All of the psychiatric illnesses can be defined by particular disturbances of thought, and feeling, and the behaviors associated with them. The characteristic speech of an acutely schizophrenic individual is often called “loosening of associations,” which reflects a disorganization of thought. The schizophrenic is distracted repeatedly by intrusive thoughts. Because he cannot think coherently, his behavior is affected, sometimes in terrible ways, and at other times in ways that are less obvious. And he is distressed. Similarly, a manic person has “flight of ideas,” a not dissimilar thought disorder marked by pressured speech and shifting attention. The mood of such a person can shift suddenly with no apparent cause from seductive to hostile, to enthusiastic, and then to gloomy. And such a person can engage in all sorts of irrational behavior, including gambling and promiscuity and exorbitant spending. (I remember a man who used to tip cleaning people in the hospital with million dollar checks that he wrote out and then handed out to them.)
But neurotic conditions can also show complicated disturbances of feeling and thought, and behavior. Patients with obsessive-compulsive disorder can experience distasteful thoughts that intrude unwanted into their consciousness. They may engage in repetitive and meaningless actions to ward off imaginary catastrophes. Hypochondriacs are so caught up with an idea—that serious illness is looming in front of them—that they lose all perspective on the meaning of their physical sensations. Others develop exaggerated fears of germs and of drugs.
And yet, the distinctions between neurotic or psychotic thinking and the thinking of everyone else can be subtle. Those aspects of mind that define the mentally ill merge into the ordinary thinking of ordinary people. What we think we know turns out to be unreliable. Our memories and perceptions are faulty, even when those errors to not rise to the level of obvious illness.
Do we know what we think we know?
The flaws of thinking that characterize someone who is paranoid are obvious. Someone hears the people next door laughing at him. Someone else hears God’s voice. Still another person follows his wife and can tell by the way she looks at a clerk that they are having an affair. A woman sees her dead father walking down a street. Another woman knows the announcers on a television program are talking to her. And wonders whether they can see her too. A man thinks people walking at a distance of two blocks are spying on him. Another man communicates with a dead pet.
But there are people who are not psychotic who have ideas that seem wrong, if not out-and-out crazy, to people who do not share those ideas. Religious ideas tend to have this character. A patient told me that she believed absolutely that a god exists who swallowed all evil and got a stomach ache which required the ministrations of a number of other gods to relieve. (She was Hindu.) Christian ideas of reincarnation seemed as absurd to her as her ideas seem to the western mind. Many people believe in miracles. Some people hold religious beliefs that require them to disbelieve in evolution—and, therefore, all the rest of biology –and geology, embryology, anthropology and astronomy. These sciences are attacked as false and coming from the devil.
Political views can also seem extreme. Conspiracy theorists come from every part of the political spectrum. A patient who is certainly not psychotic told me recently that he hated President Obama because of the murders Obama committed in college to cover up homosexual tapes that were taken of him at that time. My patient did not make up that charge. He read it on the Internet. There are ordinary people who believe the landing on the moon was staged, the H.I.V. virus was designed to kill Black people, and that the government is about to let loose a cadre of S.S.- like military forces in order to establish communism in this county. In Pakistan right now, health workers are being executed because of the belief that polio vaccine is intended to make Islamic children sterile.
There are people who are indistinguishable from everyone else who believe they were kidnapped by aliens on a flying saucer and interfered with sexually.
Scientists are not immune to such thinking. There were scientists who did not believe AIDS was caused by a virus as long as ten years after the virus was isolated. In fact, any new scientific idea is likely to be rejected by experts in the field. When continental drift was finally proved, it was not accepted by many other scientists. The idea did not receive universal acceptance until these older scientists died off. Scientists stake their reputation sometimes on ideas that were disproven long ago. Certain beliefs are so fundamental to particular individuals—to who they are– that they cannot imagine them to be wrong.
Individually, we are all likely to hold firmly to some beliefs that are manifestly false.
We believe certain things if they are believed by the people around us.
Cults: We think of a cult as a tightly-knit group which holds powerful sway over its members and which can hold to absurd views. Typically, they are physically separate from conventional groups which may be all around them. They may have a charismatic leader. They are usually regarded with suspicion, if not outright condemnation. They come to our attention when they grow past a certain size and when they enter into overt conflict with the rest of society. Three or four such groups in America immediately come to mind: the Branch Davidian cult in Waco, Texas, and the Heaven’s Gate cult associated with the comet Hale-Bopp. Both cults ended in catastrophe with members committing suicide or being murdered. The Jonestown massacre was another such incident.
We regard cults as sharing outlandish beliefs and marvel that anyone should accept those beliefs. For example, the Heaven’s Gate group castrated themselves and sometime later committed suicide with the idea that killing themselves would allow them to join other beings who were travelling on the Hale-Bopp comet. It is hard for us to remember that many of our current religions, including Christianity, was thought at the time they came into being to be cults. Their views, which were thought outlandish and distasteful at that time, have not changed much. What has changed is that they are widely accepted.
There are scientific schools of thought in which groups of believers meet regularly and do not tolerate dissent. They are like cults in that respect. Psychoanalysis has often been accused of being such a cult.
Placebos: A placebo is a pretend drug, a “sugar pill,” that is prescribed for a patient with the expectation that the patient’s belief in the efficacy of the drug will actually cause it to have an effect. And it does. The effect is real. It is not imaginary or “all in the mind.” Recently, there was a report of a man who tried to kill himself by taking an overdose of pills that turned out to be placebos. The man’s blood pressure dropped precipitously, as it might have done if the drug had inherent physiological effects. Everyone is subject to the placebo effects of drugs. This is not something that occurs only in weak-minded subjects. Whether a drug will act as a placebo depends on a number of factors: the seriousness of the condition for which the drug is being given, the emotional state of the patient, and the stature of the physician prescribing the drug. But everyone is subject to these effects.
Doctors are always wrangling with patients about brand name drugs vs. their generic equivalents. Although the drugs are identical, (within small prescribed limits), patients are often convinced they have distinguishable effects. Invariably, they prefer the brand name drug. It is a matter of their prejudices affecting their perceptions and their judgment. Once again, everyone is subject to these psychological influences.
One striking example: When Valium came off patent, the manufacturers tried to distinguish their product from all the generic drugs that rapidly became available. They cut a V into the pill, all the way through so that you could look through it. One patient told me the medicine no longer worked.
“It’s the same pill,” I told her.
“I want the original. That’s the only pill that works.”
“It’s the same exact pill, made by the same manufacturer. It’s the brand drug.”
“I don’t care. I can feel the difference. I want the original.”
“Well, you can’t have it. They don’t make it that way anymore.”
She was not reassured by my remarks. When people can feel in their bodies that something is happening, they cannot be persuaded that the reason may be psychological. Consequently, patients often experience side-effects that can have no reasonable physiological explanation. Doctors are likely to prescribe one drug after another to avoid these effects—which are not due to the drug itself, but to the idea of the drug.
Normal people are subject to very many other kinds of distortions of thinking. Hypnagogic phenomena in normal individuals can cause hallucinations before falling asleep. Is seeing believing? Not always, and not for everyone. But not many people are capable of standing apart from themselves and doubting their own perceptions. Being in love is often given as an example of not perceiving things (a partner) accurately, only half in jest.
Some philosophers have taken this skepticism in belief and what we consider knowledge to its logical extreme. Such philosophers have said that we cannot know anything of the real world. We have only our perceptions of the world. Descartes claimed that we could know one thing at least: “I think, therefore, I exist.” It is a real problem in the real world deciding what beliefs we should accept as proven, but I did not understand, as a philosophy major in college, how Descarte’s views added to our understanding of this problem. “I think, therefore, I exist,” seems no more true to me than, “I watch television, therefore I exist” or “I enjoy eggs for breakfast, therefore I exist.” He seems to be saying very little about the nature of thought or the nature of existence. My son, Michael, contributes this cartoon as commentary:
(c) Fredric Neuman