BJPsych Kaleidoscope November 2018

Command hallucinations, the phenomenon whereby inner voices instruct individuals to undertake acts, often harmful ones, are inevitably of concern in mental health. A useful point to remind ourselves that in such instances most people don’t act upon them (would you accept my instruction to hit someone?), and further, where harm does occur, it is most commonly to the individual suffering this, not to others. Nevertheless, clearly an issue: a quick rule of thumb is that they occur in about half suffering with psychosis, and in about half those instances the commands are of a dangerous nature. October’s Kaleidoscope reports on the COMMAND trial that explored the aspects of a specific talking therapy that showed benefit in reducing these distressing phenomena. ‘Voice omnipotence’ – how powerful the voice seemed to the hearer – was the main predictor of causing subsequent harm, something the therapy aims to overcome by challenging the perceived powerfulness of the voice. The paper discusses practical steps for us in our assessments including enquiring about his when looking after such individuals.

Doctors – people like us – don’t always follow prescribing guidelines and evidence, and such practice seems quite hard to shift. How to improve this? Kaleidoscope reports on two quite different trials with diverse patient populations, but the same core issue of prescribing against the evidence. One looked at the use of the antipsychotic quetiapine in older adults and individuals with intellectual disabilities; the other at opioid prescribing in the US (where it’s clearly an enormous problem). What they had in common was that one intervention clearly changed behaviour: peer-comparison. Despite what the Daily Mail might report, doctors remain human beings very much like the rest of the planet, and what our peers think and do matters to us all. I think there are lessons for all of us about our own clinical behaviours, whatever our professional specialty or practice. I certainly wouldn’t like you to think I’m just medic-bashing - I don’t want that negative peer pressure on me.

Finally, cynicism really bugs me; it’s a simple attitude to adopt, and it helps nothing. Nevertheless, it’s common, and there is the construct of what’s known as the ‘cynical genius illusion’; what that means is that we’re prone to think cynical individuals are smarter than the average bear. Picture that person in the team who is down on everything, just “sayin’ it like it is” – yeah, you know who I mean. Quite fancy themselves, don’t they? Mr or Ms Know-Everything, Seen-This-Before… Well, are cynical people smarter? Kaleidoscope reports on an evaluation from the world of cynicism studies (imagine asking a question at one of their conferences). Overall, looking at data covering several hundred thousand people, most of us agree that cynics and negative people probably know what they are talking about. However, when cognitive data was obtained from cynics, they typically do worse than average. Turning this around, competent adults tend only to be cynical in a specific situation where it’s warranted; being cynical across the board appears to be a coping strategy adopted by those who are less-gifted to avoid being duped. Keep it in mind when you’re being positive and *that* person is sneering and trying to bring you down – just smile back knowingly at them…

Dr Derek Tracy

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