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.

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28. Removing labels, without toxic chemical solutions.

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Cows are basically hippies.

Who are those people hiding behind the boiler house, just outside the strict boundary of the Foundation Trust premises? Are they common or garden smokers? Are they A and E attenders, who have finished all the books they brought to read while they wait? Or are they escaped but tagged dementia patients?

If you go near them they shy away, like geese, toward a small clutch of untidily parked Fiats and Volvos. Finally, I realise who they are – they are my colleagues who work in community psychiatry.

They are hiding for a good reason though. People are pursuing them, ‘wanting a diagnosis’. And those people are angry.

The history of mental health tends to characterise psychiatrists as predatory. The accepted wisdom is that psychiatrists are part of the forces of social control. Their traditional prey, according to folklore, is a harmless eccentric or political dissident. Their modus operandi is to label these folk with an invented illness concept in order to render them powerless in the eyes of society and the law, so as to drug them or lock them up or both. Such is the myth of ‘anti-psychiatry’.

People used to fear the psychiatrist like a 70s DJ fears the child protection team. But now the tables are turned. Some people are desperate to get labelled as mentally ill. None of my colleagues know why, but they mutter about the internet, celebrities and the drug companies, not to mention the benefits system.

The world seems to have turned upside down, like Twelfth Night. Not as regards boys playing women on stage whose characters are pretending to be men. Rather, more in terms of poacher turning game-keeper.

The story usually starts this way. A short GP letter ending with the words ‘this man thinks he has bipolar disorder, please do the needful’. A patient with a large bundle of papers downloaded from the net. Stating that the description of bipolar disorder fits him perfectly right down to the last semi colon.

The psychiatrist tries to explain that diagnoses are merely conventions about what to call things, that in the UK at least people are rather conservative about the use of diagnostic labels, that labels in their own right can become dangerous and lead to people thinking of themselves in an unhelpful way, even getting stuck in a sick role and benefits trap.

That he doesn’t really seem to have bipolar disorder, at least according to the absurdly narrow conventional diagnostic system that bow tie wearing people in Geneva have written on our behalf in quill pen on parchment.

Finally the meeting ends under a cloud, unless the psychiatrist gives in and recommends a tablet with Q or Z in its name.

It’s tempting to blame our cousins in the US and /or big pharma. There is money to be made from atypical antipsychotics, but only if a group of people can be convinced they need to take them. I have not tried this (Your Honour), but I’m pretty sure atypical antipsychotics and mood stabilisers have practically no street value.

Last time I went to the US I saw some hilarious direct to public advertising for these substances, where the baritone disclaimer tag – ‘may cause impotence, heart failure, convulsions coma and sudden death, take with caution’ – was longer than the advert itself.

I’m not sure why labels are fashionable now. Labelling theory was all the rage in the 1970s and we were all taught not to label people and put them in pigeon holes. Perhaps it started with designer clothes, where the Nike swoosh added $20 to the value of a $2 tee shirt. People who took labelling theory too literally even got tattoos. When we make a diagnosis, we always play it down – we say it’s just a name people give to this type of problem area.

My proposal is that we use a barcode instead. This is a cheap shot, but I think  one or two of my colleagues would be happy to advise people where to stick it.

25. Taking a creative powder.

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The golden age of pharmacology.

There is probably a link between bipolar disorder and heightened creativity, but this occurs mainly during the periods of elated mood. One of the first things to go when the mood dips is concentration. For creative types that’s a major hazard.

There’s only one solution for writer’s block. And that’s to write about it.

I just checked with the local NHS and apparently there is no rapid response team for this problem, unlike, say, blocked drains or blocked arteries.

The mental health service is interested in ‘thought block’, but only in the context of schizophrenia.

What I’m envisaging is a group of experts, probably led by a retired army major, who would arrive in a pimped day van, set up their equipment and get to work straight away.

The first thing to do is to remove any loaded weapons and / or bottles of whisky from the writer’s desk.

Next comes a thorough examination of the writer’s body, particularly the orifices, just to check he has not begun ‘disappearing up himself’. If there are signs of this, a Dyson cleaner makes an ideal suction device.

That also includes checking his ego boundaries, to ensure he is still able to separate himself from his characters. Clues to this can include wearing a flying helmet or shoulder holster while he types.

Psychedelic drugs should be removed, keeping samples for the lab, except for science fiction or fantasy writers, when they should be cautiously continued and titrated with Bourbon if necessary.

There are no NICE guidelines for writer’s block, though the author is probably poised over his keyboard and has been for years. But there is some expert guidance on the subject.

Dan Brown for instance likes to hang upside down in gravity boots. This could explain some of his thinking, in terms of reduced cerebral blood flow. Lots of writers prefer to be horizontal when they write, and many others like to pace up and down. Some are quite obsessive about stationary and pens. Others like to chew their pencils. It’s important to ensure they put the right end in their mouths.

Having attended to posture, the team looks toward some kind of psychological jolt. Firing a gun is often helpful, and if there is space, the team like to set up a row of porcelain figurines to use as targets. Royal Doulton seems to work best.

Coercion, blackmail and torture don’t seem to work. This is probably because anxiety levels have gone just beyond the optimum level for concentration. Writer’s block is mainly a result of ‘performance anxiety’. It is when the automatic mind makes the mistake of calling in the reflective mind for advice. Whether it’s writing, sex, walking a tightrope or putting, self monitoring can be catastrophic. The interventions are mainly to create a distraction.

For instance, waving a wad of cash under the nose brings about a rapid reaction similar to smelling salts. Not only does money talk, it speaks most eloquently.

Claims are made for psycho-stimulants and antidepressants which some people think enhance performance. Thomas Hardy might have benefitted from a little light turbo-charging, for instance. I’d like to have seen more of an action thriller conclusion to Mayor of Casterbridge, possibly involving Farfrae and Henchard shooting at each other with blunderbusses, from hot air balloons.

More useful is a gentle workout for the parts of the brain that write. A trip to a gritty location such as a Ladbroke’s in Rotherham might bring just the change of emotional tone that’s needed, but obviously the danger is melancholic overload.

Sometimes a little ‘power pottering’ is necessary, such as re-organising the tea bags or melting a vinyl record to make a flower pot. An encounter with an overloaded kitchen sink has helped many angry young men keep it real.

The most difficult thing is finding an ending, if that’s where the block has happened. If all else fails, a revision test can serve as a makeshift conclusion, e.g

Which blockage is not a medical emergency?

Heart

Arteries

Thought

Writer’s

Intestines

Which endings are valid?

Reprising earlier parts of the piece

Suddenly dying of TB

A dream sequence with exploding figurines

Throwing a badge into San Francisco Bay

Reader, I married him.