Correspondence Patient admission and caregiver stress Although the distress of a patient is the primary concern of all clinicians, I feel that it is also important to understand the psychological experiences of carers, as they have signi®cant responsibility in supporting someone who is mentally ill. I am therefore extremely satis®ed to see the recent study by Ranieri et al 1 which has investigated the link between patient admission and caregiver stress. Overall, the article presents a strong ®nding which could assist in identifying the types of support needed by carers to ensure that their own mental health is protected. However, one limitation of the study that was not identi®ed by the authors is the use of self-report measures. Although the questionnaire instruments used have been found to be reliable measures, participants are not always honest in their responses due to possible embarrassment, or the social desirability bias.2 This means that a true re¯ection of an individual's psychological state is not always captured accurately. Furthermore, I feel that `suicidality' should have been included as an additional variable due to the close link with psychological distress.3 If a signi®cant relationship was found, it might inform thinking around the types of support provided to carers.

offence causing serious physical or psychological harm, presence of a severe personality disorder, offending and disorder linked) were admitted to a treatment programme designed to reduce their risk to others.2 Unsurprisingly, there were concerns at the time that large numbers of patients who would never offend or present a signi®cant risk to others would be incarcerated and prevented from living in the community.3 For those who are not aware, the initiative has now ended, following strong opposition from doctors and others.4 I have long been concerned about the premise that most suicides can be predicted and now I have some ®gures and knowledge to quote. Perhaps, like the DSDP Programme, we as a society need to recognise that prediction in retrospect is futile and follow the paper's recommendation of the provision of `adequate care for all our patients'. John Watts, Consultant Psychiatrist, South London and Maudsley NHS

Foundation Trust, Kent and Medway Adolescent Unit, Staplehurst, UK, email: [email protected]

1 Nielssen O, Wallace D, Large M. Pokorny's complaint: the insoluble

and Adolescent Mental Health Service, Scunthorpe, UK, email: [email protected]

problem of the overwhelming number of false positives generated by suicide risk assessment. BJPsych Bull 2017; 41: 18±20. 2 Probation circular. Dangerous and severe personality disorder (DSPD) programme. 20060715141954/http://dspdprog . . . accessed 31 March 2017. 3 Duggan C. Dangerous and severe personality disorder. Br J Psychiatry 2011; 198 431±3. 4 Batty D. Q&A: dangerous and severe personality disorder. The Guardian; 2002, 17 April.

1 Ranieri V, Madigan K, Roche E, McGuinness D, Bainbridge E, Feeney L,

doi: 10.1192/pb.41.4.237a

Emily R Kruger, Assistant Psychologist, North Lincolnshire NHS Child

et al. Caregiver burden and distress following the patient's discharge from psychiatric hospital. BJPsych Bull 2017; 41: 87±91. 2 Furnham A. Response bias, social desirability and dissimulation. Pers Individ Dif 1986; 7: 385±400. 3 Sokero TP, Melartin TK, Rytsala HJ, Leskela US, Lestela-Mielonen PS, Isometsa ET. Prospective study of risk factors for attempted suicide among patients with DSM-IV major depressive disorder. Br J Psychiatry 2005; 186: 314±8.

doi: 10.1192/pb.41.4.237

Being sensible about suicides I must thank Nielssen et al for their thoughtful and concise piece on the high numbers of false positives produced by assessments of suicide risk and their conclusions that all patients, even those deemed to be at low risk of suicide, need to receive interventions.1 Having just been to an inquest into the death of a patient where the risk of suicide was deemed to be low, I can readily identify with the sentiments expressed in the paper, namely that our assessments of suicide risk are inadequate and that we should focus on care for all. I am reminded of the Dangerous and Severe Personality Disorder (DSPD) Programme in this regard. This was a UK government initiative in response to a high-pro®le case of homicide by a patient with an antisocial personality disorder, where patients who ful®lled certain criteria (at risk of an

To educate or to entertain? Droning techno music, muted colours, hazy lenses, panning camera angles and extreme close-ups. These are features I expect in ®lms such as The Shining or Silence of the Lambs, not a television documentary about schizophrenia. Why did I go mad? (BBC2 Horizon 2 May 2017) follows four individuals with a diagnosis and I cannot help but feel the BBC missed the point. Surely, the responsibility of the media today is to accurately represent mental illness, deepen understanding and reduce stigma. It was as if the four people were protagonists in their own horror movies. I was left questioning which I feared more, the psychosis or the person, and neither are helpful responses when it comes to changing our perceptions of the illness. I am disappointed in the BBC. It is important to understand where stigma arises in order to challenge beliefs and attitudes, but what hope is there when documentaries care more about entertaining than educating? Kiana H Newman-Zand, Second Year Medical Student, Queen's University

Belfast, Belfast, UK, email: [email protected] doi: 10.1192/pb.41.4.237b




Seeing, spots and blots

We were drawn to Nour & Nour's article on visual perception by the front cover illustration of the Herdmann grid, whose illusory qualities remain unexplained.1 Their focus is on visual perception and how machine learning might shed light on the neuroscience of seeing, using an example of a Google-grown arti®cial neural network to identify bananas in a banana-free image by manipulating prior expectations. Pareidolic illusions and seeing things that are not actually there are as relevant to understanding clinical disease as they are to aesthetics and there is increasing interest in trying to dissect the mechanisms underlying this intriguing and complex phenomenon. The legacy of Rorschach and his eponymous images live on in recent research revealing that it might be the detailed fractal geometry at the patterned edge which underlies the subjective response.2 Building other features into Rorschach-like computer generated images, such as right-left symmetry patterns, seems to stimulate face pareidolia through top-down processing.3 The predictive potential of a `pareidolia test' is as tantalising as ink blot patterns would have been to early researchers. We now have the tools and technologies to explore this realm of visual distortion and deception which Rorschach could only have dreamed of possessing. Building algorithms informed by real-life data should allow machine learning and modelling to be re®ned and capable of revealing new insights into the rich range of the visual perception spectrum, from normal to abnormal. Advances in both image processing and computing, together with accessible crowd-sourced subjects, will prove to be a valuable public psychophysics network to explore other aspects of visual perception and pareidolia and may be the means to test the validity of recent reports that probing this aspect of perception4 might be used as an early diagnostic tool for dementia.

, Professor of Ophthalmology, University of Edinburgh/NHS Lothian; Edinburgh, UK, email: [email protected] and Neena Dhillon, CT1 Psychiatry Trainee, NHS Fife, Fife, UK. 1 Nour MM, Nour JM. Perceptual distortions and deceptions: what computers can teach us. BJPsych Bull 2017; 41: 37±40. Baljean Dhillon



3 4

Taylor RP, Martin TP, Montgomery RD, Smith JH, Micolich AP, Boydston C, et al. Seeing shapes in seemingly random spatial patterns: fractal analysis of Rorschach inkblots. PLoS One 2017; 12: e0171289. Liu J, Li J, Feng L, Li L, Tian J, Lee K. Seeing Jesus in toast: neural behavioral correlates of face pareidolia. Cortex 2014; 53: 60±77. Sasai-Sakuma T, Nishio Y, Yokoi K, Mori E, Inoue Y. Pareidolias in REM sleep behavior disorder: a possible predictive marker of Lewy Body Diseases? Sleep 2017; 40: zsw045.

doi: 10.1192/pb.41.4.238

Vitamin D de®ciency is to be expected due to immune changes related to mental health problems

Stewart & Lewis1 have shown that adolescent psychiatric in-patients typically have vitamin D de®ciency and hypothesise that this may be due to reduced exposure to sunlight.This may well be true, but it is much more likely that the reduced vitamin D levels are due to changes in the immune system linked with psychiatric disorders. For example, it is now2 well known that depression is associated with in¯ammation and that immune markers are typically raised. What is less well 3 known is that vitamin D is a negative acute-phase reactant, which means that its levels drop in response to in¯ammation. Therefore, a low level may not indicate a de®ciency, but rather the presence of in¯ammation. It would be interesting to reanalyse the data and see whether there are any links with particular diagnoses. , Consultant Child and Adolescent Psychiatrist, Child and Adolescent Mental Health Service, Hertfordshire Partnership University Foundation NHS Trust, Hoddesdon, UK, email: [email protected] Annie Swanepoel

1 2


Stewart NF, Lewis SN. Vitamin D de®ciency in adolescents in a tier 4 psychiatric unit. BJPsych Bull 2017; 41: 404-6. Berk M, Williams LJ, Jacka FN, O'Neill A, Pasco JA, Moylan S et al. So depression is an in¯ammatory disease, but where does the depression come from? BMC Med 2013; 11:200. Waldron JL, Ashby HL, Cornes MP, Bechervaise J, Razavi C,Thomas OL et al. Vitamin D: a negative acute-phase reactant. J Clin Pathol 2013; 66: 620±2.

doi: 10.1192/pb.41.4.238a