Psychiatric Turf War

Joel and Ian Gold are brothers. Joel, a psy­chiatrist and psychoanalyst, teaches in New York. Ian, a PhD in psychology and philosophy, is at McGill University. They are part of a movement to drag psychiatry away from neurochemical thinking and to restore a place for social causation of illness, rather than just neurotransmitters that are out of whack.

Is this overdue? Yes. I am going to have a few critical things to say about the Golds’ book, Suspicious Minds: How Culture Shapes Madness, but I want to make clear up front that it should be seen as a kind of intellectual landmark, with social psychiatry launching this well-written, often amusing and frequently convincing counterattack on the neurotransmitter gang. After a slew of books on the miracles of the neurosciences, it is refreshing to see a raised eyebrow, a mouth downturned in scorn, a reaching back to the older principles that once animated psychiatry as a social science as well as a neuroscience.

The Golds undertake this mission using the Trojan Horse of delusional disorder, a technical diagnosis in psychiatry meaning holding fixed, false beliefs. “Paranoia” is often a synonym. The belief that the CIA has implanted a microtransmitter in your teeth would be an example of delusional disorder: you function perfectly well in most of your life; you are not “crazy” or demented, but when the subject comes around to your “secrets”—which you are convinced the CIA wants—you clam up and become uncommunicative because you know the CIA is listening to every word.

Delusional disorder is different from a lot of other psychiatric diseases that look vaguely similar. It is not schizophrenia, where patients do indeed have delusions, but the false ideas are fleeting and inconstant, and your entire universe of cognition is affected. It is not the delusions of psychotic depression, where the melancholic mood overrides everything else (in delusional disorder you may be quite jolly if, for example, you have the erroneous belief that someone else is in love with you). There are, in other words, many kinds of delusions, found in a range of bodily and mental illnesses, from neurosyphilis to manic delirium. Delusional disorder itself, however, is quite specific.

The Golds’ thesis is that psychiatric illness (“madness”) is shaped by culture. They start with a “short history of madness,” moving then to an analysis of a kind of delusion called “the Truman Show.” The main body of the book then links the various kinds of delusions to culture, in a series of chapters called “the social life of madness.”

Truman Show delusions involve the idea that everyone in the world is looking at you. This riffs on a 1998 film starring Jim Carrey called The Truman Show, in which the protagonist believes that he is “being watched by the whole world … [living] with every moment of his life being captured by thousands of cameras located around Seahaven,” the island where he resides. Joel Gold, the psychiatrist brother, saw several of these patients in New York and is clearly fascinated by them.

The Golds maintain that such delusions can be better understood through social science than neuroscience. They argue that evolution has equipped us with a kind of early-warning device they call the Suspicion System to pick up threats. Some parts of this system are innate, in that we are born with them, while others are culturally moulded. “Suspicious states … are responses to cues that are analogous to the rustle in the forest or the footfall in the alley.” And when the Suspicion System goes into hyperdrive, you have delusional disorder, causing us “to see malign intent where there is none.”

A lot of cheerleading goes on in the book, encouraging us to think that delusional disorders are really very common and actually not that much of a problem. The perspective is “client-friendly”: we are all a little bit messed up and it is because we inhabit an environment that makes us suspicious, not because we have too much dopamine on board.

What the Gold brothers are attempting to do is to drag delusional disorder away from the clutches of the biological psychiatrists and restore it to the care of people who at least think sympathetically about Freud’s psychoanalysis, rather than rejecting it as rubbish.

There are problems with the Golds’ thesis. In the first place, Truman Show beliefs strike me pretty well as a garden-variety delusion, although somewhat extravagant in conception—that one is starring in a show being watched by the entire world—and I can see no reason to single them out from other delusions, no matter how amusing the patients’ stories.

But at a more profound level, the task the Golds have set themselves requires several sleights of hand. One is erasing the line, pretty firm in biological psychiatry, between illness and wellness. It was an article of faith among the psychoanalysts that we are all the “walking wounded,” all of us a little bit ill with just degrees of severity rather than high walls separating us. The line between mental health and illness is not that distinct, the analysts say. “The challenge,” say the Golds, “is keeping the craziness at bay, under carefulwatch of the saner aspects of ourselves. It doesn’t take much for anyone, you and me included, to become mad.” These sentiments are perfectly laudable, in terms of destigmatizing mental illnesses.

But are they true?

The vast majority of us will never develop a psychotic illness, meaning delusions and hallucinations, aside maybe from a febrile delirium in a childhood infection. All kind of lesser things can go wrong for us, including substance abuse, mood disorders and chronic stress reactions. At any point in time, about 1 percent of the population has a delusional disorder. But that 1 percent tends to remain the same people. Most individuals are not really at risk of developing a delusional disorder, and the cheerleading from the Golds about social causation has the effect of obscuring this reality.

Moreover, the Golds make an important point, and then proceed to ignore it. They say you have to distinguish between the form of psychiatric illness (whether psychosis or not) and the content: what specific psychotic views the patient holds. And the specific content of psychosis changes a lot with culture, no doubt about that. In the 19th century, patients were often deluded about having smeared excrement on the Cross and other sacramental outrages (when in fact they had not actually done so). But that kind of delusion does not occur so often today because most people are rather indifferent to the imagery of the Cross. If you have not been exposed to an idea, you will not become delusional about it. This is why lots of patients in India have delusions about demonic possession, few here. So culture does determine content.

But culture does not really determine the form of illness. Melancholic depression, a form, is remarkably similar in all parts of the world, although the presence of such features as suicidal ideation (which we in the West have lots of) is highly variable. Yet the Golds go on to construct elaborate subtypes of delusional disorder, and the core of the book is a discussion of the different “forms of delusion”—such as delusional jealousy, persecutory delusions, grandiosity and so forth—except that those are not forms at all. They are content. We are transported back to the psychiatry, not of Sigmund Freud, but of the early 19th century, when delusional disorders received elaborate classifications on the basis of such content as “murderous monomania.” In the official diagnostic roster of psychiatry, the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association—currently in its fifth edition—content-delusions still persist in the form of such diagnoses as “pyromania,” now an “impulse control” disorder, once a delusional disorder, or a “monomania” in the language of the day. But for the most part, psychiatry has gone over to diagnoses based on form rather than content.

The core message of the book is that delusions have a psychology of their own, and much speculation is given over to exactly what this might be. I have to light a warning lamp here. It is possible that delusions, like much other psychiatric illness, do not really have a psychology, that they result from some kind of automatic brain phenomenon in the way that catatonia does not really seem to have a psychology—which is to say, a distinctive mental activity of its own. A common symptom of catatonia is the alternation of stupor and agitation, and in neither phase does much thinking seem to occur on the patient’s part. In stupor, patients are unresponsive to all save the most vigorous external stimuli; in agitation they are heedless of admonitions not to smash all the windows of the ward or to stop hitting the other patients. And afterwards, they cannot remember anything.

Delusions may not reach this level of automatic behaviour, but still, one wonders at the authors’ Socratic query of why the forms of delusion are related to the social. The answer is that not all of them are. Somatic delusions, the belief that one’s bowels have turned to concrete or that vermin are creeping over one’s skin, are common, yet not really “social” in nature.

We wade into academic waters in the discussion of what social factors might cause delusional disorder. It is a mixed bag. “Psychosis is a brain disease,” they say. No argument there. And then the authors offer a “vulnerability-stress” model to explain delusional disorders, one that draws equally on psychological stress and the neurotransmitter dopamine.

Sure, why not? We know so little about how the brain works that this could be true, as could any of a number of other competing models. Sexual trauma is obligatory in these models, but one is a bit surprised to see the authors throw in early cannabis use. One can make such models much more specific with techniques such as path analysis that weight each component, and the authors’ model is really just a list of what they think is important. But the Gold brothers are smart guys, and what they think important is worth listening to.

Schizophrenia has a way of creeping into the discussion, when it is useful to fortify the “social influencing” hypothesis. Yet delusions in schizophrenia are usually considered different from the fixed, systematic delusions of delusional disorder, where the brain and mind seem otherwise all right. In schizophrenia, the delusions are less stable and more fragmentary, and they come and go quickly. They may well result from a different brain mechanism, and the dragging in of schizophrenia gives the impression that the authors are a bit needy of evidence.

The Golds’ commitment to social shaping does lead to some curious calls. They consider erotomania—the delusional belief that someone else is in love with you—as an example of grandiosity. Hmm. These patients can be dangerous, and sometimes try to kill their love object after an imagined rejection (which is why stalkers are a menace rather than a nuisance). Yet it is not that the erotomania patient considers himself equal to the princess: he is not necessarily grandiose. He knows that the princess is in love with him. Yes, this is delusional disorder without doubt. But since the authors insist on breaking delusional disorder into these sub­categories, the insistence that this is grandiosity strikes me as a miscall.

On a rainy November afternoon, the seminar room at McGill could well be filled with excited chatter about these issues. The reading public, however, may find the many vignettes more gripping than the Suspicion System and similar speculative academic concepts with which the latter part of the book abounds. When one brings a psychoanalyst brother and a psychology brother together on such an afternoon, the conversation is bound to be lively; ideas fly all over the place. The expostulation, “Yes, that’s it!” will be common. Yet the knowledge base in neither psychiatry nor psychology will support such extensive timbering. It is the mind, not the brain, that has a psychology of its own. But much psychiatric illness is driven by the brain.

Still, Suspicious Minds is an important book, even if some of the psychologizing is off the deep end. The important thing is to wrest the discussion in psychiatry away from the extreme biological reductionism that has befallen the field for the last 30 years and to direct the conversation back to society, where it was left in the 1970s when social and community psychiatry began to fade. The social and community environment we inhabit plays an unquestionable role in giving our illnesses content—meaning what we think—even though these factors may not be so important in shaping the form of illness or in determining the response to treatment. What has been missing in particular these last three decades has been keen interest in psychopathology, the exact signs and symptoms that patients have. DSM is a disaster for the study of psychopathology because the illnesses are carved off in great chunks, or even worse, in the wrong chunks.

What the Golds are doing is directing attention back to psychopathology. They have taken delusional disorder almost as a case in point and are saying, hey, how do we break this down? What different kinds are there? And the big question that they do not ask but that is hugely relevant is: are there differences in response to treatment?

There are other big questions here that will animate other rainy November afternoons across the land. The many case studies are riveting. And the Golds are full of ready wit and clever prose. I think that for these reasons the book will be widely read by serious people.