At the Outer Limits

As a psychiatric nurse, I have a professional concern with the care of people who are prone to abnormal behaviour and psycho­logical states, and this has led to an interest, both professional and personal, in the lesser known mani­festations of psychiatric morbidity.

For many, the medical world of psychiatry evokes a mixture of fascination and fear. The marginalisation of those who are deemed to be mad, or to use the current PC terminology ‘sufferers from mental health problems’, is by no means unique to our allegedly enlightened society – it would appear to be a feature common to most human cultures in all eras. The reasons why we marginalise people defined as insane have long been the subject of much debate, but it would seem likely that we recognise in their symptoms the inflation, attenua­tion or gross distortion of the intellectual and emo­tional energies that reside within us all, hence evoking a certain rather uncomfortable recogni­tion. This is compounded by the frequent admissions of many psychiatrists themselves that psy­chiatry is an inexact science, the many well-docu­mented examples of iatrogenic trauma and death, and the generally highly misleading and sensation­alised images of psychiatric illness portrayed by the arts and the media.

The intention here is not to pander to the voyeur­istic whims of the more excitable readers of Udolpho by presenting a kind of Barnum-style psychiatric sideshow, but to try to engender a sense of empathy and understanding in readers for a much-misunder­stood and stigmatised group of people by describing some of the outer limits of psychiatry in what is hopefully a respectful, unsensational way. I have, however, tried to include examples which are sympathetic to the spirit of Udolpho.

Notions of what constitutes unacceptably abnormal behaviours or psychic states are to a great extent culturally determined, and so some psychiatric disorders may be familiar (if not exactly common) in some cultures while re­maining virtually unknown in others. A good ex­ample of this is ‘susto’ or ‘espanto’, a prolonged depressive-type state which seems to be peculiar to natives of the High Andes in South America. Suf­ferers tend to live, move, think and speak in a kind of slow-motion state which, if untreated, intensifies over time into a permanent akinetic or freezeframe condition. Similarly, ‘koro’ is a kind of panic state usually found in southern Chinese men, in which the sufferer believes that his genitals are slowly and imperceptibly retracting into his body cavity, and that death will result if this process is completed.

Immigration from other cultures may result in the ‘importing’ of rare disorders; members of some ethnic minorities in western industrialised countries, notably Asians and West Indians, may hold intense spiritual beliefs which may develop into the conviction that they themselves are possessed by demons. Such cases may not be brought to the attention of mainstream psychiatric services, and may instead be dealt with by more traditional means within the sufferer’s own ethnic group – many such exorcisms involve extremely brutal procedures, such as ritual beatings and/or starvation, in which sufferers may sustain permanent or occasionally fatal injury.

Of course, cases of alleged demonic/diabolic possession are not confined to ethnic minorities and are also found among more mainstream white populations, though they remain rare in both. Sigmund Freud provides the generally accepted psychiatric wisdom on possession states, which hold that they are neurotic rather than psychotic in nature, i.e. that sufferers retain insight into their condition. They are said to take two forms: at automaton-like state in which the sufferer is completely controlled by the alleged malign spiritual entity, and a more obsessive-compulsive form in which the sufferer feels compelled, almost always against his will, to perform certain actions, such as uttering blasphemies or obscenities, or, more rarely committing hostile acts against others. In these latter cases, the demon is not seen as having total control and seems to be more susceptible to drug and psychotherapeutic intervention.

These neurotic forms have a psychiatric equivalent in the disorder known as Giles de la Tourette’s syndrome. Rare in all cultures, GTS is characterised by a classic triad of symptoms: these are ‘coprolalia’, a compulsive and uncontrollable shouting out of obscenities which may constantly interrupt attempts at normal conversation; ‘tics’, which are uncontrollable jerky movements which may affect the whole body; and occasionally ‘echolalia’ where sufferers will compulsively repeat what is said to them. It is easy to see how in past and ever less understanding ages such behaviour may have been attributed to demonic activity. Today GTS is significantly controlled, though never cured, by neuroleptic drugs such as haloperidol. The exact causes of GTS remain unknown.

Virtually the whole realm of psychiatry has. at some time, been associated in public and official minds with demonic activity, and the continued stigma attached to psychiatric illness may well be partly a legacy of such archaic fears.

Misconceptions concerning the more common psychiatric diseases, such as the widespread belief that schizophrenia involves multiple personalties in the same person, also persist. Multiple or alternating personality is readily dis­tinguishable from (though superficially similar to) the phenomenon of the doubling of personality or the doppelgänger. As in stories like Stevenson’s Dr Jekyll and Mr Hyde, the belief which sufferers have that they are accompanied by a second self is thought to be due to a disturbance of ego function, brought about by a combination of organic damage and psychological stress, and not a symptom of a major psychotic state.

In one such case, a fifty-six-year-old woman, with a history of depressive tendencies, returned home from her husband’s funeral and immediately be­came visually aware of someone else in the room. The stranger wore an exact replica of the woman’s own sombre black attire, and silently and simulta­neously imitated her every move, as if in an invis­ible mirror. At one point, as the woman reached out to a light switch, their hands touched; the woman reported a feeling of ‘icy cold’ in the hand, as if all the blood had been drained out of it. Despite this, the woman remained calm and became convinced that her other self was in fact more real and alive than she was. At length, she became weary and lay down, closing her eyes. The double promptly vanished, and almost immediately the woman felt strengthened, as if the life of the double had re­turned to her own body. Visitations from the double continued, mostly at dusk when the woman was alone. Aware that it was ‘only an hallucination’, she continued to feel no fear, only a sense of ‘bewil­derment and unreality’.

Such hallucinations are extremely rare and are known as autoscopy. Rarer still is negative autoscopy, a most unnerving condition related to the former in which sufferers fail to perceive any image of them­selves in mirrors; cases of this in antiquity may well be a source of the similar failures in folklore of vampires and other nosferatu.

Other documented delusions concerning identity may lie at the root of the popular romantic/gothic images of vampirism and lycanthropy. In psychiat­ric literature the rare cases of the latter, involving the belief that one has transformed into a wolf, are usually considered under the more generic term of ‘therianthropy’ or shape-shifting, which refers to delusional transformations into any kind of animal. One case of non-lycanthropic therianthropy in­volved an alcoholic and depressed twenty-four year old man who held a long standing belief, dating from early adolescence, that he was a cat trapped inside a human body. He spent all of his spare time with felines, prowling, hunting and even having sexual relationships with them. He had allegedly learned cat language from the family cat as a child and asserted that a major source of his depression was an intense but unrequited love for a tigress at the local zoo. Again, the delusion remained totally resistant to all treatment.

Cases of therianthropy have involved an entire menagerie, with alleged transformations into gerbils, rabbits, birds, dogs and many other species. However, for reasons that have remained unclear, it is the lycanthropes alone among therianthropes who appear to commit the most gruesome acts of murder and mutilation, though most sufferers are relatively harmless. An historical case of the former occurred in early seventeenth century France, when a werewolf, popularly known as the loup garou, was held to be the perpetrator of a number of horrible murders and partial cannibalism. Suspicion fell on an elderly hermit, Giles Garneir, who eventually ‘confessed’ under torture that he had killed and eaten several people whilst transformed into a wolf. The nature of his confession throws much doubt on its authenticity and leaves open the question of the true culprit.

Interestingly, modem psychoanalytic explana­tions of lycanthropy resemble the old religious explanations. They are thought to represent regres­sions to primitive, animalistic levels of personality functioning which, if unrepressed, may translate into highly hostile displays of oral sadistic rage. Such levels of anger are thought to be rooted in parental rejection. These ideas are given credibility by the fact that the two most notorious lycanthropic or vampiric killers of this century, Peter Kurten and Fritz Haarmann, both suffered highly deprived and brutal childhoods at the hands of their parents.

Insanity is generally thought of in terms of problems that affect individuals. How­ever, the well-documented if uncommon phe­nomenon of folie à deux shows how the most weird and incredible ideas and beliefs may be as easily transmitted as the common cold. Typically, induced psychotic disorder occurs in socially isolated environments where a dominant personality, sub­ject to some psychotic or delusional state, gradually wears down a more submissive and dependant per­son who may adopt the psychosis rather than risk their most important, and sometimes their only, close human relationship. Isolated communities, such as convents, monasteries and army barracks, also provide examples, as in the case of one nineteenth century French convent, where one psy­chotic sister, possibly a kind of therianthrope, be­gan to meow like a cat. Soon other nuns joined in until eventually all the nuns would meet regularly every day to meow together for several hours. More recently, examples of similar contagion on a far more sinister plane are discernable in the cases of David Koresh’s cult, and the appalling mass sui­cides of James Jones’ Branch Davidians.

Perhaps most astonishing of all are the several cases reported of induced psychosis among psychi­atric professionals. One case of this concerned a doctor who, though not a psychiatrist, had a great interest in the field because of his own bipolar affective disorder, in which mood states alternate between profound depression and manic over-ener­getic elation. On a visit to a friend, a charge nurse at a large psychiatric hospital, he entered a manic phase and began to loudly and, to his friend, highly convincingly expound his recently acquired and almost magical prowess as a healer of psychiatric ills. He then took complete charge of his friend’s ward and began to stride around curing the aston­ished patients by delivering highly colourful thera­peutic diatribes, while his by-now-entranced friend followed him around, firmly convinced that together they were pioneering a new golden era in psychiatry.

The doctor then declared that they must fly immediately to Italy to inform the vacationing director of the hospital of the news. Fortunately, the doctor’s former therapist was present and took steps to prevent the departure of the now uncontrollably delusional and hyperactive pair by signing involuntary commitment papers for the doctor, after he flamboyantly refused to sign the voluntary ones. He was then interviewed by a panel of psychiatrists, to whom he denied any delusional think­ing, also accusing them of professional jealousy. His friend, once away from the doctor’s mesmerising in­fluence, soon returned to her normal self after an initial period of denial, when she claimed to have known all along of the doctor’s true mental state.

To conclude, it is suggested that the above brief whistle-stop tour through some of the more obscure corners of the psychiatric domain may best be seen as providing a small inkling of the immense, if sometimes tragic, frightening or downright baffling capacities and possibilities within the human psy­che. Hopefully too, my attempt at illuminating these obscure corners will go some way towards a demystifying and destigmatisation of people whose intellects and emotions, blighted for whatever rea­sons, remain at the end of the day as ‘fearfully and wonderfully made’ as our own.

Andrew Phelvin’s “At the Outer Limits” was published in Udolpho in Autumn 1996. This is a slightly shortened version of the original article.