Monthly Archives: February 2014

54. Looking at parallax, from a slightly different angle.

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Electric horses – the next big thing in personal transportation.

A man talks to a phone-in show on Piccadilly Radio. He says the TV aerials in the next street are of an unusual type and point a different way, not towards the transmitter. Finally he mutters the word, ‘aliens’. The radio host asks him whether he has checked for seed pods under the stairs. The joke is a bit lost on those unfamiliar with ‘Invasion of the Bodysnatchers’. The host finally grows inpatient and cuts off the most interesting guest of the day, before I can get an impression of whether he is psychotic or not.

One of the intriguing questions in public health is how many psychotic people there are hidden away who have no contact with the NHS. Surveys suggest that 1% of people have schizophrenia, which is a much higher number than we see in clinics. Have these surveys over-included a lot of people who, on the face of it, seem deluded, but on closer examination, simply share widely held beliefs about conspiracy?

On a long plane flight this week I read a book by Andy Thomas, called ‘Conspiracies – the facts, the theories, the evidence’. One of many questions that occurred to me, was why had this book suddenly been reduced in price from £6.99 to 99p? It’s hard to believe that Amazon doesn’t form part of the New World Order, the secret power said to be behind many attempts to deceive us. Maybe this book is in itself a diversionary tactic, or a tiny wink of knowingness that Big Brother gives us from time to time.

A surprisingly large number of people believe that Princess Diana was murdered or that the twin towers were brought down by some faction within the USA. In fact a surprising number of people believe both that Diana was murdered and that she is still alive. Chalk that one up to cognitive dissonance theory.

If some or all of these theories turn out to be true, it would definitely change a person’s view of the world, from that of a relatively safe place to a dark, dangerous and threatening one.

The fact that there are so many people who believe in conspiracy, and that certain conspiracies, such as Watergate, turned out to be true, raises a lot of interesting questions for clinicians.

As psychiatrists, we are taught not to get delusions mixed up with religion, politics or superstition. To be called delusional, a belief has to show a clean break in its logical development. Conspiracy theorists work with an alternative chain of logic, rather than a deluded person’s new canvas of meaning. Though many people who are psychotic suffer from persecutory type ideas, it is very rare to confuse a psychotic person with a ‘truth seeker’, as conspiracy theorists are now known, despite some very bizarre truth seeking theories, such as thinking the royal family are lizards.

There is probably very little point in trying to work out why people develop strong beliefs. The answer is ‘all sorts of reasons’. As far as delusional beliefs go, the best answer we have come up with is ‘because of a disease process’. Although delusions are held strongly, most non-delusional belief is held lightly and easily changed in the face of further inquiry. For instance, it is reported that when faced with medical need, many catholics will opt for a termination of pregnancy and that many Jehovah’s witnesses will change their minds in favour of blood transfusion. Most opinion surveys test only the topsoil of belief, and are designed to do so, by whatever vested interest is controlling the survey.

Psychiatrists are not in a hurry to identify beliefs as delusional, and despite what is said about the old Soviet Union etc, it has not been necessary for oppressive regimes to use tame psychiatrists to label dissidents as psychotic. Oppressive regimes are able to lock people up or have them disappear without pretending they are ill.

While psychiatrists don’t seem to be playing much part in locking up dissidents, they may be complicit in some more sophisticated subversions. In particular, psychiatrists play a major role in the drugs pipeline, the one that runs from a chemical works in Hull to your meso-limbic system and mine.

For instance, a steady stream of people come to outpatient clinics ‘wanting the diagnosis’ of bipolar disorder. (See Post 28). The exponential growth in the Bipolar Industry has been well described by David Healy, in his book, Mania: A Short History of Bipolar Disorder. Tellingly, this book has not been reduced by Amazon, so it probably contains some sinister truths we are not supposed to hear.

The key parts of this conspiracy are as follows: No useful new drugs have been developed in mental health for 20 years. Instead, the pharmaceutical industry has chosen to expand the market for drugs already on the market. Hence we saw a complete re-branding of ‘manic depressive disorder’ into ‘bipolar disorder’, massively expanding the diagnostic concept by including so called ‘bipolar II’ and ‘bipolar spectrum disorder’.

The outcome was a massive increase in the numbers of people with miscellaneous temperamental problems being given so called ‘mood stabilisers’, either atypical anti-psychotics or anticonvulsants, both being items from Boots’ ‘fat and sleepy’ aisle.

It took a lot of time and money to do this, and large numbers of psychiatrists collaborated in the process. There is a strange relationship between certain academics and clinicians and the drug companies and by strange relationship I mean free lunch – in Belgium.

In fuddy-duddy Britain, there is now endless conflict between psychiatrists and wannabe bipolar patients, but the signs are that the psychiatrists are surrendering. The customer is always right, especially if he is persistent, sharp-elbowed and well-googled.

We saw the same pattern in children’s mental health services. Once upon a time it was extremely rare to be diagnosed with Hyperactivity in the UK. A child had to be hyperactive all the time, not just between 4pm and KFC time. Even then, the use of psycho-stimulants like Ritalin was rare, and couched in cautionary warnings, like ‘use only as part of a carefully controlled therapy package, including social and family interventions’. Today’s community paediatricians basically fly crop dusting planes over the countryside, spraying Ritalin wherever they see a school.

Does someone have an agenda that includes more and more people taking mind altering drugs? It’s hard to imagine that a proper dictator would like to see cohorts of drunk women staggering round York on Friday nights, or lines of people queuing up for methadone outside Boots every morning. But then its hard to work out why the existing drug laws are not enforced, or why more and more heroin came out of Afghanistan despite the war in that country, or why our ward has a filing cabinet full of confiscated ‘legal highs’. Is it feasible that legal highs cannot be controlled by legislation, when there is legislation that makes Tesco throw away half its food, and legislation that stops me from connecting a gas fire?

Would a genuinely repressive regime be happy for millions of its citizens to take antidepressants, in some misguided hope that they would become more docile or cheerful in times of adversity? Marx is quoted as saying religion is the opiate of the masses, but perhaps the word he actually used was Ritalin.

The culture of propaganda has a lot to do with the rise of conspiracy theory. In the public sector we are routinely spun false statistics and like to pretend we are providing an excellent service. In mental health Trusts we want to pretend we are offering psychotherapy, when really we are offering only a nice chat, checklists and tablets. Its a kind of cover up, but we’re not in Jason Bourne territory. It’s obviously a lot cheaper to fiddle the statistics than to provide real therapists or policemen.

My colleagues are probably sitting tight, waiting for the Bipolar II epidemic to subside. Just like the Ritalin kids, the new wave ‘bipolar twos’ will soon be be stuffing their tablets behind the radiator. At the moment some people view a diagnosis of bipolar disorder as a get-out-jail-free card, in case of a minor indiscretion. These will get devalued if more people use them, instead of throwing doubles or paying £50 . Even now, fewer celebrities are coming forward purporting to have Bipolar II, and they are probably going back to having narcissism instead.

The conspiracy between Big Pharma and eminent psychiatrists will find a new condition supposedly amenable to antipsychotic drugs, such as food intolerance, or somatic symptom disorder. Then the experts and drug reps will be back in their Audis again at another round of conferences.

Sadly, most conspiracies don’t involve lizards or the CIA. Nor even do they involve a secret Mister Big, played by Morgan Freeman . They are just about drumming up trade. How boring is that? The new world order is just business as usual.

53. Eating brunch, with keen social observers.

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A five factor system based on skin conductance, showing that shy and bashful are not the same

Fed up with being an armchair sociologist, at the weekend I did some field work in Camden, in search of Hipsters. Accompanied by expert guides, we went to a comedy club, the Norfolk pub and Food Lab for brunch. From time to time I asked my guides if there were any Hipsters around, and they would discreetly point them out. It’s a lot better than birdwatching or trainspotting, because Hipsters are found in warm places with excellent coffee, rather than flooded wetlands, or Stevenage Station.

In Islington, at brunch time, most restaurants are full and we are turned away a few times. In Food Lab, to get us in, a bloke with a Macbook who has probably been there for hours, has to be moved on. My guide points out a girl near the window in a brown hat, with a boyfriend who looks like Brad Pitt. The girl is a Hipster, but not the boyfriend, I am assured. I remain puzzled.

It’s always been difficult for psychiatrists to categorise types of people. We mainly look for familiar patterns – people who look and behave like patients we have seen before. In Camden though, that’s practically everyone.

For decades, psychologists attempted to measure personality, using various scales and measuring techniques. The most surprisingly successful of these is the so called Myers Brigg Type Inventory, which is widely used by business types, and hardly at all in clinical work. Myers Briggs was not trained in psychology and it shows.

To be fair, psychology is a young science, and plenty of people dabbled in it who’d struggle to flip a burger through 180 degrees. The Myers Brigg system is based on the work of Jung, who was also not trained in psychology (and it shows), and divides people into 16 different types. You will get a four letter code, like ISTJ, at the end of it, which is about as useful as knowing you’re a Gemini. Try telling your hairdresser you’re an ISTJ for instance.

The Myers Brigg inventory struggles when it comes to validity and reliability, just like horoscopes.  And four digit codes are so difficult to remember. I get mine confused with MDMA, which is ecstasy, and NMDA, which is a nerve cell, not to mention CSNY, which is Crosby Stills, Nash and Young.

Briggs Myers’ only work of fiction, the novel Murder Yet to Come, published in 1929, won the National Detective Murder Mystery Contest for that year. It applies her ideas about personality type into a murder mystery and sounds like she foresaw Minority Report.

In parallel with Myers Brigg, we had the ‘16PF’, which also attempted to divide people into 16, and the MMPI, which had no particular core theory of personality, except to establish how similarly you answered questions to a group of 1940s  american psychiatric patients.

By the time MMPI -2 came out, in the eighties, all this statistical pomposity had been swept aside, by the Mister Men books. This established a series of simple, face-valid types, each with good graphics and the behavioural phenotype explained in a brief, amusing narrative. There are at least 49 Mister Men books, with a further 42 in the Little Miss series, giving at least 90 categories.

Unlike the four-capital-letter systems, the Mister Men series could easily replace the ICD-10 diagnostic system. Instead of which the NHS has gone for a clustering system with 21 categories. Don’t they realise that dice only have 6 sides? There are certain numbers that are used for systems like this, we know this from Ancient Babylon. Useful numbers must divide into 60. Just look at Time and Money.

If 90, or even 16, is too many categories to bother with, how about using just 3? Shortly before he died in 1997, Hans Eysenck gave a talk in Sheffield and our clinical tutor hired a coach for colleagues and trainees to go and see him. On the night of his talk there was dense freezing fog and only two of us turned up. We went anyway, arriving very late and missing most of his talk. Worse still, we were welcomed enthusiastically to the front of the hall by the chairman, like being picked on at a comedy gig, and the talk was about support groups for cardiac patients rather than anything controversial, like personality typing.

Eysenck used a two factor system to describe personality, these being Extroversion and Neuroticism. Much later he added a third dimension, called Psychoticism, adding a bit of chimp. Again, popular culture was way ahead of psychology. The beat generation had developed an axis which ran from Cool to Square. This was almost sufficient to describe what a person was like, but it proved necessary to add the dimension of Geekiness, which runs at 90 degrees to Cool-Square, or ‘orthogonally’, as a geek would say.

One of my proudest moments was when I was buying some pipe insulation at Pipeline Center, note the edgy use of US spelling, and the assistant, who was called Clinton, pointed excitedly at my watch and assured me it was the geekiest thing he had ever seen. Scoring Low on Cool, Low on Square even, but high on Geeky. A new dimensional system was born.

Which brings us back to Hipsters, who could almost certainly be defined as people who would never visit Pipeline Centre, unless they were sculptors working with tubes.

Hipsters are mainly cool, but a little bit square in some ways, and quite geeky. The web is full of Venn diagrams explaining all this. It’s been said that Hipsters cannot be categorised, since this would, of itself, make them too mainstream.

If Jung and Myers Brigg had spent more time in Islington and Pipeline Centre, they could have saved themselves a lot of time and trouble. Roger Hargreaves has made them look Silly. Apologies to the guy who was moved on at Food Lab, I’ve just realised you were probably doing field work too, but without guides.

52. Finding yourself and more importantly, your keys.

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A picture with a mental health sort of vibe, suitable for a leaflet, no sensible offer refused.

Two girls walk slowly to school alongside each other, both talking into mobile phones, possibly to each other.

A man in the public library, reading the newspaper, who moves his finger along the lines of print and whispers the words out loud.

An electrician, talking to his assistant, explains what he is doing as he puts in a new fuse box. He deliberately gives himself little electric shocks at times, explaining that this is something you should never do.

A man clutching a can of Special Brew, talking loudly, seemingly to no-one, as he staggers down the high street.

A kid, pretending to be CIA, talks into his sleeve at quiet moments during a history lesson.

I’ve been observing people talking out loud, and – heresy! – I’m just wondering if there shouldn’t be more of it.

Here’s another unpopular view – I always preferred the original release of Blade Runner to the subsequent versions, simply because of the Marlowe style spoken narrative. We’ve had ‘the final cut’, but I hope there will be more versions, for instance, a musical, with tap-dancing robots.

All this stems from the realisation that we are all several people in one. The idea that we are ‘an individual’ is handy for practical purposes, such as issuing passports and driving licences, but manifestly an oversimplification. Discarding for a moment oddities like multiple personality disorder, we spend a lot of our time in different modes of operation.

Dreaming, day-dreaming, fantasising, imagining for instance. Set on autopilot as we drive to work, often not remembering all the mini roundabouts and small mammals we drove over. Or reverting to chimp mode when there is a perceived threat.

In people who suffer from psychosis, this potential for multi mode operation has been called ‘double bookkeeping’. The ancient example is a patient who is deluded that he is the King, but is content to mop the hospital floor as a day job. Real life examples are frequent enough. One of my customers thinks he is the most senior officer in the British Army, but he is happy to work in the snack bar on a voluntary basis.

There is no need to be psychotic to indulge in double bookkeeping. The phrase ‘creative accountancy’ goes back a long way. Look, for instance, at the target culture of the modern regulated public sector, where information is routinely falsified. I even had trouble typing that word, falsified. I wanted to type ‘spun’ or ‘distorted’ or ‘laundered’, such is our reluctance to attribute malicious motivation. To call someone a liar is a serious insult and perjury can carry a jail sentence. Are all these managers and civil servants who cook the books consciously aware that they are lying, or are they using a series of mental mechanisms to justify themselves?

My hypothesis here is that it is easier to lie in a diagram or a document than it is to lie out loud. Speaking out loud seems to engage bits of mental functioning that are more careful and scrutinising. If you lose your keys, if you speak out loud the word ‘keys’, you are more likely to find them. Hearing yourself out loud seems to kick the awareness level one layer higher.

Apparently negotiations go better if you speak in the first person and include some ‘feeling’ words. If you happen to citizen’s arrest a former prime minister, be sure to mention you are disappointed with some of his bombing decisions and surprised that he thinks he can walk freely around Shoreditch, amidst Hipsters.

If you appear in court, and you hear yourself swear to tell the truth, the whole truth and nothing but the truth, you probably will. Talking to yourself is the new talking to someone else.

And that brings us to new technologies, like Siri and Google Now. If you hear yourself say, ‘is there a good japanese noodle bar round here?’ you will immediately realise that you are being silly. You don’t like noodles and you’re in Rotherham. You don’t need the latest phone, or any phone at all, you just speak into your sleeve.

That’s got implications for psychotherapy, and for the church, which has never successfully marketed its Confession product. If the magic ingredient is simply speaking out loud then you don’t really need the therapist or priest. You could dial 111 and explain your problems over the phone – just unplug it first.