Sunday, 29 June 2014


 All great novels illuminate the human condition. By identifying with the characters of a story we experience as real what is fictionally portrayed.

James Salters erotic love story "A Sport and a Pastime", first published in 1967, is a classic exemplar of this.
Written in lyrical prose and set in rural France it unfolds the intoxicating love affair between an American university dropout and a young French woman.

The title is taken from a verse in the Koran:

"Remember that life in this world is but a sport and a pastime".

It is a tale of love, attachment, separation and loss that unfolds the relationship between Phillip Dean and Anne-Marie Costallat. The relationship becomes increasingly intimate and passionate yet is recounted in subtle and delicate tones.

One senses in the desperate longings of the young couple that they sense that this cannot last. Somewhere the sinister forces of Providence will gain the upper hand and bring the dream to a heart-breaking finale.
And indeed the couple must separate. The departure scene rivals that of Bogart and Bergman on the runway in the movie Casablanca:

"...a minute or two until the warning whistle.......the train begins to move. It picks up speed very quickly. I can see him that instant I think of her solitary, her head bent forward to the morning's work.......I cannot imagine what she feels. I can only sense it by her absolute, her utter silence as the train curves, crosses the viaduct high in the morning air."

And at the conclusion the narrator adds:

"Silence. A silence which comes over my life as well.......the fields are becoming dark, the swallows shooting across them......"

Yes the story is a universal one but told with great delicacy and poignancy. It touches our nostalgic longings for things lost, an idealized past. The narrator captures our fickle memory and the distortions we are prone to:

"Certain things I remember exactly as they were. They are merely discolored a bit by time, like coins in the pocket of a forgotten alters the past to form the future. But there is a real significance to the pattern which finally appears, which resists all further change......the myriad past, it enters us and disappears. Except that within it, somewhere, like diamonds, exist the fragments that refuse to be consumed. Sifting through, if one dares, and collecting them, one discovers the true design".

This passage could be taken as an illustration of the  psychotherapeutic journey: the narrative reconstruction of the past in the service of a renewed future, the discovery of the true self.

Sunday, 4 May 2014


In a wonderful paper published in the Psychoanalytic Quarterly in 1942 Helene Deutsch describes an unusual personality type that she refers to as the "AS IF" personality.

Deutsch says that these individuals convey the impression of complete normality on the surface. They are intellectually intact and gifted. However on closer  observation it becomes  apparent that their "relationships are devoid of any trace of warmth, that all the expressions of emotion are formal, that all inner experience is completely excluded."

Helene Deutsch completed medical training in Vienna. She became interested in psychoanalysis and in 1916 she went to work with Sigmund Freud and underwent an analysis with him. In 1935 she left Europe and moved to Boston and worked at the Massachusetts General Hospital. Deutsch was a pioneer in exploring female psychology with a particular emphasis on female sexuality and motherhood.

In the article she states that these individuals behaved "as if" they had real feelings and emotional relationships. Deutsch compared them to actors who are "technically well trained" but cannot impart any sense of vitality to the role.

She described these patients as being extremely passive and having a "plastic readiness" to identify with other people's feelings, beliefs and ideologies. Their relationships lacked genuine emotional connection and felt hollow and devoid of real meaning.

Such individuals have no consistent moral or ideological beliefs. Rather their values and positions are taken from those to whom they attach and identify with.

Patients with "AS IF" personalities do not display aggression but rather present with a "mild amiability". They are prone to conform and on the surface are compliant and obedient.

Such individuals can be drawn into antisocial or criminal groups. There is no internalized conscience/superego. The AS IF personality completely identifies with external objects. They transiently take on the values and morals of the other person or the group. The authority for moral decisions only exists externally. The AS IF personality goes along with "the crowd".

The AS IF personality as described by Deutsch shares features in common with many patients who would now be diagnosed with borderline personality disorder. Borderline personality disorder is characterized principally by emotional dysregulation. The problem is too much unregulated emotion.  The AS IF personality's lack of emotion and the borderline's unstable emotion both give rise to an inner deficit in the sense of identity. In order to develop and maintain a consistent sense of identity one needs to have a predictable pattern of emotional responsiveness."

The parents of one of Deutsch's patients were described as remote and uninvolved. They showed no warmth or tenderness. The child's care was delegated to a series of different nurses and governesses. In today's language we would say that the patient did not have consistent attachment figures in her life and did not develop a secure attachment. Deutsch says that throughout her life this woman was never able to establish an emotionally warm or loving relationship.

Helene Deutsch. Some Forms of Emotional Disturbance and their Relationship to Schizophrenia. The Psychoanalytic Quarterly  1942 (11) 301-321.
Alan Eppel. Formation of Identity in "Sweet Sorrow Love, Loss and Attachment in Human Life" 2009. p.27-35.

Sunday, 9 March 2014

New Consensus on Antidepressants in Bipolar

The International Society for Bipolar Disorders recently released the findings of a task force on the use of antidepressants in Bipolar Disorder. The evidence continues to accumulate that antidepressants alone and in combination with mood stabilizers have a very small role if any, in the pharmacological management of bipolar depression. There is increasing acknowledgement that antidepressants can be harmful. Antidepressants can lead to longterm mood instability, cycle acceleration, mood switching, mixed states and increased risk of suicide.

The results summary of the task force appears quite clear:

"There is striking incongruity between the wide use of and the weak evidence base for the  
efficacy and  safety of antidepressant drugs in bipolar disorder. 
Few well-designed, long-term trials of prophylactic benefits have been 
conducted, and there is insufficient evidence for treatment benefits with  
antidepressants combined with mood stabilizers. A major concern is 
the risk for mood switch to hypomania, mania, and mixed states..."

However the conclusion summary is a little more ambiguous:

"Because of limited data, the task force could not
make broad statements endorsing antidepressant use but acknowledged 
that individual bipolar patients may benefit from antidepressants...."
Undoubtedly this was the result of the need to reach 
consensus among several dozen international experts.It remains very difficult for some psychiatrists to 
concede that antidepressants do more harm than 
good because this is superficially counterintuitive. It is also hard to admit that one's longstanding clinical 
practice may have been erroneous.


The International Society for Bipolar Disorders (ISBD) task force report on
antidepressant use in bipolar disorders.

Am J Psychiatry. 2013 Nov 1;170(11):1249-62

Monday, 27 January 2014


1. Reduce the fear of difference

2. Provide education about mental health and mental illness in the schools.

3. Encourage those affected by mental illness to go public, especially celebrities and high profile individuals who can make an impact on public opinion.

4. Appoint individuals who have experienced mental illness to boards of hospitals, community agencies and mental health programs.

5. Challenge the media. Write to editor's, call television stations and comment on social media when there are inappropriate references or stigmatizing portrayals of people with mental illness.

6. Promote the restoration of the person's wholeness, subjectively and objectively, by facilitating their multiple roles, emphasizing that the person is not an illness but has an illness.

Sunday, 19 January 2014


One of the most damaging effects of psychiatric illness is the experience of stigma. Stigmatization is the social rejection of those with mental illness. This may be seen in the tendency to ridicule or shun those with mental illness. It is seen in employment discrimination and in the derogatory language that is pervasive among many in society.
"Stigma" is a Greek word that once referred to the bodily signs that were used to show that there was something morally wrong with the person so marked. These signs were made by cuts or burns and indicated that the person was a slave, a criminal or a traitor.....a blemished person to be avoided. The numbers tattooed on the arms of concentration camp inmates by the Nazis and the yellow stars Jews were forced to wear are examples from more recent history.
Stigmatization induces feelings of anxiety, insecurity, shame and even self-hatred. Self-hatred is the result of internalizing the attitudes of others. Every new situation every new encounter brings with it the anxiety of not knowing whether one will be accepted, rejected or shamed.
Stigmatization is reinforced by distorted representations of individuals with mental illness in the media. Newspaper accounts are often sensationalist. Many false stereotypes appear in movies and television shows which often demean or mock those with mental illness.
This stigmatization is often extended to families, counselors and psychiatrists. The stigma associated with mental illness is so widespread that we have trouble agreeing on terminology to describe it. We use multiple euphemisms. What is the most reliable term to describe the distress and impact experienced by individuals with mental illness? Mental health issues, mental illness, psychiatric disorder, psychiatric illness?
In an attempt to reduce stigma many prefer the vaguer and more dilute term "mental health issues". The problem with this term is that it trivializes the problem and does not convey the seriousness and enormity of some of these conditions.  Could you imagine a surgeon telling a patient with a fractured spine that he has "back issues".

The basis for stigma is fear.

This fear is the fear of difference, the fear of contagion, the fear of vulnerability.
Fear of differences exists in all societies and shows itself in many forms such as racism, anti-Semitism, homophobia etc. Fear of strangers is an evolutionary survival mechanism. It is the fundamental component of attachment behavior where the newborn infant instinctively attaches to its mother. This is to protect the infant from hostile predators and strangers. For many people this basic process may go wrong and they grow up lacking a sense of secure attachment. They experience heightened levels of anxiety and fear when they encounter something that is strange or different. This makes them prone to display prejudice and discrimination. They are  threatened by people who are in some way different from themselves. People who are more securely attached are much more receptive and open to others and able to establish more varied relationships.
 Stigma also derives from the fear of "contagion". The fear of contagion is the fear of catching a disease, particularly if the disease is incurable. One of the greatest historical examples of this was leprosy. Those with leprosy were cast out and isolated from society. There were similar attitudes towards those with AIDS. This has lessened as the treatment for AIDS has become so successful.
The fear of contagion is unconsciously and irrationally extended to psychiatric illness and leads to ostracization and isolation of those with the illness. This is based on the defensive reasoning of "out of sight, out of mind". What this attitude amounts to is really a denial that we are all vulnerable to illness of one kind or another and that this is part of the human condition that unites us rather than separates us.
The act of stigmatizing gives the individual a false sense of superiority or immunity. It is seen in openly hostile attitudes, derogatory humor, avoidance and ridicule.
Stigma involves regarding the person as an illness rather than as a human being with multiple roles and characteristics.
Blaming the individual with the illness for having the illness is the way that people attempt to delude themselves that they are immune.
The truth is that mental illness is no different in any way from physical illness. Mental illness has nothing to do with intelligence, character or moral integrity. It does not result because of our failings of deficiencies; it is not a punishment for our sins. Anyone, repeat anyone can become mentally ill, including your mother or father, bather or sister, husband or wife, son or daughter, and yes, you and me.