The current preference is for emphasizing that psychiatry is ‘just another branch of medicine’ like cardiology or oncology. In part this is to try and make psychiatry properly respectable by highlighting its scientific credentials, its commitment to precise diagnoses and evidence-based treatments, increasing its status within medicine and in society generally. It is also to reduce the stigma which has always been associated with mental illnesses. Stressing that these are illnesses like any other illness (‘mental illnesses are brain diseases’) should reduce prejudice experienced by sufferers and the sense of responsibility and shame felt by so many patients and families. We don’t feel ashamed or blame ourselves if a family member develops arthritis, so why do we if they become depressed? It is against this backdrop of unnecessary additional suffering that the medical legitimacy of psychiatry is, quite rightly, stressed. But it is not that simple. Psychiatry is different. Even those of us who work in it are treated as different. Psychiatry can also inspire fear. It is, after all, the only branch of medicine which can force treatment on individuals. Special laws exist in all developed countries, both to protect the mentally ill against punishment but also to force them to have treatment. There appears to be a remarkable consensus about the reality and importance of mental illnesses.
There is a fascination about psychiatry that goes beyond the natural curiosity about how the body or mind works. Psychoanalysts have suggested that this fascination (often mixed with fear) is because mental illnesses act out our own inner dramas. We see the depression we are struggling with and containing displayed before us, or individuals losing control when we may fear or secretly long to let go and shed our inhibitions. There is certainly some truth in this. Psychiatry is, like all medicine, a pragmatic problem-solving
activity. It draws on scientific theories but is not derived from them or constrained by them. Unlike psychology or physics, psychiatry cannot be explained ‘top-down’ from theories. Psychiatry has been formed by the illnesses that it has been required (and agreed) to treat and further shaped by the treatments it had available at the time. The development of psychiatry is dependent on the values and structures of the societies that fostered it. It is almost impossible to understand current practices without understanding some of that history. I have devoted so much space to the controversial aspects of psychiatry for two reasons. First, because there are real philosophical and ethical differences between mental and physical illnesses that won’t go away simply because we want them to. Nor will technological advances obliterate these tensions; The challenge for psychiatry in the 21st century may be particularly acute in ethical and social questions posed by increasingly sophisticated and powerful treatments of the mind.
Secondly, psychiatry is the arena where many of the big questions of the time – philosophical, political, and social – have to be hammered out in the crucible of real human relations and suffering. The philosophical debate about free will and determinism comes alive in the courtroom arguments about a psychiatric defence or in policy decisions about the management of psychopaths. The politics of power and social control drove the dismantling of the asylums and now frames the debate on compulsory treatment. The mind–brain dichotomy hovers throughout. The sustained battering from the anti-psychiatrists in the 1960s and 1970s raised the right (indeed, they would say the existential obligation) to be different.
So welcome to an area of medicine that is both mysterious and exciting as advances in brain sciences continually bump up against the messy reality of human beings. It is an activity which despite the scanners and designer drugs still rests on establishing trusting personal relationships. And lastly welcome to a pursuit that keeps challenging us about what it is to be truly human; continually reminding us of those unresolved philosophical issues (free will, mind–body dualism, personal autonomy versus social obligations) that we usually push to the back of our minds in order to get on with life.
What is psychiatry?
The only normal people are the ones you don’t know very well. All of us know someone who has been troubled (anxious, depressed, or confused). Most of us have felt that way ourselves sometimes (adolescence is often a particular time of self-doubt and unhappiness). At these times our emotions may be overwhelming, unpredictable, and impossible to control and our thoughts strange and bizarre.
Does this mean that we have been mentally ill or need to see a psychiatrist? Luckily the answer for most of us is no. Yet when we read about psychiatry what we find described are experiences remarkably similar to these. Psychiatry is fascinating because it deals with consciousness, choice, motivation, free will, and relationships – indeed everything that makes us human. While it is often cloaked in forbidding jargon (‘affect’ instead of mood, ‘anxiety’ instead of worry, ‘phobia’ rather than fear, ‘cognition’ instead of thinking) the conditions described are still instantly recognizable.
This is one of the persisting paradoxes about psychiatry that will recur throughout this book – that its subject is simultaneously firmly rooted in common human experience and yet is somehow ‘that bit different’. We recognize similar experiences to our own in what the patient describes. They are immediately familiar to us, yet these familiar experiences are used to diagnose disorders quite outside our experience. Hopefully by the end of this book you will understand this dilemma better but I can’t promise to resolve it for you. It’s been argued about since psychiatry came into being and the argument still goes on. However, it may be best to start by defining what psychiatry is (and what it is not) before returning to the philosophical and political controversies that attend it.
All the ‘psychs’: psychology, psychotherapy, psychoanalysis, and psychiatry ‘Psyche’ is the Greek word for mind. All these four terms describe different approaches to understanding and helping individuals with psychological and emotional (mental) problems. There is lots of overlap, and sometimes the work done by the same highly qualified individual can be described by several of these terms, so it is not surprising that people confuse them. However, there are differences and getting them clear will help clarify what psychiatry is.
Psychology is the study of human thought and behaviour. It originated just over a century ago from a tradition of introspective philosophy (trying to understand the minds of others by understanding our own) and is now a firmly established science. Psychology is studied at school and as an undergraduate course at university. It encompasses the study and understanding of mental processes in all their aspects and it has many branches. Experimental psychologists conduct experiments to explore the very basics of mental functioning (perception, memory, arousal, risk-taking, etc.). Indeed experimental psychologists do not restrict themselves exclusively to humans but study animals both in their own right and as models to understand human behaviour.
Experimental psychology is generally considered a ‘hard science’ which follows the same scientific principles of investigation as physics or chemistry. There are several professions stemming from psychology (e.g. educational psychologists, industrial psychologists, forensic psychologists). Clinical psychologists have postgraduate training in abnormal psychology and use this understanding to help people deal with their problems. The most obvious early example of this approach was the application of learning theory (i.e. consistent rewards and punishments to shape behaviour) in behaviour therapy. Behaviour therapy has been particularly successful in helping disturbed children or those with learning difficulties to modify their behaviour. It works without requiring a detailed understanding of the issues by the patient. Psychological treatments have, of course, become much more sophisticated and currently one of the most successful and widely practised psychotherapies (cognitive behaviour therapy) has been developed by clinical psychologists and is provided mainly by them. Clinical psychologists are essential members of all modern mental health (‘psychiatric’) services.
Psychoanalysis is the method of treating neurotic disorders developed by Sigmund Freud towards the end of the 19th century in Vienna. In psychoanalysis the patient is encouraged to relax and say the first thing that comes into their mind (‘free association’) and to pay attention to their dreams and to the irrational aspects of their thinking. Freud was convinced that his patients suffered because they tried to keep unconscious (repress) thoughts and feelings that were unacceptable to them and that doing so caused their neurotic symptoms. The analyst listens carefully to what is said and over time begins to detect patterns and clues to these ‘conflicts’. By sharing these insights he helps the patient confront and resolve them. Psychoanalysis is intensive and very long with patients
traditionally coming for an hour a day up to five times a week for several years. Psychoanalysis is the origin of the cartoon image of the bearded psychiatrist sitting behind the patient lying on the couch. Although Freud was a doctor there is no requirement for psychoanalysts to be medically trained. In America (where psychoanalysis has always had its most powerful presence) analysts were usually also psychiatrists but this is now increasingly the exception. Even when medically trained, analysts rarely use their medical knowledge – they make a virtue of not ‘interfering’ beyond the analysis. There are several schools of psychoanalysis developed by disciples of Freud (e.g. Jung, Adler, Klein) and some have become quite remote from the original model (e.g. Reich, Lacan). Psychoanalysis has had enormous influence beyond psychiatry, particularly in literature and the arts. Terms like ‘Freudian’ and ‘Freudian slip’ are part of everyday speech.
However, because psychoanalysis lacks firm scientific evidence of its efficacy, it is increasingly marginalized in modern psychiatric practice.
It soon became clear that there was more to psychoanalysis than Freud’s original remote and neutral exploration of the unconscious. The relationships formed in this intense treatment were themselves found to be influential. Analysts began to explore these relationships and experimented with more active approaches and with different types of therapy (time-limited therapies, more structured therapies, therapies in groups and in families, etc.). These psychological approaches, in which the relationship was used actively through talking to promote self-awareness and change, are broadly understood as ‘psychotherapy’. Most of the early psychotherapies leant heavily on Freud’s theories (often called ‘psychodynamic psychotherapy’ to emphasize the impact of thoughts and feelings over time) but several of the newer ones do not. These (e.g. non-directive counselling, existential psychotherapy, transactional analysis, cognitive analytical and cognitive behaviour therapy) draw on a range of theoretical backgrounds.
What they all have in common is that they use communication within a formalized and secure relationship to explore difficulties and find ways of either adapting to them or overcoming them. Most psychodynamic psychotherapies also require (like psychoanalysis) that the therapist undergoes a treatment themselves as part of the training. Psychoanalysis remains very tightly controlled, by defining strictly who becomes a psychoanalyst, but psychotherapy is a loose concept. Some schools of psychotherapy are strict about whom they admit but the title ‘psychotherapist’ could, until recently, be used by anyone. Most psychotherapists are not psychiatrists although most psychiatrists have some psychotherapy training and skills. Some psychiatrists even work mainly as psychotherapists.
So if it is not psychology and not psychoanalysis or psychotherapy, what is psychiatry? There are overlaps with the other ‘psychs’ but there are some fundamental differences. First and foremost psychiatry is a branch of medicine – you can’t become a psychiatrist without first qualifying as a doctor. Having qualified, the future psychiatrist spends several years in further training. He or she works with, and learns about, mental illnesses in exactly the same way that a dermatologist would train by treating patients with skin disorders or an obstetrician by delivering babies. Within medicine, psychiatry is simply defined as that branch which deals with ‘mental illnesses’ (nowadays often called ‘psychiatric disorders’).
Medicine is fundamentally a pragmatic endeavour. While drawing heavily on the basic biological sciences and scientific methods, the ultimate test of whether a treatment is right is if the patient gets better. We don’t have to know how the treatment works. Therefore the definition of psychiatry is not based on theory, as in psychology or psychoanalysis, but on practice. Whatever is viewed as mental illnesses (and this has changed over time), and whatever treatments are available for these illnesses, will determine what a psychiatrist is, and what he or she does.
What is a mental illness?
There is a marked circularity about this (‘a psychiatrist is someone who diagnoses and treats psychiatric disorders’, ‘psychiatric disorders are those conditions which are diagnosed and treated by psychiatrists’). There has been endless controversy about the reliability of psychiatric diagnoses and even whether or not mental illnesses exist at all. It is worth spending a little time on why psychiatric diagnoses are so controversial both because it keeps cropping up and also because the same issues are fundamental to all medicine although rarely as striking.
The subjectivity of diagnosis
The hallmark of the psychiatrist’s trade is the interview. We make our diagnoses (and still conduct much of our treatment) in face-to-face discussions with patients. We take a careful history (as do all doctors) but then, instead of, or sometimes in addition to, conducting a physical examination (feeling the abdomen, taking the pulse, listening through a stethoscope) we conduct what is called a ‘mental state exam’. In this we probe deeper into what is worrying the patient, their mood, way of thinking, etc. Some of this involves simply noting what the patient reports (that they are hearing strange sounds or that they panic every time they think of going out) but some involves us in constructing an understanding of what they are going through using ‘directed empathy’. Directed empathy means actively putting ourselves in their shoes, understanding what they are feeling and thinking, even if they have difficulty in expressing it. For instance we may come to the conclusion that a patient who recounts a series of vindictive acts carried out against them by strangers and friends alike is, in fact, excessively suspicious (paranoid) leading to misinterpretation of common events.
This ability to piece together how other people experience things and what they are feeling is an essential human capacity. Understanding how others see the world from their perspective (often called having ‘a theory of mind’) is so important that its absence, as in Autism or Asperger’s Syndrome, is a profound handicap. Psychiatrists train up this skill and, because of increasing familiarity with the range of disorders, can use it actively to understand the confused and confusing experiences that patients recount to them.
Diagnoses based on a patient’s mental state contain no concrete evidence for the diagnosis – there are no blood tests or x-ray pictures.
A written list of what is said or a detailed description of the behaviour (e.g. the diagnostic criteria for depression) are only part of the process. Psychiatric diagnoses rely on making a judgement about why someone is doing something, not just the observation of what they are doing. Hence the criticism that they are not scientific; they are not ‘objective’. Take the example of an elderly man who is profoundly depressed. He may not say that he is depressed but instead complain of tiredness, aches and pains, poor sleep and feelings of guilt. As he deteriorates he may lie unmoving all day or even not speak at all.
A psychiatrist will probably interpret his immobility as a feature of depression. In doing this (usually supported by the other clues) he hypothesizes that the immobility is a result of despair and hopelessness. There are lots of other possible causes of immobility (or ‘stupor’ in its most extreme form) and the psychiatrist distinguishes depressive stupor from those caused by hormonal or neurological problems by building up a picture of the patient’s mental state, i.e. why he is not moving or communicating.
Imposing categories on dimensions
The range of human variation is something we cherish. We would hate a world where everyone had the same personality, where there were no sensitive individuals, no moody individuals, no brave brash ones, etc. Similarly life without emotional variation would be intolerable. Aldous Huxley’s book Brave New World (where everyone was able to remain constantly content by taking a drug called ‘Soma’) was a nightmare scenario, not a utopia. Normal intensities of sadness (e.g. in grief ) or fear (e.g. in a house fire) match anything to be found in mental illnesses. There is no consistent cut-off, no absolute distinction between the normal and the abnormal – it is not a simple matter of degree. Even hearing voices when there is nobody about (auditory hallucinations) occurs in ‘normal’ people. Research in the Netherlands found a significant number of healthy people who regularly ‘hear voices’; widows and widowers regularly hear the voice of their dead partner quite clearly (and usually find it comforting). So how can the psychiatrist claim that hallucinations are symptoms of mental illness?
Medical practice involves pattern recognition. For most disorders there is a set of symptoms and signs that characterize it. Not all have to be present to make the diagnosis, although obviously that makes it easier. If some of the symptoms are very prominent then we hardly need to confirm the others, but if none is very striking we will seek to complete the picture. The intensity and duration of the symptoms also matter (how long the anxiety lasts, how persistent and disruptive the voices). Judgments must accommodate cultural differences. Northern Europeans are usually much less emotionally demonstrative than Southern Europeans so the thresholds for concern about expressions of distress may vary, for example, between a Finn and an Italian.
Traditionally medical training involved seeing as many patients as possible to learn these patterns within the normal range of expression. More recently diagnostic systems have become more formalized, often requiring some features absolutely and then a selection of others as shown in the current diagnostic criteria for depression. This has certainly improved consistency but the process is still the same. In this example ‘lowered mood’ is treated as a yes/no, present/absent quality, when we all know that mood varies continuously between people and over time. Psychiatric diagnoses require the imposition of categories (yes/no, present/absent) onto what are really dimensions (a little/quite a bit/a bit more/quite a lot/too much).
This is very obvious in psychiatry but it is certainly not unique to it. Our popular view of illnesses is usually based on the examples of infectious diseases or surgical trauma – you’ve either got an infection or you have not, your leg is either broken or it is not. There is no ambiguity and no need for agreement or consensus. However, few illnesses are that straightforward. Even the infection example is not that simple – you can find the same bacteria that cause pneumonia in lots of perfectly healthy people. The diagnosis is not made just by finding the bacteria but by finding them in the presence of a fever and cough. Even objective, verifiable data don’t always resolve the issue. What is considered ‘pathological’ will change depending on changing knowledge about diseases and available treatments. Just as improved treatments have led us to lower the threshold for depression so the diagnosis of disorders as apparently concrete and measurable as diabetes and high blood pressure is constantly redefined.
So psychiatry is not for the faint-hearted or those who need too much intellectual security. It is, of all the branches of medicine, the one that most clearly exposes the processes behind making a diagnosis. The language is revealing – doctors ‘make’ diagnoses, they impose their patterns rather than simply discovering them. It is also the branch of medicine which most explicitly acknowledges the impact of social considerations on its practice. Both the definitions of disorders used by psychiatrists and their expression in individuals are moulded by the social context. For example, modern society identifies and treats battle stress or shell-shock in war as a psychiatric disorder whereas a century ago we punished it as cowardice. Young adults at the start of the 21st century will seek help for their problems in a manner utterly unrecognizable to how their stoical grandparents would have done. This doesn’t make psychiatry particularly unscientific or unreliable (psychiatric diagnoses are about as reliable as those in medicine overall).
However, it reminds us that, like medicine, it remains (despite current wishful thinking) both an art and a science and draws from both social and physical sciences.
Diagnostic Criteria for Major Depressive Episode (DSM IV*)
Five (or more) of the following present during the same 2 week period and is a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
Depressed mood most of the day, nearly every day (e.g. feels sad or empty) or observed by others (e.g. appears tearful).
Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (subjective account or observation).
Significant weight loss or weight gain (more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.
Insomnia or hypersomnia nearly every day.
Agitation or retardation nearly every day (observable by others).
Fatigue or loss of energy nearly every day.
Feelings of worthlessness or excessive or inappropriate guilt nearly every day.
Diminished ability to think or concentrate, or indecisiveness, nearly every day.
Recurrent thoughts of death, recurrent suicidal ideation.
The symptoms do not meet criteria for a Mixed Episode.
The symptoms cause clinically significant distress or impairment in social or occupational functioning.
The symptoms not due to drug abuse, medication, or a general medical condition.
The symptoms are not better accounted for by bereavement.
*DSM IV = the fourth version of the Diagnostic and Statistical Manual produced by the American Psychiatric Association. A codification of diagnostic criteria for psychiatric disorders used worldwide. ‘Statistical’ refers to the use of these categories to record diagnoses and treatment.
The scope of psychiatry – psychoses, neuroses, and personality problems
Psychiatrists deal with a wide range of problems. The most severe disorders are often referred to as ‘functional’ (or non-organic) psychoses and include schizophrenia and manic depression (now usually referred to as bipolar disorder). The distinction into organic and non-organic is rather messy but still useful. Although we are increasingly convinced that there are organic (usually brain) changes underlying most of these illnesses, ‘organic’ is reserved for those psychoses arising from another, usually very obvious, disease.
These include a range of causes of confusion and mental disturbance such as injury, chronic intoxication, and dementia plus a range of more short-lived physical causes such as severe infections, hormone imbalances, etc. Functional psychoses are the conditions to which the older term ‘madness’ was applied. People with these were said to have ‘lost their reason’. Overall they affect nearly 3 per cent of the population at some stage in their life. So while they are not very common they are not that rare – about one person in an average secondary school class will suffer a psychotic illness in the course of their adult life.
The defining characteristic of psychosis is the loss of insight into the personal origins of the strange experiences. The patient loses the ability to ‘reality test’ – to check his or her terrifying or melancholic thoughts and feelings against external reality and judge them. He can’t think ‘I’m blaming myself for everything and can’t see a way forward because I’m depressed.’ Rather, he thinks ‘I feel this way as punishment for what I’ve done and there is no future.’ He may actively deny that he is ill and resist the attempts of those around him to balance these misinterpretations. Being so fixated on internal experiences, unable to modify them despite evidence to the contrary, is often referred to as ‘losing contact with reality’. He denies that he is ill and cannot see that family or mental health staff wants to help. Psychoses can be terrifying experiences with high levels of anxiety and distress. The two major psychoses have so defined the development of psychiatry that it is worth our time now to learn about them in some detail.
Schizophrenia is probably the most severe of all the mental illnesses. It does not mean split personality – Dr Jekyll and Mr Hyde was not a case of schizophrenia. The name was introduced by a Swiss doctor, Eugen Bleuler, in 1911 to emphasize the disintegration (‘splitting’) of mental functioning. It affects just under 1 per cent of the population worldwide and usually starts in early adulthood (during the 20s) although it can occur as early as adolescence. While it affects men and women in equal numbers, men often become ill earlier and fare worse. The prominent features are hallucinations, delusions, thought disorder, social withdrawal, and self-neglect.
Hallucinations are ‘sensory experiences without stimuli’. Far and away the most common are auditory hallucinations – hearing voices which talk to the patient or talk about them. Seeing things is not uncommon (though rarely as complete or persistent as auditory hallucinations) and many patients have strange physical sensations of things happening in their body. Hallucinations are not simply imagining our thoughts as a voice in the head – most of us do that.
They are experienced with the full force of an external event, fully awake in broad daylight; there is no ‘as if’ quality to them and the patient believes they are entirely real.
Delusions are ‘firm, fixed false ideas that are inconsistent with the patient’s culture’. Deciding that something is a delusion requires more understanding of context than identifying a hallucination.
The striking thing about delusions is the intensity with which they are held and how impervious they are to rational argument or proof to the contrary. The patient has no doubt either about their truth or about their importance.
The world is now a very culturally mixed place and a judgment often has to be made about whether ideas are really that odd for any particular individual. For example, two quite different patients described to me their conviction that there were invisible force fields traversing their living rooms which affected them. The first was a young ‘New Age’ woman preoccupied with Ley lines, Druidic culture, and mysticism. No illness here. The second was a retired schoolmistress who was convinced the force fields were electric, originated from her neighbour and represented an attempt to influence her sexually. This latter is a classic delusion in late-onset schizophrenia and had resulted in her exposing the electrical wiring in her house to get at the source. In schizophrenia delusions are commonly persecutory (‘paranoid’) and the source of the persecution (e.g. police, communists, the devil, freemasons) varies across time and place.
Thought disorder as a symptom is often considered particularly characteristic of schizophrenia. Schizophrenia differs from other psychiatric disorders in that not only is the content of thought often unusual (not surprising given the impact of hallucinations and delusions) but its logical and grammatical form can be disturbed.
With thought disorder it can sometimes be simply impossible to understand what the patient means, although each individual word can be understood. At its most extreme, conversation can be totally incomprehensible with lots of invented words and jumbled sentences. More often, however, sentences appear logical but lead nowhere or can’t be recalled. Where they can be recalled, despite repeating and exploring them, they simply can’t be understood.
Obviously you have to be careful before diagnosing thought disorder that it isn’t just a case of the patient being cleverer than you or knowing more (both always a possibility). However, recovered patients often tell us that at these times they did not feel fully in control of their thoughts. They may have experienced thoughts being directly inserted into, or withdrawn from, their minds or that they became suddenly aware of new connections between things that were uniquely revealed to them. This sense of unique new meanings is rare in other disorders and can lead to words being used in different and puzzling ways. A patient who had just ‘become aware’ that the colour green ‘meant intimacy’ (didn’t imply intimacy or wasn’t associated with intimacy but ‘meant’ intimacy) constructed sentences using it this way fully convinced that we also understood it. Withdrawal and self-neglect are probably among the most distressing and disabling features of schizophrenia. Bleuler, who first used the term, thought that withdrawal from engagement with others was central to the disorder and he used the term ‘autism’ to describe it. Although Bleuler was the first to use the term schizophrenia he was not the one who identified the condition.
Kraepelin did that in 1896, but he called it ‘Dementia Praecox’ based on the gradual deterioration over time which he thought always occurred. Both these early researchers considered what we now call the ‘positive symptoms’ (hallucinations, delusions, and thought disorder) to be secondary to the core process of withdrawal and turning inward – the so-called ‘negative symptoms’. During the last half-century, with the development of antipsychotic drugs (which target these positive symptoms), we have tended to see it the other way round – assuming that the negative symptoms are a consequence of the positive ones. After each acute episode recovered patients did not get fully better, they were that bit less engaged, less interested in themselves or the world around them.
However, the pendulum is swinging back with more attention to these negative symptoms, not least because our drug treatments are much less effective with them.
Kraepelin was very gloomy about schizophrenia and believed that virtually no patients really got better, but Bleuler was more positive and the truth lies closer to him. It is a fluctuating illness and most patients have several bouts. About a quarter probably recover well, having only one or two episodes. Most, however, have several episodes and take longer to get better after each one and rarely get back 100 per cent to where they started. A small proportion of patients has a very poor outcome and spends much of their adult lives overwhelmingly handicapped by the disease, unable to live independently. Modern treatments, particularly antipsychotic drugs, mean that most patients only come into hospital for a few weeks or months when they relapse, not the years that characterized pre-war mental hospitals. Schizophrenia runs in families and there is little real argument any longer that genetics play a role.
Manic depressive disorder (bipolar disorder)
Modern psychiatry owes its intellectual framework to Kraepelin’s distinction between schizophrenia and manic depressive illness. This is now renamed bipolar disorder, the term used from here on. During Kraepelin’s time mental hospitals took whoever was sent to them; some got better but most didn’t. There was not that much attention to diagnosis other than perhaps distinguishing the learning disabled from the psychotic. Kraepelin noted that one group of patients alternated through several periods of profound disturbances – sometimes agitated and sometimes withdrawn and depressed. What distinguished them most from the schizophrenia patients (which he called ‘dementia praecox’) was that they made full recoveries between episodes and more of them eventually left hospital. It was the course of the illness rather than its symptoms that impressed him.
Bipolar patients can have all the same symptoms as in schizophrenia (hallucinations, delusions, thought disorder, etc.) although these occur only in the most severe forms of mania and depression. However these symptoms are accompanied by a profound disturbance of mood – either depression or elation. It is this elation that is called mania (or often hypomania).
The change in mood overshadows all else in this condition. In the depressed phase the patient suffers from severe depression and may be suicidal. In the elated phase the patient is overactive and bursting with confidence and energy. Hypomanic patients can be very destructive to themselves – spending money they haven’t got and behaving in an uninhibited manner (drinking too much, being sexually overactive without thought for the consequences, driving too fast, etc.).
The psychotic symptoms, where they occur, reflect the mood. If the patient is depressed hallucinations will be critical and persecuting, if elated the hallucinations praise and encourage.
Depressive delusions are usually of guilt and worthlessness and hypomanic delusions are expansive and grandiose: ‘I’m going to be asked to advise the president about foreign policy’, ‘My paintings are worth millions’.
In less extreme forms of hypomania patients can be very entertaining, often talking fast (‘pressure of speech’), punning and making humorous associations between ideas (‘flight of ideas’).
Many famous entertainers and artists have suffered from bipolar disorder and acknowledge that they get their inspiration when they are ‘high’. It can be difficult to be certain about diagnosis in some of the milder forms of hypomania because it usually lacks the ‘strangeness’ of the schizophrenic episode. The main disturbance is one of judgment – we would all like to spend more money or hope that our paintings are worth more than they are. Often the diagnosis needs friends and family members to be able to confirm that this is not how the person usually is. A rather flamboyant, flirty TV executive was brought to the clinic by her worried mother. The story was not, in itself, that remarkable – some rather torrid love affairs with work colleagues, recreational drug use in night clubs, and some incidences of rudeness to her boss and absences from work. There are lots of media people who conduct their lives like this. What was decisive was her mother’s description of how normally she was an over-conscientious, rather anxious woman and that this was completely out of character.
The mother was alert to the issue because her late husband had also suffered such episodes. Like schizophrenia, bipolar disorder also affects just under 1 per cent of the population, it runs in families, it starts in early adult life (though usually later than schizophrenia) and males and females are affected about equally. Although the elated phases are more dramatic depression is more frequent and persistent. The depressive phase of bipolar disorder is not easily distinguishable from the much more common disorder of clinical depression.
Treatment of psychotic disorders
Treatments in psychiatry, like any other branch of medicine, are evolving so fast that any description here would soon be out of date. A range of drugs have been developed since the 1950s (‘antipsychotics’ such as chlorpromazine, haloperidol, risperidone, clozapine, olanzapine) which are effective in settling patients during the acute phases of schizophrenia. Unlike earlier drugs like barbiturates these are tranquillizing rather than sedative. They calm the mind without making the patient fall asleep (they do often have drowsiness as a side effect but that is not their purpose).
Antipsychotics have revolutionized the treatment of acute psychotic episodes with calmer, shorter spells in hospital. Continuing on antipsychotics after recovery reduces the risk of further breakdowns, and most psychiatrists encourage schizophrenia patients to stay on them for many, many years (‘maintenance treatment’). Obviously this is not easy as all drugs have some side effects and nobody likes taking them endlessly. With support,
however, many patients do succeed in staying on them and suffer far fewer breakdowns.
Severe depressive episodes in bipolar patients can be treated either with antidepressants or, in extreme cases, with electro convulsive treatment (ECT). These are discussed below. There are also now a number of ‘mood stabilizers’ which are used in the maintenance treatment of bipolar disorder and significantly reduce the risk of breakdown. Drugs are certainly not the only treatments available for psychotic disorders but they are currently the cornerstone.
Lack of insight can pose real risks of a psychotic patient harming him or others as he tries to flee or defend himself from perceived threats or persecution. Because of this impairment in judgment about the need for treatment, and the very real risks during psychotic states, psychiatry has been the one branch of medicine where the patient’s right to refuse treatment can be overruled. Provision for compulsory treatment is universal in psychiatric services and the overall principle seems generally accepted. The conditions under which it can be applied however (who imposes it, whether it is restricted to hospital care, whether there needs to be immediate risk of physical danger, etc.) vary enormously from country to country and reflect local values.
Compulsory detention for the severely mentally ill evolved before there were any effective treatments. It reflects recognition that mental illness is not simply deviance (‘mad’ not ‘bad’). Had it not been the case those at risk solely to themselves would have been left to their own devices and those presenting a risk to others would have been simply subject to the law. It was recognized in mental illnesses that the individual was changed from his normal self, and could change back. Detaining the patient served to protect him or her while the illness ran its course until they recovered (‘were restored to reason’). Of course not everyone did get better but enough did to sustain the hope and justify the humanitarian protective impulse behind detention.
Depression and neurotic disorders
Not all psychiatric disorders involve the same break with reality found in psychoses. In fact the majority of patients seen by psychiatrists do not suffer from psychoses but from less devastating disorders. Most of these are characterized by persisting high levels of depression and anxiety. They used to be lumped together under the title of ‘neuroses’ but the term has become unfashionable in psychiatry. However, it is a useful term, albeit rather vague, and one that most people understand so it will be used here. Neuroses cause distress and suffering to those who have them and may not be at all obvious to others. They vary greatly in severity and many patients are able to lead normal lives (marrying and working) while coping with them. Some, however, can be as disabling as the psychoses.
Depression is the commonest psychiatric disorder and affects about 15 per cent of us in our lifetime. The World Health Organization ranks it second to heart disease as a cause of lifelong disability worldwide. It appears to be becoming more common (particularly in the developed world), although some of this may be better detection, greater public awareness, and greater willingness to seek help. Luckily, with the advent of antidepressants and the development of more effective psychological treatments (e.g. cognitive behaviour therapy), it usually gets better fairly quickly. Most patients are treated by their family doctor and only the most severe get referred to psychiatrists. A proportion of depressed patients eventually become diagnosed as having bipolar disorder but here we focus on the ‘non-psychotic’ group.
Depression is usually experienced as a profound sense of misery, a loss of hope in the future, and often associated with self-doubt and self-criticism. Tension and anxiety are very common, sleep is disturbed, and patients lose weight and find themselves unable to concentrate properly or get on with things. Tearfulness and thoughts of suicide are common and aches, pains, and health worries frequent. In more severe cases patients report ‘feeling nothing’ (being cold and empty, unable to enjoy anything) rather than sadness. Patients may also take to alcohol or drugs as self-medication, which almost always makes things worse.
Depression differs from our normal periods of sadness by going on and on without relief, and the weight loss and poor sleep perpetuate it.
Depression is three times more common in women than men. Some people are constitutionally or temperamentally more at risk of developing it but it is clearly influenced by life circumstances. It is much more common in those living in poverty, those who are unemployed, live alone, have few friends or who have painful or disabling physical illnesses. Early loss of a mother and a difficult childhood are associated with an increased risk of becoming depressed as an adult. Depression is also more likely to follow from severe personal problems (relationship break ups, exam failure, job loss, etc.).
Helping people with depression almost always needs more than antidepressants (though these are very effective). Counseling, help to see a way forward, specific psychotherapy, and attention to ensuring a supportive social network are all needed. Understanding depression better has led to the recognition of just how important social networks and friendships are to people. These are not optional extras and few of us can survive without them. Providing such networks for young isolated mothers and their children in programmes such as Head Start in the US and Sure Start in the UK are national programmes that include strategies to prevent depression.
Most of us will experience some periods of depression in our lives with all of the features above. Most of us will get over them spontaneously and fairly quickly. Indeed, it is possible to think of depression as a necessary and useful human process – a period when we can work through loss, acknowledge it properly, and find a new balance. At such times it is appropriate to withdraw a bit into ourselves and some psychoanalysts consider the ability to be depressed as an essential step towards personal maturity. Certainly people who don’t seem ever to be depressed strike us as different or odd. Psychiatrists have spent years trying to make a clear distinction between ‘clinical depression’ and ‘normal depression’ and, frankly, have failed. The difference is more one of degree than genetics or symptom pattern. If it goes on and on, or if the symptoms become unbearable, it needs to be treated; if it gets better on its own after a few weeks, then great.
Anxiety is fear spread thin. We’ve all experienced it and undoubtedly it is useful – a degree of anxiety is essential to keep us alert and get us to perform well – e.g. fear of failure gets us to work hard for exams. However psychological studies show that, while performance rises with anxiety up to a point, above a certain level our performance plummets. Anxiety disorders are probably about as common as depression but fewer people seek helping for them.
People with ‘Generalized Anxiety Disorder’ (GAD) are persistently over-anxious. Most of us experience similar anxiety levels from time to time, but in anxiety disorders it doesn’t settle. GAD is exhausting and sufferers can’t sleep, lose weight, and often can’t concentrate. If it goes on a long time they may become depressed.
Phobic disorders are more dramatic and noticeable. A phobia means an exaggerated fear. Most of us have a phobia – so-called simple phobias start in childhood and are constant through life.
Animal phobias are typical examples (spiders, mice, snakes). Mine is a height phobia – I can’t climb towers or go near cliff edges. Most people live with their simple phobias unless they begin to interfere seriously with life (e.g. a flying phobia in someone whose job begins to require frequent travel, a needle phobia in a woman who becomes pregnant and needs to have blood tests). Simple phobias are remarkably easy to cure by behavior therapy using ‘graded exposure’. You get used to the feared object by following a preset scheme increasing the exposure while monitoring your own anxiety (e.g. start with holding a picture of a spider then hold a small dead one, a larger dead one, a living one in a glass, a living one free, and then a tarantula!).
Most of the phobias seen by psychiatrists are not simple phobias. They are either agoraphobia or social phobia. These start in adult life, are not constant (they are worse in times of stress), and can be quite disabling. Agoraphobia is not fear of open spaces as many think, but of crowds and crowded places. It comes from the Greek word Agoros for market place, not the Latin word Ager for field. Agoraphobia affects women much more and is associated with panic attacks and often leads to staying in and avoiding crowds. It is this ‘avoidance’ that makes the disorder continues. Panic attacks are awful (racing heart, sweating, a dry mouth, and conviction that one is going to faint, wet oneself, or even die). It is no surprise that people exit the situation as fast as possible and avoid it. The pity is that if they stayed they would soon realize that panic is very short-lived (a matter of minutes, not hours) and fades on its own.
However when we rush off and the panic stops we become convinced that it was the getting away that stopped it and we don’t learn that we can ride out the panic. The memory of the last panic starts to get us anxious as we approach the situation again and this ‘fear of the fear’ increases the likelihood of another attack.
Treatment is usually based on behavior therapy, teaching the person how to stay with a panic attack and thereby reduce it. It is usually a bit more complicated than with simple phobias. Social phobia is an exaggerated anxiety on meeting people. There is some real controversy about whether this is a legitimate diagnosis or simply severe shyness, and particularly whether it should be treated with drugs. In social phobia the problem is usually one of avoidance rather than panic and the treatment involves counseling to help develop techniques for dealing with social situations.
Obsessive compulsive disorder
Most of us have experienced obsessional behavior as children – avoiding the cracks in the pavement to avoid catastrophic consequences is the commonest. Sportsmen and actors are notorious for such rituals – the tennis player who has to bounce the ball three times before serving, the leading lady who cannot play without something green in her costume. These superstitious behaviors’ have much in common with obsessive compulsive disorder (OCD). In this disorder the patient has to repeat activities or thoughts (classically hand washing or checking and counting rituals) a set number of times or in a set order to ward off anxiety or feared consequences. In the obsessional form (where there are often no external rituals) the problem is repetitive thoughts, often about awful outcomes (contamination with dirt or germs, or a fear of shouting out something blasphemous or offensive). The hallmark of OCD is that the thoughts or actions are repeated, resisted, and distressing. It isn’t a harmless superstition or quirk but can dominate and ruin lives. Compulsive cleaners, for instance, end up exhausted because they are never finished cleaning over and over again.
Obsessional ruminators can’t hold down a job because they are distracted with repeating their thoughts or counting and may wear out their partners as they seek constant reassurance about their worries.
OCD tends to be associated with specific personality traits – neat, tidy, conscientious. Most of us recognize obsessional features in ourselves and yet the full disorder seems so bizarre. Indeed, sufferers are often slow to seek help because they consider it so strange and incomprehensible – they are embarrassed by it. It has been subject to psychological over-interpretation and only recently have effective treatments been developed (behavior therapy and antidepressants in milder cases).
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.
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.
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 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.
Asylums and the origins of psychiatry
Psychiatry’s history is manageably short - barely 200 years. The mentally deranged have always been recognized and where they could not be cared for within the family some makeshift provision was made – private madhouses and spas for the rich and workhouses for the poor. Workhouses contained everyone who could not care for themselves – the feeble-minded, the sick, the feckless, and the unemployed. Conditions were grim (deliberately so to discourage the burden on the public purse) and the mentally ill often fared badly from other inmates who were impatient with them or took advantage of them. Private madhouses were hardly that much better. There was no training required to own or run them. Their main purpose seemed to be to hide mad members of rich families from view, either to protect the family’s reputation or to appropriate their fortunes. The harsh treatment of the much loved King George III generated powerful antipathy towards them in late 18th-century England. Bedlam was the first major public madhouse, opened in London in 1685 and still in existence as the much-reformed Bethlem Royal Hospital. The exhibition of the inmates was a popular public pastime in the early 18th century and generated revulsion in more educated quarters. France had established its Hotel Dieu and Hôpital Général in 1656 (the Bicêtre for men and Salpêtrière for women) which, despite their names, were not hospitals, but general establishments for custodial care more akin to workhouses.
Tollhäuser (fools’ houses) had been established in medieval Europe. The first US insane ward was established in a Boston Almshouse in 1729 and the first US Psychiatric Hospital in 1773 in Williamsburg, Virginia.
The York retreat
The impetus to separate the mentally ill and provide more appropriate care came not from doctors but from social reformers and reflected an emerging concern with the dignity of man. In our risk-obsessed days it is sobering to realize that asylums were proposed more to protect the deranged individual from society than vice versa. In France in 1792, Pinel dramatically and symbolically removed the chains from inmates in the Bicêtre and in England a Quaker family, the Tukes, proposed and built the first Asylum in York. The Tukes were convinced by the writings of Pinel and Esquirol that a calm and harmonious environment, close to nature and with kindness and predictable routines (‘moral therapy’), would bring peace to a troubled mind. The York retreat was built to contain 30 patients; opened in 1796 it achieved remarkable results – many early patients were discharged home improved or even cured. It attracted attention from all over the world and visitors came from the US and throughout Europe to study and replicate it. The UK developed early a liberal regime, reluctant to use mechanical restraints such as chains or belts (later championed by John Connelly in the ‘non-restraint movement’).
The asylum movement
In the 1820s the asylum movement began and over the next 70 years hundreds were built for the reception of indigent ‘lunatics’ in each county in England, in most European countries, and across America. The scale of investment is hard to conceive of now, with enormous, well appointed buildings to house several hundred patients each. The physical conditions within the asylum (space, heating, food, recreation) would have been significantly better than most patients could have expected at home with their families. The principles of moral therapy dictated that asylums should be spacious, away from busy towns, placed in the countryside with extensive grounds. High airy locations were selected because of current theories implicating mists and ‘miasmas’ in disease.
Doctors were put in charge of asylums primarily because they were easy to hold accountable to the board of governors. There were few effective medical interventions and the medical superintendent’s role was predominantly administrative and disciplinary. He didn’t even have the power to admit or discharge patients – that was usually held by the local magistrates.
Asylums started well, often admitting recent cases – many of whom recovered. They soon seized up, however, with those who did not recover and so became overcrowded. Throughout the latter part of the 19th century and early 20th century, the recovery rate in mental hospitals declined steadily because of an increasing concentration of these more severe cases. Therapeutic optimism gradually faded and conditions (though still much better than the workhouse) deteriorated.
Throughout the 19th century investment in asylums was maintained. They were kept high on the agenda in the US by the influential social reformer Dorothea Dix and the physician
Benjamin Rush and in England by strong central support from the influential social reformer Lord Shaftsbury. Initially quite small institutions, they rapidly grew to several hundred inmates each in Europe and up to several thousand in the US, where the building
programme started a bit later and continued longer. Between 1903 and 1933 the number of patients in US mental hospitals more than doubled from 143,000 to 366,000. Most of these were in institutions of more than 1,000 beds and US mental hospitals continued to expand. The largest was the Georgia State Sanatorium at Milledgeville which by 1950 housed over 10,000 patients.
The non-restraint movement
Cultural values are strongly reflected in the care of the mentally ill. This is still the case despite the globalization of mental health research. At the start of the asylum movement the UK and US focused on human rights and, particularly in the UK, on treating patients with as little physical restriction as possible. John Connelly, the physician superintendent at Hanwell Asylum, became the leading proponent of managing patients without strait-jackets or chains. He emphasized the value of well trained and unflappable staff and used isolation to allow patients to calm down. A US visitor to Connolly commented that English patients must be more tractable and that the approach would ‘never work at home’. This tradition has continued and the UK became the first country to run some mental hospitals entirely without locked doors (Dingleton in Scotland was a fully ‘open-door’ hospital by 1948 – before the new drugs). The UK approach remains unusual in its total absence of mechanical restraints to control agitated patients. Whether its reliance on medication to achieve this is always a good thing is, of course, open to question.
Psychiatry as a profession
Medical superintendents were responsible for running the asylums – ensuring there was enough food, sacking drunken staff, preventing abuse, and proposing discharge to the board if patients recovered. Some of the more able (such as John Connelly) became highly skilled in man-management and also took a leading role in the design of new asylums. The early asylum movement produced some remarkable architectural achievements but relatively few therapeutic ones. There was no specific training to be an asylum doctor – you went there and worked alongside the superintendent and if you were lucky you eventually replaced him. These were, however, generally thoughtful men (they were all men) and interested in science.
In the 1840s they founded their own professional bodies – the Association of Medical Superintendents in the UK in 1841 (later to become, 1865, the Royal Medical Psychological Society and in 1971 the Royal College of Psychiatrists). The formation of this professional association in 1841 coincided with the naming of the dinosaur – a coincidence not lost on the profession’s detractors.
‘Germany’ – psychiatry’s birthplace
In the second half of the 19th century there was a remarkable intellectual flourishing in German-speaking Europe. The collection of states that came to make up modern Germany were rivals of each other and characterized by local centres of government with prestigious universities and institutions. Unlike France at the time (where everything happened in Paris) there were several culturally and linguistically linked, but independent, centres of innovation – Munich, Berlin, Vienna, Zurich. From these came the great founding fathers of modern psychiatry: Griesinger, Morel, Alzheimer, Kraepelin, Bleuler, Freud, Jung. The first professor of psychiatry was established in Berlin (Griesinger 1864) and there were six by 1882. Compare this to England where the first professor of psychiatry was appointed in 1948.
These academic posts were not, on the whole, placed in mental hospitals nor were they dedicated to the treatment of the legions of psychotic and demented patients who inhabited them. Most research was conducted in university clinics and most was focused on detailed examinations of the nervous system in an attempt to elucidate the mechanisms of the ‘degeneration’ that was thought to underlie mental illnesses. Three of the most influential figures found their way into the area for more personal reasons. Falling in love was the reason for both Kraepelin and Freud and family concern for Bleuler. Freud and Kraepelin had successful research posts in university departments (Freud was dissecting the nervous system of eels). A research career at that time was incompatible (in terms of both income and time) with marriage and a family. However, both had met the women they wanted to marry so there was no alternative but to relinquish their promising research posts and look for a ‘real’ job. Luckily we know that both had long and happy marriages. Bleuler was born and brought up in the Zurich cantonment and didn’t want to move. His sister suffered from schizophrenia and he was close to her and it seemed logical to return to a job at the Burghölzi hospital where she was cared for. These three men moulded modern psychiatry.
Kraepelin moved with his new wife in 1886 to become an asylum doctor in Dorpat in what is now Estonia. The professional classes spoke German but his patients didn’t – consequently he didn’t understand a word they said and could not usefully interview them. What he did do was study their case notes and observes the fluctuations in their illnesses. From this he made the distinction between schizophrenia (which he called ‘dementia praecox’ meaning early dementia) and manic depressive disorder. Although in their acute phases it was difficult to distinguish the two disorders, important differences emerged over time. The dementia praecox patients never (he believed) fully recovered and with each bout of acute illness became more disabled. Based on the course of the illnesses he established the classification into the two major functional psychoses that persists to this day.
‘Kraeplinian’ implies a pessimistic view of schizophrenia (if defined by its poor outcome it can only be diagnosed if there is a poor outcome) and of exaggerating its difference from manic depressive disorder. However demonstrating that you could successfully classify the psychoses at all brought enormous benefits. Once you can distinguish different groups you can begin to make sensible predictions about outcome (‘prognosis’) and develop a clearer picture of each illness. Having distinguished these two it allowed psychiatrists to start distinguishing the others (dementia, cerebral syphilis, intoxications). At the simplest level it gave psychiatry a reason to pay more attention to patients’ illnesses and provided a basis for some rudimentary predictions and development of treatments. Kraepelin became a celebrated and influential figure who travelled widely in his own lifetime. He was a passionate advocate for the temperance movement and on a lecture tour of Italy it was not so much his radical diagnostic ideas that amazed his Italian colleagues as the fact that he refused to drink wine. Indeed, he considered his campaign against alcohol his main contribution to humanity.
Eugen Bleuler (1857–1939)
Bleuler first coined the term schizophrenia in 1911. It followed many years of careful study in the Burghölzi hospital in Zurich. Bleuler’s situation could hardly have been more different from Kraepelin’s. He had grown up using the same dialect as his patients, lived in the hospital where his sister was a patient with schizophrenia, and often spent evenings talking to his patients. In every way he was primed to try to understand and make sense of their inner world rather than just observe as Kraepelin had done. Is definition of schizophrenia is based on the content of the patient’s experience. This approach allowed him to make the diagnosis (providing the features were present) even if the outcome was good. Of course there were many schizophrenia patients with poor outcomes but Bleuler confirmed there were some with good outcomes.
Bleuler considered that the primary disturbances in schizophrenia were a withdrawal from close relationships and disturbances of thinking and mood. He believed that hallucinations and delusions were attempts by the patient to make sense of these experiences. He defined schizophrenia using his famous ‘Four As’ – Autism (withdrawal), Affect (mood disturbances), Association (thought disorder – different associations or meanings being attached to words), Ambivalence (lack of direction and motivation). Bleuler’s approach has been superseded in recent years by a focus on the ‘positive’ symptoms (delusions, hallucinations, thought disorder) because of their greater ease of recognition and responsiveness to drug treatment. His was certainly a more humane approach to this, the most devastating of the mental illnesses, which accords meaning to the experiences of even the most deteriorated patient.
Sigmund Freud (1856–1939)
Like Kraepelin Freud had to abandon his preferred career for marriage. He pursued the only available alternative for a Jewish doctor at that time – private practice. Freud had little experience of asylums and worked almost exclusively with neurotic patients; he always recognized the limitations of his approaches for more severely ill patients. However, a careful reading of his case histories leaves little doubt that he treated some pretty disturbed individuals. His investigations took him in a completely different direction: the founding of psychoanalysis. He thought of himself as much a scientist exploring the mind as a doctor curing it. He always believed that physical treatments (medicines) would eventually be the cure for mental illnesses. We might anticipate antagonism or avoidance between these groups a century ago but this doesn’t appear to have been the case. This was still‘pre medical-model’ psychiatry. Working in large asylums, all that was available to the doctors after they had classified their patients into broad diagnostic groups was to talk with them. Moral therapy evolved into a rough and ready psychotherapy. Few believed this cured the disease, but the role of doctors has never been restricted to just cure, but also to bringing relief from suffering. The journals of asylum doctors of this time testify to the time spent talking with patients – attempting to bring comfort and using reasoning to calm them. The work of another great German psychiatrist, Karl Jaspers (1883–1969), exemplifies this. Jaspers wrote his masterpiece in Heidelberg by the age of 30: General Psychopathology (1913). This book is still in print and has never been bettered as a description of the mental processes in psychotic illnesses. Jaspers was initially quite comfortable with the writings of the psychoanalysts and his book clearly distinguishes the two different approaches to researching mental illnesses. The first is verstehen ‘understanding’ and the second erklären ‘explaining’. Both were considered legitimate and necessary: what is the meaning of what the patient says and what is causing it? This is a dichotomy that still causes conflict in psychiatry – particularly between the psychologically minded and the biologically minded. Jaspers eventually lost patience with Freud because he felt that he implied that to understand was to explain. In its origins psychiatry needed and valued both approaches.