Raj Persaud in conversation - the podcasts
Can God Lie? Dallas Denery discusses his new book 'The Devil Wins'

The Devil Wins:
A History of Lying from the Garden of Eden to the Enlightenment
Dallas G. Denery II


From the Princeton University Press website: http://press.princeton.edu/titles/10323.html



Is it ever acceptable to lie? This question plays a surprisingly important role in the story of Europe’s transition from medieval to modern society. According to many historians, Europe became modern when Europeans began to lie—that is, when they began to argue that it is sometimes acceptable to lie. This popular account offers a clear trajectory of historical progression from a medieval world of faith, in which every lie is sinful, to a more worldly early modern society in which lying becomes a permissible strategy for self-defense and self-advancement. Unfortunately, this story is wrong.


For medieval and early modern Christians, the problem of the lie was the problem of human existence itself. To ask “Is it ever acceptable to lie?” was to ask how we, as sinners, should live in a fallen world. As it turns out, the answer to that question depended on who did the asking. The Devil Wins uncovers the complicated history of lying from the early days of the Catholic Church to the Enlightenment, revealing the diversity of attitudes about lying by considering the question from the perspectives of five representative voices—the Devil, God, theologians, courtiers, and women. Examining works by Augustine, Bonaventure, Martin Luther, Madeleine de Scudéry, Jean-Jacques Rousseau, and a host of others, Dallas G. Denery II shows how the lie, long thought to be the source of worldly corruption, eventually became the very basis of social cohesion and peace.


Dallas G. Denery II is associate professor of history at Bowdoin College. He is the author of Seeing and Being Seen in the Later Medieval World: Optics, Theology, and Religious Life and the coeditor of Uncertain Knowledge: Scepticism, Relativism, and Doubt in the Middle Ages.


"[The Devil Wins is] an informative, sophisticated, and thought-provoking account of the efforts of theologians and philosophers from the early Christian era to the Enlightenment to define lies and understand their ethical, social, and political implications."--Glenn Altschuler, Psychology Today

"Denery explores analyses of an enormous variety of deceptions, and does so with an erudition that is never pedantic or monotonous. He is an entertaining writer, with a healthy skepticism about the dogmatic condemnation of lying as always, or even mostly, morally blameworthy. . . . I think Nietzsche would have loved this book."--Clancy Martin, Chronicle of Higher Education


"In this exquisitely written book, Denery draws on centuries of rumination on the moral issues surrounding lying to address the question of how we should live in a fallen world. The serpent in the Garden of Eden led humankind astray with lies. The Devil is the father of lies. Premodern sources agonized constantly over the act of lying. Denery not only superbly narrates the long history of this obsession, but also locates the conditions that reveal an Enlightenment shift toward a not entirely comfortable modernity."--William Chester Jordan, Princeton University

"Can God lie? Are women ‘born liars’? These are just two of the questions Denery asks--and answers--in his wide-ranging, erudite study. Written in an engaging and accessible style, The Devil Wins sheds a new and fascinating light on a mendacious world stretching from the Book of Genesis to the dawn of the Enlightenment."--Renate Blumenfeld-Kosinski, author of Poets, Saints, and Visionaries of the Great Schism, 1378–1417


If you are viewing this podcast from inside the free mobile phone app 'Raj Persaud in Conversation' you can click on the 'gift box' icon which might be on the top right hand corner of your screen to download bonus content - an original paper by Dallas Denery "From Sacred Mystery to Divine Deception: Robert Holkot, John Wyclif and the Transformation of Fourteenth-Century Eucharistic Discourse,"  Journal of Religious History, June 2005:129-44.

Article in PDFPDF»

You can also find this bonus content in the initial main menu screen that comes up when you open the app on the top right hand corner of the screen under a menu icon that reveals 'extras' - click on extras to see the bonus content.

A related article which may be of interest first published in The Huffington Post by Raj Persaud and Aldert Vrij



How to Tell Who is Lying to You - The Latest Psychological Research


Syria's UN envoy has condemned what he called a "tsunami of lies" being told by some members of the United Nations Security Council. Bashar Jaafari is arguing Syrian forces were not to blame for a massacre in which 108 people were killed and 300 injured, but for which the UN blames heavy weapons by Syria's government.

In the face of what can seem like a 'tsunami of lies' on every horizon, we appear in dire need of the skill to spot who is actually telling the truth, to keep our heads above the rising tide. For example, the Leveson Inquiry continues to pursue the facts, yet some newspapers now prefer body language analysis when reporting what witnesses have said, apparently in order to glimpse the reality behind the words.

The latest psychological research on deception detection casts doubt as to whether the way the inquiry poses questions is likely to penetrate the defences of dissemblers.

It may come as a surprise that so-called experts are not good at spotting lying, but a review of 39 scientific studies by Professor of Applied Social Psychology, Aldert Vrij, a world authority on the science of deception, reveals an average accuracy rate of just 56.6% - in other words for over a third of the time lies go undetected. Men and women are no better than each other, Professor Vrij reports, and professional lie catchers such as police officers and customs officers are generally no superior to the lay public in detecting deceit.

One of the reasons we are so bad at spotting deception is there are widespread erroneous beliefs about what behaviours betray the telling of lies. For example, one of the commonest mistakes is that liars increase their body movements, the famous shiftiness, gaze aversion and fidgeting of a dissembler. In fact scientific research on this demonstrates the opposite is more true, liars more often decrease their body movements and tend to hold your gaze.

So can we learn from the psychological research into deception, to improve our ability to detect deception, and can these techniques help inquiries such as Leveson to sift fake answers from truth?

In fact there are many psychological strategies pioneered by experts such as Professor Vrij, who is based at the University of Portsmouth, which would help us all become better lie detectors, and many are detailed in his book Detecting lies and deceit: Pitfalls and opportunities (published by Wiley). Space only allows two to be mentioned here, both of which are notable in their absence from the style of questioning thus far in the Leveson Inquiry.

The first is called the 'Baseline Method', and it's based on the important principle that there is in fact no one behaviour that is universally characteristic of liars, but when any particular individual starts to stray from the truth, various cognitive, emotional and physiological processes kick in, which it is possible to detect.

But you can only spot these if you already have the 'baseline' of how someone behaves when they are telling the truth, and then compare that with the moment when you wonder if they have begun to lie.

Professor Vrij quotes a real-life example of a videotaped police interview with a murderer being asked to describe a whole day, not just the key moment the police believed he committed the homicide. Detailed analyses of the tape revealed a sudden change in behaviour as soon as the suspect started to describe his activities during the particular time of forensic interest. It was the contrast between his description of times when he didn't have to lie as he spoke, as no crime had occurred then, compared with the period the police were most interested in which was significant.

During his description of the part of the day when the police knew the murder had occurred, he spoke slower, added more pauses, and made fewer movements, compared to the baseline, the other parts of the day the police had patiently asked in detail about. He met the victim and killed her during the period where his behaviour changed when covering up.

Professor Vrij cautions that often interrogators misunderstand the true subtlety of this research finding and misapply it. Crucial in the use of the baseline technique is that correct parts of the interview are compared. Unfortunately, too often in police interviews 'small talk' at the beginning is used to establish a baseline. This is an incorrect way of deploying the technique as small talk and the actual police interviews are totally different situations. Both the guilty and innocent tend to change their behavior the moment the actual interview starts, not least because both are bound to become more nervous then.

Another psychological technique for better spotting lies pioneered by Professor Vrij and colleagues is called 'Devil's Advocate'. Interviewees are first asked questions inviting them to argue in favour of their personal view (eg "What are your reasons for supporting the US in the war in Afghanistan?"). This is followed by a Devil's Advocate question that asks interviewees to argue against their personal view (eg "Playing Devil's Advocate, is there anything you can say against the involvement of the US in Afghanistan?").

The 'Devil's Advocate Question' is an attempt to flush out what the interviewee truly believes, as if they are lying about their position on the war in Afghanistan, for example, the Devil's Advocate Question is actually what they really believe, but are covering up. As we think more deeply about, and are more able to generate, reasons that support rather than oppose our beliefs, this leaks out during the answer to the Devil's Advocate Question.

In effect, for liars the Devil's Advocate approach is a set-up where they first lie when answering the opinion-eliciting question, and are then lured into telling the truth when answering the Devil's Advocate question. Normally we aren't very good at giving reasons for a position we don't hold, so most people aren't good at being a 'devil's advocate' in this situation. Liars however are caught out because they now tend to give fuller and better answers in response to being asked to be a devil's advocate than non-liars. Using this technique Professor Vrij and colleagues found 75% of truth tellers and 78% of liars could be classified correctly.

But before we are too quick to judge those in the headlines who find themselves accused of lying, the psychological research indicates that ordinary people tell an average of 1.5 lies a day, but this rate can climb dramatically because how likely you are to deceive depends a lot on the situation you find yourself in. For example, studies find that 83% of students would lie to get a job and 90% are willing to lie on first dates to secure favorable impressions.

Raúl López-Pérez and Eli Spiegelman, academic Economists, point out in their paper entitled Why do people tell the truth? Experimental evidence for pure lie aversion, soon to be published, that one of the downsides of living in an acquisitive free market economy is how much we constantly gain materially by providing false information.

From doing our accounts, auditing, insurance claims, job interviews, negotiations, regulatory hearings, tax compliance, and all sorts of other situations we stand to gain if we lie, these economists point out, and indeed we are penalised if we are honest.

Given all the incentives to lie, López-Pérez and Spiegelman from the Universidad Autónoma de Madrid and Université de Québec a Montréal, believe the more interesting question is not why do we lie, but instead, why do some people tell the truth? Perhaps more precisely, why do some stick to the truth even when it's not in their interests?

In their research 38.76% of subjects taking part in their experiments, chose to tell the truth even when they would suffer a penalty as a result. López-Pérez and Spiegelman come up with an intriguing new theory of lying where they believe there is a minority of the population who suffer from what they call 'pure lie aversion'. This means some tell the truth because of an innate abhorrence for lying.

López-Pérez and Spiegelman argue this is a significant force behind honesty which has hitherto been neglected by science. It's certainly a factor we should perhaps look for more in our politicians, but then again, maybe we get the lying leaders we deserve because we're constantly seduced into voting for the best con artists. Perhaps all electorates should become more educated in Professor Vrij's techniques before casting their vote.

López-Pérez and Spiegelman also found that those who lied were significantly more likely to believe that others would lie as well. This means the more our politicians and authority figures, even friends or colleagues lie, the more deception will continue spreading.

Dr Raj Persaud is a Consultant Psychiatrist based in London and Aldert Vrij (PhD) is a Professor of Applied Social Psychology who has published almost 400 articles and 7 books on the above topics, including his 2008 book Detecting lies and deceit: Pitfalls and opportunities (published by Wiley), a comprehensive overview of research into nonverbal, verbal and physiological deception and lie detection.


Raj Persaud is joint podcast editor for the Royal College of Psychiatrists and also now has a free app on iTunes and google play store entitled ‘Raj Persaud in conversation’, which includes a lot of free information on the latest research findings in mental health, plus interviews with top experts from around the world.







Committed to an Asylum. Claire explains what it's like to be committed to a psychiatric hospital against your will

What is it like to be committed to a psychiatric hospital against your will? This is surely one of the most frightening experiences anyone could endure? Claire was placed under a variety of sections of the Mental Health Act and as a result found herself committed on several occasions to various psychiatric institutions. Raj Persaud talks to her to get her story out to the world on what it's like to be 'sectioned'. The interview was organised thanks to assistance from Mind - the mental health charity. Many thanks to Aimee Gee of Mind for assisting in making this interview possible.

A related article which may be of interest first published in The Huffington Post by Raj Persaud and David James


How Having, or Not Having, an NHS Psychiatric Bed Can Kill You

An investigation by BBC News and Community Care magazine into 53 of England's Mental Health Trusts reveals that 1,711 mental health beds have been closed since April 2011, including 277 between April and August 2013, representing a 9% reduction in the total number of mental health beds available in 2011/12.



The BBC News website reports possible consequences including the tragic case of 39-year-old Mandy Peck who told clinicians she was feeling suicidal, but her local mental health service centre initially claimed no beds were vacant. She jumped to her death from a multi-storey car park shortly afterwards.



As psychiatrists who have worked in the NHS, we have both experienced the chaos of trying to find a bed for a patient who needs one urgently.



The enormous pressure on the staff to find a bed means that the modern NHS becomes a constant fight for beds, creating stressful conflict with other clinicians. Even if you (eventually) secure an admission for your patient, this is at the expense of the patient who was previously in that bed, who, in order to accommodate the new admission, gets moved to another part of the country, or is discharged, or sent on leave prematurely.



Providing any kind of therapy in this frenzied environment is not possible. Admitting someone in a fragile mental state into this siege atmosphere means you are only arranging an admittance to prevent suicide or harm to others, rather than offering help to the mentally ill in need of care. You have become a form of warder, not a clinician.



The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness at the University of Manchester, published in July 1013, reports that during 2001-2011, in England, 13,469 deaths (28% of general population suicides) were patient suicides. These are persons who had been in contact with mental health services in the 12 months prior to death.



There has been a projected rise in 2011 (the last year for which data is available). In 2001 there were 1261 suicides by people in contact with mental health services and this figure had risen to a projected number of 1333 by 2011, during a period when it now looks like more beds were being lost.



Patrick Keown, Gavin Mercer and Jan Scott published a recent analysis in the British Medical Journal, finding that between 1996 and 2006 in England the number of NHS psychiatric beds decreased by 29%. Entitled Retrospective analysis of hospital episode statistics, involuntary admissions under the Mental Health Act 1983, and number of psychiatric beds in England 1996-2006, their investigation found involuntary patients occupied 23% of NHS psychiatric beds in 1996, but 36% in 2006.



The authors conclude that inpatient care transformed considerably in the decade from 1996 to 2006; more involuntary admissions to fewer NHS beds. The case mix shifted further towards psychotic and substance misuse disorders, altering the atmosphere of inpatient wards.



One interpretation of this data, and our personal experience supports this, is that the ambience on wards has changed, and for the worse, in terms of providing a therapeutic environment. Psychiatric in-patient units are now much more likely to be precarious containment areas for the extremely seriously mentally ill, not a haven, nor asylum from stress for those who need help.



For these reasons, being admitted to a psychiatric ward today may in fact be an added source of stress - not a therapeutic experience at all.



Some evidence for this comes from a recent investigation of a consecutive series of individuals aged 18 to 65 who died by suicide between the 1 January 2001 and 31 December 2006 in England, the date of death being within seven days of the date of admission to a psychiatric ward.



The study entitled, Suicide in recently admitted psychiatric in-patients: A case-control study, found around a quarter of all in-patient suicides occurred within the first week of admission to psychiatric in-patient care. 46% of cases died on the ward itself; the majority by hanging. 40% of suicide cases died within the first three days of admission. A fifth of all suicides were on authorised leave at the time of death, but 34% were off the ward without staff agreement, compared to only 1% of controls.



The authors, Isabelle Hunt, Harriet Bickley, Kirsten Windfuhr, Jenny Shaw, Louis Appleby and Nav Kapur, conclude that contrary to previous relevant research, this investigation examining wards in England found a short length of illness (less than 12 months duration) was independently predictive of suicide in the immediate admission period.



The study, published in the 'Journal of Affective Disorders' in 2013, contends that it may be that receiving a psychiatric diagnosis requiring in-patient treatment is particularly stressful, plus the experience of entering an environment that patients have described as ''frightening'' and ''intimidating' probably increases, rather than diminishes, suicidal feelings.



The authors considered there could also be an association between being admitted to a psychiatric ward and a heightened sense of being stigmatised.



Given that those on authorised and unauthorised leave account for such a large proportion of in-patient suicides from their data, the authors of this study point to two recent court cases in England after the suicide of a detained patient who absconded (Savage v. South Essex Partnership NHS Foundation Trust, 2008) and a voluntary patient who died by suicide whilst on leave (Rabone v. Pennine Care NHS Trust, 2012).



The authors of the study point out that these cases were viewed as a breach of Article 2 of the European Convention on Human Rights (which safeguards the right to life), resulting in a new obligation for health authorities and hospital staff to protect patients where there is a ''real and immediate'' risk of suicide.



The danger of the current headlines over fewer beds is that it's not just the numbers that are important - the quality of the bed, as it were, is vital. What is the point of offering a bed if the quality of the experience is so poor, aspects of it contribute to feeling worse?



The NHS neglects quality of care, which has been sacrificed on the altar of numbers, because numbers are so political.



Numbers of beds dominates the debate - and numbers are important because we have had too few beds for the system to be safe for some time now. And the decline in bed numbers appears to continue inexorably. But we should be looking beyond numbers to human beings, focusing as well on the quality of what patients get, when they actually get anything at all.





Raj Persaud is a Consultant Psychiatrist in Private Practice in Harley Street, London UK and author of several best-selling books including ‘The Mind: A Users Guide’ published by Bantam Press. Dr David James is an eminent Forensic Psychiatrist.



Raj Persaud is joint podcast editor for the Royal College of Psychiatrists and also now has a free app on iTunes and google play store entitled ‘Raj Persaud in conversation’, which includes a lot of free information on the latest research findings in mental health, plus interviews with top experts from around the world.






His books are available on amazon.co.uk here:



Are you in control of you? How much control do we have over our own lives? Magda Osman talks to Raj Persaud

If you are viewing this podcast from inside the free mobile phone app 'Raj Persaud in Conversation' you can click on the 'gift box' icon which might be on the top right hand corner of your screen to download bonus content - the original paper by Magda Osman published in 'The Psychologist' entitled 'Does our Unconscious rule?' You can also find this bonus content in the initial main menu screen that comes up when you open the app on the top right hand corner of the screen under a menu icon that reveals 'extras' - click on extras to see the bonus content.

From the Palgrave Macmillan website:



The Psychology of Agency and Control

Magda Osman


What drives us to make decisions?

Future-Minded explores the psychological processes of agency and control. If you've ever wondered why we think of coincidences as matters of fate rather than the result of the laws of probability, this book provides the answer. From memory and reasoning to our experiences of causality and consciousness, it unpicks the mechanisms we use on a daily basis to help us predict, plan for and attempt to control the future.

ISBN 9781137022264
Publication Date March 2014
Formats Paperback Ebook (PDF) Ebook (EPUB) Hardcover 
Publisher Palgrave Macmillan




A related article which may be of interest first published in The Huffington Post 02/08/2012 16:32 BST



Inside the Mind of the Olympic Gold Medal Winner

By Raj Persaud and Adrian Furnham

Winning the Gold Medal in the Olympics appears a pinnacle in any elite athlete's career, but physical fitness or technical skill may not, in fact, be the crucial factor. Increasingly sports scientists are becoming convinced that it's grit and determination, resilience and desire, which separates winners from losers.

Motivation triumphs over muscle.

But what precisely are these mysterious, hidden, but crucial mental aspects which separate the winners from the rest, who appear to be trying just as hard? Can the rest of us benefit as well from the psychological strategies of our Olympic Gold Medal winners?

Dr David Fletcher and Mustafa Sarkar, sport and performance psychologists at Loughborough University, (where much of the science behind the training of Team GB's current medal campaign has been developed) have just published one of the most in-depth studies ever, getting inside the mind of Olympic Gold Medal winners.

The investigation, published in the academic journal 'Psychology of Sport and Exercise', involved an analysis of 12 Olympic Gold Medal winners' accounts to the researchers of how they used their minds to win.

The first startling finding is that all these champions' lives were not dominated by accomplishment before getting Gold. Instead they constantly encountered obstacles and set backs on the path to success, yet it was their mental resilience in the face of adversity, which is what seemed to separate them from the rest of the field, and pulled them through to eventual victory.

One champion's reaction to being de-selected for a major international competition illustrates relentless optimism and a proactive approach, characteristic of Olympic Gold Medal winners; 'There were four of us challenging for these final two places and I got told I was on the reserve list. And at the time it was devastating but it's one of those things; if you don't take a ticket in the raffle, you're never going to win a prize. So you have to take the ticket that's part of life and it just makes you think "well, what can I do differently to make sure I do get success"?

Paradoxically, not being selected for major international competitions was frequently cited by Gold Medallists as the foundation for increased endeavour and exertion. Competition losses were viewed as learning opportunities, enabling future improved performances. Set-backs were re-interpreted in ways which meant they merely re-doubled their efforts, and didn't become disheartened.

Failure didn't break them - it made them.

One of the most intriguing findings from Fletcher and Sarkar's study is that while journalists love to wheel out the cliché of 'sacrifice' when invoking elite performance, it wasn't a concept these Gold Medal winners understood.

Instead the world's best athletes take huge personal responsibility for their choices, and are surprisingly uncomplaining about how much they forfeit for their sport. They accepted they actively chose the challenges they encountered, and as a result endured a wildly different work/life balance to the rest of us, as one commented to the researchers; 'We all worked. But in terms of the build up to the Olympics, we didn't bat an eyelid in doing it... it was our choice to do it. I don't like the word sacrifice... Sacrifice to me is about last resort and there's no alternative... that's rubbish. We made a choice to do that and I think that choice in what we did we highly valued and I think that inspired us, motivated us to perform on the pitch and as a group.'

One Gold Medal winner's reaction to training during unsociable hours is characteristic; 'I remember one of my coaches saying to me what was I doing over Christmas and I said 'Oh, I'll be training twice on Christmas Day . I know [opponent's name] won't be training on Christmas Day twice and that will give me the edge'. It was more the mental side of things because I knew that I'd be doing something that he wasn't doing.'

These private dimensions of winning tend not to be confided to the microphones thrust in winners' faces as they step down from the victory podium. Their sharing of such intimate secrets to success is therefore what makes this Loughborough University study so rare and valuable.

An example of their incessant thinking and re-thinking of every fine detailed aspect of their lives is this quote from a champion cyclist to the researchers; 'Initially, training was just something to get out of the way. And then gradually I'd do training and I'd think, "Am I getting the most out of this? Am I exploiting the session?" And, you know, if I did take a bad lift in the gym I'd think, "I could have done that better. That's a missed opportunity. What have I got to do to be better?" So I had an obsession on getting everything right rather than just waiting for the day of the final and then hoping. It was about getting everything right before the final so I had all the tools ready for when I was racing.'

Another undisclosed aspect of the mind of winners is what almost seems a sense of destiny - as this comment to Dr David Fletcher and Mustafa Sarkar illustrates; 'I don't know if there is going to be a theme where timing and luck have been in the right place, but I'm a great believer in it. I wasn't selected for the original trip... and on the Thursday night before they [the team] were leaving, I was called up because an individual's wife had gone into labor [and I was told] 'be at [the airport] the next day: we're playing [country] on the Saturday'.

They believe they make their own luck and that those who persevere will eventually benefit from chance.

Perhaps the greatest shock that is going to come from Fletcher and Sarkar's study entitled, 'A grounded theory of psychological resilience in Olympic champions', is that these Olympic Gold Medal winners were not as fixated, as the media and the nation appears to be, on winning gold.

Instead, it was fulfilling their athletic potential which primarily motivated them, rather than becoming an Olympic champion. Some involved in this research pointed out, amazingly, that their gold medal performance was not, in their view, the most outstanding moment in their career.

The following comment illustrates an athlete's viewpoint on her gold medal performance in the 2000 Olympic Games; 'This may come as a bit of a shock but I didn't have a great competition in Sydney. I was consistent... but it wasn't a great performance... '

The research on competitors who are most likely to cheat, via doping or any other means, is that if it's being on the podium, waving the Gold Medal and soaking up the applause which is what is primarily driving you, then you will be tempted to take a short cut to get there.

But there are competitors, and this may sound strange after a week when the nation became obsessed with getting a Gold, for whom the Gold Medal doesn't represent what it does for the rest of us praying for one. Instead the Gold Medal to these elite performers is merely an acknowledgement of excellence, and it's that total mastery of self and sport which has always been the primary ambition. For these athletes coming first would still be vital, no matter if there was no audience, no media and no medal.

The medal is merely a measure, not a goal.

These contestants, research has found, are much less likely to cheat in any way, no matter what temptation is placed in front of them.

In a week where various forms of 'cheating' have dominated the sports news agenda, there is a danger in our obsession for Gold, that we could forget this fundamental aspect of the Olympic ideal.


Raj Persaud is joint podcast editor for the Royal College of Psychiatrists and also now has a free app on iTunes and google play store entitled 'Raj Persaud in conversation', which includes a lot of free information on the latest research findings in mental health, plus interviews with top experts from around the world. Download it free from these links




Hospitalized against your will. Margaret was committed to a Psychiatric Institution against her will

Margaret talks to Raj Persaud about her frightening experience of being admitted to a psychiatric hospital against her will with no idea as to why this was happening. This interview was made possible by 'Mind' - the mental health charity and particular thanks go to Aimee Gee of 'Mind', for her assistance in making it possible.


A related article which may be of interest:


Should Anorexics Be Force-Fed?


By Raj Persaud and Peter Bruggen


first published in The Huffington Post: http://www.huffingtonpost.co.uk/dr-raj-persaud/should-anorexics-be-force_b_1608531.html


Should Anorexics be force fed? The latest legal ruling could kill the patient - but doing nothing might also condemn her to death.


The Daily Telegraph has reported that a leading judge who sits in the Court of Protection, Mr Justice Peter Jackson, has ruled that a former medical student suffering from severe anorexia nervosa, and who is at a life-threatening low weight, should be force-fed against her wishes by doctors.


Dr Evan Harris, the former Liberal Democrat MP and member of the British Medical Association's ethics committee, is quoted by the Daily Telegraph to have responded: "The implications of force-feeding are really significant because she would need restraining or sedation and the treatment would last a year... It might not succeed and is itself life-threatening. To impose that on a patient who might be competent in refusing treatment is a very major step."


The 32-year-old woman is described as not having eaten solid food for a year and her parents are reported by the Daily Telegraph to have told the court: "It upsets us greatly to advocate for our daughter's right to die... We feel she has suffered enough..."


Mr Justice Jackson is reported by the newspaper to have conceded the woman stood only a 20% chance of recovery even if she was put on an invasive force-feeding programme that would last at least a year.


Is it really true that medical intervention can be as dangerous as leaving people with an eating disorder to starve themselves to death? And is it also true that it's pretty pointless anyway?


In a 2010 study by Dr Marie Vignaud from the University Hospital of Clermont-Ferrand, France, all patients with Anorexia Nervosa admitted to 11 Intensive Care Units in France between 2006-2008 were investigated, and of 68 admissions, seven died during the admission.


The study published in the academic medical journal Critical Care, found the commonest cause of death was 'Refeeding Syndrome'. This is a potentially fatal shift in fluid and electrolyte levels (minerals such as sodium, potassium and calcium which are distributed around the body where the delicate balance across cell membranes is vital for life) that may occur in the malnourished receiving artificial nutrition.


Precisely because of the dangers of re-feeding, Dr Vignaud and colleagues contend oral re-feeding is the best approach to weight restoration. But faced with absolute refusal to eat, or in cases with extreme malnutrition, feeding via a nasogastric tube may be life-saving, the authors argue. In even more extreme cases, or when the digestive tract itself is no longer functioning, intravenous feeding should be used despite the risks, they believe.



Vignaud and colleagues point out the dangers of medical re-feeding have to be balanced against the fact that Anorexia Nervosa is in itself one of the most fatal psychiatric disorders, with a mortality rate of almost 6% for every 10 years of having the illness; 12 times the rate expected for similar age- and gender-matched groups.



It's perhaps sobering to realise in the light of these statistics that rates of anorexia appear to have been going up since the 1930's. A 2007 study published in the American Journal of Psychiatry by a group lead by Anna Keski-Rahkonen at the University of Helsinki, Finland, found that up to 50% of Anorexia Nervosa cases remain undetected by healthcare systems. Current estimates are that lifetime prevalence rates for Anorexia Nervosa in 20-40-year-old women are estimated between 1.2% and 2.2%. The rates for other milder eating disorders would be much higher.



In a study yet to be officially published, Daniel Rigaud and colleagues from the Service d'Endocrinologie-Nutrition, in Dijon France, followed up 41 severely malnourished anorexia nervosa patients and compared them with 443 less malnourished Anorexia Nervosa patients. The severely malnourished group of 41 had reached an average seriously low weight of 26 kilograms (four stones 1.3 pounds) with an average height of 160 cm (5.2 feet) which translates to an average Body Mass Index of 10 (bear in mind the normal healthy range is roughly 20-25).



Body Mass Index is the measure nutritionists use to calculate whether your weight is healthy as it takes into account your height. The formula is your weight in kilograms divided by your height in metres squared. A BMI lower than 10 kg/m2 in adults is widely considered incompatible with life.


Rigaud's study, due to be published in the academic journal 'Clinical Nutrition', found that all of the 41 severely malnourished anorexia patients received tube-refeeding: but during the in-patient stay, one patient died, two others suffered from myocardial infarction, two others from acute pancreatitis, and five from mental confusion.



Compared with the other 443 less severe Anorexia Nervosa patients (average weight in this less severe group was 40 kg or six stone 4.2 pounds), the 40 remaining patients (one died shortly after admission) had a worse six year outcome: a further two died (7% versus 1.2% in the 443 less ill group), and only 41% recovered (versus 62% in the less ill group).



Rigaud and colleagues conclude that in Anorexia Nervosa patients with a Body Mass Index of less than 11 kg/m2, prudent tube-refeeding could avoid short-term mortality, but long-term, the prognosis remains ominous.



Perhaps part of the problem lies in the very battle against the fervent desire of the anorexic; perhaps something is being missed. Jill Holm-Denoma and colleagues at the University of Vermont, USA, in 2008 proposed a theory that the high death rate in anorexia nervosa may be linked also to an especially high suicide motivation, which may have been previously missed by clinicians and relatives. Their study is based on previous research which finds the risk of death by suicide among anorexic women is approximately 57 times the expected rate.



The study, published in the 'Journal of Affective Disorders', considered the suicides of nine women with Anorexia Nervosa. They were found to be more likely to use highly lethal methods, with low rescue potential, that would likely kill anyone. Three died by throwing themselves in front of a train, and two more died by hanging.



Another reason courts may have to intervene against the wishes of severely anorexic patients, doctors argue, is their brains are likely to be incapable of reasoning rationally because the mind itself begins to be affected by the malnutrition. Brain imaging studies find reduced cerebral volume and the greater and faster the weight loss, the smaller the total brain volume. Refeeding, if it leads to weight gain, can largely reverse this brain shrinkage.



The latest study to report this kind of finding was conducted by a group lead by Boris Suchana from the Institute of Cognitive Neuroscience, Ruhr-University Bochum, Germany, in a study published in the journal 'Behavioural Brain Research' in 2010. This intriguing brain imaging study found a particular reduction in gray matter density with anorexia sufferers in a specific part of the brain associated with body size misjudgement. This raises the possibility that sufferers from anorexia get caught in a vicious cycle whereby losing weight might produce brain changes which in turn alter perception, and thus encourage more weight loss.



Anorexia Nervosa is a serious and complex disorder for which treatment must be tailored to the needs of the individual, but where 'the system' seldom allows this. Life saving intervention is required more than in most other psychiatric disorders.



Patrick Keown from Queen Elizabeth Hospital, Gateshead, and colleagues, published in the British Medical Journal in July 2011 an analysis on the impact of the dramatic reduction in UK NHS psychiatric hospital beds between 1988-2008 - a period when alternatives to hospital admission in the form of community care was supposed to be provided.



Keown and colleagues found the rate of involuntary admissions (being 'sectioned' under the Mental Health Act) per year in the NHS increased by more than 60%, while the provision of mental illness beds decreased by more than 60% over the same period. The authors calculated the closure of two mental illness beds contributes to an additional involuntary admission in the subsequent year. This data referred to all of psychiatry - not just eating disorders - but it might also contribute to our understanding of why anorexia has ended up in the courts, and in the news now.



A dramatic rise in the use of compulsory admissions over the last two decades does not mean that psychiatric disorders have in their nature got worse, but that the prospects for those who have them seem more bleak.



This is because a progressively starved, more disorganised NHS is less effectively caring.



Those desperately trying to look after patients who've reached the end of this road, are therefore forced to seek help from sources outside the health service.


So now we dispense with the doctors, and retain the lawyers.



Raj Persaud is a Consultant Psychiatrist in Private Practice in Harley Street, London UK and author of several best-selling books including ‘The Mind: A Users Guide’ published by Bantam Press. 

Raj Persaud is joint podcast editor for the Royal College of Psychiatrists and also now has a free app on iTunes and google play store entitled ‘Raj Persaud in conversation’, which includes a lot of free information on the latest research findings in mental health, plus interviews with top experts from around the world.



His books are available on amazon.co.uk here: