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The Royal College of Psychiatrists Improving the lives of people with mental illness

Busy times, a royal riddle and dinner with a prince

It’s all happening at the moment, folks. I used to moan that we never got enough publicity. Suddenly I am nostalgic for those good old (quiet) days.

We have been talking on prison suicides (a predictable and self-inflicted disaster for which someone, and we all know who, should be held accountable). There has been the regular drum beat that antidepressants spell the end of civilisation (no they don’t).

There is a Panorama running on Monday night about problems in mental health care. I haven’t seen it, but am confident about two things. First, that my long interview will be reduced to ten seconds, missing out all the important bits and second, yet another Chief Executive will be heading for the tumbrils.

Their life expectancy is not much better than a first world war Flying Officer.

On the other hand, if you want something funny (funny peculiar I am afraid, not funny ha ha) listen in to the Life Scientific (BBC R4, Tuesday 14 February).

 

On the move

And I have been using my new bus pass. How long I will have it remains to be seen, since 30 minutes after it dropped on the mat, Simon Stevens was on the radio announcing that stopping perks like free bus passes was the only way to save the NHS.

But before he removes the only good thing about turning 60 I have been on the move. Health Education England to talk about the mental health workforce – yesterday the new data on career destinations of Foundation Year was slipped into the public domain.

It’s bad news for the profession – numbers of those going into higher training has declined for the fifth year running – but actually a little glimmer of light for us – psychiatry has shown a small but definite upturn.

Then back on the bus for multiple trips to the Department of Health and NHS-England– IAPTS, Out of Area Placements, CAMHS leads, addiction services and the lack of them, and so on.

Then the Ministry of Justice, followed by a stroll round the corner to talk sex with the Bishops, and then back to Home Office, and more Prevent.

We continue to work with them, DH, GMC, the police services and Uncle Tom Cobley about this.

Come to the Presidential Lecture on 14 March for a real bean fight about this, as we let Derek Summerfield off the leash.

But in the meantime we continue to steer the difficult path between our legal duties to prevent terrorism (a duty on every citizen), our duty to try and help those with mental disorders who might also pose some risks to themselves or others (familiar territory) and our duty not to cross ethical lines.

 

Knowing our history

One of the reasons I like psychiatry is that we as a profession are aware of past and present misdemeanours - political abuse of psychiatry in the old Soviet Union, or more recent dubious practices by psychologists in Guantanamo Bay. We know, and need to know, our history.

Which brings me by a tortuous and twisting path to history, which is what I want to write about today. I and probably you need a break from NHS politics and the constant game of “Cherchez l’argent”.

So I want to talk about America and a despotic ruler who many think is mentally ill. No, no, no, not him – I said this was history. We are talking George III.

Most of us only know two things about George. He lost us America and he went mad, although those with a degree in Advanced King George Studies might have heard that he wasn’t actually mad, but suffering from porphyria.

You may have caught last Monday (31 January) a BBC 2 documentary called “George III: The Genius of the Mad King”, which challenges all the above, as well as including a cameo from the Queen, standing next to a historian in full flight, whilst her expression says “I have no idea who you are, but you are clearly deranged”.

I shall leave the “Losing America wasn’t George’s fault” to others, and stick to psychiatry. Now making retrospective psychiatric diagnoses of historical figures is fraught with difficulty. There usually aren’t medical notes, and even if there are, the meaning of the words used have usually changed over time. The disorders themselves may also have changed.

However, one advantage of being a monarch is that there is plenty of material to study, especially as now we can read the letters he wrote whilst ill and when well. Even then, caution is needed. The illness of a King was a delicate matter – one of his doctors resorted to hiding the unpalatable truth behind Latin even in his private diary, writing that “Rex noster insanit” - Our King is mad.

 

The most likely diagnosis

The most likely diagnosis is that he was suffering episodes of mania, a severe version of what we now label “bipolar disorder”.

The over excitement, pressure of speech, sexual disinhibition, excessive disorganised activity, sleep problems and so on are characteristic. We are taught to look out for grandiose delusions - such as believing one is, or is related to royalty, as another feature of mania.

This doesn’t work so well when the patient is a genuine King, but the records give plenty of other evidence of delusional thinking common in mania.

Watch the programme also if you want to know why 5 December 1788 is the birth of our speciality and indeed ourselves.

But what about the porphyria? Everyone who has seen “The Madness of George III”, with the King so brilliantly played on stage and screen by Nigel Hawthorne, will remember that the film concludes by informing the audience that the King wasn’t mad at all, but had a rare metabolic disorder that only looked like madness.

The script suggests that the pompous doctors, played as comic turns, overlooked this, and it was only his servants who noted that the King’s urine returned to its normal colour as his mind returned - a classic sign of an episode of porphyria.

It was two psychiatrists, the mother and son team of Ida MacAlpine and Richard Hunter, who first proposed this diagnosis in 1968.

True, there were symptoms that might have suggested porphyria, a genetic disorder which has been found in some members of the Royal Houses of Europe. But later critics highlighted serious mistakes and inconsistencies in the sources, and that mania was more likely.

The question resurfaced ten years ago when scientists analysed a lock of the King’s hair, hoping this would prove that he had genetic evidence of porphyria, but they failed to extract any DNA, so it is as you were.

Why did the theory of porphyria gain such traction over the years? MacAlpine and Hunter were disillusioned. They were fed up with psycho analysis, and instead believed that most mental disorders were caused by either known (such as porphyria) or as yet unknown organic physical conditions.

Diagnosing an organic metabolic disorder in one of the most famous “madmen” in history would be a wake up call to modern psychiatry, and also remove the stigma or taint of mental illness from the Royal Family.

 

What can we learn?

Are there any lessons here for us? MacAlpine and Hunter’s wish to remove the stigma associated with mental illness remains a noble cause.

But instead of directly combating that stigma, their preferred method was to say that he wasn’t really mad at all, but had an organic and hence legitimate disorder.

They were probably mistaken in their preferred diagnosis, but that misses the point. It is wrong to go looking into the urine, even if Royal, solely to prove that this is a real disorder, as opposed to unreal mental illness, which was MacAlpine and Hunter’s position.

We do research to better understand bipolar disorder, and to develop better treatments, but not to prove it exists.

Now let’s fast forward to King George’s descendants to see how much times have changed. And a quick warning that the noise you are about to hear is the sound of a name being dropped.

Last week I hosted a private dinner at the Royal College of Psychiatrists attended by HRH Prince Harry on how we can improve the mental health of our current serving and ex serving personnel.

These things are off record, but I can say (and I swear I am not grovelling) that he was bloody good, and impressed even the old lags like me around the table.

The Heads Together campaign which the younger Royals lead is directly challenging the Hunter/MacAlpine assumptions that there is a hierarchy of illness, in which physical illness is placed above mental illness. King George would have approved.

Professor Sir Simon Wessely

 

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Comments

Re: Busy times, a royal riddle
This is a welcome blog by our President and I very much share Sir Simon Wessely's cautious approach to making retrospective diagnoses. The discipline of Pathography is fascinating but it is also fraught with difficulty.

Seven years ago I wrote this letter about King George III and his madness. It was published in the History of Psychiatry Journal.

I am not sure if any study has been done in mother and son psychiatrists, Macalpine and Hunter. If not it would make a great subject for a PhD!

https://holeousia.com/2013/03/07/re-evaluating-the-porphyria-diagnosis-of-king-george-iiis-madness/

kind wishes

Dr Peter J Gordon
NHS Scotland
Re: Busy times, a royal riddle
I have enjoyed ?? reading your blog posts. They have often reminded me of one of my early teachers when I began my psychiatry training. Apperception at its best!

You will be missed. I wonder if the college would consider hosting, videos of talks that are difficult for many of us to get to, on it website or YouTube channel.
Re: Busy times, a royal riddle
Actually it turns out looking at the urine to diagnose psychiatric disorders might be a jolly good idea.... as it may be a way into the microbiome. Let's see what the future holds rather than the past...
March 14th - tell me more
I will definitely come down from Brum for the presidential lecture from Derek Summerfield on March 14th. I look forward to putting some questions to him face to face about some of the tub thumping going on about such a complex topic. The college statement on PREVENT is very balanced. The same cannot be said all contributions to this complex discourse. Can we have some more details on this event please?

Jonathan Hurlow
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Professor Sir Simon Wessely

   

Professor Sir Simon Wessely

President


Sir Simon Wessely is Regius Professor of Psychiatry and Co-Director King’s Centre for Military Health Research and Academic Department of Military Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London.  He is a clinical liaison psychiatrist, with a particular interest in unexplained symptoms and syndromes. 

He has responsibility for undergraduate and postgraduate psychiatry training, and is particularly committed to sharing his enthusiasm for clinical psychiatry with medical students. He also remains research active, continuing to publish on many areas of psychiatry, psychological treatments, epidemiology and military health.

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