Wednesday, December 16, 2015

Psychiatric interviewing

I have mentioned Susan Lamb before (see eg. previous post). Her most recent article picks up Adolf Meyer's use of the term 'the new psychiatry' (although I don't think he used this phrase that often). Meyer emphasised the importance of history taking and mental state examination rather than neurobiology. To quote from the Meyer reference that Susan gives in the article, "Today it is far more necessary that a physician should learn to cope with the psychic data than even with the anatomy of the cortex." Meyer didn't always express himself that clearly, but what he meant should be apparent and it's still the same today. Psychiatrists need the skill of psychiatric interviewing even more than neurobiological understanding. This isn't always apparent from the way psychiatrists approach their work.

The best Notes on eliciting and recording clinical information were drawn up in a pamphlet by the Teaching Committee at the Institute of Psychiatry and published in 1973. They were used for ensuring a fairly uniform style and layout for recording clinical data throughout the Maudsley and Bethlem Royal Hospitals. These were disseminated throughout the country and I'm glad I was introduced to them in my first placement in psychiatry in Cambridge. It's difficult these days to obtain a copy of this guidance. The copy I currently have was withdrawn from the library of the Kings College School of Medicine and Dentistry, which includes the Institute, as too out of date to be kept on the shelves. But clinical interviewing hasn't really moved on and this edition is clear and concise.

As the pamphlet says, "A high standard of clinical recording is a hallmark of good medical practice and is nowhere more important than in psychiatry". More attention is paid to psychological and social phenomena than in a general medical examination. The interview itself serves as the psychiatrist's main tool of investigation.

Introduction of the anatomoclinical method in medicine in the nineteenth century led to the association of bedside observations of patients with autopsy findings of pathological lesions in organs and tissues. Pathology emerged as a distinct discipline. Microscopic studies established cellular abnormalities for disease and it was generally assumed there would be a histological basis for psychopathology. It was eventually established that dementia paralytica was a late consequence of syphilis. Senile dementia was also seen as having a physical cause such as Alzheimer's disease. 

However, most psychopathology is functional, in the sense that there are no structural abnormalities in the brain. Taking a pragmatic approach, as Susan says, Meyer still used the anatomoclinical method to study psychopathology "functionally in experiences and social interactions" and "not organically, at the level of tissues or cells". This new vision of the clinical skill of psychiatric interviewing made Meyer the dean of American psychiatry in the first half of the twentieth century. 

We need a new "new psychiatry" to help us move on from modern concepts of mental illness as chemical imbalance or some other abnormality in the brain (see previous post). Psychological formulation is a way forward (see previous post), although psychosocial assessment is more embedded in psychiatry than it may often appear in current practice.

Saturday, November 28, 2015

Is 'psychosis' a substitute for 'schizophrenia'?

Huw Green in his article in Social Theory & Health mentions that Mary Boyle reluctantly adopts the word 'psychosis' as a substitute for 'schizophrenia' in order to discuss the topic of psychiatric diagnosis she has chosen to address. He uses this situation to reinforce his view that talk about psychiatric diagnosis is inevitably a form of communication. I have similarly criticised Mary for attempting to abandon psychiatric diagnosis completely (see my article). Psychiatric diagnosis needs to be recognised for what it is - an attempt to describe psychological states. It is, therefore, related to unobservables and not describable in a natural scientific sense. There will inevitably be limitations in the application of psychiatric diagnosis, whatever way symptoms and signs are grouped and conceptualised. Psychiatric practice needs to acknowledge this state of uncertainty. The concepts of mental illness do not need to be abandoned for this reason alone.

It's not surprising, therefore, that Mary reintroduces a notion of psychosis, however much she may think that the concept of schizophrenia is unscientific. But, neither is psychosis an absolute concept. Even the BPS attempt to explain psychosis and schizophrenia in everyday language still uses the terms (see previous post). The usefulness or validity of terms like 'psychosis' and 'schizophrenia' may depend on the ability to identify certain patterns between different patient presentations (see another previous post).

For example, the experience of hearing voices can be a dissociative symptom. This situation may have been used as a rather superficial argument for the abandonment of the diagnosis of schizophrenia but it does create a category of 'dissociative voice hearing'. As Green says, if the new catgory provides "more clinical information than the DSM, there is a chance that [it] will be adopted and applied instead, or even incorporated into that manual". Dissociation, in fact, does feature as a category already in DSM, including dissociative identity disorder (see changes made in DSM-5). It's a weakness of the BPS report, mentioned above, that it makes no attempt to discuss the difference between psychosis/schizophrenia and dissociation. The point I'm making is that it is a meaningful discussion to have and we do need to have words to communicate about it.

As Green concludes, "no psychiatric language is able to 'do justice' to the particulars of any given case". However, it serves a function in giving rise to a general form of pragmatic knowledge. DSM-5 has failed in its attempt to move from symptom-based diagnoses to aetiologically-based diagnoses using the latest advances from neurosciences and genetics (see previous post). We need to make the most of this failure (which should have been predicted anyway) to have a better diagnostic understanding of terms like psychosis and schizophrenia, if they have any meaning at all (see another previous post).

Simplistic notion of antidepressants correcting chemical imbalance in the brain is publically untenable

Jeffrey Lacasse and Jonathan Leo have published an update (see new article) on their article from 10 years ago on drug company advertisements about antidepressants correcting serotonin levels in the brain. As they say, "Some advertisements were more tentative or clever in their wording than others, but it seemed obvious that the drug companies were at least pushing the boundaries" of the scientific evidence. What they've found from data collected in 2014/5 is that the simplistic narrative of chemical imbalance is no longer widespread. Drugs tend to be advertised as "affecting" neurotransmitters rather than normalising transmitter levels. There are still problematic advertisements but the language has been moderated substantially.

I don't think we should necessarily be taken in by this change. Although simplistic notions of biochemical imbalance may no longer be publically tenable or displayed in advertisements, I'm not sure if practising psychiatrists really care that the theory is wrong. In fact, they probably still think that antidepressants correct a chemical imbalance, even if it hasn't definitely been shown in research (eg. see previous post). They like to think antidepressants work in practice, so there must be some reason why they work. So, even if the academic evidence isn't there for 'chemical imbalance', psychiatrists still function as though it justifies their clinical practice. In fact, they may still indicate this to patients. Few psychiatrists tell patients that even in the clinical trials the difference between placebo and active treatment is small. Any difference was called 'clinically insignificant', at least as regards reducing depressive symptoms, by NICE in a previous version of its depression guideline (see my BMJ eletter). There are also a substantial number of patients that do not improve in the clinical trials. Antidepressants are not always as effective as psychiatrists may make out to patients.

Psychiatrists use the chemical imbalance theory as a means of persuading patients to take their medication (see another eletter). The role of psychiatry is to give hope to depressed people. It is also to be honest with them about the cause of their problems and the appropriate treatment. Patients are able to understand that the 'chemical imbalance theory' has only ever been a theory. What they find more difficult to appreciate is why they are told that this theory has been proven, when this is clearly not the case.

Wednesday, November 25, 2015

Uncertainty about the value of Ritalin for ADHD

A comprehensive systematic review has been published in the Cochrane Library of the benefits and harms of methylphenidate (Ritalin) for children and adolescents with attention deficit hyperactivity disorder (ADHD) (see enhanced article). All 185 trials included were assessed to be at high risk of bias. It was possible for people in the trials to know which treatment the children were taking, the reporting of the results was not complete in many trials and for some outcomes the results varied across trials. The authors concluded that the low quality of the underpinning evidence meant they could not be certain of the magnitude of any effects on teacher-reported ADHD symptoms and general behaviour and parent-reported quality of life of the children. The most common adverse events were sleep problems and decreased appetite. To quote from the conclusion, "At the moment, the quality of the available evidence means that we cannot say for sure whether taking methylphenidate will improve the lives of children and adolescents with ADHD".

Saturday, November 14, 2015

Are early intervention services beneficial?

Ghio et al (2015) have published a survey of attitudes of mental health workers towards early interventions in psychiatry. They admit the results may be biased towards a more favourable opinion because the survey was distributed to participants at conferences in Italy on this topic, and these people might have been motivated by specific interests. Overall, professionals seem to have a positive attitude towards early interventions in psychiatry, with perceived outcomes in areas like reducing the severity of long-term social consequences and the disease itself and avoiding chronicity.

As I said in my review of Jo Moncrieff's book The bitterest pills, Jo has provided one of the best summary critiques of early intervention in psychosis (chapter 10 of the book). Duration of untreated psychosis (DUP) is associated with poorer outcome but this was never a new finding as it has always been recognised than more acute onset of psychosis has a better outcome. Despite the attractiveness of early intervention services (EIS), the danger is that they may actually lead to over-treatment.

Whatever the advantages of intensive treatment for reducing readmission, there is little evidence that the underlying psychotic disease process is fundamentally modified by EIS. Two trials of EIS in Copenhagen and Aarhus County, Denmark and Lambeth, London did not specifically examine whether starting anti-psychotic medication early improves outcomes. Nonetheless, drug companies exploit the situation by encouraging early prescribing.

The early intervention approach becomes even more controversial when attempts may be made to bring people into treatment even before they have become psychotic, with the intended aim of reducing DUP even further. Thankfully, psychosis risk syndrome was specifically excluded from DSM-5 for lack of validity and insufficient evidence that early intervention in the so-called prodrome is effective (see previous post).

When I first trained, more people were probably admitted to hospital than now with a first episode of psychosis. However, there was no necessary rush to start anti-psychotic medication. Instead patients may have been assessed drug free for a week, to ensure that the primary diagnosis was psychosis. Overmedicating people with anti-psychotics may create unnecessary dependency and is not good practice.

Thursday, November 12, 2015

Asking the wrong questions about psychiatry

Stephan et al (2015) in two papers in The Lancet Psychiatry entitled 'Charting the landscape of priority problems in psychiatry' (Part I: Classification and diagnosis and Part II: Pathogenesis and aetiology) begin from the fact that "few, if any, breakthroughs in basic scientific research have led to substantive improvements in psychiatric clinical practice". They are right to conclude from this situation that there is a need for refocusing of research agendas in psychiatry.

However, they then start from the wrong premise. They still want to "endow psychiatry with a mechanistic, neuroscientifically informed basis”.  They, therefore, produce a list of 17 problems for psychiatry, created by asking an international group of scientists and clinicians to state what they perceive as “the single most important problem or hypothesis" that needs to be addressed to meet this objective.

How long will it take for psychiatry to realise that its very nature is that it has "major conceptual and practical challenges"? It's no good expecting research to bypass this situation.

Psychiatric diagnoses are simply categories justified by clinical utility. Their value-laden nature are not a sign of scientific deficiency but of their meaningful nature. Mental disorders are not natural kinds and there are inevitably fuzzy boundaries between different syndromes. Psychiatry needs to avoid the reification of diagnostic concepts.

As far as aetiology is concerned, genes set the boundaries of the possible but environments define the actual nature of mental disorder. The human brain is socially constructed in the literal sense that brain cytoarchitecture itself is fashioned by input from the social environment. Minds are enabled but not reducible to brains.

As I keep saying, please do not misunderstand me. Of course mental states map onto the brain. But the localisation of function to structure in the brain is not a new problem. Psychiatry can still be practiced even though there is a mind-brain problem. There's no need to create 17 pseudo-problems to solve by research before progress can be made.

Friday, October 09, 2015

Fixing the brain is not the new world for psychiatry

Joe Herbert starts well in his article on Aeon Why we can't treat mental illness by fixing the brain?. He explains that although we have some understanding of how a brain neurone is activated and how this activation is passed on to another neurone, we do not know the answer to the wider question of "how a collection of neurons makes a thought, a memory, a decision, an emotion". As he says, "The problem of relating events at the level of neurons with the known functions of the brain is a critical one." There is a "mysterious and seemingly unfathomable gap" between psychology and neuroscience, which "bedevils not only psychiatry, but all attempts to understand the meaning of humanity".

Herbert recognises within psychiatry that there is "no evidence at all that the levels of serotonin or noradrenaline in the brains of depressed people are any different from normal". As he says, "a pathologist looking at the brain of a depressed person could not distinguish it from the brain of someone who was mentally well".

This is all well and good. But then he goes on to spoil the article by speculating that "one day, someone, somewhere will make the critical step, or steps, and we will enter a new world of psychiatry". The advance would be one "that can relate what psychiatrists see in their patients to what can be seen in the brain".

I suppose such wishful thinking can be used to justify the research of his Cambridge Centre for Brain Repair. However, there's no need to wait, and I think we'll be waiting forever, for some new breakthrough at a cellular, chemical or 'systems' level. The problem is conceptual and philosophical, not scientific in that sense. Mental health problems can be treated psychosocially now. It's misleading to suggest that the way forward is by moving psychiatry to neurology (see eg. previous post).

Sunday, September 13, 2015

Hokum is not fine by me

Max Pemberton, in  this week's Dr Max the Mind Doctor column in the Daily Mail (see section entitled Hokum is fine by me if it works) mentions a recent decision by a judge to reject a patient’s challenge to the Lothian Health Board’s decision to stop funding homeopathy services on the NHS (see BMJ news article). Dr Max admits homeopathy is merely placebo but says he doesn't care as long as it makes the patient feel better. He seems happy enough, I guess like a lot of doctors, to deceive his patients (see my BMJ letter, on bottom of the page from this link).

I do understand that the patient may have a different view. She apparently had found homeopathy helpful for her arthritis and anxiety. I'm not convinced the Health Board has considered the potential harm (nocebo) effect of removing a placebo, for which I guess it could be held accountable, as presumably it was originally funding the homeopathy. What I'm objecting to is Dr Max supporting the use of homeopathy, which he regards as "utter hokum".

Wednesday, September 09, 2015

Reconsidering psychiatry

Hugh Middleton (who I have mentioned in a previous post) has recently published Psychiatry reconsidered: From medical treatment to supportive understanding. As he is the current co-chair of the Critical Psychiatry Network, of which I am a founding member, you may well think I would agree with a lot of what he says, and I do. However, I have some concerns about how he expresses the critical psychiatry position. These concerns are similar to those I have expressed about Peter Kinderman's book A prescription for psychiatry (see previous blog and links to other posts on his book from that blog).

Where Hugh and I agree is that mental health difficulties are not brain diseases. The implication is that psychiatric diagnosis is not about identifying brain abnormalities and treatment is not about correcting such abnormalities, such as biochemical imbalances in the brain. Rather, referrals to psychiatric services are made for psychosocial reasons because of people's distress and/or the disruption they cause to others. Mental health problems are primarily functional and not organic (eg. see previous post).

It follows that there are differences between psychiatry and the rest of medicine. However, Hugh makes too much of these differences from my perspective. He points to "the unsuitability of locating provision for people with 'mental health difficulties' alongside other aspects of medical practice" (p. 8). He also suggests "psychiatry is not proper medicine" [his italics] (p. 9-10) and that psychiatry is "not about treating illnesses" (p. 9). My own view is that this position, at least potentially, is misleading.

Our difference arises from our understanding of 'mental illness'. I think that abnormalities of mental function can be understood as 'illnesses' in the same way as bodily dysfunctions. On the other hand, Hugh restricts 'illness' to physical pathology. He is, therefore, inclined to follow Thomas Szasz, who was very clear that the concept of mental illness is a category error, because he defines 'illness' as bodily pathology (eg. see previous post). The trouble is, from my point of view, that this distinction is not so absolute. People commonly complain of physical symptoms which have a psychogenic origin - what medicine these days calls 'medically unexplained symptoms', or previously may have called psychosomatic illness. These presentations are so common, in some ways, that they are central to medical practice. In other words, psychiatry is proper medicine. Medical practice should take a patient-centred perspective (see previous post), which inevitably requires engagement with mental health problems. I don't want to polarise the difference between patient-centred and disease-centred medicine, and diagnosis and treatment in medicine need to be patient-centred even when treating physical disease.

I'm also not entirely happy with Hugh leaving the issue of coercion to the last chapter, entitled Afterword. As he says, historically psychiatry "was commonly brutal" (p. 204). In fact, institutional practice can still be abusive. Human rights are a central issue for psychiatry. Because of its social role, psychiatry inevitably manages madness on behalf of society (eg. see my book chapter). This was why modern psychiatry originated in the 19th century, however much psychotherapy and other informal, voluntary services now dominate practice. But, these more modern developments haven't made the 'sharp end' of psychiatry irrelevant. They have led to the closure of the traditional asylum, but people are still detained under the Mental Health Act in hospital and, for some, this makes them eligible for the imposition of conditions under a Community Treatment Order (CTO). True, Hugh does recognise this situation, and here he differs from Szasz, although he uses it as a dubious justification for electroconvulsive therapy (ECT) in limited circumstances. And, it was the reform of the Mental Health Act, that produced the 2007 amendments, that led to the formation of the Critical Psychiatry Network in 1999. I think these issues should have warranted more than an afterword when reconsidering psychiatry.

Tuesday, September 01, 2015

Adolf Meyer's legacy

I have mentioned Susan Lamb's Pathologist of the mind in a previous post. The book has been reviewed by Andrew Scull in the TLS (see WSJ version). Andrew argues that "comprehensive reassessment of Meyer’s life, career and influence is long overdue" (is Andrew writing this thesis?) but suggests Susan's book isn't that work because it scarcely considers his later career. I think this judgement may be a bit harsh as Susan primarily seeks to defend Meyer's theoretical position, which was called "psychobiology", which I think was consistent through Meyer's life once he had switched from neuropathology. Andrew isn't convinced that Susan's been successful in her aim.

I've commented on Meyer favourably in previous posts (eg. see The psychogenic legacy of Adolf Meyer). I've argued that critical psychiatry is a neo-Meyerian perspective. This doesn't mean, like Andrew, that I'm suggesting a straightforward following of Meyer or 'resurrecting his ghost' (eg. see previous post). But Andrew says Meyer's programme was "largely devoid of substance" and that he was an emperor with no clothes. I agree Meyer's obsessional "quest for data" could become futile, but at least it ensured that the psychosocial reasons for patients' presentations were considered, which can't be said for much of modern psychiatric assessment. The problem is that the reality of psychiatry may be that it is "essentially empty" in Andrew's sense. It probably doesn't boil down to much more than relationships between people. If Andrew's hoping for more from psychiatry, I suspect he'll be disillusioned.

The biomedical model has an intrinsic advantage over psychobiology in that it provides an apparent clarity. But modern psychiatry seems more willing to hide behind absolute definitions rather than face the uncertainty of human action. Psychobiology is not an aetiological psychiatry, in the sense of providing psychoanalytical mechanisms or Kraepelinian disease entities. True, Meyer's tendency to fudge and compromise may not have always provided the best of ethical foundations for psychiatry. But I don't think Andrew should be quite so dismissive of Meyer's theoretical position, or Susan's attempt to explain it.

Monday, August 31, 2015

Italian critical psychiatry

I mentioned John Foot's new book The man who closed the asylums: Franco Basaglia and the revolution in mental health care in a previous post before it was published in english. There has been very little published in english about Basaglia, which makes John's book very welcome. He tells the story of Basaglia's move from academia to direct the asylum at Gorizia in 1961, leading up to the passing in Italy in 1978 of law 180, which prevented new admissions to existing mental hospitals and shifted the perspective from segregation and control in the asylum to treatment and rehabilitation in society. Despite the opposition at the time, psychiatric hospitals have closed anyway over most of the Western world, as they became increasingly irrelevant to modern mental health services.

This story is interesting because, as Basaglia said in his own words, he became famous "because I 'opened up' a psychiatric hospital". He was charged twice with criminal liability following serious patient homicides because he was the "man that freed the mad".

However, what most interested me about the book was how little I know about Italian critical psychiatry, particularly the writing of Giovanni Jervis, who worked for a few years with Basaglia at Gorizia. From there he went to Reggio Emilia to develop community services.  His Manuale critico di psichiatria was reprinted continuously from 1975-97. With Gilberto Corbellini, he wrote La razionalità negata. Psichiatria e antipsichiatria in Italia (2008). It would be nice to be able to read both these books (and other related books) in english.

Jervis was not in total agreement with Basaglia. He accepted the social role of psychiatry, but still tried to expose the "margins of dissent and dysfunctionality in the system". Within the Centre for Mental Hygiene in Reggio Emilia, there was a split between Jervis and Giorgio Antonucci, who was more anti-psychiatry, in that he "aimed to destroy psychiatry as a separate technique". Within english language 'anti-psychiatry' there was a similar tension between Laing and Szsaz. I think modern critical psychiatry may well benefit from understanding the Italian historical tradition better.

Wednesday, August 05, 2015

Modern psychiatry's disgrace

I've mentioned before the unethical nature of modern psychiatry (eg. see previous post). Robert Whitaker and Lisa Cosgrove in their book Psychiatry under the influence call it institutional corruption. They highlight the over-marketing of stimulants for ADHD, the expansion of the notion of depression, the extension of SSRI antidepressants for other neurotic conditions besides depression and for children, and the promotion of mood stabilisers. Psychiatry has been happy to go along with these developments and of course it has suited the drug industry. But, it has required a less than rigorous examination of the evidence and a weak drug regulatory system. The book argues that declaration of conflict of interests is insufficient to correct the problem (see previous post).

Saturday, August 01, 2015

The possibility of a causal link between tobacco use and psychosis does not merit further examination

Following my previous post, yet another article on the association between smoking and psychosis has been published in The Lancet Psychiatry. Usefully the article makes reference to the Bradford Hill criteria for deciding whether an association should be interpreted as causal. It suggests that the association is plausibly causal because nicotine may increase dopamine consistent with the excess striatal dopamine theory of schizophrenia. Trouble is that efforts to validate the dopamine theory of schizophrenia empirically have failed (Kendler & Schaffner, 2011).

As the comment in the same issue of The Lancet Psychiatry says, "The most likely explanation ... is that cigarette smoking is associated with an increased risk for schizophrenia." Factors in the social environment, such as family history, urban environment and childhood adversity, are associated with both smoking and psychosis. A social environmental explanation of both psychosis and smoking is much more plausible than a biochemical explanation that the empirical evidence contradicts.

Tuesday, July 28, 2015

Smokescreen about the origins of psychosis

I said in a previous post that it was illogical to interpret an association between cigarette smoking and psychosis as causal, but this hasn't stopped Gage & Munafo in correspondence in Lancet Psychiatry trying. This publication was rushed through online first, presumably because the journal thinks it is potentially important. It follows a comment in the same journal by Fergusson et al published this month

As the correspondence authors say, "Of course, these data alone are not definitive". To reiterate, as they also said in a previous Lancet Psychiatry comment, "Although evidence of a causal effect of cigarette smoking on schizophrenia risk is consistent, it is certainly not definitive".

Please tell me why cigarette smoking can't be a proxy measure for poor premorbid adjustment associated with psychosis! Are people so blind to the psychosocial origins of psychosis that we have to be led down such aberrant research alleys? There seems to be a more fundamental need for revising our understanding of the psychosocial origins of psychosis than speculating wrongly about whether cigarette smoking causes psychosis.

Tuesday, July 21, 2015

Patient-centred psychiatry

I was pleased to hear from Anna Ludvigsen that the Royal College of Psychiatrists has a scoping group to look at how to make training more patient-centred. Believe it or not, medicine hasn't always been patient-centred. Historically, clinical training has emphasised a doctor-centred or disease-centred approach, which involves diagnosing the patient's disease and prescribing a management plan appropriate to the diagnosis. A patient-centred approach is designed to attain an understanding of the patient as well as the disease.

Patient-centred medicine is based on the University of Western Ontario method (Levenstein et al 1986, Stewart et al 2003). It is not technology-centred, doctor-centred, hospital-centred or disease-centred. Instead, it explores patients' main reasons for consultation, their concerns and their need for information. It seeks an integrated understanding of the whole person, including emotional needs and life issues. It finds common ground with patients on what the problem is and mutually agrees about how to manage the problem. Its focus encourages prevention and health promotion. It also emphasises the continuing relationship between the patient and the doctor. It provides a realistic and effective use of time in the consultation. It also has to be sensitive to context as, for example, an acutely ill patient may require more focus on disease. It also has to be sensitive to patient preference as, for example, some patients may require more information than others.

The approach may well have its origins with Michael and Enid Balint, both psychoanalysts, who began work in the 1950s to help general practitioners reach a better understanding of the emotional content of the doctor patient-relationship. and so improve their therapeutic potential (see UK Balint Society). Patient-centredness may be a poorly understood concept. Doctors vary in the degree to which their practice is patient-centred, although on the whole most doctors provide patients with partially patient-centred care.

Critical psychiatry is the application of the patient-centred method in psychiatry. Inherently it is a challenge to biomedical psychiatry. In my publications, I have tried to emphasise how it restates the conceptual position of Adolf Meyer and George Engel (eg. see my article).

Sunday, July 05, 2015

Need to integrate mental and brain activities

Following my previous post, Ed Pinkney @mwproject sent a tweet asking me to elaborate on what I meant by the "need to integrate mental and brain activities" and I said I would. Psychiatry functions within the mind-brain philosophical problem. Psychiatrists don't need to be philosophers but they do need to realise there's an issue in this respect.

Nineteenth century medicine developed on the basis of the anatomoclinical method, which recognised disease as having a bodily pathological origin. Psychiatry didn't quite fit with this, although it was recognised that dementia paralytica was a late consequence of syphilis, senile dementia had a physical cause such as Alzheimer's disease, that there could be focal abnormalities in the brain and that learning disability could also have physical causes (eg. see my book chapter). However, most psychiatric illnesses are functional, in the sense that there are no structural abnormalities in the brain.

As this is the case, how should psychiatry be practiced? All medicine should be patient-centred. The danger is that if doctors focus on disease, they may be distracted from dealing with the ill person. There may actually be some self-protective element in this, considering the emotional consequences of dealing with the suffering of patients, but ultimately medical training is about learning to focus on the ill person. This situation is even more prominent in psychiatry, as the symptoms and signs that patients have are part of them as people rather than due to a structural abnormality in the brain. Don't misunderstand me! Of course, the thoughts, feelings and behaviour of people who are not mentally ill are due to their brain. We have an integrated understanding of their mental and brain activities. In the same way, we should have an integrated understanding of the mental and brain activities of people who are mentally ill.

Saturday, July 04, 2015

Biopsychosocial formulation

There is an article in Lancet Psychiatry about rethinking biosychosocial formulation. I think the article is a little unfair on George Engel but I do understand what it means about the eclectic way in which the biopsychosocial model is implemented. It wasn't how Engel meant it to work to encourage "students to think about the patient from three different perspectives, rather than beginning with the premise that everything that happens to the patient is biological". This comment also reminds me of the emphasis of Susan Lamb in her book on Adolf Meyer (see previous post). What's needed is to integrate mental and brain activities.

The describe/review/link model may well help us to move on from the eclecticism of modern psychiatry for which this mistaken implementation of the biopsychosocial model may be blamed (see my review of Nassir Ghaemi's book and his response). I agree with the authors of the article about the importance of formulation (eg. see previous post).

Friday, July 03, 2015

Psychiatry's 'nemesis'

I don't want to make a habit of commenting on trainees' articles when they get them published in Royal College of Psychiatrists' journals (see previous posts - Neurology-psychiatry integration and Being explicit about the nature of mental illness), but I just wanted to pick up a comment from Helen Henfrey in her recent BJPsych editorial. She suggests that, "Psychiatry is unique among other specialties in that it has its own ‘nemesis’ in the form of the ‘antipsychiatry movement’". True, she has put the word 'nemesis' in inverted commas. Psychiatry in fact needs to be critical and I think it would help recruitment to psychiatry, which is what her article is about, if it engaged with anti-psychiatry.

If anti-psychiatry is psychiatry's nemesis, it is partly psychiatry's creation by including RD Laing and Thomas Szasz within its remit (eg. see my book chapter). Of course there are people that want to abolish psychiatry. Laing and Szasz were legitimate psychiatrists in challenging the biomedical model of mental illness (eg. see previous post on Szsaz). I've commented before (eg. see previous post) that recruitment to psychiatry would be improved by encouraging debate about the basis of psychiatry. Helen Henfrey shouldn't be frightened of conflict with so-called anti-psychiatry. Psychiatry by its very nature is conflictual and that's part of its attraction as a career.

Thursday, July 02, 2015

Do psychiatric medications correct a chemical abnormality in the brain?

I don't think David Taylor, Director of Pharmacy and Pathology, South London and Maudsley NHS Foundation Trust & Professor of Psychopharmacology, King's College, London can be a prescriber. This may be why, in his BJPsych Advances article, he suggests that psychiatrists don't infer that people with a diagnosis of schizophrenia need antipsychotics to block a surfeit of dopamine. If so, why is this what some psychiatrists tell patients? Medical students may even be taught to explain to patients that this is the reason they need antipsychotics. Perhaps Taylor needs to be more explicit that psychiatrists are wrong to tell people that medications correct a chemical imbalance and, if he does some medical student examining, mark students wrong when they suggest this.

I do agree with him that, "Rarely is there any certainty about [psychiatric] diagnosis". I think psychiatrists will still regard quetiapine as something to do with dopamine by calling it a dopamine multifunctional receptor antagonist (DAmF-RAn). They will just believe that they can use it for more conditions besides schizophrenia. I accept that the rationale for psychiatric prescribing is often not properly thought through (eg. see previous post).

Framing the model of drug action as drug-centred rather than disease-centred is primarily a critique of the biomedical model (eg. see my book review). It emphasises the non-specific effects of medication. I suspect that Taylor still thinks psychiatric medications correct a chemical abnormality in the brain. In that sense, he is not drug-centred, even disease-centred. What he means is that he doesn't accept simplistic hypotheses of biochemical imbalance. All well and good, but the critique of the biomedical model is more fundamental. There may be no difference between the chemical processes underlying mental illness and our "normal" behaviour.

Friday, June 05, 2015

Neurology-psychiatry integration

I've hesitated before (see previous post) in case I undermine an enthusiastic psychiatric trainee, who has just been successful in getting a journal paper published. In the same issue of BJPsych Bulletin, mentioned in my previous post, Thomas Reilly has a special article concluding there is no dividing line between neurology and psychiatry (see article). Perhaps he needs to read my previous post because he incorrectly comes to this conclusion because he believes psychiatric illness is a neuropathological disorder.

What worries me is what trainees are being taught. I've no objection to Thomas Reilly getting neurological training. It might help in his understanding of the differences between neurology and psychiatry. Of course all doctors should have a biopsychosocial understanding, as he suggests. I'm not wanting to overemphasise the difference between psychiatry and the rest of medicine. But psychiatry primarily treats functional disorders not organic. Of course, conversion disorders may present to neurologists but it may well be the skill of their neurological examination that makes the diagnosis, because they don't find the expected signs. Medicine is full of cases with "unexplained symptoms" that never get referred to a psychiatrist and the psychological origin of the problems is missed. I hope that Thomas Reilly does become slick in neurological examination, as the best of neurologists are. But in practice, he'll not need that skill very much in his assessment of psychiatric patients. What he needs to develop is his psychological formulation of cases (see another previous post).

Tuesday, June 02, 2015

Functional and organic psychiatry

Alwyn Lishman (see interview in The Psychiatrist), the author of the classic book Organic Psychiatry, knows more about neuropsychiatry than most people, so when he says that Wilhelm Griesinger was too narrow in his approach to psychiatry, this needs to be taken seriously. Nonetheless, Michael Fitzgerald looks to Griesinger to justify his argument in a BJPsych Bulletin editorial that neurology and psychiatry should merge into a single speciality, although he agrees that Griesinger went too far in ignoring environmental influences. In fact, Griesinger was not quite as reductionistic in his view that mental diseases are brain diseases as is commonly assumed (Marx, 1972). He suggested that the initial phase of mental illness did not involve structural changes. Structural change only occurred in what he called the second phase, in which mental image formation or will were affected, and also in the third phase, which implied deterioration and incurability (see my book chapter).

I've commented before on the issue about the merger of neurology and psychiatry when two of the main references from Fitzgerald's paper were first published (see previous post and BMJ letter). Ronald Pies is more of an advocate for Fitzgerald's position than Fitzgerald seems to realise, although if the merger happened, Pies thinks there will be a need for “certain kinds of linguistic and philosophical ‘bridging devices’” (see my book review). The main problem with the proposal for merger is that it is based on a mistaken notion that mental illness is brain disease (eg. see previous post). Ernst von Feuchtersleben published his book in the same year as Griesinger in 1845 and questioned whether mental disorders were always due only to disorders of the brain.  He argued for a functional understanding of mental disorder, which of course has a biological basis. As I keep saying, although mind is enabled by the brain, it is not reducible to it.

Psychiatry should look to von Feuchtersleben for its origins rather than Griesinger. This would cement its relationship with the rest of medicine better than Fitzgerald's proposal. It is in fact Fitzgerald's misunderstanding that undermines the relationship between doctor and patient.  Relations between people should not be reduced to objective connections in the brain. I've said before (eg. see previous post) that psychiatry should be seen as the pre-eminent medical speciality. The current president of the Royal College of Psychiatrists seems to agree with me in a tweet.

Wednesday, May 27, 2015

Misguided medical training in psychiatry

Niall Boyce has clarified in a tweet what he means in a Lancet Psychiatry editorial about the critique of the biomedical model in psychiatry. He thinks the critique is "worth considering". But he is relaxed about it because he knows neuroscientific findings will eventually affect practice. Actually the point of the critique is that this is a myth. Psychiatry has always had this wish and it's about time that it realised that this is "pie in the sky".

And, as Anne Cooke points out in a tweet in response, Niall has conflated his arguments in his rebuttal by promoting a medical training for mental health practice. I've always said that there are advantages to a medical training (eg. see previous post). However, there are disadvantages as well in that it encourages a biomedical approach, which Niall obviously finds difficult to give up.

Saturday, May 16, 2015

Reducing psychotropic medication prescribing

Peter Gøtzsche, who I have mentioned before (eg. see previous post), has caused controversy at a Maudsley debate and in a BMJ Head to head by suggesting that psychotropic medication should be reduced to 2% of its current level of prescribing. As far as he is concerned, it "should almost exclusively be used in acute situations and always with a firm plan for tapering off, which can be difficult for many patients".

His argument is that the results of clinical trials are biased by unblinding and what he calls the 'cold turkey' effect of the washout period. Any remaining benefit, if there is any, is not justified by the mortality caused by medication.

Whether psychotropic medication increases mortality is controversial. I have mentioned before (see eg. previous post) that it may create a vulnerability to relapse. People may actually do better if they manage to work through their problems without medication. Peter Gøtzsche's stark presentation of the issue at least encourages this debate, even if it risks overstatement.

Wednesday, May 13, 2015

Renewing mental health practice

I have been re-reading the final chapter of my edited book Critical psychiatry: The limits of madness. Next year will be 10 years since the book was published. The first chapter outlines the various chapters written by the contributors. The book came out of three conferences held in Sheffield, Birmingham and London in 2001-3.

It's also 16 years since the Critical Psychiatry Network was first formed. I've mused before about the impact of critical psychiatry (see previous post), maybe, as I said, because I am approaching full pension. How should critical psychiatry be taken forward?

Tuesday, May 12, 2015

Psychiatric research folly

A perspective in Science by Thomas Insel & Bruce Cuthbert should make american psychiatry fearful about the scientific credibility of its NIMH director. He's gone completely 'over the top' in his speculation about RDoC and precision medicine (see previous post). He thinks there's been a "tectonic shift" to now considering mental disorders as brain disorders. Following his lead, this folie à plusieurs has apparently led to "nearly 1000 papers addressing various aspects of RDoC over the past year". 

I've made fun of Daniel Amen suggesting there are 7 types of ADD (see previous post). However, Insel believes three subtypes of ADHD have been discovered with different responses to stimulant medication. He suggests biologically meaningful subgroups of psychotic or mood disorders are being discovered. He does admit these are "preliminary reports" and the "results will need replication". RDoC domains are supposed to be better at predicting length of hospital stay or hospital readmission than symptom-based diagnoses. 

Even though Insel accepts that "many challenges must be faced", I'm sorry but I'm not part of what he calls the "emerging consensus that such new approaches are necessary to move the field forward". Psychiatry's going 'off beam'. People may appear to be going along with Insel because he holds the research funding purse strings. His speculation builds on his 'brain circuitry disorders' concept of mental illness (see previous post). Science demeans its name by publishing such phantasy.

Wednesday, May 06, 2015

Being explicit about the nature of mental illness

I am not sure why Ketan Jethwa has moved to a core training post in medicine from an academic psychiatry training post. Could it reflect his disillusionment with psychiatry or is he wanting to ensure  an adequate medical foundation for his psychiatric career? I don't want to undermine him because he has written a good quality article for BJPsych Advances. However, I think his piece does require comment.

He suggests psychiatry has an identity crisis because of the nature of mental illness. I'm not sure if I would call it an 'identity crisis', but I agree that how the nature of mental illness is understood does matter. Jethwa argues for psychiatry being a clinical neuroscience and suggests, following Bullmore et al (2009) (see previous post), that British psychiatry over recent years has taken an increasing 'neurophobic' position. He goes on, "It is imperative that the scientific underpinnings of psychiatry are explicit within mental health services and in interactions with patients and the public in general". The trouble is that he hasn't been explicit about the neuroscientific basis of psychiatry. He seems disappointed that psychiatry can't be more explicit. I have said before (eg. see previous post) that modern psychiatry is setting itself up to disillusion trainees by promoting neuroscience as the solution to mental illness in the way Jethwa hopes it can be. I fear that it may have lost another good quality trainee in his case. I hope I'm wrong!

Saturday, May 02, 2015

Bipolar craziness

Much of Edward Shorter's recent book, What psychiatry left out of the DSM-5: Historical mental disorders today, is, to my mind, speculative nonsense. However, there is a chapter on 'Bipolar craziness', which I think has some useful references. I've mentioned before (eg. see previous post) how the concept of bipolar spectrum has extended during my working lifetime to a notion whose meaning must be questioned. As Shorter says at the end of his chapter:-
Unlike in previous editions, when DSM- 5 was launched in 2013 the discussion of bipolar disorder was no longer merely a section of an "affective disorders" chapter but had a chapter of its own, as though the previous hundred years of world psychiatry had never existed.

Unipolar and bipolar disorders are now seen as separate disorders whereas they used to be seen as two subcategories of manic-depressive illness. I am not necessarily saying that the previous way of looking at this diagnostic issue was better, but it is clear that at least some of the motivation for the change has been to promote mood stabilisers for bipolar disorder (see eg. previous post).

It's suggested antidepressants should be avoided in treating patients with bipolar disorder in favour of mood stabilisers. However, I've also mentioned before that the risk of manic switch when using antidepressants has been exaggerated. NIMH has endorsed the use of the diagnosis bipolar disorder not otherwise specified to categorise bipolar disorder as on a spectrum (see press release). It affirmed that such patients were being inappropriately treated by giving antidepressants or other psychotropic medication in the absence of mood stabilisers. However, systematic reviews have not found evidence that switching to mania is a complication of antidepressant treatment (Gijsman et al 2004, Visser & Van Der Mast 2005). In a placebo-controlled trial, use of adjunctive, standard antidepressant medication, as compared with the use of mood stabilisers, was not associated with an increased risk of treatment-emergent affective switch (Sachs et al 2007). Moreover, there was no difference in efficacy.

The limitation of medication, whether antidepressants or mood stabilisers, needs to be recognised. Just because antidepressants are not always effective does not necessarily mean that even mood stabilisers will be helpful in so-called bipolar spectrum.

Saturday, April 25, 2015

Madness in civilisation

I'm not sure if it really works, as I did in my previous post, collecting together tweets of quotes or amended quotes from a book which I've sent when I'm reading it. Another book I've recently read is Andrew Scull's Madness in civilization: A cultural history of insanity from the Bible to Freud, from the madhouse to modern medicine. It has been reviewed by Phil Thomas on Madness in America. I don't think the book is as good as some of Scull's previous books, such as Madhouse (see my BMJ review). It's trying to provide a wide-ranging survey of the history of madness over the last 3000 years. 

What I tweeted about from Scull's new book was the way that we seem to need myths to understand madness and illness in general. For example, the theory of the four humours - blood, phlegm, black bile and yellow bile - remained a major influence in understanding the working of the body until well into the 1800s. But we haven't really advanced:-
Biomedical hypothesis justifies modern psychiatric practice in same way as humoral theory justified bleeding, purging and use of emetics
29/03/2015 10:56
Humoral theory of disease was immensely powerful, making sense of symptoms and pointing the way towards remedies for what had gone wrong.
28/03/2015 20:22
Humoral theory provided reassurance to the patient and an elaborate rationale for the interventions of the physician
28/03/2015 20:24
This wasn't the only theory:-
Religious and secular, supernatural and what purported to be naturalistic explanations of illness persisted down the centuries
28/03/2015 20:27
Notion that madness might sometimes be a means to truth (divine madness, as some would have it) would resurface repeatedly
28/03/2015 20:27
Anti-phlogistic physicians saw disease as fundamentally a problem of inflammation and fever.
28/03/2015 20:29
Bleeding, purging and making use of emetics, all designed to counteract and to deplete the over-active, over-heated body
28/03/2015 20:30
Religious and spiritual interventions might be tried alongside the bleeding, purging and emetics of the anti-phlogistic physicians
28/03/2015 20:31
So, the notion of chemical imbalance in the brain (eg. see previous post) even though it's wrong, like humoral theory, persists because it provides an 'aura of factuality' (see previous post). The historical perspective provided by books like Madness in civilisation helps us to realise that modern claims about brain dysfunction in mental illness are not really facts but part of a myth, even delusion, to suggest an understanding of mental illness and justification for its treatment.

Friday, April 24, 2015

Pathologist of the mind

As I have been reading it, I have been tweeting quotes or amended quotes from Pathologist of the mind: Adolf Meyer and the origins of American psychiatry by Susan Lamb (who I have already quoted in a previous post). I thought I would bring some of these tweets together to try and explain the importance of Adolf Meyer's work.

Susan's book (see her website) is a scholarly account that the literature has needed. Meyer himself failed to be explicit in getting across his theory of psychiatry, which was called Psychobiology (eg. see my article). Susan includes clinical material from his archives which also helps to relate his theory to his practice.

As Susan says in her conclusion, one of the key insights is that:-
Meyer viewed mental activity and brain activity as a single biological response
24/04/2015 13:12
She goes on, "to overlook this principle is to risk misconstruing Meyer's thinking, practice, and teaching". Or, as she says in another tweet:-
The tendency to equate the descriptor 'biological' with 'physical, bodily or somatic' can render anything Meyer said or did unintelligible
08/03/2015 20:15
The second key insight is "to appreciate the essentially medical orientation of Meyer's thinking, practice, and teaching". For Meyer:-
Mental dysfunction, as much as brain disease, is a medical condition resulting from pathological processes
08/03/2015 17:34
This meant that:-
Meyer framed prevalent forms of mental illness not as distinct brain diseases, as did majority of his peers, but as failed adaptation
08/03/2015 17:37
This is why I have emphasised the views of Adolf Meyer in discussions of psychiatric diagnosis on this blog (eg. see previous post). Meyer was also clear that:-
Brain research is comparative neurology not psychiatry
08/03/2015 20:58
In other words, Meyer warned against going beyond statements about the person to wishful 'neurologising tautology' about the brain. Even though:-
Kraepelin was part of first wave in the generational backlash against the hegemony of brain mythology in the late 19th century
26/03/2015 16:59
Meyer lamented the Kraepelinian craze to diagnose, classify and to generate statistics
26/03/2015 17:11
Meyer took over the Huxleyan notion of science as being organised common sense. 
Science is defined by application of rigour to observing, documenting, comparing and ordering data
08/03/2015 22:01
Science is not defined by principles of physics or chemistry, nor by experimental techniques
08/03/2015 22:00
In summary:-
Psychobiology provided basis to liberate psychiatry from dogma that explained mental activity in reductive, dualistic or deterministic terms
24/04/2015 13:09
To emphasise, Meyer was primarily interested in the implication of these ideas for clinical practice. 
Meyer was no philosopher. He was a pathologist on a mission
17/03/2015 08:59
Susan also agrees with me in my spat with Nasser Ghaemi (see previous post) that:-
The pluralism of psychobiology was neither arbitrary nor uncritical
17/03/2015 09:00

Tuesday, April 07, 2015

No one should believe the chemical imbalance theory

post on Slate Star Codex argues that the idea that "depression is a drop-dead simple serotonin deficiency was never taken seriously by mainstream psychiatry". There may be some truth in this view, but there's no doubt that many people have been taken in by the theory (see eg. previous post). They're surprised that the theory hasn't been proven. They may even have been told by a psychiatrist that their depression is due to a chemical imbalance.

And there's no doubt that drug companies have taken advantage of these beliefs as shown in the Zoloft (sertraline) advertisement above. True, the commercial does say that the cause of depression is unknown. But it then goes on to suggest that sertraline corrects a chemical imbalance to which depression may be related. And Slate Star Codex doesn't want to totally abandon the idea that "it's very likely it [depression] will involve chemicals in some way".

Actually, the 'chemicals in depression' may not be much different from those that create normal feelings. It may not make much sense to view depression as a neurochemical disorder. The kinds of processes that underlie mental illness at the biochemical level may be no different from those that produce thoughts, feelings and behaviour amongst the 'normal'. We tend to assume that there must be a neuropathological basis for mental illness, as there is a pathological basis for physical illness. But 'mental illness' is very different from physical illness, if only because of the mind-body philosophical problem.

And, the sertraline advert is also misleading in that it says that sertraline "is not habit forming". Antidepressant discontinuation problems do occur with SSRI antidepressants, like sertraline (eg. see previous post). It's not surprising that people may get psychologically dependent on a drug which they think has improved their mood (see my book chapter).

Thursday, April 02, 2015

Psychiatrists do believe psychosis is a brain disease

Ronald Pies (whose recent book I have reviewed) has criticised the BPS report on psychosis (see previous post) in a Psychiatric Times article for underestimating the potential seriousness of psychosis and misconceiving its nature by focusing on hearing "voices". I agree that the report, for example, does not try and distinguish psychosis from dissociative identity disorder, in which people may also hear voices.

Pies also says that the report's argument against descriptive diagnosis is "historically ill-informed and medically naive" for suggesting psychiatric diagnosis should provide an explanation of people's problems. Again, I agree that psychiatric diagnosis is primarily phenomenological, in that it involves assessment of a person's mental state. Nor, as Pies says, is the "existence of societal prejudice and discrimination" a valid argument against psychiatric diagnosis, as inevitably the implication of a psychiatric diagnosis is that something has 'gone wrong' with the person's psychosocial functioning.

As I have explained in my book review, where I do have a problem with Pies is that I do not think he sufficiently knowledges that minds are not reducible to brains. For example, in another Psychiatric Times article on the BPS report, he says that "schizophrenia is often associated with neuropathology". He deliberately highlights the word "associated" because he does not want to imply causation necessarily. However, he tends to imply just that and it's difficult to see that he means otherwise. Psychiatrists do believe schizophrenia and psychosis are brain diseases and I think Ronald Pies does as well.

(With thanks to Around The Web post on Mad in America)

Sunday, March 29, 2015

The psychogenic legacy of Adolf Meyer

Useful paper by Jordan Devylder on Adolf Meyer's psychogenic model of schizophrenia (dementia praecox), relevant to a previous post, summarises what I have been trying to say about Meyer. The article describes the development of Meyer's psychogenic theory in the context of related work in the period from Kraepelin to Bleuler. It reminds us that Kraepelin provided a "provisional and very indefinite" hypothesis that the biological cause of dementia praecox was intoxication from the sex glands causing a poisoning of the brain during puberty. As Meyer said, this was a theory that was "so vague as to demand consideration only if actual facts can be adduced and other facts should fail".

The article argues that we are beginning to see a revival of Meyerian psychiatry. I'm not convinced by Devylder's attempt to link this with the stress-vulnerability model, which is essentially still biomedical. However, as he says, "Meyer's legacy ... is the psychogenic perspective" (see my chapter The biopsychological approach in psychiatry: The Meyerian legacy in my edited book Critical psychiatry: The limits of madness).

The importance of antidepressant discontinuation problems

Giovanni Fava (who I have mentioned in a previous post) et al (2015) have produced what seems to be the first systematic review of clinical aspects of the discontinuation of serotonin specific reuptake inhibitor (SSRI) antidepressants. As they point out, the limited attention to this topic is surprising, considering its importance as SSRIs are widely used in practice.

Discontinuation symptoms may occur with any type of SSRI but seem to be more frequent with paroxetine. Gradual tapering does not eliminate the risk. The syndrome typically occurs within a few days and lasts a few weeks but many variations are possible, including late onset and/or longer persistence. A wide range of psychological and physical symptoms may occur. As I mentioned in a previous post, a survey has confirmed that the primary symptom is anxiety. In my book chapterWhy were doctors so slow to recognise antidepressant discontinuation problems?, I made reference to the paper by Schatzberg et al (1997), which described the core psychological symptoms as anxiety/agitation, crying spells and irritability. That paper also divided the physical symptoms into five clusters: disequilibrium, gastrointestinal, flu-like, sensory and sleep disturbances. There are many similarities with the withdrawal symptoms from benzodiazepines and other antidepressants. Discontinuation symptoms may easily be misidentified as signs of impending relapse.

As Fava et al point out, the use of the term 'discontinuation syndrome', rather than 'withdrawal syndrome' was heavily supported by the pharmaceutical industry to emphasise that SSRIs do not cause addiction or dependence. I have always emphasised the psychological dependence caused by SSRIs since my letter to the BMJ and my Antidepressant discontinuation reactions website. This vulnerability should not be minimised.