Multiple sclerosis and depression

We all feel down sometimes. That's natural, and part of life's rich tapestry.

But sometimes, for some of us, that short-term feeling turns into something much longer-lasting and more profound. Clinical depression can involve feelings of sadness and hopelessness, irritability, losing interest in activities, loss of ability to concentrate of make decisions, tearfulness, tiredness, sleep disturbances, and physical aches and pains. It is often linked with anxiety.

 

Each year, around 6% of the UK population have an episode of depression, and more than 15% will have an episode during their lifestime.Having a long-term physical illness increases your risk of depression up to about one in three, and NICE have recently issued guidelines for this situation.


Multiple sclerosis, being a long-term condition, follows this pattern. Up to 50% of people with MS experience depression at some point in their lives, and around 20% within each year. People with MS are at 7.5 times the risk of suicide of the general population.. There are several reasons for this:

• To have MS is to be in a state of uncertainty. Your life has changed completely. You have a long-term condition with a variable course, which could potentially progress to severe disability. Your self-image changes: you fear losing independence, you may lose your job or friendships.
• Depression can also be caused by MS's physical changes to the brain. If it damages the parts of the brain that control mood and emotional expression, behavioural changes can result, including depression.
• MS can also affect the immune and neuroendocrine systems. For instance, studies have found changes in immune markers in people with MS who are depressed.
• Depression can be a side-effect of certain drugs, such as the corticosteroids often prescribed for MS relapses.

There is some evidence that depression is (not surprisingly) more common around the time of a relapse, but people with more severe physical disability are not more likely to be depressed. Nor is it related to how long you've had MS.

There is no shame in having depression. It's a disabling condition just as much as a broken leg, heart disease - or, indeed, MS. It's important that we learn to recognise its onset in ourselves, and seek help. It doesn't mean weakness or need to be hidden. I see my depression as a long-term condition to be managed, like my MS.

Treatments for depression can be very effective. If you think you may be depressed, please visit your doctor and explain how you feel. If you are suicidal, contact the Samaritans.

So, if you have MS, it's entirely possible that you also have depression. Clearly not an ideal situation, but entirely treatable and manageable. As I said: all part of life's rich tapestry!

Every breath you take....

My friend got a Brown Envelope from the DWP yesterday (they deserve the capitals).

DWP envelopes are terrifying: they contain our futures. Another friend spends most of her time in bed, barely able even to sit up. The letter in her envelope demanded that she attend a medical to decide whether she can get ESA. She was given two alternative locations: the nearer is on the third floor with no lift (she uses a wheelchair) and the other is 2 hours journey away, on inaccessible public transport.

The first person I mentioned got good news: following an appeal, she's in the support group for ESA (as she should be). But she's still uneasy. She can't help worrying that the DWP are filming her on "good" (read: less bad) days.

I confessed that I worry I'm being filmed through the windows of my house, if I do something like lift the kettle. She felt the same.

Others joined in the conversation. It began to seem that this was quite common.

Certainly, it's good to know I'm not alone in my paranoia. But isn't it dreadful that so many people are being made to feel this way?

Constant media coverage of benefit scroungers, and misleading use of statistics. Politicians with anecdotes of someone they met once who was really quite fit for work, honest guv. Dob-your-neighbour-in hotlines.

Just because you're paranoid doesn't mean they're not out to get you.

Sick in the head? Part 2

This is the second in a three part series on Munchausen's syndrome. Part one is here.

So, in Munchausen's syndrome the individual mimics the symptoms of a real medical condition, or actually causes them in themselves. Munchausen's syndrome by proxy is in many ways even harder to understand for the onlooker: here the individual causes illness in others, typically in a child. It is a form of extended child abuse, and the motivation is to assume the sick role by proxy. In some cases the child goes on to develop Munchausen's themselves, to go on getting the attention they received when they were in ill health.

One study showed that in over 90% of cases, the abuser was the mother. In other cases it was another female caregiver. This may be due to females being placed preponderantly in caregiving roles, or to socialisation patterns encouraging women to seek help and sympathy from others.

The term Munchausen's by proxy is thought to have been coined by paediatrician Roy Meadow in 1977. In the late 1990s and early 2000s Meadow testified in several murder cases, some of which resulted in parents being wrongly convicted of murdering their children: there was no doubt that harm had been done to the children, but Meadow commented on motive without evidence, and subsequently the judgements were reversed.

The person with Munchausen's by proxy is typically seen as very helpful in the hospital setting, and is often appreciated by the nursing staff for the care given to his or her child. Their frequent visits make the child accessible to them, and changes in the child's condition occur only when they are there, almost never witnessed by hospital staff.

Readers in the UK may recall the case of Beverley Allitt, labelled the Angel of Death by the media.

Allitt was a State Enrolled Nurse who worked on a children's ward. Over a two-month period she killed four children and injured nine others by injecting them with substances such as potassium chloride, which can stop the heart. She was sentenced to a minimum term of 40 years, which she is serving in a secure hospital. Her motives are not known, but it is thought she may have been suffering from Munchausen's by proxy.

Munchausen's by proxy may be linked to Hero Syndrome, where the individual seeks recognition by creating a desperate situation that they can resolve. The phenomenon has been noted to affect emergency workers such as nurses, police officers, firefighters and ambulance crew. Perhaps Allitt's 13 victims are only the ones we know about, and there were others where she became a "hero" by recognising their desperate illness - the illness she'd caused - in time to save them?

Over these two posts I've looked at Munchausen's syndrome, where an individual mimics illness symptoms or causes harm to themselves, and Munchausen's syndrome by proxy, where an individual causes harm to someone else, usually a child. In the final post of this series, I'll be considering a newly described condition, Munchausen's by internet.

Sick in the head? Part 1

This is the first of a planned three-post series about Munchausen syndrome. In this post I'll talk about the classic syndrome. In the second post I'll talk about Munchausen syndrome by proxy, and in the final post about a newly described variant, Munchausen syndrome by internet.

I used to know someone in meatspace who constantly told lies. About the tiniest, most unimportant things. One minute she was a dental nurse, the next she was working for MI5 (neither was true). It was like her real life wasn't interesting enough, so she had to make up another one to get more attention. We constantly called her out on it (apart from anything else, she wasn't consistent in her lies) but it didn't seem to bother her. Getting attention was the important thing, even if it was negative.

Many people need attention, but for those of us who have serious physical illnesses, and have to take multiple medications and undergo medical procedures to remain moderately stable (note: I didn't say well!), it seems truly bizarre that anyone would deliberately exaggerate or create illness symptoms to get it. People who do this may be suffering from Munchausen's syndrome. These symptoms can in some cases be as credible and measurable as heart arrhythmias, and people with Munchausen's may undergo multiple hospital admissions, treatments and operations. Typically someone with Munchausen's may:

• invent psychological symptoms such as hearing voices or seeing things that are not really there
• pretend to have physical symptoms such as chest pains or stomach ache
• deliberately aggravate an existing illness
• heat a thermometer to suggest fever, contaminate a samples of urine etc
• actively make themselves physically ill: for instance by rubbing dirt into a minor wound to cause infection

People with Munchausen's are aware that they are exaggerating or inventing their symptoms. This makes it distinct from hypochondriasis. Hypochondriacs genuinely believe that they are ill. Although it has always been the case that people with Munchausen's have tended to be very well-informed about the symptoms of the conditions they are mimicking, there is now evidence that the use of the internet has increased this knowledge still further.

The name derives from Baron Karl Friedrich Hieronymus Freiherr von Münchhausen, an 18th Century German nobleman who reputedly told many tall tales about himself. His feats apparently included riding cannonballs, travelling to the moon, and escaping from a swamp by pulling himself out by his own hair.

Although the person with it is aware of what they are doing, Munchausen's is a genuine illness - or perhaps, to be more accurate, a symptom: generally of a mood disorder, an anxiety disorder or a borderline personality disorder. There seem to be two groups generally affected, though nobody knows why: women aged 20-40, often with a background in healthcare; and men aged 30-50. It's not known how common Munchausen's is, though a fairly large study in a Canadian hospital estimated that out of 1300 patients 10 were faking their symptoms, a rate of 0.8% or nearly one in every 100. It's thought to be more common in men than in women.

Munchausen's syndrome is not included as a separate condition in the WHO's International Statistical Classification of Diseases, 10th revision (ICD-10) or in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). The official diagnosis in these classifications is 'factitious disorder' and Munchausen's is seen as an extreme version of this. The DSM-IV-TR criteria for factitious disorder are:

• The patient intentionally produces or feigns physical or psychological signs or symptoms.
• Motivation for the behaviour is to assume the sick role.
• External incentives for the behaviour are absent.

The sick role is a term used in medical sociology. It is a concept created by Talcott Parsons, and concerns the social aspects of falling ill, and the privileges and responsibilities that accompany it. To simplify his theory, an individual who falls sick is not only functionally sick, but must now adhere to the socially patterned role of "being sick". This role contains within itself certain customary rights and obligations:

Rights

• The sick person is exempt from normal social roles
• The sick person is not responsible for their condition

Obligations

• The sick person should try to get well
• The sick person should seek technically competent help and cooperate with the medical professional

So, by mimicking or exaggerating symptoms, someone with Munchausen's syndrome both gains attention and becomes exempt from their normal social roles such as going to work. For someone in the grips of a mood disorder such as severe depression, this could be very tempting bait.

There is little evidence as to what causes Munchausen's. One theory is that people with the condition have an anti-social personality disorder which leads them to take pleasure from manipulating doctors and other healthcare professionals. Another theory is that Munchausen's is an attempt to form relationships and become more socially acceptable, by people who previously have been "loners" with few friends and little family contact. Many people with Munchausen's claim to have experienced physical or sexual abuse as children, though these claims are impossible to verify. Many also seem to have experienced serious illness as children.

In the next post in this series, I will be looking at Munchausen's by proxy - where the individual harms others rather than themself.