A major theoretical crisis exists over the origins of bizarre behaviors, those senseless, life-damaging behaviors exhibited by patients often considered “mad,” “mentally disturbed,” or “crazy.” The crisis revolves particularly around the “brain-disease hypothesis,” which attributes schizophrenia and other types of bizarre behaviors to neurological impairments.
Despite over a century of research, scientists have failed to find a specific brain abnormality associated exclusively with this disorder. Furthermore, the majority of those diagnosed with schizophrenia show no neuropathological abnormalities at all, while the same abnormalities found in some schizophrenic patients can also be found in people who do not suffer from the disorder.
Additionally, neurologists have failed to explain the large heterogeneity of schizophrenic symptoms—how the same disease can cause such extreme differences in symptomatology, ranging from paranoid delusions and murderous insanity (e.g., the Unabomber), to nonviolent, hallucinatory madness (e.g., John Nash), to disorganized speech. Another problem concerns the fact that a significant percentage of schizophrenic patients recover with the sole aid of psychotherapy, “something never accomplished by a person with Parkinson’s, Alzheimer’s, or multiple sclerosis.”
Meanwhile, antipsychotic drugs, widely prescribed and often considered a boon of modern medicine, achieve low rates of recovery and come with an array of disastrous outcomes, such as an increased risk of metabolic dysfunction, motor dysfunction, cardiovascular disease, cognitive dysfunction, smaller brain tissue volume, and mortality.
Historically, the brain-disease hypothesis gained scientific attention for no better reason than the inability of Freud’s psychoanalysis to explain correlations between schizophrenia and neurological abnormalities. Starting in the ’80s, psychiatrists expanded the brain-disease hypothesis to cover neurotic disorders as well, once considered the sole territory of psychoanalysis.
The incursion came thanks not to any new supportive data, but once again as a result of psychoanalysis’ empirical deterioration, which, as noted by Harrington, was utilized “to overthrow the Freudian and bring back the brain as the primary object of psychiatric research, diagnosis, and treatment.”
However, not only is the relationship between neurosis and brain impairments much weaker than in schizophrenia, medical theories are confronted with more difficult theoretical problems. As with schizophrenia, these theories fail to clarify the mechanism which permits symptoms within the same behavioral disorder to vary between patients.
Conversion disorder, for example, is characterized by a wide range of symptoms, including paralysis, blindness, psychogenic movements, and epilepsy. Yet, neurologists, which in the recent years attribute this disorder to abnormal neurological activity, unable to explain this symptomatic heterogeneity. Moreover, they cannot even describe how neurological defects might cause these symptoms in the first place.
An additional problem is their inability to explain the dramatic rise in recent years in the prevalence of eating disorders and dissociative identity disorder. This rise has been restricted to Western societies, and Westernization through mass media has been shown to affect the prevalence of these disorders in non-Western countries. If these disorders were indeed neurological, Westernization would have no effect.
Another difficulty concerns bizarre phobias, such as sudden extreme phobia toward neutral stimuli. such as trains, chocolate, and insects, which emerge in the absence of anxiety-provoking events and severely disrupt the individual’s daily functioning. The question of panic disorder is similarly troubling: Even after many years of exposure to a feared stimuli, and absent any aversive consequences, panic sometimes still resists extinction—a fact that bothers proponents of trauma and learning theories.
Despite these difficulties, there has, unfortunately, been a growing consensus around medical models among members of the American Psychiatric Association (APA). The APA’s task force arrived at the conclusion that “there is no group of conditions which together comprise ‘neurosis’” in 1976, and consequently the APA decided to remove this category from the DSM-III in 1980. Although pressure from psychoanalysis advocates helped to maintain the term in parenthetical phrases, it was eventually excluded entirely from the DSM-IV in 1994.
The DSM has thus become a medical text, one in which psychological disorders are categorized as neurological diseases. This diagnostic approach has been sharply criticized by a number of researchers, not least for the APA’s close ties to the pharmaceutical industry.
Psycho-Bizarreness Theory: A Reinstatement of Freud’s Vision
Given the above evidence, the inevitable conclusion is that the brain-disease model was a terrible historical mistake. Psychiatry has no scientific legitimacy to treat schizophrenia or other mental disorders.
At the same time, Freud remains one of the great scientific figures of the 20th century. His most important contribution is his vision that schizophrenia, criminal insanity, and neurosis all share the same diagnostic criteria and etiology.
Freud himself failed to integrate this insight into psychoanalysis, largely due to his deterministic assumption, common to all traditional theories, that mental disorders are inflicted by forces beyond the patient’s conscious control. Though he sensed that patients somehow chose their particular behaviors, as implied in his concept “choice of neurosis,” he did not adhere to this idea.
Similarly, although the rationality of madness is embedded in Freud’s theory, he still viewed mental disorders as essentially irrational, seeing them as running counter to the individual’s best interests. A new theory, designated Psycho-Bizarreness Theory (PBT), recently published in our book The Rationality of Irrationality, adopts Freud’s vision, but inserts radical changes in his original suggestions.
Empirical Diagnostic Criteria of Bizarreness
Research and clinical data suggest that bizarre behaviors share five major and two secondary criteria. The most important criterion is sudden onset: the individual displays dramatic behavioral changes in the absence of an event that is uniquely linked with such changes and is proven to be a sufficient trigger for occurrence.
For example, a variety of obsessive-compulsive rituals, panic disorder, agoraphobia, and conversion symptoms occur in the absence of a specific (e.g., neurological, environmental, or social) factor that can be consistently associated with them.
In some cases, the onset may be gradual, such as with conversion disorder and anorexia nervosa, which progressively deteriorate until reaching a point of radical change. However, there is no observable event that is exclusively associated with or can account for this deterioration.
Researchers often report findings that seem to indicate that a certain event is the cause of a given behavioral disorder. Such evidence only violates the criterion of spontaneous onset if the event is proven to be necessary and sufficient for developing the disorder.
The four other major criteria of bizarreness include:
- Impact on attention and daily functioning: Mad behaviors intensively preoccupy the individual, severely disrupt his or her daily functioning, and may cause severe social damage, such as in criminal insanity.
- Unawareness: The individual is unaware of the underlying causes of his or her behavioral change.
- Rarity: Since people are rarely subjected to an intolerable level of stress, and madness is just one of several behavioral options (e.g., depression, suicide, and substance abuse) available to them, the prevalence of these behaviors must be low, below 3%.
- Social stigma: According to Carson, Butcher, and Coleman’s Abnormal Psychology and Modern Life, “almost by definition … abnormal behavior is behavior that is unintelligible to the vast majority of persons observing it.”
Two secondary criteria, not necessary for the diagnosis of bizarreness, are stress and depression. These criteria should be employed only to exclude some exceptional deviant behaviors that seem to meet the five major criteria but are not bizarre (such as autism, the onset of which is not associated with stress or depression).
Numerous case studies support the validity of PBT’s diagnostic criteria for bizarre/mad behaviors. In one of my studies, 15 psychiatrists and 50 clinical psychologists evaluated randomly-arranged deviant behaviors on each of PBT’s major criteria. Neurosis and psychosis were the only disorders that met all five of the criteria, compared to specific phobias (e.g., dentist and animal phobia) that met none. Psychosis scored significantly higher on all the five criteria when compared to neurosis. Post-traumatic stress disorder, a non-bizarre behavior, only met the second criterion of “impact on attention and daily functioning.”
Etiology of Bizarreness
PBT’s basic assumption is that when individuals are confronted with intolerable levels of stress, their behavioral options for handling the situation are limited. They may choose to remain emotionally distressed; to adopt drastic measures, such as suicide, substance abuse, or aggression; or to seek help and therapy.
At the same time, a minority will unconsciously choose to adopt mad behaviors—termed by Freud “bizarre,” but equivalent to the common term “madness”—including schizophrenia, criminal insanity, and neurosis.
Stress may be the result of environmental events, unacceptable impulses, and/or poor coping skills. It may also be, incidentally, the result of neurological impairments; the causes are not mutually exclusive. A number of studies have shown that schizophrenic patients with neurological impairments typically have severe attention deficits, low cognitive abilities, and poor social skills. As a result, they are likely to experience acute social isolation and poor adjustment over the course of childhood, adolescence, and adulthood.
PBT re-envisions the nature of “madness” altogether. Contrary to the traditional view, PBT sees madness as a rational coping mechanism which individuals adopt out of expediency. We can now reassess the relationship between schizophrenia and brain abnormalities. Those brain abnormalities observed in some schizophrenic patients constitute a source of stress motivating the individual to adopt his or her specific madness; they are not, however, the source of the disease.
PBT affirms Freud’s claim that repression is the key to understanding bizarre behaviors, yet it defines the term differently than how it is commonly understood. Based on Freud’s original definition of the term, PBT defines repression as “a coping mechanism by which the individual blocks the accessibility of stress-related thoughts through deliberate distractive means.”
In other words, people choose mad behaviors which they feel, intuitively, will block the accessibility of their stress-related thoughts. Hence, in PBT, repression is the consequence rather than the cause of madness. This is a radical departure from the psychoanalytic doctrine, which famously takes bizarre behavior to be a consequence of repressed traumas and desires.
Madness as an Economic Decision
Like a consumer choosing between different goods, individuals seeking to alleviate their intolerable stress through bizarre behaviors choose their specific madness according to three basic economic principles:
- Need: The behavior must increase the individual’s control over his or her stressor and/or provide social privileges, such as sympathy or monetary rewards. In times of war, for example, soldiers are more likely to adopt conversion disorders such as paralysis, blindness, and epilepsy rather than, say, anorexia nervosa. And people who blame themselves for their failures in coping with life’s demands, and thereby suffer from low self-esteem, are likely to choose a mad behavior such as schizophrenia which can inflate their self-esteem by way of delusions.
- Availability: The behavior must be present and available within the individual’s conscious and unconscious experiences, as are determined by unique personal events and various channels of information (e.g., mass media, family, peer group, etc.).
- Cost-Benefit Advantage: The benefit earned by the specific madness must exceed its cost. The individual must intuitively feel that the behavior effectively relieves his or her emotional distress.
The Development of Unawareness
We have claimed that individuals choose, through a kind of intuitive calculation, the behavior that will best repress their stressors. How do they then become oblivious to their own choice? In essence, patients become unaware of their own Knowledge of Self-Involvement (KSI) and True Reason (TR) for acting bizarrely through a variety of cognitive processes. They subsequently develop a self-deceptive belief that enable them to attribute the cause of their symptoms to factors beyond their conscious control, stabilizing their KSI/TR-unawareness.
This new concept of “unawareness” has numerous advantages over the Freudian concept of the unconscious. It avoids recent empirical challenges to the latter’s validity, explains clinical evidence indicating the frequent coexistence of awareness and unawareness, and provides a precise account of the mechanisms controlling therapeutic change and facilitating recovery.
In terms of the possibilities for therapy, PBT integrates all therapeutic interventions proven to be effective in the treatment of mad behaviors, from cognitive-behavioral therapy to religious therapy, under a single theoretical umbrella. An intervention is selected not based on its original theoretical grounding but rather based on the patient’s unique symptoms, background, and needs.
PBT equips clinicians with a set of principles that guide them to the right therapeutic approach for each patient. In addition, PBT outlines a new intervention, termed “Rational-Insight Therapy,” which aims to increase patients’ awareness of their current stressors and the faulty behavioral methods they have used in response. Simultaneously, it strengthens the patient’s coping skills through targeted training.
Numerous cases of bizarre behavior can help illustrate PBT’s interpretive power. Three famous cases, the first involving neurosis, the second schizophrenia, and the third criminal insanity, together confirm Freud’s ingenious insight that bizarre behaviors share the same diagnostic criteria and etiology despite their completely different symptomatology. They also support PBT’s idea that the major psychological function of such behaviors is repression (i.e., blocking the accessibility of stress-related thoughts), and that similar to consumer decision-making, the choice of a specific symptom is determined by the principles of controllability, availability, and cost-benefit advantage.
In the first case, William Leonard, a university professor, developed acute agoraphobia and panic symptoms upon seeing a freight train from a distance. The event affected him so dramatically that for he was unable to travel a short distance beyond his parents’ home. Psychologists have puzzled over his mysterious “illness” ever since.
In the second case, Theodore John Kaczynski (aka the Unabomber), a professor of mathematics, developed schizophrenia which manifested as a delusion that the industrial revolution and its consequences were a disaster for mankind (Graysmith, 1996). Attempting to spark a social revolution, he mailed bombs to various places, killing three people and injuring 23. Though he had the option to plead insanity and escape the death penalty, he vehemently resisted doing so.
In the third case, Charles Cullen, a hospital nurse, confessed to murdering as many as 40 patients over 16 years by injecting them with overdoses of various medications. According to some estimates, he may have been responsible for the deaths of over 400 patients.
All three cases conform to PBT’s criteria of bizarreness. Each individual displayed dramatic behavioral changes in the absence of a sufficient and necessary trigger (1); the behaviors negatively affected their attention and daily functioning (2); they were unaware of the underlying cause of their behavior (3); their symptoms were extremely rare (4); and their symptoms were stigmatized as a reflection of mental illness (5).
According to PBT, these three cases share the same etiology: current stress. Leonard’s panic attack took place soon after his wife, the daughter of a highly respected family, committed suicide. Their community had always regarded him as demanding and self-centered, and likely held him responsible for her death. Theodore Kaczynski suffered from “an almost total absence of interpersonal relationship” causing “acute sexual starvation” and severe depression. Charles Cullen divorced his wife, and suffered from loneliness, depression, and bullying his whole life. He attempted suicide multiple times, beginning from as early an age as nine.
In an interview with CBS’ 60 Minutes, Cullen said, “I tried to kill myself throughout my life because I never really liked being who I was. I didn’t feel I was worthy of anything.” Clearly the major function of these symptoms was repression. They intensively preoccupied each individuals’ attention, thus blocking the accessibility of their stress-related thoughts and relieving their depression.
The choice of symptoms in all three cases was determined by the same three principles that guide a consumer’s decision-making when buying a product. Leonard’s panic disorder and agoraphobia enabled him to exercise control over his stressor. They created distance between him and his hostile community; gave him a sense of victimhood, eliminating his guilt over his wife’s death; and helped him avoid potential rejection by colleagues at the university.
Kaczynski’s delusion that he could reform industrial civilization provided him with imaginary control over the very society that had rejected him. It also helped combat his sense of failure and boost his self-esteem, Kaczynski felt he was on a mission of messianic proportions.
Cullen’s behaviors, by giving him control over his patients’ life and death, granted him God-like powers. By killing others, he inflated his self-esteem so much that he no longer felt miserable and suicidal.
The symptoms in each case were influenced by the principle of availability. At the age of two, Leonard had nearly been run over by a train. He elicited memories of this childhood incident while experimenting with self-hypnosis, and thereafter made use of this newly uncovered “trauma,” along with his familiarity with psychoanalytic theory, to claim that he had been seized by a bizarre disorder of Freudian origins.
Kaczynski’s delusions, meanwhile, were suggested to him by the technophobic philosophy of Jacques Ellul, whose book, The Technological Society, he had read six times. Other influences may have been the violent riots he witnessed in the ‘60s, as well as the high availability of weapons in the United States in general.
Cullen utilized his profession and workplace to develop a unique pathological coping mechanism that served his repression and controllability needs at a relatively low cost. As a nurse, Cullen was able to conceal his killings for many years by using medications normally employed to save people’s lives. He knew that drugs like digoxin and insulin became deadly when administered in large doses, and were otherwise undetectable.
The cost-benefit principle guides individuals toward behaviors they intuitively feel will reduce their emotional distress at the lowest possible cost. It may be argued that, in general, the cost individuals pay for their mad behaviors is not worth their temporary emotional relief. Both Kaczynski and Cullen, for example, risked imprisonment and death for their crimes. Yet studies from the field of economics indicate that when experiencing emotional distress, the choice of a product is often determined by the individual’s immediate need to relieve tension, rather than by long-term considerations.
Thus, given the emotional distress to which these individuals were exposed, their behaviors were rational insofar as they served their immediate needs. The benefit Kaczynski obtained from his crimes was apparently so high that he refused to plead insanity to avoid the death penalty. This confession would have meant not only abandoning his coping mechanism and exposing himself to the original unbearable stress, but also dealing another blow to his self-esteem, which might have pushed him to suicide.
In Leonard’s case, the benefit was much higher than the cost compared with the above two cases. He received paid leave from his university. His new status as a victim deflected his community’s rejection and blame. Meanwhile, he endured only minimal discomfort in his daily life as a result of his illness. When the university threatened to fire him for his long absences (i.e., when the controllability demands changed) Leonard and his parents moved closer to the university so he could resume his teaching duties without venturing too far away. He rode his bicycle downtown whenever he pleased, rationalizing this violation of his illness by claiming that “the speed of the bicycle magnifies my beat.” He even traveled twice by train to meet his fiancée, though he claimed the experience was like sitting in an electric chair.
As the Nobel Prize-winning economist Robert Aumann has remarked, Psycho-Bizarreness theory “fits in very well with the concept of rationality as understood in economics, where a person’s behavior is considered ‘rational’ if under his circumstances, it advances his goals … Thus, Rofe’s theory, revolutionary as it sounds, fits well into the frameworks of economics, game theory and evolution.” Based on this model, my recommendations for effective and lasting reform in the practice of psychopathology are as follows:
- In line with growing criticism of the APA and its financially-motivated theoretical bias, the current DSM must be abandoned as the major classificatory system for psychiatric professionals.
- Freud’s original diagnostic categories of neurosis and psychosis must be reinstated, in accordance with PBT’s diagnostic criteria.
- Patients suffering from psychotic disorders like schizophrenia and bipolar disorder must be treated in rehabilitation centers under the care of psychologists, rather than in hospitals administering a medication regimen.
- The use of psychiatric drugs must be limited to the most severe cases, namely those exhibiting therapy-resistant depression with a high risk of suicide.
- Criminal insanity must be diagnosed by empirical criteria, such as those offered by PBT. The criminally insane should be held fully accountable for their actions and punished accordingly, with regard for the stressful circumstances that may have encouraged their adoption of the disorder.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.