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It’s a Madhouse

7 December, 2013 Reply

So, the care of people with schizophrenia in Britain is in the news.

Sadly, there’s not much (if anything) different anywhere else I’ve worked or read about. People with schizophrenia often get no, or inadequate, care – delivered often in unhelpful environments or ways. Like people with other major psychiatric illnesses (though quite probably worse), they die very young. In many cases, meaningful relationships and satisfying employment are (kept) out of reach.

Sometimes the illness is such that our current treatments are inadequate, (and many of them do very clearly have major problems of their own), but sometimes (often?) it is the case that they are failed by the service – and by society.

We have come a long way in psychiatry, but there is still a long way to go.

Diagnosis – schizophrenia and complete remission

27 September, 2013 Reply

Psychiatric diagnosis is a funny process – even with the operational criteria in DSM and ICD. There are so many things that affect the way one thinks about it. I was confronted with one of those things recently, with a patient for whom I've made the diagnosis of schizophrenia. On the basis of phenomenology and history, it was (and is) clear to me that schizophrenia is the most appropriate diagnosis. While there have been some symptoms of mood disturbance of one sort and another, they've not been to the level, or of such a nature, that they have turned me away from schizophrenia towards mood disorder.

As a quick aside, while I don't entirely dismiss "schizoaffective disorder", I … well I kind of do. ;-) It is a diagnosis that is most often mis-applied, in a sloppy fashion, because a patient has a mix of symptoms that are somewhat difficult to tease apart. In this specific case, I have not thought that schizoaffective disorder was a justifiable diagnosis (unsurprisingly, if you don't meet the requirements for a mood disorder, you don't make it to schizoaffective disorder).

And we're back…

So with what have I been confronted? With the fact that this person no longer has any symptoms. That's what. And we are so conditioned to see schizophrenia as unremittingly awful that our immediate response to someone doing that well is to question that we could be dealing with a schizophrenia. "Maybe it's really a mood disorder…"

Even though we know that in fact mood disorders, just as schizophrenias, can indeed have functional decline and chronic or residual symptoms. And even though we know that schizophrenia has a variable outcome, with a group doing very poorly, a group doing ok, and lo and behold a group doing well.

Anyway, I'm sticking with schizophrenia, because symptomatic remission now doesn't invalidate the earlier phenomenology – or most particularly, the history. I just think it's interesting that someone doing well makes us* question the diagnosis. Yes we should be open to questioning and revisiting diagnoses, but this isn't really enough of a reason. It's a manifestation of the nihilistic and hopeless view we often maintain about schizophrenia. Sadly it is an illness that sometimes has an awful outcome – but that's not always the case, and we seem to have trouble recognising that.

And that has to have an effect on how able we are to provide hope to someone newly diagnosed with schizophrenia….

(* not just me; I've often heard it said, when discussing someone with schizophrenia who's functioning well: "it can't be schizophrenia, they must have schizoaffective disorder" or similar.)

Sometimes

29 August, 2013 Reply

Sometimes a patient just breaks your heart. Someone you try to help, but for whom you can only achieve so much. Someone against whom fortune just seems to conspire. Someone who despite being seriously unwell, manages to make a powerful, and at times really poignant, personal connection.

So much potential. So much illness. So much anger and resentment.

So much sadness.

Anders Breivik found Sane, and Legally Responsible

24 August, 2013 Reply

I’ve just read that Anders Breivik was found fit to be held criminally responsible for the mass killings in Norway: Anders Behring Breivik declared sane and sentenced to 21 years.

I must say that didn’t surprise me (for at least a couple of reasons), but what really interested me was the disagreement between the psychiatric reports, with a first report saying he was psychotic at the time of the attacks, and a subsequent report saying not.

I tend to refrain from armchair diagnosis, as it’s really not reasonable to proclaim about the mental state of someone I haven’t interviewed – or viewed interviews of, at the very least, and even then I wouldn’t rush to it. I was struck, and really quite annoyed, by the mass of people rushing to label him a “delusional and insane … lunatic“. As I wrote at the time, there wasn’t the evidence in what information was available, to say he was (or was not) psychiatrically ill. I must say though, that I’m not really surprised that all but two of the psychiatrists who assessed Breivik found him not to be psychiatrically ill.

However, there is an extremely important confounding factor here: the desire to hold Anders Breivik legally responsible for his actions, and to incarcerate him – rather than to see him as being ill and in need of treatment. As I mentioned in my previous post, the legal question of Breivik’s insanity, as distinct from psychiatric illness, is in some ways easier to speculate about: even if he were ill, he appeared to understand quite clearly the nature of his actions. As to the moral wrongfulness, some things I read at the tme suggested that despite regarding the murders as necessary, he did appreciate (to a degree) that they were also wrong. So it’s definitely conceivable (at least if Norway’s legislation in this regard is based on the McNaughton Rules) that even were Breivik psychiatrically ill, he might not be legally insane, and that he might therefore be found legally responsible.

Of course it’s further complicated by the fact that Breivik expressly wanted to be found legally responsible, so that his actions wouldn’t be “dismissed” as the product of psychosis. Complicated. And horrible.

Fit Teenagers, Happier Adults

14 June, 2013 Reply

There’s an interesting paper just published by the British Journal of psychiatry, that seems to demonstrate that better cardiovascular fitness as a teenager is correlated with decreased risk for later serious depression: press release here.

As I’ve been blithering about here – and have decided to move mostly to my shiny new Tumblr: The Running Reprobate, I’ve become a convert to running. I’ve experienced a really interesting lifting of mood every time I run – even if it’s only for 20 metres or something; running properly simply feels good.

Couple that with the evidence (at least suggestive; wish I knew where I’d seen it … Or maybe I heard it at the Brain Science Institute seminar last year – that could be it) that exercise is a really major factor in cognitive development/maintenance, and we really start to see that we should never stop running.

We know that exercise is good for depression (recent press notwithstanding), and that less fit adults – like adults with worse diets – are more likely to be depressed. Now it seems that fitness (and I’d lay good odds on diet as well) when younger has long-lasting effects on depression risk – suggesting that it is important in the brain developing properly.

So. Again: run, and don’t stop running.

And eat good noms: grains, nuts, oily fish, veggies…

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