Of all the organs we are accustomed to knowing, more or less, what function they have—or at least to thinking that they have one—the brain is an exception in the way we tend to regard it. We know its shape and where it is located, but when we observe its manifestations—thoughts, feelings, behaviors—we do not tend to think that these could be the result of the function of an organ. Spirit, soul, energy: these are concepts we intuitively accept, even though they are not part of our concrete experience. We can see the brain, and we know in considerable detail how it works, yet it still seems “strange” to think of the mind as an expression of the brain.
One way to “realize” that the brain is indeed an organ is to study its diseases. By observing changes and disruptions, and by studying the “pieces” that are missing or altered, we can reconstruct the structure of the engine and understand how it functions when it is intact and in balance. In psychiatry, studying disease means, more than in other medical disciplines, observing the patient and recording how the person expresses himself or herself, because the brain, like other organs, cannot prevent itself from revealing what it is. It does not lie; it reveals itself through its signs: thoughts, emotions, attitudes, reactions.
Certainly, most of us are not accustomed to seeing patients every day and do not have a precise understanding of psychiatric illnesses. Yet the news, especially crime reports, often surprises and shocks us with behaviors described as “incomprehensible,” or as bolts from the blue occurring in apparently normal lives. “Madness” is imagined as a total upheaval, in which not a single part remains intact, but this does not correspond to reality. Above all, the “parts” that go out of order are not necessarily altered all the time. Indeed, intermittent forms of “madness” are much more common than stable ones. We often hear the terms “raptus” or “confusional state,” expressing the idea of a sudden and total loss of control, as though the brain had been “possessed” (literally, seized) by a force that agitates it randomly and drives it in senseless or excessive directions. But “raptus” almost never explains anything if it is understood as a sort of “muddle” in which the person simply goes haywire. This is why it is so often said that someone was “crazy but lucid.”
The term “madness” has no precise meaning in psychiatry, but if there is a medical term that comes close to it, it is psychosis. Psychosis simply means a broad alteration in the way a person perceives the environment and processes it—that is, what the person thinks about his or her situation and the environment in which he or she lives. The core symptom of psychosis is delusion.
To be in a delusional state means to depart from thought that is constructed in an understandable way, to think almost automatically in response to internal impressions or external stimuli, proceeding through associations or general themes without a filter that distinguishes what is “real” from what is imaginary.
A person experiencing delusions no longer has fantasy in the ordinary sense. Fantasy and imagination are functions that exist when a person is able to think about something that does not exist without therefore superimposing it on reality. In fact, people cultivate fantasies with desire, ambition, regret, amusement, or personal fascination. In delusion, by contrast, the initial elements of thought—whatever “comes to mind”—arise as “true.” They are not merely starting points for thought; they are treated as facts.
Quite simply, if someone on the street looks at me with an expression that seems hostile, the very fact that I think “he seems hostile” means that I perceive a hostile facial expression while automatically applying a filter that tells me there is no reason for that person to be hostile toward me. That person may have any number of reasons for looking that way. The expression would seem significant if there were some reason to think that the person actually had something against me.
A person experiencing delusions does not verify what he or she thinks. Instead, the person simply continues reasoning from the premise “he was looking at me badly.” From there, together with other similar elements—coming either from inside or outside—the person may construct the idea that, for example, there is a conspiracy against him or her, that strangers are following the person in order to monitor or harm them, or that people are communicating something that the person cannot understand.
Little by little, the construction becomes more complicated and meanings become increasingly defined, in an ever more convoluted and complex way. Every detail, rather than being recognized as unrelated to the original thought, becomes something that must forcibly be fitted into it—a puzzle piece that has to match and is therefore reshaped until it does. In this way, the person no longer understands reality as it is. Instead, he or she selects the elements that support the initial thought, while the rest are obscured or filed away, and insignificant details become important keys to interpretation.
Indeed, if the person who looked at us badly then greets us warmly—perhaps because we know each other—the person experiencing delusions will not think, “I was mistaken; that person was not angry with me after all.” Instead, the person may think, “There you go—he is making fun of me; he is hinting ironically that he really does have something against me.”
A person experiencing delusions was once also described as “alienated,” precisely because his or her reality was foreign to that of other people, and vice versa. It is somewhat like an “alien” communicating in a language that others cannot understand and translating our language into something incomprehensible to us.
The person does not realize that anything is abnormal, and the person’s entire behavior does not necessarily become altered. Some people may be incomprehensibly convinced of a “truth” or a “reality” without being able to explain how they arrived at that conclusion. They never actually reached a conclusion: they simply thought it was true, and therefore “it is true,” even though they cannot justify it logically.
The problem is that they do not even feel the need to verify it. This is not an intuition or a hypothesis, however strange or apparently nonsensical. It is a “reality” that is already born as true, and on which the person bases decisions and deductions.
People experiencing delusions are often convinced that their thinking is actually “superior,” because it has managed to understand “what really matters,” the absolute truth—something so true that it requires no proof, because they feel it to be true and have no doubt about it from the outset.
In fact, having such a conviction can make a person feel extremely “independent” and fulfilled, because he or she becomes the source of truth, part of the truth, rather than simply a brain that reasons and searches for answers but almost never possesses absolute certainty.
When a person’s life develops along two parallel tracks, one shared with other people and another “delusional,” the condition is referred to as paraphrenia. The paraphrenic person generally cultivates his or her delusion without coming into conflict with others, except when contradicted or criticized.
There may be religious delusions, delusions concerning the paranormal, events in life that never actually occurred (false memories), relationships with other people, one’s “secret” identity, inventions one believes one has conceived, or impending catastrophes.
A paraphrenic person may even become a teacher, because his or her “truths” may appeal to, excite, or convince other people.
The word schizophrenia is very well known, although it is often used incorrectly. In everyday language, “schizophrenic” refers to an unstable person who changes his or her way of thinking and behaving, as if they were two or more different people depending on the moment, with mood swings and fluctuations in “energy” (from indifferent to agitated), capable of sudden and impulsive decisions.
This meaning has little to do with the technical one and instead resembles what is technically called bipolar disorder.
Schizophrenia is an illness that “breaks apart” the normal pathways through which a person is organized, obviously on the basis of alterations in the brain. In particular, it causes thought and behavior to become connected in ways that are disconnected from the emotional “meaning” of things.
Contrary to what we tend to think, the purely rational meaning of what we think does not motivate our behavior by itself. Behavior becomes more or less likely, and is directed in one direction rather than another, according to our emotional state. We make emotional choices and correct them rationally, but fundamentally, what has meaning for us depends on an “affective” balance. Even memories—of what we want to repeat and what has mattered to us—are essentially emotional.
In schizophrenia, emotion becomes flattened. It may be expressed quantitatively, as a state of agitation or indifference in terms of movement, but what is lost is meaning.
What the person with schizophrenia thinks is a construction that seems to arise from nowhere and ends in behavior, without an emotion to justify it. Sometimes there remains a logic connecting thought to behavior, but it is a logic resembling a fragment of a story: one can understand what happens in that particular section, but it is difficult to understand what the overall story is, and one cannot truly identify with the characters.
Each part is like an episode of a television drama whose plot keeps changing. The script can be understood, but the overall story cannot.
Schizophrenia is a condition that tends to progress, and over the years thoughts and delusions generally decrease in quantity and complexity, leaving a kind of psychological “emptiness”: indifference, apathy, poverty of ideas and reasoning, and increasingly weak instincts.
In the past, this form of psychosis was also described as “dementia praecox,” or early-onset dementia, in contrast with senile dementias. The schizophrenic brain functions without an emotional organization or sorting of experiences and with certain automatic connections between thinking something and translating that thought literally into action.
Several films have portrayed psychotic states. Among them are A Beautiful Mind, Spider, and Conspiracy Theory.
An older film that depicts a form of paraphrenia is Harvey, starring James Stewart. The protagonist lives with an imaginary friend. He talks to him and is convinced that other people can see him and speak to him as well. The friend is a gigantic white rabbit whom the protagonist first saw one evening while drunk, standing beside a lamppost.
The protagonist sees something that does not exist, or is at least outside ordinary experience, but he does not ask himself how a gigantic talking white rabbit could exist, follow him, and live with him. He simply knows that this is the case.
Indeed, when people naively ask him why he named his friend “Harvey,” he replies that this is simply his name, and explains how he “knew” it through a logically nonsensical explanation that is nothing other than an example of delusional thinking.
The themes of delusion are human, as are its contents. In their content, delusions reproduce experiences and fantasies, much as dreams do.
What is strikingly abnormal is their incomprehensibility—even to the person himself or herself—once the delusional state has ended. The person may not remember, or may no longer be able to reconstruct, the reasons for his or her behavior, even while remembering what was thought.
The meaning that connected the elements of thought is no longer there. In fact, there may never have been any such meaning. Thus, once judgment has been restored, two things that were associated during the delusion—for example, “that person is wearing yellow, therefore he wants to kill me”—no longer appear connected.
The person may remember defending himself and perhaps even killing that person because he thought the person wanted to kill him because he was wearing yellow, but he no longer understands why he made that connection.
Sometimes it is as if the behaviors carried out under the influence of the delusion had been performed by someone else. And because delusions are often fragmented, the same person may no longer attribute past actions to himself or herself, because each “piece” of life is disconnected from the others.
There is no emotional meaning, no logic that makes the story continuous. There are many chapters, but they do not form a single story, as though each belonged to a different book.
Crime reports often contain cases in which a person is convicted of murder but claims not to remember the event, or has confused and fragmented memories, as if reliving a dream, or does not know whether something was actually seen or merely dreamed.
This can give rise to confused and contradictory accounts in which imaginary accomplices or assassins appear. These may represent the person himself or herself as he or she experienced the delusional state at that moment, or may result from a memory of oneself that is not connected to a sense of personal identity.
For example, a person may describe himself performing an action while insisting that it was someone else, with another name—perhaps an invented one—another role, and different characteristics.
A person experiencing delusions, particularly someone with schizophrenia, may for example “split” his or her mind into different personalities, as though at different moments or in response to different thoughts the person no longer recognizes a single “self,” but instead experiences different entities that may enter or leave, come from outside, influence or guide him or her, and perhaps be given different names.
For example: “A was going home, met B, and then C also came along and convinced them to do a certain thing.” This may mean that different emotional states or thoughts have “created” different characters, as if they were different souls. In reality, the person is describing something he or she did alone: the person was A, B, and C.
The potential for dangerousness in psychosis obviously exists, particularly when psychosis occurs in the context of specific illnesses or conditions such as drug abuse, bipolar disorder, schizophrenia, or paranoia. At the same time, there are many socially accepted forms of delusion (simple paraphrenias), which may have no aggressive implications and may instead underlie cultural trends or fashions concerning nutrition, health, “spiritual” orientation, or lifestyle.
The more passive risk for people experiencing delusions may instead be that they are easily manipulated or drawn into organizations or groups that organize the delusion as a collective or community activity for financial or other exploitative purposes. Such groups may also prevent people from receiving treatment, or condition them not to seek it.
One of the most common causes of psychosis in young people, especially temporary forms of psychosis, is drug use.
Crime reports involving young or very young people responsible for murders—sometimes carefully planned and then carried out with extreme violence—often reveal drug use during the preceding period. This fact is mentioned but also underestimated, as though the cause of the “evil” had to be sought in culture and society or in a deviant personality.
In reality, many people can reach a certain point of negative feelings, indifference toward family attachments, narcissism, and pursuit of their own interests. Drugs can make the difference when they lead a person to believe that he or she has found a solution that is genuinely good, meaningful, and capable of resolving everything else, for all time to come.
Cannabis, in particular, has become a source of concern in recent years as a possible cause of “new” psychoses that may persist over time.
Suicides, too, are sometimes not simply acts intended to end suffering. They may be impulsive acts in which, at that particular moment, there is a delusional meaning that no one will ever be able to reconstruct with precision.
There are cases of suicide carried out because of a delusion that one will be reborn into a better world, ascend to a higher spiritual level, or kill a negative part of oneself so that the positive part can prevail, or influence events through one’s own death.
Some depressed people die by suicide while experiencing the delusion that their imaginary guilt will be forgiven through their death, and that their family members will be saved by their sacrifice.
Some people in a state of extreme excitement kill themselves without realizing the danger, convinced that they are immortal, that they are being called to heaven, or that they possess superpowers.
Some people with schizophrenia kill themselves or injure themselves—or injure others—because of the “voices” they hear, which to them are nothing more than instructions to be followed.
A famous American multiple murderer, the “Son of Sam,” acquired this nickname because he himself claimed responsibility for the killings, saying that he was the spiritual son of a man named Sam, his neighbor. In his delusional system, Sam communicated to him through the barking of his dog, telling him when and whom to kill.
At times he regarded Sam as a kind of deity to be respected; at other times, as a demon who forced him to do things he did not want to do, turning him into an instrument in Sam’s hands through a form of mental coercion.
In several murders committed by psychotic individuals, the first reaction is usually to ask, “How could he have killed?” Little attention is paid to the fact that the least comprehensible part of the whole episode may instead be the construction of delusional reasons on the basis of which the person decides to kill—sometimes with the urgency of someone who feels that his or her life, physical integrity, reputation, or something similar is under immediate threat.
Behind many apparent “raptuses” there are long histories of delusions that have gradually become more continuous and increasingly complex, like a process that continually gathers evidence pointing in the same direction and discovers ever larger and more threatening conspiracies.
What is striking about the final aggressive act is also, perhaps, its suddenness: why did it happen at that particular moment rather than at any other, and why not earlier?
This is usually related to various factors and to the fact that the behavior of a person experiencing delusions is itself disorganized, including in the way aggressive responses are produced.
Delusion is too often confused with intuitive genius, as though the innovative and brilliant scientist who “pulls” thoughts out of nowhere, even against prevailing ideas, were simply a psychotic person who happened to be more fortunate than others who ended up in a psychiatric hospital.
Nothing could be further from the truth.
A scientist who has a sudden insight without knowing where it came from subsequently proceeds to verify it. This is precisely what the psychotic person does not do.
Delusion involves only one step: the person thinks and therefore concludes. There is no need or interest in verification. It is enough to “know” already.
“Madness” can affect brilliant people, but it is not the same thing as genius. Nor does it have anything to do with intelligence or character.
It is a kind of “malfunction,” sometimes brief and sometimes persistent, that can affect the human brain—any human brain.
Delusion is not the same thing as fantasy either, because the capacity for fantasy is not so far removed from the ability to memorize, process, and associate elements of reality that it cannot also create imaginary realities.
Brilliant, intuitive brains, capable of rapid thought and extensive association and imagination, can at some point derail and enter a delusional state. But when this happens, their creative, reasoning, and inventive abilities break down and become disorganized.
This is particularly true in the case of bipolar psychosis, or manic-depressive illness.
It can therefore be said that in “great” minds there may be a seed that predisposes simultaneously to intellectual vitality, innovative insight, and the courage to break established patterns—and also to the possibility of periodically “going into overload.”