APPENDIX 45
Memorandum submitted by the Family Practice
Press
THE TEMPORAL
LOBE TIMEBOMB
"When you hear the diagnosis, you and
your loved ones will probably experience many of the same emotional
reactions: denial, anger resentment, depression, resignation and
acceptance. You may feel traumatized and depressed. While you
cannot forget the news you have just received, it is common to
become numb and hide or deny your initial feelings. The denial
can last a few days to a few weeks, or even a few months. This
initial stage is a very common reaction."
American Brain Tumour Association statement
INTRODUCTION
Following a number of violent attacks
on myself and my son, after he was born my ex-wife was referred
to psychiatrist who suspected a brain tumour. She then had two
EEG tests which indicated a lesion. Her personality had also changed
completely, the first sign of a tumour.
There was consideration as to whether
she had a Borderline Personality Disorder or a brain tumour. The
Law states that a woman can have a "suspected personality
disorder" but can only be labelled as such when she has committed
a crime!
Although her condition cannot be proved
until further exploratory surgery, it is likely that she may have
a meningioma.
What is a meningioma?
A meningioma is a type of tumour that
develops from the meninges, the membrane that surrounds the brain
and spinal cord. There are three layers of meninges, called the
dura mater, arachnoid and pia mater. Most meningiomas (90%) are
categorized as benign tumours, with the remaining 10% being atypical
or malignant. However, the word "benign" can be misleading
in this case, as when benign tumours grow and constrict and affect
the brain, they can cause disability and even be life threatening.
In many cases, benign meningiomas grow
slowly. This means that depending upon where it is located, a
meningioma may reach a relatively large size before it causes
symptoms. Other meningiomas grow more rapidly, or have sudden
growth spurts. There is no way to predict the rate of growth for
a meningioma, or to know for certain how long a specific tumour
was growing before diagnosis.
Most people with a meningioma will only
have a tumour at only one site, but it is also possible to have
several tumours growing simultaneously in different parts of the
brain and spinal cord. When multiple meningiomas occur, more than
one type of treatment may have to be used.
Meningiomas vary in their symptoms and
appropriate treatment options depending on where they are located.
A primary brain tumor originates in the
central nervous system, while metastatic brain tumors spread to
the brain from other parts of the body. Meningiomas account for
about 27% of primary brain tumors, making them the most common
of that type.
Who is at risk?
Meningiomas are most common in people
between the ages of 40 and 70. They are more common in women than
in men. Among middle-aged patients, there is a marked female bias,
with a female: male ratio of almost 3:1 in the brain and up to
6:1 in the spinal cord. Meningiomas are very rare in children,
with paediatric cases accounting for only 1.5% of the total.
There is also the added problem that
when tumours are sited on the Left Hand Temporal Lobe, the patient
has no insight into his or her behaviour as the tumour actually
switches off the insight.
What is even more interesting and refers
directly to problems encountered by numerous mothers after childbirth
is as described by John R Mangiardi, MD and Howard Kane, Wm.
The meningioma is the neurosurgeon's
"friend" and often his most enduring challenge. For
both the physician and patient, this tumor carries a true tag
of benign. It also carries the possibility of "cure"
in approximately 80% of cases. Thus, the long-term outcome for
a patient with this tumor is a direct function of the skill and
assiduousness of the surgeon who removes it.
Elsewhere in the Brain Surgery Information
Center's Primer on Brain Tumor Biology, it was mentioned that
"benign" often does not really mean benign. Be assured
that in this case, the tumor really is benign.
As mentioned earlier in the Primer, each
type of brain tumor arises from a specific cell type. The cell
of origin for the meningioma is call the arachnoid cap cell, found
on the surface coverings (called meninges) of the brain in the
paccionian granulations. These serve as the one-way valve system
between the water system of the brain and the veins that drain
from the brain to the heart.
Interestingly, these tumors have an embryologic
relationship with cells found in the muscle layer of the utereus.
In fact, it is exceedingly difficult for the pathologist to distinguish
the meningioma from the fibroid tumors of the utereus under the
microscope. Also, they share the characteristic female hormonal
receptors (estrogen and progesterone) on their cell surfaces.
This characteristic has lead to the testing of anti-estrogen receptor
agents, such as tamoxifin, as a growth-inhibiting agent in these
tumors. Clinical studies to date have failed to provide siginificantly
positive results.
Meningiomas are rarely malignant in their
behavior. But when malignant, meningiomas grow rapidly and are
destructive; they are quite difficult to treat, and recur oftentimes
in less than a year after surgical removal. They are also difficult
for the pathologist to diagnose under the microscope. Probably
the only finding that correlates well with the diagnosis is that
of numerous cells seen in division ("mitosis"). The
pathologist may occasionally speak of brain and skull invasion,
cells with an abnormal appearance, or other bizarre findings,
however none of these completey fit the diagnosis. Ultimately,
the diagnosis is determined by the activity of the particular
tumor over time.
A cousin to the meningioma is the hemangiopericytoma.
The cell of origin for this tumor is the perivascular pericyte
(located around blood vessels). Although very similar to the benign
meninigiomas, these tumors tend to recur with great rapidity (less
than one year) and frequency. Some physicians classify these tumors
with the malignant meningiomas.
LACK OF
INSIGHT—A BARRIER
TO VOLUNTARY
TREATMENT
"Lack of insight" (the inability
of a person to realize, or accept, that he is suffering a mental
illness) has long been believed to stem from defensive denial,
partly because of the stigma associated with these diseases. While
denial no doubt contributes to some people with mental illness
refusing treatment, research shows that lack of insight just as
frequently results from the underlying brain disorder itself.
The brains of those who suffer from this particular symptom of
mental illness are often structurally different from those who
do not. Treatment refusals stemming from lack of insight are thus
not "informed medical decisions." It is the malfunctioning
of the brain itself that causes the impaired decision-making.
There is nothing civilly right about denying treatment to people
with impaired decision-making who are too sick to obtain help
for themselves. Many scientists in numerous professional publications
have reported significant correlation between poor insight and
deficits in frontal lobe functioning. Others, some of whom are
quoted below, have reported on the devastating consequences of
the lack of insight: Impaired insight is a very common symptom
of schizophrenia and bipolar disorder. Both inpatients and outpatients
with schizophrenia and bipolar disorder (manic depression) have
shown the same rate of unawareness: about 50%. (Husted J Journal
of the American Academy of Psychiatry and Law Vol 27, no 1,
1999. Amador X, et al. Archives of General Psychiatry,
1994. Being unaware of being ill—lacking insight—is
strongly correlated with non-adherence to treatment. (Amador X;
Strauss D; Yale S; Gorman J and Endicott J, The American Journal
of Psychiatry 150:873-879, 1993.)
Patients with schizophrenia and schizoaffective
disorder with poor insight have very poor adherence to either
psychosocial treatment or medication even when they have expressed
their desire to participate and work at the program. (Lysaker
P; Bell M; Milstein R; Bryson G and Beam Goulet J, Insight
and Psychiatry Vol 57, November 1994.)
Lack of insight not only leads to noncompliance
with community treatment but leads to the revolving door of involuntary
hospitalizations. (McEvoy J, Freter S, Everett G, Geller J, Appelbaum
P, Apperson L and Roth L, Journal of Nervous and Mental Disease
177(1): 48-51, 1989.)
There have been fewer studies of insight
as it relates to affective disorders such as bipolar disorder,
nevertheless, as in schizophrenia, studies of affective disorders
find that lower levels of insight are correlated with a poorer
course of illness, lack of adherence to treatment and increased
involuntary hospitalizations. (Ghaemi N and Pope H, Jr, Lack
of Insight in Psychotic and Affective Disorders: A Review of Empirical
Studies. Harvard Review of Psychiatry, May/June: 22-33, 1994.
Also see Amador et al, Unawareness of Illness in Schizophrenia,
Schizoaffective and Affective Disorders. Archives of General
Psychiatry, 1994.)
The inability of the noninsightful patients
to understand they have a brain disorder or to accurately evaluated
their living conditions and plan for daily needs supports the
necessity for some form of "community Assisted Treatment."
Without supervision or court order, the person may not seek treatment,
or if temporarily coerced into treatment when hospitalized, be
unable or unwilling after discharge to comply with the treatment
regime. (Husted, J, Journal of the American Academy of Psychiatry
and Law Vol 27, no 1, 1999).
This vital piece of the jigsaw to find
the cause of my ex-wife's problem is key to understanding the
problem and the mistakes made by numerous professionals. Her father
had a benign tumour on the left hand side of his brain removed
which gives the genetic link to her problems. However, she had
an ovarian cyst removed before we were married in July 1987. This
was considered as a "one-off" by the specialist Dr Lloyd
and Dr Martin Scurr by the term "no sequalae."
What they never considered was that the ovarian cyst which, as
you can see above is a cousin to a meningioma, could have been
the secondary to the tumour growing in her brain—the silent
killer.
Her calm behaviour during pregnancy can
be explained by the lack of estrogen feeding the tumour. When
my son was born there was a rush of the hormone into her body
thus feeding the tumour which had a growth spurt. Thus, subconsciously
she blamed my son for her change of behaviour.
One can easily see the mistakes made
by lawyers and doctors alike after this change, they had never
met her before thus accepted her as a difficult subject to deal
with, outwardly pretty and treasonable, with this crazy husband
who kept complaining about her behaviour. Another problem was
that, given the site of the tumour, she could not remember her
extreme behaviour when questioned.
Therefore you can see of the danger of
the blanket diagnosis of Personality Disorder when a tumour could
be the cause of many of the problems in our prisons. St Andrews
Hospital also informed me that a patient can have a Personality
Disorder but cannot not have one with a positive EEG. This blanket
supposition has clearly put children in danger and many may have
died.
A vital task for Government and the Law
is to consider a review of all child abuse cases involving suspected
Personality Disorder? As you can see women are three times more
likely to suffer than men, this could solve a lot of child abuse
cases and bring treatment of those female sufferers before they
are sent to prison. It will also aid lawyers in the Family Division
when preparing child abuse and domestic violence cases.
BORDERLINE PERSONALITY
DISORDER (BPD)
Borderline Personality Disorder (BPD)
is one of the most controversial diagnoses in psychology today.
Since it was first introduced in the DSM, psychologists and psychiatrists
have been trying to give the somewhat amorphous concepts behind
BPD a concrete form.
Some researchers, like Judith Herman,
believe that BPD is a name given to a particular manifestation
of post-traumatic stress disorder: in Trauma and Recovery, she
theorizes that when PTSD takes a form that emphasizes heavily
its elements of identity and relationship disturbance, it gets
called BPD; when the somatic (body) elements are emphasized, it
gets called hysteria, and when the dissociative/deformation of
consciousness elements are the focus, it gets called DID/MPD.
Others believe that the term "borderline personality"
has been so misunderstood and misused that trying to refine it
is pointless and suggest instead simply scrapping the term.
What causes Borderline Personality Disorder?
It would be remiss to discuss BPD without
including a comment about Linehan's work. In contrast to the symptom
list approaches detailed below, Linehan has developed a comprehensive
sociobiological theory which appears to be borne out by the successes
found in controlled studies of her Dialectical Behavioral Therapy.
Linehan theorizes that borderlines are
born with an innate biological tendency to react more intensely
to lower levels of stress than others and to take longer to recover.
They peak "higher" emotionally on less provocation and
take longer coming down. In addition, they were raised in environments
in which their beliefs about themselves and their environment
were continually devalued and invalidated.
DSM-IV criteria
The DSM-IV gives these nine criteria;
a diagnosis requires that the subject present with at least five
of these. In I Hate You—Don't Leave Me! Jerold Kriesman
and Hal Straus refer to BPD as "emotional hemophilia; (a
borderline) lacks the clotting mechanism needed to moderate his
spurts of feeling. Stimulate a passion, and the borderline emotionally
bleeds to death."
Traits involving emotions:
Quite frequently people with BPD have
a very hard time controlling their emotions. They may feel ruled
by them. One researcher (Marsha Linehan) said, "People with
BPD are like people with third degree burns over 90% of their
bodies. Lacking emotional skin, they feel agony at the slightest
touch or movement."
1. Shifts in mood lasting
only a few hours.
2. Anger that is inappropriate,
intense or uncontrollable.
Traits involving behavior:
3. Self-destructive acts,
such as self-mutilation or suicidal threats and gestures that
happen more than once.
4. Two potentially self-damaging
impulsive behaviors. These could include alcohol and other drug
abuse, compulsive spending, gambling, eating disorders, shoplifting,
reckless driving, compulsive sexual behavior.
Traits involving identity:
5. Marked, persistent identity
disturbance shown by uncertainty in at least two areas. These
areas can include self-image, sexual orientation, career choice
or other long-term goals, friendships, values. People with BPD
may not feel like they know who they are, or what they think,
or what their opinions are, or what religion they should be. Instead,
they may try to be what they think other people want them to be.
Someone with BPD said, "I have a hard time figuring out my
personality. I tend to be whomever I'm with."
6. Chronic feelings of emptiness
or boredom. Someone with BPD said, "I remember describing
the feeling of having a deep hole in my stomach. An emptiness
that I didn't know how to fill. My therapist told me that was
from almost a "lack of a life". The more things you
get into your life, the more relationships you get involved in,
all of that fills that hole. As a borderline, I had no life. There
were times when I couldn't stay in the same room with other people.
It almost felt like what I think a panic attack would feel like."
Traits involving relationships:
7. Unstable, chaotic intense
relationships characterized by splitting (see below).
8. Frantic efforts to avoid
real or imagined abandonment.
— Splitting: the
self and others are viewed as "all good" or "all
bad." Someone with BPD said, "One day I would think
my doctor was the best and I loved her, but if she challenged
me in any way I hated her. There was no middle ground as in like.
In my world, people were either the best or the worst. I couldn't
understand the concept of middle ground."
— Alternating clinging
and distancing behaviors (I Hate You, Don't Leave Me). Sometimes
you want to be close to someone. But when you get close it feels
TOO close and you feel like you have to get some space. This happens
often.
— Great difficulty
trusting people and themselves. Early trust may have been shattered
by people who were close to you.
— Sensitivity to
criticism or rejection.
— Feeling of "needing"
someone else to survive.
— Heavy need for
affection and reassurance. Some people with BPD may have an unusually
high degree of interpersonal sensitivity, insight and empathy
9. Transient, stress-related
paranoid ideation or severe dissociative symptoms. This means
feeling "out of it," or not being able to remember what
you said or did. This mostly happens in times of severe stress.
Miscellaneous attributes of people with
BPD:
— People with BPD
are often bright, witty, funny, life of the party.
— They may have
problems with object constancy. When a person leaves (even temporarily),
they may have a problem recreating or remembering feelings of
love that were present between themselves and the other. Often,
BPD patients want to keep something belonging to the loved one
around during separations.
— They frequently
have difficulty tolerating aloneness, even for short periods of
time.
— Their lives may
be a chaotic landscape of job losses, interrupted educational
pursuits, broken engagements, hospitalizations.
— Many have a background
of childhood physical, sexual, or emotional abuse or physical/emotional
neglect.
CONCLUSION
There are only 3,000 brain tumours a
year in the UK, thus few GPs see a sufferer and his or her relatives.
the fact that meningiomas as three times more common in women
than men must flag up concern that not enough research ahs been
done on the subject as the current statistics do not reflect this
number.
We would ask for an immediate Royal Commission
for research into brain tumours and their cause of domestic violence
in particular.
7 January 2008
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