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A. Ryle and I. B. KerrCognitive analytic therapy

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Flashbacks and PTSDFlashbacks and PTSD

JonesJones et alet al(2003) claim to provide evidence(2003) claim to provide evidence

that flashbacks in post-traumatic stress dis-that flashbacks in post-traumatic stress dis-

order (PTSD) are culture-bound becauseorder (PTSD) are culture-bound because

they were reported less frequently followingthey were reported less frequently following

earlier conflicts. They discuss the centralearlier conflicts. They discuss the central

issue of whether this was due to an under-issue of whether this was due to an under-

reporting bias either because patients de-reporting bias either because patients de-

clared them less frequently or becauseclared them less frequently or because

doctors did not ask about them. In thisdoctors did not ask about them. In this

discussion they conclude that this was notdiscussion they conclude that this was not

probable because the veterans wereprobable because the veterans were

assessed frequently and because they wereassessed frequently and because they were

financially motivated by the prospect of afinancially motivated by the prospect of a

war pension. They have ignored the mostwar pension. They have ignored the most

important counter-argument that veteransimportant counter-argument that veterans

of recent conflicts are most likely to over-of recent conflicts are most likely to over-

report flashbacks in order to obtainreport flashbacks in order to obtain

compensation because: (a) the PTSDcompensation because: (a) the PTSD

criteria are now publicised by the media;criteria are now publicised by the media;

and (b) enquiry about flashbacks is nowand (b) enquiry about flashbacks is now

includedincluded in the routine clinical assessmentin the routine clinical assessment

of veterans.of veterans.

A systematic study of exaggerating PTSDA systematic study of exaggerating PTSD

symptoms for compensation claims (Lees-symptoms for compensation claims (Lees-

Haley, 1997) indicates that at least 25%Haley, 1997) indicates that at least 25%

of present-day claimants overreport psy-of present-day claimants overreport psy-

chological symptoms. In earlier conflictschological symptoms. In earlier conflicts

the post-trauma flashback symptom wasthe post-trauma flashback symptom was

mostly unknown by soldiers, clinicians ormostly unknown by soldiers, clinicians or

the media and there is no evidence of athe media and there is no evidence of a

compensation culture at that time. There-compensation culture at that time. There-

fore, Jonesfore, Jones et alet als finding probably hass finding probably has

more to do with the cultural aspects ofmore to do with the cultural aspects of

compensation and malingering than thecompensation and malingering than the

cultural aspects of PTSD. In failing to dealcultural aspects of PTSD. In failing to deal

with this important issue I do not believewith this important issue I do not believe

the authors have provided sufficientlythe authors have provided sufficiently

strong causal evidence for their conclusionstrong causal evidence for their conclusion

that some characteristics of PTSD arethat some characteristics of PTSD are

culture-bound.culture-bound.

Jones, E.,Vermaas, R. H., McCartney,H.,Jones, E.,Vermaas, R. H., McCartney, H., et alet al

(2003)(2003) Flashbacks and post-traumatic stress disorder:Flashbacks and post-traumatic stress disorder:

the genesis of a 20th-century diagnosis.the genesis of a 20th-century diagnosis. British Journal ofBritish Journal of

PsychiatryPsychiatry,, 182182, 158^163., 158^163.

Lees-Haley, P. R. (1997)Lees-Haley, P. R. (1997) MMPI-2 base rates for 492MMPI-2 base rates for 492

personal injury plaintiffs: implications and challenges forpersonal injury plaintiffs: implications and challenges for

forensic assessment.forensic assessment.Journal of Clinical PsychologyJournal of Clinical Psychology,, 5353,,

745^755.745^755.

L. A. NealL. A. Neal Bristol Priory Hospital,Heath HouseBristol Priory Hospital,Heath House

Lane, Stapleton,Bristol BS16 1EQ,UKLane, Stapleton,Bristol BS16 1EQ,UK

JonesJones et alet al (2003) draw conclusions that I(2003) draw conclusions that I

believe are not entirely supported by thebelieve are not entirely supported by the

results of their study. The results show usresults of their study. The results show us

that the percentage of flashbacks in post-that the percentage of flashbacks in post-

combat syndromes is as low as 9%, thuscombat syndromes is as low as 9%, thus

challenging the credibility of flashbacks aschallenging the credibility of flashbacks as

a diagnostic sign for PTSD. Moreover, thea diagnostic sign for PTSD. Moreover, the

study showed that only 9% of the soldiersstudy showed that only 9% of the soldiers

with combat syndrome exhibit flashbacks.with combat syndrome exhibit flashbacks.

The argument that PTSD is a culture-The argument that PTSD is a culture-

bound syndrome is quite overstated. Itbound syndrome is quite overstated. It

seems that somatic symptoms are far moreseems that somatic symptoms are far more

widespread in PTSD than are flashbacks.widespread in PTSD than are flashbacks.These somatic symptoms stand at the baseThese somatic symptoms stand at the base

of traumatic syndromes. The link betweenof traumatic syndromes. The link between

PTSD and culture is weaker than we mightPTSD and culture is weaker than we might

think. Elbert & Schauer (2002) state thatthink. Elbert & Schauer (2002) state that

survivors from different cultures (Sudansurvivors from different cultures (Sudan

and Somalia) exhibit psychiatric symptomsand Somalia) exhibit psychiatric symptoms

of PTSD. Jonesof PTSD. Jones et alet al(2003) state that many(2003) state that many

historical documents regarding trauma lackhistorical documents regarding trauma lack

a common denominator, and they are righta common denominator, and they are right

to some extent. However, I have shownto some extent. However, I have shown

(2001, 2002) that the somatic symptoms(2001, 2002) that the somatic symptoms

of nightmares, sleep disturbances and in-of nightmares, sleep disturbances and in-

creased anxiety occurring as a response tocreased anxiety occurring as a response totraumatic events are symptoms that havetraumatic events are symptoms that have

not changed in 4000 years. There is somenot changed in 4000 years. There is some

connection between trauma and culture,connection between trauma and culture,

but this connection is mild at most. I dobut this connection is mild at most. I do

agree with Jonesagree with Jones et alet althat PTSD is an evol-that PTSD is an evol-

ving syndrome. In my opinion, the core ofving syndrome. In my opinion, the core of

PTSD (somatic symptoms) is timeless andPTSD (somatic symptoms) is timeless and

not culture-bound. However, other less-not culture-bound. However, other less-

common symptoms are prone to somecommon symptoms are prone to some

cultural influence.cultural influence.

Ben-Ezra, M. (2001)Ben-Ezra, M. (2001) The earliest evidence of post-The earliest evidence of post-

traumatic stress? (letter)traumatic stress? (letter) British Journal of PsychiatryBritish Journal of Psychiatry,, 179179,,

467.467.

__(2002)(2002) Trauma 40 00 years ago? (letter)Trauma 4000 years ago? (letter) AmericanAmerican

Journal of PsychiatryJournal of Psychiatry,, 159159, 1437., 1437.

Elbert, T. & Schauer, M. (20 02)Elbert, T. & Schauer, M. (20 02) Psychological trauma:Psychological trauma:

burnt into memory.burnt into memory. NatureNature,, 419419, 883., 883.

Jones, E.,Vermaas, R. H., McCartney,H.,Jones, E.,Vermaas, R. H., McCartney, H., et alet al


the genesis of a 20th-century diagnosis.the genesis of a 20th-century diagnosis. British Journal ofBritish Journal ofPsychiatryPsychiatry,, 182182, 158^163., 158^163.

M. Ben-EzraM. Ben-Ezra Depar tment of Psychology,Tel-AvivDepar tment of Psychology,Tel-Aviv

University, PO Box 39040, Tel Aviv 69978, Israel.University, PO Box 39040,Tel Aviv 69978, Israel.

E-mail: menbeE-mail: menbe@@post.tau.ac.ilpost.tau.ac.il

Nobody, I think, would doubt thatNobody, I think, would doubt that thethe

diagnosis and management of some mentaldiagnosis and management of some mental

illnesses, perhaps PTSD especially, isillnesses, perhaps PTSD especially, is

culture-bound. However, I think the paperculture-bound. However, I think the paper

on flashbacks by Joneson flashbacks by Jones et alet al (2003) is(2003) is

misleading.misleading.A flashback is not defined in the glossaryA flashback is not defined in the glossary

of technical terms in either DSMIIIof technical terms in either DSMIII

(American Psychiatric Association, 1980)(American Psychiatric Association, 1980)

or DSMIIIR (American Psychiatric Asso-or DSMIIIR (American Psychiatric Asso-

ciation, 1987). The only mention of flash-ciation, 1987). The only mention of flash-

backs in DSMIII is as a complication ofbacks in DSMIII is as a complication of

hallucinogen hallucinosis. It does appearhallucinogen hallucinosis. It does appear

in the diagnostic criteria (B3) for PTSD inin the diagnostic criteria (B3) for PTSD in

DSMIIIR (in parenthesis) but the readerDSMIIIR (in parenthesis) but the reader

is referred in the index to post-hallucinogenis referred in the index to post-hallucinogen

perception disorder. Thus, while DSMIIIperception disorder. Thus, while DSMIII

refers to dissociative states and DSMIIIRrefers to dissociative states and DSMIIIR

refers to dissociative (flashback) episodes,refers to dissociative (flashback) episodes,both, in the context of the diagnosis, areboth, in the context of the diagnosis, are

described as rare. Thus, at the time of pub-described as rare. Thus, at the time of pub-

lication of these manuals, they were not alication of these manuals, they were not a

core symptom of PTSD.core symptom of PTSD.

DSMIV (American Psychiatric Asso-DSMIV (American Psychiatric Asso-

ciation, 1994) retains dissociative flash-ciation, 1994) retains dissociative flash-

back episodes (without parenthesis) asback episodes (without parenthesis) as

one of the ways a traumatic event is persis-one of the ways a traumatic event is persis-

tently re-experienced, and in the glossary oftently re-experienced, and in the glossary of

technical terms defines a flashback as a re-technical terms defines a flashback as a re-

currence of a memory, feeling, or percep-currence of a memory, feeling, or percep-

tual experience from the past. Thus,tual experience from the past. Thus,

flashbacks, unless they are qualified asflashbacks, unless they are qualified asdissociative, have become synonymousdissociative, have become synonymous

with recurrent and intrusive distressingwith recurrent and intrusive distressing

recollections of the events includingrecollections of the events including

images, thoughts or perceptions. They doimages, thoughts or perceptions. They do

not even have to be intrusive. Such unplea-not even have to be intrusive. Such unplea-

sant memories are universal in combatsant memories are universal in combat

veterans of any war. What has changed inveterans of any war. What has changed in

this instance is how the term is used notthis instance is how the term is used not

the phenomenon itself.the phenomenon itself.

That earlier conflicts showed a greaterThat earlier conflicts showed a greater

emphasis on somatic symptoms (Jonesemphasis on somatic symptoms (Jones

et alet al, 2003) indicates more clearly the, 2003) indicates more clearly the

impact of social values on symptomatol-impact of social values on symptomatol-ogy. Where a particular manifestation ofogy. Where a particular manifestation of

7 57 5

B R I T I S H J O U R N A L O F P S Y C H I AT R YB R I T I S H J O U R N A L O F P S Y C H I AT R Y ( 2 0 0 3 ) , 1 8 3 , 7 5 ^ 8 1( 2 0 0 3 ) , 1 8 3 , 7 5 ^ 8 1

CorrespondenceCorrespondence

EDITED BY STANLEY ZAMMITEDITED BY STANLEY ZAMMIT

ContentsContents && Flashbacks and PTSDFlashbacks and PTSD && Human rights and mentalhealthHuman rights and mentalhealth && Slavery andSlavery and

psychiatrypsychiatry && Treatment of common mental disorders in generalpractice: are currentTreatment of common mental disorders in general practice: are current

guidelines useless?guidelines useless? && Managementof borderlinepersonalitydisorderManagementof borderline personalitydisorder && CognitiveanalyticCognitive analytic

therapytherapy && Cinders, youshall go tothe ballCinders, youshall go tothe ball

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C O R R E S P O N D E N C EC O R R E S P O N D E N C E

distress meets with disapproval the sug-distress meets with disapproval the sug-

gestion in these cases of lack of moralgestion in these cases of lack of moral

fibre or worse somatic symptoms couldfibre or worse somatic symptoms could

be expected. In the early 1970s a Thaibe expected. In the early 1970s a Thai

psychiatrist returning to Thailand frompsychiatrist returning to Thailand from

training in the USA indicated to me thattraining in the USA indicated to me that

he had to educate his patients before hehe had to educate his patients before hecould diagnose depression (P. Chaowasilp,could diagnose depression (P. Chaowasilp,

personal communication, 1972). At thatpersonal communication, 1972). At that

time, all his patients with depressiontime, all his patients with depression

presented with somatic complaints.presented with somatic complaints.

American Psychiatric Association (1980)American Psychiatric Association (1980) DiagnosticDiagnostic

and Statistical Manual of Mental Disordersand Statistical Manual of Mental Disorders (3rd edn)(3rd edn)

(DSM ^ III).Washington,DC: APA.(DSM ^ III).Washington,DC: APA.

__(1987)(1987) Diagnostic and Statistical Manual of MentalDiagnostic and Statistical Manual of Mental

DisordersDisorders (3rd edn, revised) (DSM ^ III ^ R).Washington,(3rd edn, revised) (DSM ^ III ^ R).Washington,

DC: APA.DC: APA.


DisordersDisorders (4th edn) (DSM ^ IV).Washington,DC : APA.(4th edn) (DSM ^ IV).Washington,DC: APA.

Jones, E.,Vermaas, R. H., McCartney, H.,Jones, E.,Vermaas, R. H., McCartney, H., et alet al




I. P. Burges WatsonI. P. Burges Watson The Hobar t Clinic, Rokeby,The Hobart Clinic, Rokeby,

Tasmania, Australia 7019Tasmania, Australia 7019

The study by JonesThe study by Jones et alet al (2003) adds an(2003) adds an

interesting perspective on the concept ofinteresting perspective on the concept of

PTSD. However, there are methodologicalPTSD. However, there are methodological

matters that concern me.matters that concern me.

First, why are no subjects included fromFirst, why are no subjects included from

the Falklands Conflict of 1982? Jonesthe Falklands Conflict of 1982? Jones etetalal cite OBrien & Hughes (1991), whosecite OBrien & Hughes (1991), whose

work suggests that a much higher incidencework suggests that a much higher incidence

of flashbacks might be found among thatof flashbacks might be found among that

population.population.

Second, how many raters were usedSecond, how many raters were used

to confirm the existence of PTSDto confirm the existence of PTSD

symptoms in the case records? What weresymptoms in the case records? What were

the interrater reliabilities? How was anythe interrater reliabilities? How was any

disagreement resolved?disagreement resolved?

Third, during my brief sojourn as Med-Third, during my brief sojourn as Med-

ical Member (Psychiatrist) of the War Pen-ical Member (Psychiatrist) of the War Pen-

sions Appeal Tribunals, I studied in detailsions Appeal Tribunals, I studied in detail

some 80 War Pension Agency case records,some 80 War Pension Agency case records,many for non-psychological cases. Mymany for non-psychological cases. My

overriding concern was the lack of symp-overriding concern was the lack of symp-

tom recording. Frequently, the relevanttom recording. Frequently, the relevant

questions on War Pension Agency medicalquestions on War Pension Agency medical

assessments concerning mental state re-assessments concerning mental state re-

ceived one-word answers, or were deletedceived one-word answers, or were deleted

entirely. How did these researchers dealentirely. How did these researchers deal

with such cases?with such cases?

Jones, E.,Vermaas, R. H., McCartney, H.,Jones, E.,Vermaas, R. H., McCartney, H., et alet al




OBrien, L. S. & Hughes, S. J. (1991)OBrien, L. S. & Hughes, S. J. (1991) Symptoms ofSymptoms of

post-traumatic stress disorder in Falklands veterans f ivepost-traumatic stress disorder in Falklands veterans f ive

years after the conflict.years after the conflict. British Journal of PsychiatryBritish Journal of Psychiatry,, 159159,,

135^141.135^141.

D. M. HambridgeD. M. Hambridge 9 Weavervale Park,9 Weavervale Park,

Warrington Road,Bartington, Northwich,CheshireWarrington Road,Bartington, Northwich,Cheshire

CW8 4QU,UKCW8 4QU,UK

Authors reply:Authors reply: Leigh Neal has suggestedLeigh Neal has suggested

that the increased incidence of flashbacksthat the increased incidence of flashbacks

that we detected for Gulf War veterans isthat we detected for Gulf War veterans is

not a genuine observation but simply thenot a genuine observation but simply the

result of contemporary overreporting. Thisresult of contemporary overreporting. This

effect he attributes to our compensationeffect he attributes to our compensation

culture and malingering. While we fullyculture and malingering. While we fully

agree that claimants with PTSD may onagree that claimants with PTSD may on

occasion elaborate psychological symptomsoccasion elaborate psychological symptoms

for financial reasons, this factor is hardlyfor financial reasons, this factor is hardly

novel (Wessely, 2003). There was, fornovel (Wessely, 2003). There was, for

example, an epidemic of war pensionexample, an epidemic of war pensionclaims for shell shock and neurasthenia inclaims for shell shock and neurasthenia in

the aftermath of the First World War. Bythe aftermath of the First World War. By

March 1921, it was estimated that of theMarch 1921, it was estimated that of the

1.3 million awards, 65 000 were for func-1.3 million awards, 65 000 were for func-

tional nervous disorders (Jonestional nervous disorders (Jones et al et al ,,

2002). So concerned was the Ministry of2002). So concerned was the Ministry of

Pensions that applications were beingPensions that applications were being

falsified or exaggerated that they appointedfalsified or exaggerated that they appointed

Sir John Collie, an expert in rooting outSir John Collie, an expert in rooting out

fraud, to chair their special medical boardfraud, to chair their special medical board

for neurasthenia and functional nervefor neurasthenia and functional nerve

disease. In 1917, Collie had included adisease. In 1917, Collie had included a

chapter on the military in his textbook, inchapter on the military in his textbook, inwhich he observed that the thin line whichwhich he observed that the thin line which

divides genuine functional nerve diseasedivides genuine functional nerve disease

and shamming is exceedingly difficult toand shamming is exceedingly difficult to

define (Collie, 1917: p. 375). In fact, con-define (Collie, 1917: p. 375). In fact, con-

cerns about spurious or exaggerated claimscerns about spurious or exaggerated claims

for functional disorders pre-dated thisfor functional disorders pre-dated this

conflict and followed the passing of theconflict and followed the passing of the

Workmens Compensation Acts of 1897Workmens Compensation Acts of 1897

and 1906. In the 6 years following theand 1906. In the 6 years following the

1906 Act, the sums paid in accident com-1906 Act, the sums paid in accident com-

pensation rose by 63.5% despite the factpensation rose by 63.5% despite the fact

that the number of people in employmentthat the number of people in employment

remained the same (Trimble, 1981). Theremained the same (Trimble, 1981). Theresearch in the 1880s by Herbert Page toresearch in the 1880s by Herbert Page to

establish that most cases of railway spineestablish that most cases of railway spine

were without organic basis was driven bywere without organic basis was driven by

the large settlements being paid by railwaythe large settlements being paid by railway

companies to passengers who had exagger-companies to passengers who had exagger-

ated or falsified symptoms followingated or falsified symptoms following

accidents. Indeed, the termaccidents. Indeed, the term Rentenkampf-Rentenkampf-

neurosenneurosen (pension struggle neurosis) had(pension struggle neurosis) had

been coined following Bismarcks accidentbeen coined following Bismarcks accident

insurance legislation of 1884 and reflectedinsurance legislation of 1884 and reflected

widespread concerns that workers andwidespread concerns that workers and

passengers were defrauding companiespassengers were defrauding companies

through dubious medical claims (Lerner,through dubious medical claims (Lerner,2001).2001).

Other than agreeing that these thingsOther than agreeing that these things

can and do happen, it is always risky tocan and do happen, it is always risky to

make statements about the incidence ofmake statements about the incidence of

malingering, as clinicians have no particu-malingering, as clinicians have no particu-

lar expertise in its measurement. Dr Neallar expertise in its measurement. Dr Neal

has no more information than we have, orhas no more information than we have, or

anyanyone else for that matter, on the trueone else for that matter, on the truerates of malingering, let alone whetherrates of malingering, let alone whether

or notor not it is increasing. What the above doesit is increasing. What the above does

show is that concern about the phenomen-show is that concern about the phenomen-

on is certainly not new.on is certainly not new.

Menachem Ben-Ezra rightly points outMenachem Ben-Ezra rightly points out

that the flashback is a comparatively rarethat the flashback is a comparatively rare

symptom among PTSD sufferers. He arguessymptom among PTSD sufferers. He argues

that other symptoms, such as nightmares,that other symptoms, such as nightmares,

sleep disturbance and elevated anxiety, aresleep disturbance and elevated anxiety, are

common and enduring features, and, there-common and enduring features, and, there-

fore, not culture-bound. While we agreefore, not culture-bound. While we agree

that these symptoms were widely reportedthat these symptoms were widely reported

in the past, their existencein the past, their existence per seper se does notdoes notjustify the creation of a new and veryjustify the creation of a new and very

specific disorder. The complex diagnosticspecific disorder. The complex diagnostic

criteria for PTSD in DSMIV (Americancriteria for PTSD in DSMIV (American

Psychiatric Association, 1994) comprisePsychiatric Association, 1994) comprise

six sub-groups, which extend over threesix sub-groups, which extend over three

pages. Anxiety, sleep disturbance andpages. Anxiety, sleep disturbance and

nightmares are not disorders in themselves,nightmares are not disorders in themselves,

as most people suffer from them at someas most people suffer from them at some

time. It is only when they become severetime. It is only when they become severe

or arise inappropriately that psychiatristsor arise inappropriately that psychiatrists

elevate them to psychiatric disorders. Withelevate them to psychiatric disorders. With

the exception of hallucinogen persistingthe exception of hallucinogen persisting

perception disorder, flashbacks are almostperception disorder, flashbacks are almostunique to PTSD. As a result, we chose thisunique to PTSD. As a result, we chose this

symptom as a way of trying to evaluatesymptom as a way of trying to evaluate

the incidence of this modern diagnosis. Itthe incidence of this modern diagnosis. It

should not be forgotten that PTSD did notshould not be forgotten that PTSD did not

enter DSMIII (American Psychiatric Asso-enter DSMIII (American Psychiatric Asso-

ciation, 1980) as a result of a series ofciation, 1980) as a result of a series of

rigorous epidemiological investigations butrigorous epidemiological investigations but

in the context of an anti-war movement,in the context of an anti-war movement,

which sought to demonstrate that service-which sought to demonstrate that service-

men suffered long-term effects from com-men suffered long-term effects from com-

bat. Only after it had been formallybat. Only after it had been formally

recognised by therecognised by the American PsychiatricAmerican Psychiatric

Association was PTSDAssociation was PTSD then subject tothen subject tointense scientific analysis (Young, 1995).intense scientific analysis (Young, 1995).

Dr Burges Watson has identified notDr Burges Watson has identified not

only the growing significance attached toonly the growing significance attached to

the flashback but also the disparity betweenthe flashback but also the disparity between

the way that flashbacks are described asthe way that flashbacks are described as

part of the diagnostic criteria for PTSDpart of the diagnostic criteria for PTSD

and in the DSMIV glossary. In the former,and in the DSMIV glossary. In the former,

they are included within acting or feelingthey are included within acting or feeling

as if the traumatic event were recurringas if the traumatic event were recurring

(includes a sense of reliving the experience,(includes a sense of reliving the experience,

illusions, hallucinations, and dissociativeillusions, hallucinations, and dissociative

flashback episodes. . .), while the latterflashback episodes . . .), while the latter

contains a brief definition: a recurrence ofcontains a brief definition: a recurrence ofa memory, feeling, or perceptual experiencea memory, feeling, or perceptual experience

7 67 6

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from the past (American Psychiatric Asso-from the past (American Psychiatric Asso-

ciation, 1994: pp. 428, 766). Dr Burgesciation, 1994: pp. 428, 766). Dr Burges

Watson infers from this that the flashbackWatson infers from this that the flashback

is a new term for an old phenomenon; whatis a new term for an old phenomenon; what

in the past would have been described as ain the past would have been described as a

vivid memory of conflict is today called avivid memory of conflict is today called a

flashback. The objection to this hypothesisflashback. The objection to this hypothesisis that we discovered both phenomena inis that we discovered both phenomena in

medical records from the First and Secondmedical records from the First and Second

World Wars. We were careful to adopt aWorld Wars. We were careful to adopt a

rigorous definition of flashback (whichrigorous definition of flashback (which

included the sense of reliving the traumaticincluded the sense of reliving the traumatic

episode) to distinguish it from eideticepisode) to distinguish it from eidetic

memories.memories.

In answer to Dr Hambidge, we wereIn answer to Dr Hambidge, we were

unable to include veterans of the Falklandsunable to include veterans of the Falklands

War because ministerial permission was notWar because ministerial permission was not

granted to study recent war pension files ofgranted to study recent war pension files of

service personnel still living, and becauseservice personnel still living, and because

the Medical Assessment Programme isthe Medical Assessment Programme islimited to veterans of the Persian Gulflimited to veterans of the Persian Gulf

War. As regards the collection of data,War. As regards the collection of data,

three research assistants recorded symp-three research assistants recorded symp-

toms on a standardised form by copyingtoms on a standardised form by copying

verbatim from medical notes. These wereverbatim from medical notes. These were

then reviewed in detail by the lead investi-then reviewed in detail by the lead investi-

gator, who re-examined the files to ensuregator, who re-examined the files to ensure

accuracy and consistency of interpretation.accuracy and consistency of interpretation.

War pension files with missing informationWar pension files with missing information

were excluded from the study. In general,were excluded from the study. In general,

the case notes were comprehensive, oftenthe case notes were comprehensive, often

detailing a servicemans history from enlist-detailing a servicemans history from enlist-

ment until death. As these are a continuousment until death. As these are a continuousseries of records, there is no reason to sup-series of records, there is no reason to sup-

pose that deficiencies in reporting werepose that deficiencies in reporting were

confined to modern assessors rather thanconfined to modern assessors rather than

being spread randomly throughout thebeing spread randomly throughout the

archive.archive.

Declaration of interestDeclaration of interest

The study was funded by the US ArmyThe study was funded by the US Army

Research and Material Command underResearch and Material Command under

grant number DMD17-98-1-8009. Edgargrant number DMD17-98-1-8009. Edgar

Jones was supported by a grant from theJones was supported by a grant from the

US Department of Defense.US Department of Defense.

American Psychiatric Association (1980)American Psychiatric Association (1980) DiagnosticDiagnostic

and Statistical Manual of Mental Disordersand Statistical Manual of Mental Disorders (3rd edn)(3rd edn)

(DSM ^ III).Washington,DC: APA.(DSM ^ III).Washington,DC: APA.


DisordersDisorders (4th edn) (DSM ^ IV).Washington,DC: APA.(4th edn) (DSM ^ IV).Washington,DC: APA.

Collie, J. (1917)Collie, J. (1917) Malingering and Feigned Sickness withMalingering and Feigned Sickness with

notes on the Workmens Compensation Act,190 6notes on the Workmens Compensation Act,190 6. London:. London:

Edward Arnold.Edward Arnold.

Jones, E., Palmer, I. & Wessely, S. (200 2)Jones, E., Palmer, I. & Wessely, S. (2002) WarWar

pensions (1900^1945): changing models of psychologicalpensions (1900^1945): changing models of psychological

understanding.understanding. British Journal of PsychiatryBritish Journal of Psychiatry,, 180180, 374^379., 374^379.

Lerner, P. (2001)Lerner, P. (2001) From traumatic neurosis to maleFrom traumatic neurosis to male

hysteria: the decline and fall of Hermann Oppenheim,hysteria: the decline and fall of Hermann Oppenheim,

1889^ 1919.In1889^ 1919.In Traumatic Pasts, History, Psychiatry andTraumatic Pasts, History, Psychiatry and

Trauma in the Modern Age, 1870^1930Trauma in the Modern Age, 1870^1930 (eds M.S. Micale &(eds M.S. Micale &

P. Lerner).Cambridge: Cambridge University Press.P. Lerner). Cambridge: Cambridge University Press.

Trimble, M. R. (1981)Trimble, M. R. (1981) Post-Traumatic Neurosis, FromPost-Traumatic Neurosis, From

Railway Spine to the WhiplashRailway Spine to the Whiplash. Chichester:John Wiley &. Chichester:John Wiley &

Sons.Sons.

Wessely, S . (2003)Wessely, S . (2003) Historical aspects of malingering. InHistorical aspects of malingering. In

Malingering and Illness DeceptionMalingering and Illness Deception (eds P. Halligan,C. Bass(eds P. Halligan, C. Bass

& M.Oakley).Oxford: Oxford University Press, in press.& M.Oakley).Oxford: Oxford University Press, in press.

Young, A. (1995)Young, A. (1995) The Harmony of Illusions: InventingThe Harmony of Illusions: Inventing

Post-Traumatic Stress DisorderPost-Traumatic Stress Disorder. Princeton, NJ: Princeton. Princeton, NJ: Princeton

University Press.University Press.

E. Jones, R. H.Vermaas, C. Beech, S.E. Jones, R. H.Vermaas,C. Beech, S.

WesselyWessely Department of Psychological Medicine,Department of Psychological Medicine,

GKT School of Medicine,103 Denmark Hill,LondonGKT School of Medicine,103 Denmark Hill,London

SE5 8AZ,UKSE5 8AZ,UK

H. McCartneyH. McCartney Joint Services Command andJoint Services Command and

Staff College,Watchfield,UKStaff College,Watchfield,UK

I. PalmerI. Palmer Royal Defence Medical College,Royal Defence Medical College,

Gosport,UKGosport,UK

K. HyamsK. Hyams Department of Veterans Affairs,Department of Veterans Affairs,Washington DC,USAWashington DC,USA

Human rights and mental healthHuman rights and mental health

I agree with BindmanI agree with Bindman et alet al (2003) that, to(2003) that, to

date, the jurisprudence of the Europeandate, the jurisprudence of the European

Court of Human Rights has not set a highCourt of Human Rights has not set a high

standard for modern mental health ser-standard for modern mental health ser-

vices. This is apparent not only in areas ofvices. This is apparent not only in areas of

the process of detention and its lawfulness,the process of detention and its lawfulness,

but also in areas of treatment standards andbut also in areas of treatment standards and

material standards of the facilities in whichmaterial standards of the facilities in which

people are detained. I would also echo theirpeople are detained. I would also echo theirsentiment that the wording of article 5(1)esentiment that the wording of article 5(1)e

of the European Convention on Humanof the European Convention on Human

Rights is at best unfortunate and at worstRights is at best unfortunate and at worst

deeply stigmatising. That said, I believe thatdeeply stigmatising. That said, I believe that

the doctrine of the livingthe doctrine of the living instrument (instrument (TyrerTyrer

v. United Kingdomv. United Kingdom, 1978; Reed & Murdoch,, 1978; Reed & Murdoch,

2002) in Strasbourg2002) in Strasbourg jurisprudence is of fun-jurisprudence is of fun-

damental importance in interpretation ofdamental importance in interpretation of

the Convention and may yet lead to im-the Convention and may yet lead to im-

proved protection of the human rights ofproved protection of the human rights of

both patients with mental illnesses andboth patients with mental illnesses and

people with learning disabilities.people with learning disabilities.

With respect to patients who areWith respect to patients who arede factode facto detained, the case ofdetained, the case of Rierra BlumeRierra Blume

v. Spainv. Spain (1999) may improve rights protec-(1999) may improve rights protec-

tion. Here, the European Court of Humantion. Here, the European Court of Human

Rights ruled that the complainants, whoRights ruled that the complainants, who

had been escorted by the police to receive,had been escorted by the police to receive,

among other things, psychiatric treatment,among other things, psychiatric treatment,

had beenhad been de factode facto detained and that theirdetained and that their

detention was unlawful. However, manydetention was unlawful. However, many

patients for various reasons, especiallypatients for various reasons, especially

non-protesting patients as in the Bourne-non-protesting patients as in the Bourne-

wood case (wood case (R v. Bournewood CommunityR v. Bournewood Community

and Mental Health NHS Trustand Mental Health NHS Trust, 1998), will, 1998), will

not take cases to the courts, and the protec-not take cases to the courts, and the protec-tion of their rights may depend on relativestion of their rights may depend on relatives

or voluntary organisations acting on theiror voluntary organisations acting on their

behalf.behalf.

Legal protection with regard to theLegal protection with regard to the

autonomy of patients with mental illnessesautonomy of patients with mental illnesses

and people with learning disabilities mayand people with learning disabilities may

improve by a back-door means, arisingimprove by a back-door means, arising

from the debate over privacy protectionfrom the debate over privacy protectionand article 8 rights (right to respect forand article 8 rights (right to respect for

private and family life). However, rightsprivate and family life). However, rights

can be secured in court only if challengescan be secured in court only if challenges

are brought, and many people with mentalare brought, and many people with mental

illnesses or learning disabilities may notillnesses or learning disabilities may not

have the awareness or the means to bringhave the awareness or the means to bring

such challenges. The importance of wayssuch challenges. The importance of ways

other than legislation for highlighting andother than legislation for highlighting and

securing rights, such as the Royal Collegesecuring rights, such as the Royal College

of Psychiatrists anti-stigma campaignof Psychiatrists anti-stigma campaign

Changing Minds, education campaignsChanging Minds, education campaigns

about mental illness and the work ofabout mental illness and the work of

numerous voluntary agencies, cannot benumerous voluntary agencies, cannot beunderestimated in promoting equal rightsunderestimated in promoting equal rights

and opportunities for these populationand opportunities for these population

groups.groups.

Bindman, J., Maingay, S. & Szmukler, G. (2 003)Bindman, J., Maingay, S . & Szmukler, G. (2 003) TheThe

Human Rights Act and mental health legislation.Human Rights Act and mental health legislation. BritishBritish

Journal of PsychiatryJournal of Psychiatry,, 182182, 91^94., 91^94.

Reed, R. & Murdoch, J. (2002)Reed, R. & Murdoch, J. (2002) A Guide to HumanA Guide to Human

Rights Law in ScotlandRights Law in Scotland, pp.117^119. Edinburgh:, pp.117^119. Edinburgh:

Butterworths.Butterworths.

R v. Bournewood Community and Mental Health NHSR v. Bournewood Community and Mental Health NHS

Trust, ex parteTrust, ex parte (1998) 3 All ER 289.(1998) 3 All ER 289.

Rierra Blume v. SpainRierra Blume v. Spain (199 9) Judgements of the European(199 9) Judgements of the EuropeanCourt of Human Rights (October14).Paras 16^18;Court of Human Rights (October 14). Paras16^18;

30^ 35. Available at http://ww w.echr.coe.int/30^ 35. Available at http://www.echr.coe.int/

Tyrer v. United KingdomTyrer v. United Kingdom (1978) 2 EHRR 1.(1978) 2 EHRR 1.

L. FindlayL. Findlay Kirklands Hospital,Bothwell,Kirklands Hospital,Bothwell,

Lanarkshire G71 8BB,UKLanarkshire G718BB,UK

Slavery and psychiatrySlavery and psychiatry

Raj Persaud (2003) begins his reviewRaj Persaud (2003) begins his review

of Thomas Szaszs bookof Thomas Szaszs book Liberation byLiberation by

Oppression: A Comparative Study ofOppression: A Comparative Study of

Slavery and PsychiatrySlavery and Psychiatry by asserting thatby asserting that

something false is true: Thomas Szaszsomething false is true: Thomas Szaszbecame famous for being at the vanguardbecame famous for being at the vanguard

of the anti-psychiatry movement. First,of the anti-psychiatry movement. First,

Szasz has never been part of the anti-Szasz has never been part of the anti-

psychiatry movement, much less at the van-psychiatry movement, much less at the van-

guard of it. Second, there is as much truthguard of it. Second, there is as much truth

in Persauds assertion as there is in assertingin Persauds assertion as there is in asserting

that the Nazis were simply practising med-that the Nazis were simply practising med-

icine. Szasz has made it absolutely clear foricine. Szasz has made it absolutely clear for

over 50 years now that he supports psy-over 50 years now that he supports psy-

chiatry between consenting adults, that is,chiatry between consenting adults, that is,

he supports contractual psychiatry. Third,he supports contractual psychiatry. Third,

Dr Persaud then asserts that Szasz is an allyDr Persaud then asserts that Szasz is an ally

rather than an enemy of the Nationalrather than an enemy of the NationalHealth Service general adult psychiatrist.Health Service general adult psychiatrist.

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This is another fiction masquerading asThis is another fiction masquerading as

fact. Szasz is not an ally of National Healthfact. Szasz is not an ally of National Health

Service psychiatrists, none of whom, to myService psychiatrists, none of whom, to my

knowledge, has denounced or renouncedknowledge, has denounced or renounced

the practice of psychiatric slavery. More-the practice of psychiatric slavery. More-

over, Szasz is a classical liberal, not a socia-over, Szasz is a classical liberal, not a socia-

list. The two cardinal principles of thelist. The two cardinal principles of theclassical liberal credo are the affirmationclassical liberal credo are the affirmation

of the right to bodily and mental self-of the right to bodily and mental self-

ownership and the prohibition againstownership and the prohibition against

initiating violence.initiating violence.

These rather serious misrepresentationsThese rather serious misrepresentations

aside, Persaud ignores the core ideas inaside, Persaud ignores the core ideas in

Szaszs book. Institutional psychiatry is anSzaszs book. Institutional psychiatry is an

extension of law: institutional psychiatristsextension of law: institutional psychiatrists

are agents of the state, not of their patients.are agents of the state, not of their patients.

Doctors who practise contractual medicineDoctors who practise contractual medicine

are agents of their patients, not of the state.are agents of their patients, not of the state.

The importance of this difference cannot beThe importance of this difference cannot be

overemphasised.overemphasised.People labelled by institutional psy-People labelled by institutional psy-

chiatrists as mentally ill are concurrentlychiatrists as mentally ill are concurrently

defined by the courts as less than human,defined by the courts as less than human,

in much the same way Negroes in Amer-in much the same way Negroes in Amer-

ica were once defined as three-fifths per-ica were once defined as three-fifths per-

sons. This is how Black people were,sons. This is how Black people were,

and people with mental illnesses are, de-and people with mental illnesses are, de-

prived of liberty and justice by the state.prived of liberty and justice by the state.

Labelling of anyone as less than humanLabelling of anyone as less than human

is legal fiction, something false that is as-is legal fiction, something false that is as-

serted as true, that the courts will notserted as true, that the courts will not

allow to be disproved. Just as definingallow to be disproved. Just as defining

Negroes as three-fifths persons served toNegroes as three-fifths persons served tomaintain the institution ofmaintain the institution of slavery,slavery,

defining people as mentally ill servesdefining people as mentally ill serves toto

maintain the institution of psychiatry.maintain the institution of psychiatry.

A person has a right to refuse treatmentA person has a right to refuse treatment

for cancer. A person does not have a rightfor cancer. A person does not have a right

to refuse treatment for mental illness. Ifto refuse treatment for mental illness. If

institutional psychiatrists are deprived ofinstitutional psychiatrists are deprived of

their power by the state to deprive mentallytheir power by the state to deprive mentally

ill persons of their liberty, that is, if theill persons of their liberty, that is, if the

state did not allow psychiatrists to enslavestate did not allow psychiatrists to enslave

their patients in the name of liberatingtheir patients in the name of liberating

them, institutional psychiatry would gothem, institutional psychiatry would go

the way of slavery, as well it should.the way of slavery, as well it should.

Persaud,R. (2003)Persaud,R. (2003) Bookreview:Bookreview: Liberationby OppressionLiberationby Oppression

( T. Szasz).(T. Szasz). British Journal of PsychiatryBritish Journal of Psychiatry,, 182182, 273., 273.

J. A. SchalerJ. A. Schaler Department of Justice, Law andDepartment of Justice, Law and

Society, School of Public Affairs, AmericanSociety, School of Public Affairs, American

University,Ward Circle Building, 44 00 Mass. Ave.,University,Ward Circle Building, 4400 Mass. Ave.,

NW,Washington, DC 20016^80 43,USANW,Washington, DC 20016^8 043,USA

Treatment of common mentalTreatment of common mental

disorders in general practice: aredisorders in general practice: are

current guidelines useless?current guidelines useless?

The paper by CroudaceThe paper by Croudace et alet al (2003) con-(2003) con-firms the pattern set by previous studiesfirms the pattern set by previous studies

(Upton(Upton et alet al, 1999; King, 1999; King et alet al, 2002) in, 2002) in

showing little or no effect of educationalshowing little or no effect of educational

and treatment initiatives on primary careand treatment initiatives on primary care

physicians practice of psychiatry. Thephysicians practice of psychiatry. The

authors provide various explanations forauthors provide various explanations for

the negative outcome; one of these the negative outcome; one of these

failures in the content of the guidelinesfailures in the content of the guidelinesthemselves in terms of their evidence basethemselves in terms of their evidence base

or relevance deserves greater promi-or relevance deserves greater promi-

nence. Although psychiatry can claim somenence. Although psychiatry can claim some

credit for advances in the diagnoses andcredit for advances in the diagnoses and

treatment of more-severe disorders seen intreatment of more-severe disorders seen in

secondary care, our interventions for thesecondary care, our interventions for the

common mental disorders in primary carecommon mental disorders in primary care

are much less securely founded.are much less securely founded.

The guidelines do not take properThe guidelines do not take proper

account of the well-established fact thataccount of the well-established fact that

approximately two out of five patientsapproximately two out of five patients

presenting with common mental illnessespresenting with common mental illnesses

in general practice (even when consideredin general practice (even when consideredill enough to merit psychiatric input) im-ill enough to merit psychiatric input) im-

prove rapidly within a few weeks. Theseprove rapidly within a few weeks. These

probably merit the often forgotten diag-probably merit the often forgotten diag-

nosis of adjustment disorder (Caseynosis of adjustment disorder (Casey et alet al,,

2001). Thirty per cent pursue a slower2001). Thirty per cent pursue a slower

course of recovery and a further 30%,course of recovery and a further 30%,

mostly with mixed anxiety and depressivemostly with mixed anxiety and depressive

disorder, have a worse outcome with fre-disorder, have a worse outcome with fre-

quent relapses (Tyrerquent relapses (Tyrer et alet al, 2003), although, 2003), although

in the short term a variety of interventionsin the short term a variety of interventions

can be effective.can be effective.

The methodology of CroudaceThe methodology of Croudace et alet alss

study is to be commended and the resultsstudy is to be commended and the resultsshow that even when guidelines lead toshow that even when guidelines lead to

greater specificity in identifying illness, thisgreater specificity in identifying illness, this

is not accompanied by better outcomes.is not accompanied by better outcomes.

Pressured general practitioners in the pastPressured general practitioners in the past

used to take the approach that if a patientused to take the approach that if a patient

with mental health symptoms presentedwith mental health symptoms presented

for treatment, the doctor could listen sym-for treatment, the doctor could listen sym-

pathetically and, unless there was signifi-pathetically and, unless there was signifi-

cant risk, would ask them to come backcant risk, would ask them to come back

in 4 weeks time. If the patient returned,in 4 weeks time. If the patient returned,

he or she might have a more serious pro-he or she might have a more serious pro-

blem necessitating formal treatment. Suchblem necessitating formal treatment. Such

an approach may have a greater evidencean approach may have a greater evidencebase than any of our guidelines. It nicelybase than any of our guidelines. It nicely

separates those with adjustment disordersseparates those with adjustment disorders

from the rest, prevents inappropriatefrom the rest, prevents inappropriate

therapies that might lead to iatrogenic pro-therapies that might lead to iatrogenic pro-

blems like dependence, and is an excellentblems like dependence, and is an excellent

predictor of improvement many years laterpredictor of improvement many years later

(Seivewright(Seivewright et alet al, 1998). If we were able to, 1998). If we were able to

help general practitioners at the time ofhelp general practitioners at the time of

presentation to diagnose which patientspresentation to diagnose which patients

needed intervention and which did not,needed intervention and which did not,

we might be doing a better service thanwe might be doing a better service than

any of the current guidelines that litterany of the current guidelines that litter

general practice surgeries in this and manygeneral practice surgeries in this and manyother countries.other countries.

Casey, P., Dowrick,C. & Wilkinson, G. (2 001)Casey, P., Dowrick, C. & Wilkinson, G. (2001)

Adjustment disorders: f ault line in the psychiatricAdjustment disorders: f ault line in the psychiatric

glossary.glossary. British Journal of PsychiatryBritish Journal of Psychiatry,, 179179, 479 ^481., 479^481.

Croudace,T., Evans, J., Harrison, G.,Croudace,T., Evans, J., Harrison, G., et alet al (2003)(2003)

Impact of the ICD^10 Primary Health Care (PHC)Impact of the ICD^ 10 Primary Health Care (PHC)

diagnostic and management guidelines for mentaldiagnostic and management guidelines for mental

disorders on detection and o utcome in primary care.disorders on detection and outcome in primary care.

Cluster randomised controlled trial.Cluster randomised controlled trial. British Journal ofBritish Journal ofPsychiatryPsychiatry,, 182182, 20^30., 20^30.

King, M., Davidson, O., Taylor, F.,King, M., Davidson,O., Taylor, F., et alet al (2002)(2002)

Effectiveness of teaching general practitioners skills inEffectiveness of teaching general practitioners skills in

brief cognitive behaviour therapy to treat patients withbrief cognitive behaviour therapy to treat patients with

depression: randomised controlled trial.depression: randomised controlled trial. BMJBMJ,, 324324,,

947^951.947^951.

Seivewright, H., Tyrer, P. & Johnson , T. (1998)Seivewright, H.,Tyrer, P. & Johns on, T. (1998)

Prediction of outcome in neurotic disorder: a five yearPrediction of outcome in n eurotic disorder: a five year

prospective study.prospective study. Psychological MedicinePsychological Medicine,, 2828, 1149^ 1157., 1149^ 1157.

Tyrer, P., S eivewright, H. & Johnson, T. (2 003)Tyrer, P., Seivewright, H. & Johnson, T. (2003 ) TheThe

core elements of neurosis: mixed anxiety^ depressioncore elements of neurosis: mixed anxiety^ depression

(cothymia) and personality disorder.(cothymia) and personality disorder.Journal of PersonalityJournal of Personality

DisordersDisorders, in press., in press.

Upton, M.W., Evans, M., Goldberg, D. P.,Upton, M.W., Evans, M., Goldberg, D. P., et alet al (1999)(1999)

Evaluation of ICD ^10 PHC mental health guidelines inEvaluation of ICD ^10 PHC mental health guidelines indetecting and managing depression within primary care.detecting a nd managing depression within primary care.

British Journal of PsychiatryBritish Journal of Psychiatry,, 175175, 476^482., 476^482.

NoteNote

This letter was submitted before theThis letter was submitted before the

appointment of P.T. as Editor of theappointment of P.T. as Editor of the

JournalJournal..

P. Tyrer, M. KingP. Tyrer, M. King MRCCollaborative Group forMRCCollaborative Group for

the Evaluation of Complex Mental Healththe Evaluation of Complex Mental Health

Interventions in Primary and Secondary Care,Interventionsin Primary and Secondary Care,

Imperial College and Royal Free Campus of RoyalImperial College and Royal Free Campus of Royal

Free and University College Medical School,Free and University College Medical School,

Rowland Hill Street,London NW3 2PF,UKRowland Hill Street, London NW3 2PF,UK

J. FluxmanJ. Fluxman General Practitioner, Harrow RoadGeneral Practitioner, Harrow Road

Medical Centre, London,UKMedical Centre, London, UK

Management of borderlineManagement of borderline

personality disorderpersonality disorder

VerheulVerheul et alet als article (2003) states thats article (2003) states that

dialectical behaviour therapy is an effica-dialectical behaviour therapy is an effica-

cious treatment for high-risk behaviours incious treatment for high-risk behaviours in

patients with borderline personality dis-patients with borderline personality dis-

order and suggests that this occurs via fourorder and suggests that this occurs via four

core features (Linehan, 1993): routinecore features (Linehan, 1993): routinemonitoring; modification of high-riskmonitoring; modification of high-risk

behaviours; encouragement of patients tobehaviours; encouragement of patients to

consult therapists before carrying out theseconsult therapists before carrying out these

behaviours; and prevention of therapistbehaviours; and prevention of therapist

burnout.burnout.

We propose a management strategy forWe propose a management strategy for

these patients delivered via a systemicthese patients delivered via a systemic

approach that incorporates these principlesapproach that incorporates these principles

and is especially relevant for services with-and is especially relevant for services with-

out the capacity to provide the skills baseout the capacity to provide the skills base

or intensity required for effective dialecticalor intensity required for effective dialectical

behaviour therapy. Such an approachbehaviour therapy. Such an approach

has been developed by our service andhas been developed by our service andisis currently the principal method ofcurrently the principal method of

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working with clients with borderlineworking with clients with borderline

personality disorder in the lower Northpersonality disorder in the lower North

Island of New Zealand. It is a service-Island of New Zealand. It is a service-

wide intervention with a long-term per-wide intervention with a long-term per-

spective, providing stabilisation andspective, providing stabilisation and

containment for both patient and staff.containment for both patient and staff.

It is encapsulated in a management planIt is encapsulated in a management plan a behavioural intervention to minimise a behavioural intervention to minimise

reinforcement of hazardous behavioursreinforcement of hazardous behaviours

and promote self-responsibility.and promote self-responsibility.

The plan defines the treatment systemThe plan defines the treatment system

(e.g. psychiatric team, family, police, acci-(e.g. psychiatric team, family, police, acci-

dent and emergency department staff), con-dent and emergency department staff), con-

tains an acceptance of risk and explains thetains an acceptance of risk and explains the

dangers of risk-averse responses from thedangers of risk-averse responses from the

service (Maltsberger, 1994). This breaksservice (Maltsberger, 1994). This breaks

the cycle of assuming responsibility forthe cycle of assuming responsibility for

the client and replaying a traumatisingthe client and replaying a traumatising

parentchild dynamic, with subsequentparentchild dynamic, with subsequent

regression, increased risk and institutional-regression, increased risk and institutional-isation. We found that this is achievedisation. We found that this is achieved

through the process of writing and imple-through the process of writing and imple-

menting the plan and it enables patients tomenting the plan and it enables patients to

move towards autonomous functioning. Itmove towards autonomous functioning. It

must be agreed to by all involved andmust be agreed to by all involved and

regular review meetings provide a forumregular review meetings provide a forum

for staff to own and manage their differ-for staff to own and manage their differ-

ences. Each plan should be an individual-ences. Each plan should be an individual-

ised document written by the caseised document written by the case

manager in consultation with the client;manager in consultation with the client;

however, we have designed a template forhowever, we have designed a template for

ease of use. This work grew from the ideasease of use. This work grew from the ideas

of Krawitz & Watson (1999) around theof Krawitz & Watson (1999) around theuse of brief admissions as a successful partuse of brief admissions as a successful part

of long-term management, and the obser-of long-term management, and the obser-

vation that the majority of work by out-vation that the majority of work by out-

of-hours services involved these revolvingof-hours services involved these revolving

door patients. As yet, our approach hasdoor patients. As yet, our approach has

been validated only by empirical evidence.been validated only by empirical evidence.

A paper is currently in preparation.A paper is currently in preparation.

Krawitz, R. & Watson,C . (1999)Krawitz, R. & Watson,C . (1999) Borderline PersonalityBorderline Personality

Disorder: Pathways to Effective Service Delivery and ClinicalDisorder: Pathways to Effective Service Delivery and Clinical

Treatment OptionsTreatment Options.Wellington: Mental Health.Wellington: Mental Health

Commission of New Zealand.Commission of New Zealand.

Linehan, M. (1993)Linehan, M. (1993) Cognitive Behavioural Treatment ofCognitive Behavioural Treatment of

Borderline Personality DisorderBorderline Personality Disorder. New York: Guilford Press.. New York: Guilford Press.

Maltsberger, J. T. (1994)Maltsberger, J. T. (1994) Calculated risk taking in theCalculated risk taking in the

treatment of intractably suicidal patients.treatment of intractably suicidal patients. PsychiatryPsychiatry,, 5757,,

199^212.199^212.

Verheul, R., van den Bosch, L. M.C ., Koeter, M.W. J.,Verheul, R., van den Bosch, L. M.C ., Koeter, M.W.J.,

et alet al (2003)(2003) Dialectical behaviour therapy for womenDialectical behaviour therapy for women

with borderline personality disorder. 12-month,with borderline personality disorder. 12-month,

randomised clinical trial inThe Netherlands.randomised clinical trial inThe Netherlands. BritishBritish


T. Flewett, P. Bradley, A. RedversT. Flewett, P. Bradley, A. Redvers PersonalityPersonality

Psychotherapy Service,PO Box 1729,Wellington,Psychotherapy Service,PO Box 1729,Wellington,New ZealandNew Zealand

Cognitive analytic therapyCognitive analytic therapy

The review by Marks (2003) of our bookThe review by Marks (2003) of our book

Introducing Cognitive Analytic Therapy:Introducing Cognitive Analytic Therapy:

Principles and PracticePrinciples and Practice (Ryle & Kerr,(Ryle & Kerr,

2002) is both rude and misleading. His re-2002) is both rude and misleading. His re-

miniscences about a visit to Leningrad inminiscences about a visit to Leningrad in1966 have nothing to do with the book1966 have nothing to do with the book

and we certainly do not see Pavlovian ther-and we certainly do not see Pavlovian ther-

apy (with which we are entirely unfami-apy (with which we are entirely unfami-

liar) as part of cognitive analytic therapyliar) as part of cognitive analytic therapy

(CAT). His objection to the fact that our(CAT). His objection to the fact that our

explicitly integrative model draws on aexplicitly integrative model draws on a

wide range of sources tells us more aboutwide range of sources tells us more about

the limitations of his own conceptualthe limitations of his own conceptual

framework than about CAT. Theseframework than about CAT. These

limitations are also evident in his inabilitylimitations are also evident in his inability

to understand or unwillingness to mentionto understand or unwillingness to mention

the key features of CAT, which he seriouslythe key features of CAT, which he seriously

misrepresents. These include: (a) focusmisrepresents. These include: (a) focuson reciprocal role procedures, whichon reciprocal role procedures, which

are formed though the internalisation ofare formed though the internalisation of

socially meaningful, intersubjectivesocially meaningful, intersubjective

experience and subsequently determineexperience and subsequently determine

bothboth interpersonal behaviours and self-interpersonal behaviours and self-

management; and (b) the practical empha-management; and (b) the practical empha-

sis on the joint creation of descriptions ofsis on the joint creation of descriptions of

these, which serve to enlarge patients capa-these, which serve to enlarge patients capa-

city for self-reflection and change andcity for self-reflection and change and

therapists ability to provide reparative,therapists ability to provide reparative,

non-collusive relationships.non-collusive relationships.

The reviewers bias is epitomised in hisThe reviewers bias is epitomised in his

discussion of one of the case histories indiscussion of one of the case histories inthe book (pp. 138144). While assertingthe book (pp. 138144). While asserting

that this patient with obsessivecompulsivethat this patient with obsessivecompulsive

rituals would have been better served byrituals would have been better served by

nine sessions of behavioural therapy or bynine sessions of behavioural therapy or by

one session plus computer-aided therapy,one session plus computer-aided therapy,

he fails to record that the patient was pre-he fails to record that the patient was pre-

sented precisely to illustrate the limitationssented precisely to illustrate the limitations

of cognitivebehavioural approaches andof cognitivebehavioural approaches and

does not mention that she had previouslydoes not mention that she had previously

dropped out of an anxiety-managementdropped out of an anxiety-management

group and of cognitivebehavioural treat-group and of cognitivebehavioural treat-

ment. Of this she had noted that the morement. Of this she had noted that the more

her symptoms were worked on, the moreher symptoms were worked on, the moregrimly she hung onto them. This was notgrimly she hung onto them. This was not

a report of the treatment of obsessivea report of the treatment of obsessive

compulsive rituals, it was a summary ofcompulsive rituals, it was a summary of

the psychotherapy of a person, an unhappythe psychotherapy of a person, an unhappy

woman with a history of many years ofwoman with a history of many years of

panic, phobias, obsessivecompulsive beha-panic, phobias, obsessivecompulsive beha-

viours and irritable bowel syndrome. Theviours and irritable bowel syndrome. The

case was chosen, in part, to demonstratecase was chosen, in part, to demonstrate

how focus on presenting symptoms canhow focus on presenting symptoms can

actually be counterproductive and para-actually be counterproductive and para-

doxically collude with the enactment ofdoxically collude with the enactment of

underlying reciprocal role procedures in aunderlying reciprocal role procedures in a

patient who had come to be regarded aspatient who had come to be regarded asdifficult and resistant. This patients listdifficult and resistant. This patients list

of target problem procedures, as workedof target problem procedures, as worked

out with her, included a pervasive needout with her, included a pervasive need

to control both her feelings and otherto control both her feelings and other

peoples behaviours. As is usual in CAT,peoples behaviours. As is usual in CAT,

this formulation, and her therapy, focusedthis formulation, and her therapy, focused

on intra- and interpersonal attitudes,on intra- and interpersonal attitudes,

assumptions and behaviours (procedures)assumptions and behaviours (procedures)and paid little direct attention to her symp-and paid little direct attention to her symp-

toms. Therapy included, importantly, worktoms. Therapy included, importantly, work

on reciprocal enactments with the therapist.on reciprocal enactments with the therapist.

Assessment at termination and follow-upAssessment at termination and follow-up

showed major improvements in her life,showed major improvements in her life,

and psychometric testing demonstrated re-and psychometric testing demonstrated re-

ductions in symptoms at termination withductions in symptoms at termination with

further reductions at 6-month follow-up.further reductions at 6-month follow-up.

We think it unfortunate that so ob-We think it unfortunate that so ob-

viously partisan a reviewer was selected toviously partisan a reviewer was selected to

discuss a book outside his area of expertisediscuss a book outside his area of expertise

and sympathy and that it was consideredand sympathy and that it was considered

appropriate to publish so tendentious aappropriate to publish so tendentious areview of the work of colleagues.review of the work of colleagues.

Marks, I. (2003)Marks, I. (2003) Book Review:Book Review: Introducing CognitiveIntroducing Cognitive

Analytic TherapyAnalytic Therapy (A. Ryle & I. B. Kerr).(A. Ryle & I. B.Kerr). British Journal ofBritish Journal of


Ryle, A. & Kerr, I. B. (2002)Ryle, A. & Kerr, I. B. (2002) Introducing CognitiveIntroducing Cognitive

Analytic Therapy: Principles and PracticeAnalytic Therapy: Principles and Practice. Chichester: John. Chichester: John

Wiley & Sons.Wiley & Sons.

A. RyleA. Ryle CPTS, Munro Centre,Guys Hospital,CPTS, Munro Centre,Guys Hospital,

London SE1 9RT,UKLondon SE1 9RT, UK

I. B. KerrI. B. Kerr Community Health Sheffield NHSCommunity Health Sheffield NHS

Trust, Limbrick Centre, Sheffield,UKTrust, Limbrick Centre, Sheffield,UK

Cinders, you shall go to the ballCinders, you shall go to the ball

Goodwin has described bipolar disorder asGoodwin has described bipolar disorder as

the Cinderella of psychiatry, largely on thethe Cinderella of psychiatry, largely on the

basis of his study showing the relative pau-basis of his study showing the relative pau-

city of research studies in bipolar disordercity of research studies in bipolar disorder

compared with schizophrenia (Goodwin,compared with schizophrenia (Goodwin,

2000). This study has been reinforced by2000). This study has been reinforced by

ClementClement et alet al (2003), who similarly con-(2003), who similarly con-

cluded that bipolar disorder is underrepre-cluded that bipolar disorder is underrepre-

sented compared with schizophrenia andsented compared with schizophrenia and

that this disparity is not declining overthat this disparity is not declining over

time. The importance of this discrepancytime. The importance of this discrepancyis demonstrated by the finding that bipolaris demonstrated by the finding that bipolar

disorder causes a greater global burden ofdisorder causes a greater global burden of

disease than schizophrenia (Murray &disease than schizophrenia (Murray &

Lopez, 1997) and by the huge financial im-Lopez, 1997) and by the huge financial im-

pact of bipolar disorder on society (Daspact of bipolar disorder on society (Das

Gupta & Guest, 2002)Gupta & Guest, 2002)

Clement and colleagues appear to lay theClement and colleagues appear to lay the

responsibility for the relative lack ofresponsibility for the relative lack of

bipolar research on a national shortage ofbipolar research on a national shortage of

specialist clinical services and on the lackspecialist clinical services and on the lack

of interest of researchers. However, clinicalof interest of researchers. However, clinical

services such as our own in the Northernservices such as our own in the Northern

Deanery are flourishing and we suggest thatDeanery are flourishing and we suggest thathistorical difficulties in obtaining publichistorical difficulties in obtaining public

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funding for bipolar disorder are of greaterfunding for bipolar disorder are of greater

impact. Clementimpact. Clement et alet al examined citationsexamined citations

in 5-year periods from 1966 to 2000.in 5-year periods from 1966 to 2000.

However, examination of Medline citationsHowever, examination of Medline citations

on an annual basis between 1996 andon an annual basis between 1996 and

2002 shows that the relative difference2002 shows that the relative difference

between research in bipolar disordersbetween research in bipolar disordersand schizophrenia may be becoming smal-and schizophrenia may be becoming smal-

ler. It appears that this has not beenler. It appears that this has not been

driven by a change in priorities of publicdriven by a change in priorities of public

funding bodies but rather by the presencefunding bodies but rather by the presence

of a private organisation, the Stanleyof a private organisation, the Stanley

Medical Research Institute, which fundsMedical Research Institute, which funds

approximately half of all US studies in bi-approximately half of all US studies in bi-

polar disorder and has provided US$130polar disorder and has provided US$130

million for research since its inception inmillion for research since its inception in

1989. This timely report by Clement and1989. This timely report by Clement and

colleagues should serve as a rallying callcolleagues should serve as a rallying call

to governments and charitable fundingto governments and charitable funding

bodies to give bipolar disorder the prioritybodies to give bipolar disorder the priority

it demands.it demands.

Declaration of interestDeclaration of interest

The authors are supported in theirThe authors are supported in their

research by the Staney Medical Researchresearch by the Staney Medical Research

Institute.Institute.

Clement, S., Singh, S. P. & Burns,T. (2003)Clement, S., Singh, S. P. & Burns,T. (2003) Status ofStatus of

bipolar disorder research. Bibliometric study.bipolar disorder research. Bibliometric study. BritishBritish


Das Gupta, R. & Guest, J. F. (2002)Das Gupta, R. & Guest, J. F. (2002) Annual cost ofAnnual cost of

bipolar disorder to UK society.bipolar disorder to UK society. British Journal ofBritish Journal of

PsychiatryPsychiatry,, 180180, 227^ 233., 227^ 233.

Goodwin, G. (200 0)Goodwin, G. (20 00) Perspectives for clinical researchPerspectives for clinical research

on bipolar disorders in the new millennium.on bipolar disorders in the new millennium. BipolarBipolar

DisorderDisorder,, 22, 302^304., 302^304.

Murray, C. & Lopez, A. (1997)Murray, C. & Lopez, A. (1997) Global mortality,Global mor tality,

disability, and the contribution of risk factors: Globaldisability, and the contribution of risk factors: Global

Burden of Disease Study.Burden of Disease Study. LancetLancet,, 349349, 1436^1442., 1436^1442.

S. Watson, A. H.YoungS. Watson, A. H.Young School of Neurology,School of Neurology,

Neurobiology and Psychiatry, University ofNeurobiology and Psychiatry,University of

Newcastle,Department of Psychiatry, The RoyalNewcastle,Depar tment of Psychiatry, The Royal

Victoria Infirmary, Queen Victoria Road, NewcastleVictoria Infirmary, Queen Victoria Road, Newcastle

uponTyne NE14 LF,UKuponTyne NE14 LF,UK

One hundred years agoOne hundred years ago

Insanity from hasheesh (Insanity from hasheesh (extractextract) by) by

John Warnock, MD, MedicalJohn Warnock, MD, Medical

Director, Egyptian Hospital for theDirector, Egyptian Hospital for the

Insane, CairoInsane, Cairo

In the report for the year 1899 of the Ben-In the report for the year 1899 of the Ben-

gal asylums, it is stated that 45 out of 220gal asylums, it is stated that 45 out of 220

cases admitted were due to the use ofcases admitted were due to the use of

Cannabis Indica.Cannabis Indica.

In Egypt, statistics are available sinceIn Egypt, statistics are available since

the year 1895. During the six years 1896the year 1895. During the six years 1896

1901, out of 2564 male cases of insanity1901, out of 2564 male cases of insanity

admitted to the Egyptian Asylum at Cairo,admitted to the Egyptian Asylum at Cairo,

689 were attributed to the abuse of hasheesh,689 were attributed to the abuse of hasheesh,

i.e.i.e., nearly, nearly 27 per cent27 per cent. Very few female. Very few female

patients used hasheesh, and it is noteworthypatients used hasheesh, and it is noteworthy

that insanity is more than three times asthat insanity is more than three times as

common among the hasheesh-using sex ascommon among the hasheesh-using sex as

among women, who, comparatively, seldomamong women, who, comparatively, seldom

use the drug.use the drug.

I think this difference in the insanityI think this difference in the insanity

rate between the sexes is significant, andrate between the sexes is significant, and

goes a long way to prove the importancegoes a long way to prove the importance

of hasheesh as a cause of insanity amongof hasheesh as a cause of insanity among

Egyptian men. Let it also be rememberedEgyptian men. Let it also be remembered

that in England insanity is more frequentthat in England insanity is more frequent

among women than among men (35 to 31).among women than among men (35 to 31).

My experience does not confirm theMy experience does not confirm the

Indian Commissions belief that CannabisIndian Commissions belief that Cannabis

Indica onlyIndica only sometimessometimes causes insanity. Incauses insanity. In

Egypt itEgypt it frequentlyfrequently causes insanity. As tocauses insanity. As to

whether excessive use of hemp drugs iswhether excessive use of hemp drugs is

commoner here than in India I can givecommoner here than in India I can give

no opinion, but many thousands use it dailyno opinion, but many thousands use it daily

here. Probably only excessive users, orhere. Probably only excessive users, or

persons peculiarly susceptible to its toxicpersons peculiarly susceptible to its toxic

effects, become so insane as to need asylumeffects, become so insane as to need asylum

treatment. Whether the moderate use oftreatment. Whether the moderate use of

hasheesh has ill effects I have no means ofhasheesh has ill effects I have no means of

judging, and this paper is now read to elicitjudging, and this paper is now read to elicit

the opinions of my colleagues in Egypt,the opinions of my colleagues in Egypt,

whose daily practice must give them oppor-whose daily practice must give them oppor-

tunities of studying the effects of the ordin-tunities of studying the effects of the ordin-

ary use of hasheesh. I should be grateful forary use of hasheesh. I should be grateful for

information on this question.information on this question.

I have never met with dysentery orI have never met with dysentery or

bronchitis as the direct result of the use ofbronchitis as the direct result of the use of

hasheesh.hasheesh.

Again, in my experience, I find thatAgain, in my experience, I find that

persons insane from hasheesh have a prone-persons insane from hasheesh have a prone-

ness to commit crimes, especially those ofness to commit crimes, especially those of

violence, and I have a strong suspicion thatviolence, and I have a strong suspicion that

much disorderly conduct results frommuch disorderly conduct results from

hasheesh smoking, just as alcohol amonghasheesh smoking, just as alcohol among

Europeans leads to such misconduct.Europeans leads to such misconduct.

To sum up, the use of Cannabis IndicaTo sum up, the use of Cannabis Indica

in Egypt seems to have graver mental andin Egypt seems to have graver mental and

social results than in India, and is responsi-social results than in India, and is responsi-

ble for a large amount of insanity and crimeble for a large amount of insanity and crime

in this country.in this country.

REFERENCEREFERENCE

Journal of Mental ScienceJournal of Mental Science, January 1903,109^110., January 1903,109^110.

Researched by Henry Rollin, Emeritus ConsultantResearched by Henry Rollin, Emeritus Consultant

Psychiatrist, Horton Hospital, Epsom, SurreyPsychiatrist, Horton Hospital, Epsom, Surrey

CorrigendaCorrigenda

Adolescent precursors of cannabis depen-Adolescent precursors of cannabis depen-

dence: findings from the Victoriandence: findings from the Victorian

Adolescent Health Cohort Study.Adolescent Health Cohort Study. BJPBJP,,

182182, 330336. The full reference to Patton, 330336. The full reference to Patton

et alet al (2002) should read: Patton, G. C.,(2002) should read: Patton, G. C.,

Coffey, C., Carlin, J. B.,Coffey, C., Carlin, J. B., et al et al (2002)(2002)Cannabis use and mental health inCannabis use and mental health in

young people: cohort study.young people: cohort study. BMJBMJ,, 325325,,

11951198.11951198.

Non-right-handedness and schizo-Non-right-handedness and schizo-

phrenia (letter).phrenia (letter). BJPBJP,, 181181, 349350. The, 349350. The

first sentence of the last paragraphfirst sentence of the last paragraph

should read: In schizophrenia, I haveshould read: In schizophrenia, I havesuggested that the gene may lose itssuggested that the gene may lose its

directional coding and become agnosicdirectional coding and become agnosic

for right or left.for right or left.

Long-term outcome of long-stay psy-Long-term outcome of long-stay psy-

chiatric in-patients considered unsuitablechiatric in-patients considered unsuitable

to live in the community. TAPS Projectto live in the community. TAPS Project

44.44. BJPBJP,,181181

, 428432. Table 1 (p. 430), 428432. Table 1 (p.430)should read:should read:

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8 181

Table 1Table 1 Changes in patientsmeasures at 1-year and 5-year follow-ups (Changes in patientsmeasures at 1-year and 5 -year follow-ups (nn61)61)11

VariableVariable BaselineBaseline22 1 year1 year22 5 years5 years22 Baseline minusBaseline minus

1-year score1-year score33

95% CI95% CI BaselineminusBaseline minus

5-year score5-year score33

95% CI95% CI PP

Present State ExaminationPresent State Examination

Total scoreTotal score 17.8417.84 14.6114.61 17.1617.16 772.572.57 777.48 to 2.337.48 to 2.33 0.580.58 773.34 to 4.513.34 to 4.51 NSNS

Negative symptomsNegative symptoms 1.111.11 1.491.49 1.821.82 0.280.28 770.12 to 0.680.12 to 0.68 0.650.65 0.24 to 1.070.24 to 1.07 550.0030.003

Delusions and hallucinationsDelusions and hallucinations 4.264.26 4.414.41 4.644.64 0.240.24 771.90 to 2.401.90 to 2.40 0.700.70 770.91 to 2.310.91 to 2.31 NSNS

Social Behaviour ScheduleSocial Behaviour Schedule

Total scoreTotal score 6.076.07 5.975.97 5.075.07 770.060.06 770.75 to 0.630.75 to 0.63 771.001.00 771.91 to1.91 to770.090.09 550.0330.033

Basic Everyday Living SkillsBasic Everyday Living Skills

DomesticDomestic 10.3610.36 11.1411.14 13.5513.55 0.780.78 770.76 to 2.320.76 to 2.32 3.193.19 1.24 to 5.141.24 to 5.14 550.0020.002

SocialSocial 6.796.79 7.467.46 7.927.92 0.820.82 770.01 to 1.730.0 1 to 1.73 1.541.54 0.29 to 2.790.29 to 2.79 550.0170.017

Self-careSelf-care 20.4920.49 20.5320.53 23.8423.84 00 770.90 to 1.900.90 to 1.90 3.833.83 1.58 to 6.081.58 to 6.08 550.0020.002

CommunityCommunity 5.895.89 5.975.97 7.027.02 0.230.23 770.59 to1.050.59 to 1.05 1.291.29 0.30 to 2.290.30 to 2.29 550.0120.012

Social Network ScheduleSocial Network Schedule

Total namesTotal names 10.3310.33 7.727.72 7.217.21 773.673.67 778.32 to 0.998.32 to 0.99 772.622.62 776.34 to 1.116.34 to 1.11 NSNS

1. Patients who died during the 5 years have been excluded.1. Pa tients who died during the 5 years have been excluded.2. The numbers of patients in these columns differ. Thus, for Present State Examination total score, data were available for 57 subjects at baseline, 70 at1 year and 56 at 5 years.2. The numbers of patients in these columns differ.Thus, for Present State Examination total score, data were available for 57 subjects at baseline, 70 at 1 year and 56 at 5 years.3. Only patients with data at the two timepoints being comparedare included in the analyses.Thus,for Present State Examination total score the comparison betweenbaseline and13. Onlypatients with data at the two timepoints being comparedare included in the analyses.Thus,for Present State Examination total score the comparison between baseline and1year involved 54 subjects and that between baseline and 5 years involved 43 subjects. Further details available from the authors upon request.year involved 54 subjects and that between baseline and 5 years involved 43 subjects. Further details available from the authors upon request.

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