Misidentification syndromes are some of the most fascinating psychiatric disorders around.  I would say ‘cool’ but I’m sure that suffering from one can be very dispiriting, and will continue to use this adjective for trainers and indie bands only.  They involve a disturbance in the judgement of uniqueness of certain events.

First up, there’s Capgras Syndrome; also known as I’illusion de sosies (Illusion of doubles).  Here, a person is under the impression that someone close to them has been removed and replaced by an identical looking impostor.  It is named after Joseph Capgras, a French psychiatrist, who described this in a paper published in 1923.

Capgras Syndrome is associated with schizophrenia in more than half the cases. The theory behind it runs like this: when the eye sees a face, the brain processes the information in two parallel streams, which can be damaged independently.  Faces are at once explicitly identified via the temporal cortex and also more rapidly though the amygdala, which is involved with the limbic - emotional processing - system.  We can see an example of this rapid processing if we were to find ourselves running away from something without fully understanding what it is. 

If the temporal cortex path is damaged, the brain will have difficulty in recognising a face.  However, via extra-visual clues, emotional responses to familiar faces are preserved.  Therefore someone with prosopagnosia (inability to recognise faces) will still have an emotional response to the faces of people they know.  If the amygdala path is compromised then the person will still recognise the face, but the expected emotional response will be absent.  This could lead the feeling that a familiar face is ‘not quite right’ and to the erroneous conclusion that his is because of an impostor.

Subtly different is Fregoli Syndrome.  Rather than named after a pioneering psychiatrist, this disorder was named after Leopold Fregoli (1867-1936) who was an Italian actor and the greatest quick change artist of this day.  He was famous for his ability in impersonations and his quickness in exchanging roles, so much so that at times rumours spread that his act was in fact performed by more than one person.  This is also known as the illusion of a negative double, and the suffer believes that various people he or she meets is actually the same person in disguise.  This often has a paranoid flavour, with the sufferer believing that that are pursued by a someone that assumes different identities. 

A sort of combination of Capgras Syndrome and Fregoli syndrome is intermetamorphosis syndrome, first described by P Courbon and J. Tusques (1932); in this, the subject develops the delusional conviction that various people have been transformed physically and psychologically into other people.  This disorder involves false physical resemblance and false recognition. 

Almost there.  Reduplicative paramnesia was described by Pick in 1903 and is often seen in post traumatic brain injuries. With this, there is a belief that a familiar person, place, object or body part has been duplicated. For example, a person may believe that they are in fact not in the hospital to which they were admitted, but an identical-looking hospital in a different part of the country. 

Finally, there’s delusion of subjective doubles, in which a person believes there is a doppleganger or double accompanying the self.  Apparently meetings with doubles were a popular theme of 19th century romantic literature (see Dostoyevsky’s The Double).  It was believed that we each have a doppleganger who normally remains unseen; if we see our doppelganger then death is imminent…

It’s not that unusual for people to say to me:

‘On psychiatric wards you can’t tell the staff from the patients’

or

‘Aren’t psychiatrists all mad?’

Depending on how narky I am, I sometime say to people:

‘Is what you’re saying that people with mental health are in some way unworthy of our attentions, to such an extent that the only people who might wish to treat them would need to be mentally unwell themselves?’

Which normally stops them in their tracks.  I do believe there may be a degree of unspoken prejudice within the question, and my distaste for this is contained within my answer.  It may also be that people don’t talk to psychiatrists very often and this is the first thing they can think to say in their quest to make small talk; in this case they should think more carefully before saying something stupid.

As for the ‘madness’, there are a few possibilities:

1. Psychiatrists are mentally unwell before they enter the profession
2. Psychiatrists become mad by virtue of engaging in psychiatric practice.  Is it possible that by spending so much time with disinhibited people that we become disinhibited ourselves?  Are mental health problems contagious?
3. This is all bollocks and psychiatrists are not any more likely to suffer mental health problems than anyone else.

I can only find one paper on this subject.  This was published in 1989 and is not available on the internet so I have not read it in full, but intend to track it down.  Its abstract suggests that there is no evidence that psychiatrists suffer more from mental health disorders than other medical practitioners.

But do medical practitioners suffer more from mental health problems than the working population at large?

It’s not a great leap of logic to think that the caring professions might attract people who are more sensitive than might the more robust jobs in the City of London.  Some people with mental health problems feel contained by a job in the caring professions and may feel that they are more understood and that their problems will get more sympathy.  In psychodynamic terms people who wish to be cared for may express this wish by caring for others.  This is the defence mechanism of projection.

It is also the case that if you work in the public sector than you are less likely to get sacked should you have a problem with your mental health.  A source close to me who works in the city tells me that people with mental health problems there tend to be quietly paid off. Furthermore medical jobs are stressful and often support and understanding are lacking.

Last month the Department of Health came out with a report entitled Mental Health and Ill Health in Doctors The introduction is particularly interesting and concise.  

Here are the main points

• It is reported that personality traits of perfectionism, self-criticism and dependency are common in medical students
• Doctors have higher rates of mental disorder than the general population
• Problems with alcohol, drugs and depression are particularly common.  Up to 7% doctors will have a substance misuse problem in their lifetime
• Suicide rates are increased especially in female doctors, anaesthetists, GPs and psychiatrists
• Medicine is a stressful profession.  Sources of stress include:
• Work pressure - workload, inadequacy of resources and poor support
• Nature of work - high demand and low control, in conjunction with the inherent trauma of dealing with suffering
• Poor relationships with colleagues - particularly poor team working
• Service pressures - investigations, complaints and court cases
• A charicature persists that good doctors do not make mistakes and that illness, especially mental is regarded as a weakness.
• Taking time off is letting colleagues and patients down
• Disclosure of mental illness or substance misuse is to invite disciplinary involvement.
• The average doctor takes three days sick leave each year.  The general population on average take 8 and nurses 15. 
• 40% of early retirement is due to psychiatric problems.
• Even those with serious mental illness if they are provided with appropriate help and are given support at work can continue to practise successfully.

So, pick any given doctor and there’s at a greater than one in ten chance that they will have had, at some time, a serious problem with their mental health.

For an excellent blog written by a psychiatrist with bipolar disorder can I direct you to Trick Cycling for Beginners.

It’s a few months since a video of Tom Cruise expounding on Scientology was released on the internet.  Described as ‘a complete fanatic‘ by the Gawker blog and worse elsewhere, he did come across as single-minded on the subject.  A recent book by Diana Spencer biographer Andrew Morton suggests that Cruise may be second in command in the Scientology Church behind David Miscavige.  

As much as it is possible with someone who has the adoration of thousands and earns more than I do in a year in about ten minutes, I do have some sympathy with Cruise for the ridicule he has received.  The beliefs of any religion or cult sound ridiculous when one takes a step back from them.  And impenetrable jargon could be expected from someone who believes himself to be talking to the converted.  It is only because the belief structure of, say, Christianity is so accepted in our culture that it does not seem fantastical.  If you subscribe to this viewpoint, then in saying what he says Cruise is no more deluded than any evangelical Christian, albeit one that is a member of a large, secretive and powerful group.

But this is not what I wish to examine here. 

For all the qualified sympathy I have for Cruise, he would be unlikely to extend the same to me.  Scientologists don’t like psychiatrists or psychologists.  Here Cruise talks about his dislike of psychiatry in the context of his previous comments on Brooke Shields using anti-depressants.  Taking an uncompromising stance, he insists that he had studied the history of psychiatry and had formed a negative opinion he wishes to share with others on this basis. 

In 1969 the Church of Scientology set up an organisation called the Citizens Commission on Human Rights which runs an  ‘Industry of Death’ museum located at 6616 Sunset Boulevard.  They have also made a documentary called ‘Psychiatry: An Industry of Death’ clips of which can be watched on YouTube

Here are some of the allegations levelled at psychiatrists by the CCHR website:

Psychiatrists are using electroshock, drugs and other barbaric means to torture political dissidents.

20 million children worldwide are taking psychiatric drugs, which can cause suicide, hostility, violence, mania and drug dependence.

More than 100,000 patients die each year in psychiatric institutions.

Annually, psychiatrists kill up to 10,000 people with their use of electroshock—460 volts of electricity sent searing through the brain. Three-quarters of all electroshock victims are women.

Psychiatrists and psychologists have raped 250,000 women. Studies show that 10 to 25 percent of psychiatrists sexually assault their patients; of every 20 of these victims one is likely to be a minor. 

Here’s a tour video of the Industry of Death Museum. Bedlam (now the Bethlem Hospital, South London) where ‘patients were chained like animals’ gets an early mention.  It appears that, according to the museum, psychiatrists are responsible for pretty much every ill of the modern world, including eugenics, ethnic cleansing and terrorism.  This seems somewhat unfair.  Details of these accusations can be seen as chronicled by two jokers at this blog who describe their visit to museum as the highlight of their trip to LA.

A lot of what the Scientologists metaphorically beat psychiatrists with has some basis in truth.  It’s no secret that psychiatry has been used to control political dissidents and that our knowledge of what causes psychiatric disease is patchy.  It is also a common criticism that psychiatrists seek to pathologise all of human behaviour and emotion.  But I do not think that you can legitimately criticise modern psychiatry because some people have sought to use what we know of psychology for nefarious ends, nor can they discount accumulated knowledge on mental health problems on the basis that their aetiology is incompletely understood; there are in fact plenty of diseases about which little is understood and that are treated empirically - think autoimmune disease.  

What do the Scientologists suggest instead of current approach for the mentally ill of society?  They make some suggestions for alternatives on the CCHR website.  Here there seems to be a strong emphasis placed on rooting out physical causes for psychiatric problems, something that psychiatrists should do as a matter of course.  For acute settings, In 1974, Scientology founder Hubbard penned the Introspective Rundown intended for Scientologists suffering from a psychotic breakdown.  Lisa McPherson was undergoing this protocol when she died in 1995.

Tom Cruise himself suggests an approach involving exercise and vitamins.  I have no doubt that increased exercise and diet  (but not vitamins, all they are good for it producing expensive urine) would would improve my patient’s mental health markedly, but I’d like to see him persuading them to do it without brainwashing them first.  

Update: Here’s an interesting article about scientology and psychiatry from Salon.com

Reported in the article from International Scientology News #38, 1995

"There are a lot of opinions out there as to what is wrong with Earth, 1995. But if you really want to eliminate those problems all you have to do is work for the objectives that we, as members of the IAS, have set for the year 2000: Objective One - place Scientology at the absolute forefront of Society. Objective Two - eliminate psychiatry in all its forms. Let’s get rid of psychiatry, and let’s bring Scientology to every man, woman and child
on this planet."

This quote is also reported in wikipedia

Here’s an answer from the internet:

‘The largest brain in the world was found in the head of an insane man, and the psychiatrist’s job is to remedy the psychological problems of people, thereby shrinking their head from border line nuts to a regular or average size’.

I’m not sure that this is right, and will be avoiding wikianswers for the foreseeable future. 

A wider internet search gives a consensus that psychiatrists are so-called because of a pejorative comparison between them and tribes whose custom it is to shrink the heads of their slain enemies.  I almost wrote ‘primitive tribes’ there, but I have no idea how to shrink a head, and it might be very difficult.  This ‘head-shrinking’ explanation sounds plausible. 

As luck would have it, I joined Camden Libraries* today, and membership has given me access to the complete online Oxford English Dictionary.  With this resource at hand I am able to tell you that the term was first used by American novelist Thomas Pynchon in his book ‘The Crying of Lot’, where he says:

‘It was Dr Hilarius, her shrink or psychotherapist’

This is merely the word’s first recorded use and doesn’t means that Pynchon invented the term.  He is famously reclusive, and so it’s unlikely I’ll be able to ask anyway.  This website suggests ‘magazine cartoons of the 1950’s and 1960’s were awash in cannibalistic natives, witch doctors and the like, so the imagery of "shrink" is not all that surprising’.  Like a lot of expressions it was probably in use before a novelist, like Pynchon, with an ear for vernacular, picked it up. 

I’m making less progress on the history of ‘trick cyclist’ and all I’ve managed to find out so far is that it’s a ‘humorous alteration of psychiatrist’ (OED again), which I knew already.  If anyone knows anything about this please let me know. 

Often, when I meet someone I don’t know and I tell them that I’m a psychiatrist, they say something like ‘Oh, so are you psychoanalysing me?’ I don’t exactly known what they mean, but I have a feeling it’s something like ‘are you looking into the deep recesses of my soul, and seeing things about myself that I don’t even know?’

Which would be a neat trick. 

I used to think that this was a relatively silly question, which shows a lack of understanding of both psychotherapy and psychiatrists.  For a start it assumes that all psychiatrists are psychotherapists, which is not the case; this misunderstanding is fairly universal within the media, so is understandable.  It also treats all psychotherapy as if it were one single approach (this being Freudian) and there are many many different psychotherapeutic methods. 

What people are actually saying is, if you are a psychiatrist you must be a psychoanalyst and if you are an analyst you must be a Freudian psychoanalyst.  It does, however, give an idea of the strange and mysterious powers that people might consider a psychiatrist to possess.  

Here’s a definition of psychoanalysis:

Psychoanalysis n. a school of psychology and a method of treating mental disorders based upon the teachings of Sigmund Freud (1856-1939).  Psychoanalysis employs the technique of free association in the course of intensive psychotherapy in order to being repressed fears and conflicts to the conscious mind where they can be dealt with. (Oxford Concise Medical Dictionary)

So, if we’re being picky, psychoanalysis involves a element of treatment and just dissecting someone’s personality apart when you meet them is not psychoanalysis, it’s being nosey.  

Lastly an important part of psychodynamic psychotherapy is in the therapeutic alliance formed between analyst and patient - this is unlikely to be formed during a ten minute conversation at a party.  Even the briefest of analyst-patient contacts involve sessions over multiple weeks. 

Recently, I have in a way begun to see what people mean.  We have a case discussion group at the hospital in which I work where one of our number presents the case of a patient, who for whatever reason sticks in their mind.  When I presented a history it became evident that there was a question that I hadn’t asked.  My position on this was that I had simply forgotten; the psychoanalytical view was that my forgetting had significance (perhaps I was subconsciously afraid to ask the patient?), as would my reaction to being challenged on my oversight.  The point is, that something relatively innocuous had provided information about me which others could now see but of which I previously had no knowledge. 

I now sometimes find myself being careful what I say lest it be interpreted in some way.  For example I hesitate to make a joke in case it betrays a discomfort with subject matter.  Is this what people mean?  As psychiatrists, and doctors in general, we’re observers of behaviour.  A neurologist is trained to spot a posture consistent with a neurological disease, an orthopaedic surgeon, a limp.  With psychiatrists it’s a little less concrete, but we’re all trying to spot signs that tell us that someone might need our help.  If that’s psychoanalysis, then yes, I suppose I am.

Psychiatric syndromes like hypochondriasis, somatization disorder and Munchausen’s disorder could be uncharitably characterized by the layman as ‘he’s making it up, innit’.  Not as simple as that alas, which one of the reason you have to train psychiatrists rather than pull them off the street.

Munchausen syndrome (also known as factitious disorder): the patient seeks medical attention by the intentional production or feigning of symptoms.  The motivation for this is considered not to be known to the patient and he/she keeps their stimulation or induction secret.  It was named (1) after Rudolf Raspe’s 1785 fictional German cavalry officer, Baron Karl von Munchausen, who always lied fantastically about his military exploits.  A classic case might have what is called a ‘grid iron’ stomach because of all the scars from numerous abdominal operations.  Also a feature is ‘perigrination’ where a patient will move from hospital to hospital seeking treatment, once rejected from a department.

Munchausen syndrome by proxy: This was first defined by Meadows (2) and has become controversial.  Defined as ‘the deliberate production or feigning of physical or psychological symptoms or signs in another person who is under that individual’s care’.  it is considered to be a form of child abuse.  It is also not unknown for healthcare workers to fabricate health crises in their patients so that they can ’save’ them. 

Hypochondriasis: the patient is convinced that they have a life-threatening illness, despite evidence to the contrary.  They often misattribute normal bodily sensations as being pathological. 

Malingering: the patient knowingly fabricates a medical illness for known gain.  This is considered to be rare. 

Somatization disorder: With this a patient presents with multiple, medically unexplained symptoms. Originally described as Briquet’s syndrome in the 1960s.  Patients sometimes show a lack of concern for the nature and implications of their symptoms and the presentation may also be illogical for example, the patient may complain of intolerable pain, but still appear calm and composed.

So, in summary, if they’re doing it, but they don’t know why then it’s Munchausen’s syndrome; if they’re doing it to someone else and they don’t know why then that’s Munchausen’s by proxy; if they think they’re going to die and you can’t persuade them otherwise then that’s hypochondriasis; if they’re not doing it, but they feel unwell but are pretty vague about it then they’re somatizing and if they’re doing it, they know why and they want money for it then they’re malingering.  Clear?

Addendum: Jan-Michael has asked about how the above relate to conversion disorders, which is a good question.  Conversion disorders are presumed to be psychogenic in origin.  The patient experiences a conflict or trauma of some kind and the unpleasant affect is transformed (/converted) into symptoms.  Examples are dissociative amnesia, dissociative fugue, dissociative stupor, trance and possession disorders, dissociative disorders of movement and sensation and dissociative convulsions. 

In common with somatisation disorder, both involve physical symptoms and with both there is no evidence of a physical disorder that might explain these symptoms.  The difference is that to diagnose dissociative disorder there should be clear evidence of psychological causation for the symptoms, even if the patient denies it.  There is no need for this to make a somatisation disorder diagnosis.  Also with somatization disorder, the patient tends to present with a variety of vague symptoms whilst in a dissociate disorder the symptoms are more focused. 

In terms of classification, disorders with a predominantly physical or somatic mode of presentation are grouped together.  In ICD-10 F40-48 covers neurotic, stress related and somatoform disorders.  Within this F44 covers Dissociative [conversion] disorders and F45 covers somatoform disorders.  Somatoform disorder is classified within this as F45.0 and hypochondrical disorder is classified as F45.2.  Malingering is classified elsewhere as Z76.5 (Z0-Z99 Factors influencing health status and contact with health services) and Munchausen’s F68.1 ‘intentional production or feigning of symptoms or disabilities either physical or psychological [factitious disorder]‘ (F68 other disorders of adult personality and behaviour)

(1) Asher, R. (1951). Munchausen’s syndrome. Lancet, i, 339–41.

(2) Meadow, R. (1977). Munchausen syndrome by proxy: the hinterland of child abuse. Lancet, ii, 343–5.

Judging by how often I’m asked this question, there is a lot of confusion out there about the differences between psychiatrists and psychologists. For a lot of people the two professions are synonymous.

There is overlap between the two roles, and both professions deal with a similar group of patients; we both work for the well being of patients who have problems concerning their mental health or behaviour (or both). There are however a large number of differences.

Firstly, psychologists and psychiatrists have different training. A psychiatrist goes to medical school and, in the UK , will have spent at least a year working in physical medicine. A psychologist starts their training with a psychology degree, going on to higher degrees and has no medical background.

This leads us to the really big difference: psychiatrists can prescribe medications for patients (as ever there are exceptions to this – nurses can take a prescribing course, but their remit would mostly be restricted to commonplace short term medication, for example night sedation) and psychologists do not. Psychiatrists therefore spend a lot of their time initiating and monitoring pharmaceutical treatments and assessing patients’ mental state in the light of this.

In contrast to the psychiatrists’ focus on medication as a treatment for mental illness, a psychologist’s approach focuses extensively on psychotherapy and treating emotional and mental suffering in patients with behavioral interventions. This might involve problem solving techniques or identifying and tackling dysfunctional behavioural patterns perhaps via psychological therapy such as CBT. Psychologists are also qualified to conduct psychological testing, which is important in assessing a person’s mental state and determining the most effective course of treatment.

One final difference is that psychiatrists are also involved in involuntarily detaining patients on psychiatric wards when it is felt that a patient is at risk to themselves and/or others and cannot be treated in the community; this is not part of psychologist’s remit.

So, as a simple example, let’s say that a person is referred to a mental health team because of severe anxiety. Their psychiatrist would consider prescribing them anti-anxiety medication. A psychologist will be more focused on behavioural intervention. This might involve CBT or, with a phobia, graded exposure.

People also mix up the role of psychiatrists and psychologists with that of psychotherapists/psychoanalysts. Again there is overlap between this profession and psychiatry - but it’s a story for another day.

Added 14 June 2008

Here’s what ‘Psychology: A Very Short Introduction’ has to say on the subject.

‘There are some fields with which psychology is frequently confused - and indeed there are good reasons for the confusion. First, psychology is not psychiatry. Psychiatry is a branch of medicine which specialises in helping people to overcome mental disorders. It therefore concentrates on what happens when things go wrong: on mental illness and mental distress. Psychologists also apply their skills in the clinic, but they are not medical doctors and combine with their focus on psychological problems and distress a wide knowledge of normal psychological processes and development. They are not usually able to prescribe drugs; rather they specialise in helping people to understand control or modify their thoughts or behaviour in order to reduce their suffering and distress’

Added 13 August 2008

And in 1980 under Mao psychology was condemned as being

‘90% useless’ and ‘10% distorted and bourgeois phoney science’

Source: Bond M.H. 1995 Beyond the Chinese Face: Insights from Psychology

Via Affluenza by Oliver James page 128

There’s an Israeli academic who is speculating that the Old Testament’s Moses may have been under the influence of psychadelic drugs at the time of his writing the 10 commandments.  Benny Shanon is a professor of cognitive psychology at the Hebrew University of Jerusalem, says that these formed an integral part of the religious rites of Israelites in biblical times.  The article is in the Time and Mind journal of philosophy (I can’t find a link for this)

Given how speculative this is, it’s hardly worthy of comment and it’s more likely been said to get a bit of publicity and piss off a few religious leaders.  More interesting is the articles in the press about which of our current and former world leaders have been fond of recreational substances. 

In no particular order:

Boris Yeltsin - Distilled in 1938 Most celebrated incident was his failure to disembark from a plane to meet Albert Reynolds in Shannon Airport

Winston Churchill - The Winston Churchill Centre maintains that he was not an alcoholic but ‘dependent’, two states between which to differentiate would require a very fine pair of scales.  Probably wins the prize for the most quoted about the benefits of alcohol.  Try to Bessie Braddock, socialist member of parliament

George W. Bush - the current president has been arrested for driving under the influence and there is also speculation about his other drug use

Bill Clinton - "When I was in England, I experimented with marijuana a time or two, and I didn’t like it. I didn’t inhale and never tried it again."  Also known for his fondness of cigars…

David Cameron - Not strictly a leader, but he has been pressed at times to come clean about his drug use in the past.  He has refused to do so. 

Anthony Eden - British Prime Minister Anthony Eden was prescribed Benzedrine an amphetamine following damage to his bile duct during a gallstone operation.  It is widely reported across the internet that he ‘lived on benzedrine’ during the Suez crisis, but I can find no citation for this. 

John F Kennedy - is now known to have suffered from adrenal insufficiency.  His medical records have been made public and have detailed his use of hydrocortisone, testosterone, codeine, methadone, Ritalin, antihistamines, anti-anxiety drugs, barbiturates, and regular injections of Procaine to ease his back. Kennedy is described as being in almost constant pain in his last years by some sources, which seems in conflict with stories of his sexual adventures.  This article also suggests the the President smoked cannabis and took LSD

Adolf Hitler - said to have received daily amphetamine injections from his personal physician. 

I’ve also written about the drug use of the current UK home secretary Jacqui Smith

How should we judge the behaviour of these men.  I would argue that if our leaders seek to leglisate against the public’s use of recreational drugs, then the hyprocrisy evident in their own use is very relevant, and cause for public interest.  We also have a right to be concerned if decisions being taken on our behalves are being taken by people who may be comprimized.  However maybe if we wish a great leader (I’m not counting Hitler here), we must appreciate that their greatness may come hand in hand with their flaws.

Here’s an interesting article on celebrity drug use.  If anyone has other examples of similar leaders please let me know.

This is a story that I wrote during idle moments during the MMC/MTAS debacle last year when I was wondering if I should get another career. 

In those first weeks without a job I felt shifty and aimless.  Despite waking early, in the mornings I could not get out of bed.  The flat was very cold; I had been forced to economise by switching off the heating. To keep warm I would lie with my head under the covers and my knees folded up into my chest. For lunch I’d eat soft white cheese on semi-stale bread and afterwards spend the hours browsing the shelves of libraries, sometimes visiting several over the course of an afternoon.  I almost never cleaned my teeth.

In time I grew restless such that only the longest walks taken during the brief winter sunshine would exhaust me enough to sleep that evening without ruminating on my situation.  Despite residing in distant Dalston, I would walk into central London, taking in Oxford street, a hateful place, Regent Street, where you could surf the internet for free in the Apple Store, and Piccadilly Circus, where I would try and kick pigeons by luring them toward my foot on which I had placed bird feed.  I walked home in the dark my arms folded tightly across my chest my eyes focused on the ground.

Then as time passed I ceased to sleep at all.

At first I put this down to the number of cigarettes I was smoking throughout the day.   They provided entertainment for my hands and I reasoned it was justification enough in my smoking them that at least one part of me was occupied.  But I cut down and this made no difference.  Late night television hurt my eyes and my head and the neighbours politely complained about the floorboards creaking as I, in sleepless desperation, paced up and down on the bare wooden floor in the early hours of the morning.  Having once been sued by the residents committee as a result of unenthusiastic recycling, I knew that for my own safety I should spend at home as little time as possible.

Central London after dark is different to during the day. As my evenings progressed I would pass the same people night after night, as if all of us were involved in a sponsored walk.  With this over the weeks an embarrassed and unenthusiastic ‘hi’ evolved into a cadged cigarette and then eventually something resembling friendship.  It was difficult at first; if you don’t talk all day, sounds do not pass easily from your mouth; your tongue cannot make the words.  Of the people I met, an unusually high number introduced themselves as ‘Dave’.  I cannot say whether such a name predisposes to either misfortune causing insomnia, insomnia de novo, or whether in losing the structure in their lives my fellow street walkers also lost their ability to create interesting pseudonyms.  Whatever the reason, my name was soon ‘Dave’ too; it seemed to make things easier. 

On coldest nights we ‘Daves’ would gravitate towards places of warmth.  These were provided by some of the larger buildings that had hot air outlets that discharged onto the street.  We kept these havens scrupulously clean.  For example one night we discovered a drunk Arsenal supporter vomiting liberally across our favourite spot.  Chasing him off, we all clubbed together to purchase a 65p bottle of thick bleach and some jay cloths from Tesco Metro; then only after some furious cleaning did we settle down as usual to our habitual positions, standing as close to the hot air as possible, completing discarded cryptic crossword puzzles and swapping stories concerning the origins of our various gradations of misery.

Another place of warmth was the hot dog stands.  There were several that dotted around the area, drawn to the financial opportunities presented by thousands of tourists, drunks, clubbers, lovers and assorted street life hungered by sight-seeing, lager, ecstasy, lust and chronic malnutrition.  At four in the morning, my feet cold and hurting, I’d stop and have one with onions and mustard, or a burger in an unsavoury bun.  Sometimes I’d buy a tomato and add it in, cutting it with my scouting penknife now blunt and worn.

When they weren’t too busy, the men at the burger stalls were eager to talk, most of them happy to take the opportunity to brush up their English with a conversation beyond simply the desire of their customers for brightly coloured condiments.  They would show me pictures of their families - most often very geographically distant  - and I was often offered a place to stay should I ever find myself in Bagdad or Kabul.  Their trade was fugitive, their carts illegal and liable to be seized, and so it was not unusual to find my conversations curtailed by a customer who was actually a council official, with a stall requisitioning van in close pursuit.

So the turnover of vendors was swift, and with the passage of time I found myself on the other side of the fence; a user-turned-dealer, if you will.

Despite its illegality, the dog burger trade is run rather like a private company.  There’s an interview, a period of assessment, payment by the hour.  That is where the similarities end of course, as I am sure that stealing from McDonalds results in disciplinary process, rather than repeated kicks in the face.  Not that I would have considered jeopardising my new job in any way as I wheeled my cart into Soho at 9pm for my first shift. 

It was on this night with my new career, and every subsequent, that I witnessed with paternal consternation, the bacchanalian drinking of today’s youth.  Although it was by then a year since the NHS had no longer needed my services I couldn’t help looking on my customers as future patients, such was their disregard for their health.  And alcohol distils out idiots; one such fool made this painfully obvious.  I had turned my back on my cart, its sausages sizzling gently and their smell far too enticing to be anything other than chemically synthesised, to talk to some plump girls in short skirts.  I was feeling the best I had done in months, not actually good, but for the first time in a long time I thought that perhaps there might be, for me, a future ahead.  My intoxication by this rare positivity would not last long as I heard a loud yell from close vicinity.  It seemed that the girls were flirting with me simply to distract a lonely man.  Meanwhile, behind my back one of their friends was gaily relieving himself only my hotplate; I had wondered why the girls seemed to be laughing so keenly as I spoke.  Alas his heroic turn in front of the ladies was to be short lived.  His no doubt substantial alcohol intake had given him an advanced sway and this to his penis sustaining gave a nasty looking burn.  I was too astonished to be cross, and for reasons of economy was unable to discard the twenty or so sausages he had soiled, serving them without discount to a batch of gurning clubbers ten minutes later. 

The nights passed quickly: I’d sometimes set myself challenges – one night to talk only in Shakespeare quotes, another I would invite every third customer to a party on a road that didn’t exist.  Over time I grew to have an established clientele, who were becoming the closest things I had to friends.  Unfortunately this was at the expense of my previous buddies.  There had been some friction between us as I had neither the permission nor inclination to give away free produce.  It didn’t bother me much; I was happier now and could remember more than one name. 

Three months on and I had begun to sleep again.  At first not much, perhaps 45 minutes during woman’s hour, but soon I was able to sleep from half way through ‘In Our Time’ until the closing minutes of ‘You and Yours’.  My ‘manager’ – although I am sure that the title would amuse him – a Pole called Rudolf, had moved from a position of initial distrust and suspicion to regularly reminding me that I was his most trusted employee.  Although I was pleased with this accolade I found his hearty back-slaps disabling.  They were however an accurate indicator of his gratitude as I was making him money, and not just from the burgers:  the probity of his staff meant much to him as it afforded him more time to deal drugs to wealthy Kings Road kids during the day. 

I have one last tale to tell: with my job there’s always was a lot of standing around and not always all that much to do.  I would wonder about stuff, like how radio waves travel through walls and how long it takes for every cell in your body to change.  It was during one such reverie when I turned to serve a customer who happened to be one of my old colleagues, who had treated me so carelessly. 

’£3.50’ I said, adding an extra 50p on the price.  It was a hotdog that he wanted

He looked at me in a puzzled way.  ‘Do I know you?’ he said.

‘Don’t worry’ I replied.  ‘I have one of those faces that looks just like other peoples.  Perhaps I’ve sold you one of these before?’ I handed him the hot dog. 

He still looked disturbed.  ‘I don’t think so’, his face relaxed and he handed me a five pound note.  ‘You must meet a lot of people out here’ he said conversationally.

‘Yes’ I said.

Do you know the way to ‘Soho House?’

‘Yes’ I said and provided him with instructions that would send him in entirely the wrong direction.  I even drew him a map. 

‘Enjoy your day’.  I called after him as he left.  These special moments come all too infrequently.