10 July 2019

Forensic feuilleton: The spectre of illness terrorism

Psychiatry RedHerring

When a man’s partner is killed he’s supposed to do something about it. It doesn’t make any difference what you thought of him. He was your partner and you’re supposed to do something about it. Then it happens we were in the detective business. Well, when one of your organisation gets killed it’s bad business to let the killer get away with it. It’s bad all around – bad for that one organisation, bad for every detective everywhere.
– Dashiell Hammett, The Maltese Falcon

In an age when mass murders are occurring far too often, it is worth remembering the lethal events of what became known as the Wickham Terrace massacre.

On 1 December 1955, Karl Kast, a disgruntled patient claiming compensation for a back injury which could not be found by five specialists, came to Wickham Terrace, Brisbane’s Harley Street, with a revolver and a satchel containing 12 pipe bombs.

In a spree lasting 10 minutes, Kast shot three doctors, two of whom were killed, and then blew himself up. The incident was later written up as a singular example of the dangers of labelling a patient a malingerer.

Distant as it was, the Wickham Terrace massacre is a reminder of the ultimate risk that every doctor faces in carrying out their profession: being attacked and killed by their patients.

Perpetrators typically fall into two categories — spontaneous offenders, who are spurred by their immediate circumstances, and predatory offenders, who plan attacks methodically.

In healthcare, the most frequent victims are emergency room workers attacked by people who are mentally ill, under the influence of drugs or alcohol, turn violent when informed of a family member’s death or refused narcotics.

Cardiac surgeon Patrick Pritzwald-Stegmann died after being punched by a patient in the foyer of the hospital in May 2017. ED staff are under attack so often that some describe busy nights in casualty as like being under siege.

This danger to doctors receives little attention and fatalities are thought to be random and rare events, rather than a clarion call to raise awareness and security. This is an illusion: violence, including murderous assault, of doctors is on the increase round the world.

Psychiatrists, who are exposed to psychotic and paranoid patients, have the highest risk An example of the danger was the 2006 murder

of Washington psychiatrist Wayne Fenton, a leading authority on schizophrenia, punched to death by a 19-year-old schizophrenic patient in his rooms.

Other specialities are increasingly coming under fire. Plastic surgeons who operate on patients with body dysmorphic disorder are at special risk. Such patients can never be satisfied by the outcome of procedures and what is essentially a somatic monomania can turn to homicide.

These events are bad enough, but a growing threat comes from a different source: patient groups who adopt an aggressive attitude to the medical profession when their illness does not receive the recognition or treatment they believe it deserves.

They are a diverse collection, ranging from Morgellons syndrome (alleged parasitic infestation of skin), parents of autistic children who blame vaccination for the condition, to chronic fatigue syndrome (otherwise known as ME) sufferers.

These groups pour out their frustrations on the internet which provides never-ending reiteration and confirmation of their beliefs in the most subjective and personalised fashion while refuting any scientific evidence to the contrary.

In the face of this torrent of propaganda, believers will ramp up their rage at not having their illness beliefs accepted.

What is worse is the actions they make in response. Take the ME group, which is large, vociferous and belligerent. Any medical scientist who has views contrary to the group belief is subjected to tirades of virulent abuse.

Professor Myra McClure’s research found that ME was primarily a psychiatric condition. Such was the hate mail she received that she stopped her work.

Professor Simon Wessely, President of the Royal College of Psychiatrists, who came to similar conclusions, received a number of death threats and moved out of the field.

More recently, Dr Michael Sharpe found a program of CBT had good results in alleviating the symptoms of ME. He was accused of being a fraud and a charlatan, if not conspiring in a cover-up. He has now given up his work because of what was described as the hatred, insults, violent and unbalanced nature of texts and mail he received.

Showing the degree of irrationality, if not fanaticism, in the group’s reactions, these are experts who unequivocally accept the existence of ME and find treatments that are scientifically confirmed to work on condition.

The objection of the extremists is that programs of exercise and CBT means that ME is a psychiatric illness, which they emphatically refute. The same applies to studies which, despite extensive funding and research, are unable to show that ME is caused by a virus.

There is an adamantine refusal to accept that psychological treatments can be used for a range of medical disorders and classifying things so categorically is unscientific dualism.

There is much to be said about the huge gap between these groups, who have the perception of illness, and disease, which is dealt with on a scientific basis by doctors.

Before this can be sorted out, the more immediate risk needs to be appreciated. The internet postings of fanatics in these groups increasingly resembles that of political extremists on the left and right, dominated by vitriolic abuse, condemnation, paranoia and threats.

It is the latter that raises the greatest concern. How long will it be before an illness terrorist takes matters into his own hands? We have already seen murders of abortion clinic doctors by extremists.

This is a medical-political issue, setting the tone for what will undoubtedly follow. It is a classic situation where extremists have their levels of paranoia fed until they feel they have no choice but to eliminate the perceived cause of their alienation.

It is only a question of time before an illness terrorist takes a medical life for no reason other than they are to be blamed for a condition which cannot be validated scientifically.

The problem of the misuse of the internet for extremist purposes is so large that it will take the combined effect of governments acting in unison to bring it under control.

As the New Zealand mosque massacre shows, the consequences can be catastrophic. Internet facilitation of illness terrorism is not going to be rectified in the short term, making a raised awareness of the dangers essential.

It is incumbent on the medical profession recognise the threat to doctors before it becomes an awful reality.

Robert M Kaplan is a forensic psychiatrist, writer and historian