47. Predicting the New Year, without proper guidelines.


Psychiatrists are able to read the future. That’s why there are very few about – most have made a killing on the stock market or at the bookies and have retired to Tahiti. Or so our managers think.

Just to prove the point, here are some predictions for the New Year:

1. Badgers will launch a surprise counter attack on David Cameron. They are already digging a tunnel towards Downing Street. Badgers are classic terrorists, with long memories and sharp teeth. In panic retribution measures, Brian May will be blamed and sent to the Tower of London.

2. People will begin to notice that google searches are getting more polluted by advertising. Google will offer a premium service where you pay a subscription for an ad free version.

3. Universities will begin a series of mergers and takeovers, so that eventually there are only four big players, as with supermarkets, petrol, energy etc. University Challenge will start at the semi finals.

4. There will be an upsurge in Placebo based treatments of all kinds, and NICE will issue lengthy guidelines on how to choose and use them, with a forward by Prince Charles.

5. Private GP practices will develop in the larger cities. They will give you the sleeping tablets, painkillers and Betnovate cream that you have longed to obtain, without any tut-tutting.

6. Building regulations will be tightened up, so that new buildings will have wider letterboxes, to accommodate take-away pizza.

7. Swiss cheese makers will be stopped from injecting carbon dioxide into the holes to make it weigh heavier on the scales. Conversely, Ryanair will check for Helium in your hand luggage.

8. The forces of social control – police, probation, mental health and social work – will increasingly blur together. The new force will be re-branded as Lifestyle Services. The uniform will look suspiciously like G4S.

9. Further updates in nomenclature. G4S to G5S, E45 cream to E46. Boots 7 goes to 7.1. Players No. 6 are re-launched as Players Number Free. They pre-empt the packaging ban by going for a plain white carton. It worked for the Beatles after all.

WD40 surprises everyone by going straight to WD million.

10. Liverpool FC will embrace Mindfulness. Their new kit will be orange robes.

If you want a more accurate prediction, and you don’t know any psychiatrists, you can do equally well or better yourself, using a set of dice or random number tables. Please note, NICE do not recommend the use of tea leaves, bones, fund managers or even physicists. Prediction is very difficult, said Niels Bohr, especially about the future.

From Tahiti, I wish you a Happy New Year.


46. Christmas Quiz

Image I

For each question choose which one answer is correct:

1. The Mind and Body are:

a)      Inseparable

b)      Made of different kinds of slime

c)      Connected by USB

2. The Human Mind uses an Operating System which :

a)      Usually responds to turning off and on again

b)      Was initially rejected by Steve Jobs

c)      Is essentially adapted from the Chimpanzee

3. Who will not come to your rescue?

a)      DIY SOS

b)      The A Team

c)      David Miliband


4. Where did the sickman go, after disappearing from medical cosmology?

a)      Costa Coffee

b)      Became conceptualised as a cell complex

c)      Outside, having a fag

5. Suitable scenarios for a Truth And Reconciliation Commission include:

a)      Desmond Tutu’s kitchen

b)      Nigella Lawson’s kitchen

c)      Pussy Riot’s charity gig at the KremlinPussy-Riot

6. Examples of Word Inflation include:

a)      Management Speak

b)      Cognitive Therapy

c)      Dan Brown Omnibus Edition


7. The following has proven antidepressant effects:

a)      Aerobics

b)      Chairobics

c)      Blairobics

8. What has happened to Ashleigh and Pudsy?

a)      They are hiding from animal rights activists

b)      Creative differences between them led to a bitter legal dispute

c)      Panto season

9. Which of these problems is not a cosmetics range?

a)      Opium

b)      Obsession

c)      Paedophile

9. Which of these bands is an effective antidepressant?

a)      Primal Scream

b)      Placebo

c)      AC/DC

11.  Who should you send for if one of your brainwashed assassins goes berserk?

a)      Patrick Stewart as Eddie Roebuck

b)      Patrick Stewart as Dr Jonas

c)      Patrick Stewart as Macbeth

12.  Who bore the brunt of the Michael Jackson inquiry?

a)      Bubbles, for not seeming to care

b)      Paul McCartney, for insisting the girl was his

c)      Conrad Murray, for ticking the wrong boxes on his risk assessment forms

Merry Christmas dear reader!

45. Hosing out the caves of plenty.


Celebrating the end of the cull.

Consider this: Celine Dion has sold over 200 million albums worldwide. Kodak sold over 70 million Instamatic cameras.  And more than 5 million ZX Sinclair computers were produced. Where have they all gone? The answer is: the house on Gladstone Street, the one with the twenty-foot-high overgrown garden and council notices pinned to the door.

There’s a new diagnosis in town and its name is Hoarding Disorder. Everyone’s talking about it, but no-one is doing much about it yet. That may be because there is no recommended drug therapy, and it’s even a bit dubious whether behaviour therapy will help, unless the sufferer wants to change.

I know, the word sufferer is politically incorrect, I’ve been on the disability and diversity courses. And in this case it is literally incorrect, as the people who suffer are neighbours, relatives and carers, rather than the hoarders themselves.

In DSM5, Hoarding Disorder escaped from the OCD section and was given its own little category. It’s significantly different from OCD, so, like South Sudan, though considerably more cluttered than that country, it has gone its own way.

There are a few other categories associated with squalor, including the so-called Diogenes Syndrome. And there are some similar scenarios which are not considered mental health problems, such as Collecting and Teenage Room Disorder.

Most psychiatrists will have visited homes like the one on Gladstone Street, and sat in sticky chairs, next to overflowing ash trays the size of buckets. We get pressurised by housing departments and public health officers to assess the people who live in these conditions.

In Diogenes Syndrome, which apparently is unfairly named, as Diogenes was a minimalist and lived in a barrel, the affected person simply gives up on the fight to organise, recycle and dispose of stuff, so that a rising tide of garbage fills their house, and finally flows out of the doors and windows, past the complicated row of empty recycling bins.

We could regard these problems as brain based, as in frontal lobe dementia, or part of some other problem, such as Depression, disorganised-type schizophrenia, or Compulsive. We could take a view that such habits are eccentric, or even just lazy. I prefer to look at environmental causes. Hoarders are basically overwhelmed by modern life. It’s not so much the quality of the environment as the quantity. They are victims of what should be called ‘Stuff Inflation’.

Whereas economic inflation leads to money losing its value, stuff inflation leads to manufactured items getting cheaper per cubic inch. Combining this effect with reduced living space – British homes are small on average – gives an ever increasing stuff to bloke ratio. There’s even a magazine called Stuff. And there’s a shop called Poundland, from which Stuff flows, like water from a fountain.

If the alcohol industry creates more product than people can consume, some of it will accumulate excessively in certain individuals. If the availability of alcohol is adjusted up or down, a lesser or greater number of people will consume it to excess.

Similarly, if the world’s factories create more stuff than can be recycled or land-filled, a pooling effect will occur.

Quite how these ‘trickle down’ effects affect particular individuals is the big question for clinicians. Like Magpies, humans have an innate urge to acquire items, and there is a whole industry directed toward persuasion. Why Magpies like shiny metal trinkets is a bit of a mystery. I have never seen a Magpie wearing jewellery, or queuing up in Cash Converters, or playing a slot machine.

I suspect that, like many mental health problems, Hoarding Disorder will turn out to lie on one end of a spectrum rather than behave as a discrete disease entity. I’d be surprised to find anyone who didn’t show some signs of hoarding, if we looked in their loft, car boot or Celine Dion collection.

People hate to lose things they already have, and retain an evolutionarily useful tendency to stock up in case of a bad winter or poor harvest. People need some token or another to explain why they have been at work all day.

Faced with a tsunami of disposabilia, some people just give up trying to cope with it. Hoarding may be just one of many ways people give up on dealing with modern life.. There are so many waiting for DIY SOS, or International Rescue, or the A Team to come, but sadly, there is no De-cluttering service in Yellow Pages. The time cost of sorting through piles of possessions far outweighs the value of any items unearthed, so it even costs money to have everything taken away.

The solution probably lies at political level, with more powerful Stuff Police and a new Ministry of Trinkets. A landfill windfall tax for Poundland would be a good start. NICE could come out officially in support of Minimalism. More of the plinths in Trafalgar Square could be kept empty. I think the NHS has already adopted the slogan Less is More. David Cameron could issue an official apology to Diogenes.

On a personal level I think we should recognise that we can all go down this road if we are not careful, so some attention to Stuff Hygiene is needed.

In previous EPs we destroyed any vinyl records or cassette tapes we had left. We invited the British Heart Foundation into our homes, as bailiffs of charity.

Beyond this, the solution may lie in The Cloud. Somewhere in the world there are some very untidy banks of computers, but, importantly, they are not in Gladstone Street.

44. Saying goodbye to Virginia, more sensitively.


Marshmallow invasion: The first wave.

You might find this hard to believe, but it’s quite a while since I’ve been punched in the nose. Especially considering the number of times I have ‘misjudged the rapport’ with our service users. However, I just discovered a product called ‘First Defence’, which creates a very similar sensation, but without the violence. First Defence sounds like the name of an outsourcing company for mercenaries, or possibly the military wing of the bus company, but rather, is a product made by Procter and Gamble, to prevent the early symptoms of a cold turning into a screaming, streaming viral attack. It’s a kind of Early Intervention Service, in a little spray.
Many of the Early Intervention services for mental health problems have been scaled down or discontinued. However, there has been a refocussing of efforts to stop our patients going on to develop lifestyle-related problems such as obesity, diabetes and vascular disease. NICE intend to step up the anti-smoking component of our role.
For every new consultation, our first questions will be about smoking, exercise, diet and alcohol use. For our inpatients, nurses will not be allowed to facilitate or supervise them going for a smoke. Furthermore our nurses will not be allowed themselves to smoke, wearing any kind of uniform or NHS regalia, not even a Charter Mark badge from 1994, nor one of those badge / lanyard accoutrements that staff-not-at-risk-of-being-strangled wear round the neck.
Please note the new CCTV cameras behind the bike sheds.
You can see now why I started with the punch in the nose issue. Before the patient has a chance to tell us anything, we will have:
Recorded the names and ages of their children and where they go to school.
Made them sign a confidentiality agreement stating that we will shop them to the police or social services if they come out with anything too alarming.
Calculated their Body Mass Index, including commenting whether they are shaped like an apple or a pear. I could perhaps disguise that bit as a personality test – if you were a kind of fruit, what fruit would you be?
Guaranteed to break the ice, I think you’ll agree. We’ll hear about your problems shortly, as soon as we’ve got through my agenda.
Whether we can make a difference to patients’ lifestyle is rather dubious. A sceptic might point out that it is really difficult to treat obesity or cigarette smoking in people who are feeling fine, let alone those who are going through difficult times. Even well directed smoking cessation programs struggle to achieve a lasting effect beyond the first 6 months. By 12 months most people with major mental health problems are back on the weed. Yet, in anticipation of the NICE guidelines, the effectiveness of such programs is being ludicrously oversold, often by the same people who dispute the efficacy of medication for mental health problems.
Psychiatrists will not be allowed to stay out of the lifestyle war. Unfortunately, we have unwittingly caused part of the problem by promoting tablets that cause weight gain, and letting people smoke in our hospitals, to help them calm down. Most people with psychotic conditions like to smoke – upwards of 70%. In surveys they say they enjoy the experience.
The orthodox view is that cigarettes do not help people concentrate or relax. They merely reduce the effects of nicotine withdrawal the smoker is already suffering. We have tended to view smoking as a relatively minor problem relative to mental illness. Now we are being asked to make it more of a concern. This is all OK, except for the damage it might do to people’s relationships with their doctors and nurses.
Coming across as positive is one thing, adopting the tone of a sports coach is another.
Very few psychiatrists wanted to be PE teachers when they were little. It’s just a hunch. Many of my colleagues – let’s put it nicely – wouldn’t make it as underwear models. Are we in a good position to set the lifestyle agenda? ‘Mindful walking’, to us, is being careful not to trip over those yellow signs that cleaners leave on stairways. Some of us even remember what the inside of a golden virginia packet looks like.
We know from long experience that telling people what to do is a bad idea. We know from many surveys that people like us to listen to them. We know that genuineness and empathy are key therapeutic ingredients. Yet only this week a social worker, who had just detained one of our patients under the mental health act, told me she thought what would really help the gentleman concerned was a back-packing trip across Scotland, rather than tablets.
Luckily, there is no section of the act that mandates back-packing or cross-country running. Yet.

43. Deciding whether to decide, or not.


Some KFCs are quite opulent on the inside.

I’m hoping to acquire one of those official looking G4S-style jackets that parking inspectors wear, along with a peaked cap and mirror shades. The reason is, I live next to a school, and every morning the parking situation gets worse. The invention of the SUV has blurred the harsh boundaries of road, pavements and yellow lines and turned them into a mere probability distribution. There’s an Audi Q7 that behaves like a two tonne hippo, just setting itself down wherever it pleases. If I just stood outside, in my Parking jacket, maybe the madness would stop. Until I got arrested, anyway.

Parking properly is one of those skills, like cooking Yorkshire Pudding or wiring a plug, that 57% of people can’t do. Recently two surveys showed that modern school-leavers are no more literate than their grandparents were at the same age, and that they would lose a 100 metres race to their grandad. And that’s as he is now, aged 95, with advanced emphysema.

Surprisingly then, Britain, the country at the bottom of the skills league table, where only recent immigrants actually know how to do anything, introduced the Mental Capacity Act.

Luckily, like the parking outside the school, it is not enforced.

So called ‘mental capacity’ means that a person is able to make a decision. It depends to a large extent on how complicated the decision is as to whether the capacity is present or not. For instance a person could have mental capacity to choose breakfast, but not have capacity to make a will. In between these, somewhere, is capacity to have sex or get married, or both. If a person does not have capacity, they should first of all be suffering from a deficit of ‘mind or brain’. Then they must fail one or more of the following steps of decision making: Understanding the information, Retaining the information, Weighing the information up, and Communicating the decision.

Immediately obvious is the amount of greyness in the ‘weighing up’ part.

While the Mental Capacity Act makes it clear that making an unwise decision need not mean that the weighing up process is defective, it certainly leaves scope for an argument over the point where an unwise decision becomes irrational, and the point where irrational means lacking capacity.

Perhaps the intention of the mental capacity act was to give the illusion of clarity, while still leaving a huge judgement call to doctors or other professionals. The irony is that no professional person really understands the mental capacity act and certainly doesn’t retain it in his mind or communicate it well. The mental capacity act code of practice was written on the planet Zarg, in Zarg language, which is similar to Welsh.

So, only case law will reveal the dividing lines between unwise and irrational.  A series of judgements will set the goalposts for issues like leaving all your money to the scientologists, marrying your attractive but 70 years younger carer, buying a Porsche 911 to celebrate your 100th birthday etc.

For instance, last year, a judge ruled that an autistic woman with an IQ of 64 did not have mental capacity to have sex,

‘on the grounds she does not fully understand she could say no to such actions’.

Mr Justice Hedley said the 29-year-old lacked the mental capacity to consent to having sex, and made the order to protect her best interests.

He said she had to be protected from ‘potentially exploitative and damaging’ relations in the future, as she had already been involved in risky behaviour with people.


Would scientists or doctors have come to the same decision as the judge? I suspect that scientists would tolerate fuzziness better than lawyers, simply accepting that the person had some mental capacity but not as much as most other people. But the legal system is black and white, not grey.

Whether a person can choose to have sex or not soon becomes a question about how the mind and body work together. And this in turn leads to an examination of how the Automatic part of the Mind interacts with the Reflective Part. It would be nice to think that sexual behaviour falls to the Reflective Mind, but its association with the older parts of the brain and the older types of intoxicant means that it probably doesn’t. Whatever the IQ.

So rather than being a Parking Officer, perhaps I could be a Mental Capacity Inspector. Outside the school, armed with my new jacket, the Mental Capacity Act Code and the Oxford Dictionary of Zarg, it’s time to Stand up for Sensible.

Firstly, do these errantly parking motorists suffer from a disorder of mind or brain? Most of them look absent minded and some are clearly in a trance like state. Some seem distressed, shouting at their children. At least two are using nicotine. One appears to be wearing a dressing gown and slippers. In fact, none of them seems entirely well.

Then, have they really decided where they want to park? Do they know what yellow lines mean? Can they weigh up the ethical trade off between blocking the traffic and parking on the pavement? Would they know that squashing cyclists can hurt them?

Enforcing Parking Capacity is just the start. Irrational behaviour is going on all over town, much of it in the context of mind / brain dysfunction, such as Special Brew Disorder.

Firstly, the National Lottery till at the newsagent. Anyone who doesn’t understand Probability – a GCSE in Pure Maths with Statistics will suffice – should be politely turned away in their own best interests.

Then Ladbrokes. Look at these other customers – do they look like rich people?

The tattoo shop – this sounds silly, but do you know that won’t wash off? And KFC. It’s chicken Jim, but not as we know it.

The mental capacity act can only do so much, since it respects unwise decisions, or any decision made by someone of sound mind. That’s why we still need the Style Police and the Fashion Police. It’s vital these functions don’t go to G4S, even if they have the jackets already.