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  • Clinical Anecdotes:A Logic in Madness
  • Aaron J. Hauptman (bio)
Key Words

autonomy, rationality, mental illness, ethics

The ultimate language of madness is that of reason.

(Foucault 1961/1988, 95)

In short, under the chaotic and manifest delirium reigns the order of a secret delirium. In this second delirium, which is, in a sense, pure reason, reason delivered of all the external tinsel of dementia, is located the paradoxical truth of madness. And this in a double sense, since we find here both what makes madness true (irrefutable logic, perfectly organized discourse, faultless connection in the transparency of a virtual language) and what makes it truly madness (its own nature, the special style of all its manifestations, and the internal structure of delirium).

(Foucault 1961/1988, 91)

At the urging of his parents, Mr. A, a college-age young man with a past diagnosis of Asperger’s syndrome, presented for assessment to an inpatient psychiatric hospital after making suicidal statements. He had been in his normal state of health and functioning well until a few months before presentation, at which point he had precipitously fallen into a severe depression. The trigger was the abrupt end of a 1-year-long relationship. This had been an exclusively online, romantic relationship that ended terribly and with a sudden shock after being cruelly manipulated by the other party. For his part, he had seen his partner as the love of his life and expected that they would meet in person and marry. A series of frantic moves after his significant other failed to show up for their planned in-person tryst resulted in his discovering the extent to which he was being manipulated, and the relationship was immediately broken off. A bright young man with classic symptoms of high-functioning autistic spectrum disorder, including concrete thinking and often considerable struggle with interpersonal relationships secondary to challenges in intuiting other peoples’ mental and emotional states, he had never been in a romantic relationship before and this turn of events was crushing.

On assessment, he was clearly depressed. He admitted to sleep disturbance, loss of interest in activities, long periods of low energy that he spent in bed, weight loss owing to lack of appetite, subjective depression, and thoughts of death, all classic symptoms of severe major depression. He had been unable to get out of bed for months before this assessment and had ceased showering and changing clothes except for infrequent instances that came about at the desperate urging of his family. At the time of his presentation, he was increasingly vocal about desiring to let himself starve to death and he had already lost considerable weight.

Clearly, he posed a risk to himself and his situation warranted a course of inpatient treatment. Begrudgingly, he accepted voluntary hospital admission. Once settled in, however, he made it very clear that under no circumstances would he use psychotropic medication. Electroconvulsive [End Page 303] therapy: clearly also not an option. Despite his depression, he had a doggedness with rationality, characteristic of his diagnosis of autism, and, although he still would not shower or shave, he would settle in readily to debate the logic of his treatment. His argument went along the following lines: I am depressed for a very good reason and if, because of that, I have these feelings then it is right for me to have these feelings. An artificial change of course, he seemed to feel, would be dishonest. He was still in love. He knew at this point that his love’s object was a fiction, but to him this did not change things. An improvement based on anything but an internally driven shift in his thinking was indefensible to him.

A number of people tried to argue with him. “You could have started off depressed for a good reason,” one would say, “but then it became something organic.” “Depression is always organic, isn’t it? It is in your brain!” he would reply. He would argue that reneging on the love of his life would make him despicable and dishonest. He seemed to feel that the only thing left to attach him to the emotion and the promise of...

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