The "insanity" of King George 3d: a classic case of porphyria

Difficult Patients: Malingerers, Feigners, Chronic Complainers, and Real Imposters

Malingering is the intentional production of false or grossly exaggerated symptoms motivated by internal and external incentives. The true incidence of malingering in the emergency department is unknown because of the difficulty of identifying whether patients are fabricating their symptoms. Malingering is considered a diagnosis of exclusion; a differential diagnosis framework is described to guide emergency physicians. Several case studies are presented and analyzed from a medical ethics perspective. Practical recommendations include use of the NEAL (neutral, empathetic, and avoid labeling) strategy when caring for patients suspected of malingering.

The acute mania of King George III: A computational linguistic analysis

We used a computational linguistic approach, exploiting machine learning techniques, to examine the letters written by King George III during mentally healthy and apparently mentally ill periods of his life. The aims of the study were: first, to establish the existence of alterations in the King's written language at the onset of his first manic episode; and secondly to identify salient sources of variation contributing to the changes. Effects on language were sought in two control conditions (politically stressful vs. politically tranquil periods and seasonal variation). We found clear differences in the letter corpus, across a range of different features, in association with the onset of mental derangement, which were driven by a combination of linguistic and information theory features that appeared to be specific to the contrast between acute mania and mental stability. The paucity of existing data relevant to changes in written language in the presence of acute mania suggests that lexical, syntactic and stylometric descriptions of written discourse produced by a cohort of patients with a diagnosis of acute mania will be necessary to support the diagnosis independently and to look for other periods of mental illness of the course of the King's life, and in other historically significant figures with similarly large archives of handwritten documents.

Porphyria cutanea tarda: an intriguing genetic disease and marker

Porphyrias are a group of intriguing genetic diseases of the heme pathway, of which porphyria cutanea tarda (PCT) is the most common. Resulting from a defect in enzymes in the porphyria pathway, PCT has been linked to several conditions. Recent studies have demonstrated a change in thinking regarding the human immunodeficiency virus (HIV) and development of PCT. The exacerbation of PCT with contraction of HIV is now believed to result from coinfection from the hepatitis C virus (HCV). Blistering of sun-exposed skin, a classic presenting sign of PCT, is not exclusive to the condition. Cutaneous findings must also trigger physicians to consider additional types of porphyrias, such as variegate porphyria. The diagnosis of pseudoporphyria, which does not result from enzymatic absence, must be considered in patients with photosensitivity and cutaneous bullae. Recent health food trends, such as chlorophyll, have been linked to pseudoporphyria. PCT is a serious condition in which accurate diagnosis is necessary for appropriate management.

Update review of the acute porphyrias

Acute porphyrias are rare inherited disorders due to deficiencies of haem synthesis enzymes. To date, all UK cases have been one of the three autosomal dominant forms, although penetrance is low and most gene carriers remain asymptomatic. Clinical presentation is typically with acute neurovisceral attacks characterised by severe abdominal pain, vomiting, tachycardia and hypertension. Severe attacks may be complicated by hyponatraemia, peripheral neuropathy sometimes causing paralysis, seizures and psychiatric features. Attacks are triggered by prescribed drugs, alcohol, hormonal changes, fasting or stress. The diagnosis is made by finding increased porphobilinogen excretion in a light-protected random urine sample. Management includes administration of intravenous human haemin and supportive treatment with non-porphyrinogenic drugs. A few patients develop recurrent attacks, a chronic illness requiring specialist management. Late complications include chronic pain, hepatocellular carcinoma, chronic renal failure and hypertension. In the UK, the National Acute Porphyria Service provides clinical advice and supplies haemin when indicated.

Shift, Interrupted: Strategies for Managing Difficult Patients Including Those with Personality Disorders and Somatic Symptoms in the Emergency Department

Difficult patients are often those who present with a mix of physical and psychiatric symptoms, and seem refractory to usual treatments or reassurance. such patients can include those with personality disorders, those with somatization symptoms; they can come across as entitled, drug-seeking, manipulative, or simply draining to the provider. Such patients are often frequent visitors to Emergency Departments. Other reasons for difficult encounters could be rooted in provider bias or countertransference, rather than sole patient factors. Emergency providers need to have high awareness of these possibilities, and be prepared to manage such situations, otherwise workup can be sub-standard and dangerous medical mistakes can be made.

Down the Rabbit Hole: Emergency Department Medical Clearance of Patients with Psychiatric or Behavioral Emergencies

Patients presenting with behavior or psychiatric complaints may have an underlying medical disorder causing or worsening their symptoms. Misdiagnosing a medical illness as psychiatric can lead to increased morbidity and mortality. A thorough history and physical examination, including mental status, are important to identify these causes and guide further testing. Laboratory and ancillary testing should be guided by what is indicated based on clinical assessment. Certain patient populations and signs and symptoms have a higher association with organic causes of behavioral complaints. Many medical problems can present with or exacerbate psychiatric symptoms, and a thorough medical assessment is imperative.

Porphyria Diagnostics-Part 1: A Brief Overview of the Porphyrias

Porphyria diseases are a group of metabolic disorders caused by abnormal functioning of heme biosynthesis enzymes and characterized by excessive accumulation and excretion of porphyrins and their precursors. Precisely which of these chemicals builds up depends on the type of porphyria. Porphyria is not a single disease but a group of nine disorders: acute intermittent porphyria (AIP), hereditary coproporphyria (HCP), variegate porphyria (VP), δ-aminolevulinic acid dehydratase deficiency porphyria (ADP), porphyria cutanea tarda (PCT), hepatoerythropoietic porphyria (HEP), congenital erythropoietic porphyria (CEP), erythropoietic protoporphyria (EPP), and X-linked protoporphyria (XLP). Each porphyria results from overproduction of heme precursors secondary to partial deficiency or, in XLP, increased activity of one of the enzymes of heme biosynthesis. Taken together, all forms of porphyria afflict fewer than 200,000 people in the United States. Based on European studies, the most common porphyria, PCT, has a prevalence of 1 in 10,000, the most common acute porphyria, AlP, has a prevalence of ∼1 in 20,000, and the most common erythropoietic porphyria, EPP, is estimated at 1 in 50,000 to 75,000. CEP is extremely rare, with prevalence estimates of 1 in 1,000,000 or less. Only six cases of ADP are documented. The current porphyria literature is very exhaustive and a brief overview of porphyria diseases is essential in order for the reader to better appreciate the relevance of this area of research prior to undertaking biochemical diagnostics procedures. This unit summarizes the current knowledge on the classification, clinical features, etiology, pathogenesis, and genetics of porphyria diseases.

Court orders on procreation

OBJECTIVE

The aim of this study is to empirically evaluate judgments entered from 1913 to 2013 in the matters of compulsory sterilization.

METHODS

Holdings and dispositions at the U.S. Appellate and Supreme courts are randomly located in LexisNexis using Shepard's symbols. Continuous variables are processed with the Mantel-Haenszel method. Court orders are used as units of analysis.

RESULTS

The majority of cases (56.4 %) concern minors at a mean age of 11.7 years. Forty-four (80 %) petitions are filed by the parents or guardians; 11 (20 %) are parens patriae. Petitions for female sterilization are denied in 56.4 % cases under the Federal Laws (2 U.S.C. 431; 28 U.S.C; 29 U.S.C; 42 U.S.C; 424 U.S.), Procedural due process clause of the 14th Amendment, statutes, and common law precedents. Petitions for female sterilization are granted in 36.4 % cases under the statutory penal codes, the Law of the land, precedents, and the dicta. No significant associations are found between the parity and degree of mental impairment (r = 0.342). Substantial correlations are met between the gender, degree of impairment (r (2) = 0.724), and dispositions (r (2) = 802). The mean age of women is 20.78 years; the mean age of men is 30.25 years. Correlations fail to establish reasoning between the age of the subjects and the entered judgments (r (2) = 0. 356).

CONCLUSIONS

(1) The female/male ratio (8:1) and age gap of the respondents indicate on a disproportionate impact of the statutes. (2) The procedure of sterilization in itself is incommensurate with equality, as the volume of surgery is uneven in males and females. (3) The case law is instructive with respect to which arguments have not been advanced. (4) Lastly, due to the etiological intricacy of mental impairment, with genetic transmission strikingly different in men and women, expert-witnesses ought to act in a medical vacuum because there is no mathematical certainty as to the transmission mode of the traits in question (exon and intron mutations, triplet repeat disorders, histone disorders, autosomal-dominant or autosomal-recessive transmission, sex chromosome-linkage, polygenomic imprinting, and organic reasons).

FitzPatrick Lecture: King George III and the porphyria myth - causes, consequences and re-evaluation of his mental illness with computer diagnostics

Recent studies have shown that the claim that King George III suffered from acute porphyria is seriously at fault. This article explores some of the causes of this misdiagnosis and the consequences of the misleading claims, also reporting on the nature of the king's recurrent mental illness according to computer diagnostics. In addition, techniques of cognitive archaeology are used to investigate the nature of the king's final decade of mental illness, which resulted in the appointment of the Prince of Wales as Prince Regent. The results of this analysis confirm that the king suffered from bipolar disorder type I, with a final decade of dementia, due, in part, to the neurotoxicity of his recurrent episodes of acute mania.

The human flavoproteome

Vitamin B2 (riboflavin) is an essential dietary compound used for the enzymatic biosynthesis of FMN and FAD. The human genome contains 90 genes encoding for flavin-dependent proteins, six for riboflavin uptake and transformation into the active coenzymes FMN and FAD as well as two for the reduction to the dihydroflavin form. Flavoproteins utilize either FMN (16%) or FAD (84%) while five human flavoenzymes have a requirement for both FMN and FAD. The majority of flavin-dependent enzymes catalyze oxidation-reduction processes in primary metabolic pathways such as the citric acid cycle, β-oxidation and degradation of amino acids. Ten flavoproteins occur as isozymes and assume special functions in the human organism. Two thirds of flavin-dependent proteins are associated with disorders caused by allelic variants affecting protein function. Flavin-dependent proteins also play an important role in the biosynthesis of other essential cofactors and hormones such as coenzyme A, coenzyme Q, heme, pyridoxal 5'-phosphate, steroids and thyroxine. Moreover, they are important for the regulation of folate metabolites by using tetrahydrofolate as cosubstrate in choline degradation, reduction of N-5.10-methylenetetrahydrofolate to N-5-methyltetrahydrofolate and maintenance of the catalytically competent form of methionine synthase. These flavoenzymes are discussed in detail to highlight their role in health and disease.

'Struensee's memoir on the situation of the King' (1772): Christian VII of Denmark

Christian VII of Denmark (1749-1808) was insane throughout his long reign. The royal physician, Johann Friedrich Struensée (1737-72), usurped his power. In 1771 the King appointed him Privy Cabinet Minister. Struensée revolutionized the whole administration of the Danish-Norwegian kingdom and had an adulterous relationship with the Queen, Caroline Mathilda, George III's sister. In January 1772 he was arrested, sentenced to death for lese-majesty and executed. During his confinement, he wrote a memoir on the King's condition, which he considered to be caused by, or the effect of, masturbation. In 1906 Christiansen interpreted it as a case of dementia praecox, i.e. schizophrenia. It is now suggested that Christian's insanity, like that of George III (his cousin), might have been due to porphyria - the 'royal malady', possibly inherited through his mother, Princess Louise of England or his father, King Frederik V, who died from an illness which retrospectively resembles a case of porphyria.

Porphyric neuropathy

Porphyric neuropathy often poses a diagnostic dilemma; it is typically associated with the hepatic porphyrias, characterized by acute life-threatening attacks of neurovisceral symptoms that mimic a range of acute medical and psychiatric conditions. The development of acute neurovisceral attacks is responsive to environmental factors, including drugs, hormones, and diet. This chapter reviews the clinical manifestations, genetics, pathophysiology, and mechanisms of neurotoxicity of the acute hepatic porphyrias. While the etiology of the neurological manifestations in the acute porphyrias remains undefined, the main hypotheses include toxicity of porphyrin precursors and deficiency of heme synthesis. These hypotheses will be discussed with reference to novel experimental models of porphyric neuropathy.

Purple pigments: the pathophysiology of acute porphyric neuropathy

The porphyrias are inherited metabolic disorders arising from disturbance in the haem biosynthesis pathway. The neuropathy associated with acute intermittent porphyria (AIP) occurs due to mutation involving the enzyme porphobilinogen deaminase (PBGD) and is characterised by motor-predominant features. Definitive diagnosis often encompasses a combination of biochemical, enzyme analysis and genetic testing, with clinical neurophysiological findings of a predominantly motor axonal neuropathy. Symptomatic and supportive treatment are the mainstays during an acute attack. If administered early, intravenous haemin may prevent progression of neuropathy. While the pathophysiology of AIP neuropathy remains unclear, axonal dysfunction appears intrinsically linked to the effects of neural energy deficits acquired through haem deficiency coupled to the neurotoxic effects of porphyrin precursors. The present review will provide an overview of AIP neuropathy, including discussion of recent advances in understanding developed through neurophysiological approaches that have further delineated the pathophysiology of axonal degeneration.

King George III, bipolar disorder, porphyria and lessons for historians

In the 1960s, Ida Macalpine and Richard Hunter, mother and son psychiatrists, stated that George III's medical records showed that he suffered from acute porphyria. In spite of well-argued criticisms by Geoffrey Dean and Charles Dent based on their extensive clinical experience of the acute porphyrias, Macalpine and Hunter were able to garnish extensive support for their claims from historians, psychiatrists, physicians and the media circus and their view is now surprisingly widely accepted. Recent research of George III's extensive medical records has shown that Macalpine and Hunter were highly selective in their reporting and interpretation of his signs and symptoms and that the diagnosis of the acute porphyria cannot be sustained. The basis for the false claims and the consequences for historians are considered and indicate that there is now an opportunity to reassess George III's contributions to events in his reign.

The madness of King George III: a psychiatric re-assessment

This research, based on a study of King George III's medical records and of contemporary diaries of his courtiers and equerries, further confirms the considerable doubt on the claim of Richard Hunter and Ida Macalpine that the King suffered from recurrent attacks of acute porphyria.The present study examines the above records from a psychiatric viewpoint, together with some additional reports, to re-assess the nature of the King's maladies. It concludes that he suffered from recurrent mania (four episodes), with chronic mania and possibly a degree of fatuity during the last decade of his life.This is in agreement with previous reports that he suffered from manic-depressive psychosis.

King George III and porphyria: a clinical re-examination of the historical evidence

The diagnosis that George III suffered from acute porphyria has gained widespread acceptance,but re-examination of the evidence suggests it is unlikely that he had porphyria.The porphyria diagnosis was advanced by Ida Macalpine and Richard Hunter, whose clinical symptomatology and historical methodology were flawed.They highlighted selected symptoms, while ignoring, dismissing or suppressing counter-evidence.Their claims about peripheral neuropathy, cataracts, vocal hoarseness and abdominal pains are re-evaluated; and it is also demonstrated that evidence of discoloured urine is exceedingly weak. Macalpine and Hunter believed that mental illnesses were primarily caused by physical diseases, and their diagnosis of George III formed part of a wider agenda to promote controversial views about past, contemporary and future methods in psychiatry.

Nutritional regulation of hepatic heme biosynthesis and porphyria through PGC-1alpha

Inducible hepatic porphyrias are inherited genetic disorders of enzymes of heme biosynthesis. The main clinical manifestations are acute attacks of neuropsychiatric symptoms frequently precipitated by drugs, hormones, or fasting, associated with increased urinary excretion of delta-aminolevulinic acid (ALA). Acute attacks are treated by heme infusion and glucose administration, but the mechanisms underlying the precipitating effects of fasting and the beneficial effects of glucose are unknown. We show that the rate-limiting enzyme in hepatic heme biosynthesis, 5-aminolevulinate synthase (ALAS-1), is regulated by the peroxisome proliferator-activated receptor gamma coactivator 1alpha (PGC-1alpha). Elevation of PGC-1alpha in mice via adenoviral vectors increases the levels of heme precursors in vivo as observed in acute attacks. The induction of ALAS-1 by fasting is lost in liver-specific PGC-1alpha knockout animals, as is the ability of porphyrogenic drugs to dysregulate heme biosynthesis. These data show that PGC-1alpha links nutritional status to heme biosynthesis and acute hepatic porphyria.

King George III and porphyria: an elemental hypothesis and investigation

In 1969 it was proposed that the episodic madness suffered by King George III (1738-1820) resulted from an acute hereditary porphyria, variegate porphyria, caused by deficiency of protoporphyrinogen oxidase. The diagnosis was based on the historical archive and a contentious claim that living members of the House of Hanover were affected with the condition. A re-examination of the medical evidence and the appearance of new historical material have suggested that porphyria did indeed exist in the Royal Houses of Europe. We report the analysis of hair obtained from George III. Although no genomic DNA could be obtained, metal analysis revealed high concentrations of arsenic. Since arsenic interferes with haem metabolism, it might have contributed to the King's unusually severe and prolonged bouts of illness. We have identified sources of arsenic in the context of the medication George III received from physicians.

Porphyric neuropathy

The hepatic porphyrias are a group of rare metabolic disorders characterized by enzymatic defects in the biosynthesis of heme, a metalloporphyrin that is the principal product of porphyrin metabolism. The hepatic porphyrias are genetically transmitted as autosomal-dominant disorders with variable expression that produce a particularly severe form of neuropathy. Most medical students readily recognize acute attacks of porphyria when the classic triad of abdominal pain, psychosis, and neuropathy is present. Yet, porphyric neuropathy is a source of confusion in practice, and patients with porphyria rarely receive the correct diagnosis early in the course of the illness. Porphyric neuropathy is manifest by symptoms, signs, and cerebrospinal fluid abnormalities resembling acute Guillain-Barré syndrome. However, accompanying psychological features, a proximal predilection of asymmetric weakness, and electrodiagnostic findings indicative of an axonal polyradiculopathy or neuronopathy all suggest the diagnosis of porphyria. Confirmation of the diagnosis depends on use of appropriate laboratory studies. The underlying pathophysiology of porphyric neuropathy has not been established, but it may be related to direct neurotoxicity of elevated levels of delta-aminolevulinic acid. The severity of the neuropathy and the availability of potential treatments, including avoidance of provocative factors, make identification important.

From King George to neuroglobin: the psychiatric aspects of acute intermittent porphyria

The porphyrias are a heterogeneous group of inherited deficiencies in the heme biosynthetic pathway. Acute intermittent porphyria is both the most prevalent and most severe form of this illness. Psychiatric symptoms are part of the classic presentation of this disorder, and psychiatric patients have a higher rate of porphyria than the general population. Despite this, clinicians often fail to consider this diagnosis in the differential for recalcitrant psychosis or depression. Many patients are asymptomatic until exposed to certain medications, liver damage, or hormonal changes. Diagnosis requires a high index of suspicion and a thorough history, physical examination, and laboratory evaluation. The author reviews historical aspects, diagnostic features, and optimal treatment of acute intermittent porphyria, considers possible etiologies of its psychiatric symptoms, and provides two case histories as examples.

Lead poisoning, haem synthesis and 5-aminolaevulinic acid dehydratase

In mammals and yeast, 5-aminolaevulinic acid dehydratase is a zinc-dependent enzyme that catalyses the synthesis of porphobilinogen-the pyrrole building block that is incorporated into all modified tetrapyrroles, including haem, chlorophyll and vitamin B12. The X-ray structure of this enzyme reveals how substitution of the catalytically important zinc ion by lead inactivates the enzyme and causes a form of pseudo-porphyria.

George III: a revised view of the royal malady

George III of England's episodic psychotic illness is described. The data has previously been used to substantiate the diagnosis of an unlikely hereditary metabolic disease, porphyria. A scientific perspective, aimed at removing psychiatric diagnosis from dependence on subjective evaluations, is corrected by the diagnosis of a mood disorder. His unipolar mania of late onset is a syndrome, the sine qua non of bipolar disorder, in this instance complicated by the toxicity of quinine, antimony, and purgatives.

The little imitator--porphyria: a neuropsychiatric disorder

Three common subtypes of porphyria give rise to neuropsychiatric disorders; acute intermittent porphyria, variegate porphyria, and coproporphyria. The second two also give rise to cutaneous symptoms. Neurological or psychiatric symptoms occur in most acute attacks, and may mimic many other disorders. The diagnosis may be missed because it is not even considered or because of technical problems, such as sample collection and storage, and interpretation of results. A negative screening test does not exclude the diagnosis. Porphyria may be overrepresented in psychiatric populations, but the lack of control groups makes this uncertain. The management of patients with porphyria and psychiatric symptoms causes considerable problems. Three cases are described to illustrate some of these issues. Advances in molecular biology permit identification of patients and latent carriers in the family. Care to avoid relapses and improved treatments have reduced the mortality.

For the want of an heir: the obstetrical history of Queen Anne

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Irregular gout: humoral fantasy or saturnine malady

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Acute porphyria amongst psychiatric patients

A total of 519 consecutive patients, admitted to psychiatric wards of two different hospitals, were screened for evidence of increased excretion of porphobilinogen in the urine by original Watson Schwartz test and modified Watson Schwartz test supported with quantitative estimation of porphobilinogen by Remington's method in search of cases of acute porphyria amongst psychiatric patients. An additional 273 normal healthy volunteers were also screened as controls. Two cases (0.38%) were found which could be unequivocally diagnosed to be suffering from acute intermittent porphyria amongst psychiatric patients. These cases belonged to the category of missed diagnosis being labelled as hysterical. Seven more cases were positive by modified Watson Schwartz test but the test was only transiently positive and the Ehrlichaldehyde reactor substance was unstable. In the absence of detailed enzymatic and family studies, these cases have been kept under the category of suspected prophyria. A significant number of psychiatric patients (12.9%) gave positive original Watson-Schwartz test but were negative for modified test. Similar reaction was seen in 2.6% of healthy controls. The significance of this finding needs to be evaluated.

The climacteric disease

Evidence is provided to show that the account of "The Climacteric Disease" given in 1813 by Sir Henry Halford, Physician to King George III, was his interpretation that the King's illness was due to aging as a disease. This laid foundations upon which are placed the unfavorable attitudes toward Geriatric Medicine today, and which may effect the provision of medical care for the elderly and aged tomorrow.

Medical numismatic notes, XVIII: portraits of physicians on british trade tokens

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Porphyria in the royal houses of Stuart, Hanover, and Prussia. A follow-up study of George 3d's illness

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English token coins and medicine

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