Suspicious Minds: How Culture Shapes Madness by Joel Gold
My rating: 3 of 5 stars

The Enduring Mystery of Psychosis

As the old advert promoting advanced education used to say, “A mind is a terrible thing to waste.” It is frightening to consider how close we all are to the epitome of the wasted mind that is psychosis. If we are lucky enough to avoid psychosis in early life, we are still likely to have friends or family members who seem to just leave the domain of sanity and mentally inhabit some other region. And there is always that longer term threat of dementia to contend with. Whatever place those with advanced Alzheimer’s emigrate to, it represents a sort of hell to those left behind.

The central concept underlying a diagnosis of psychosis is ‘delusion.’ The psychotic, it is said, lives in a world of delusion. Psychiatry and psychology have come up with various classifications of these delusions, usually keyed on human desires and fears - power/impotence, sex/violation, reputation/disgrace, etc. The content of these delusions, researchers claim, vary by culture and epoch, but their form (a somewhat malleable term) remains constant. The most influential current theories about these delusions, according to the Golds, all centre on the social desire to belong, to be a valued member of society. Part of the rationale for such theories is that social cohesion is an evolutionary necessity. We can be driven mad by our intense personal drive to be part of a psychically as well as physically supportive community.

The authors suggest at several points that there are many more psychotics, and people on the verge of psychosis, than medical science has yet identified. One can hardly avoid referring to QAnon conspiracists, anti-vaxxers, and supporters of the Big Trump Lie of a stolen election as confirmation of the suggestion. A poll out this week shows that approximately half of all Americans believe in at least one of the various fantasies circulating on the internet - from Hillary Clinton’s sex-trade in children, to the toxicity of vapour trails and 5G, to Mike Lindell’s rants about Chinese vote-flipping. Delusion is obviously rampant. Or to put it another way, many Americans have found the home they’ve always dreamed of.

Or delusion might be rampant if only we could be sure about what psychosis (or more broadly, mental illness) signified. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) is a 500 page Bible for the profession. The DSM lists the detailed symptoms of almost 300 named mental disorders along with helpful hints about what ‘therapies’ (mostly drugs) might be indicated. The rub is that psychiatrists have almost no idea how and why these therapies affect brain chemistry. The DSM taxonomy has no basis in biology. It is purely a lexicon of symptoms. As the authors note, “… we still don’t have anything like a theory of mental illness that is good enough even to be wrong.”

Even more worrisome is that the idea of ‘delusion’ is fundamentally undefined. According to the DSM, “a delusion is a false belief based on incorrect inference about external reality that is firmly sustained despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary.” The editors of the DSM have clearly had a defective training in philosophy to put such a statement in print without embarrassment. What constitutes proof? Who determines this? When does stubbornness become delusion? And what is this vague criterion of ‘almost everyone?’

So I can understand the Golds’s central question: “Which of the myriad irrational beliefs that people have are delusional? In our view, this is the most important ignored question in the study of delusion.” I agree. But then I hit an intellectual dead end with their claim: “Our answer, in brief, is that delusions are symptoms of a disorder in a mental capacity whose function is to navigate the threats of social living. What distinguishes them from other bizarre thoughts is their origin in this mental capacity.” Come on guys. Disorder of a mental capacity? Isn’t that where we started? The term moves the quest on not an iota.

That one man’s delusion is another’s cause is obvious. The distinction is one of politics not science. This is obvious from the history of the psychiatric discipline itself. Delusion, it seems, might be the fundamental principle not only of psychosis but of the psychiatric profession as well.

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