Last month’s radio programme about lobotomy (1) is interesting because it slightly departs from the usual historical scripts, which are: evil psychiatrists used lobotomy as a destructive form of social control, or well-meaning but weak ones rubber-stamped the decisions of others, such as Nurse Ratched in One Flew Over the Cuckoo’s Nest.
It emphasises that the inventor, and two of the main promoters of lobotomy were in fact not psychiatrists. Politician and neurologist Egas Moniz started the ball rolling. Then, American neurologist Walter Freeman, and the British surgeon Sir Wylie McKissock, both continued to do thousands of operations despite evidence for uncertain therapeutic results.
Historical radio and TV programmes about the bad aspects of the old asylum system (which I don’t advocate returning to, but will say it was always underfunded) are often a means, I think, of deflecting attention from current NHS mental health failings. Other occasional broadcasts about the mental health systems of second- or third-world countries generally have the same function.
At least this one is a little different. However, it seems to me that there is a clear parallel between lobotomy and another kind of invasive operation for a serious behavioural (and often psychiatric) disorder today.
Although obesity surgeons are not household names (yet), there has never been a proper trial of gastric banding or the more serious procedure of partial gastric reduction, despite thousands of operations being done annually (2). The rush to surgery is delaying the development of new non-surgical treatments, and the application of at least one recently developed and partially tested treatment (for obesity-linked ADD / ADHD).
The programme-maker did not draw attention to this obvious parallel. Was he or his boss warned off by England’s Department of Health, which for much of the last decade had surgeons both as chief medical officer and as a health minister? Or was it (perhaps more likely) BBC self-censorship?
BBC journalists don’t themselves seem to believe, any more, that the “licence fee” protects their independence because it is supposedly “not a tax”. But they continue to resist the suggestion that their work should be subject to the Freedom of Information Act.
So ordinary patients who have experienced poor results, infections or other complications from bariatric surgery, may never be able to discover the extent of any such BBC collusion. The same goes for relatives who, following one of the thankfully few deaths directly caused by bariatric surgery, may take a retrospective interest in how this surgical descendant of lobotomy was promoted.
(2) See my previous pieces on obesity: https://drnmblog.wordpress.com/category/obesity/
Drafted 2nd December; final version 8th December
Some people with ADD / ADHD use cannabis regularly, and I have had patients who moved on to prescribed ADD / ADHD medication, finding it both more helpful and lower in unwanted effects than cannabis.
As the diagnosis of ADD / ADHD grows in the UK, I suspect this will become more of a factor in the debate about whether cannabis should be criminalised to a lesser extent, or even decriminalised altogether.
I don’t have a formal professional view either way on that issue, especially as I’m not a specialist in “Substance Misuse”. But I would say that the arguments of the leading UK advocate for reducing criminal sanctions on cannabis, Professor David Nutt, seem far from clear-cut.
On his Blog (http://profdavidnutt.wordpress.com), Professor Nutt suggests that the risk of increasing schizophrenia in young people, which could result from decriminalisation, is not of great concern. On his own figures, for every extra million young men using cannabis, about 200 might develop schizophrenia who wouldn’t otherwise do so.
His argument seems to be that alcohol use would probably decline (because of switching from alcohol to cannabis), and the benefits from that would outweigh any cannabis-related harms.
He might be right, but I think at least two aspects of the debate have not received as much attention as they should.
First, it does seem very difficult to compare the harm of an often devastating psychotic disorder, with alcohol-related problems. Is it really as simple as saying that improving and extending life for tens of thousands of people, by reducing their alcohol intake, logically outweighs the risk of “only” a few hundred people developing schizophrenia?
Secondly, I think the wider debate about “harm reduction”, and Professor Nutt’s related view that UK medical doctors should be able to prescribe cannabis (as they can elsewhere in Europe) would benefit from an acknowledgement that medical prescribing of some mind-altering substances has been, and remains, too lax.
When UK general practitioners, from the mid-1990’s, were widely encouraged to prescribe antidepressants after little more than a ten-minute consultation, this state-approved practice was never properly tested. The concerns about misuse and harms of Seroxat and other antidepressants followed.
Of course, as a specialist prescriber of mind-altering substances myself (hopefully, always as a reasonable therapy), I have a direct vested interest. But it does seem to me that promoters of medication, whether natural or synthetic, branded or generic, freely available or eye-wateringly expensive, would generally be more credible if they listened to my (free) advice.
I went back to school myself yesterday, starting an MA in Victorian Studies at Birkbeck College, part of the University of London. This follows on from my last blog piece, because quite a few other “Dickens obsessives” have done this course, and some of those teaching on it seem to acknowledge similar afflictions…
Many of my patients, especially those with ADD / ADHD, have thought about picking up where things went wrong in their own education. This may mean going back to do a similar course to the one which they dropped out of; or deciding that was the wrong choice anyway, and studying something quite different.
Although I have dropped out of a couple of courses myself in the past, I’m pretty sure it won’t happen this time. To some extent this is because I believe that I understand my own mild ADD tendencies better (1): my nineteenth-century interest is not an “obsession” in the clinical sense of being related to obsessive-compulsive disorder (OCD), but more of a recurrent ADD / ADHD “hyperfocus”.
When the comedian Rory Bremner talked about his possible ADHD in May this year, it attracted a lot of media attention. But I was uneasy, feeling that the half-hour BBC radio programme appeared to risk trivialising his problems: nearly forgetting his lines on stage, losing things, being a bit disorganised. Hardly a definite case for treatment in someone who is, after all, a very succesful entertainer.
There was no mention of his own past history of anxiety and depression (2), conditions which are well-documented as being linked to ADD / ADHD. In my experience, ADD / ADHD is often a direct cause of anxiety and depression, not least because disorganisation and impulsivity lead to negative life events.
A couple of weeks ago the mental health charity SANE launched its “Black Dog” campaign, to re-raise awareness of depression (3). Despite Bremner being a prominent part of SANE’s campaign, it attracted nowhere near the same media coverage nationally.
I have no idea whether Rory Bremner’s past problems with anxiety and depression had any link with ADHD. But it does seem worrying that the May BBC radio programme did not explore the possible harmful consequences of undertreatment.
*See The Gift of ADHD?, below at: https://drnmblog.wordpress.com/2011/03/20/the-gift-of-adhd/
Drafted by 5th August 2011, published at DrNMblog.wordpress.com on 6th October 2011
Until recently, most of my ADD / ADHD patients who did well on a trial of medication, were then able to obtain further NHS prescriptions from their GP.
My website highlights the 2009 NICE (National Institute for Health and Clinical Excellence) ADHD guidelines, because the guidelines are strongly in favour of diagnosis and treatment choice. When NICE was set up as a state-funded body in 1999 there was a commitment, which was made legally stronger in 2005, that the NHS would be provided with enough money to follow its recommendations.
Last year, the new Government’s Conservative Health Secretary, Andrew Lansley, abolished this legal commitment for GP’s to follow NICE guidelines.
Under financial pressure to reduce prescribing, GP’s look at adult ADD / ADHD, and see that no medication is licensed. Unless the GP has direct experience of treatment benefits, this relatively new diagnosis inevitably becomes a target for cost reduction.
The fact is, medication licensing is really about the claims that a pharmaceutical company can make for its product, rather than what clinicians can prescribe (and the NICE guidelines are more relevant to that). But such distinctions make little difference to GP’s, especially when fully licensed ADD / ADHD treatment in children and teenagers is still often opposed by prominent NHS academic psychiatrists.
My own experience is that ADD / ADHD medication, together with counselling and psychotherapy which takes diagnosis properly into account, can improve interpersonal and work functioning enormously. If patients do have to fund diagnosis and treatment themselves, it is likely to be well worth it, as long as they have moderate or severe ADD / ADHD. Treatment could even be cost-effective if the ADD / ADHD is milder: what price can you put on better relationships?
Drafted by 2nd July 2011, published at DrNMblog.wordpress.com on 6th October 2011
Presentation / Debate at SimplyWellBeing adult ADHD group meeting: Hammersmith Irish Cultural Centre, 20th March 2011
“Thanks again to Andrew [Lewis] for inviting me to offer a few comments on whether ADHD can have advantages, or should even be seen as a gift, rather than a disorder.
Just to mention that when I talk about “ADHD”, I mean what I usually write as “ADD / ADHD”, because the distinction is important to many people who do not have significant hyperactivity.
It’s now just over a year since I first met Andrew. In that very first meeting, he suggested I give a talk in this Sunday morning group, on ADHD diagnosis and medication. The fact that I’m back now suggests that he does not entirely regret that impulsive decision.
If we look at impulsivity, rather than the other two aspects of ADHD, inattention and hyperactivity, it’s probably easiest to see the potential advantages. Another word for impulsivity is spontaneity, and many people who are the opposite of impulsive, who never do anything unless they have thought through all the possible consequences, often feel oppressed by their lack of spontaneity. People who lack spontaneity may well have mild Asperger syndrome or autistic spectrum conditions.
One interesting thing about ADHD, which Andrew and I have discussed, is that if you look at perhaps the four most prominent US specialists, the psychiatrists Ed Hallowell and John Ratey say that ADHD often, maybe always (1), has advantages of creativity and originality; while the psychologists Russell Barkley and Thom Browne both tend to say that abilities and talents in an individual are separate from ADHD.
Who is right? Despite what Andrew may be going to say, I think this is logically a very difficult question. I really don’t know the answer, and for the moment I’m not convinced that it really matters, as long as the individual person with ADHD is advised that the self-understanding, and possibly treatment, which goes with the diagnosis, tends to free up previously undeveloped abilities and talents. Both sides of this particular debate agree on that.
Hallowell, Ratey, Barkley and Browne are working and writing in the US, and not the UK. There is a reason, I think, why we should perhaps make sure the psychologists’ views are heard over here, maybe even at the expense of the psychiatrists’, at least for a while. And I am speaking as a psychiatrist myself.
The more you stress the advantages of any disorder or condition, the less serious you tend to make it sound. Even before the current climate of financial savings, which is affecting the NHS, public opinion in the UK was very sceptical about ADHD.
The idea that you need assessment by a professional, for a neurodevelopmental condition that is a hidden gift, could sound like an indulgence to many people. I might be wrong though, because diagnosis of dyslexia has increased substantially over the last couple of decades,
despite similar claims.
The idea that you need treatment for a hidden gift, with ADHD medication which can have side effects, and can sometimes be abused, will probably sound like “enhancement” rather than “treatment” to many sceptics. I am not at all sure that the UK is ready to allow psychological enhancement with Ritalin right now.
Again, I might be wrong, and it could be that concerns of this kind motivate the better development of non-medication-based approaches, as well as medications other than Ritalin.
But for the moment I will stick to talking about treatment of a “disorder” rather than a “diversity” or even a “condition”, and leave it up to my patients to decide whether the gifts that their ADHD has been holding back, are part of their ADHD or not.”
(1) I think they lean towards “always” rather than “often”. But they are not fully explicit on this: see Delivered from Distraction (2005), pages 5 and 14-15
Oliver James (see the previous Blog piece, 4th February) is unpopular with many people and parents affected by ADD / ADHD. Not a big surprise, given his strong view that genes have been over-emphasised, and early parenting neglected, as causes of all the common mental and behavioural disorders. Also his rampant anti-Americanism (1) (it is probably significant that ADD / ADHD diagnosis and treatment, especially for adults, has largely developed in the US).
I think that he is largely wrong on those key issues, but also that his books still contain interesting and sometimes valid points. He is right, for example, to suggest that many people can gain as much “insight” from “work, sport or art”, as from psychotherapy (2).
There is no magic formula to reveal who will, or will not, be helped by psychotherapy. And James even implies that “therapy culture” could make you worse (3), although this is more of a comment on reality television than ordinary professional practice.
His linking of the Positive Psychology movement with materialism and consumerism is doubtful to say the least, because academics like Seligman have constantly stressed the primacy of interpersonal relationships for promoting happiness and preventing depression. I wonder if James was trying to make a somewhat different point about the limits of his own “Affluenza” argument: below a certain level of material provision family and social life become difficult, and psychotherapy of any kind should not collude in denying that.
As for ADD / ADHD, it is disappointing that books written in 2002 and 2007, while recognising that autism may be substantially genetic, do not accept the same might apply to other developmental conditions.
Where I agree with Oliver James most of all, in these books, is the sense that exploration of the past through psychotherapy is an uncertain process, and that objective sources such as accounts from others, or school records, should be sought wherever possible. His recommendation to “Interview your mother or father or a sibling or an adult who was close to the family when you were small” (4) sounds close to a description of the diagnostic history-taking approach used by psychiatrists and clinical psychologists.
Therefore I think it a bit of a regression when he appears to suggest, in Affluenza, that psychotherapy may reliably uncover buried memories from childhood (5). Despite a clear non-endorsement of transference-based reconstruction (6), he fails to offer any warning about the possibility of “false memories”, either overly negative or positive, being created in the psychotherapy process itself.
(1) They F*** you up (2002) paperback: p228 (2) p259 (3) p246 (4) p182
(5) Affluenza (2007) paperback: p442: “…help with directly recalling what went on in my childhood”
(6) p442: Avoid the therapist “…if they fob you off with ‘We will investigate how your past is affecting you through the way you relate to me’”
I only share James’ views about using transference as investigation: the therapeutic technique may be useful for some people, as long as the therapist does not make claims for reliable historical reconstruction.
Thanks to Andrew Lewis and Richard Sherry for comments on these two pieces.
Aware that this Blog has not covered psychotherapy as much as originally intended, I have spent the last ten days catching up with two best-selling books by the psychologist Oliver James: They F*** you up (2002), and Affluenza (2007).
My verdict? Very interesting, lively, recommended. But…
…perhaps the thing that struck me most were certain passages in Affluenza, which develop TFYU’s warning that the UK should not “follow in the footsteps of the most pathological developed nation on earth, the USA…[but should]…emulate the example set by so many of our European neighbours, like Denmark and France”(1).
By 2007, this trans-national analysis has focused on two particular evils: the “American way” of marketing, advertising and consumerism (2) and “the hollow ring of…American positive psychology”, with its “crude deletion of negative thoughts (3).
The basic idea is: “Studies from fourteen countries reveal that people who favour the key Virus values – money, possessions, physical and social appearances, and fame – are at greater risk of emotional distress”(2).
The author provides apparently clear answers: seek “authenticity” in activities and relationships; although beware that some apparently non-consumerist activities may be pursued for inauthentic “people-pleasing” reasons (4).
Conversely, if you “would like to be rich”, this may well be an authentic means to pursue such ends as “not to have to work all the time…[leaving] enough time to hang out with friends and family”(4). Presumably this applies to James himself, who happens to be in the “upper echelons” of society (5)
(although I doubt he would describe himself as “rich”).
To sort these pitfalls out is partly the task of psychotherapy, and I share the author’s approval of cognitive-analytic therapy (CAT), having myself had some experience of practising it in the early nineties, and knowing a senior CAT therapist for many years.
Few would argue that the US is not a world leader in marketing, advertising and consumerism, however I think there is a bit of grit in the oyster of James’ well-marketed argument. He relies on international data recording rates of distress and depression; but these are “soft”, difficult to make non-subjective, and depend on translation between languages and cultures.
The ultimate “hard” data relating to distress and depression are suicide rates, and the statistics have for decades indicated that Danish and French people deliberately end their lives much more often than Americans (6), despite living in cultures of “Being” rather than “Having”.
(1) They F*** you up (2002): paperback p300-301
(2) Affluenza (2007): paperback p12-14 (3) p142 (4) p180-2 (5) p97
(6) http://www.who.int/mental_health/prevention/suicide/country_reports/en/index.html The suicide rate of Denmark has come down markedly since 1990,
and in 2005 was the same as the USA, whose rate has been stable (and not high in international terms) since the mid-1950’s. Oliver James states that
Denmark’s suicide rate is lower than that of Edinburgh (p109), but he gives no reference for this. The French suicide rate has also fallen, however in 2005 it remained 50% higher than that of the USA. The 2005 USA suicide rate for 15-24 year olds is double that of Denmark and 150% that of France: Affluenza mainly discusses older age groups, but it could be predicting sustained shifts in psychology and behaviour.
(Oliver James Part II: Review of Affluenza)
‘(Oliver James Part I)’ added to title 29th March 2018
Over the last three weeks the BMJ has published several articles by the investigative journalist Brian Deer, and an editorial co-written by a leading GMC member, alleging that ex-Doctor Andrew Wakefield’s research linking MMR to autism was a fraud.
Brian Deer, The Sunday Times and Channel Four’s Dispatches should be congratulated. The current BMJ editor is right to say that medicine needs more investigative journalism, and to highlight the need for wider vaccination against measles.
But several problems remain. The neutral observer might well ask how the “good” investigative journalism of Mr Deer is to be reliably distinguished from the “bad” of the Daily Mail, the Daily Telegraph and Private Eye (1). Is it really just the detail, the lengths to which Mr Deer went? I am not convinced that if the Mail’s Melanie Phillips (say) had spent the same amount of time on the story, she would have ended up believing Andrew Wakefield to have been fraudulent, or even deliberately dishonest.
Mr Deer himself seems to recognise the limits of his three BMJ pieces. In a Press Gazette interview last year he indicated that there is no real distinction between scientific journals, newspapers and magazines. He stated in a Guardian Blog (12th January 2011) that the BMJ was part of an “insidious cartel”. What difference does it make, then, that his first BMJ piece was “peer reviewed”, anonymously as usual? Perhaps it would have been more consistent for him to decline such a closed process.
The Lancet’s Richard Horton is alleged to have acted from largely “medical establishment” motives. But in my view there are two significant flaws in the Deer/BMJ account, across the several pieces and editorials. First, it distorts and minimises the history of the “autistic enterocolitis” construct, which developed from a decade or more of speculative but “peer reviewed” research, and not merelyWakefield’s undisclosed legal action.
Second, it ignores the wider context in which the worldwide anti-vaccinationist movement has grown. The British Medical Journal and the Lancet have both played an important role in the current debate, following Vioxx and other cases, about “industry” conflicts of interest and the right balances between openness, promotional claims, and business interests.
However, the BMJ has gone much further, even at the height of the MMR scare in the UK, in promoting scepticism about the “inappropriate domination of the Western view of mental health”, a process in which “doctors and the pharmaceutical industry” irresponsibly push both “Western cultural ideas” and “a rapid growth in the numbers of children diagnosed with conditions such as attention deficit hyperactivity disorder and autism” (Timimi, BMJ, 2005).
Two days after Brian Deer’s second article, a Blog piece entitled “How to stop the medical arms race” by a former BMJ editor revealingly set out the default position of the journal (Smith, BMJ, 13th January 2011): select evidence of “technology” and “doctors” leading to worse outcomes, not better. That Richard Smith’s Blog piece was typically urbane and self-deprecating might suggest that here, rather than in the Lancet, lie the real views of the “medical establishment”.
The BMJ has also published many opinion pieces by the “No Free Lunch” campaigner Des Spence which strongly criticise Western medicine. For example: “big pharma use[s] political lobbying to pervert the course of medical justice” (11th March 2009), and “A medicated childhood is blunt, defies reason, and is just bad medicine.” (21st July 2010).
Dr Spence has stated that because of the need to “protect the consumerist patient from themselves”, he and other GP’s suggest “complementary treatment, and even placebos” (4th February 2009). This seems to be a lesser-evil approach, but I have been unable to find any acknowledgement that such GP behaviour, rather than patients’ “health neurosis” (2), could cause the rejection of MMR vaccination (29th July 2009).
Taken together, when some parents, journalists and politicians read views like this, in the light of their own experience of the indifference shown by the “medical establishment” to neurodevelopmental disorders (3), it is not very surprising that they prefer a different version of events: Andrew Wakefield’s continued fight against Western medicine’s vaccine industry, which scored a temporary victory during the fitness to practise (FTP) panel’s 45 days of deliberating in secret (to use Brian Deer’s preferred term, rather than the GMC’s euphemistic in camera). The Wakefield FTP hearing transcript is still not publicly available on the GMC website (4), despite the BMJ’s declaration two weeks ago that it had been published.
Finally, the eminent “evidence-based medicine” expert Professor Trisha Greenhalgh appears to risk inflaming the situation further by repeating a comparison of the MMR sceptics with “flat-earthers” (rapid response, 18th January). This perhaps shows how remote the BMJ is perceived to be from the concerns of ordinary patients, and the “front-line” staff who do not have the luxury of engaging with pro-MMR families only.
If medical journals are really just newspapers with mystique, might it follow that a way out would be for medicine to become an honest trade rather than a dodgy “profession”? No doubt the size of the financial transaction between the BMJ and Brian Deer was small; and it remains open whether the journal’s new policy of modestly remunerating “good” investigative journalism at the expense of “bad”, will have the desired result in respect of the larger dragons of commercialised medicine, which the BMJ appears to see as its mission to slay.
A version of this piece was submitted as a “rapid response” to the last of Brian Deer’s articles, on the day of it’s publication (18th January). Four days later, no “rapid responses” had been published, which will only add to the suspicion that the BMJ is attempting to rig the debate. [The BMJ published an edited version of my “rapid response” in the 12th February print edition:
http://www.bmj.com/content/342/bmj.d809.extract, and a longer online version on 4th February:
All the BMJ quotations can be searched for at http://www.bmj.com/search.dtl .
(1) I attribute this simplistic good/bad dichotomy to the BMJ. It is not my own view, as it should be clear from the rest of this piece that I consider the BMJ itself to have partly caused what is now denounced. The current Private Eye health editor, Phil Hammond, has said that the magazine should not have reported on the Wakefield/MMR issue in the way that it did.
(2) [“Health neurosis” is a quotation from Dr Spence’s 28th July 2009 article: note added 28th February.] This could be called “blaming the victim”, although Des Spence would perhaps argue that the “neurotic”MMR-sceptic is primarily the victim of Western medicine, rather than some GPs’ well-meant promotion of homeopathy and other alternatives.
(3) The prominent vaccine specialist Paul Offit acknowledges this, in the latest introduction (readable with Amazon’s “look inside”) to his book Autism’s False Prophet’s. [Notes 2 and 3 were incorrectly transposed in original: corrected 28th February]
(4) Searching for “Wakefield transcript” or even just “Wakefield”, on http://www.gmc-uk.org/ .
A boy who had to leave a “big sporty” independent school because of ADHD, was so good at rugby that he helped his team to win a match by scoring a try on his last day, according to an account written anonymously by his mother in last Friday’s Daily Telegraph (1).
Although I currently see teenagers only from eighteen years of age, a couple of years ago I saw some children in their mid-teens at independent schools, because of my association with Professor Peter Hill. Many of my adult patients have had non-state education.
It is clear that some schools in the private sector are more accepting of ADD / ADHD and other developmental problems than others. It seems surprising, though, that the school in the Telegraph article, which in 2008 apparently claimed to welcome children with special educational needs, was not more helpful in guiding the parents towards proper diagnosis and treatment at an earlier stage.
The story had a happy ending, with a good response to ADHD medication, and “…a course of therapy with a psychologist from our local authority’s Child and Adolescent Mental Health Service.” Enabling the boy’s settling in to another independent school.
The original school may well have changed its attitudes and procedures by now. But other parents in a similar situation may want to consider whether obtaining early external assessment and perhaps intervention can save the relationship with a school. It might have been the fear of the anonymous parents in the Telegraph article that the school would be antagonised, but that rarely seems to happen in practice.