Australia’s Teen Suicide Epidemic
SUICIDE PREVENTION, AWARENESS, AND SUPPORT
Hysterical disorders
Hysteria is no longer a fashionable term. In general use it often just means over-emotional (and usually in women) – ‘Oh don’t be so hysterical!’ Hysterical disorders were originally thought to be restricted to women. Hysteros is the Greek word for womb and there were once fanciful theories of the symptoms being caused by the womb wandering within the body. In psychiatry it has played an important role – particularly in psychoanalysis which still gives the best explanation of it.
Hysterical disorders are most often striking physical or neurological symptoms for which no organic cause can be found. In ‘conversion’ disorders anxiety or conflict is expressed as (‘converted into’) a pain or disability. The most dramatic are paralyses or blindness. The patient insists that they cannot see or move their arm and yet all tests indicate that they ‘really’ can. In dissociative disorders patients deal with their conflicts by insisting that they are not in touch with some aspect of their mental functioning (‘dissociating’ from it).
In the most extreme case an individual may insist they have multiple personalities and are not responsible for what different ‘personalities’ do. One of the surprising features of hysterical disorders is that the patient appears relatively content with what appear to others to be very frightening physical conditions. Charcot, the great 19th-century French neurologist, called this contentment ‘la belle indifférence’.
Conversion and dissociation mechanisms are very common (and temporarily often very helpful) in times of enormous stress. Soldiers in war often carry on apparently calm under fire but afterwards have absolutely no memory of it. Most of us have developed a terrible headache or felt unwell inexplicably only later to realize that it was a way of avoiding something we couldn’t face. In some cases we may doubt if the mechanism is really unconscious, as when it is used in a legal defence (e.g. automatism in murder trials).
Hysteria in adults is getting less common in more ‘psychologically sophisticated’ societies. In the First World War soldiers, who could not easily acknowledge their terror, developed shell shock (a coarse shaking of the hands and ‘jumpiness’) which was undoubtedly hysterical. They were genuinely unaware that (were ‘unconscious of’ the fact that) the fear of battle caused their symptoms. By the Second World War it was fully understood that soldiers could be terrified of battle. Those who could not cope did not develop shell shock but ‘battle stress’. They felt the terror and could not function but recognized what it was and asked for help. They did not have to deny the fear and convert it into ‘acceptable’ symptoms such as tremor or paralysis. While conversion symptoms are relatively rare now in psychiatric wards they continue to be a significant issue in other medical specialties where the more neutral term ‘somatization’ is used. Treatment is usually based on identifying the stresses and helping the patient find other ways of dealing with them. Treatment of acute hysterical disorders with abreactions (i.e. giving a sedative drug and getting the patient to talk through the situation under its influence) was often amazingly dramatic and effective.
Personality disorders
We all have a personality. Personality is that collection of relatively permanent characteristics that makes us different from each other. It’s generally how we first think of individuals or describe them. Psychiatrists inevitably became interested in personality. First because they have to distinguish between illness and personality (is this person suffering from a depression or are they always morose and pessimistic?). But they soon noted that there were personality types that were more commonly associated with some of the disorders they treated and for this reason they used the same or similar terms. The schizoid personality is rather distant and strange and the paranoid personality is over-sensitive and prone to suspicion. The hysterical is prone to intense fluctuating emotions, needing passionate relationships and to be the centre of attention, whereas the obsessional is careful and inflexible. The psychopathic personality (variously called sociopathic and antisocial) is not just a delinquent but is characterized by an absence of feeling for those around him or any sense of remorse. Their difference from ordinary criminals is such that prisons have as much difficulty dealing with them as do psychiatric hospitals.
The role of psychiatry in the treatment of extremes of personality, ‘personality disorders’ (PD) is controversial and most psychiatrists are skeptical that they have any specific cures. However, personality affects everything about us and so the treatment of any psychiatric disorder will require proper attention to personality. Different societies present problems for different personalities and the classification of personality disorders is changing. The difference between the sexes in the distribution of the two most prominent diagnoses is striking. Currently women are much more likely to be diagnosed with ‘borderline’ PD (fluctuating, intense emotions and difficult relationships, self-harm and low self-esteem, quite similar to the old-term ‘hysterical’ PD) and men with ‘antisocial’ PD (violence, delinquency, and impulsiveness quite similar to ‘psychopathic’ PD). It is not hard to see how these two disorders could be manifestations of the same personal alienation and disappointment but expressed as ‘different’ disorders because of how our culture moulds the behaviours of men and women.
Addictions
It is far from clear what psychiatry’s role should be in the treatment of alcohol and drug abuse. Most people who abuse them do not have mental illnesses. However there are a number of compelling reasons why psychiatry is involved. People with mental health problems have a very much increased risk of turning to drink or drugs, possibly to dull the pain in their lives (particularly in depression and personality disorders). Drug and alcohol abuse also makes getting better much more difficult. It is almost impossible to recover fully from depression while drinking to excess and young schizophrenia patients who abuse drugs find it difficult to attain control of their illnesses.
Addictions can also cause mental illnesses. Severe alcohol abuse can lead to paranoid psychoses, delirium tremens, depression, and eventually dementia. Amphetamine and cocaine are associated with quite severe paranoid disorders which can result in violence; acute psychotic reactions are common with LSD and Ecstasy. In addition the poverty and social chaos associated with illegal drug use can lead to depression and despair. So psychiatry is inevitably involved with treating alcohol and drug misuse. However, whether psychiatry should lead it, or simply be one of a range of inputs available to help, can be debated, as can the benefit of classifying addictions as illnesses.
Suicide
Suicide is a tragic, but not infrequent, occurrence in psychiatry. About a quarter of those who commit suicide are in current contact with psychiatrists and in the UK two-thirds have consulted their GP in the last month (40 per cent in the last week). The psychiatric disorders with the highest risk for suicide are alcoholism and depression, although it is increasingly recognized as a long-term risk in psychotic disorders and anorexia nervosa. Although suicide attempts are more common in young people and women, completed suicides are three times as common in men and increase steadily with age. Because of the distress and stigma associated with suicide (attempted suicide has been punished as a crime in many societies and was illegal in the UK up till the 1960s) some have sought to show that almost all who commit suicide have some form of mental illness. This is fairly unconvincing but understandable as the state of mind of the person who committed suicide used to have serious implications (such as loss of the right to burial in consecrated ground).
The French sociologist Durkheim’s book La Suicide published in 1897 opened a dramatically different perspective. It focused on the different rates of suicide in Catholics and Protestants and emphasized the importance of social isolation. He believed the Catholic faith protected from suicide and Catholic countries indeed do report lower suicide rates. This may be because they are more reluctant to acknowledge a death as suicide; in Dublin in the 1970s psychiatrists asked to assess the cause of sudden deaths concluded suicide four times as frequently as did local coroners. However there are undoubtedly variations in suicide rates between different countries.
Contrary to enduring myth, it is not Sweden that has the highest suicide rate but the countries of central and eastern Europe – e.g. Hungary, the Czech Republic, former East Germany. Currently there are astronomically high suicide rates in the collapsing former Soviet Union, with rates of 70 male suicides per 100,000 populations (compared with the US 17 and the UK 12). Lithuania has the highest recorded rate at 76 per 100,000 and dramatically demonstrates the societal influence on suicide rates. As Russian speakers have gone from being the privileged elite to being the unwelcome minority their suicide rate is now much higher than Lithuanian speakers. It was previously the other way round. Nor are differences just reporting practices. The same national rankings are maintained in immigrants to the US from these different countries.
With such an environmental effect it could be argued that suicide is not a particularly psychiatric issue. But there is some encouragement that psychiatry is able to influence suicide. There is no specific ‘anti-suicide treatment’ (apart from some rather specialized psychological interventions to reduce suicidal ruminations in chronic depression). However, active identification of mental illnesses and their treatment may have an impact. There is no truth in the old wives’ tale that those who talk about it don’t do it (as 40 per cent consulting their GP in the preceding month testifies). A programme of teaching GPs on a Swedish island to enquire about depression and suicidal thinking and then treat the depression demonstrated a fall in the rate.
There are also known risk periods (e.g. just after discharge from psychiatric hospital) when extra support can make all the difference. The suicidal impulse is not static – it comes and goes. Consequently simply making it more difficult does reduce the risk – reducing the pack size of dangerous painkillers has significantly reduced deaths in the UK as has introducing non-lethal gas instead of the old coal-gas. Even netting off bridges helps – perhaps introducing delay and time to reflect, allowing the impulse to fade. The worldwide access to help lines such as the Samaritans who offer a sympathetic ear attests to the need to think things through and make human contact.
While the last century saw an overall decline in the suicide rate (with two marked dips during the wars) there is continuing cause for concern. There has been a steady rise, worldwide, in suicides in young men, and rates in some high-risk groups (small farmers, young South Asian women) are still distressingly high. Some of this is due to easy access to lethal means (pesticides and shotguns for farmers and an increasing use of car exhaust fumes) but some is probably due to weakening family ties, a sense of powerlessness plus the complications of drug and alcohol misuse. Perhaps even more challenging is the change in society’s attitudes towards suicide. While still desperately traumatic for the family it now attracts little stigma. Indeed it is increasingly seen as just one more option available to individuals with serious and painful illnesses (always a high-risk group) or those who feel their life has run its course. Switzerland has legalized assisted suicide in such cases, although those with mental illnesses are generally excluded. As living wills become increasingly accepted and if legally assisted suicide spreads from Switzerland (as it undoubtedly will), suicide may over time be seen as again more a moral and ethical issue of personal autonomy rather than a psychiatric one. Even more important, then, that suicide driven by judgements distorted through the lens of a mental illness should be prevented to protect such true autonomy.
Why is psychiatry a medical activity? It is not accepted by everybody that mental health services should be run by psychiatrists (especially within the services themselves!). Are these ‘mental health services’ or ‘psychiatric services’? Much of the controversy focuses on the ‘medical model’ which is thought to be too narrow and too dominant. Psychology and social care can both make a strong case to offer the lead, and mental health nursing often stresses its independence. It will be obvious from what has been said so far that good practice (whether called mental health or psychiatric) requires a broader focus than just medicine. So how did psychiatry become so dominant?
One argument stems from the overlap between mental and physical diseases. Nearly all mental disease states can be mimicked by physical diseases and a failure to diagnose these may carry real risks. Thyroid disorders can present as depression (‘myxoedema madness’) or as an anxiety state. Deficiency of the B vitamin Niacin presents as dementia (Pellagra); myasthenia and early multiple sclerosis can easily be misdiagnosed as hysterical disorders. The list is extensive. This is, however, a pretty poor argument. Most patients come to mental health services via their family doctor who will filter out these physical problems. Where this doesn’t happen it soon becomes clear that a patient is ‘not like the other depressives’ and a medical or neurological opinion easily sought. This may have been a more convincing argument when psychiatric patients were isolated away from other medical care in large mental hospitals but is hardly relevant in the 21st century.
A second argument is that many of the most successful treatments have been developed using a medical approach and, as many of these are drugs, you need a doctor to manage the treatment. The second part of this is not so convincing – psychiatrists attend and prescribe to residential facilities such as nursing homes and autism schools without being in charge. However, there is an argument that the ‘medical model’ has been very successful. By the medical model I mean an approach that, although drawing heavily on scientific theory and methods, is fundamentally pragmatic. If it works keep doing it; if it doesn’t, stop it; if you’re not sure conduct a careful experiment to find out. Psychiatry’s overall independence from a defining theory, and its broadly scientific approach, are probably its major virtues. There is also within it a benign paternalism and willingness to accept responsibility that, while publicly decried, is often privately welcomed.
The status of doctors as the heads of mental hospitals arose, however, for quite other reasons. Certainly there was little doubt about the overlap between mental and physical disorders in the 19th century. Many mental hospitals in patients suffered from brain complications of syphilis that soon killed them and many more were severely physically ill. Doctors, however, did not establish mental hospitals but were put in charge of them. This was not because they had effective treatments to offer but because their social standing and accountability made them effective guardians against abuse of patients. This abuse had been a widespread scandal throughout the madhouses the asylums replaced. At that time medical approaches to madness were probably more damaging than helpful. Doctors may have got their dominant position for surprising reasons but maintain it currently for more understandable ones.
A consultation with a psychiatrist
What will happen if your GP refers you to a psychiatrist? Practice varies but follows a broadly predictable pattern. It will almost certainly be an interview – most consultations are entirely conversational with no physical examinations or blood tests. It will usually last between 30 and 60 minutes.
The first thing the psychiatrist is likely to do is ask you to tell him or her in your own words what has been going on, what is distressing you, and what you think the problem is. Although the GP will have summarized this in the referral letter, most of us like to hear it from you and get a really clear picture. From then on the psychiatrist is likely to steer the discussion to get a broader picture of you and your life (your ‘history’). He will find out about your upbringing and your family and usually ask detailed questions about family illnesses (especially psychiatric ones). After that he will ask about your health – both physical and psychiatric – over your lifetime and (particularly in younger people) about drug and alcohol use, as these often have a major impact on psychiatric problems. More detailed questioning is likely about areas relevant to your specific problem (important relationships, work stresses, etc.). After taking a history the psychiatrist conducts what is called a ‘mental state assessment’. This is a detailed evaluation of your symptoms – worries, mood, sleep, preoccupations. Usually this is also carried out as a conversation although sometimes there may be some quite formal questions and simple tests of memory. These are generally brief and not difficult – it’s not like doing an IQ test.
After taking a history and conducting a mental state examination the psychiatrist will usually have come to an opinion of what the problem is (often called a ‘formulation’). This formulation usually includes a diagnosis plus much more, such as thoughts about current difficulties and stresses that have brought on the problem. He will discuss these with you to get your opinion and then talk through the various options he thinks appropriate. This can involve a range of treatments (talking or tablets) or, rarely, a hospital admission. Surprisingly often, however, advice and reassurance is all that is needed. Nearly a quarter of referrals to psychiatrists in the UK are one-off consultations resulting in advice to the patient or GP.
Because so many psychiatric problems affect family members, psychiatrists will often want to talk with them, both to get a clearer understanding of what is going on but also to explain any proposed treatments to them (they may be very worried) and how best to help. Obviously this is not always appropriate – the circumstances may be very personal and private and adult patients have the right to total confidentiality if they wish it.
What the psychiatrist will not do is read your mind or asks trick questions. Sometimes it can seem this way because he appears to know much more than you’ve told him. There is nothing magical about this – it is simply that he will have heard similar stories before and will understand what is going on. That is, after all, his job – to know what depression and anxiety feel like and knows how people cope with difficulties in their lives. Many find this, in itself, reassuring – that their problems are not unique; others have had similar difficulties and got over them. Similarly psychiatrists are not there to ‘catch you out’ with trick questions. They want to know what you are going through and give advice on how to manage it. What will also not happen is a sudden admission to hospital against your will. There are no psychiatric diagnoses that require immediate compulsory hospitalization.
That only happens when there is overwhelming evidence of real risk and usually after much discussion and with a lot of involvement of family and GP.
Having made his assessment and discussed the treatment with you he may make a further appointment either for you to see him or another member of the team for treatment (e.g. a nurse or psychologist) or say that you don’t need to come back. Whichever happens he will write to your GP and keep him informed. So we now know a bit about the scope of psychiatry – how it fits into the other approaches to understanding the mind, what sort of disorders or illnesses it treats, and the major treatment approaches. You may by now regret having started reading – so many uncertainties, overlaps, and contradictions. Couldn’t it have been simpler? We’ll probably not. If we were to invent psychiatry from scratch it would be different. What we have, however, developed piecemeal over the last two centuries. It is the product of powerful competing forces and momentous historical developments and is confronted just now by truly remarkable advances in the neurosciences. So keep reading and by the end it should make some sort of sense – you will remember that you were never promised certainty.
