The Three Faces of Madness
On Sickness, Sorrow, and Self-Pity
The longer I practice medicine, the more I suspect that “mental illness” is not one thing. Psychiatry has gathered under a single umbrella a wide variety of human misery, from organic brain disease to ordinary heartbreak. In the ER, all of it arrives through the same door. To the electronic chart, a schizophrenic hearing voices, a man who lost his job and wants to die, and a teenage woman screaming at her mother for not buying her a new phone are all coded as psychiatric crises, yet they clearly reflect entirely different realities.
Medicine, in its hunger for uniformity, has tried to treat them all the same way, with the same vocabulary, the same sympathy, and often the same pills. I have come to believe that there are not one, but three kinds of madness, and confusing them has made psychiatry both omnipotent and impotent at once.
I. The Organic
The first kind of madness is genuine disease, a biological derangement of the mind itself.
These are people I do not doubt are sick in the medical sense. Those who hear voices no one else can hear, who respond to commands from invisible tyrants, who cannot tell whether the person in front of them is friend or figment. Schizophrenia is the purest form, though others belong here as well: mania so violent it shatters sleep and reason, catatonia that stills even the will to eat or move.
These patients are tragic precisely because their suffering is not of their own making. They are, as the old phrase had it, possessed, though not in the supernatural sense but the literal one. Their minds no longer belong to them. I can restrain them, sedate them, protect them from self-destruction, but I cannot call them to account for what they have done. They are not morally responsible, and therefore, paradoxically, they are innocent.
True psychosis is rare, yet it justifies the entire psychiatric enterprise. Without it, psychiatry would have no claim to being medicine at all.
II. The Rational Despair
The second face of madness is harder to categorize because it is not irrational at all. It is despair that has become intolerable.
The man who wants to die after the death of his wife, the woman who cannot bear another round of chemotherapy, the veteran who has seen too much to believe in anything good—these are in my opinion not really diseases of the brain but philosophical crises and rational, existential dread.
We call them “depression,” as though the word itself explained the thing. We prescribe medications based on theorized imbalances of neurotransmitters, yet we make no effort to measure this supposed imbalance when making the diagnosis. What these patients suffer is a deficit not of serotonin but of purpose. They are not wrong to despair; they are right, in a sense too awful to bear. The etiology of this particular disease is found not in the patient’s biology but in his circumstance.
There are forms of grief that should not be medicated. Suffering cannot always be cured with a pill, and to treat it as a chemical imbalance is to trivialize what it means to be human. These are the patients I can speak to honestly, because their pain is intelligible. It is not a disorder, at least not in the same sense as schizophrenia; this kind of despair is a rational albeit maladaptive response to devastating and tragic lives and events.
But medicine cannot tolerate meaning. There is no ICD code for an existential crisis and no electronic medical record has the capacity to prescribe Viktor Frankl and Marcus Aurelius. So it calls their despair “major depressive disorder” and their exhaustion “generalized anxiety.”
III. The Learned Helplessness
The third face of madness is neither organic nor tragic. It is behavioral, learned, and often rewarded. These are the patients who have discovered that weakness can be power. They present as victims but behave as tyrants. They do not want to die; they want the world to accommodate them. They demand crisis housing, transportation vouchers, and endless attention, all under the banner of mental health.
This is not illness. It is a moral failure, reinforced by a system that confuses compassion with indulgence.
I see it daily: criminals offered the choice of jail or hospital, patients who insist they will cut themselves if not given narcotics, those brought in after making flippant threats of suicide in an effort to emotionally manipulate friends, families, and lovers. Their symptoms are real in the sense that all behavior is real, but they are also strategic. They have learned that medicine rewards helplessness.
Not all of it is deception, at least not in the calculated sense. Much of it is simple attention-seeking from the lonely, the alienated, the forgotten. They are chronically isolated people who have exhausted the patience of everyone who once tried to help them. Their self-destructive gestures are not driven by intent to deceive but by a need to be seen, if only for a few hours under fluorescent lights in a hospital gown. They do not want to die so much as to be noticed. They have learned to translate loneliness into the only language we still respond to: psychiatric emergency.
When every misfortune is a disorder, personal responsibility becomes pathology. Psychiatry once sought to make the insane sane; now it seeks to make the irresponsible comfortable.
The Moral Confusion
The tragedy is that all three kinds of patients are mixed together in the same waiting room, triaged by the same staff, and recorded under the same diagnostic codes. We cannot treat them differently because our vocabulary no longer permits it. To draw moral distinctions is now considered cruel. It is safer to call everyone “sick” and to medicate accordingly.
Yet this flattening of human suffering into biochemical disorder has cost us more than language. It has robbed us of discernment. The physician’s art was once to judge, to separate the curable from the incurable, the tragic from the culpable. Today, judgment itself is taboo. We call it “stigma” when it is, in truth, the only way to tell the difference between a patient who needs medicine and one who needs moral correction.
For the ER doctor, this confusion defines our daily work.
We must decide, often within minutes, which kind of madness we are seeing, and yet the chart allows no such distinction. Every decision carries risk, and every mistake carries liability. So we admit, medicate, and document, because it is safer to pretend that all madness is medical.
But deep down, we know it is not.
Psychiatry, in its eagerness to be scientific, seems to have forgotten that the mind is not only a machine but a moral being. It can break, but it can also choose. To deny that choice is to deny humanity itself.
This article is part 2 of a series on psychiatric crises in the emergency department. Find the other articles in the series below: