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We live in stressful times. And there is an undeniable relationship between stress, mental disorders and even certain types of psychosis, or what we colloquially call "madness." In modern cities like San Diego, Los Angeles or San Francisco, the ravaging madness of mental illness is ever-present, witnessed daily in so many of the homeless and destitute denizens downtown. But, tragically, this is truly just the tip of the proverbial iceberg. Like stress, psychosis (see my prior post) is a pervasive problem today. With alarming frequency, this madness sometimes culminates in violent and murderous behavior. (See my prior posts.) Naturally, mental health professionals tend to see more madness than most. But none nearly as much as those intrepid clinicians staffing our hospital emergency rooms, psychiatric crisis teams, acute inpatient units and county jails. When a citizen's behavior becomes so grossly bizarre, threatening, self-destructive or violent that it demands the attention of authorities like the police, that individual may be legally detained against his or her will and forcibly taken to a designated psychiatric facility for immediate evaluation and possible involuntary hospitalization. This scenario plays out hundreds if not thousands of times each day, in every major American city. Last week it happened at least once in San Diego. Fortunately, no one was hurt. Ordinarily, it would not have made news. But because of the person to whom it happened and its timing, the event quickly became a hot item, especially on the internet:
"Several callers reported the male was wearing only underwear and running into the street," said the official statement released by San Diego police spokeswoman Lt. Andra Brown. "One caller reported that the male had removed his underwear and was nude, perhaps masturbating, but that was not confirmed by responding officers. The callers reported the underwear-clad male was in the street, interfering with traffic, screaming, yelling incoherently and pounding his fists on the sidewalk. Several people in the area tried to calm the male but he continued to act in a bizarre and irrational manner."
This is the description of an actual incident involving 33-year-old filmmaker Jason Russell. His controversial video, Kony 2012, went mega-viral a few weeks ago. Kony 2012 is a documentary film produced by Invisible Children, Inc. The film's apparent purpose is to promote the charity's 'Stop Kony' movement, which seeks to bring to swift justice indicted Ugandan war criminal Joseph Kony. According to Wikipedia, the short film had over 80 million views on YouTube, and almost 17 million views on Vimeo, with substantial additional hits from a central website created by Invisible Children. With all this instant international attention, a veritable feeding frenzy, it seemed everything was going swimmingly for Mr. Russell and his highly impassioned cause. So what exactly took place on the sunny streets of San Diego?
Yesterday, Mr. Russell's wife, Danica, publicly announced that the official provisional diagnosis provided by his doctors for her husband's recent scary episode was "brief reactive psychosis." Substance abuse has evidently been excluded as a cause. According to DSM-IV-TR, brief reactive psychosis (a former DSM-lll-R disorder now technically diagnosed as Brief Psychotic Disorder With Marked Stressor) is used to describe a relatively rare, time-limited (less than one month) acute psychotic episode in which "symptoms occur shortly after and apparently in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the person's culture."
Based on my own fairly extensive clinical experience with such patients, the diagnosis reached by his doctors makes sense given the reported circumstances. Brief reactive psychosis is a Brief Psychotic Disorder specifically defined as occurring in response to severe stress and being transitory and time-limited in nature. The prognosis, unlike in most other psychotic disorders, tends to be fairly good, unless the psychotic symptoms (e.g., paranoid delusions and/or hallucinations, disorganized speech, bizarre behavior ) persist signficantly beyond the one month period. That is to say, in order to confirm this diagnosis, we sometimes have to wait to see whether the symptoms remit before one month or not. If psychotic symptoms persist, a different diagnosis needs to be considered. The good news for Mr. Russell, his family, friends and fans is that, in brief reactive psychosis, there is typically a full recovery. But, yes, severe stress can precipitate psychosis. Unfortunately, this is not an uncommon occurence, especially in individuals psychologically, genetically or characterologically susceptible to psychosis. And particularly in the chronically stressful "pressure cooker" that is American society today, increasing numbers are at risk.
While there were happily no criminal charges brought against Russell, this is precisely the sort of case that typically would be seen for psychological evaluation either in an emergency psychiatric service or county jail. Luckily, in Mr. Russell's case, it turned out to be the former rather than latter. While I know only what I, like others, have read in news reports regarding Jason Russell's situation, having worked as a clinical and forensic psychologist in both settings, I can offer readers some insight as to what the psychiatric or forensic evaluation of such bizarre behavior might look like generically. And what it can reveal about the underlying psychological causes, meaning and nature of madness. This posting is meant to provide a partial and, hopefully, informative glimpse into what psychologists and psychiatrists in emergency rooms and crisis centers deal with routinely and how that difficult yet fascinating work is done.
Strange as it may sound, emergency room psychiatrists, clinical psychologists and other crisis team workers deal with such episodes and their aftermath quite regularly. When cases symptomatically similar to this one would arrive at the Emergency Psychiatric Service at Santa Clara Valley Medical Center in the San Francisco Bay Area's famous "Silicon Valley," one of the first things we would try to rule out was substance intoxication. (There are also certain neurological conditions capable of causing such irrational behaviors that must also be ruled out.) Frequently, bizarre outbursts such as the one attributed to Jason Russell turn out to be substance-related, as, for instance, in the use of methamphetamine, "crack" cocaine, PCP or possibly hallucinogens like LSD, mescaline or Ecstasy. Extreme or sometimes even idiosyncratic alcohol intoxication can also sometimes cause bizarre, irrational or violent behavior. Lab tests are routinely run on the patient's blood and urine to determine the presence of any such drugs, and the results, which take some time, are awaited prior to deciding upon a firm diagnosis and treatment plan.
But drug abuse is not always--and not even necessarily usually--part of the clinical picture in situations such as this. And it must be remembered that even when intoxication is present, this does not preclude underlying mental disorders or emotional disturbance. Still, before an accurate and helpful diagnosis of patients exhibiting uncharacteristically bizarre behavior can be arrived at, substance intoxication must always be carefully ruled out or ruled in. If it turns out that someone had not been taking drugs recently and was not intoxicated at the time of the incident, we then move on to consider the possible presence of some non-substance induced Psychotic Disorder such as Schizophrenia, Schizophreniform Disorder, Schizoaffective Disorder or Brief Psychotic Disorder, depending in part upon when the symptoms started. Another obvious diagnostic consideration in such cases could be Bipolar Disorder, particularly a possibly full-blown manic episode with psychotic features. Does the individual have any prior similar psychiatric history? Previous hospitalizations? Was he or she taking psychotropic medication? If so, what kind?
Say, for example, the patient brought in to the hospital on a 72 hour involuntary psychiatric hold or arrested and incarcerated by police, has no history of substance abuse nor any mental health history, and is determined not to have been under the influence of drugs or alcohol at the time of the episode. What then? Well, we don't like to acknowledge this frightening fact, but the truth is that any of us, given the right or wrong circumstances, under extraordinary stress, can potentially become temporarily psychotic. Even without any prior significant psychiatric history. According to Russell's wife, he was suffering from "exhaustion, dehydration and malnutrition." Can exhaustion, dehydration and malnutrition cause a psychotic break? Or induce a manic episode? Curiously, manic episodes, which can often include psychotic symptoms like delusions and hallucinations, are typically accompanied by a decreased desire for sleep, but can be induced by prolonged insomnia or other significant physical or psychological stressors. Once determined by the doctors evaluating them that someone had indeed experienced a sudden psychotic or manic episode, what would be the most likely causes of such a clearly dangerous and irrational state of mind?
While extreme instances of sleep deprivation, dehydration or malnutrition, when combined, could conceivably induce psychotic symptoms and delirium in almost anyone--especially those genetically or characterologically predisposed to psychosis--this seems, on the face of it, an unlikely and insufficient explanation of what happened to Jason Russell. In addition to his physical condition, his wife has apparently also cited the tumultuous and unexpected events of recent weeks regarding the intense attention his video received, as well as, and perhaps especially, the quite severe criticisms leveled at him for its perceived oversimplification and misrepresentation of certain circumstantial facts. Mr. Russell reportedly took these vicious and public attacks very personally. Did he fall into a major depressive episode? Had his sudden success and media attention proved overwhelming? Yes, paradoxically, success, celebrity and fame can be extremely stressful, especially when it happens so precipitously.
According to witnesses, Russell allegedly was seen in various stages of undress, naked at one point, possibly masturbating, playing in traffic, vandalizing vehicles, screaming incoherently and violently smashing his fists onto the concrete sidewalk, as if in a fit of rage. Typically, when in the throes of a severe psychotic or manic episode, the individual's judgment and impulse control is grossly impaired, which is part of what makes such states of mind so dangerous. Suicidality and/or homicidality, for instance, become very real concerns, which is one of the reasons such individuals are regularly detained and involuntarily psychiatrically hospitalized to prevent them from harming themselves or others. Forensically speaking, such dangerous states of mind commonly become the disputed focus of most insanity defenses, wherein the question is raised as to whether the defendant in said state of mind was able to distinguish between right and wrong and appreciate the nature and quality of his or her actions at the time of the crime.
Based on my experience in evaluating numerous similar cases, both clinically and forensically, there is commonly some history of either serious substance abuse or long-term mental health issues in such patients or defendants. But not always. For example, one thing I would want to know when evaluating someone like Mr. Russell is whether he had ever experienced a previous psychotic episode, manic or hypomanic episode, or major depressive episode. Or whether there is any family history of mental illness. Was he or she experiencing any significant psychiatric symptoms prior to the incident? Or suffering from extreme stress or recent losses? It appears that Jason Russell may have been understandably furious and conflicted about being criticized for a project to which he had so long dedicated a great deal of time, effort and energy. (See my prior posts on anger disorders.) He had identified in the notorious warlord Joseph Kony a personification of evil, not unlike Captain Ahab's projection of evil onto the great White Whale, Moby-Dick. Had Russell, like the mad Ahab, become completely obsessed with bringing Kony down for his evil deeds? But at what cost? And what of his own shadow? Had it been chronically disowned? Madness almost always has meaning. It is a matter of making existential and psychological sense of psychosis rather than seeing it simplistically and solely as the product of a "broken brain" or biochemical imbalance.
Indeed, Mr. Russell's breakdown--with its apparent sexual, irrational and angry overtones--could have been the unconsciously compensatory product of a prolonged, disciplined, self-sacrificing and extremely stressful creative process. There is a well-known and documented relationship between creativity and madness. (See, for example, clinical psychologist Kay Redfield Jamison's fascinating book Touched With Fire: Manic Depressive Illness and the Artistic Temperament or my Anger, Madness, and the Daimonic: The Psychological Genesis of Violence, Evil, and Creativity.) Did his denied shadow (or what I call the daimonic) come back with a vengeance? Taking total temporary possession of his personality? (See my prior post on so-called demonic possession.) Was this yet another case of what Nietzsche referred to as the "return of the repressed"? (See my prior post.) Or had Mr. Russell been suddenly faced with an existential crisis of epic proportions when his life was turned upside down and the well-intentioned meaning of that life publicly demeaned and besmirched? Was he literally "mad," meaning angry or enraged?
Repressed anger, in my opinion, plays a central role in the etiology of psychosis or madness, as well as many other mental disorders. Dramatic and dangeorus incidents such as these rarely spring fully formed like Athena from the head of Zeus. They are typically the culmination of various events, both outer and inner, building up to the eventual explosion or implosion of madness or what we call mental illness. And the precipitating event is usually merely the "last straw" triggering an already pre-existing latent mental disorder, rage or emotional imbalance. These episodes can certainly be exacerbated or triggered by physiological stressors such as sleep deprivation, exhaustion and malnutrition, and by stress in general. (See my prior post on sleep.) But the underlying and unconscious psychological causes and true meaning of madness almost always run much deeper and are far richer than any superficial physiological, biochemical or neurological explanations even begin to recognize.
I do not know the details of what happened to Jason Russell, who apparently remains hospitalized, nor can I render any diagnosis from afar. I can only wish him well, and hope for a speedy and full recovery. For those fellow professionals toiling in the trenches of emergency psychiatry, the mystery of psychosis and its causes is constantly and impressively encountered. One of the most important and lasting lessons I learned early in my own psychological career is that such severe psychiatric crises, terrifying and destructive as they may be, are potentially profoundly meaningful, transformational, and can teach us much about ourselves, the human psyche, and life itself. (See, for example, my prior post on C.G. Jung's Red Book.)
