TRUSTING WHAT YOU SEE AND HEAR isn’t just a matter of judging the reliability of other people. For some patients, “Did it really happen?” refers to the sensation itself — was it real or imagined? I hadn’t wanted to bring up Neil’s hallucinations so soon after we discussed the important issues of muffins versus scones, latté versus cappuccino — but Neil reminded me of that odor of burning rubber that sometimes preceded his seizures.
      “And, of course, no one else smells it. Are hallucinations always a sign of schizophrenia or temporal lobe epilepsy? I’d always thought,” he added, “at least, until my neurologist straightened me out on the matter, that hallucinations were what defined schizophrenia — which had me more than a little worried.”
      According to the picture that is emerging of post-traumatic stress disorders, hallucinations are not even necessarily a sign of a serious mental illness. Quite a few people have probably had an occasional hallucination — for example, after the death of a pet dog or a close relative. And stress disorders are surprisingly common, what with people and pets dying, car accidents, burglaries, divorces, and the like.
      A San Francisco psychiatrist, Mardi Horowitz, likes to tell the story of his quickest diagnosis and course of therapy, five minutes start to finish. Over the years, he tended to have conversations with an elderly neighbor over the back fence, often about this guy’s hip replacement or his prostate troubles or his cataract surgery. But this time, the neighbor happened to mention his handgun.
      This seemed out of character, so the psychiatrist gently asked, “Are you having thoughts of suicide?”
      The neighbor said that he could put up with all those medical problems of the past, but he wasn’t going to let his mind go, not without doing something about it while he still could.
      The psychiatrist asked, What sorts of new problems?
      Hallucinations. He keeps seeing his dog (who died of old age three months earlier) out of the corner of his eye, sometimes hears her bark.
      The psychiatrist replied that he’d bet it happened most often about the time of day that the dog had been fed.
      Er, yes.
      The psychiatrist explained that people who are grieving often suffer hallucinations. [That’s presumably why the word ghost had to be added to our dictionary, because so many people have shared a similar experience.]
      The neighbor thought he was being humored. So the psychiatrist asked if he’d believe it if he saw it written in a book. Well, maybe. And so the psychiatrist went into his house and returned to the backyard fence with the textbook and showed it to the neighbor.
      Yes, said the neighbor after reading the page — but those are people they’re hallucinating — dead wives and husbands and children. This is a dog I’m hearing.
      Well, the dog meant a lot more to you than most people, right?
      Psychiatrist recommended a new dog. Neighbor got new dog, lived happily ever after.
      “Let’s aim for one of those `lives happily ever after’ for my story,” Neil said, amused but serious.
      And then he continued. “From what you’ve told me, I gather that hallucinations don’t necessarily mean an `organic’ psychiatric illness. Does this mean that they can be a mind problem, rather than a brain problem? So what psychiatric disorders are brain problems?”
      Ahem. All psychiatric problems are brain problems, and the psychiatrists are changing their classification scheme to try and avoid that cartesian dichotomy. Organic has tended to mean obvious damage of some sort, producing psychiatric symptoms. As from head injuries, strokes, and tumors.
      But it doesn’t have to be easily visible damage produced in reaction to something external to the brain. Focal degeneration is sometimes seen — Maurice Ravel’s inability to compose during the last four years of his life is thought to have been due to a degeneration of cortex in the lower part of his left parietal lobe. And, of course, degeneration includes Alzheimer’s dementia, the most common organic disorder, 4 million cases in the United States alone due to more widespread degeneration of the brain.
      “That’s really brain rot?” Neil asked.
      Well, not the whole brain, but crucial parts of it. Alzheimer’s disease is a condition in which neurons wither up and die, often in the cortex along the inner side of the temporal lobe, such as in the hippocampus. Initially the result is a loss of recent memory, but it’s followed by loss of other functions as the degeneration extends to other brain circuits. They lose long-ago memories as well as failing to store new memories. Eventually even vocabulary and skills are lost — they’ll fail to recognize a knife and know what it’s used for. The degeneration is associated with the accumulation of an abnormal protein, amyloid, in a characteristic pattern called senile plaques, although the cause of the Alzheimer’s degeneration is unknown.
      You can also get brain damage from substance abuse, such as all those cases of instant, and permanent, Parkinson’s disease in young people who took the street drug MPTP. Adolf Hitler abused psychostimulants for years, and some psychiatrists think that an organic delusional syndrome might have caused his delusions of grandeur and persecution. Sometimes delusions persist long after amphetamine abuse ceases.
      “I’ve always wondered about whether there’s an organic cause for arsonists,” Neil said. “Not the professional arsonists — but the ones who like the thrill of it all.”
      Those serial arsonists are a surprisingly well-defined group of people — and yes, there’s some evidence of an organic basis for their behavior. To everyone’s surprise, they’re not psychotic — in other words, they don’t have delusions and hallucinations. They’re nearly all male — and alcoholics. They seem to have a more general disorder with serotonin and blood sugars. They’re generally coming off a binge when their blood glucose levels plunge and their brain serotonin levels change. In this state, they seek excitement by setting fires.
      “Sounds like mania.”
      No, they don’t share most of the other symptoms experienced by the people with mania. Fitting the same syndrome as the impulsive fire-setters, however, are those who impulsively attempt to kill someone.
      “What do you mean by impulsive? No obvious premeditation?”
      When the police said that the victim was unknown to the assailant and didn’t do anything to provoke the attack. Furthermore, the police couldn’t see that a robbery motive was involved. These people are also at risk of doing violence to themselves, many of them once having been hospitalized after attempting suicide. And they aren’t characteristically violent, or setting fires, while in prison — where alcohol is generally unavailable.
      The manslaughter-or-arson disorder, whatever you want to call it, doesn’t fit very well into our usual subdivisions — few of them, for example, fit the usual diagnostic criteria for major depressions, despite all those suicide attempts. It could easily be a metabolic disorder involving some of those lawn-sprinkler neurotransmitters such as serotonin.
      “So is this a thought disorder? A mood disorder? I’m confused.”
      You’re not alone — it’s hard to tell how they’ll classify it. Mood disorders such as mania and depression involve inappropriate emotional responses. Thought disorders involve inappropriate thoughts. Schizophrenia, delusional disorder, and a few minor ones constitute the thought disorders — but let’s stick to mania for a minute.
      In mania, you see excessive excitement and a lot of impulsive behaviors, but when the mania is mild, such people can be very energetic and get a lot done. Still, they get into trouble from hypersexuality, inappropriate laughing and joking, buying sprees, and reckless driving. They tend to get disorganized as the mania increases, and even more prone to poor judgment. Their speech becomes pressured and they may answer questions at great length. They sometimes even keep talking after their audience has fled the room. Virginia Woolf, when becoming manic, would talk almost without stopping for two or three days. For the first day, she made some sense, but by the third day she was totally incoherent. That’s back before lithium salts as a treatment for mania; schizophrenia and mania used to be confused with each other, especially in the United States, until the response to lithium treatment served to better define the two patient populations.
      The euphoria and the sometimes infectious cheerfulness of mania is confusing, but the psychiatrist can usually tell manic euphoria from a genuine “good mood” by other symptoms that are clearly pathological, such as uncharacteristically poor judgment and extreme grandiosity.
      And, of course, mania usually alternates with depression, to form a bipolar disorder. Mania’s association with depression was first noted 1,800 years ago. The bipolar patients are not continuously abnormal, being quite functional in the periods in between their manic and depressive phases — indeed, they may get a lot done. But there is a lot of alcoholism and drug abuse associated with manic-depressive illness.
      More often, depression comes by itself. Depressed people sleep poorly (or too much) and feel fatigued, they get little pleasure out of daily activities, they have difficulty concentrating, and they may feel worthless or guilty. A depressed mood might be an appropriate emotion after death of a loved one, but not as a response to the only sunny day of the month in Seattle.
      Depression can be very profound, preventing the patient from doing any activity and with a significant risk of suicide. The lifetime rate for attempted suicide in individuals with no history of mental disorder is 1 percent, but for the depressed it is 18 percent, going up to 24 percent in manic-depressives. And 70-90 percent of all suicides seem to be in people with mood disorders.
      “Depression is what they used to call melancholy?”
      That’s the Hippocratic name for it, 2,500 years ago, and Aristotle thought that “those who have become eminent in philosophy, politics, poetry, and the arts have all had tendencies toward melancholia.” But mood disorders can be traced back 10,000 years to King Saul in the Old Testament book of Samuel. Saul developed periods of severe depression, guilt, and incapacity; later he became psychotic and attempted to kill his son Jonathan along with David, nemesis of Goliath.
      “Hamlet?”
      There are lots of examples — St. Augustine, John Keats, William James, Leo Tolstoy, Ernest Hemingway, Sylvia Plath, John Berryman, Ann Sexton, Winston Churchill — quite a few politicians, actually. Poets seem to have the highest rates of mood disorders and suicide. The psychiatrist Nancy Andreasen, who started out as a professor of English literature, did a study of creative writers using modern psychiatric criteria for schizophrenia that showed that the writers had three times the expected rate of mood disorders, and none had schizophrenia; their parents and siblings also had the same rate of mood disorders. Other studies show artists, poets, and writers with eight to ten times the major depression rate for the general population and ten to forty times the rate for manic-depressive illness and its milder variants. So perhaps Aristotle was right.
      “So are there really more depressed women than men?”
      About twice as many, for depression by itself. But manic-depressive illness is an equal-opportunity disease.
      Mood disorders and schizophrenia are relatively common. About 4 percent of the population is suffering from depression at any one time, maybe 10 percent have had a major depression in the last year, with about 20 percent of the general population experiencing an episode sometime during their life. Another 10 percent of the population has had problems with alcohol or abused drugs in the preceeding year. Schizophrenia is only a fraction of a percent on the preceeding-year scale but that disguises a lifetime prevalence between 1 and 2 percent, with about a tenth of the schizophrenics in the hospital at any one time and many of the rest unemployable — so it’s expensive, something like $73 billion annually in the United States alone.