The difference of a diagnosis.

I have Social Anxiety Disorder. Its all official and everything, having just come back from the doctors' surgery, where all of my rehearsed, clear and concise explanations of how I have been feeling lately descended into some soggy, disordered sentences and lots of apologies. 

What, precisely does this mean? It means I feel weird, and I don't quite know what to do with myself. It's interesting, the effect of having a label. I imagine this particular effect is broadly similar for many diagnoses, to lesser and greater degrees. It's a waveform: you just start relaxing into it, and feeling relived by it, then you think 'oh shit, there's something wrong with me!', then it all starts again.

There is a satisfying feeling of loose ends being tied up. It's the explanatory scene at the end of every episode of Poirot, the metaphorical jigsaw pieces being placed. You think of all the things that you've been feeling over the years and you squidge all of your individual experiences into the shape of the words on the leaflet you've been given.

But its weirdly hard to relinquish the long-held belief that actually you're just quite shit at life, that its your own fault and you're just not trying hard enough, to something external like an Actual Real Life Diagnosis. Bits of what I thought were my personality are instantly explained and I can't quite accept that its not just me being defective.

There is also a fear that now I have an excuse, a reason to stop berating myself, I will luxuriate in it. Will I kick back and stop pushing myself as much as I have been, and retreat? Will it take even more effort now to venture out and smile, with a diagnosis weighing me down?

People who know me may be inclined to think that this is bollocks, that I'm just going through a rough patch and will be fine in a bit. I keep telling myself that too, to be honest. I'll shake it off and it'll be fine. but this is an underlying thing that has always been there. Most of the time it lurks, but sometimes it pushes itself into the front row, knocks out the bouncers, and jumps on the stage and dances naked. In other words, its pretty damn distracting, and it takes up a fair amount of my working brain. 

There are a few cruel dichotomies that I am the victim of in life. I love nothing more than lying for hours in the sunshine, yet I have the palest, most prone to burning skin, for example. And this is one too. I love being around people. I love my friends more than anything, and I rely on them for my very existence. But this thing, this bloody diagnosis, means I can end up spending the precious time I have with them fighting with my instincts to run away from them, even though I desperately want to be with them.

You could be the one person who I want to spend the most amount of time with in the world. You could be the person that I am most interested in getting to know, or the person who I most want to impress. I might be really interested in your opinions, and desperately want to know about your life. But what will most likely happen is that I will sit in awkward silence and you will think "she hates me", or "she's not remotely sociable" or "bloody hell, she's really boring". If only you could hear the things running through my head at these times though. In my brain, I am running through all of my most sparkling, wittiest, intelligent observations and quietly discarding every one of them as being too unworthy of your consideration. Yeah, I know I should let you judge that, and I think about it constantly afterwards and how stupid I have been for not saying anything, but in the moment, none of those rational thoughts help. Conversely, you could be someone who I know I will never meet again. You could be a random person on the street who asks me directions, or a train conductor, or a waitress in a restaurant I will never visit again, and I will still have the same reactions.

I can often mask it, but my body lets me down. I can be sat having a nice chat with someone I have been friends with for years, and I am internally in full on fight-or-flight mode. My heart is pounding irregularly, my brain is rushing and I blush extravagantly. If this is how I am with people who I know love me, and who I have known for years, imagine how I am when I meet new people.

Some of you might be thinking 'why in the hell is she writing about this in public?' Some would say that this is the kind of thing that should be kept under wraps, behind closed doors, under the carpet and all that kind of thing. Well, I say bollocks to that. I have written before about how stubborn the stigma of mental health is, and I just don't subscribe to the idea that we still, in this day and age, need to be embarrassed about it. It's actually really hard and scary to write about it all in public, but it makes me feel better and I don't want to hide it away. I have enough faith in you, Dear Reader, that you wont think any less of me for it or judge me too much. 

Hxxx

Postscript: Homeopathic Harms 3.1: C's Story

Imagine you're twelve years old.

You're on the cusp of adolescence, a time where you start to move away from the comfort and protection of your family and begin to forge your own way in life. Friendships become increasingly important, and you're in a constant process of trying to make new ones, maintaining old ones, and falling out with others. The world seems confusing, terrifying, and wonderful in varying measures, and you spend a lot of your time watching those around you and drinking in how they act, what works and what doesn't, deciding how to act yourself to fit in and be accepted. This is the time when, though the ground is constantly shifting beneath your feet. you start to put down little social foundations and try to make sense of the world.


There is a wealth of evidence that suggests many benefits of connecting with people of your own age during adolescence. At such a crucial, tumultuous time of life, being socially isolated from your peers can have long lasting and harmful effects.


What's this got to do with homeopathy?

I've written before about how poor advice from homeopaths can potentially cause a lot of damage, and through our Homeopathic Harms series of blog posts, Nancy (of the Evidence Based Skepticism blog) and I have hopefully managed to convey to you an idea of how it can sometimes be the seemingly innocuous and difficult to quantify harms that can be most worrying.

I received an e-mail the other day that I have since been thinking a lot about and which I wanted to share with you. Its a real-life example of just how much harm poor advice from a homeopath can cause. The chap who sent me the email has very kindly allowed me to share his story with you, but of course I am going to respect his anonymity and refer to him as C.

C's story

C. had delayed puberty. Now this is something that is fairly common, happening in about 3% of cases, and which can be caused by a number of factors, but the most common type is Constitutional delay in growth and puberty (CDGP). This is basically a technical way of saying 'Just one of those things, which might be caused a whole load of stuff or possibly just chance.'

Conventional medicine would manage CDGP by... well, usually just by waiting, really. Monitoring, and reassurance are often all that is required. Otherwise, short courses of sex hormones should be enough to do the trick. If the delay in puberty is caused by something, then ideally the underlying cause would be appropriately treated. You can see some good, reliable guidance on management here.

Note, by the way, that the definition of delayed puberty according to patient.co.uk specifies '...in boys beyond 14 years old'.  Now, I have no way of saying what the definition of delayed puberty was at the time that we join C's story, but his experiences began when he was 12- well below the point where we would diagnose delayed puberty nowadays.

C's mother consulted a homeopath. He was given some homeopathic pills, which on account of just being made out of sugar, had no beneficial effects, but also no harmful effects. However, the homeopath also appears to have given C's mum some advice, the goal of which seems to have been isolating him from his peers between the ages

C was:

• not allowed to stay at school for lunchtime, but instead had to go home.
• not allowed to stay at school after the school day had finished.
• not allowed to cross the local footbridge over the motorway, which cut him off from the majority of his peers.
• not allowed to go down the street of the one classmate who lived on his side of the motorway.
• allowed and encouraged to socialise with one boy who was two years his junior.

The first question is why. Why on earth would a homeopath give such advice? We can only speculate that the homeopath in question thought- apropos of nothing- that since C was a late developer he should be kept away from people his own age and instead only socialise with younger children. I've had a look around some homeopathic websites on the internet, and found nothing that looks similar to this sort of advice. [I did, however, find this website, which amused me no end due to its impressive reference list. No, really, go and look at the link and scroll to the bottom, if you want a good laugh]. In fact, I couldn't find anything at all suggesting that enforced social isolation is good for anyone or for treating anything, really.

C's case would appear to be one of a homeopath acting outside of their competence and providing bizarre and very harmful advice. In C's case, homeopathic treatment was certainly not safe, although this had nothing to do with the sugar pills themselves.

The result of this set of rules on C were, in his own words:

"a boy who was immature, shy and lacking in self-confidence. When it came to puberty I had significant mental health problems (starting with OCD due to high levels of anxiety) which have had an impact throughout my life....I didn't regain a sense of normality (in terms of socialising properly) until the age of 25-26."

Limitations

C's story is, of course, merely one anecdote, and as good skeptics we of course have to realise the limitations of it. There's nothing to say that, if C hadn't have followed these rules, he wouldn't have gone on to develop any mental health problems, and indeed delayed puberty itself is not without an increased risk of psychological problems.

Given our very human need to fit in, it may be the case that children with delayed puberty have a preference for younger friends, as they stand out less. This is entirely understandable, but in C's case it is clear that his situation was enforced upon him.

 But given the established link between social isolation in adolescence with mental health issues, I think we can pretty safely say that this is a case where at the very least homeopathy worsened his situation. His quality of life was undoubtedly affected when he had to obey the rules.

Thankyou to C

Many, many thanks to C for sharing his story with me. I think its so important to hear these stories, as they might help to raise awareness of the less obvious, nebulous harms that can arise from treatment by unregulated, alternative practitioners. Unfortunately, its really difficult to quantify these sorts of harms into cold hard evidence, and that's why I, and many others like me, keep banging on as loudly as we can about them. If you have any examples of potential harm caused by homeopathy, it goes without saying that I would love to hear from you.


H xxx

I ain't afraid of no ghosts... oh hang on...

"Girls, come over here. You'll be safe from the evil spirit on this side of the vault. A lady came in today and blessed it- you can see how she left healing flowers as part of the ritual."

This sentence would appear at first glance to be the sort of thing that would send me into an apoplectic rage. There is so much woo encapsulated in that one little sentence: ghosts (which don't exist), sexism (the men were left on the un-blessed side), god (who doesn't exist) healing flowers (medicinal woo) and rituals (spiritual nonsense which makes no difference).

However, standing in the pitch black, musty cold of one of Edinburgh's vaults, clinging onto my friend Hesther and a complete stranger for dear life, I found myself repeating in my head 'its alright, I'm safe. A lady has been in and blessed it. Nothing bad is going to happen' over and over again in a desperate and unsuccessful bid to stave off hysteria.

This was just over a year ago. Every year, my friends and I take a trip over the border to take in the Edinburgh Fringe Festival. In amongst the sight-seeing, drinking, burning of the candle at both ends, and stand-up comedy binging, we always tend to do something ghostie-related. Edinburgh is a very charismatically historical and spooky city. The first year, we went to Mary King's Close, then last year was a vaults tour. Each time, I have shown myself up as a pathetic, borderline hysterical scaredy-cat.

In another vault during last year's tour, we were told how a coven of Wiccan witches had tried to use a particular vault as a meeting room (I suspect meeting room isn't the correct terminology, to be honest, but never mind.). They had moved some stones to form a protective circle in the middle of the vault, but found that terrible things happened when they were inside the circle, including the appearance of a terrifying, animalistic evil demon which trapped them in the vault, stalking the corridor murderously so they couldn't get out. The tour guide very dramatically informed us of how no one had set foot inside the circle in her presence, but how she would leave us alone for a while and we could do so if we wished, before swooping out theatrically. Now, you and I know that this was just a room, and a tourist putting a toe into a circle of inert stones is not going to make a non-existent demon turn up.

However, as one chap went to put his foot within the circle, an inhuman sound emanated from the corner of the vault. It could only be described as a guttural shriek, and went something like:

"DONTEVENFUCKINGDAREORIWILLKILLYOUWITHMYBAREHANDS"

Something like that, anyway. I can't quire remember the exact words I used. Here I was, an atheist who believes firmly in science, screeching violent threats at a complete stranger all because he had moved his foot vaguely in the direction of the stone circle. I was, to say the least, utterly terrified, and it was only after a good few vodkas in the bar afterwards that I started to calm down.

But this was before I started to get really interested and involved in skepticism. I've since found myself being a whole lot more rational about many aspects of my life, and applying skeptical principles, critical thinking, and rationality has become a lot more second nature to me. This year's tour, which took in some supposedly more active vaults, as well as a graveyard and mausoleum, home of Edinburgh's most active and evil poltergeist, would be a breeze. After all, I would be able to calmly rationalise all aspects of it and see it for what it really is: pure entertainment. Skeptical pharmacist extraordinaire that I am, I would be serenely smirking at all of my friends and the rest of the tour group as they clung onto one another and shrieked.

Umm, well...

As it happened, I was marginally less hysterical than last time. I would love to say that this was due to my skepticism, but in actual fact is due to the fact that there was a bigger group of people, the tour guide was more comedic than dramatic, and that I had imbibed some gin beforehand.  But I do mean marginally. I was still clinging onto whoever was near me for comfort, (whimpering "don't leave me, please don't leave me"). I used up the last vestiges of my phone's battery for light because I was so terrified of the darkness. In the graveyard, I was telling myself that ghosts were less powerful in the open air, rather than that ghosts do not exist. In the mausoleum, I consoled myself with the fact that the Mackenzie poltergeist would probably like me because I'm an atheist and not a catholic, rather than that it is merely a tall tale made up to appease tourists and that there was a perfectly rational explanation for everything. Barely a rational thought crossed my mind for the whole sodding one and a half hours of the tour. 

It would seem then, based on this n=1 social experiment, that one is perfectly able to be paralyzingly frightened of something that you don't believe in, given the right circumstances. In the dark, having to listen to stories of ghostly hands grabbing at ankles, i can confirm that there is a minority part of my brain that not only takes over the rational, skeptical majority, but beats it into a pulpy submission then stamps on it repeatedly.

Hxxx

P.S. Spirits almost definitely did have something to do with the fact that I randomly fell over just before the tour even started.

Pills, Thrills and Methadone Spills 2: A Book Review

Community pharmacy can be a pretty lonely career at times. It can be a horrendously stressful and pressured environment to work in. It can also be hysterically funny, and those times often make the rest of it worthwhile. In a workplace that is ultimately centred around illness, the pinpricks of hilarity become all the more important.

Its good, then, that someone decided to make a book of all those funny moments that happen in the average pharmacy day. Its even better when they decide to do so twice. Enter the second instalment of Pills, Thrills and Methadone Spills by fellow anonymous pharmacist Mr Dispenser.

Those of us pharmacy types who use (for which read obsessively depend on) Twitter or who read any pharmacy magazines will no doubt be aware of Mr Dispenser, who is a regular day-brightener with his wit and humour. 

Partly constructed of tweets, part blog-anthology, this is a warm and good natured collection of anecdotes. All but the most curmudgeonly of pharmacists will find themselves laughing out loud, and there will certainly be many moments of recognition in there too. You find yourself thinking 'oh I've got one of those stories too'.

Its a nicely inclusive format, which I think in its own little way helps to address the isolation of the job.  If you look closely enough, you'll even find a couple of pearls of wisdom from yours truly, which is nice. Its like sitting in a pub with a big group of other pharmacists and having a good old chortle about the daft things you encounter everyday. You're left feeling much cheerier about your lot, and with a nice sociable glow. to a non-pharmacy eye, some parts may be slightly close to the bone, but I think that from within the profession its clear that it is meant affectionately.

There is, however, a bit of a disappointing #everydaysexism moment later on in the book in 'Gender Bender'. Given that I write this whilst an unfinished blog post about how harmful portrayals of women can be sits in my blogger account, this is me courteously reminding Mr Dispenser that all women do not merely discuss hair and nails and read Hello magazine, nor do they all coo over babies whilst men leer at sports cars and read Top Gear magazine (Which, by the way, I used to have a wardrobe full of. despite having no driving license). So less of the stereotyping, please, and we will all get along fine at this year's Pharmacy Show

Now lets address the font. Very attentive readers of this blog will know that there is one font that I consider to be an abomination against mankind. Comic sans  is not big, its not clever, and its certainly not jaunty. It doesn't make me think "ooh, a light-hearted and humourous piece of writing!", but rather makes me stabby. There's is nothing wrong with good old arial, and the writing in this book is funny and clever enough on its own without having to resort to comic bloody sans.

Hxxx

DISCLAIMER: This book isn't actually due out yet for 8 weeks or so and may be subject to font changes and editing. If this occurs, I'm going to leave this post as it is, as a testament and reminder of how I can occasionally have some influence. Also possibly because I will be too lazy to amend it.   

You can also find this post- and a whole variety of mine and many other lovely people's book reviews over at Backlight, my collaborative book review blog for busy people. 

The Home Office can go back to where it came from, if you ask me.

Immigration is all over the news today. The last few days have seen a very, very uncomfortable atmosphere developing, which has been widely likened to that seen in Nazi Germany. In a bid to curry favour with UKIP voters (for which read either bigots, or just sadly ill-informed people), the Home Office have begun gleefully posting pictures of people of colour being shoved into the back of vans, along with bragging about how many illegal immigrants they have rounded up in that particular day. And then there is that bloody van driving around too.

Now, dear readers, I am going to sort of write something vaguely political. I'm going to do so in my own, incompetent, ranty way, so do forgive me if it ends up having very little to do with anything except for my thought. I've had very little sleep last night, and am grumpy as anything already. There might even be some mild swearing. There will almost definitely be terrible typos. Just stick with me, though, eh?

Can a white, British girl like me get angry about such things? well, in short yes, and there are many, many similar angry people out there. All it really takes is to have a heart, and some empathy for other humans, to realise that what is going on out there is very, very wrong. Okay, so people might be in the country illegally, and they should have done it by the books ideally. But its easy to see that these people are hardly lying on a bed of solid gold rose petals, being fanned by the poor, downtrodden white folk who have lost their proper job because an unspecified European could do it cheaper. They're probably working crappy jobs for little pay and long hours, and probably living in shitty places. They're dealing with constant shit from ignorant white people.  And they're here because its a better life than what they left behind.

If you were to switch the TV on at about 4 o'clock in the afternoon, you will probably find a programme on called A Place In The Sun, or similar. In such programmes, white, middle class, British couples tramp around a foreign country looking for a quaint little 6 bedroomed villa with an olympic sized swimming pool and a simply darling, quaint, local little village just down the road where there are all the amenities *they* need to suit *their* needs, and all for a charming price of £5000. "oh, well its a different way of life", they say. "The pace is so relaxed over here. We don't even mind if it takes 20 mins for Betty down at the Dog and Duck to bring us our steak and kidney puddings- there are plenty of other ex-pats for us to talk to in the meantime"

Why is this sort of immigration not such a problem? Why do we as a country not think that actually we are in no place to criticise, when we merrily trample the globe and plonk ourselves down wherever we like, safe in the knowledge that we can merely speak up to overcome the language gap?

Immigrants to the UK might use our free healthcare system. They probably use it because they're sick, and given that they are humans, and  I don't like to see anyone feeling under the weather, I'm pretty cool with that. What of our English acquaintances over in Spain? They'll be paying their way, right? They won't be discussing ways to get round recent changes to the country's healthcare systems on Expat forums, oh no of course they wont. You might also be interested in this article in today's The Lancet, which looks at just how much UK Health Tourism there actually is compared to what the papers say. The implications of UK citizens buggering off to Mexico for cheaper plastic surgery, then returning with a nasty infection that needs to be treated by the NHS don't seem to be shouted about in the Daily Mail quite as much as they probably should be. 

Well, but they are at least there legally. It's not like British people would be in a country illegally now, would they? And its not like there would be a massive outcry if the Australian government decided to start doing random checks on anyone wearing a bowler hat just in case they happen to be evil British illegals.

I was nearly an immigrant once. I was going to move to Canada. I studied for nearly two years and passed the PEBC Evaluating Exam (7 hours and a 72 page syllabus, including questions on High Performance Liquid Chromatography, if you please). I kept going back there for holidays and interviews and the like. I was welcomed warmly wherever I went, and was able to freely explore the cities without fear. I knew that, had I moved over there, I wouldn't have had to spend my life having to justify my place there, or defend the fact that I had a job which could have gone to a Canadian citizen. We British folk have that privilege and it is the very scraping-of-the-barrel-least that we can do to at least acknowledge it.

As for stopping people of colour on the street to see if they are an illegal immigrant... Its somewhat of a revelation to me that in this day and age anyone can look "a bit foreign". Believe it or not, Home Office, but there have been black people in this country for many, many years. Some of them were even born here. And then some of those have gone on to have children too. I know, right? What a revelation that British people aren't all pale. Some of us don't even wear socks and sandals with our cricket whites. People just look like people, and unless they happen to be walking around with their noses stuck into a copy of The Illegal Immigrant's Guide To Avoiding Detection By The UK Home Office, there's really no way to judge.

Are we really that insular an (Anglo-Saxon) nation that we can't see our own double standards? Are we really that unable to see people as people, and look past their colour, nationality, and creed? Yes, we are wired to want to stick with people who are similar to ourselves. But it really doesn't take that much effort to overcome that and look through minor differences and just take each person on an individual basis. I know I have generalised horribly in the words above, but I am doing so to demonstrate a point- that the double standards in this country are really quite horrific. And yes, there are many facets to the whole thing that I haven't considered here, blah blah blah. In the end, all I am trying to say is that I'm very saddened, ashamed and disheartened by this whole nonsense, and that I'm a firm believer that immigration is a beautiful, enriching thing that should benefit everyone. Its not scary, its not negative, and it means that we are a better, more versatile and robust country because of it.

If you're reading this and thinking 'hmm, well maybe, but there needs to be limits, and UKIP's immigration policies seem to make sense', then this is a plea for you to dig a little deeper into what those policies are, the evidence that they are based on, and who they benefit.

If you're reading this and thinking 'naive lefty silly girl', then get lost. If, however, you're reading it and thinking 'naive lefty silly YOUNG girl' then by all means go right ahead.

Hxxx

To self-monitor blood glucose or not?

Today's news greets us with a story about "rationing" of diabetes glucose test strips. Diabetes UK, in a survey of about 2,200 people, found that 39% of people with diabetes have had their prescriptions refused or restricted. Meanwhile, politicians are wading in stating that restrictions are unacceptable.

Now, this sounds bad. But when you start applying some skeptical principles to this area, it all becomes slightly less clear. Here are some brief points to consider about self monitoring of blood glucose (SMBG) to put today's news into context:

Test strips are expensive. Spending on test strips in the UK is pretty high, and has been rising year on year since 2008. In 2010/2011, a whopping £158.4 million was spent on testing in England alone. These things are expensive, and a lot of them are being prescribed. Historically, they have been over-prescribed, and this has been a priority area for the NHS to attempt to prescribe more rationally. (NB: rationally does not necessarily mean rationing, it just means using resources more effectively.)

The UK Guidelines are clear that SMBG has an established place in the management of diabetes controlled by insulin, whether this is type one or type two. Its also accepted in the guidelines that it is useful for patients with type 2 diabetes who are at risk of hypoglycaemia. Reports such as this one from the NHS Diabetes Working Group are also clear that rationing should not be undertaken in patients who are deriving benefit from SMBG. 

SMBG doesn't actually do anything to control diabetes. It isn't an intervention, it's a testing tool. The only way it can have a positive impact on diabetes treatment is if the results are used to guide treatment or behavioural choices. So its useful for insulin dosing, for example, as it is variable and needs to be responsive to what you have eaten that day. However, if you take a twice daily dose of metformin 500mg, say, SMBG isn't going to really help anything. I think this point isn't quite as clear as it should be to some patients, carers, and even healthcare professionals. 

It only gives you a result for one pinpoint in time. It doesn't tell you anything at all about more long term control. This limits how useful it is in assessing lifestyle changes, such as exercise and longer term changes in diet.

Studies have found that some patients are not using SMBG to guide treatment changes or choices- so they are essentially testing for no gain at all. If this is the case, then it is clear that the SMBG can be discontinued with no impact on the patient's overall care- in fact its an all-round win situation, as the NHS saves some cash and the patient no longer has to bother doing a painful test.

Its not a no risk option. Apart from the obvious discomfort of testing, there is some (although limited) evidence that some patients can feel more depressed, anxious, and even obsessive if they are using SMBG.

The evidence that SMBG works is very limited, and is confounded by lots of different factors. You can find more detailed information on the evidence base in this Medicines Q&A. The technology of SMBG was welcomed with open arms by patients and healthcare professionals alike, and it was widely accepted before there was robust evidence that it worked to improve outcomes. In these sorts of situations, where people are used to using a technology or drug etc, it becomes quite difficult to start being rational about it, without people feeling that they are having something taken away from them. If you really want to have a good look at the evidence, you can have a look at this Health Technology Asessment by Clar et al. It's only 156 pages long (!) but it is a really good quality summary of the evidence.

The evidence that SMBG is cost effective is even more limited. We simply don't know if it represents good value for money for the NHS. Meanwhile, there are interventions which we do know are cost-effective. So doesn't it make sense to limit spending on the unknown, and to put funds into the interventions that we know work instead?

Its a real shame if these sorts of issues have been ignored in favour of rationing. Rationing test strips for patients who are insulin treated isn't rational prescribing, its just daft. But there is a serious issue of overuse and over dependence on SMBG, which blanket rationing makes more difficult to address. The UK guidance makes a lot of sense given the state of the evidence we have access to at the moment, and I would be very sorry to see it being misused in some patients, whilst others are fruitlessly undertaking a needless task at a potential cost to their quality of life and the NHS.

Hxxx