Madness Explained

by Richard P. Bental

  Sigmund Freud2

  In the first chapter of this book I described how Emil Kraepelin’s early career was influenced by an unsatisfactory encounter with Professor Paul Flechsig, a respected psychiatrist who worked at the University of Leipzig. Flechsig belonged to a generation of doctors who devoted more of their time to anatomical studies than to developing their clinical acumen. After they fell out, Kraepelin sought a new mentor, and thereby came under the influence of Wilhelm Wundt. The rest, as they say, is history.

  Flechsig’s contribution to the evolution of his discipline was not entirely negative. More at home with a microscope than with fellow human beings, he carried out important research on the localization of brain functions, helping to define the projection and association areas in the cerebral cortex.3 However, he is rarely remembered for these efforts, or for his argument with Kraepelin. Instead he is most often remembered for his role in one of the most curious cases in the history of his calling.

  Judge Daniel Paul Schreber experienced his first nervous breakdown in 1884, after failing to gain election to the Reichstag. He was 42 at the time. Very little is known about this episode, but he was treated by Flechsig and, after six months, recovered enough to resume a normal life. Eight years later he suffered a second breakdown, which was more enduring. He had just been appointed President of the Supreme Court of Saxony. One night he found himself wondering what it would be like to be a woman experiencing sexual intercourse. Several days later, he developed the first of an expanding set of delusional ideas. His subsequent psychosis lasted nine years, during which time he wrote his Memoirs of my Nervous Illness,4 a book that was to make him one of the most frequently discussed patients in medical history.5 The ideas that Schreber described in his autobiography defy easy summary, but began with hypochondriacal delusions, for example that his brain was softening, that he was decomposing and suffering from plague. These beliefs rapidly progressed to the conviction that Flechsig was transforming him into a woman in order to sexually abuse him. Later they evolved into a complex theological system, in which ‘rays’ from God, attracted by the highly excited nerves in Schreber’s mind, would, he believed bring about a series of ‘miracles’ that would eventually feminize his body and induce a state of ‘voluptuousness’. This process, he believed, would culminate in a state of heavenly bliss whereupon he would be reconciled with the Almighty. Examples of these imaginary events included the ‘miracles of heat and cold’ during which Schreber believed that blood was being forced to different parts of his body, and ‘the head-compressing machine’ into which Schreber believed his head was being forced by ‘little devils’.

  Memoirs of my Nervous Illness attracted the attention of the father of psychoanalysis, who wrote a speculative analysis of Schreber’s delusions, thus cementing the judge’s reputation with future generations of researchers. Undeterred by the fact that he had never met Schreber, his dissection of the case is vintage Freud.6 Readingit today, it is impossible not to be impressed by the skill with which he marshalled various strands of evidence, until they pointed towards a conclusion that, in the cold light of day, seems quite implausible. In brief, Freud maintained that Schreber harboured homosexual feelings for his father, a well-known physician, which he had displaced on to his psychiatrist, Flechsig. According to Freud, in a further series of defensive manoeuvres, Schreber’s love for his psychiatrist was then transformed into Flechsig’s imagined hatred of Schreber, which eventually generalized into God’s bizarre manipulations of Schreber’s body. In this way, the judge was said to have avoided awareness of impulses that otherwise would be disturbing to his conscious mind.

  Later writers who were inspired by psychoanalysis agreed with Freud that paranoid delusions have a defensive function, but took a less exotic view of the underlying emotions that were being defended against. Bleuler, for example, regarded all delusions as attempts to attribute unacceptable ideas to external agencies but disputed that these were necessarily homoerotic.7 Over half a century later, Kenneth Colby, an American psychoanalyst who became a pioneer in the apparently unrelated field of artificial intelligence, created a computer simulation of paranoid thinking, which assumed that paranoid individuals are highly sensitive to threats to their self-esteem, but protect themselves from feelings of inadequacy by blaming disappointments on other people.8

  Although Schreber’s beliefs would not be completely out of place on a modern psychiatric ward, the delusions of today’s patients are usually less complex, and therefore more easily summarized. Sometimes they straddle the fine line between tragedy and comedy as in the case of a young man called Ian, who suffered a breakdown shortly after leaving school and obtaining his first job. His most troubling symptom was a series of extraordinary beliefs about his abilities and achievements, on which he acted to the consternation of his long-suffering parents. Maintaining that he was a millionaire, he regularly telephoned a local bank to inquire about his savings, and struck up quite a good relationship with a sympathetic bank clerk. (At considerable cost to her employer, she would spend long periods on the telephone, reassuring him that his imaginary millions had not been stolen.) At other times he would ring military bases and inform them that he was a general who was about to carry out an inspection. One day, plausibly dressed in a well-cut suit, he left his ward and strayed on to another, where he announced that he was a new consultant psychiatrist. Searching for a job to match his perceived status, he awarded himself a knighthood and applied for the position of chief executive of a hospital in Wales. His requests for further information about suitable positions often culminated in the delivery of bulky envelopes addressed to ‘Sir Ian…’.

  Ian’s delusions resisted his family’s best efforts to challenge them. Neither logical argument, nor their increasingly exasperated efforts to point out the gap between his boasts and reality, seemed to bring about any change in his behaviour. This kind of incorrigibility has been considered a hallmark of delusions since clinicians first began to study them. It receives its most severe challenge when patients with incompatible delusions meet each other.

  One such encounter was described by the French philosopher Voltaire who, in 1763, observed the meeting between two inhabitants of a madhouse, one believing that he was ‘incorporated with Jesus Christ’, the other believing that he was ‘the eternal father’. The second of the patients was sufficiently shocked by the experience to recover his sanity temporarily. However, a less positive outcome was achieved in the only modern experiment of this sort, published in 1964 by Milton Rokeach. A social psychologist based at the University of Michigan, Rokeach was interested in the causes of dogmatism, and decided that the nearby state psychiatric hospital at Ypsilanti provided a wonderful opportunity to study rigidly held beliefs. Discovering that three of the patients at the hospital believed that they were Christ, he arranged for them to live together on a ward. Confronted by others who also claimed to be Jesus, two clung to their delusional identities. The third accepted the claims of his companions, but began to entertain a series of new beliefs that were just as bizarre, at one point claiming that he was a psychiatrist who was married to God. All three expressed sympathy towards the other two, apparently convinced that they were mad.9

  Apparently not Beyond Belief

  Although delusions vary, they tend to encompass a small number of themes. The most common type is persecutory or paranoid,* in which the individual feels himself the victim of some kind of malevolent plot. In a study of patients who had recently been admitted to hospital in Denmark, it was found that 42 per cent of those with delusions had beliefs of this sort.10 The imaginary persecutors are sometimes people known to the patient, but more often are institutions such as government bodies or criminal gangs, or ethnic, religious or ideological groups such as Catholics, communists or Jews. A patient I once saw had become psychotic after travelling to Australia, and had been deported back to Britain and hospitalized. He believed that he was the object of a conspiracy conducted by the British Home Office and the Austral
ian secret service. It was, of course, part of the conspiracy that his psychiatrists should diagnose him as suffering from schizophrenia. As I attempted to interview him one day, he leaned forward and, whispering, asked me to admit that I knew about the plot, assuring me that no one would be able to overhear our conversation.

  British psychologists Peter Trower and Paul Chadwick have argued that it is important to distinguish between those individuals who believe that their persecution is unwarranted (said to be suffering from ‘poor me’ paranoia) and those individuals who believe that persecution or anticipated persecution is richly deserved on account of some terrible sin they have committed (said to be suffering from ‘bad me’ paranoia).11 Whether this distinction will prove to be useful remains to be seen; in Kraepelin’s own classification, delusions of sin were listed separately from persecutory delusions, and it may be better to think of ‘bad me’ paranoia as belonging to a general category of depressive delusions in which the individual is tormented by extremely negative self-evaluations. Certainly, delusions of guilt or badness are common in patients diagnosed as suffering from psychotic depression, who often believe that others share the negative opinions they hold about themselves.12

  Grandiose delusions, such as those expressed by Ian and the three Christs, embrace four main themes: beliefs that the individual has special powers, is wealthy, has some kind of special mission, or has some type of special identity.13 Often they occur with persecutory delusions. Another of my patients, who lived in very poor circumstances, asserted that he was the illegitimate heir to a fortune (special identity), had invented the helicopter and the pop-up toaster (special powers), and that the huge royalties from these achievements (wealth) had been stolen by the staff at the hospital he was reluctantly attending (persecution). My attempts to offer him help were confounded by his demands that I call in the police so that these crimes could be investigated.

  Delusions of reference, in which innocuous events are held to have some special significance for the patient, are commonly observed but have been much less studied by psychologists and psychiatrists.14 (Peter Chadwick, a psychologist who has suffered from a psychotic illness, has written a moving account of a delusional episode, which began when a radio programme he was listening to seemed to be directed at him.)15

  Somatic or hypochondriacal delusions, in which the patient entertains bizarre beliefs about his body, are probably under-recorded, either because they are eclipsed by other symptoms, or because they are assumed to be complaints about side effects of medication. In a survey of 550 psychotic patients, psychiatrists Ian McGilchrist and John Cutting recorded this kind of belief in 55 per cent of those questioned, which would make them even more common than persecutory delusions. McGilchrist and Cutting have argued that somatic delusions can be subdivided into two main categories: elaborated beliefs about the body that have apparently been inferred from sensations, and beliefs that seem to involve the misinterpretation of sensory experiences.16 Schreber’s belief that he was changing sex presumably belongs to the first class, of ‘cognitive’ somatic delusions, whereas patients’ assertions that they are burning, being sexually interfered with, or are blocked and filling with fluid would belong to the second, ‘perceptual’ category.

  Much less common delusional themes include delusional parasitosis (in which the patient believes that he is infested by insects crawling under his skin),17 dismorphobia (the belief that the individual is disfigured or ugly despite being completely normal in appearance), erotomania (in which the patient believes that she is secretly loved by someone who is in fact indifferent, usually a person who is famous or holds a position of authority)18 and delusional jealousy (in which a loved one is irrationally believed to be unfaithful).19 Some authors have cited this last type of delusion as evidence that a belief does not have to be false in order to qualify as delusional: partners often get so fed up with the restrictions placed upon them by their irrationally jealous spouses that they eventually run off with somebody else.20

  A few rare but more colourful delusional systems have received more attention from researchers, some of whom have been rewarded by having obscure disorders named after them. An example is the Cotard syndrome, first described by the French psychiatrist Jules Cotard in 1882, following an encounter with a 43-year-old female patient who believed that she had ‘no brains, chests or entrails and was just skin and bone’, that ‘neither God nor the Devil existed’ and that she was ‘eternal and would live forever’ and therefore did not need to eat.21 After Cotard’s death, it was widely believed that he had identified a peculiar form of depression in which nihilistic delusions are the prominent symptom. However, a recent survey of 100 cases of Cotard syndrome reported in the literature found that there was considerable variation in the symptoms recorded, and that many of the patients met the criteria for conventional diagnoses such as depression, bipolar disorder and schizophrenia.22

  Another unusual disorder is the Capgras syndrome, named after another French doctor, Joseph Capgras, who first described the delusion that a loved one had been replaced by an impostor, robot or doppelgänger.23 This last type of belief belongs to a small family of delusional ideas in which misidentifications are the central theme. Other members of the family include the Frégoli delusion (named after a famous Italian impersonator of the 1920s), in which the individual believes that persecutors have disguised themselves as familiar people,24 and the delusion of inanimate doubles,25 in which emotionally significant personal items are believed to have been maliciously replaced by poor copies.

  The reader will recall that Karl Jaspers held all truly delusional beliefs to be ununderstandable, by which he meant that they are meaningless and unconnected to the individual’s personality or experience. I have already criticized this account for being far too subjective – the understandability of delusions seems to depend, to some extent, on the effort made to understand them. Indeed, when such efforts are made, it is apparent that the most common delusional themes observed in clinical practice, including most of those that I have just described, reflect patients’ concerns about their position in the social universe. This much was recognized by Kurt Schneider, who argued that in all cases of delusion, ‘Abnormal significance tends mostly towards self-reference and is almost always of a special kind: it is momentous, urgent, somehow filled with personal significance…’26 This intuition has been supported by research conducted by Philippa Garety and her colleagues at the Institute of Psychiatry in London. They used a simple five-way classification to record the delusional beliefs of 55 patients. Consistent with the research in Denmark I mentioned earlier (p. 297), the most common type of delusion observed was persecutory (35 per cent) followed by abnormal negative beliefs about the self (32 per cent), and abnormal positive beliefs about the self (26 per cent). Less common were negative delusions about the world (only three patients) and positive delusions about the world (only one patient).27

  Interestingly, this finding seems to have some cross-cultural validity. In a comparison of the delusions of psychiatric inpatients from Europe, the Caribbean, India, Africa, the Middle East and the Far East, persecutory delusions were the most common in all but one region, the exception being the Far East, where sexual delusions were more often reported.28 Nevertheless, cultural, religious and socio-economic factors obviously influence the precise nature of the threat perceived by paranoid patients. For example, middle- and upper-class Egyptian patients typically report persecutory delusions that have scientific or secular themes, whereas the delusions of poorer patients often involve religious institutions.29 Paranoid delusions in Korean patients tend to reflect fears of rape, whereas fears of vampires and poisoning are more common in Chinese patients.30 There is also evidence that the content of delusions has changed over time. In the United States during the 1930s (a period of material deprivation and personal powerlessness), delusions of wealth and special powers were common, whereas delusions about threats of violence have been more common in recent decades.31

  De
fining delusions

  Most modern definitions of delusions emphasize characteristics other than ununderstandability, but none distinguishes between delusional and ordinary beliefs in a manner that is entirely satisfactory. In DSM-IV a delusion is defined as:

  A false personal belief based on incorrect inference about external reality and firmly sustained in spite of what almost everyone else believes and in spite of what usually constitutes incontrovertible and obvious proof or evidence to the contrary.32

  As some sceptics have pointed out, this definition begs questions about what we mean by ‘incorrect inference’, ‘external reality’ and ‘incontrovertible and obvious proof’.33 Perhaps conscious of this limitation, the authors of DSM-IV go on to add, ‘[It] is not ordinarily accepted by other members of the person’s culture or subculture’, thereby opening up the possibility that a belief regarded as delusional in one culture might be considered perfectly rational in another.

  Of course, much of the difficulty in defining delusions can be resolved if we accept that they exist on a continuum with ordinary beliefs and attitudes. In Chapter 5, we have already considered evidence that seems to support this idea. I think most readers will be able to think of acquaintances whose thoughts seem drawn to the same concerns that preoccupy psychiatric patients (the academic who suspects that rivals are stealing her ideas, the New Age enthusiast who sees special significance in coincidences, the unhappy young man who believes that a beautiful but indifferent woman will eventually admit to loving him).