherent weakness of character or constitution.  While Esmarch and Jessen had asserted as early as 1857 that syphilis caused general paresis, progress toward the general acceptance by the medical community of this idea was only accomplished later by Alfred Fournier. In 1913 all doubt about the syphilitic nature of paresis was finally eliminated when Noguchi and Moore demonstrated the syphillitic spirochaetes in the brains of paretics.

In 1927 Julius Wagner-Jauregg was given the first and only Nobel Prize awarded to a psychiatrist.  This was for work done in 1917 by which time he had been selflessly studying the the relationship between fever and psychosis 30 years.  Wagner-Jauregg had exposed three neurosyphilitic patients to malaria drawn from the blood of a wounded soldier.  The resulting high fever killed the syphilis spirochetes, leading to their recovery (the fate of the soldier is not recorded).  Given that there were few cures for anything in 1917, Wagner-Jauregg’s achievement was a milestone in psychiatric and medical science.  There was now a reliable, albeit risky, cure for neurosyphilis.

After WWII the use of penicillin to treat syphilis has made general paresis a rarity and now even patients manifesting early symptoms of actual general paresis are capable of full recovery with a course of penicillin. The disorder is now virtually unknown outside  third world countries, although it has been reported in western HIV sufferers.   I was recently told by someone who should know about these things, that it is no longer routine to test for syphilis in sufferers of dementia. 

If you can get hold of it Hare (1959) has written an interesting historical analysis. 

Trivia: 
Murderous Ugandan dictator Idi Amin is thought to have died from neurosyphilis

Also check out:
Tuskegee Syphilis Study - a clinical study, conducted between 1932 and 1972 in Tuskegee Alabama in which 399 poor and mostly illiterate African Americans were studied to observe the natural progression of the syphilis if left untreated.  Wikipedia page / List Universe: Top ten evil human experiments #3

* I’ve always thought this is an extremely evocative name for a disease (although I grant the use of the word ‘insane’ is archaic and potentially un-PC)

** non medics - these are known, rather tastelessly, as prostitute’s pupils as they accommodate, but don’t react (to light)… 

Cognitive dissonance is a psychological theory which was first described by Leon Festinger and, simply put, is the state of having two cognitions (ideas) that are mutually inconsistent.  It is held that the state of cognitive dissonance is a very unpleasant one, characterised by psychological tension and discomfort.  The theory holds that we are as motivated to change our behaviour due to cognitive dissonance as we might be to act to reduce hunger. 

An example of this might be a person who has always been very opposed to extra-marital affairs.  If he or she found themselves having such an affair, this would be inconsistent with this attitude causing cognitive dissonance. At this point he or she would have two choices: stop the affair, or justify the affair.  We are more likely to change our attitudes and justify our behaviour, than alter our behaviour.  

This makes sense from an evolutionary point of view as we are programmed to develop a set of beliefs to guide our lives.  It is not beneficial to be so open minded that we would be constantly changing our minds as this would make swift action difficult.  To avoid cognitive dissonance in the first place we are programmed to have an in built confirmation bias; this is where we notice, seek and remember information that confirms what we already believe and disregard or minimize information that conflicts with our world view. 

For a gentle introduction on this subject listen to this clip on cognitive dissonance on the Today Programme 

*** 

Frontier Psychiatrist has just returned from the Hay Festival and in retrospect I can see confirmation bias at work in my choices of speaker meetings.  I almost entirely went to see people with whom I knew I already agreed, and justified this to myself on the basis that their ideas would useful as a source of further ammunition when arguing on the rare occasions when I get invited to parties. 

The only real exception to this was Cherie Blair,  wife of the former British Prime Minister, for whom I had a free ticket.  She makes me feel conflicted, which is hardly surprising as she’s rather conflicted herself.  She hates the press, but she wishes to use it to have her side of the story told.  She protects her privacy vigorously, but divulges cringing personal details in her autobiography.   She calls this autobiography ‘Speaking for Myself’ as if, as a highly successful barrister, she’s such a victim that she’s never had the chance before.  She’s a socialist, but she owns three houses.  And she makes her problems with being the wife of a head of state so painfully obvious; she publishes a book called ‘The Goldfish Bowl’ about previous spouses in Number 10.   Psychoanalysing this woman is too easy.  She also gave a really boring speech.

Elsewhere: 

I was looking forward to seeing Gore Vidal, but he left me not just cold, but feeling soiled, such was his constant negativity.  He criticized John McCain for not attempting to escape from a Vietcong POW camp.  I don’t think that Vidal has any experience of such scrapes, so should hold counsel until he’s tried himself.  My brother asked him whether he had any ‘words of advice for young people‘.  ‘Grow up’ said Vidal.  Perhaps it’s too late to take his own advice.

Much smaller fry was Mark E. Smith of The Fall.  The interviewer was Jon Gower. I’ve never heard of him either.  Early on during the interview Smith accused Gower of not having read this autobiography.  Gower had to admit that he hadn’t finished it, but to show he’d read what he had carefully, asked the most in depth and convoluted questions, most of which were answered by Smith with a simple ‘yeah’ followed by tittering from the audience.  I spent most of the interview wanting to jump on the stage and wrestle the microphone away from him.  Every psychiatrist knows - the best way to get someone’s story is to ask open questions.  A breath test for Smith and full refund to the audience wouldn’t have been out of place either. That was my question about the security guards.

Christopher Hitchens did nothing to quash allegations of a drink problem by coming to the stage with a glass of wine.  Apart from his rudeness towards a audience questioner, which boarded on bullying, we were in complete agreement.  Further agreement but slight boredom accompanied talks by Naomi Klein and Joseph Stiglitz.  It’s not always a good idea to read the corresponding books before seeing a talk, as the speakers just regurgitate the same facts you’ve already read.  Will Self as ever didn’t disappoint.  My brother got further coverage in the press by asking him about his love of long and seldom used words.

For us the festival ended with Rob Brydon.  Oliver James says that he’s rarely met a comedian who’s not personality disordered or depressed.  I hope he’s wrong in Mr Brydon’s case, as he seems so very nice and so very amusing.  

People in the press have been playing one of my nasty habits - guess the diagnosis of someone you’ve never met.  In this case the beleaguered UK Prime Minister Gordon Brown.

For anyone who lives in a cave, Mr Brown came to be PM about a year ago having been the Chancellor of the Exchequer for ten years.  During this time he presided over unbroken economic growth and was well know for his prudent policies and dour demeanour.  Whilst his lack of easy charm and attention to detail made him apparently trustworthy as the head of the economy, they haven’t played out well as PM, especially as he is following the TV friendly and charismatic - but warmongering  - Tony Blair.  Incidentally, I met Brown’s private secretary, a rather attractive girl, at a party once and was thinking of trying to get off with her but regrettably she left before I could work any magic. 

Writing in The Times, GP Dr Thomas Stuttaford has speculated that Mr Brown has personality traits which might lead him to be diagnosed with a DSM-IV cluster A personality disorder.  He also says that Tony Blair would meet all the criteria for histrionic personality disorder

(If you need to brush up on personality disorders here’s a link to my previous post on the subject) 

BPS research digest disapproves

There are two issues here.  Is Dr Stuttaford proper to speculate in such a way?  Yes, in that we are in a free country, and it would be cheeky for me to say no when I have done similar myself*.  But he is very careless.  You can’t make these kind of diagnoses without meeting the patient, and it is sloppy to take a cursory glance at the DSM criteria and then imply that if someone possibly meets particular criteria and the diagnosis is likely.  He should at least have stated that what he is presenting is purely idle speculation.

Is he actually right?  Unlikely. With regards to Tony Blair, Dr Stuttaford can’t have looked very carefully at the DSM-IV histrionic personality disorder criteria.  Is he saying, for instance, that Tony Blair’s interactions with others are ‘often characterized by inappropriate sexually seductive or provocative behaviour’ or that he ‘consistently uses physical appearance to draw attention to (him)self’? (DSM IV criteria)

He says of Mr Brown:

‘He is likely to be demanding, self- absorbed, have difficulties in relationships with others, suffer discomfort in social situations with unfamiliar people, have vaguely unsettling inappropriate gestures or facial expressions and may be so focused that he finds it difficult to concentrate on subjects other than that which has caught his immediate attention’

I find it difficult to believe that anyone with these sort of characteristics could not only elevate himself to the job of PM(think of the political deals and alliances necessary), but also run the country for more than five minutes with this sort of personality.  ICD-10 states that a personality disorder is ‘usually accompanied with considerable personal and social disruption’ which sounds incompatible with any of Mr Brown’s achievements.   Dr Stuttaford is talking bollocks I fear. 

David Owen, former Labour minister and SDP leader, has written a book about illness suffered by heads of state, and has also coined a term ‘hubris syndrome’ which I think he is un-secretly hoping will pass into common parlance, if not into diagnostic manuals.  Rather less prestigiously, I wrote a post on a leaders and their drug problems, prompted by speculation that Moses was under the influence of psychedelic drugs. 

Other articles on this subject:

NHSBlogdoctor

*It would be hard to imagine that  Josef Fritzl is not  even a little bit anti-social though…