Editorial
Happy New Year and welcome to our sixth edition, we are excited to offer some prizes for future contributions and hope you will enjoy the work of those who have written for this edition, please see final page for further details. This issue focuses on diagnoses in psychiatry.
This topic was addressed in the opening lecture of the General Adult faculty conference in October 2015, when History of Psychiatry author Edward Shorter presented a fascinating insight into the history of psychiatric diagnosis. He took us on a journey from the term ‘hysteria’ to Freud’s work and the psychodynamic movement. From there we journeyed into the beginnings of neurological models of psychiatric illness withde Morsier and de Clérambault. The advent of drugs such as lithium and Prozac were discussed. Finally we arrived in the present day where we employ psychodynamic, biological and social factors to understand psychiatric conditions. This journey highlights not least the distance we have travelled relative to other medical specialities but also the distance left to travel.
Psychiatry is still plagued by lack of consensus over how to define mental illness itself. Current systems can be criticised for tautology: is illness simply what we define it as? Therefore who decides where the lines between health and illness are drawn? Furthermore, for service-users, is a diagnosis stigmatising and depersonalizing? We still lack biomarkers for common mental illnesses.
The current reality is that with modern NHS funding systems and monitoring agencies it is difficult to treat someone without a definitive recorded diagnosis.
Some would argue that a diagnosis allows the recognition of patterns of symptoms that affect people in broadly the same way. Categorising these patterns allows us to target services. Furthermore, some service users may find diagnoses helpful in understanding that they are not alone in their experience.
We may be wise to bear in mind our origins; the huge changes we have gone through over a very short space of time and understand that the diagnosis we give today may mean nothing in 30 years’ time. We should therefore endeavour to see the person and treat them accordingly, rather than seeing a label.
Rowena Karyn
Thinh Ngo
Indeed, as William Shakespeare put it in his play, Romeo and Juliet, set in Verona all those years ago, “what’s in a name?” In the play, Juliet describes her feeling of despair as her lover Romeo is part of the rival Montague family...
What’s Monatgue? It is nor, nor foot,
Nor arm, nor face, nor any other part
Belonging to a man. O, be some other name!
What’s in a name? that which we call a rose
By any other name would smell as sweet
But what of the other groups of people that feel tarnished by a name, an arbitrary label? Juliet ponders whether a rose would smell as sweet if it were given some other name. The answer is of course, yes! A rose has for centuries been a symbol of true love; it is the connotation that gives the rose its allure, not its name. The meaning of a word is the emotion or attitude we assign to it, the word itself is surely but a mixture of letters.
Mental health diagnoses are used as a structure to describe complex patterns of symptoms and clinical presentations. They can be very helpful in summarising a patient’s difficulties and guiding treatment, and without them our notes might be little more than wordy descriptions. But a diagnosis should be carefully considered. We should not waltz in like whirling dervishes and diagnose everything in a heartbeat, only to change our minds in a few years.
We should of course exercise some sensitivity in assigning a diagnosis, but the terms in themselves are not damaging. Like the name Montague in Shakespeare’s play, it is the connotation that gives the word its power.
We live in a world full of sensationalist tabloid headlines that can leave our patients feeling stigmatised; derogatory language that paints people with mental illness as ‘Psychos’, ‘Murderers’ or ’Bonkers’. The media is a powerful thing, consumed by millions the world over. There is a risk that people will believe everything they read and regurgitate it without thinking as their own point of view. Media producers must realise the great influence their output can have on reinforcing unhealthy and unhelpful stereotypes for people with mental illness. Until society and the media start thinking about
mental health differently and uses non-stigmatising language, call it what you will, it won’t make any difference to the esteem of our patients.
It is our responsibility to make measured and well-informed evidence-based decisions when diagnosing our patients. We must endeavour to educate patients and their family and friends so they become the expert and so they don’t step in the excrement that is sometimes churned out by our papers. The rest is up to you, society! We could learn from Romeo, who fought against the stigma he suffered. Our battle is no less of a task.
‘Time to Change’ is England's most ambitious campaign yet into ending discrimination surrounding mental health ( One aspect of their work has been to create a media advisory service which includes script advice for storylines featuring characters with mental health problems and their own "mind your language" section for journalists. A step in the right direction!
AmbrinaRoshiGhauri
I think that there is no question why patients should not receive a diagnosis. It is a standard practice in all fields of medicine to diagnose and then treat the patients accordingly and Psychiatry should not be an exception to this rule. In fact, it is more important in the field of psychiatry because we are dealing with the disease of mind which makes patients very sensitive. The patients as well as the doctors know that they are faced with a problem and to work together to solve it. We have to be open and honest with the patients to build a therapeutic relation to help them get better.
Giving an appropriate diagnosis can help other people to treat the patients better as well. The patients with psychiatric conditions can behave in a way which might be different from social norms which can make them vulnerable. Giving them a diagnosis can help associated people to understand the difficulties of these individuals. For example, a child with ADHD could simply be blamed for being naughty. Once the diagnosis of ADHD is given, the whole perception is changed. Psychiatrists may start them on appropriate treatment. The school will make appropriate arrangements to support the child and parents are offered parenting courses. We can only help the children once we can understand their difficulties and it is very difficult to do that without knowing the diagnosis.
Knowing the diagnosis can help the patients to understand themselves better. Patients can make sense of their own feelings, thoughts and behaviours once they understand their diagnosis. Diagnosis and treatment can be interlinked. For example, there is strong evidence in support of CBT for depression and anxiety. CBT can be helpful to assist the patient to understand the link between their thoughts, emotions, behaviours, body sensations. The therapist can use it in a better way if they know the diagnosis and they can tailor the discussion during the therapy according to the patient’s needs.
It is also very important for the patients with a psychotic illness and their relatives to know about their diagnosis. Even for the very unwell patients who lack insight, the professionals need to give a name to the illness in order to communicate amongst themselves. The relatives of the patients also need psychoeducation about their loved one’s condition. The patients with psychosis who have got partial insight must be in constant stress due to their perceived reality which is beyond their understanding. It must be terrifying to hear voices, see people or having hallucinations in any other modality when everyone else around is denying the existence of such a stimulus. As a community we tend to support each other knowingly or not knowingly when we acknowledge the shared experiences. These individuals feel excluded when people surrounding them do not share their experience. Similarly the patients with paranoid delusions of persecutory nature are distressed when they are constantly worried about their safety. We can have a very important role once we can diagnose the condition which led to such a presentation and treat them accordingly. The management will be different if the psychosis is due to mania, psychotic depression, drugs or schizophrenia. We can decide about giving the appropriate medication (antipsychotics and/or mood stabilisers) or no medication at all after making diagnosis. We can also help these patients by explaining their illness to them and normalise their experience by saying that other patients suffering from the same condition have reported similar experiences. We may also consider their psychotherapy and group therapy after we have identified their diagnosis to decrease their stress. In short I strongly believe that it is vital to make a diagnosis for mental health conditions and to explain it to the patients in order to manage their illness properly.
Tom Stockmann
Interview with Sally Halcro, service user in the Peer-supported Open Dialogue service inNELFT NHS Foundation Trust
How does Open Dialogue compare to your previous experience of services?
I have good insight into my disorder, but at the beginning it felt like I was getting passed around different services like a piece of paper, and offered different advice which was very confusing and frustrating for me and my family. I think Open Dialogue means I have a voice, which is being listened to instead of being ignored, and I can talk un-judged and openly about my experiences, thoughts and feelings I have had in regards to my recent manic bipolar episode.
Open Dialogue involves a series of ‘network meetings’ – can you describe these?
There’s my `team` - a psychiatrist, support worker, care co-ordinator - and family members of my choice. Therefore, the meetings become familiar instead of repeating stories as I have done in the past. It helps that the meetings are held in my flat, instead of a hospital environment, where I feel more comfortable, so it doesn’t add to me feeling anxious or nervous.
The sessions also give family members a chance to discuss their version of events and experiences of dealing with me whilst I was unwell. This can be very enlightening as sometimes I have forgotten or was not aware of these at the time. Also, it gives me a chance to explain what I was thinking and why I behaved in a certain way.
Is there any aspect you find particularly helpful?
During the meeting, the team will have a ‘reflection time’, where they talk between themselves about the conversations we have had so far. This is part of the meeting I enjoy and find the most helpful because you know from this that they have truly been listening to what we have all been saying. They bring a different angle to the conversation that I hadn’t thought about before, thus creating further dialogue to think about or chat about further.
Can you recall an example?
I vividly remember the doctor talking to his colleagues and saying ‘when Sally is talking she describes certain situations better than reading a medical book’. Hearing that made me feel like he had realised how traumatic and scary my disorder can be at times, because I describe a rawness and a reality
that the books that he had read failed to deliver.
What did that mean to you?
It was at this part of the meeting when I realised I could trust the team. The transparency between my family circle and them meant we were all on the same page and I believe trust is a crucial part of any relationship and it means they know me and have my best interests at heart.
Any final reflections?
I think if this service were available when I first became unwell, my episode would not have been so severe, and I would have coped better. My voice would have been listened to straight away.
More information about NHS Peer-supported Open Dialogue can be found at: and
Where you can find out about our conference on April 25th 2016 and subscribe to our Bulletin.
EshaAbrolRos Humphreys
The Broadening the Foundation Programme Report (1) set a target of 22.5% of foundation year 1 and 2 doctors undertaking a psychiatry post by 2017. Whilst there are potential advantages of early psychiatry experience reaching a wider range of doctors (2; Table 1), a proportion of foundation doctors may feel daunted or disappointed by the prospect of a four-month psychiatry placement.
Keeping in mind the unique needs of foundation doctors new to psychiatry, a committee of medical students, foundation doctors and psychiatry trainees, in collaboration with the London Division, developed a twilight event on the 8th September 2015.
This informal event focussed on experience sharing, storytelling and networking. Acknowledging that many foundation trainees remain unsure about their eventual chosen specialty, the event was also designed to generate
discussions about how to make the most of their opportunity in psychiatry, whatever their future ambitions. The evening was divided into an interactive panel discussion, followed a brief presentation on “top tips” for core training applications. The event closed with a social event with current trainees.
Professor Sir Simon Wessely opened with a characteristically lively welcoming talk. He reminded us of the ubiquity of psychological morbidity across medicine. He also gave a compelling argument why all foundation doctors, whichever specialty they end up in, will realise that they have much to gain from their psychiatry posts.
The panel consisted of a diverse range of foundation, core and higher trainees and an orthopaedic higher trainee. They described their foundation experiences in psychiatry and how these enhanced their development as doctors. An important theme was the time they got with their patients - a
luxury unknown to many other foundation posts - and the quality of these doctor-patient interactions. Panel members also highlighted the unique experience of regular consultant led supervision. Questions from delegates following the panel discussion were revealing and summarised in Table 2.
This event was popular with both medical students and current foundation doctors in London, with 51 applicants and 100% attendance rate. It also attracted delegate from outside London, despite not having been formally advertised as a national event, indicating that there is an appetite for similar events regionally. In addition, discussions with the delegates illuminated common concerns, which medical students and foundation doctors hold about working in psychiatry within the foundation programme and beyond. These could be used to inform future recruitment initiatives.
Genevieve Holt
D. H. Lawrence (1885-1930) was an English writer from a working class background, whose works are highly regarded for their contribution to literature as well as being well-known for inspiring controversy; his fiction openly explores physical intimacy and its role in human relationships and did so at a time when such reflections were considered obscene. Many of his novels were initially published in heavily edited form, with later (posthumous) editions revealing original content that was deemed inappropriate when first penned. His material often focuses on the emotional well-being of ordinary characters as they deal with difficult circumstances and dysfunctional interactions.
One hundred years later, Husbands and Sons is a contemporary adaptation combining three of Lawrence’s plays – A Collier’s Friday Night (circa 1909), The Widowing of
Mrs Holroyd (1914) and The Daughter-in-Law (1913) – to create a stage production that portrays three mining families in the Edwardian era. Staged in the round, each story is progressively revealed in parallel, allowing the audience to gradually develop insights about individual characters as do the characters themselves.
Gritty – how this play was described in the first review I read just after I purchased tickets - is an understatement. Unrelenting misery pervades the almost three-hours of stage time, requiring epic performances from its actors, notably including Anne-Marie Duff. The characters are drawn from Lawrence’s own experience of growing up in a coal-mining town, the son of a barely-literate miner and an educated but impoverished mother. Deprivation and loneliness provide a constant backdrop to the lives of the miners’ wives, whose narratives feature in each of the three households.
Each seeks comfort in her own way, searching for protection and hope in abject circumstances, all the while battered emotionally - and sometimes physically- by adversity in various forms.
Observing these stories unfold, it is easy to find parallels with the stories of some of the people we, as psychiatrists, encounter. Perils of the pit may now be long gone, but poverty, vulnerability, and isolation endure, with desperation to survive or escape these hardships emerging as a regular theme in consultations of today’s inner city London. Lawrence was gifted in his ability to articulate human emotions, and being immersed in the world that he has crafted through his own life experience is a terrible – yet exquisitely beautiful – lesson in the human condition.