Wednesday, March 12, 2008

Manie Sans Delire

Making a diagnosis of PERSONALITY DISORDER is difficult. The validity of such diagnosis is controversial lately. It was claimed by some that a diagnosis of personality disorder is ready to be given by a psychiatrist to all those whom he/she dislike. Me myself and one of my dear colleagues, at the beginning of our first year of residency in psychiatry, used this diagnosis against each other while we have problems with each other. We used this diagnosis as a type of hurting. As a type of revenge. And believe me it was very annoying and really hurting and have long lasting effects. Till one of the older residents in psychiatry told us to stop this childish behavior which, as he said, IS DANGEROUS AND UNETHICAL. But some personality disorders are less controversial than others. It is estimated that 10-14 % of the general population meet the diagnostic criteria for at least one personality disorder.

The antisocial personality disorder is an old concept in psychiatry. In 1812, Benjamin Rush introduced the concept of MORAL DERANGEMENT. In 1835, Prichard introduced the term MORAL INSANITY. It was Pinel (1801/1962) who coined a term that I like, it was MANIE SANS DELIRE, which means MADNESS WITHOUT CONFUSION OF MIND. I like the term, first, because it is in French, and when you use it the other will think that you are a highly cultured person. And Second, because it defines itself.

Nowadays, the DSM IV criteria of antisocial personality disorder can be easily remembered using the mnemonic CORRUPT:
1. Conformity to law lacking,
2. Obligations ignored,
3. Reckless disregard for safety of self and others,
4. Remorse lacking,
5. Underhanded (deceitful, lies, cons others),
6. Planning insufficient (impulsive), and
7. Temper.
(3 of these seven are required to be a trait of the personality for life so that the diagnosis is made, and it cannot be made under 18 years of age).

Psychopathy was related early in the formulation of the concept to criminality. Not all psychopaths are criminals. Henderson (1939) described CREATIVE, INADEQUATE, AND AGGGRESSIVE PSYCHOPATH, citing Lawrence of Arabia as an example of creative psychopath.

What am up to is to state that I think that Silvador Dali was having an antisocial personality disorder. As a child he used a sharp instrument to wound the cheek of a goat and, used its blood to write his name on its face. He also pushed a friend of him for a bridge after he made sure that no body is watching, and he confess in his memo that he did not felt any remorse. He also kicked his sister on her head while she was crawling. At school he jumped from above the stairs to cause alarm and apprehension in pupils faces, and to seek attention. He repeated his jumps, from higher and higher points and he got many wounds and bruises, but he said that it was ok because he aimed to seek their attention and fright and he succeeded.

During his life as an adult you can find many evidences for his impulsivity and temper, for his break of social norms, and recklessness.

His indulgence in painting can be explained by this statement from Fish’s psychopathology when describing the antisocial personality disorder:

“As the boredom threshold is low, these individuals resort to thrill-seeking
behaviours such as substance misuse, gambling and promiscuity”.

And I will add to those thrill-seeking behaviors: Art. Especially the unusual art. Artist are highly imitated by many. From here comes the danger of imitating a person with mental illness.

Monday, March 10, 2008

Thought form Vs. thought content

I think that Bou Jidra is writing as if he dreams. Also Silvador Dali had drawn his paintings as if he was dreaming, to jump above the obstacle of repression, and declare the naked truth. Regarding the way that we, students of psychiatry, study thinking, we divide a thought into a content, and a form. In Fish’s psychopathology, our best text of psychopathology, there is also disorder of the stream of thought (tempo and continuity). Schneider suggested that there were three features of healthy thinking: 1. Constancy: this is the characteristic persistence of a completed thought whether or not it is simple or complicated in its content. 2. Organization: the contents of thought are related to each other in consciousness and do not blend with each other, but are separated in an organized way. 3. Continuity: there is a continuity of the sense continuum, so that event the most heterogeneous subsidiary thoughts, sudden ideas or observations which emerge are arranged in order in the whole content of consciousness. The patient last week, Mr. F, when interred the ward, started playing sport, some patients joined him. He refused to stay one day unshaved, some patients joined him. He made a list of things he wanted the hospital to provide for him. On of the seniors said: some people with formal thought disorder may have beneficial thought contents. That saying by that senior, sparked contradictory thoughts in my mind, I argued my self again and again, sometimes am with what he said, sometimes am against it. As an ordinary academic student of psychiatry, I got to be against what he said. But. I remembered how I was always confused about what some artist do. Let us take for example, Rashid Bou Jidra, an Algerian novelist, and a writer of scenario also, one of the scenarios is that for the film of L’akhthar Hamina: sineen il jamr. Bou jidra, write long novels, with sometimes a complicated form, to a degree that I can say, with a type of formal thought disorder. But it carries a content that is full of meanings. Of surprises. Of lights focused into dark dots in our consciousness. Bou Jidra, himself, was admitted once to a psychiatric hospital. He wrote about that experience a novel called “el ra3an” . many of his novels talks here or there about an admission to a psychiatric hospital, or being mentally ill. If we talk about dreams, it is full of formal thought disorder. But reality in dreams sometimes is so deep, so intense, more than reality in awakening. We can find in dreams that we don’t like this person, or we are afraid from this trip, a revelation that appears in dream, but it hides itself in awakening. I think that Bou Jidra is writing as if he dreams. Also Silvador Dali had drawn his paintings as if he is dreaming, to jump above the obstacle of repression, and declare the naked truth.

Thursday, March 06, 2008


He entered the room. He is a man in his 50s, wearing jeans, his hair is long and white. His hair was so long for an Iraqi. His hair touches his shoulders. He was so proud of it I think, cause as he sit, he took out his comb and start searching for a mirror. He did not find any. He looked at the window. It was of some help. He combed his hair. When he ended, I opened my mouth and said:
Mr. F, am doctor Sami, I knew that you are new here, I came to see you, to see what did happen that brought you here, and I would like to help you.
He said: first, I need to have a glass of water.
I brought him one. He thanked me. Then asked me: in what year did you graduate from college?
I answered: 2002. and I never said anything else for the coming 30 minutes.
He then started to talk. I cannot remember what he said but he started talking and he never ended. He shifted from one subject to another. I did not stop him. I managed to found that he had the DIGFAST (Distractability, Indiscretion, Grandiosity, Flight of ideas, Activity increase, Sleep deficit, & Talkativness. DIGFAST is a mnemonic to remember the DSM IV criteria for mania). I wondered how long he would continue talking. He was taking few sips of water every now and then when he felt that his throat is dry. The glass of water helped him to continue. He talked about Jean Paul Sartre, Selvador Dali, and many many others. He talked about philosophy. About sport, health, politics, Marxism, Islam, and many other things. 30 minutes passed so fast. I looked at the watch, it was 11:45 am, I opened my mouth and said to him: Mr. F, I have only 15 minutes left with you, and I want to ask you about something, told me about your sleep.
He started to lecture me again about health, sport. I opened my mouth and said: and your sleep? At that point he felt angry at me. Told me that am trying to control him. I made up my diagnosis then let him talk again for the 15 minutes then asked him my final question on that first interview: am afraid I got to go Mr.F. I stood up, he did not. I start walking slowly and asked him: we will see each other in the coming days more, is there anything I can help you with at time being ?
He answered: I want a white paper to draw you something.
I gave him 2 and went, telling him that I will see his drawings next time we met and that would be after one day. The second day I went to the ward. The senior had discharged him. He was no more there, but he left me this drawing (see above the picture with the arabic writing; the other picture is a picture of a face who seems depressed, my diagnosis was BIPOLAR DISORDER, did the sad face symbolise his depression? and why a female? is this related to his long hair? did he wish to be a female? many questions I didn't ask)

The writing in the first picture is from the holy Quran, and it says: noon, (noon is the name of the letter N in Arabic), I swear by the pen and what they write in lines, by the wealth of God you are not crazy. That was a very poor translation by me, it got a very nice musical rhyme when it is said in Arabic, the sounds will be different, I will write it with English letters to imagine the music of these words: noon, wal kalami wa ma yasturoon, ma anta bi nimati rabbika bi majnoon.