Madness has slipped the Ship of Fools, and is spreading abroad. Soon, it will be everywhere. A hundred years ago the Journal of Mental Science predicted that by the year 2301 we will all be mad, so great was the apparent increase in the numbers of the insane in the nineteenth century. In this post-institutional era government concern has shifted from counting lunatics to counting the risks they present. Today, governments in most advanced liberal democracies are intent on patrolling and controlling the boundaries of sanity to make sure that the mad are ‘known’, counted, identified, assessed, labelled and kept securely in their place. The British Government is enacting oppressive mental health legislation that will lock people up even though they may have committed no offence. In America, young adults in forty States are being scrutinised for signs of instability in the ‘Teen Screen’ programme, so that mental illness can be identified and treated with medication in the earliest stages. What Nikolas Rose calls the ‘psy’ complex (psychiatry and psychology) has become a tool of government. Guiltily, fearfully, we scrutinise our inner worlds for the daemons within, lest we be marked out from the rest.

This growing fixation with the boundaries of ‘normal’ human subjectivity can be seen in the explosion of psychiatric diagnoses over the last fifty years. The first edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) published in 1952 contained barely a hundred disorders. The latest edition, DSM-IV-TR published in 2000 has quadrupled that number. ‘Psy’ is creeping into all areas of our lives. When I was a medical student in the late 1960’s I was taught that premenstrual tension was a common condition experienced by 40% - 60% of women, and thought to arise from an interaction between hormonal changes and psychological factors. Then, sometime in the late 1980’s papers began to appear in the medical journals about a new disorder called premenstrual dysphoric disorder. Now it features as a fully fledged illness in DSM-IV with its own criteria. Back in the 1960s we described our friends who found company difficult as shy. Now, we diagnose them with avoidant personality disorder. Modern psychiatry has invented approaching fifty names for Hippocrates’ Melancholia. Today, we gaze out from Bentham’s Panopticon over a rapidly receding horizon, a rising flood-tide of insanity.

And still the madness machines groan on, balefully grinding out more categories into which our suffering can be pigeon-holed. After eight years of preliminary work the American Psychiatric Association will appoint the work groups for DSM-V this year. On the DSM-V prelude website (www.dsm5.org) you will find a ‘suggestions’ page for feedback about DSM-IV, and suggestions for new disorders to be included in the updated system. This is serious business; all suggestions will be added to the DSM-V prelude database for eventual routing to the appropriate work group in 2007. There is even a nosological madness abroad, for the instructions even go so far as to categorise the categories into which suggestions might fall:

1. Comments concerning shortcomings and limitations of existing DSM diagnoses, but excluding suggestions how to fix them, as well as miscellaneous suggestions not otherwise classified.
2. Suggestions for specific changes to diagnostic criteria or diagnostic groupings.
3. Suggestions for a new subtype of diagnosis to be added to an existing disorder.
4. Suggestions for a new disorder to be added to DSM-V
5. Suggestions for deletion of an existing disorder.

So, the person who wrote the instructions has obsessional compulsive disorder. Nevertheless, it seems right that the Land of the Free, the self-appointed global guarantor of liberty should extend democratic ideals to the contested domain of madness. Are we not missing something important here? Is this not a chance to democratise the world of madness? Is this not an opportunity to have our say about madness? Perhaps; perhaps not.

But before the cold, icy light of dawn breaks my delirium, I want you to imagine possibilities with me, a vision that perhaps we share. A dream rooted in opposition, and through which we can draw attention to the real madness of this world. I am proposing that we take DSM-V’s invitation seriously, and submit suggestions for new disorders to help them in their task. In doing so, I also believe that we can make the invitation work to the advantage of all of us by changing the world for the better. (Hopeless idealism, I hear you say, in which case might I suggest that you submit Hopelessly Idealistic Personality Disorder as a new category for DSM-V.) But then they might just pay attention to my suggestion, and were they to do so they might just create the possibility for a new world in which strife and famine are no more. You will doubtless consider me mad for saying this. Perhaps you are right. If so, kick me into the cell, lock the door and throw away the key! But do not rush into making judgements; let me explain myself.

My proposal for the DSM-V prelude website is for a new category of mental disorder. After many years of clinical work and careful thought I have identified a new genus of psychosis previously undiscovered. There is no reference to the condition in psychiatric textbooks. I have spent half a life-time scouring the medical literature, and can find no reference to it. Despite this, the condition can readily be identified, and I am certain that once described you will instantly recognise the difficult and intractable problem to which I refer. The condition is a serious and potentially lethal disorder carrying great risks. It is found exclusively in men, especially those over the age of 40. It is characterised by a complete and utter lack of insight and delusional beliefs of a particularly dangerous variety, because they are commonly acted upon. Unusual experiences such as hearing voices are also commonly associated with the condition. In time-honoured medical tradition I will describe a case history that draws out the salient features of this condition.

George Bush is an American citizen, born into a wealthy New England family. His early life appears to have been unremarkable. When he was a child his family moved to Texas because of his father’s business interests, and he was sent to an elite preparatory school in Massachusetts. In 1964 he entered Yale to read history. He was a keen sportsman, playing baseball and football, and like his father and grandfather, both of whom went to Yale, he became a member of the University’s secret society, the Skull and Bones. He was also a member of the Delta Kappa Epsilon fraternity, eventually becoming its president. He was described by his tutors at Yale as an ‘average’ student, and he left in 1968 for national service in the National Guard, when most of his contemporaries were fighting in Vietnam. He trained as an F-102 fighter pilot, and was promoted to First Lieutenant in November 1970.

At this point his problems first became apparent. In May 1972 he went to Alabama and requested reassignment to an inactive unit there. It seems odd that a pilot should request transfer to a unit that had no aeroplanes. His request was denied, and for the last two years of his national service he seems to have disappeared. His premorbid personality is described by acquaintances as outgoing and sociable, with a good sense of humour. Despite being regarded by some as unintelligent, his IQ on entering Yale was 129, which places him in the bright-normal range. In 1975 he entered Harvard Business School, after he tried unsuccessfully to gain a place to study law in the University of Texas. On leaving Harvard with an MBA he started work by setting up his own oil and gas company. After a few years this hit financial difficulties, and he was bought out by a competitor. As a result he became a millionaire.

In his early adult life there is evidence that he may have had problems with alcohol. Whilst in the DKE house at Yale it is reported that he drank heavily. In 1972 he smashed his car into a neighbour’s garbage can after he had driven back from a party intoxicated. He tried to pick a fight with his father when he came outside to see what was going on. It is also alleged that in 1974 he spent Superbowl Sunday at a party hosted by Hunter S. Thompson, whose autobiographical novel Fear and Loathing in Las Vegas extols the virtues of a wide variety of drugs, including LSD, mescaline and cannabis. George Bush vehemently denies using illicit substances. In October 1976, he was arrested for drunken driving, convicted, fined $150 and banned from driving for two years. When questioned he denied being dependent on alcohol, "I don’t think I was clinically an alcoholic; I didn’t have the genuine addiction. I don’t know why I drank. I like to drink, I guess." he said.

In 1977 he married a librarian, and four years later she gave birth to their first children, twin girls. Over the next few years his drinking caused his wife a great deal of concern, and on the occasion of his 40^th birthday he vowed to give up alcohol after she had threatened to leave him if he didn’t. Shortly after this he appears to have reached a turning point in his life. He stopped drinking, and went through a religious conversion. He was brought up an Episcopalian, but adopted his wife’s faith, Methodism.

His psychosis started insidiously, suggesting that his condition has a poor prognosis with little hope of a return to full normality. Sometime in the mid 1990s he phoned his close friend, the charismatic preacher James Robison, to tell him that he had heard the voice of God speaking to him, and telling him to run for president of the USA. Without any insight he acted on his hallucinations, stood for president, and was duly elected. Shortly after his election, three and a half thousand people were slaughtered in Al Qaeda’s murderous attack on the World Trade Centre. This major international tragedy had a devastating effect upon our subject’s mental state. Writing in Ha’aretz the Israeli journalist Arnon Regular describes a meeting with high level Palestinian officials, including Mahmoud Abbas, at which George Bush is reported to have said "God told me to strike at Al-Qaeda and I struck them, and then he instructed me to strike at Saddam, which I did, and now I am determined to solve the problems in the Middle East."

Since then he has made persistent claims to be on a divine mission. Speaking to West Point graduates he expressed the delusional belief that the World is in a conflict between good and evil, and that America is "…firmly on the side of the angels…" He has also claimed to be aware of a "…wonder-working power…" that he believes to be abroad in the United States. It is worth noting that his favourite film is Field of Dreams, based on the novel Shoeless Joe by W.P Kinsella, in which an Iowa farmer builds a baseball field in his pastures in response to command hallucinations. George Bush has also acted on his delusional beliefs. In 2002 he sent troops into Afghanistan in order to clear out the Taliban and impose democracy and freedom. In 2003 he invaded Iraq to rid the country of its dictator acting on the delusional belief that Saddam Hussein had stockpiled weapons of mass destruction. His actions in response to his delusions have had catastrophic implications, with a reported minimum of 53,954 civilian deaths reported by Iraq Body Count , and some 3259 US and coalition troops killed. No such weapons were ever discovered. There is also some evidence that this form of psychosis may also exist in a socially induced form similar to folie à deux. A number of his close American associates show similar patterns of behaviour, as well as a UK citizen, Mr. Tony Blair, who has spoken openly about being "…judged by God…" Table 1 sets out the diagnostic criteria for this terrible condition, provisionally identified as World Domination Disorder. To meet the full criteria for the disorder, it is suggested that there must be two items present from each of categories A and B, one of which must be item three (acting on these experiences) in either A or B, plus any two items from category C. For partial criteria for the disorder, there must be two items present from either category A or B, one of which must be item three, plus any two items from category C.

This proposal for a new psychiatric diagnosis is advanced in the hope that it will galvanise the finest neuroscientific and psychopharmacological brain/minds to carry out research into the disorder, and that this will result in the development of new drugs and physical treatments aimed at rectifying the neurochemical imbalance that almost certainly causes the disorder. Studies in rats have shown that aggressive and domineering behaviour is mediated through pathways in the brain controlled by noradrenaline and serotonin. In addition, these neuronal circuits are thought to be determined by genetic mechanisms associated with the Y chromosome. Experience indicates that the disorder is found only in men. Indeed, it is possible that WDD is a sex-linked disorder. If so, at some future point it may be possible to engineer sperms genetically by removing the deviant segment of DNA and replacing it with a harmless variety. In this way this dangerous and lethal condition may eventually be brought under control. Or will it?

The reality of course is that this will not happen. But setting aside satire and hyperbole, there are disturbing resonances between the language that is popularly used by journalists to talk about medical progress and warfare. Doctors are engaged in the ‘battle’ against mental illness. Psychiatric drugs are likened to magic bullets that ‘target’ specific brain receptors in much the same way a ground to air missile targets an enemy aircraft. The expressions ‘smart’ drugs and ‘smart’ bombs are both used to convey a sanitised notion of precision and accuracy. They imply that it is possible to strike out against a targeted enemy, whether through drugs that focus their effects on specific brain receptors with minimum side effects, or through the use of guided bombs that specifically ‘take out’ the enemy with minimum civilian casualties. There is an uncomfortable resonance between ‘side–effects’ in drug treatment and ‘collateral damage’. Both confirm that a battle against disease or an enemy cannot be pursued without cost, and in consequence we must disguise the moral nature of this behind an anodyne expression. ‘Collateral damage’ sits more comfortably on our consciences than ‘civilians who were slaughtered during the course of a military engagement’. The expression ‘side effect’ is so much easier on the ears than neuroleptic malignant syndrome or Seroxat-induced suicidal impulses.

However, let us assume for the sake of argument that WDD is not simply a fiction, but that it really does exist as a neurochemical imbalance, alongside all the other chimerical neurochemical imbalances like avoidant disorder and premenstrual dysphoric disorder. These ‘disorders’ have been the subject of intense research by clinical neuroscientists and psychiatrists, mostly sponsored by the pharmaceutical industry. Is it right to believe that WDD would be investigated with the same fervour? This answer to this is of course no. One reason for this is that the interests of the pharmaceutical industry are inextricably bound to the political interests of the US government and the Bush family in particular. On 17^th July 1990, in Presidential Proclamation 6158, George Bush Senior declared the new decade the ‘Decade of the Brain’ to "…enhance public awareness of the benefits to be derived from brain research’ through appropriate programs, ceremonies, and activities." Fourteen years later, George W. Bush unveiled a sweeping new initiative based on a report published by the New Freedom Commission on Mental Health. This recommended "state-of-the-art treatments" using "specific medications for specific conditions." It commended the Texas Medication Algorithm Project (TMAP) as a "model" medication treatment plan that "illustrates an evidence-based practice that results in better consumer outcomes." TMAP entails whole population screening for mental disorder, starting in school with the so-called ‘teen screen’. Anyone who meets the criteria for depression, bipolar disorder or schizophrenia, is immediately started on medication.

Now you may of course think that there’s nothing wrong with that. Isn’t it important that all possible steps are taken to stop young lives being blighted by mental illness? A fair point, perhaps, but not when you consider the shaky basis on which the ‘science’ underpinning this argument rests. In his book Mad in America, science journalist Robert Whittaker describes in detail the failure of science to advance our understanding of the causes of madness. There is simply no firmly established causal relationship between disordered brain function and psychotic experience. Today’s drugs used to treat schizophrenia differ little in terms of their lack of sophistication and abusiveness from the leucotomies, insulin coma and electroshock of yesteryear. Population screening is presented as a progressive, rational and impeccably scientific way of improving health and well-being, when it serves a different set of interests. What is much less well-known are the close links that exist between the Bush political dynasty and the pharmaceutical industry. Jean Lenzer points out that Eli Lilly who manufacture olanzapine, a drug heavily promoted in TMAP, has multiple ties to the Bush administration. George Bush Sr. was a member of Lilly’s board of directors and Bush Jr. appointed Lilly’s chief executive officer, Sidney Taurel, to a seat on the Homeland Security Council. Lilly made $1.6m in political contributions in 2000—82% of which went to Bush and the Republican Party. This suggests that the commercial interests of the pharmaceutical industry are having a profound influence on how society is encouraged to think about emotional distress. So what should we make of the madness of George-II?

Many people diagnosed as mentally ill have strange experiences involving God. Some act on their experiences because they believe that they are carrying out God’s will, or that they are under instruction from God. Despite the findings of the recent Confidential Inquiry into Suicide and Homicide by People with Mental Illness the overwhelming majority of these people pose little or no risk to themselves or to others. Despite this their freedom is constrained; they are admitted to hospital as compulsory patients, diagnosed as suffering from schizophrenia and forced to take medication against their wishes. The World Health Organisation has drawn attention to the economic burden of mental illness. In the USA alone this has been estimated at $148 billion per annum. On the other hand, President George W. Bush has experiences that to all intents and purposes are indistinguishable from those of many people who receive a diagnosis of schizophrenia. When he acts on his experiences, he declares a War on Terror and invades two sovereign countries, actions that have resulted in tens of thousands of civilian deaths and the deaths of thousands of US and coalition troops. The direct and indirect economic costs of the War in Iraq have been estimated at $1 trillion. One cannot help but recall something that R.D. Laing said at the height of the Vietnam War:

Laing draws our attention to the values attached to psychosis in democratic societies. Psychopathology and clinical neuroscience turn the spiritual experiences of ordinary men and women into the symptoms of schizophrenia. In doing so, Laing reminds us that the advent of science and technology, and the detached and objective view of the world they entail means that we are no longer capable of seeing that madness has an important moral dimension. What is madness? Am I mad if I hear the voice of Christ telling me that I must starve myself to atone for the World’s sins? Or am I mad if I hear the voice of God telling me that I have a divine mission to conquer evil and order the invasion of another country, bringing death and destruction on countless thousands of innocent civilians?

I have one final suggestion for the DSM-V prelude page. Recall that category five in the obsessional category of categories referred to deletions of existing disorders from the DSM. My suggestion is why not scrap the lot! After all, in December 1973 the American Psychiatric Association held a plebiscite in which they voted to remove homosexuality from the DSM because it could no longer be considered a mental disorder. So, let them delete all the categories. Let us make a fresh start by seeing madness as one way in which human difference is expressed, like our sexuality or spirituality. Let’s scrap all the categories, all that is apart from WDD.