Are Normal People Sane?

Wednesday, 18 February 2009





Overview

Psychiatrists have for many years regarded conditions such as anxiety or depression as being at the extreme end of a normal distribution of the characteristic. In contrast, traditional psychiatric classification considers disorders such as schizophrenia as discrete conditions qualitatively quite distinct from normality. 

However, recent surveys have suggested that minor psychotic symptoms are relatively common amongst the general population, and that they are increased by the same factors as increase the risk of schizophrenia. Furthermore, other studies indicate that those diagnosed as psychotic are in many ways rational. This new evidence suggests that a continuum of liability to psychosis exists, and that the mad are saner than is often thought while the normal are not so sane as we commonly assume.gen

 

Part of the series of psychiatry lectures presented in association with the Mental Health Knowledge Centre at the Institute of Psychiatry, King's College London (http://www.iop.kcl.ac.uk/).  Other lectures include:   
    Shell Shock or Cowardice? The Case of Harry Farr by Professor Simon Wessely 
    The Stigma of Mental Illness: Inevitable or Unjustifiable? by Professor Graham Thornicroft
    Is it all in the Genes? by Professor Peter McGuffin

Extra lecture materials






Transcript of the lecture

 

ARE NORMAL PEOPLE SANE?

 

Professor Robin Murray

 

My specialism is in schizophrenia, so I thought it would be useful to talk a little bit first about what psychosis is.  Probably the best illustration of that is a series of self-portraits that a man called Brian Charnley painted. 

He had been diagnosed as having schizophrenia and so he took his medication and, to all intents and purposes, he was entirely okay, with no problems whatsoever.  But he thought it would be useful to stop taking his medication and really try and illustrate how the development of how one becomes psychotic. So this is what he did, so he stopped taking his medication and proceeded to do a series of self portraits as the effects of the drugs wore off and his schizophrenia took over.

He began this in April, at a stage when he was completely okay, with this portrait of himself:

On the 20th April he writes in his diary: 'The person upstairs is reading my mind and speaking back to me in a sort of ego crucifixion. The large rabbit ear is because I'm confused and extremely sensitive to human voices, like a wild animal.' This is the painting he made of himself at this time:

Hearing voices is a characteristic of schizophrenia, and I think this portrait is a good illustration of it.  Most of the time, we only hear the things that we focus on and we are screening out other irrelevant sounds, such as people shuffling or the noise of the computer etc.  You do not normally pay attention to these types of unimportant sounds, but when people are psychotic, all the stimuli, both what they hear and what they see, seems to overload them and flood in on them.  They then find it very difficult to concentrate on any one bit. 

On 6th May, and he says: 'I feel like a target for people's cruel remarks.'  You can see that he has illustrated this by painting nails and darts coming towards him, and actually going into his eyes:

I find this to be a very disturbing picture.  I could attempt to paint arrows coming at me, but the idea of nails actually going into the eyes seems to be invasion of oneself.

In the middle of May he writes: 'My mind seems to be thought-broadcasting very severely, and it's beyond my will to do about it.  I've summed this up by painting my brain as an enormous mouth.'

In communication we think something in our minds, our speech area sends message to the larynx and we speak.  But when people are psychotic, they sometimes think that their thoughts can be sent by telepathy.  This is generally very disturbing, because the idea of your nearest and dearest know what you're thinking will be quite frightening to most of us.  This is because we do not always think kind or well-meaning things to our nearest and dearest, let alone people we actually dislike.  So it is very embarrassing.  Sometimes people even believe that their thoughts are beamed out on the BBC - this is what we call thought-broadcasting.

Also in May, he paints this picture of himself:

Of it he says: 'The blue is there because I feel depressed.  The wavy lines are just because I feel when I am safe a voice from the street cuts me emotionally by its extrasensory perception of my condition.'

What he is here saying is that extrasensory perception (ESP) can get into his mind.  In the picture, he still depicts his brain as a big mouth, but you can here see that he is beginning to get depressed.  He had been on what is called anti-psychotics and anti-depressants, and he had stopped both of them, and so he is becoming more psychotic and he is becoming more depressed.

In June, the self-portrait shows two decapitated eggshells, their contents devoured:

The eggs, he says, 'have been emptied like a head stripped of its contents.  It has nothing left in it, no more secrets.' 

When people are depressed, we sometimes say they are nihilistic; they say they have no brain, they have no insides, that there is nothing of any worth about them.  If any psychiatrist had seen that picture at that point, alarm bells would have rung, but sadly, he did not see a psychiatrist and he killed himself.  So was a very clever man, he had planned it all out, he had done it in consort with a journalist, but neither of them realised that one of the things that happens when you go psychotic is that you lose insight.  So instead of saying to himself, 'I've stopped my medication, and this has resulted in me thinking that there was nothing in my head, it was all devoured, or that my brain was like an enormous month,' and instead of saying it was 'as if' all this were the case, he began to believe that this was absolute truth and that the world would be better off without him.  So, sadly, in the end he killed himself. 

Brian Charnley was an identical twin.  His co-twin did not have schizophrenia, had no mental problems and was very well.  Of course, his co-twin was very distressed by this, but made something good come out of it, because there was an exhibition in the National Gallery of Brian's paintings.  So I think this series of portraits does describe what the psychotic experience is like.

As I said, I am really a schizophrenia researcher, and that implies that there is a disease called schizophrenia.  Psychiatrists have traditionally believed that, out there, we are all sane, and that there is then one or two percent of the population who are mad.  The traditional view is that there is a categorical distinction between those who were sane and those who were mad.  This is a curious sort of belief, which psychiatrists have adhered to very strongly even though writers and philosophers have not.

For example, Ralph Waldo Emerson says: 'Sanity is very rare.  Every man, almost every woman, has a dash of madness.'  Aristotle can be found to write: 'No excellent soul is exempt from a mixture of madness.'  Nietzsche writes: 'Insanity in individuals is something rare, but in groups and in parties and in nations and epochs, it is the rule.'  A good historical example of this is the McCarthy era in the United States, when it was not a rational dispute and the whole nation did, in a sense, go psychotic.  The last quote I would like give is by the novelist, Rita May Brown: 'The statistics on insanity are that one out of every four Americans is suffering from mental illness.  Think of your three best friends... if they're okay, then it's you!'

So, writers and many philosophers believed that many of us could have a bit of madness, but psychiatrists did not believe this, and I think the reason for that was that psychiatry grew out of the asylums. 

Where the Imperial War Museum is now based was once the Bethlem Psychiatric Hospital.  That institution has a rather unsavoury pre-modern history in its treatment of their 'patients'.  It was based on the idea that outside its gates were all the sane, and every now and then, somebody would be sent into the mental hospital in the hope that they would recover, but of course, in these days, they had no real treatment and so they very often stayed there.  The psychiatrists of the day were on the inside of these hospitals practising on and studying the people in there, and they were not studying the people outside of those institutions. 

Of course, in the 1800s, lots of these mental hospitals were built, in the UK, in Europe and in North America, and it was actually, in a sense,  a very moral movement to try build them out in the country, so that the fresh air and good sanitation would - they thought - be good for these people.  Of course, in effect, the patients were often sent a long way away from their relatives, who could not visit them.  So even if they did begin to recover, the relatives had lost touch with them and there was nowhere for them to go, so they just accumulated in the asylums.  So there was this gradual increase of all the psychiatric beds until the 1950s, when anti-psychotic medication came in.  1952 was also the time when the approach took a liberal line of trying to reintegrate the mentally ill into the general population.  So it is that today, as you will probably know, the asylums have all been largely knocked down or else turned into very expensive flats, so what used to be a dormitory might now cost a million pounds, because these asylums were very beautiful and very nicely made.  

Now we are in the situation where most of the mentally ill are out in the community, and the scandals are not of bad treatment in the hospital, but that the mentally ill patients are attacking people.  There is a well-known incident when a man called Jonathan Zito was stabbed on a railway train by somebody with psychosis.  So even though we do not lock up people that are mentally ill, the newspapers still tend to regard them as lunatics or as people quite different from us.  This is an issue not just here, but also in Europe and in the United States.

Therefore, the way that psychiatrists have effectively approached treatment is that, if somebody is referred to a psychiatrist by the GP, the question of the psychiatrist is; 'Is this person psychotic?  Are they schizophrenic?'  I use these words almost interchangeably because schizophrenia is really the severe end of psychosis - psychotic people have hallucinations and delusions, and I will come back to that.  So, a psychiatrist's job is really to say, 'This individual is not psychotic and does not require treatment,' or 'This person is psychotic and does require treatment.'  So this is what psychiatrists have traditionally done; it is something of an all or none thing affair; that psychosis is a disease and you either have it or you don't.  So we have this notion that there are these mad people and they have bizarre ideas, they cannot think logically and they cannot plan for the future, and then the rest of us are sane, and we can do these things.

There is a sort of system called the DSM, the Diagnostic and Statistical Manual of Mental Disorders.  People like me - psychiatrists - come together in groups and decide what the definitions of mental disorders are; they decide what the distinguishing marks and border lines are of the sane and the insane.  They effectively say, 'The criteria for schizophrenia are x, y and z.' There are various different types of this process going on, and many books are produced, which make a lot of money for the psychiatric publishers and so on.

We diagnose schizophrenia essentially on the basis of two things: hallucination, which is a perception in the absence of a stimulus.  This is not like an illusion because with an illusion, there is a perception there.  You see the sand shimmering and you think it is an oasis, but there is sand and the air is shimmering because of the heat, so you actually see something which is genuinely there but you misinterpret it.  In contrast, a hallucination is where you actually create a perception where there is none, and you can see visions.  In psychosis, people usually hear voices, and voices which may plague them and say terrible things to them - 'You're a shit!  Why don't you kill yourself?  The world would be better off without you!' - or they sometimes have conversations - 'There he is.  He's getting up.  Why is he so lazy?  Why is he so slow?  He never washes,' and then another voice which may say, 'No, he's doing his best - he's not been well, he's trying hard,' and voices that may argue. 

And then the other way that we diagnose psychosis or madness is on the basis of delusions.  A delusion is a fixed, false and unshakeable idea in which people invest a great deal of emotion: 'The CIA are persecuting me,' 'My parents are poisoning me,' 'The doctors are poisoning me,' or other very bizarre things perhaps like 'The CIA have put a chip in my brain,' or 'Somebody's planted a reptile in my intestines'. 

When people have very bizarre delusions or very strange hallucinations, it is not at all difficult to make a diagnosis, but the problem comes when it is less clear.  Traditionally, psychiatrists have thought that schizophrenia was like a brain disease, and so we spent a lot of time doing brain scans and showing that people with schizophrenia have slightly less grey matter, and the bit of the brain called the hippocampus is about 5% smaller.  It is not something gross like in Alzheimer's disease, but we tend to think that these changes are partly developmental, and the disorder runs in families, to some extent, like heart disease or diabetes.  You do not inherit it directly, but you do inherit a predisposition towards it.  Also, if something nasty happens to your brain as you are developing, you are more likely to develop something like schizophrenia.  For instance, if you have hypoxia at birth or prematurity, then there is increased danger of developing schizophrenia.

Recently, however, we have been more interested in questions of social factors.  For example, we have looked at schizophrenia in different places in the country; we have looked at how common schizophrenia is in Bristol and in Nottingham and in South East London.  It is interesting to ask yourself whether you would think that the incidence of schizophrenia would be the same in Bristol, Nottingham and in South East London, or different for some reason.  In fact, schizophrenia is three times more common in South London than it is in Nottingham and Bristol, and in Nottingham and Bristol, it is actually more common than in the countryside.  So the bigger the city, the greater the frequency of schizophrenia.

Within cities you will find another characteristic of the incidences of schizophrenia, which is that it is more common in the less affluent areas: there is a relationship between schizophrenia and poverty.  This is why you will see that South London has a very high level of schizophrenia, focussing in areas such as New Cross and Peckham, while places such as Richmond and Dulwich have a very low incidence of schizophrenia.  If we were to divide up London into its different areas, some areas would find incidences of schizophrenia nine times commoner than in other areas.

Having found this relationship between schizophrenia and poverty, the question that has puzzled researchers, is whether it is the case that if you start off in any level of the social strata and then begin to suffer a mental illness, will you tumble down and end up living in a bed-sit in a place like Peckham or New Cross, or is it that actually being brought up in Peckham or New Cross gives you a higher chance of mental illness?  The answer is that there is probably a bit of both, but being brought up in an inner city certainly increases your risk of schizophrenia. 

Interestingly, the one factor that predicts the incidence of schizophrenia most accurately is the proportion of the population who vote in a General Election.  It is not that mad people vote Labour or mad people vote Conservative, but if you live in an area where there is a sense of community and people care and there is, to some extent, some cohesiveness, then there is generally a higher percentage of people who vote, and there are also lower incidences of schizophrenia.  But if you live in a disorganised area, where nobody votes, and nobody knows their neighbours, and there is no, what people would call, 'social capital', then this pushes up the incidence of schizophrenia.

If we look at the statistics, we also find that there are different incidence levels of schizophrenia across different ethnicities.  Migrants always have higher incidence of schizophrenia.  For example, compared to British whites, non-British whites - Europeans, North Americans, Australians etc. - coming in London have an incidence 2.5 times that of the local white population.  Asians - Indians and Pakistanis mainly - have an incidence 1.4 times higher than British whites; Africans have an incidence essentially six times higher; and African-Caribbeans have an incidence nine times higher.  So if you are an African-Caribbean living in the UK, you are nine times more likely to receive a diagnosis of schizophrenia. 

There has been a lot of argument as to whether this was white psychiatrists misdiagnosing black people's culture, but I think that idea is now dismissed.  This is because if you are black and you are born in Brixton, or even if you are a third generation - so you really know very little about Caribbean culture - you are still nine times more likely to be diagnosed with schizophrenia.  We have also had black psychiatrists from Africa or the Caribbean come, and they still diagnose the same proportion of black patients as schizophrenic.  So it does seem that there is something about being a migrant that makes you more likely to develop schizophrenia.

I do not think it is very hard to understand why this would be the case.  For instance, I'm not sure that any of us would feel very comfortable in buying a second hand car in another country unlike ours - be it Greece, Morocco, Mexico or Sri Lanka.  It is bad enough trying to buy a second hand car in your own country, where you understand and are familiar with the norms, because you wonder whether they out to trick you or cheat you.  But if you buy such a car in a place where you are unfamiliar with the norms and you do not quite understand the social interactions, then this unease will only increase.

Another example is of your going on your holidays to Rome, and hiring a taxi at Rome airport.  For perhaps most of us, it will not take many minutes before you begin to think, 'Is this person going round in circles or taking a long way in order to make money out of me?!' 

So when you are in an alien culture, when you are in a culture from which you feel distance, you are more likely to become a little bit paranoid.  Indeed, it is a protective factor.  So one of the reasons for the higher levels of schizophrenia is this alienation from mainstream culture.  From this perhaps follows a question like: is the black community more alienated?  If you are born into a one-parent family in Brixton, your teachers do not seem to be helpful to you, you leave school, you do not get a job, the police keep picking you up, it seems that you will almost certainly believe that the system is against you.  In this way, it is almost like you can be taught to be paranoid that the system is against you?  So this question is very important here.

Another factor which we know increases the risk, and has caused some controversy recently, has been drugs, and in particular, cannabis.  The symptoms of the progression of schizophrenia in this way is a mounting paranoia, delusion and hallucination. This paranoia will quite often take the form of believing that people can read your mind and that you are being watched.  Sometimes people take their rooms apart or they will destroy their electricity or their television looking for these cameras which they believe are recording them.  Actually even, if they believe they have a chip implanted in a bit of their anatomy, they will actually try and dig it out.  This story of growing into schizophrenia through drug use is on the rise; we have increasingly seen a lot of people using amphetamine, cocaine and cannabis who have gone psychotic. 

So we know that psychosis correlates with some biological factors, some hereditary factors, drug abuse, and some types of social adversity.  But it is important to realise that no single one of these is The cause of psychosis.  If you talk to a cardiologist, they do not say there is one cause of heart disease.  They say you inherit some susceptibility, your cholesterol gets high, you smoke, you do not take any exercise, you get obese, your blood pressure goes up - all of these factors are risk factors.  It is the same for schizophrenia.  You inherit susceptibility, you may have some developmental hypoxia that slightly damages your neural connections, as you are getting older, you may take drugs, you may be abused by your parents, and you may migrate - all of these factors will contribute to your chances of getting psychosis.

But this idea has still has been built on the idea that normal people do not have any psychosis and mad people have all the psychosis.  This is very different from the way we think about anxiety and depression.  I am sure most of us, when we hear that somebody is off work because they are depressed or somebody has killed themselves, we sympathise with them and feel empathy for their position.  I think that we all realise that everyone of us suffers mild forms of depression every now and again, even if it is nothing very prominent or significant.  You can also imagine that, if it was to develop a bit more, you might get an anxiety neurosis or a depressive illness and have to see a psychiatrist.  In contrast, traditionally, we have thought that hearing voices or believing that the world was against you or people were trying to poison you, or other such psychotic ideas, are restricted to only the psychotic; we have thought that normal people do not have these psychotic thoughts.

More recently, we have actually started asking normal people about these sort of experiences, and whether they have these psychotic symptoms.  In fact, one of the biggest studies was the Netherlands Mental Health Survey and Incidence Study (NEMESIS), done in 2000, by a chap called Jim Van Os, in Holland, of 7,076 individuals.  They asked such questions as: 'Do you think people are against you?'  'Do you think people interfere with your brain?' 'Do you ever hear voices?' which are classic symptoms of psychosis.  Essentially, what they found was, as you would expect, 1.5% of people fitted the diagnosis of schizophrenia.  But, further to this, about 4% of people had delusions and hallucinations that psychiatrists would think really needed treatment, even though they were not diagnosed.  Also, they found that 17% of the interviewed Dutch population had a psychotic or a psychotic-like symptom.  This means that, since a study in this country would inevitably show like figures, 17% of all of us might have a psychotic symptom of some kind.

The possible thought then is that maybe these are just silly little symptoms and not really important.  We all know how people get worked up and how neighbours can come to blows and, occasionally, even come to kill each other, over something as petty as the demarcation of their hedge.  We might think that it is nothing unusual or ultimately psychologically telling that one person thinks the other person is spending all his time moving the hedge, or people that live in flats think that the person above is deliberately walking backwards and forwards in order to disturb them in the night.  The question, then, is whether any of these symptoms have anything to do with serious schizophrenia? 

The reasoning is very like our dealing with the question of why some people are obese?  Is it that 95% of the population are quite slim and then 5% are grossly obese?  Sadly, this is not any longer the case, but is there a segregation?  And so the question is: is it that the general level of weight and eating habits has a bearing on the frequency of a gross obesity?  Yes, of course - we now know that.  The question for us, then, is: does the general level of paranoia and psychosis in the population have a bearing on the number of schizophrenic people we have?

So, in this Dutch study by Van Os, he started with the idea that we discussed earlier: that from the rural to the most urban, you get more schizophrenia.  So you might expect to get an increasing degree of schizophrenia as you move to places that are increasingly urban.  So he measured for schizophrenia symptoms in rural areas, in not so rural areas, in moderate cities and in big cities in the Netherlands.  It could be that schizophrenia is going up, but the rate of minor psychotic symptoms in the general population is the same, which would mean that these minor psychotic symptoms could have nothing to do with schizophrenia.  However, in fact, what he found was that the rate of schizophrenia went up, as was to be expected, but so did the rate of paranoid and psychotic symptoms.  So the people in the cities had more minor psychotic symptoms than the people in the country.

We did a similar study of 8,500 British people; we screened them all for psychosis.  We know the things that cause schizophrenia, or increase the risk of schizophrenia, but we looked to see whether people have seemingly innocuous paranoia about their boss, or whether they have a strange idea that someone from down the road can hear their voice.  Do these people, that have these sort of low-level schizophrenia-like experiences, have the same socio-demographic characteristics as people actually with schizophrenia?  The results that we found was that it was indeed the case that the types of socio-demographic characteristics that lead to genuine schizophrenia also lead to an increased occurrence of these seemingly unimportant low-level schizophrenic-like experiences.  We said that if you have one of these minor paranoid or hallucinatory experiences in the general population, you are more likely to have a lower IQ, which we know is associated with schizophrenia; poorer education, we know is associated with schizophrenia; living in cities is associated with schizophrenia; being dependent on cannabis we know is associated with schizophrenia; being victimised or having adverse life events.  Obviously, you may wonder why some people have an adverse life event and become depressed.  Well, the type of life events which are associated with schizophrenia are much more intrusive ones, like being beaten up or having people burgle your house, so these are things where you are almost right to be paranoid because these are the ones that increase your risk of schizophrenia, and neurotic symptoms.

Louise Johns, who did this British research, said that: 'Minor psychotic symptoms in the general population are related to the same variables as schizophrenia.  Psychosis is at one extreme of a distribution of psychotic systems.' 

A lot of evidence has come out this way, saying that it is not that people with schizophrenia are like men from Mars and the rest of us are nothing like them; it is that there is a gradation, from people who are not at all psychotic and have never had any eccentric or odd ideas, to people who are a bit paranoid, through to people - and I am sure most of us know people like this - that are very touchy, and at the very first possibility, they will develop strange ideas that people are against them or something is happening to them because some individual is against them. 

So we need to think of schizophrenia like many medical disorders, which we think of as part of a continuum.  We can perhaps see it as akin, in this way, to blood pressure: we do not think that the vast majority of us have normal blood pressure and then a few unfortunates have sky-high, malignant blood pressure; there is a gradation.  Or the same comparison can be made with obesity, or diabetes, or anaemia.  So, for example, with blood pressure, the physicians say, 'Well, there is this gradation, but when your diastolic blood pressure gets to 90 milligrams of mercury, we will treat it.' 

The idea of a dimension makes us think of causal factors operating in the general population, like obesity.  It would be ridiculous to just go around trying to get very fat people to diet and putting bands around the stomach.  What we really need to do is for the rest of us to all try and take more exercise and not eat so much as a whole. 

I am sure you are all familiar with reading the newspapers and seeing that there is somebody who has done a violent act, where one psychiatrist stands up in court and says, 'This person is definitely schizophrenic - absolutely, clearly schizophrenic - and therefore he should not be responsible for his actions,' and the other psychiatrist stands up and says, 'This person is clearly not schizophrenic.'  It is ridiculous, but there is - it is as if, as if one physician was standing up and saying, 'This person is definitely grossly hypertensive,' and the other physician is saying,  'This person has an absolutely normal blood pressure,' when the difference is really between 89 and 91.  So it would be more sensible for psychiatrists to have this sort of dimensional view rather than this categorical view.

If we have such a view, then we all have to think that we are somewhere on this continuum.  So we should each ask ourselves:  Do you ever feel that others are against you?  Do you ever believe that others are influencing your mind?  Do you believe that other people talk about you?  Can you communicate with animals?  Or, if I make it more pointed, do you ever feel that your boss is against you?

To fill out these sorts of example questions a little, I could tell many stories of being the editor of a medical journal.  I can assure you that one of the normal reactions of academic researchers, when their paper is rejected, is, 'Why have you done this to me?!  Why did you get my worst enemy to referee this?'  People are provoked into paranoia very easily by this form of sort of rejection.

Do you ever believe that others are influencing your mind?  What is advertising about?  We all have our beliefs quietly shaped in some way by TV advertising, but where do we draw the line when we think about this?

If you have a pet, can you tell what it's thinking?  Is that sane?  It is clear that you know your pet's normal physiology and how it holds itself and you know when it wants to go for a walk and that sort of thing, but I think that most of us will build more on that than the fact might justify.

I will give you a strange example.  One of the nurses in my unit was on the radio with a prominent psychiatrist to talk about schizophrenia.  Afterwards, the psychiatrist discovered that the nurse was besotted with dogs.  He said, 'Oh, I love dogs too!  Can you tell what your dog is thinking?'  She said, 'Well, yes, sort of - I know roughly what he's thinking.'  He said, 'No, no, but can you really read his mind, and can he read your mind?'  She said, 'Well, sort of.'  He said, 'I can communicate with animals,' and he offered to give her an example.  The story he then told related to how psychiatrists sometimes have to go out into the community and what we call 'section' somebody - that is, if somebody is maybe going to kill themselves or is threatening harm to somebody else, we have to go out, sometimes with the police, and take them into hospital.  So, to the nurse, the psychiatrist then said, 'I went out to see this man that the police wanted me to section, and as I got there, outside the door, there was this little cat, and this cat looked at me and said, 'If you section my master, what will become of me? Who will feed me?''  He said, 'I thought about this, and I thought this was a very sensible point that the cat had made,' so he arranged for the man to be treated at home.  It probably was a good thing for the man to be treated at home, and it may well have been good for the cat as well and so on, but it is difficult to accept the psychiatrist's version of events as fully normal and acceptable; as completely and unquestionably sane.  I know this psychiatrist; he is a very respectable, straightforward man, and you would not, in any way, think he had any psychotic symptoms except in this one way which is clearly unusual at least.

So, to come back to important questions, a hallucination is something you hear in the absence of a stimulus, so, does the Pope hear the voice of God?  Or is somebody who hears the voice of God only hallucinating?  Usually we psychiatrists get out of this by saying we would only diagnosis hallucination if it is out of the normal cultural context.  So we would say, if other people have the same experiences or believe the same thing, we would not regard it as pathological.

What about delusions - a fixed, false, unshakeable idea?  For example, if I were to announce to you that last week I heard the voice of God, whose words were, 'Robin, you should go and migrate to Ethiopia, and you should smoke lots and lots of cannabis, and worship the Emperor Hali Salasi' - would I be psychotic?  I do not think that there would be many who would disagree with me in saying that I was indeed psychotic.  But why?  Is it not because not many aging Scottish Professors do this type of thing, so we cannot explain it or place it within any sort of wider social context?

A better belief to discuss here might be the belief in aliens.  If you were to go to work on Monday and somebody asked how you spent the weekend and you replied, 'Oh, it was really amazing actually - on Friday night, this little spaceship landed and little green men came out and took me off to another planet and did all sorts of strange things to me, and brought me back on Sunday night,' how would your friends and colleagues react?  They would think this was very much outside the norm and so they would probably see this as a sign of psychosis.  But, on the other hand, there are a great many people who believe this sort of thing without seeming to suffer other signs of psychosis.

Another example might be of Ian Paisley in Northern Ireland, who regarded the previous Pope as the Anti-Christ.  In the 1980s, he said: 'I denounce you, Anti-Christ.  I refuse you as the enemy and Anti-Christ with all your false doctrines.' Is that a delusion?  - It is not a delusion, because a lot of people in Northern Ireland believe it.  This could be seen as a culturally normal belief, so you would not get somebody diagnosed as having schizophrenia on that basis, although I do not think there is any evidence to support it.

What about 'There are weapons of mass destruction in Iraq?'  Was that a delusion?  It was a fixed belief, it was unshakeable, it was held with great conviction and it was a false belief.  But, despite all of this, it was not a delusion, because it was shared by a large number of people.  It was not by the millions of people that walked through London, but it was certainly held in the high political classes and it was shared by a lot of people.  But if somebody said to you today, 'There are weapons of mass destruction in Iraq,' would it be a delusion?  It might well be, because you would have great difficulty in finding anyone else who believed it.  So, to some extent, a delusion is diagnosed when you cannot persuade other people of your belief.

Another example could be Mohamed Al Fayed's belief which has been reported in the press to be that Princess Diana and his son Dodi were murdered as a result of a conspiracy masterminded by the Duke of Edinburgh.  Is this belief within normality or not?  As far as I can tell, there is no evidence for it, it is something that he has maintained with unshakable determination over a long time, and it is, as far as we can tell, false.  I do not think many other people share it, but it is sort of understandable: here is a man whose son was on the verge, he thinks, of a very important relationship with a royal princess, and they were both killed so suddenly?  It was such a traumatic experience and also there is a question as to who is responsible for this death.  You can understand the psychological mechanisms which may have contributed to Mr Al Fayed having a belief which is quite different than that which is held by the general population.  So, for these reasons, if he was to see a psychiatrist, a psychiatrist would not think he had schizophrenia.

But I think it also illustrates how easy it is for some people to fall into being diagnosed with schizophrenia by psychiatrists, if it occurs within certain parts of society.  For instance, if you were poor and you have a belief like the ones we have mentioned, if you go to the Job Centre and you have a row with the person across the counter because of that strange belief, they will send for the police.  You would then be more than likely to have a row with the police and perhaps even fight with the police, which would mean that you would be carted off to a psychiatric hospital, as you all the while maintain your belief.  But, alternatively, if you have a lot of money and are in a position of power, then you can sustain some very strange ideas without ever being in danger of occurrences as these.  If you are the Prime Minister, you could actually go to war on the basis of a false belief that, in other circumstances, might be seen as delusional and demanding of psychiatric attention.

So, the idea that bizarre beliefs are not common in normal people is incorrect, but you may think that these illustrations I have given you so far do not affect you.  But what about horoscopes?  A great many people read the horoscope section of the paper and, at least, entertain the things they say about your star sign.  For example, a great many people in this country will have read Mystic Meg in The Sun newspaper, where, if you're Aquarius like me, you will have recently read the following piece of advice: 'The mind-sharpening planet Mercury shines directly on you, so the time is right to step outside your normal comfort zone.'  For me this is quite good, as I have never given a public lecture in Central London before, and so this seems to be speaking about me giving this Gresham lecture.  But Mystic Meg then goes on to say, 'Single. At first you just notice that you think alike and finish each other's sentences, but there is love potential.'  Perhaps most people who might read this will dismiss horoscopes as something they do not believe.  But then why do the newspapers print them if people do not believe them?  I think that the majority of people partly believe them: of course, there is a range of how much people believe horoscopes - some people, the Richard Dawkins of the world, will not believe any of this, but there are people who will believe it completely.  There is, again, a gradation of people who will believe it to varying degrees.

So, let me conclude at this point by saying that I think we used to think, if you take the general population, that all of us 'normal' people here in this hall were entirely sane, and there were just a few people with schizophrenia, who were perhaps in hospitals, or who should be there; then, we began to think that maybe sometimes some people are a bit paranoid so they might be part of spectrum; and then, now, we think that quite a considerable proportion of the population will have minor psychotic ideas, just like everyone's being somewhere on the distribution of diabetes or obesity.  Therefore we should not sort of think that people with schizophrenia are something like an alien race and quite different from the rest of us.  In fact, if we are given the right environmental circumstances, most of us have the capacity to develop psychotic ideas and have hallucinations and delusions.

 

 

©Professor Robin Murray, Gresham College, 18 February 2009