Mad or Bad?: A Few Thumbnail Sketches

MAD OR BAD?

A few thumbnail sketches

James Wakely

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© 2012 by James Wakely. All rights reserved.

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Published by AuthorHouse 04/12/2012

ISBN: 978-1-4678-7940-8 (sc)

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CONTENTS

CHAPTER 1

CHAPTER 2

CHAPTER 3

CHAPTER 4

CHAPTER 5

CHAPTER 6

CHAPTER 7

CHAPTER 8

CHAPTER 9

CHAPTER 10

CHAPTER 11

To The Old Bear

INTRODUCTION

Why am I writing this?

My time as a (deputy) police surgeon has left me aware of how Law Courts no longer reliably or consistently actually punish criminals as a deterrent against future crime.

a) In England, police budgets have been cut, year after year. So there are fewer police on the streets. Sometimes an increase in funding used to occur, but even then it was by a smaller percentage than inflation. This has not gone unnoticed by those on the streets whom it affects. Only politicians can change that. And in a time of recession, they will have to feel they have the support of the public.

b) Prisons are overcrowded. Magistrates have—for a long time now—been under distinct orders not so sentence anyone to actual prison sentences, if possible. (Though have the recent riots changed that for a while?) Again, not unnoticed by those on the streets. And again, only politicians can change this.

c) The MAD or BAD factor:—which this book aims to address. Just about every criminal with any psychiatric problem is now assessed before appearing in court by a psychiatric nurse or similar, so they can be diverted to psychiatric services instead, if more appropriate than a criminal law court. Whilst this is entirely noble and laudable, it is overused. Some undoubtedly need psychiatric help, and punishing them would be utterly wrong. But which ones? My time as a psychiatrist might just enable me to help the reader sort wheat from chaff here. I have distinct memories of one psychiatric nurse whom I phoned about one prisoner I was called in to see, as a police surgeon, who had apparently been sexually abused as a child. Her long sigh over the phone, as she mentioned that ALL her prisoners had been thus abused . . . apparently. Yes, she would make a point of seeing him the next day, in the Court cells . . . but . . . convinced . . . ? No, hardly.

d) Probation officers are so over stretched, handling three or even four times the number of cases they should be handling. Offenders can just up and disappear, so easily. Again, the politicians are the only ones who can sort this.

And blaming police for being slow to quell street riots, with the unfair complaints they get sometimes . . . so the politicians can cover up their political errors of judgement over the years . . . ?

So who am I writing this for? (Besides those politicians.)

(1) For the general public—in particular two parents who lost their son in tragic circumstances—

killed by a fellow prisoner on his first night in prison. They shall not actually be named. It is simply nauseating to see how psychiatric flim-flams by prisoners who have killed, stabbed, beaten and generally maimed others succeed in getting them off the hook. The more widespread the basic knowledge in this book becomes, the fewer absurd flim-flams will succeed in court—or even be attempted in the first place. And the less successful certain pond life specimens will be when they attack ambulance staff or nurses and try to get away with it on psychiatric grounds. Also when they attack police, doctors, firemen, fellow prisoners . . . and other commodities that the legal system clearly seems to deem expendable . . . which leads me on to . . .

(2) For the Courts, and anyone involved with them:—judges, magistrates, solicitors, barristers, the police and CPS. (CPS = Crown Prosecution Service—sometimes nicknamed the Criminals’ Protection Service). I would like to see magistrates and judges better able to decide things for themselves, rather than be so woefully dependent on psychiatric experts, or be so completely at sea when a defence prostitute (sorry, did I say "prostitute? I meant to say barrister" of course . . . ) turns to them with "And my client has been diagnosed as having an impulsive personality disorder by Dr. Steven Bloggs, consultant psychiatrist . . ." This sort of ploy by defence barristers gives the genuine majority of psychiatric patients—who should not actually be punished—a bad name. All too often, nothing strikes the CPS with apathy faster than a psychiatric facet to a case . . . Slightest possibility of Mad totally excludes Bad could virtually sum up their thinking. Most psychiatric problems consist of depression, not madness . . . So an arsonist? Quite simply no attempt is made to even charge him. Well . . . He was depressed, wasn’t he? So . . . counselling . . . psychiatrists . . . (Actually, just wanted a new flat provided, or after a bit of attention, really . . . but give up trying to convince the CPS . . . )

(3) Fellow health care professionals—doctors (which includes psychiatrists), psychologists, nurses, social workers, occupational therapists, a few of whom will no doubt want to contest my comparison of the personality disorders with body odour and halitosis. No, I’m not implying that people with personality disorders all have bad breath or B.O.! Merely that a psychiatric diagnosis like personality disorder, particularly if on its own, i.e. no other psychiatric diagnoses in the offing, is usually no more a mental illness than B.O. or halitosis is a physical illness alongside meningitis, pneumonia, cancer, malaria, gastro enteritis. They may ask about the patient with full OCD (obsessive compulsive disorder) whose life is effectively destroyed by it. Or the multiple personality disorder so clearly portrayed by Sally Field in the film Sybil. I answer about those possible exceptions later. (The first goes beyond a mere personality disorder; the second was a traumatic defence mechanism.) In the early chapters of this book, I am raising queries. The answers—if any—come nearer the end. Not till then do I really foist any of my opinions on the reader. (Though I suspect my style may well give away my feelings quite often.)

I’m not claiming to know it all, but I think my thumbnail sketches (based on real life) in the following chapters will suffice to spark off some thinking and debate at least . . . the cat needs putting among the pigeons. Otherwise ambulance personnel, nurses, doctors, police and allied professions will continue to be assaulted and put at risk in other worse ways by people who will just get away with it . . . again and again . . . and again. Plus the occasional genuine and vulnerable psychiatric patient will be wrongly imprisoned in a jungle where they will not cope. (Or even die.)

Much as I have seen how lives can be revolutionised, and re made with psychiatry, psychology, nursing care and occupational therapy etc, I definitely do not trust psychologists who reckon that they can use counselling / therapy once a week / month on a psychopath or a sex offender—to the extent where the Courts need not remove them from circulation. You might as well issue a decree forbidding women from eating chocolate for the rest of Time. Sex offenders and psychopaths will be very well motivated to string you along in therapy sessions.

As such, this book is a thumbnail sketch of practical psychiatry—mostly for those who are not planning to be career psychiatrists. Real psychiatrists might huff and puff quite a bit over parts of it. To lay my cards on the table, I am a General Practitioner at heart who ended up doing eight years psychiatry (mostly part time) while also dovetailing that with a job as a police surgeon. The psychiatry job was initially meant to be a six month thing—but it was so fascinating (exasperating, too, at times) that six months became several years. And I am now back in a psychiatric job (For two years now) that might eventually give me the answers to some of the questions throughout this book—I’m not sure I have them, as yet. I want you readers to decide.

The first chapter sets the scenes. I know it will absorb you. In later chapters, you actually have to knuckle down to some extent and absorb some psychiatry. It will not be that difficult. One criticism of this book by a former patient of mine (a magistrate) was that the book is too detailed in parts—going to the level required for medical students and doctors. But lay people do not need to absorb everything in it to get the general gist. In case the longer chapters become too much, I have summarised them in the first two / two and a half pages of each chapter, so you can jump to the next at once, if you prefer, once you have read those two pages. And then also the next . . . And so on, until the very last chapter. The exceptions are chapters 5 (anxiety), 8 (disorders of movement = drug side effects) and 10 (hyperactivity); they are very short and therefore have no two page summary at their beginning. The last chapter (loose strings) has no summary either, but by then, you’ll be getting tested, to some extent, and asked what you think . . . by then, you will be better able to decide—no matter that you do not remember all the precise medical details.

My fear is that factors (a), (b), (c) and (d) above are leading to increased crime and lawlessness in England. I cannot change the world, but perhaps by altering (c)—the Mad or Bad factor—I can change a little. And I’m sure I’ll have included a few mistakes somewhere. Please do not blame my mentors, whom I mention by name. It’s not their fault if their pupil occasionally shows stupidity!

James Wakely

Former General Practitioner

Former Police Surgeon (Forensic Physician)

Associate Specialist in Psychiatry of Learning Disability.

-—-—-—-—-—-—-—-—-—-

CONTENTS

(1) DEBATES & QUESTIONS—using actual case histories. The deep end, gentle reader . . . I was going to go through each diagnosis in turn, and explain lots, and leave this chapter till last, but it’s so dull and stodgy that way . . . I thought I’d get you started with this. You’ll pick up just what schizophrenia is, and how to distinguish depression from manic-depression as we go along, never fear . . .

(2) SCHIZOPHRENIA—Although madness, this is not a split mind or dual personality. Perhaps split thinking would have been a better translation from the ancient Greek?

(3) DEPRESSION—Please be warned:—A doctor and the man in the street have very different definitions of this.

(4) MANIA, HYPOMANIA AND MANIC-DEPRESSION—Otherwise known as bipolar (affective) disorder. If any mental illness could be called multiple personality, this might be it. Because of its highs it is a very different beast indeed from simple depression.

(5) ANXIETY & HYPERVENTILATION (& muscle spasm) Not much new jargon in this chapter. (Except hyperventilation is over breathing.)

(6) PHYSICAL PROBLEMS & ILLNESSES—1:—

that can appear as psychiatric illness—And thereby tend to make us doctors appear foolish . . . at great cost to the patient. Quite a lot of these! (Excluding vitamins, alcohol and illicit drugs.)

(7) PHYSICAL PROBLEMS & ILLNESSES—2—

vitamins, alcohol & illicit drugs.

(8) DISORDERS OF MOVEMENT—Side effects caused by our wonderful medications. This chapter is only 4 pages, and legal eagles might want to give most of it a miss—unless they fancy suing doctors.

(9) THE PERSONALITY DISORDERS—These should not usually be a valid defence in Court regardless of the offence. They are not mental illness.

(10) HYPERACTIVITY—or? merely the undisciplined?

(11) LOOSE STRINGS TO TIE UP . . . In which I finally inflict a few of my opinions on the reader and wonder about a few improvements. Pinch of salt here, dear reader, perhaps . . .

CHAPTER 1

DEBATES & QUESTIONS

Or—if you will pardon

some informality—the CHERUBS.

Welcome to the deep end! I shall first introduce you to the cherubs who have influenced my thinking. The first one took amphetamines, which may have unhinged his mind, or worsened some pre-existing unhinging of his mind. I shall therefore call him Amph.

Amph, who stamped his prison cell mate to death on their first night together in prison (I talk about him in more detail later in my next chapter on schizophrenia) pleaded Guilty not to murder, but to manslaughter on the grounds of diminished responsibility. This basically saved the hassle and expense of a lengthy trial deciding if he was guilty of murder. He was sent to Rampton, one of the few such high security forensic hospitals in the country. As he was considered of diminished responsibility, Rampton hospital was thought more suitable than a prison.

Question:—Why don’t I feel happy about his case? An eminent Professor of Forensic Psychiatry diagnosed him in the end as schizophrenic, after all. The psychiatric team in charge of him had begun to wonder if such might be the case, before that fateful weekend he was arrested and the next week remanded into custody—i.e put in prison—where he ended up killing his cell mate (no name out of respect to the cell mate’s parents).

(Preliminary) answer:—I have been deceived by many a schizophrenic into thinking them normal (for a while). But none of them—neither the easily detected nor the tricky ones nor even the violent ones—ever gave me that feeling of being menaced outright, the way Amph did. Only true psychopaths have done that. (Psychopaths as defined in the older diagnostic system. We now call them dis-social or anti-social personalities. But more on that later.) So ultimately, I have only a gut feeling to go on. Would a gut feeling stand up in a Court of Law? Hardly. But gut feelings don’t go away that easily. As such, he was more a psychopath (old definition of this) who took amphetamines, thus frying his brain, than a genuine schizophrenic to me. Though, I may be wrong. Being a doctor was never any guarantee of infallibility.

Anyway, the people I really feel sorry for are the parents who lost their son thanks to him. If any publisher seriously thinks about publishing this book, I would like to contact them sometime. I felt my job as a police surgeon forbade me that, before. But now I am no longer a police surgeon . . . (Not easy to find people like that, in fact. Perhaps they will contact me?)

*     *     *

Anyway, Amph may be the main reason I took this off the shelves and blew the dust off. But he wasn’t the only one. Amph will be mentioned in more detail in the next chapter on schizophrenia. Let me share another case that I saw. Let’s call him MC. His real name will be kept out of this, and only those who knew him professionally in a small sea side town will recognise him or be able to find out his details. Ambulance control found this one man phoning 999 up to 42 times one Christmas day (and plenty of other days, too). They had no alternative but to send an ambulance. (Though occasionally he called again before they got there. After all, only 24 hours in a day . . . ) These dozens of visits to A&E each day went on for months to a year and more . . .

On two occasions that I heard of, from paramedic friends, a genuine cardiac arrest / collapse waited for 40 minutes or so for an ambulance to arrive, because—out of usual working hours—MC had used up the only remaining ambulance in the area. Both cases stayed dead after the ambulance crews finally did arrive. They might have stayed so anyway, but MC certainly didn’t improve their survival chances any. (That particular Ambulance Service—before it merged with others—used to not handle complaints about staff in fair, unbiased fashion. Ambulance drivers were very much guilty until proven innocent, surprisingly. I suspect the ambulance crews in those two cases fudged the paper work, so it would now be impossible to prove how long they took to arrive, or even trace the two cases . . . Do not get the impression I blame those ambulance crews one whit . . . )

Attempts to treat MC in the local psychiatric ward failed miserably to prevent the dozens of daily 999 calls once he was sent home again. Trying to help him get over his alcohol problem was a real reminder of Sisyphus in the ancient Greek Underworld. (Whose task was to roll a heavy rock up a large steep hill, only to always find that once he had, it rolled down the other side again . . . He was supposedly condemned to that situation for eternity.) MC just simply didn’t want to give up his alcohol. He also wasn’t actually that depressed, either, though we certainly gave the anti-depressants a good try, too.

Nothing worked. In the end, he was charged in court. Not with the indirect killings he was guilty of, as the Court never even heard about them, but for the electricity he’d used in making the calls. (Such is British Law. So . . . sensible!) He actually spent some weeks in prison for this, until some Social Worker managed to secure his early release . . . (Why??!! I will never know. I still think that was one very stupid thing for the social worker to do. I never found out which social worker. I would not have been polite.)

Whereupon the 999 calls began again . . . risking more lives.

Gentle reader, take it from me. There was no medical emergency to warrant the calls. He was checked out ever so thoroughly, again and again and again and . . . He was not genuinely depressed or anxious with panic attacks. He did not have schizophrenia, manic depression or indeed any actual psychiatric illness. The simple truth of the matter was he liked the attention. He was a histrionic personality disorder. And once he found he was released from prison early . . . he could gleefully continue in centre stage, where happiness would overtake him.

The best cure would have been a punishment that would be reliably repeated each time he made another unnecessary 999 phone call. Such a method would have managed to remove the overall secondary gain from the behaviour. (I’m quoting a textbook there.) The cancelled prison sentence was not consistent enough.

But he is an excellent example of how a personality disorder is allowed to endanger other people’s lives, and—far worse—get away with it. Repeatedly. There are plenty like him, cluttering up the Out of Hours emergency medical services switchboards every weekend. Take a look at any decent sized city . . . The next time your father with cancer calls for a home visit by the doctor over a weekend, and waits umpteen hours for said visit, wonder about cherubs like MC . . .

*     *     *

One thing about such patients is that they give me a sensation of being led by a ring in the nose. In case there is an element of depression, they have to be tried on anti-depressants. To see if any improvement ensues. The trouble is that for a time, this dignifies them with a genuine psychiatric diagnosis (depression), as opposed to the psychiatric equivalent of body odour, or a mere personality disorder. For quite a time, they can tell others (particularly the police, when they’re arrested) the doctor thinks they have depression. i.e. a genuine mental illness. Eight months later, they haven’t changed a whit, the aberrant behaviour still goes on and it is quite clear that the depression label was a futile attempt at helping them. Oh, yes, one little snippet—they often don’t tell the psychiatrist about the aberrant behaviour that just happens to endanger other people’s lives. One hears indirectly—if lucky—from the police or ambulance. The psychiatrist or GP might not be told the full story. Just told enough to keep the certificates