“Sure. Go ahead. Crash their
party,” my friend e-mailed me. That gave me the courage to do it.
I had picked up a leaflet announcing this symposium
at the
Triptych conference.
It stated clearly that the symposium was
intended for psychiatrists and doctors’ assistants. “Doctor’s
assistant” is a euphemism for a young, recently licensed physician
training under the auspices of a specialist. I suspect the term was
invented to obscure from patients that they are being treated by an
inexperienced, unqualified doctor. The leaflet did not specifically
say that non-physicians should not sign up but it was obvious.
Furthermore, there are legal reasons to exclude non-physicians from
such a symposium (see my
Triptych
notes).
The symposium was organized by the “Psychiatry
Research Foundation” the goals of which are to “stimulate research and
education in psychiatry.” This symposium was, according to the leaflet,
their first (apparently also their last), and financed by an
“unrestricted educational grant”
(written in English whereas the rest of the leaflet was in Dutch) from
GlaxoSmithKline. One of the two organizers was Peter van Harten. Was
this the same Peter van Harten who spoke at the Triptych conference at
last minute’s notice when one of the other speakers took ill? The name
was the same but the town and employer were different. The other
organizer was Wijbrand Hoek, who was listed in the leaflet as a
psychiatric educator in The Hague. I heard later that he had worked
extensively in the U.S. Both are of course highly distinguished in
their field.
The price was $100 for psychiatrists and $60 for
“doctors’ assistants.”
The application card that came with the leaflet did
not ask whether I was a psychiatrist or an assistant. There was only a
blank space, apparently for the physician to rubber stamp his
particulars. How would they know how much to charge? I stuck on my
return address label and postponed mailing it for a few weeks so as not
to seem too eager.
Then I heard nothing more. I figured that the
absence of the proper rubber stamp alerted the administrator to the
fact that I am not a physician. Or perhaps my name and address were
found to be missing from the yearly publication of licensed physicians
in the country. I had only given my first initial, my last name which
is extremely common in this country, and a post office box number. No
medical license number of course – I don’t have one. I expected to be
asked who I really am, but I wasn’t.
Six days before the conference I was surprised to
receive a letter addressed to “The well nobly educated mistress M. de
Vries” … confirming my participation! The letter also said that as
there had been too few registrations, I could bring along a
doctor’s assistant free of charge. Enclosed was an invoice for $100. I
paid.
Normally I would not inform you details about my
appearance, but when one is going to be an impostor, one must look the
part.
A major give-away was my obesity. Physicians are
almost always slender, I suspect, not because they have superior
self-control, but because the over-weight ones are sifted out. In my
country students are admitted to medical school on the basis of, would
you believe, lottery! But control over who makes it through to the
finish line is in the hands of the doctors. A widely held belief among
physicians as well as the general public is that fat interferes with
brain function. Of course there wasn’t much I could do about my figure
in six days. Even a burqa couldn’t hide it.
Also likely to arouse suspicion was any sign of
religiosity. Because I wear a head scarf I am often mistaken for a
Moslem woman, which I do not consider an insult, but many people do.
The symposium was being held the day after our national elections. Our
immigrant Islamic community had been a major issue in the campaigns.
Their men were characterized as criminals and their women as illiterate
and oppressed. Such generalizations are at best silly, but doctors can
be as silly as the rest of society.
Although my own ancestors came to this country half
a millennium ago, if I wore a head scarf I might too be thought
illiterate, oppressed, and incapable of attaining a degree in medicine.
Going bare-headed was not an option for me. So I bought an inexpensive
wig at a head shop in town. It was the only gray wig in the store. The
others were black, auburn, blond, purple, and green. The bemused store
owner asked me whether I would also like a belly piercing.
The wig had an additional purpose. Together with my
new glasses, I hoped it would make me incognito. It would be pretty
embarrassing to come face to face with a psychiatrist who knows me.
A mistake I had made at the Triptych conference was
to wear a blazer, thinking that it would make me look powerful. The
conference hall had been too hot to keep it on, whereas pinning that
all-important name tag (see my
Triptych
notes) onto my blouse ruined
it. So this time I wore a loosely knitted vest solely for the purpose
of pinning on the name tag. It takes experience to become a doctor.
My preparations did not concern only my exterior. I
vowed to keep my mouth shut and speak only when spoken to, for me a
difficult feat. Anything I say might give away that I am not a
physician.
The leaflet announced that I would be seeing videos
of movement disorders. I would have to handle that. A doctor can’t be
squeamish. Though I wondered what they could show me that I haven’t
seen yet.
At the reception desk I received my name tag and a
green zippered organizer. It contained a pen, a notepad, and pockets
for keeping credit cards or business cards. A swan decorated the
organizer and the pen. Was it the logo of GlaxoSmithKline?
It also contained a list of the participants
according to the workshops for which they had signed up. We had had to
choose two workshops out of four. My name was at the top of the list
for each workshop for which I had signed up, so apparently I had been
the first to send in the application card after all.
The workshops were:
I. Skill in diagnosing the complex
presentations in geriatric psychiatry;
II. Skill in recognizing and treating movement
disorders [caused] by medicines;
III. Skill in supervising;
IV. Skill in interpreting epidemiological research.
In total 37 physicians had signed up, including one
of the organizers who had signed up to his own and another work-shop,
and one impostor (me). Let’s discount the organizer and say 36.
Most of the doctors were women. Psychiatry is
popular among female physicians because psychiatrists have to work only
during office hours. At least, I would like to think that is the
reason, and not some inherent inferiority of my sex. I have been cured
of the notion I had back in the sixties that if women were able to
achieve positions of power the world we be better. Women in positions
of power turn into men.
With 25 (divided over two time-slots) Peter van
Harten’s workshop about movement disorders had the most sign-ups,
including me.
Second was the workshop about supervision, with 22
sign-ups. That included me too. I didn’t know what was meant by
“supervision”, but I wanted to be sure to have a chance to speak to the
professor who was to give the workshop, Jan Pols. I had contacted him a
year or two earlier and asked permission to translate his dissertation
– about the life and works of Thomas Szasz – into English. As I had not
heard from him since, I figured that signing up to his workshop would
ensure me a chance to approach him about it again.
Third in size with 18 sign-ups was the one about
geriatric psychiatry by Thea Heeren, a distinguished physician from
Utrecht.
Last, with only seven sign-ups, was the workshop
given by the other organizer, Wijbrand Hoek, about epidemiological
research.
The workshops were only after lunch, though. First
were the lectures. The brief opening speech was held by one of the
organizers. At the end of the symposium we would receive a certificate
for four points (credits towards the obligatory educational updates
that physicians have to have to renew their licenses). And would
everybody please turn off his mobile phone? At this request most of the
bodies in the room simultaneously bent over as if they were Moslem men
at
prayer. I bent over too, and rummaged about in my bag pretending to
turn off my mobile phone, which I do not own.
The first lecturer was Thea Heeren. She introduced
herself as being head of both geriatrics and youth at the psychiatric
institution where she works. Although some people find this combination
amusing, she said, in reality there is a great deal of overlap in these
two types of psychiatry. The elderly are a more heterogeneous group.
This is because they have lived longer, so they have been exposed to
more experiences, both biological and psychological. That makes it all
the more difficult to determine what is “normal” in that group.
Heeren singled out four factors as characterizing
the elderly – lessening of cognitive faculties, somatic illness,
medicinal intake, and psycho-social difficulties.
A table was projected onto a screen representing the
percentage of dementia (senility?) in the elderly:
age 60 - 69 1 - 2% (Perhaps I
copied this down wrong and it is 1-5%)
age 70 - 79 5-10%
age 80 - 89 10 - 20%
age 90 - 99 30 - 40%
age 100 + 75%
Students, said Heeren, tend to think most elderly
people are senile. It comes as a surprise to them that more than 80% of
people in their eighties are still lucid.
The older people are, the more chronic illnesses we
encounter among them. With age the functional impairments increase.
That means difficulties in walking, using instruments, and other normal
daily activities. The group of elderly people can be subdivided into
younger elderly people and older elderly people. The older ones have
more problems than the younger ones. (Remember, this is a lecture being
given supposedly to licensed physicians only. She must not credit them
with much common sense.)
Most people age 65 and over use medicines. In one
study people were asked at random if they had taken any medicines in
the last two weeks. Of the people aged 65 and over 75% answered yes.
More surprisingly, of the people aged 40 to 65, 44% also answered yes.
The researchers drew the conclusion that a lot of people take medicines
(really?).
Older people have psycho-social problems. Their
relationships with their children change, their friends and family
become fewer. Research indicates that ¾ of the people aged 85+
are women. Also ¾ of the people aged 85+ don’t have a marriage
partner. Therefore, although researchers have not studied the issue
separately, they estimate that most people who are aged 85+ are women
without partners. It is
postulated that loneliness is a major factor in psychiatric
disturbances in this age group, however, the matter has as yet not been
researched. (Without research we cannot know this?)
We don’t know much about the elderly among immigrant
groups. Psychiatrists rarely see them. This is not because they don’t
have psychiatric problems, but because they don’t know how to find
their way to psychiatry yet. (How would she know?)
The psychiatrist should give every elderly patient
an MMSE test. (This was the first and one of very few terms I heard
throughout the symposium that, not being a psychiatrist, I wasn’t
familiar with. However it doesn’t take ten years of medical training to
figure out that one of the Ms must stand for “memory” or “mental” and
the E for
“evaluation” or “examination.”) The test doesn’t take a lot of time so
there’s no excuse not
to do it. The questions should not be woven into the general
conversation. The physician should set aside a special part of the
consultation for it and tell the patient that it is a test. The reason
is that patients will sometimes disguise their memory problems. For
instance, if you ask “What day is it?” the patient may say, “I just
told my daughter, but now it’s slipped my mind.” Such answers can
mislead the physician.
Another standard test is the clock. The patient is
asked to draw a clock. Interpreting the results is difficult. (So
what’s the point of it?)
The consultation should also include a fluency test
for frontal function. (Presumably she means frontal lobes?) In this
test the physician picks a letter of the alphabet and tells the patient
to think of as many words, such as names of furniture items or animals,
that begin with that letter. Proper names don’t count. People with
frontal dysfunction will often not be able to name very many. (How many
do they have to name to pass the test, assuming the physician did not
pick Q or X?) Unfortunately thorough cognitive testing takes a lot of
the physician’s time.
Attention should also be paid to sensory function.
Does the patient need glasses or a hearing aid? Are they effective?
Perhaps there have been recent changes, and the patient has to have new
glasses made? Sometimes patients have glasses but leave them in a
drawer. That’s why they have trouble seeing. (Honestly, folks, she said
that.)
Mobility can also be a factor. The patient may use a
crutch or wheel chair. If the patient arrives in a wheel chair, the
physician should ask whether the patient is confined to the wheel
chair.
Sometimes a wheel chair is used only for transportation, but at home
the patient can walk.
How much should psychiatrists know about somatic
illness? Nowadays psychiatrists are not initiated into it much. One
should not overestimate oneself. To cover the somatic side a geriatric
psychiatrist might work together with a geriatric (somatic) physician.
It is a good idea to be on the lookout for possible primary somatic
disruption.
It’s surprising (says she) that psychiatrists know
so little about neuro-psychological testing. These consist of the MRI
and SPECT. There is some controversy about whether psychiatrists should
be able to evaluate such scans themselves. Certainly the evaluation of
a SPECT scan is too specialistic and a psychiatrist cannot be expected
to do that.
This is a flair photo of a depressed patient. (A
picture of a brain is projected onto screen. We are expected to take
her word for it that this is the brain of a depressed person. No
further evidence is cited, and nothing else is said about it.)
The physician should always ask the patient about
the medicines he uses. Is the patient compliant?
The physician should also ask about the
psycho-social circumstances. Has the partner recently died? Friends?
Have relationships with the children changed? Was there a move? Often
psychiatric symptoms arise after the patient has moved to a nursing
home (I wonder why). Are there physical impairments? Loneliness?
Loneliness is a problem that will probably be looked into sometime in
the future.
Regarding diagnosis and classification,
sometimes
it is difficult to squeeze a problem into a DSM IV classification.
(My emphasis.)
What I suppose she meant was that these people’s
problems are perfectly normal and non-medical but let’s not
forget that we are psychiatrists and it is our job to pick labels for
them from the
DSM IV.
This last, to me most revealing statement closed
her presentation. You’ll surely agree with me that she told us nothing
we didn’t know already, nor did she suggest any way of relieving the
elderly person’s suffering, including loneliness, regardless of which
DSM IV classification the psychiatrist manages to squeeze him into. I
wish I could have attended her workshop without missing the others. I
am curious just what skills were practiced in it. Perhaps picking a
diagnosis from the DSM IV with a pin?
The next lecturer was Peter van Harten, who
presented himself as an expert in identifying movement disorders caused
by neuroleptic drugs. He gave a web site and phone number of his
clinic. Physicians could refer patients to his clinic if they suspected
movement disorders. The first step is recognition, he said. (Step
towards what? At no time did he offer any real solutions, certainly not
refraining from prescribing these drugs to new patients.)
Parkinson’s disease is caused when 80% or more of
dopamine production is lost or blocked. The symptoms may cause the
patient anxiety. Sometimes patients are ashamed of them. They can cause
restlessness and even pain. Sometimes they are irreversible. Sometimes
they resemble psychiatric disturbances. Psychiatric patients have
trouble expressing themselves. Some are autistic. Patients often
interpret their symptoms differently [from physicians].
While treating one disease you’re introducing another one. It is the
psychiatrist’s job to dance between schizophrenia and movement
disorders.
The first pictures projected on the screen were
stills of a woman. The eyes were covered with a black bar the way the
newspapers cover the eyes of suspected criminals. This did nothing to
conceal her identity, as if anybody cared about that, but did cause an
unavoidable association with crime.
Next a film clip was shown about various disordered
movements of the tongue. It wasn’t pretty to see. The names alone of
the disorders of mouth and tongue
reveal how dehumanizing these conditions are – rabbit syndrome, worm
tongue, fly tongue. The last in that list refers apparently not to the
tongue of a
fly, but to the lizard's catching a fly. The video showed someone with
fly tongue, which must be extremely painful and distressing, not to
mention embarrassing. Imagine your tongue involuntarily whipping
rapidly in and far out of your mouth in rapid succession. In spite of
my resolutions, I could not help feeling tears
of compassion and anger about what had been done to this person welling
up in my eyes. As I dabbed at them with
a paper tissue, the psychiatrists … laughed! They thought the fly
tongue
was funny! Maybe not all 35 of them laughed, but there were repeated
ripples of laughter through the room, and no one turned to the others
and chastised them for it. Their laughter increased my feelings of
outrage and disgust.
We were shown additional clips in which Van Harten
pointed out disordered movements of the diaphragm, causing the chest to
jerk, and “rest tremors” which is the trembling of the hands while at
rest. In my opinion the involuntary movement of the hands was much too
violent to
be called a tremor. We were also shown a case of bradykynesia. That is
when the arms don’t move along with the rest of the body while walking.
Myoclonia is when muscles suddenly contract, making jerking movements.
They can be anywhere in the body, the arms, legs, diaphragm, eyes.
A list of drugs that can cause these movement
disorders was projected onto the screen. Unfortunately I didn’t jot
them down fast enough. They included all the ones we know about
already, neuroleptics, antidepressants, lithium, anti-epileptics,
anti-emitics, Parkinson’s disease drugs, and anticholinergics, but also
anti-malaria
drugs, and, surprisingly, contraceptives. Van Harten admitted that
movement disorders caused by contraceptives are rare. I suspect they
are non-existent. “The pill” is so widely used that surely some women
who have movement disorders from psychoactive drugs also happen to be
on a contraceptive. That makes it look like not a specific problem of
psychiatry, which of course it is. I wondered about anticholinergics
being on the list, as biperiden, an anticholinergic prescribed to
people with Parkinson’s disease, was mentioned repeatedly throughout
the symposium as the antidote to dystonia. I wondered how Van Harten
would explain that, but I didn’t dare ask, and nobody else did either.
In response to a remark from one of the doctors in
the audience, Van Harten confirmed that “negroids” are “probably more
susceptible to movement disorders”. He mentioned nothing
about the supposed higher susceptibility perhaps being a reason not to
drug blacks, or anybody. (Philip Thomas in his book “
The
Dialectics of Schizophrenia” points out that black men are drugged
more than other people because they are perceived to be more
“dangerous” due to social
prejudice. Most doctors and nurses working in psychiatry in the
Netherlands are young, white, and female.)
After this lecture was a coffee break. Having
watched the videos of people who were physically and mentally tortured
by the effects of psychoactive drugs, drugs that save or improve
nobody’s life and should never have been administered, I left the
lecture hall feeling similar to how I felt when leaving
Yad
VaShem, the
Holocaust memorial in Jerusalem. Sick. The physicians shared nothing of
this feeling. They were standing around, holding their coffee cups,
smiling, joking, laughing. Occasionally two apparently old friends
would meet and kiss. I was reminded of Robert Jay Lifton’s theory about
physicians’ duality. In order to do his job, the doctor has to protect
his emotions. He achieves this by seeing himself as different from his
patients. The book in which Lifton proposed this theory was “The Nazi
Doctors.” He tells of one nazi physician who lived at Auschwitz with
his wife and child, under the smoke of the crematoria where thousands
of men, women, and children were murdered daily. I am not saying that
physicians should never have any light-hearted moments because they
deal with death. Illness and death are a legitimate part of life.
Torture and murder are not.
I happen not to drink coffee, but even if I did,
doing it among those laughing doctors would have turned my stomach. I
returned the lecture hall and read a book I had brought along.
The next lecturer after the coffee break was Jan
Pols. I was going to find out what was meant by “supervision.” It
turned out to be the relationship between the specialist and the
“doctor’s assistant.” I had thought that might be meant, but couldn’t
imagine that a doctor can actually earn credits towards renewing his
physician’s license by attending a lecture on how to boss his
student-assistant. Judging by the workshop sign-ups the subject is
popular.
Pols called supervision “the cornerstone of the
training.” It’s a matter of attitude, he said. Surprisingly, he claimed
that ¾ of the assistant–supervisor relationships end in a
dispute.
He projected a list on the screen of four different
types of supervisor-assistant relationships.
The first he called old-fashioned. That is the
relationship between a master and an apprentice. The master is
constantly present, teaching and directing the assistant. That type
does not occur in modern times, because the supervisor isn’t even
present most of the time.
The second resembles the relationship between a
psychotherapist and his patient. The assistant discusses his problems
in dealing with the patients with his supervisor. The supervisor
supports the assistant emotionally in his work.
The third type of relationship is boss-employee. The
assistant carries out the supervisor’s orders and substitutes for the
supervisor in his absence (which is almost always).
The fourth type is egalitarian. Pols called it
“intervision.” Supervisor and assistant discuss the medical issues as
though they were colleagues of equal levels of medical knowledge.
(You get to guess which type is most common
nowadays,
at least in psychiatric institutions. Hint: patients don’t even know
what the supervisor looks like.)
Pols spoke of the imbalance of power between
supervisor and assistant. The assistant needs the supervisor’s approval
to complete his training. A fall-out with the supervisor could be
damaging for the young doctor’s future career.
I seem not to have taken a lot of notes during
Pols’s lecture. It was all so obvious. What he didn’t say was more
interesting to me than what he did. If I hadn’t read his dissertation I
would wonder whether he had given any thought to the imbalance of power
between doctor and patient. How much of the young trainee doctor’s
behavior toward patients is motivated by his drive to console himself
for his powerlessness toward his supervisor?
Pols seemed to admit that the trainee learns nothing
from the supervisor during training. In psychiatry, there isn’t
anything to learn, anyway. The entire process is a charade.
The last lecture before lunch was by the other
organizer of the symposium, Wijbrand Hoek, on the subject of
interpreting epidemiological research. Hoek opened with the statement
that no psychiatric disturbance exists which is not a mixture of genes
and environment. If he had ended his sentence nine words earlier I
might have agreed with it. “I realize that epidemiological research is
unpopular,” he said, “as evidenced by the few sign-ups to the
workshop.” In fact, so few had signed up to it, that he would have to
give the workshop only once instead of twice like the others.
Next he asked, “How many people in the Netherlands
suffer from schizophrenia?” He looked around the lecture hall like my
fourth grade teacher used to look around the classroom when deciding
who to call on. I dreaded his eyes meeting mine. If he pointed at me
and said, “You over there, what’s the answer?” I would have lost
control of my tongue and responded, “Zero, but hundreds of thousand
suffer from psychiatry.” He might make me stand in the corner for
impudence.
Fortunately I wasn’t called on. Hoek projected
multiple choice answers on the screen:
a. 80,000
b. 120,000
c. 160,000
d. 320,000
Then he asked for a show of hands. How many say a? Two. How many b?
six. How many c? Most, probably 27. How many d? One. I abstained.
The correct answer, he said, was b. How come so many
thought c? Because we are told that 1% of the population suffers from
schizophrenia. The population of the Netherlands is 16,000,000, 1% of
which would be 160,000. The mistake most of the doctors had made,
according to Hoek, was
forgetting that that 1% means over an entire life-time. There are
nearly three million children in the Netherlands who are too young to
have symptoms of schizophrenia.
(At home I tried repeating his figures using a
calculator. Either I wrote the figures down wrong in my notes or he was
using them rather loosely.)
This explains, he said, why there is less prevalence
of schizophrenia in Africa (as though Africa were some little island
with a homogenous population). You and I might think that it’s because
Africa was cursed with fewer psychiatrists. Believers in the
psychological model of schizophrenia might say it is because African
families are more closely knit and support each other. The
epidemiologist explained it by saying there are more children in
Africa. 50% of the population is too young to have symptoms of
schizophrenia, as opposed to only 15% in the Netherlands. So you see,
if we discount the children, Africans are at least as crazy as we are!
Maybe he moonlights at the
WFMH.
Another chart was projected on the screen.
Monozygotic twins 50%
Dizygotic twins
15%
Siblings
9%
He pointed to the 50%. “What does this tell you?” Hoek asked, looking
around the room again like a school teacher. Nobody responded. “That
schizophrenia is genetic, of course.” Of course. Except then how do you
explain all those identical twins that did not identically get labeled?
Hoek must have been reading my mind. “We examined one of those
monozygotic twin pairs, and found that they were treated differently by
their parents. This proves that schizophrenia is partly genetic and
partly environmental.” I don’t see how that proves anything.
Then Hoek pointed to the 15%. “What does this tell
you?” he asked. One of the doctors in the audience must have proposed
the answer in a hardly audible whisper. “Right,” said Hoek, “both
siblings emerged from the same pregnancy. Prenatal influences also
contribute to schizophrenia.” What
doesn't contribute to
schizophrenia?
Then he projected a chart on the screen which
represented the number of cases of schizophrenia diagnosed in the
Netherlands every year. One of the bars shot up higher than the others.
There were twice as many schizophrenia diagnoses that year (I don't
remember exactly which, but it was some time in the sixties) than in
other years, he said. His explanation? The mothers of those people
would have been pregnant during the winter of 1945, which the Dutch
call “The winter of famine.” Because of the German occupation there was
a shortage of food.
Even the physicians in the audience were skeptical
of this explanation. The fact that there were more cases of
schizophrenia in the cities than in the countryside supported his
claim, Hoek said, because farmers had access to food while city
dwellers were under siege. Hmm. Maybe the people who were considered
schizophrenic had migrated to the cities after birth? Or maybe there
were just more
psychiatrists in the cities that year? Or the cities of the sixties
were
saturated with LSD? One alert doctor in the audience asked why another
bar on the chart was so low. Did it reflect a protective influence?
Hoek said he didn’t know.
To reinforce his prenatal famine theory, Hoek
flashed pictures on the screen of a healthy neonate, a preemie, and a
baby born too small for gestational age. Then another chart was flashed
on the screen. According to him, prenatal famine in the first trimester
of pregnancy makes people schizophrenic, in the second trimester of
pregnancy makes them have antisocial personalities, and in the third
trimester of pregnancy makes them become
depressed. He likened it to harelips and spina bifida, congenital
conditions which are believed to be caused by a combination of genes
and folic acid deficiency.
It is well-known that preemies and small-for-date
babies are at high risk for all sorts of problems long before they
reach the age before which according to Hoek himself schizophrenia is
not diagnosed. My impression was that Hoek’s prenatal famine theory was
precious to him. The messiness of his method contrasted sharply with
the neatness of his apparel.
After that came lunch. I didn’t go into the
lunchroom. Even if there had been something there that I was willing to
eat, which I doubted, dining with doctors was taxing my acting ability.
And I couldn’t repress the memory of their laughter at the helpless
person having those awful tongue movements.
If there was a stand where drugs were plugged like
there had been at the
Triptych
conference, I did not see it. What I saw
were two books which participants could order, I presume, free of
charge. One was about “anxiety disorders” and the other I don’t
remember, but something similar. Probably promoting drugs this way is
worse than the way it was done at the Triptych. These books recommended
the sponsor’s products in the guise of educational text books.
I had been assigned to Pols’s workshop about
supervision during the first time slot. As I had already had the
opportunity of discussing his dissertation with him during the lunch
break, I did something daring. I went to Hoek’s workshop about
epidemiological research instead of Pols’s to which I was signed up.
The daring was double, first because of the audacity of changing my
mind on the spot, and second, because it would be more difficult to
remain inconspicuous in such a small group. But I wanted to hear more
about how psychiatrists come up with these far-flung and
unsubstantiated theories.
At the workshop Hoek suggested that we go around the
table, each saying his name and where he practices. I was prepared for
this. When my turn came, I said, “I’m Mira de Vries and I’m
independent.” “Independent” is here another term for private practice.
Of course what I “practice” is activism against psychiatry, but
independent I am, no lie. To my surprise the eighth doctor in the
workshop also said he was independent. Private practice is rare in this
socialist country. Was he an impostor too?
The eight of us were divided into two groups of
four. We were given the task of figuring the outcome of an
epidemiological study, which at this point we were told was
hypothetical. We were to discuss among ourselves how to set up the
study. Keeping my mouth firmly shut was now no longer a safe strategy.
I was going to have to say something once in a while.
The study was to determine whether cocaine is a risk
factor for neuroleptic-induced acute dystonia. In my words, would it be
possible to blame cocaine instead of the neuroleptic?
We were to pretend that we were researches working
at the only psychiatric institution in Curaçao. The study
involved 29 people of whom nine were defined as cocaine users. To be
included in the study they had to be male, between the ages of 17 and
45, not have taken neuroleptic drugs during the previous month, and
prescribed high-potency neuroleptics upon admission. We were told that
six of the cocaine users and three of the non-cocaine users had
developed acute dystonia within five days.
Two of the other three in my group, one man and one
woman, treated me the same as they treated the others. Physicians among
themselves are generally not arrogant. But one, I’ll call her Argy,
sent me bad vibrations. Every time I contributed a thought, she
responded by glaring at me. I could almost hear her thinking, "Boy, is
that fat old doctor stupid." Ironically, as I learned later, most of my
suggestions were
also brought up by the other group or by Hoek himself. For instance,
how could we determine who was on cocaine? Was the cocaine use
continued or discontinued in the hospital? Perhaps there was use of
other drugs as well? Did the diagnosis make a difference? So I wasn’t
doing too badly. Argy decided to include all diagnoses “for which
neuroleptics are indicated” and wondered how was the acute dystonia to
be diagnosed? The doctor would ask the nurse in the morning, she
decided.
When I suggested that the one-month neuroleptic-free
criterion wasn’t adequate, considering that many neuroleptics have a
half-life as long or are depot drugs, Argy claimed that after a month
there’s no neuroleptic left in the blood. I know that is not always
true, and anyway, it’s what it does to the brain that counts. What
wiped the arrogance off of Argy’s face was when I asked, “How can we
determine that the acute dystonia is not caused by the forced
withdrawal from the cocaine, quite apart from the neuroleptic?” Argy
had just bragged that she frequently treats “psychotic cocaine
addicts.” Now her voice dropped, and she sputtered, “I don’t know
anything about the withdrawal symptoms of cocaine,” and looking
helplessly at the other two doctors, who also claimed to treat
psychotic addicts, she asked “do you?” They shook their heads. They had
just admitted not knowing what they are doing when treating cocaine
addicts.
At one point Argy said, “I wonder how ethical this
research would be?” I had almost leaned over to kiss her when she
added, “These patients should be administered biperiden with their
neuroleptics.” Yuck, I had almost kissed the creepess, or whatever you
call a female creep.
Why was Argy arrogant towards me but not the others?
Did she suspect that I was an impostor? My theory is
that like many arrogant people, Argy was sensitive to my insecurity.
You see, arrogance is caused by a combination of genetic and
environmental factors…
The research was revealed to have been not
hypothetical but real. It was conducted by Hoek himself and Van Harten,
the movement disorder man, and published in the Journal of Clinical
Psychiatry, volume 59, No. 3, in March, 1998 (in case you want to look
it up). Each workshop participant received a reprint. Now I could see
by the different address given that Van Harten was the Triptych man
after all. Users at the Triptych would have appreciated a presentation
about movement disorders. Instead, there, Van Harten made propaganda
for the
DSM IV
(see my
Triptych notes).
The conclusion we had been supposed to reach was, as
the article claimed, that cocaine users are 4.5 times more likely to
develop acute dystonia when treated with neuroleptic drugs. “What
other conclusion do you draw from this?” asked Hoek. In the quiet that
ensued, I wanted
to shout, “Stop poisoning people with neuroleptics” but I held my
tongue. The correct answer, according to him, was to administer
biperiden along with the neuroleptics during the first five days. I
don’t believe biperiden is the wonder drug that it was repeatedly made
out to be at that symposium. But perhaps prescribing it does wonders
for doctors’ consciences.
The others expressed doubts about Hoek’s research.
29 participants were not enough, they said. There were too many
variables. “If you eliminate all the variables, you don’t have enough
people left to include in the research,” Hoek defended. It wasn’t
ethical, said the others. He admitted receiving funding from the U.S.
sponsor to carry out the research in Curaçao because approval
could not be obtained for conducting it in the U.S. Nothing about the
sponsor was mentioned in the article.
As we started leaving for the break, Hoek also
handed out a reprint of his article called “Schizoid Personality
Disorder After Prenatal Exposure to Famine” published by the American
Journal of Psychiatry, volume 153, no. 12, in December, 1996. That
caused the doctors who still lingered in the room to pick up the
subject again. I was so immersed in the conversation that I forgot that
I had resolved to speak only when spoken to. “If it were true, it
should also apply to women who vomit a lot during pregnancy,” I said.
“If you take only babies born at normal birth weight, you’ll be
eliminating all the variables of NICU (neonatal intensive care unit).”
Hoek brushed the idea off. “You couldn’t delineate
that. My wife felt nauseous…” I interrupted him. “There’s a big
difference between nausea and hyperemisis gravidarum.” The fancy Latin
term which I happened to remember from my doctor’s excuse note to my
employer came in handy. Another doctor said, “You could use
hospitalization of the mother as a criterion.”
“It would be too difficult. You’d have to follow the
infants born to those mothers for twenty-five years,” said Hoek.
“Or ask mothers of twenty-five-year-olds whether
they vomited heavily during pregnancy,” I suggested. “I assure you no
mother forgets that, even after 25 years.”
Hoek’s eyes suddenly lit up. “That’s a good idea,”
he said.
Embarrassingly, a few minutes later we literally
bumped into each other coming out of the rest room. Hoek started
talking to me again about the prenatal famine. He thought my suggestion
about examining the consequences of maternal vomiting in relation to
the development of schizophrenia was very good, and he might well
follow up on it. He hadn’t noticed that I had said nothing about
schizophrenia. “How did you think of this idea?” he asked me.
“Personal experience,” I said.
My second workshop was Van Harten again, and his
videos of movement disorders. He told the story of a 12-yr-old girl
brought into a hospital by ambulance. She was in a state of acute
dystonia. The photograph of her showed her arched backward, hands and
feet in a spasm, tongue swollen and extended, eyes locked upward, etc.
I could not help but think not only of how terrified the poor child
must have been, but also of the emotional trauma to her mother.
According to Van Harten, the mother denied that her daughter had taken
any pills. It turned out she had received an anti-emitic suppository.
According to the story, biperiden saved the day again.
Dystonia is caused by calcium deficiency in the
muscle, he explained, as though the neuroleptic had nothing to do with
it.
We were shown videos of the same people as before,
but also others, as now there was more time, he said. He pointed out
torticollis (holding the head turned to the side), trismus (the
jaws are locked), mouths that are always open, facial grimaces, Pisa
syndrome (leaning to the side while walking) and many more. He
mentioned that the movement disorders seem exasperated by physical
activity. Someone may keep his hands still while sitting, but when
asked to walk, the hands will start pulling into a cramped-looking
position or shake.
Van Harten showed stills of feet so disfigured by
dystonia that walking was not possible. He described the slurred speech
that is caused by neuroleptics, which he ascribed to dystonia of the
tongue. Some people have discovered that they can ease the tension in
certain muscles by stroking another muscle, he said, demonstrating the
stroking. His use of the Latin name for an arm muscle was one of the
other rare moments that I was confronted with a term I didn’t know,
although
I would probably have learned it in high school biology class if I
hadn’t slept through it.
He showed a video of a woman in an oculogyre crisis.
That means her eyes were locked upwards. This phenomenon had started
about a year after her mother passed away. When asked about it, the
woman would say that it happened because her mother was calling her
from heaven. Another picture showed the same woman after the physician
had injected Botox toxin into her facial muscles to prevent spasms.
Another video showed a man on neuroleptics for
fifteen years. His eyes kept being involuntarily squeezed shut,
interfering, needless to say, with his vision. This same man also had
Pisa Syndrome. He (victim) explained it as having happened when he bent
over to catch a key ring he had dropped. Van Harten did not use the
term “confabulation” for such desperate attempts of people with brains
befuddled by drugs to understand what is happening to their bodies.
Instead he called them “psychotic explanations.”
We were told about a man whose pelvis kept
rhythmically moving back and forth, which Van Harten called “copulating
movements.” There was a video of an elderly lady, the same one we had
seen before with the jerky diaphragm. Her face was distorted, her
breathing labored, her speech difficult, and her tongue kept
rhythmically protruding from her mouth. It looked black. She complained
that it hurt. She emitted involuntary grunts. Her husband, who was out
of the picture, said that he can always tell where in the house she is
by her grunts. That prompted the wretched physicians in the audience to
laugh again. The answers the woman in the video gave to the
psychiatrist’s (Van Harten?) questions revealed that she was painfully
aware of what was happening to her.
Van Harten asked the audience some questions, like,
how can you tell whether a movement disorder is caused by the
neuroleptic or by a stroke? None of the doctors knew the answer. I
wanted to say that a stroke would appear suddenly but movement
disorders appear gradually (not that strokes cause movement disorders),
but I was afraid of revealing my medical
ignorance. My answer turned out to be right. I was to experience that
with several of the questions he asked.
He explained about neuroleptics on the one hand
causing movement disorders, and on the other hand suppressing them.
That is why they often become visible when the drug is reduced, and
reinstating the drug suppresses them… temporarily. Someone asked why,
so Van Harten explained that it has to do with the level of dopamine
blockage. One of the doctors in the audience didn’t understand and Van
Harten repeated his explanation several times.
He asked a doctor from the audience to volunteer as
a patient so that he could demonstrate how to examine the patient for
movement disorders. For instance, the doctor should ask the patient to
hang his hands to the side of the chair, because while lying on the
lap, trembling can be disguised. The patient should be asked to walk,
because activity may bring out movement disorders previously
suppressed, such as the hands twitching or even tongue movements.
While the patient is walking the doctor can also check for Pisa
syndrome, and whether the arms move normally or don’t. Van Harten
handed out written instructions on how to perform the exam.
All right, so he’s taught the doctors how to watch
for it. But what are they supposed to do about it besides administer
biperiden? Even Van Harten admitted that biperiden is effective “only
for dystonia.” He didn’t say, but the professional publications do,
that biperiden makes movement disorders worse. The people who are
having the dystonias are surely the same people who are having the
movement disorders. I don’t believe that it is going to be possible to
switch all these people to clozapine, like he seemed to suggest,
considering my own experience
with switching drugs. And I also don’t believe switching to clozapine
always makes the disorders go away, not to mention that it introduces a
whole new array of other movement disorders. At no time did Van Harten
suggest
that perhaps doctors should stop prescribing the drugs that cause these
disorders, and neither did the physicians in the audience.
I wish to appeal to my readers, and particularly the
real physicians among us: please, obtain those videos. Surely you can
do it under some pretext or other. Say you want to instruct students
about movement disorders or whatever. I have Van Harten’s phone number
to give you.
We have to show those videos to the world. Perhaps
that controversial TV station in Britain, the one which showed a
pathologist cutting open a human cadaver, would be willing to air these
shocking pictures.
If it had not been for media attention, doctors
would still be prescribing thalidomide to pregnant women. If we don’t
get these pictures out into the media, pharmaceutical torture will
never stop. Particularly we should show the video of the elderly woman,
as it is blatantly obvious that she was a sweet little old lady and not
some dangerous criminal. A picture is worth a zillion words.
Why should these pictures be only for a closed
company of doctors to snicker at, like a bunch of boys secretly viewing
pornography? Why not seize them and use them to alert the world to this
pharmacaust?
Please, I beseech you.
At the end of the symposium I was given my
certificate of attendance,
earning
me four credits “in the category
[of] General Psychiatry”. It was signed by Van Harten and Hoek. The
name printed on the certificate was “M. de Vries”. I didn’t have a
chance to see any of the other certificates. Did they also only have a
first initial and a last name, with no other identifying information?
There must be dozens of doctors in this country who answer to the name
of M. de Vries. Maybe I could sell them photocopies to use when they
have to renew their licenses.
What new skills did the doctors learn? Perhaps the
seven who attended Hoek’s workshop learned how to bluff their way
through shoddy research and reach the desired conclusions. If the
doctors gained skills at detecting movement disorders, it is only
because they previously had less experience seeing them than I. No
skill at all is required to see the suffering of pharmacaust victims.
Perhaps the physicians’ skill is that they can giggle about it. As I do
not have a degree in medicine to grant me immunity from this cruelty, I
could well be the next victim myself.
I have but one small consolation. I successfully
crashed their party.
