Case History
The person who is the subject of this case report is a 60 year old married American citizen. He was born in New Haven, Connecticut into a wealthy New England family. His father had a distinguished military career, who after a successful career in the Texas oil industry entered politics, and became president of the USA from 1989 ? 1993. Our subject?s early life appears to have been unremarkable. His family moved to Texas when he was a child because of his father?s business interests, and he was sent to a prestigious, elite preparatory school in Massachusetts. In 1964 he entered Yale University to read for a degree in history. He was a keen sportsman, playing baseball and football, and like his father and grandfather, both of whom went to Yale, he became a member of the University?s secret society, the Skull and Bones. He was also a member of the Delta Kappa Epsilon fraternity, eventually becoming its president. He was described by his tutors at Yale as an ?average? student, and he left in 1968 to do his national service in the Texas Air National Guard, when most of his contemporaries were fighting in Vietnam. He trained as an F-102 fighter pilot, and was promoted to First Lieutenant in November 1970. At this stage his difficulties were becoming apparent. In May 1972 he went to Alabama and requested reassignment to an inactive unit there. It seems odd that a pilot should request transfer to a unit that had no aeroplanes. His request was denied, and for the last two years of his national service he seems to have disappeared. His premorbid personality is described by acquaintances as outgoing and sociable, with a good sense of humour. Despite being seen by some as unintelligent, his IQ on entering Yale was 129, putting him in the bright-normal range.
In 1975 he entered Harvard Business School, after he tried unsuccessfully to gain a place to study law in the University of Texas. On leaving Harvard with an MBA he started work by setting up his own oil and gas company. After a few years this hit financial difficulties, and was bought out by a competitor, and as a result of this he became a millionaire.
In his early adulthood there is evidence that he had a problem with alcohol. Whilst in the DKE house at Yale it is reported that he drank heavily. On leaving the National Guard, he drifted aimlessly without direction, and during this period his drinking problem seems to have intensified. In 1972 he smashed his car into a neighbour?s garbage can after he had driven intoxicated back from a party. He tried to pick a fight with his father when he came outside to see what was going on. It is also alleged that in 1974 he spent Superbowl Sunday at a party hosted by Hunter S. Thompson, whose autobiographical novel Fear and Loathing in Las Vegas extols the virtues of a wide variety of drugs, including LSD, mescaline and cannabis. In October 1976, he was arrested for drunken driving, convicted, fined $150 and banned from driving for two years. When questioned he denied being dependent on alcohol, ?I don?t think I was clinically an alcoholic; I didn?t have the genuine addiction. I don?t know why I drank. I like to drink, I guess? he said.
In 1977 he married a librarian, and four years later she gave birth to their first children, twin girls. Over the next few years his drinking caused his wife much concern, and on the occasion of his 40th birthday in 1986 he vowed to give up alcohol after she had threatened to leave him if he didn?t. Shortly after this he appears to have reached a turning point in his life. He stopped drinking, and went through a religious conversion. He was brought up an Episcopalian, but adopted his wife?s faith, Methodism. These changes may also have had something to do with his father?s decision to stand as Republican candidate for the presidency of the USA in 1988. During this time he worked as a member of his father?s campaign staff, becoming particularly popular with the Christian political right, and in 1999 he announced his own intention of standing as president as a ?compassionate conservative?.
His psychosis appears to have had an insidious onset, suggesting that his condition has a poor prognosis with little hope of a return to full normality. Sometime in the mid 1990s he phoned his close friend, the charismatic preacher and host of the American TV show Life Today, James Robison, to tell him that he had heard the voice of God speaking to him, telling him to run for president of the USA. He acted on this imperative verbal auditory hallucination, stood for president, and was duly elected. Shortly after his election, three and a half thousand people were slaughtered in Al Qaeda?s murderous attack on the World Trade Centre. This major international tragedy had a devastating effect upon our subject?s mental state. At a meeting held with high level Palestinian officials, including then premier Mahmoud Abbas, he is reported to have said:
?God told me to strike at Al-Qaeda and I struck them, and then he instructed me to strike at Saddam, which I did, and now I am determined to solve the problems in the Middle East.??
Since then he has made persistent claims to be on a divine mission. Speaking to West Point graduates he expressed the delusional belief that we are in a conflict between good and evil, and that America is ??firmly on the side of the angels?? He has also claimed to be aware of a ??wonder-working power?? that he believes to be abroad in the United States. Interestingly his favourite film is Field of Dreams, based on the novel Shoeless Joe by W.P Kinsella, in which an Iowa farmer builds a baseball field in his pastures in response to verbal auditory hallucinations. GB too has acted on his delusional beliefs. In 2002 he sent troops into Afghanistan in order to clear out the Taliban and impose democracy and freedom. In 2003 he invaded Iraq to rid the country of its dictator Saddam Hussein acting on the delusional belief that he had stockpiled weapons of mass destruction. His actions in response to his delusions have had catastrophic implications, with a maximum of 43687 civilian deaths reported by Iraq Body Count1 , and some 2553 US troops killed2. No such weapons were ever discovered. There is also some evidence that this form of psychosis may also exist in a socially induced form similar to Folie ? deux. His close friend, a UK citizen T.B., shows evidence of similar problems.
It may be helpful at this point if I set out the diagnostic criteria for this condition, which I am proposing to call World Domination Disorder:
A. Unusual Beliefs
Believing that you have a divinely inspired mission to rid the world of evil.
Believing, or claiming to be a democratically elected head of state, and believing or claiming that the majority of the population support you.
Acting on these beliefs.
B. Unusual Experiences:
Hearing voices, especially of a religiose or grandiose nature (e.g. hearing the voice of God telling you that you are on a divine mission, and are engaged in a struggle on the part of good, against evil).
Having the experience that one?s actions and will are under the control or influence of God.
Acting on these experiences.
C. Moral Insanity:
Moral insanity indicated by:
Failure of, or arrested state of development of, moral imagination (e.g. unable to appreciate the consequences of 40,000 Iraqi deaths)
Evidence that this is a developmental disorder, for example of an abnormal premorbid personality.
Inability distinguish between the values of transnational corporate capitalism and democracy.
Inability to distinguish between the values of evangelical Christian fundamentalism and democracy.
No insight.
In order to meet the full criteria for the disorder, it is suggested that there must be two items present from each of categories A and B, one of which must be item three (acting on these experiences) in either A or B, plus any two items from category C. In order to meet partial criteria for the disorder, there must be two items present from either category A or B, one of which must be item three, plus any two items from category C.
This suggestion for a new category of mental disorder is put forward in the hope that the finest neuroscientific and psychopharmacological brains will be stimulated to carry out research into the disorder, and that this research will result in the development of a new class of drugs and physical treatments aimed at rectifying the neurochemical imbalance that is almost certain to underlie the condition. Studies have shown that in rats, aggressive and domineering behaviour is mediated through circuits in the brain controlled by noradrenaline and serotonin. In addition, these circuits are thought to be determined by genetic mechanisms associated with the Y chromosome. Indeed, some authorities consider WDD to be a sex-linked recessive disorder. The case history I have presented supports this hypothesis. If so, at some future point it may be possible to genetically engineer sperms by removing the deviant segment of DNA and replacing it with a harmless variety. In this way this dangerous and lethal condition may eventually be brought under control. Or will it?
Experience indicates of course that such a course of action is extremely unlikely to take place. Setting satire and hyperbole aside, there are disturbing resonances between the language that is popularly used by journalists to talk about progress in medicine and warfare. Doctors are engaged in the ?battle? against mental illness. Drugs are described as magic bullets aimed at ?targeting? specific types of brain receptors in much the same way a ground to air missile targets an enemy aircraft. The expressions ?smart? drugs and ?smart? bombs are both used to convey a sanitised notion of precision and accuracy, of the capability of striking out against the targeted enemy, whether through focussed effects on specific receptor sites in the brain, or through the use of guided bombs that specifically ?take out? suspects, with minimum side effects or civilian casualties. There is an uncomfortable resonance between ?side?effects? in drug treatment and ?collateral damage?. Both carry the implication that a battle against disease or an enemy cannot be pursued without cost, and in consequence we must disguise the true nature of this, especially its moral dimensions, behind an anodyne expression. ?Collateral damage? is so much easier on the ears than ?civilians who were slaughtered during the course of a military engagement?. The expression ?side effect? sits more comfortably on our consciences than neuroleptic malignant syndrome. However, let us assume for the sake or argument, that there really is such a thing as WDD; that it really does exist as a neurochemical imbalance alongside all the other chimerical neurochemical imbalances like major depressive disorder, social avoidance disorder, and premenstrual dysphoric disorder. All these ?disorders? have been the subject of major areas of research by clinical neuroscientists and psychiatrists, largely sponsored by the pharmaceutical industry. Is it right to believe that WDD would be investigated with the same fervour? This answer to this is of course no, because the interests of the pharmaceutical industry are inextricably bound to the political interests of the US government.
I want to end by returning to the problem of Bush?s madness. Many people diagnosed as mentally ill have strange experiences involving God. Some act on these experiences because they believe that they are acting on God?s will, or under instruction from God. The overwhelming majority of these people pose little or no risk to themselves or to other people, but their freedom is constrained. They are admitted to hospital as compulsory patients, diagnosed as suffering from schizophrenia and forced to take medication against their wishes. The World Health Organisation has drawn attention to what it describes as the global economic burden of schizophrenia. In the USA this has been estimated at $148 billion per annum1. On the other hand, President George W. Bush has experiences that to all intents and purposes appear to be indistinguishable from those experienced by many people who receive a diagnosis of schizophrenia. When he acts on his experiences he declares a War on Terror and invades two sovereign countries, actions that have resulted in approximately 45,000 civilian deaths3, the deaths of 2,600 US troops, and 230 troops from the UK and other countries4. The direct and indirect economic costs of the War in Iraq have been estimated at $1 trillion2. One cannot help but remember something that R.D. Laing said. Writing at the height of the Vietnam War, he made the following point:
'People called brain surgeons have stuck knives into the brains of hundreds and thousands of people in the last twenty years: people who may never have used a knife against anyone themselves; they may have broken a few windows, sometimes screamed, but they have killed fewer people than the rest of the population, many many fewer if we count the mass exterminations of wars, declared and undeclared, waged by the legalized 'sane' members of our society.' 3
Laing directs our attention to the values attached to psychosis in democratic societies. Psychopathology and biological science turn the spiritual experiences of ordinary men and women into the symptoms of schizophrenia. In doing so, Laing also reminds us that the advent of science and technology, and the cool detached rationality with which we are supposed to view the world means that we no longer are capable of grasping the essential moral dimension of madness. What is madness? Are we mad if we hear the voice of Christ or the Devil? Or are we mad if we believe we have a divine mission to conquer evil and order the invasion of another country, bringing death and destruction on countless thousands of innocent civilians, children, women and older people?
I have one final suggestion for the DSM-V prelude page. Recall that category five of the category of categories referred to deletions of existing disorders from the DSM. Here is my suggestion. Scrap the lot! After all, in December 1973 the American Psychiatric Association voted to remove homosexuality from the DSM because it could not be considered to be a mental disorder. So, let them delete all the categories and let?s see if we can make a fresh start by seeing madness as the expression of a wide range of human differences, like the different ways we express our sexuality or spirituality. Instead, let us demand an end to the true madness of this world, hate, exploitation, oppression, injustice and intolerance.
