Nick Read » Medicine

How you make me feel; projection and its identification.

Nick Read — Sat, 09 Apr 2011 21:06:44 +0000

Why do we trust some people and not others? Why do we admire some people? Why do some people make us uncomfortable? Is it because they remind us of significant figures in our lives; our mother, our father, a brother or sister, a lover, a husband, wife, a teacher? Are they suitable objects for our projections?

Projection is a ubiquitous feature of human nature. It is the cornerstone of evolution; what makes us human; the effect of an opposable thumb. As soon as we could throw, we could make things happen; we could control the future (see Projection, the missile of evolution. December 24^th, 2010), but this required us to perform the mental trick of imagination; to think the way things might be, to make believe.

Psychological projection performs that same mental trick, it transfers what we feel onto somebody else, to imagine it is they who have those some feelings and attitudes. So we protect ourselves from psychic damage by projecting the bad stuff onto those we recognise already possess some of the characteristics we want to get rid of. ‘She’s just so selfish.’ ‘I can’t trust him’. He’s so lazy, careless, unreliable, fussy, messy. This happens all the time. Just listen to how ‘a gossip of girls’ on the train criticise absent ‘friends’. Look at how politicians try to achieve a semblance of dominance and control by rubbishing their competitors; how newspapers take hold of that and amplify it. But it’s not just bad stuff. Idealisation is a kind of projection. When we admire somebody, respect somebody, fall in love with somebody, we transfer our wishes for how would like to be onto that person. They become a mentor, a role model, an object of desire.

Projection starts, like everything else, in childhood. Children deal with uncomfortable feelings like fear and anger by externalising them. First identify your enemy, locate all the bad stuff into them and then you can justify an attack. Or identify the one you admire, locate all your wishes in that person and make them your best friend. Projection is a mental trick. There are goodies and baddies; in my childhood these were cowboys and Indians; the English and the Germans. How differently you see things as you grow up. Maturity is a state of recognising the bad feelings, taking them back and containing them, realising that what we criticise in other people is also part of us, accepting our essential humanity.

Groups, organisations, institutions, governments, states, do it all the time. They are pathologically split; they operate at a very childlike manner and project all their own concealed characteristics, especially the bad ones like unreliability, inadequacy, lack of sophistication, to say nothing of selfishness and ruthlessness onto their competitors. Colonel Gadaffi is currently the embodiment of all evil though only a few years ago, he was our special friend. But the only thing that’s changed is our own projections. Members of an exclusive culture, music critics, art enthusiasts, historians, theatre buffs, vintage car collectors, can tend to puff themselves up by broadcasting their lacunae of esoterica to an audience they assume knows nothing and can be diminished by their ignorance.

But projection can only really work in society if others identify with it. This is what the psycholanalysts (another in- group) call projective identification or to put it in everyday speak, ‘how others make us feel’. In voodoo, pointing the bone can cause others to feel so guilty by inference whether they are or not, that they slink away and die. They have been ostracised from the tribe; they are not worthy to belong anymore and they cannot therefore survive. Social exclusion is a powerful force; guilt and shame, powerful identifications. People who have done something shameful to attract the projections of others, who use it as a shield for their own shame. And it’s always the ones with most to be ashamed of that seek out those they can offload on to. Those who feel unhappy make those who are close to them unhappy too

Projective identification operates in so many aspects of human behaviour. Bullies can’t contain their own fear, so they make others frightened of them. Suspicious people are secretive and engender mistrust and lies. Needy people cannot give and induce need in others. Those who are envious put on airs and graces to try to make others envy them. Lovers who feel insecure may do something to make their partners feel jealous. Unhappy and lonely people make those who are close to them unhappy too because at least they are toegether in their misery. Teachers, who are not confident, can make their students feel stupid, but equally the over-confident student can make a teacher defensive. ‘You make me feel sick, you make me so angry, you just make me depressed.’ These are all common identifications within relationships.

Those who carry a grudge are attracted to political groups, but can be very dangerous because they can cause others to feel bad and act out. So did Ian Brady make Myra Hindley do it. Projective identification is never a justification in law but it happens.

War is mutual projection as each side used propaganda to unsettle the other. Sport is the same. Winning the mental battle wins the war or the tennis match. Do not flinch; maintain the upper hand. And we the observers so want the underdog, the good guy to win, we will do all we can to inspire him with our enthusiasm. It almost worked with Tim and we’re trying our best with Andy, the nearly men of British tennis.

Some doctors are so anxious they can make their patients terrified. Michael Balint, the author of ‘The Doctor, the Patient and the Illness’ recognised this. Patients pass the anxiety of not knowing what’s wrong with them on to the doctor, so that he orders more tests in order not to appear a failure. Or their attitude may make their doctors feel angry, depressed, tired. Emotional transference is such a powerful phenomenon. As a therapist, I had always marvelled at how one client could make me feel so wound up and energetic; the next so tired I could fall asleep and have actually done so, but they were lying on the couch and I was sitting behind them and they never noticed.

Actors are masters of projection. They tune into their audience and can make us all identify with the emotions they project. I have had two actors in therapy. One made me feel so angry, I actually had chest pain and needed to ask him to leave. The other made me feel such surges of desire and compassion, it was all I could do not to take her in my arms and love her right there and then.

But it’s not all negative. We can also use projection to bring out the best in people. Look at the way babies project their hunger onto their mother, who identifies with it and feeds them. Falling in love feeds upon itself. We project our beliefs and feelings into those whom we love and if they love us too and are a suitable object for our projection, they identify our desire and act in a way that intensifies it.

Lovers give each other those feelings of security, excitement, togetherness, they’ve been looking for all their life, but what then happens to the bad feelings? Well, if they can never let this love become as imperfect as the rest of life, then these feelings are projected out onto others, and the exclusive couple clings together united against the world, unable to trust anybody else. But most marriages are not like that. They are states of mutual projection and identification, and partners try to look after their own well being by making their partners shoulder the blame and feel bad. You never think! You’re totally selfish! I just can’t rely on you. In a way they need the other to get rid of the bad feelings. When it works well, it’s a trade off. One may make the other feel alive while the other projects a feeling of safety. It works. The problems come when one of them changes the dynamic; meets somebody else, suffers a setback that destroys their confidence, accepts a job that satisfies their needs.

Projective identification requires us to think. When somebody behaves angrily or badly to us, we need to reflect on our own attitude and behaviour and the reason for it. How did it all start? What was the trigger, the fear? We all have responsibility in our functioning society to bring out the best in people, the most constructive response, but in a narcissistic, self seeking society, people all too often have to have their own way, because ‘we’re worth it’. It may be unfashionable to say, but I do believe that we have the friends, the colleagues, the children and the relationships we deserve because we help to make them the way they are for us

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Chaos in the Bowels

Nick Read — Mon, 27 Sep 2010 14:07:40 +0000

Jules Henri Poincare (1854 – 1912) was in trouble. The most famous mathematician of his generation, he set himself the task of predicting accurately the orbits of the earth, moon and sun. His solution was brilliant. It was nominated for a prestigious international prize, but just before he was due to present his theory and collect his award, he found he had made a mistake. If he had used different assumptions at the outset, he would get very different results. Mortified, he wrote a follow up paper explaining his mistake, but in so doing, made the first mathematical contribution to what became known as chaos theory, though this aspect of his work was largely ignored until the 1970s when ‘chaos’ became the rule for many systems.

Chaos is evident in all aspects of life. Weather forecasting is an exercise in probabilities because we can never be sure of the starting conditions. We can’t factor in all the variables. This is why it is said that a butterfly flapping its wings in West Africa will result in a typhoon is south- east Asia. It’s not meant to be taken literally, just a mathematical possibility to illustrate how small unconsidered variations can cause enormous effects.

And take sport. They said England had a good chance of winning The World Cup this year, but what went wrong? Could a glance across the table by a teammate’s wife have set in train a sequence of events that unsettled the captain, led to a players revolt against the coach and culminated in a catastrophic collapse of confidence?

And what about politics, computing, and the stock market? Somebody can’t sell his house in Wisconsin and we end up with a global recession. Or the rail network. The wrong leaves on the line in the Home Counties and business in the City of London slithers to a halt. Small variations can have massive effects. A tiny wobble in the orbit of an asteroid could destroy all life on earth.

And in medicine, a small change in environmental conditions, a particular event, can so easily bring about illness. Perhaps a tune on the radio could revoke a memory that could upset the gut and result in an argument that ends a marriage. With no chance at resolution the gut upset persists as unresolved IBS. When scientists do trials of treatment, they try to hold all the conditions constant. This is what is called a controlled study. It relies on certain assumptions about which factors are important. Age and gender may be controlled, diet might be in a few studies, emotional factors almost never and yet these may be crucial. So they can never really control the outcome. If they make the same measurements 100 times in the same patient and they will come up with a hundred different results. So what do they do? Employ a statistician to tell them an answer they might (or might not) be able to rely on! But they still might be ignoring certain crucial factors because they don’t think they count or they are impossible to control. As Albert Einstein declared, ‘Not everything that counts can be counted. And not everything that can be counted, counts.’

Irritable Bowel Syndrome is an idiosyncratic disease. It is more an expression of the personality, life experience and life style than those variables that can be easily measured. Moreover it can’t be easily defined because there is no identifiable change in body structure or chemistry. It is whatever doctors say it is. No wonder treatment is so variable and so personal. It’s an exercise in chaos; a bit of a lottery. What works for one person may not necessarily work for another. But you can cut down the variability by reading the self management programme and getting to know about your illness, yourself and with some guidance managing your own symptoms.

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Visionary or Disaster; a perspective on William Sargant

Nick Read — Sun, 21 Mar 2010 18:55:37 +0000

We don’t hear very much about William Sargant now, but in his day, he was the most eminent figure in British psychiatry, a large man with a leonine profile and convictions as strong as his character; somebody you obeyed and never argued with. David Owen, one time British foreign secretary, worked under Sargant at St Thomas’ in the 1960s and recalled him as “a dominating personality with the therapeutic courage of a lion” and as “the sort of person of whom legends are made”. But others, who preferred to remain anonymous, described him as “autocratic, a danger and a disaster” He was a man who could excite strong opinions.

Although he was part of the listening profession, Sargant wasn’t a great listener. Describing himself as “a physician in psychological medicine”, he abhorred psychotherapy and dedicated his life to leading the biological revolution in psychiatry, promoting such treatments as psychosurgery, deep sleep treatment, electroconvulsive therapy, insulin shock therapy and the development of mind altering drugs. He had the courage of his convictions, but his reliance on dogma rather than evidence have made him a controversial figure. His book, Battle for the mind, a physiology of conversion and brainwashing, written with the help of Robert Graves, emphasises the apparent need for evangelists and politicians who would change people’s minds to excite them first.

William Walters Sargant was born in 1907 into a ‘larger than life’ Methodist family in North London. Five of his uncles were Methodist preachers, one brother was a bishop; another, Thomas Sargant, a human rights campaigner.

He got a place at St John’s College, Cambridge and became President of The Cambridge University Medical Society. He did his clinical training at St Mary’s, where he excelled in the Hospitals Rugby Competition. Too impulsive and sure of himself to be a great academic, his one foray into medical research, a paper on the use of large amounts of iron to treat pernicious anaemia was criticised and this may have led to his mental and physical breakdown and his subsequent shift to psychiatry, where the absence of validated treatments gave him free rein to develop his convictions.

It was at the Maudsley under Edward Mapother that Sargant became convinced that ‘the future of psychiatric treatment lay in the discovery of simple physiological treatments which could be as widely applied as in general medicine‘. During the war, Sargant worked at the Sutton Emergency Medical Service but was frustrated when London County Council medical advisors tried to curb his experimentation with new treatments but, as he said “we generally got our own way in the end”.

While at Sutton, Sargant treated veterans with battle trauma by abreaction, deliberately getting them to relive their experience on the premise that it would eventually wear away. He described a man who was shot at by German pilots as he swam out to the boats at Dunkirk, experienced all over again the terror of drowning but then walked away from the session without a care in the world. Sargant never really validated or controlled his studies or even analysed the results of his treatments. He was no scientist; he just did what he considered right.

In 1948 he was appointed director of the department of psychological medicine at St Thomas’s Hospital, London, and remained there until the 1980s. There he developed his procedures for ‘brainwashing’ . He created a 22 bed sleep ward on the top floor of the adjacent Royal Waterloo Hospital,, in which he would keep his traumatised patients in a continuous state of heavy sedation for periods of up to three months and subject them to insulin coma therapy and frequent electroconvulsive treatment. This brainwashing, he claimed, re-patterned the brain, wiping it clean of the traumatic experience so that when they woke up they couldn’t remember what had happened .

Sargant also advocated increasing the frequency of ECT sessions for those he describes as “resistant, obsessional patients” in order to produce “therapeutic confusion” and so remove their power of refusal. “All sorts of treatment can be given while the patient is kept sleeping, including a variety of drugs and ECT [which] together generally induce considerable memory loss for the period under narcosis. We may be seeing here a new exciting beginning in psychiatry and the possibility of a treatment era such as followed the introduction of anaesthesia in surgery”.

No informed consent was requested for what was an experimental procedure. No systematic study ever validated Sargant’s cerebral lavage, but there are patients still alive who claim never to have recovered their pre-traumatic memory and become profoundly incapacitated as a result. Sargant, himself, ascribed such failures to the patient’s lack of a “good previous personality” and discharged them to the wards of long stay mental hospitals. These patients have never been compensated. All patient records at St Thomas’s and the related health authorities relating to Sargant’s activities were destroyed.

But there was worse. When Harry Bailey, an Australian psychiatrist enthusiastically adopted Sargant’s methods with enthusiasm, 26 of his patients died. Sargant also admitted some fatalities. The fact that more had not succumbed was almost certainly due to the quality of care by the St Thomas’s ‘Nightingale’ nurses, who monitored the patients sleep every 15 minutes and woke them up every six hours for feeding and toileting.

Sargant’s ward was closed soon after his death in the 1980s; his books removed from the libraries, his influence suppressed, his opinions castigated.

One of my teachers, a surgeon, used to tell us that there were three types of doctor; the good, the bad and the downright dangerous. Sargant was the latter. Evangelism and conviction are dangerous qualities in medicine and Sargant has been roundly condemned as ‘someone of extreme views who was cruel and irresponsible and refused to listen to advice’; some suggested that he was motivated by repressed anger rather than a desire to help people. In medicine, tyranny is dressed in a white coat.

But Sargant was a man of his time. Revolutions would not occur without the extremist, the outspoken, the dogmatic and the domineering. So those who would praise modern developments in the pharmacological treatments of schizophrenia, dementia and depression, have a debt of gratitude to Sargant the prophet, who had to be condemned for his extremism.

For medicine is a profession that requires us to listen, make careful observations and assess any new definitive treatments by the most scrupulous scientific methods. Doctors have to be seen as caring and careful. I once knew a doctor who had the unfortunate surname of Reckless; he should have changed it.

But, in Sargant’s defence (which is a bit like the defence of indefensible) the effects of new psychiatric treatments are not easy to assess. There are no measureable end points like inflammation, blood pressure, blood sugar levels. There’s just patient testimony. ‘Yes, I’m feeling much better, thank you.’ Good results may be more due to the care and attention of the doctors and nurses than any effect of the treatment. It all depends how you ask the question and what statistical methods are applied. Powerful advocates and suggestible patients can still produce ‘effective’ treatments. Perhaps that’s the nature of the mind; it’s confidence and faith that heals the traumatised psyche – and there are many routes to that. In a therapeutic wilderness, the most important thing is to be mindful to select treatments that do not have the potential to damage.

Take antidepressants (or don’t take them), the most commonly prescribed drugs in the western canon. Are they effective, or do they just dull the sensibilities, sanitise the anguish and despair, and keep people in depression by suppressing the motivation for change?

Even Sargant acknowledged, albeit in typical grandiose manner, how psychiatric treatments may strip away the personality and motivation.

“What would have happened if such treatments had been available for the last five hundred years?… John Wesley who had years of depressive torment before accepting the idea of salvation by faith rather than good works, might have avoided this, and simply gone back to help his father as curate of Epworth following treatment. Wilberforce, too, might have gone back to being a man about town, and avoided his long fight to abolish slavery and his addiction to laudanum. Loyola and St Francis might also have continued with their military careers. Perhaps, even earlier, Jesus Christ might simply have returned to his carpentry following the use of modern treatments.”

A recent systematic review could not establish any efficacy for the newer antidepressants, the latest generation of Sargant’s mind altering drugs, though they all have significant adverse effects. So why are billions still taking them? What does it say about society and those who run it?

Sargant, the maverick, the charismatic loner, the one who dared but was considered out of step and downright dangerous, was as described in his autobiography, ‘A Quiet Mind’, a heavy smoker, suffered with tuberculosis and struggled with depression for most of his life. It was his karma, (the collective guilt of a family of preachers?), and he lived up to it by putting his patients and his own reputation in considerable danger. Was this some death wish, some demon of self destruction? Winston Churchill, another depressive, comes to mind; so wonderful but so dangerous – relishing the excitement of risk, rushing up to the roof of 10 Downing Street during the blitz to watch the fireworks, but suffering agonies during peacetime inactivity. No wonder Clemmie found him difficult.

David Owen who admired Sargant’s courage and spirit, has recently written a slim volume on hubris, in which Sargant doesn’t even get a mention. Ah!

William Sargant was the subject of a Radio 4 documentary ‘The Mind Bender General’, first broadcast in 2009 and repeated last Wednesday.

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Dr Haggard’s Disease

Nick Read — Sat, 12 Dec 2009 19:32:14 +0000

It was 1937; and there was trouble on the horizon. They recognized each other at a funeral. There was a spark. Then they found they were sitting next to each other at the Cushing’s dinner party. He was Dr Edward Haggard, house surgeon at St Basil’s and a bit of a loner; she, Fanny Vaughan, a delicate dark beauty; older, more sophisticated than he and married to the Senior Pathologist. They conversed easily. She made him feel confident and clever. She laughed a lot. She insisted they talk about pleasure, not medicine. Wickedly, she asked him if surgeons made good lovers. Amazed at his temerity, he replied ‘try me’.

She did. Their affair started a few weeks after. It was she who made the running and set the limits. They would meet, make love in his room, and then part without agreeing further assignations. He would be in an agony of anxiety until she reappeared. But slowly, a pattern emerged. She bought stuff for his room; rugs, lamps, bed cover, flowers unguents, transforming it from a monastic cell to a boudoir. Then she got careless. On a whim, she came to meet him in the hospital. They made love on a bench in the hospital lobby. She was spotted and word got back to her husband.

When next Edward met the senior pathologist, they argued. Dr Vaughan hit him and he fell down the stairs, breaking the neck of his right femur. It was a double blow. Fanny broke off their relationship and refused to see him again.

Edward’s recovery was slow. It was as if the pain of his grief was transferred to the pin in his hip. Whenever he thought of her, it attacked him. He became addicted to morphia.

He was sacked from St Basil’s and left to take over a remote single handed general practice on the south coast. He thought of Fanny constantly and was determined to keep their relationship alive n his mind. At times, her presence was so strong, he could smell her perfume, hear her voice, feel her softness of her skin. He even took to wearing her fur coat.

Then James, Fanny’s son, came to visit him, a slim delicate dark haired boy, much like the mother. He was stationed at the nearly RAF base. They became friends. He learnt that Fanny had died of nephritis, but he felt he had regained her through the son. One day, while treating James for a shrapnel wound, he noticed that James did not only have his mother’s soft skin, he had ambiguous genitalia and some breast development. It was like he was transforming into her. James was killed when his Spitfire crash landed. Edward cradled his head in his arms, kissed her for the last time.

As in his other novels, Spider and Asylum, Patrick McGrath has written a dark gothic suspense on a background theme of mental illness. What was Dr Haggard’s illness? He had fallen in love with Fanny, and whereas she was much more realistic and in control, he had imbued her with all the virtues and attributes. He made up stories. She was the victim bride of a bully. He had to rescue her. She would run away with him. She was the missing half that would make him whole. But for Fanny, it was an affair, a thrill, a bit of excitement in an otherwise dull life. It had a beginning, a climax and an end.

The ending was cruel, she was ruthless. He was devastated. But even after she rejected him, Edward still continued to worship her idea. He suffered agonies in his hip from his broken heart but he would not, could not, let go. Without her, there was no meaning in life.

Meeting his son restored the connection, but that was when reality and fantasy entwined. The body was transforming into hers’. He became his angel, a high flyer, who would die consumed by fire. His love had been returned to him. And Edward was transforming too into a small figure in a black fur. He was merging with her.

So as the story limped its painful path to a catastrophic conclusion, we realize that Edward is not only deluded but hallucinating. With penetrating insight and consummate skill, McGrath has once again demonstrated the power of infatuation to instigate the decline of a lonely personality into obsessive psychosis.

Edward Haggard was always at risk. He was intensely solitary, much preoccupied with metaphysics and passionately fond of poetry. His father was a rector and Edward ‘had all the makings of a certain type of priest’. It was predictable that he would imbue their affair with so much more meaning than she. He would create a phantasy (Melanie Klein’s spelling) out of it and would continue to inhabit that phantasy even though the reality had long gone. His disease was an excess of meaning, a toxic imagination. What started as the sort of identification that all lovers experience, descended by degrees to fixation, obsession, delusion and hallucination. There is a point in the story when we realize that things are not right, perhaps the embodiment of Fanny in James. After that we begin to question the whole fabric of the story. How much of it was delusion and when did it take hold? There was probably an affair – some crisis had to propel Edward out of Earth’s orbit – but did he ever meet James, did James ever exist, did Fanny become frightened by his obsession with her and was Ratcliffe really the boorish bully he described?

The make believe of love cannot last. It has to be transformed into the fond reality of everyday life or shatter and be rationalized as a mistake. Edward could do neither. He preserved his meaning, fed it, allowed it to grow until it took over his whole personality, disconnecting him from the conventions of society and ultimately defining him as mad. In selfishly seeking out the sensitive man who would provide some meaning to her life, Fanny never considered the possible consequences.

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How to keep your shape when all about are losing theirs; is there an answer to the obesity epidemic?

Nick Read — Sun, 29 Nov 2009 13:42:15 +0000

For the last twenty years, we have been getting noticeably fatter. Rates of obesity in America and Western Europe have more than doubled since the nineteen eighties. And the problem shows no sign of diminishing. If trends continue, it has been estimated by 2050, one in two adults and one in four children will be obese with all the health risks that entails; coronary heart disease, strokes, high blood pressure, diabetes, cancer, arthritis, gallstones, accidents and a profound reduction in life expectancy. Alongside loneliness and depression, obesity is one of the three major public health issues of our time.

So what is going on? Weight gain is not a mystery. Fat does not materialise out of nowhere. Obesity can only be explained in terms of an imbalance of energy consumption over energy expenditure. Fat people are eating too much and not exercising enough. It’s all down, so cynics assert, to a combination of gluttony and sloth, a gross demonstration of moral failure. But is that a fair indictment? Some people may have a genetic tendency to put on weight; after all, the biggest risk factor for obesity is having parents who are overweight or obese. The idea that a pre-history of starvation might have selected a thrifty gene was currency until very recently, through we now know that the way we conserve energy is under the control of several different genes.

And there is also an environmental issue. The Foresight Report, published in 2007, declared that obesity is a normal response to an abnormal social environment. The watchword is convenience. People in the west are money rich and time poor. There is always too much to do. Time must not be wasted. We eat fast food and get around in fast cars, trains and planes. Time spent on cooking, the cost of food, buying local food, growing our own food have all decreased. Fewer people grow their own vegetables or buy local produce. We have become disconnected from food.production and preparation in the same way as we are uncoupled from the use of our own legs to get around. Fewer people are walking or cycling to work. Children are taken to school by car. And fewer people engage in energetic sports or activities. On the other hand, the availability of fast food outlets, low cost bistros and restaurants, food variety, food promotion and portion sizes have all increased alongside the ownership of cars and improvement in public transport. In fact, less and less people need to go to work any more. They can just plug into their virtual Microsoft office and stay at home. We are rather like the cafeteria rats, who, when confined to their cages and fed a varied, appetizing diet in abundance, grow enormously fat.

This fast food, car based revolution has given licence for passive overconsumption and immobility. With too many opportunities to eat and less requirement for physical activity, people cannot help but gain weight, or so it seems. Fast, convenience food is cheap and rich in fat. Restaurants tend to serve big portions of high fat foods. And people tend to eat what is put on their plates. One experiment showed that when soup was presented in a bottomless, refillable bowl, people just kept eating. Time that might be spent in physical activity is all too readily plundered by the computer and television. The exhausted boredom, induced by the tedious combination of overstimulation and inertia can tend to cause people to seek solace in comfort eating.

But if it was just the environment that was responsible for the obesity epidemic, then why aren’t we all fat. 80% of adults living in an obesogenic social environment are not obese and 40% are not even overweight.

Take the French, for example; they traditionally eat a diet that is so high in cholesterol and fat and yet have less heart disease and obesity. The most obvious explanation is portion size. Dr Paul Rozin in a recent article entitled ‘The Ecology of Eating’ showed that portion sizes for the same meals were 25% per cent larger in the United States than in France. Barbara Rolls showed that increasing portion sizes over the course of a week increased energy intake by 4,500 Cals, equivalent to 1.5 Kg of fat. Increasing the consumption of fat resets physiological satiety mechanisms, so that more fat can be accommodated and people want to eat the same high fat meal again. People often notice a marked increase in appetite and weight after the annual Christmas blow-out. The opposite works after starvation; fat receptors can be up or down-regulated. Exercise is good because it blunts this desensitisation and hunger.

The way food is served, the availability, variety, portion size and even the shape of plates all have a role in increasing intake. We eat more when food is prepared by someone else. If we are eating with others, we tend to conform to the norm. Food outlets tend to serve the most enormous portions. They give too much choice and choice is inimicable to regulation. When people are presented with a meal containing a variety of foods, they will eat much more than if they are given limitless quantities of the same food.

So the answer to preventing obesity seems so easy. If it is just a matter of the environment, then all you have to do is alter your personal environment. Eat less, cut down on portion sizes, choose low fat foods, don’t have seconds, don’t eat between meals, ration chocolate and alcohol, cook at home, only eat meat twice a week, cut down on butter, pastry, don’t rely on public transport so much, walk, cycle, take regular exercise. Take control of your life. Go on a diet. Put yourself on an exercise regime. About 70% of women and 30% of men claim to be on weight reducing diet. So why for most, doesn’t it work?

Twenty years ago, the journalist, Geoffrey Cannon, published his eye catching title, ‘Dieting makes you fat’. His thesis might be explained in part by the facts that it is fat people who tend to diet and it is very difficult to lose weight by dieting. But there is another factor; if you deprive somebody of something you will increase the desire for it, and when they are let off the hook, they will rapidly eat more. Dieters tend to crave food and the foods they crave the most are those that they are trying to resist.

Disinhibited eating is enhanced by the last supper effect (I’ll just have one more chocolate, then I’ll stop) and the what the hell effect, (oh, now I’ve had sticky toffee pudding, I may as well have another portion), as well as by alcohol consumption, eating alone, the behaviour of co-diner, and negative mood. Dieting is more difficult when people are under an increased emotional load and feel brittle. The hedonic tendency to eat between meals might indicate an insecurity that demands satisfaction through the most basic source. Walking on the moors in late spring, I notice how lambs rush to their ewes to suckle as soon as I approach. Is that an example of the same insecurity?

The overwhelming temptation to break one’s diet is an illustration of what psychologists call, ‘Wegeners White Bear Effect’. The more you try to suppress any thoughts about something, the more you will tend to think about it, which results in a rebound in the behaviour you are trying to suppress. Suppression can make people exquisitely sensitive to environmental cues. The eponymous heroine in the novel, Leila’s Feast, illustrates how starvation can make somebody very aware of food. Leila wrote her cookery book while she was starving in a Japanese prisoner of war camp. A recent UK survey showed that people tended to think about eating 200 times a day. This might suggest that they were exerting a tight control on their eating behaviour, which would just enhance the craving for food.

You have to devote time and thought to cooking healthy meals. It takes too much work to exercise. It’s all too hard, especially if you are doing it against such a resistance. In the past, if we didn’t work, we would starve. Now our eating has become uncoupled from the production and preparation of food. We don’t need to work to get our meals, so why should we? If food is there, why not eat it? So perhaps human nature hasn’t changed that much, we may have always tended to be lazy and greedy.

But this still doesn’t explain why we aren’t all fat. Maybe it’s all down to the culture of eating. The French eat less but spend more time eating. They make more of an occasion out of eating; the ambience is different. The French tend to eat together. A meal serves more functions that just the supply of energy. Eating is part of a whole sequence of social grooming. Eating together with family and friends provides relaxation, companionship, comfort and reassurance. A family that eats together tends to stay together. One in five families in the UK sit down to eat together only once or less than once a week. Many people in the United States or in Britain eat alone and can miss out on the social benefits of mealtimes and so may consume extra large portions to compensate for a degree of social deprivation.

So is overeating related to deprivation? It is well known that people who have been subjected to starvation tend to stockpile food, eat up every last morsel and overfeed their children. Population studies have shown a definite link between poverty and obesity, but not all poor people get fat. The historian, Peter Brears, suggested that working mothers lose the skill and the time to prepare meals and tend to rely more on convenience food, rich in fat. In the Foresight report the only group who are less likely to become obese are reasonably affluent women living in the south east of England who have the time to keep fit and choose healthy dietary options.

But since mealtimes are a whole nurturing experience rather than just a nourishing experience, is eating a surrogate for other types of deprivation? Does the loneliness and depression that is also so prevalent in the United States and Britain, make them more likely to turn to food for comfort and solace? People who don’t actively engage in life get bored and eat to feed their interest and confidence rather than their body. When I conducted psychological interviews on patients with morbid obesity, I uncovered a severe degree of loneliness, depression and emotional deprivation. So is there a typical obese personality; insecure, needy, bored and chaotic, the sort of person who might tend to turn to drugs, alcohol, cigarettes, love and companionship as well as food to satisfy their compulsive needs? When something happens, a person’s ability to regulate their food intake gets disturbed alongside regulation of other behaviours, sleep, mood and bowel habit, for example. There are super-regulators, who intensify their control and tend to lose weight and others, who are perhaps more chaotic and needy, who become dysregulated and obese. So do food manufacturers and restauranteurs just supply what is needed so badly?

A recent report suggested that the tendency of people to use food to satisfy their emotional needs may be gender specific. The psychologist, David Lewis, was recently reported as saying that when it comes to tongues, melting chocolate better than passionate kissing, at least for women. All men know that sex is better than chocolate; for women it’s the other way round..

So have psychological factors, such as life traumas, deprivation, need, loneliness and depression, which seem to have increased over the same period impacted with the environmental changes to create the current obesity epidemic? And how much of a role do genetic factors play?

The current obesity epidemic is such a complex mix of mind, body and meaning with culture, history and development each playing their part. There is no easy explanation, though the interaction of the loneliness, boredom and insecurity of modern life with the abundance of cheap high energy foods and the reduced requirement for physical work seem to be essential drivers.

So how can we remain slim and healthy in an obesogenic environment? Maybe the answer is to dare to stand out from the crowd and adopt an active, healthy and interesting life style where eating is not a predominant factor. Children, who go on the fat camps run by Dr Paul Gately, lose weight as they gain in self esteem. So the message is don’t rely on dieting; this is almost like treating deprivation with deprivation. Don’t necessarily diet (though you may just watch your weight), but get out there, do things, be active, get involved and maybe, just maybe, you can allow your weight to look after itself just fine.

This article was inspired by a talk delivered by Andrew Hill, Leeds Professor of Health Psychology, to the Guilds of Food and Health Writers at their joint meeting at Artisan, Booth’s bistro in Kendal, Cumbria.

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Not so much a Dame as a Sheila!

Nick Read — Tue, 18 Aug 2009 20:29:53 +0000

I was the first candidate after lunch. I waited nervously outside sister’s office. The lady arrived late and loud, flanked by two co-examiners, who were chuckling politely.

She glanced at her clipboard and announced briskly; ‘Now, Dr Read, examine this man’s chest.’

I carefully went through the procedure, inspection, palpation, percussion, auscult………

‘Hurry up! Hurry up!’

‘I think the patient has a right pleural effusion,’ I offered tentatively.

‘You only think he has! You’ll have to do better than that. Now, examine this mans heart.’ She wafted an imperious arm in the direction of the next bed.

I got out my stethoscope, bent over the patient, but before I could listen to his heart, I heard the lady comment.

‘He’s alright, but he’s very nervous!’

A resolve, like controlled anger, stiffened inside me. I was quick.

‘Opening snap, mid-diastolic murmur with presystolic accentuation, splinter haemorrhages under his nails; Mitral Stenosis with SBE.’

‘OK. Next.’

‘Intention tremor, nystagmus. This patient has cerebellar ataxia.’

‘Next.’

‘Enlarged liver and spleen. Rubbery Lymph nodes in both groins. I suspect lymphoma.’

‘Good! Now, just examine this mans eyes and anything else you think might be relevant.’

The patient eyed me with mischief. I got my ophthalmoscope out and noted he had microaneurysms, blot haemorrhages, hard waxy exudates. I took in the puncture marks, the lumps of fat under the skin of his abdomen. With a pin, I tested sensation in his arms and legs. Finally, I bent down and smelt his breath.

Feeling confident now, I turned round, faced up to the lady and announced firmly.

‘This patient has long standing insulin-dependant diabetes with retinopathy and neuropathy. He was probably admitted in diabetic coma, since I can still detect the ketotic smell of Golden Delicious apples on his breath.’

The lady was smiling, a curious almost triumphant smile. So was the patient! Confused, I looked down at his plate. My heart sank. It was the patient who broke the silence.

‘Funny you say that doc! I’ve just finished that apple.’

This article was submitted to commemorate the 150^th anniversary of the MRCP examination by the Royal College of Physicians on 15^th September 2009. My examiner was Professor Dame Sheila Sherlock.

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Doing things by the book; the flawed excellence of the new NHS.

Nick Read — Wed, 17 Jun 2009 20:28:27 +0000

I should have listened to her dentist. She cared enough to call me in London and tell me that the Xray had shown a small translucency around the root of the bottom right canine and there was a sinus pointing to the gum. ‘Your mum will need that tooth out,’ she said.

I demurred. I have an aversion to what I see as unnecessary fuss. After all I had with a discharging sinus into my gum for the last five years and it hadn’t blown up. And mum was already attending the ear clinic for deafness, the eye clinic for injections of Lucentis (costing the NHS £1000 a shot); she was attending the memory clinic for Alzheimer’s and now her teeth were playing up. It was a running joke between us.

‘Eyes, ears, teeth and memory. At least your nose is alright, mum!’

‘No it’s not. Feel it. It’s so cold!’

She still had a sense of humour. I was her feed.

Anyway, that tooth flared up. She got an abscess in it. Her temperature didn’t go up more than a degree but she became drowsy, more confused, went off her food and wasn’t drinking enough. The extremes of life are such vulnerable times. For the very young and the seriously old, an infection can set in train a sequence of events that can lead to death.

At first they tried Amoxycillin, but she became nauseous and the temperature didn’t shift. So they changed it to Augmentin. She rallied a bit, but then declined. The day she fell asleep in her porridge, I finally decided that she needed more help. I called the doctor. She would not be able to visit for three hours and suggested I dial 999.

‘Don’t give her any food or drink. Collect all her medications together. Call us immediately if she gets any chest pain. Somebody will be with you in half an hour.’ They were as good as her word.

The paramedic had a strong jaw and a decisive manner. After just ten minutes, he gave his report. ‘Pulse 72 regular, BP 110/70, Blood sugar 5.1. Temperature 37.8. She’s a bit dehydrated. Respiration good. Lungs clear. No obvious pain. Pupils equal. Responding normally but drowsy. I suspect she has an infection but we need to get her into hospital to get some fluid inside her, treat the infection and check her brain scan.’

My heart sank. To my mind, hospital is where the elderly go to die. It took three hours for her to be ‘processed’ through casualty while she sat propped up on a trolley in extreme discomfort and with nothing to drink.

After an overnight stay in the noisy confusion of the Medical Assessment Unit, she was moved to the pride of the hospital, the spacious, high-tech environment of the Hadfield Unit, a state of the art intensive care facility for the elderly.

When next I visited the next day, mum lay adrift, cocooned in pillows in a bay the size of a large meeting room with enough space to wheel in Xray equipment, heavy duty cardiac resuscitators, scanners and whatever else was needed. It seemed alien, impersonal, a futuristic medical facility on a starship, staffed by holograms. It looked like she had already died and was in the departure lounge awaiting transportation to another dimension.

The doctors, a pretty young woman with long hair, flaired trousers and short top that exposed a little too much midriff and a young man in jeans, an open necked check shirt and stethoscope draped around his neck, were posing for a photo-shoot at the entrance to the bay.

Why don’t they wear white coats these days? Perhaps I am just too old fashioned, but it would convey a degree of professionalism that would inspire confidence. But they were approachable and friendly and offered their opinions with authority and tact.

It was the nursing that worried me. The woman in the bed across the bay from mum was on the commode. I had seen the orderly deliver it twenty minutes earlier. She was calling out in some distress. ‘Is there anybody there? Please help me. Oh please help. Is there anybody there?’ But the nurses strolled past and ignored her. After another five minutes, I could stand it no longer. I went up to the gossip of nurses busily sitting at their station.

‘Excuse me but the lady in bay three seems to be in trouble. She has been calling out for the last half an hour.’

They stared at me crossly. I could have used my ‘I am a doctor’ ploy, but I didn’t want to. Why shouldn’t they respond to me as a human being? One of them, the most senior, I guess, her dark blue uniform buttoned up very tight, responded tersely.

‘Oh, that’s Eileen. She’s always calling out!’

‘But I really think you should….’

‘Oh all right, then!’

Eileen had fallen off the commode on to the floor. Later the senior nurse had the decency to thank me.

But why in this intensive care environment, did nobody seem to care enough? Why did they leave meals in front of patients who couldn’t feed themselves and just return to take them away? Why did nobody help people drink? Why was mum never mobilised except when I took her to the window and back? Why did nobody just sit and talk to her? She was so terrified.

Mum’s mental state just deteriorated in hospital. Always a proud, private person, she seemed to give up all sense of dignity and self. There was an outbreak of diarrhoea on the ward. Mum got it and for the first time since infancy, suffered from incontinence. Then she got a urinary infection.

It was two weeks before her physical condition had stabilised sufficiently to get her out of hospital, but by then, she had become part of the routine; she was terrified to go.

Mum was no better after her stay in hospital. She returned just as confused as when she went in. She didn’t seem to know where she was anymore. As the days past, her agitation increased. I called her GP. He was kind and prepared to take time to assess the situation. We decided to stop the Cipramil she had been on since before she got ill and start Lorazepam, a short acting tranquilliser with sedative properties. It didn’t help. She became more drowsy and one day she didn’t wake up at all, but when we eased back on the dose, she became very agitated and confused.

I called the memory clinic. At first they couldn’t remember her. I was put through to ‘Mick the Memory’, the kindly clinical psychologist who knew mum well. He didn’t think their prescription of Cipramil was part of mum’s deterioration had suggested I bring her in for an urgent appointment. I explained again that she was too weak and confused to leave her flat. Could they come and see her?

‘Oh’, he laughed, ’We don’t do domiciliaries. Let me speak to Dr McDonald and I’ll ring you back.’

He was back within the hour with a solution. ‘Dr McDonald has referred your mother to ‘the rapid response dementia team’. They will come and see her in a few days.’

They were late! Nevertheless I was impressed. They had sent a consultant psychiatrist and a senior psychiatric nurse. Dr Patel wore a black suit, white shirt and tie and an expensive perfume. His black shoes gleamed while he stroked his smooth chin thoughtfully, pondering whether it was a good idea not to treat mum for a urinary tract infection and whether we should try to cut the Lorazepam tablets in half. But Dr Patel seemed was singularly reluctant to go into the bedroom and see mum. His nurse did, but was bothered that mum was not awake enough to collect a urine sample, but she had forgotten to bring any sample bottles. They left after ninety minutes with the recommendation we continue with the same treatment and a promise to return every day over the weekend.

That night while attempting to reach the commode, mum fell. The carer, who was due to watch her, was working in the sitting room and did not hear her try to get out of bed on the baby alarm I had bought from Lewis’s that morning. She dialled 999. It was protocol.

The paramedics checked her, decided there was no injury, and left suggesting that we fit her bed with cot sides and call ‘the urgency and incontinence team’.

The urgency and incontinence team can’t come until next Wednesday. Clearly my call wasn’t urgent enough. I went out and bought a pack of incontinence pads and three absorbent waterproof bed covers, called, somewhat curiously, Kylies. Although quite compact, they claimed to absorb 3 litres of fluid.

I don’t wish to be too critical of the NHS. Any organisation that has intensive care wards for the dying and professionally staffed rapid-response dementia service, cannot be that bad. My concern is that our much vaunted nationalised health care system seems to have misunderstood that the most sophisticated technology, the most highly trained staff do not necessarily equate with quality of care. Hospital nurses seem to have lost the ability to look after patients. The real personal care has now been devolved to orderlies and cleaners while the nurses sit behind their desk writing reports and organising treatment plans. Mum’s GP is good; he balances his scientific understanding of medicine with the art of compassion and healing. He is an exception. There are others; Mick the Memory, Liz the dentist, but too many others adhere slavishly to evidence-based practice without engaging their minds.

We hear all the time about how expensive the NHS is, but just a cursory glance will reveal how much resource is wasted for how little gain. Is it necessary to have such a high tech unit to keep the dying alive? Isn’t it better to provide a caring environment to ease the last days of life and allow people to die in dignity surrounded by their family. The Hadfield Unit only allowed visitors in for an hour in the afternoon and two hours in the early evening. Mum was lonely and frightened. in there. No wonder her mental state deteriorated. And the consultant on the dementia team may have smelt nice, but would the nurse have done the job just as well by herself?

Evidence based treatments, expensive drugs that over-treat the problem and cause too many unwanted effects, the rigid reliance of management protocols and algorithms; they all fail because they don’t take account of peoples’ individual needs. And in the gap between efficiency and compassion lies a lonely person, often abandoned by their family and reduced by the state to the status of a machine past its sell by date.

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