Ronald W. Pies, MD

Dr Pies is Professor Emeritus of Psychiatry and Lecturer on Bioethics and Humanities, SUNY Upstate Medical University; Clinical Professor of Psychiatry, Tufts University School of Medicine; and Editor in Chief Emeritus of 

 (2007-2010). Dr Pies is the author of several books. A collection of his works can be found on

Anyone who thinks all psychiatric disease categories are merely “socially constructed labels” cooked up by modern-day, “institutional psychiatry” should read Avicenna’s writings on melancholia—and then think again.

Avicenna (980 CE-1037 CE) is the Latinized name of 

, the Persian philosopher, thinker, and physician who is often considered “the most famous and influential of the philosopher-scientists of the medieval Islamic world.”

 By one account, Avicenna had read and memorized the entire Qurʾān by age 10! Among philosophers of the medieval period, Avicenna is probably best remembered for his distinction between 

—an esoteric matter we need not pursue here.

 But among historians of medicine, ibn Sina is probably best known as the author of 

), which served as the preeminent European medical text as recently as the 17th century.

Why should psychiatrists today care about a thousand-year-old manuscript?

As a specialist in mood disorders, my interest in 

 lies in Avicenna’s remarkable description of 

He saw it, first of all, as affecting both the 

, and he divided melancholia into early phase and chronic phase. Symptoms of early phase melancholia included suspicions of evil, fear without cause, quick anger, involuntary muscle movements, dizziness, and tinnitus. Chronic melancholia symptoms included moaning, suspicion, sadness, restlessness, [and] “abnormal fear, such as . . . that the sky may fall on one’s head . . . [or] being swallowed by the earth.”

 These fears certainly sound like delusions, thus suggesting psychotic features in chronic melancholia. Avicenna also noted some features of chronic melancholia that are consistent with—or similar to—what we would now call a “mixed state” or perhaps a switch into mania: increased libido, involuntary laughter and imagining “that [one] is king.”

At first glance,Avicenna’s composite description—probably based on many patients he had observed—may seem like a hodgepodge of unrelated signs and symptoms. But upon closer examination, I believe Avicenna’s description sorts out into 5 main clusters: encompassing anxious/depressive, manic, psychotic, cognitive and somatic features (

). I have noted, in brackets, what might be our modern-day analogues of some of Avicenna’s terms.

Avicenna’s concept of melancholia overlaps with, but is not identical to, some modern formulations of melancholia5—which also differ from the DSM-5’s specifier, “with melancholic features” (

A cautionary note: my analysis is based on a 12th century translation from Avicenna’s original Arabic into Latin and then into English which almost guarantees problems of interpretation.

 Nevertheless, I believe we can still draw meaningful conclusions from Avicenna’s rich description of melancholia. Indeed, I believe Avicenna was identifying a clinical entity that is consistent with what today we would call a 

. This has been succinctly described by S. Nassir Ghaemi, MD, MPH, and Sivan Mauer, MD, as follows

It is . . . important to acknowledge that the phenomenology of mood conditions involves the frequent, if not usual, admixture of manic and depressive symptoms at the same time—called mixed states. In this scenario, a full-blown clinical depression may be present, but some manic symptoms may also be present such as rapid thoughts, increased sexual drive, and marked anger and mood lability. Thus, one can think of mood episodes on a spectrum from pure depression to pure mania, with many mixed states in between.

Ghaemi and Mauer draw a remarkable conclusion from the prevalence of such mixed states

If this phenomenology is correct, then it has important implications for the classification of diagnoses. The current [DSM] diagnostic system is based completely on the distinction of depression and mania. If manic vs depressive states cannot be distinguished in most cases, then the current diagnostic system would be very difficult to implement validly. Put otherwise, the frequent presence of mixed states would invalidate the diagnostic system built on a mania vs depression dichotomy.

There are a few things that should be considered as part of this discussion.

There remains some controversy regarding the nosological status of melancholia.

 For instance, there is some debate as to whether it constitutes a stand-alone category, or whether—invoking a dimensional model—melancholia represents simply a more severe type of depression.

of these issues is provided by Gordon Parker, MD, PhD, DSc, in 

, January 20, 2017. With respect to melancholia as a distinct category or illness, Max Fink, MD, and Michael Alan Taylor, MD, have propounded a very specific description of a discrete disease entity, characterized by “specific behaviors, vegetative signs, and validated by neuroendocrine abnormalities (cortisolemia).”

In the discussion, I am alluding to the title of Julian Jaynes’s controversial book, 

The Origin of Consciousness in the Breakdown of the Bicameral Mind. 

In their seminal paper, Ghaemi and Dalley lay out the case for breaking down the dichotomous classification of mood disorders and for returning to a more Kraeplinian understanding of manic and depressive states. Ghaemi and Dalley first explain the difference between the Kraeplinian concept of manic-depressive illness (MDI) and our present DSM model of unipolar versus bipolar disorder. In essence

For bipolar disorder, the condition is defined by polarity: presence or absence of a manic episode…For MDI, the condition is defined by episodicity: recurrent mood episodes define the illness, irrespective of polarity…MDI means recurrent manic 

depressive episodes. Bipolar disorder means recurrent manic 

depressive epi­sodes. These are quite different concepts.

The authors also punch some holes in the DSM category of major depressive disorder (MDD), which they argue is of “questionable” validity. My own view of MDD, as I have quipped to Dr Ghaemi, is that it is broad and vague enough to apply to a week-old ham sandwich! 


1. Fink M, Taylor MA. Resurrecting melancholia. 

2. Ghaemi SN, Dalley S. The bipolar spectrum: conceptions and misconceptions. 

On this last point, Ghaemi has much more to say regarding what I would call—with a nod to Julian Jaynes—“the breakdown of the bicameral model” (

). Indeed, allowing for the difficulties of translation, I believe Avicenna would be in agreement with this non-dichotomous—or perhaps we should say unified—view of mood disorders. Moreover, Avicenna’s observation of apparent psychotic features in melancholia should not be surprising, since delusions or hallucinations occur in about one-half of manic states and in about 10% of depressive states.8 Indeed, recent work by van Bergen et al9 found that a lifetime history of psychotic symptoms was present in 73.8% of patients with bipolar type I and included delusions in 68.9% of patients and hallucinations in 42.6%.

We should note that not all the signs and symptoms observed by Avicenna map neatly onto modern-day descriptions of mixed states. For example, Avicenna describes “laziness” and “inertia” in melancholia, whereas recent work by Koukopoulos et al

 suggests that most mixed states are characterized primarily by psychomotor excitation—eg, rapid thoughts, marked rage/irritability, agitation, and impulsivity—added to depressive features. This discrepancy should not be surprising. Avicenna’s global description probably reflected his experience with many different patients with varying presentations of melancholia, which, for Avicenna, encompassed the entire range of both depressive and manic symptoms.

Finally, we should note that the DSM-5’s mixed features modifier—defined as the presence of non-overlapping mood symptoms from the opposite mood state—differs in several important respects from mixed states as described by Ghaemi and Mauer,7 who are critical of the DSM-5’s formulation.

Avicenna’s forbears: Aristotle and ibn Imran

To be sure, Avicenna was not the first or the last ancient or classical writer to describe melancholia. Aristotle (384 BCE–322 BCE) described not only melancholia, but—very likely—manic-depressive illness.

 Indeed, as with Avicenna, Aristotle’s concept of melancholia probably “included what today would be called mania.”

And, about a century before Avicenna, the Iraqi-Arab physician ibn Imran (died c 906 CE) wrote a treatise describing melancholia and manic-depressive illness in strikingly modern terms.13 Notably, Avicenna may have been among the first physicians to document that anger is often a transitional state from melancholic depression to mania—implicitly recognizing the switch phenomenon.

The term “melancholia” is derived from 2 Greek words: 

, meaning “black” and “bile,” respectively. Black bile is one component of the theory of the 4 humors, which dominated medical theory and practice from the time of Hippocrates (ca 460–c. 370 BCE) until the middle of the 19th century.

 Avicenna’s concept of melancholia owed much to this theory, and attributed melancholia to “an excess of black bile in the brain.”

 We can set aside this long-outdated humoral theory without diminishing the importance of Avicenna’s clinical description of melancholia and its relevance to our modern construct of mixed states. Furthermore, we should take careful note of Avicenna’s view of melancholia as a multi-system disease, particularly one involving the heart

[I]n most cases, some heart diseases initiate a process which ultimately leads to depression; and [even] if the cause of depression in some cases originates from the brain, [the] heart will be involved and make the problem worse.

It is really only within the last century or so that Avicenna’s intuition has been partially validated, although the specific mechanisms he posited differ considerably from those of modern medicine. Recent studies show that, indeed, there are important connections between clinical depression and cardiac disease. For example, approximately 20% of patients with ischemic heart disease (IHD) suffer from comorbid depression, and depression is an independent predictor of IHD in otherwise healthy individuals, even after controlling for risk factors such as smoking.

Serious psychiatric diseases have plagued mankind for at least the period of recorded human history, and probably much earlier. Although I have cited sources going back to classical Greece, narratives from the Hebrew Bible suggest that melancholia and various mixed affective states were recognized even in Biblical times, eg, in the condition 

 The medieval physician and philosopher Avicenna appears to have described a type of mixed affective state—embodying manic, depressive, and psychotic features—a millennium before institutional psychiatry existed. To be sure, the humoral mechanisms he posited are no longer credited, but his clinical observations of melancholic patients are largely consistent with those of modern-day clinicians. In short, the notion that melancholic depression, mixed states and manic-depressive illness are inventions of modern-day psychiatry is, historically speaking, flatly wrong. Finally, Avicenna’s description of melancholia presenting as a mixed state has important implications for our modern-day nosology and our treatment of mood disorders.

: I wish to express my appreciation to my friend and colleague, Dr Nassir Ghaemi, for his valuable comments, suggestions, and perspectives on an earlier draft of this article.

 is professor emeritus of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical University; clinical professor of psychiatry, Tufts University School of Medicine; and editor in chief emeritus of 

1. Flannery M. Avicenna, Persian philosopher and scientist. Britannica.com. Accessed September 16, 2020. 

https://www.britannica.com/biography/Avicenna

2. Rizvi SH. Avicenna (Ibn Sina) (c. 980-1037). 

3. Araj-Khodaei M, Noorbala AA, Parsian Z, et al. Avicenna (980-1032CE): The Pioneer in Treatment of Depression. 

The Nature of Melancholy: From Aristotle to Kristeva. 

5. Fink M, Taylor MA. Resurrecting melancholia. 

January 20, 2017. Accessed September 16, 2020. 

https://www.psychiatrictimes.com/view/update-melancholia

7. Ghaemi SN, Mauer S. Diagnosis, classification, and differential diagnosis of mood disorders. In: Geddes JR, Andreasen NC, Goodwin GM, eds. 

 3rd ed. Oxford, Oxford University Press; 2020.

8. Dunayevich E, Keck PE. Prevalence and description of psychotic features in bipolar mania. 

9. van Bergen AH, Verkooijen S, Vreeker A, et al. The characteristics of psychotic features in bipolar disorder. 

10. Koukopoulos A, Sani G, Ghaemi SN. Mixed features of depression: why DSM-5 is wrong (and so was DSM-IV). 

11. Pies R. The historical roots of the "bipolar spectrum": did Aristotle anticipate Kraepelin's broad concept of manic-depression? 

12. Ghaemi SN. Perspective: Aristotle on manic-depressive illness and greatness [published online ahead of print, 2020 Apr 10]. 

13. Omrani A, Holtzman NS, Akiskal HS, Ghaemi SN. Ibn Imran's 10th century Treatise on Melancholy. 

14. Haque A. Psychology from Islamic Perspective: Contributions of Early Muslim scholars to contemporary Muslim psychologists. 

15. Lagay F. The legacy of humoral medicine. 

 2002;4(7). Accessed September 18, 2020. 

https://journalofethics.ama-assn.org/article/legacy-humoral-medicine/2002-07

16. Harnett DS, Pies R. Mood disorders and medical illness in the elderly. In: Ellison JM, Kyomen HH, Verma S, eds. 

What was the Mental Disease that Afflicted King Saul?

Articles

Avicenna may have been among the first physicians to document that anger is often a transitional state from melancholic depression to mania—implicitly recognizing the “switch” phenomenon.

How Avicenna Recognized Melancholia and Mixed States—1000 Years Before Modern Psychiatry

The Bible tells us to lay hands on the sick and they shall recover and will continue to do that without the fear of the spread of any virus. —Pastor Tony Spell, Life Tabernacle Church, Baton Rouge, LA

Can prayer on behalf of those with serious illness be of benefit to a cohort of anonymous recipients? We recently became aware of a randomized, controlled study aimed at answering precisely this question for a population of patients with COVID-19 in the intensive care unit.

 Whatever one’s religious or spiritual beliefs—or lack thereof—this study raises profound questions and concerns for psychiatrists. For example, what is the effect on patients and their families if their prayers for ailing loved ones are not answered? What is the potential for religious and spiritual interventions to relieve—or to exacerbate—the stress of the COVID-19 pandemic? In this article, we explore the double-edged sword of religious and spiritual responses to the pandemic.

The upside of religion and spirituality during the pandemic

 sponsored by the American Psychiatric Association highlighted the adverse psychological effects of the current pandemic and the prominent place of religious faith in addressing these effects.

 The survey results indicate that nearly half of Americans (48%) are anxious about the possibility of contracting coronavirus; about 40% are anxious about becoming seriously ill or dying from coronavirus; and even more Americans (62%) are anxious about the possibility of family and loved ones getting coronavirus. The APA survey is cited in a new 

(DHHS) resource for faith-based leaders assisting their communities to manage the challenges COVID-19 presents to their faith and lives. Importantly for our topic, DHHS cites research that “one in four people who seek help for mental health concerns turn to faith leaders before they seek help from clinical professionals.”

Indeed, there is a long philosophical and historical relationship between religion, spirituality, and healing, as well as a modern body of solid empirical evidence showing the beneficial effects that traditional religion and more contemporary spirituality have on physical and mental health.

 Although there is valid criticism of the methodological limits of some studies—including, for example, the difficulty in establishing causality—most health care practitioners, including mental health professionals, have seen these benefits for many patients under their care.

"One in four people who seek help for mental health concerns turn to faith leaders before they seek help from clinical professionals.”

For example, a rigorous 16-year follow-up study showed that women (N = 74,534) who attended religious services more than once per week experienced 33% lower all-cause mortality, including cancer and heart disease, compared with women who had never attended religious services.

 Li and colleagues noted that, “There may be many pathways from attendance at religious services to health” and that effects on depressive symptoms, smoking, social support, and optimism were potentially important mediators. No single mediator explained more than about 25% of the effect.

Even more pertinent to psychiatry findings from a study published in the 

suggest that persons who endorsed religion and spirituality as being of “high importance” in their lives had only one-tenth the risk for depression (especially recurrent depression), compared with those for whom religion was of less or no importance—no matter the nature of the religious or spiritual beliefs.

This association held true even more strongly if an individual had a depressed parent.

We might just say, all well and good: religion and spirituality, through 1 or more mechanisms, can have a positive impact on heart disease and depression. But how could religious belief and spiritual practice be helpful in the worldwide COVID-19 pandemic when we do not even have a vaccine? Intuitively, it might seem more likely that, in the context of such a devastating plague, certain religious beliefs would only worsen fear and despair—perhaps conjuring up images of apocalyptic plagues and divine punishment for sin, or leading people to feel that God had abandoned them and then to reject religion and spirituality completely.

Although scientific research on this issue is not yet available, news stories and public opinion polls suggest that the picture is actually more ambiguous, and that there is both an up- and a downside to religion and spirituality in COVID-19, as we will discuss in the remainder of this article.

Many mainstream churches, synagogues, mosques, and temples—faced almost overnight with the need to promote public health restrictions and cancel the services that are the heart of much communal worship—

 that reduced isolation and offered solidarity in prayer, medication, and religious reading.

Moreover, a recent Gallup Poll—again belying the scenario that COVID-19 will lead to a loss of faith or negative expressions of religiosity—has found that the COVID-19 crisis has enhanced spirituality and religion for many Americans. During the period when the pandemic was rapidly spreading to many parts of the US (March 28-April 1), 19% of those interviewed felt their faith or spirituality had “gotten better” during the crisis. Commenting on this finding, Gallup senior scientist Frank Newport, PhD,

that “One of the traditional roles of religious individuals and religious entities has been to serve a positive, integrative, pro-social, charitable function in crisis situations.”

The downside of religion and spirituality

In our view, the best available evidence points to a predominantly positive effect of spirituality/religion on mental health and coping, especially during times of crisis. However, as Mosqueiro and colleagues

 observe, “there is also a downside to this relationship . . . [as] religion can be a major source of stress for many people.”

 have described what they call a spiritual struggle in some individuals, defined as “any dysfunctional religious or spiritual belief that is capable of generating or exacerbating suffering.” This is also called negative religious coping and may include religious guilt, the belief that God is malicious, and the fear of [divine] retribution.

In the context of the coronavirus pandemic, clinicians may need to consider the following questions: What happens to religiously oriented people when things go badly, despite their faith and prayer, when for example, a loved one dies of COVID-19 despite the prayers and faith in God of family members? Might the family think that they did not pray hard enough or were not cheerful and positive enough? Or that their loved one was somehow unworthy of being saved? Consider how people of faith—especially someone with a psychiatric disorder, such as major depression, obsessive-compulsive disorder, or posttraumatic stress disorder—would feel if a priest, rabbi, or other religious leader assured them that if they attend a large religious gathering, God will protect them from COVID-19; and later, the individual becomes ill and learns that other members of the congregation—including, the leader himself—have died of COVID-19. This is exactly what befell a respected Virginia pastor who had promised his congregation that “God is larger than this dreaded virus.”

 Not only may the members of that congregation experience an exacerbation of their underlying mental health condition, they may also lose trust in the very community and beliefs that were providing support and purpose.

We are not aware of any systematic research that has examined these questions with respect to the COVID-19 pandemic, which is still at a relatively early stage. However, studying these issues may have important implications for psychiatry and mental health treatment. For example, Rosmarin and colleagues

 found that spiritual struggle (negative religious coping) was a strong predictor of greater symptoms of both depression and mania and appears to be a common and important risk factor for depressive symptoms. However, religious affiliation, belief in God, and frequency of religious service attendance were all unrelated to affective symptoms. These findings suggest that it is not religious belief or religiously oriented behavior per se that negatively affects mood; but rather, the dimension of spiritual struggle and its accompanying cognitions (eg, “God must be punishing me,” “I must be unworthy of being saved”).

Negative religious coping may be more common among faiths and congregations that encourage the belief that people can will themselves into remission from some disease through prayer—and that continued disease is a sure sign that the person has failed in some respect. Thus, Christina Puchalski, MD, MS, FACP, FAAHPM, Director of the 

George Washington University Institute for Spirituality and Health

, reports “I’ve had very religious patients who told me that ‘my church group said I didn’t pray hard enough, because otherwise my diabetes would have been cured.’”

We wonder how such a self-blaming belief may be playing out in very religious patients who are suffering prolonged and severe bouts of COVID-19—but again, we are not aware of research in this area, at this stage of the pandemic. Nevertheless, we note with concern CNN reporter Miguel Marquez’s observation at a recent protest against restrictions imposed in the wake of the COVID-19 pandemic.

 Marquez caught sight of a truck that bore the message, “

 As clinicians, we wonder what happens to people of strong religious faith when the “Jesus vaccine” does not work for them or their families.

Healthy religious and spiritual expression has almost always offered solace in disaster, consolation in bereavement, hope in sickness, and peace in death, for millions of human beings over the millennia. These are powerful reasons why, despite Freud’s prediction in 

 nearly 100 years ago, that religion was a mass delusion that reason would soon banish—religious and spiritual expression has retained its vital significance in human life. Until quite recently, Freud’s view captured the ambivalent, if not frankly adversarial, relationship psychiatry has had, historically, with religious belief. In our view, such animus is not in the best interest of our religiously oriented patients. Fortunately, as Professor of Medical Humanities, Farr Curlin, MD,

 has noted, “This historical antagonism appears to be waning.”

We believe that mental health and religious professionals must work together to help persons of faith toward an authentic understanding of spiritual practice and religious devotion. Furthermore, we believe that certain religiously based misconceptions can actually work against the interests of the patient. For example, a purely instrumental view of prayer can inhibit what we would call the experience of relational openness to God. In this regard, Daniel Sulmasy, MD, PhD,

 a former Franciscan monk and philosopher – physician, has pointed to the danger of “trying to control or manipulate God’s power, even for a good purpose, such as healing . . . .” Dr Sulmasy specifically relates this to the matter we raised at the beginning of this article—that of the “unanswered prayer.” He writes:

Is one to suppose that God is absent from those that are not healed? Should one question the purity, intensity, sincerity, quantity, or duration of these patients’ prayers or of those who prayed for them? From the point of view of true faith, God is never absent from persons who seek him with a sincere heart. Persons whose prayers for healing are not answered with healing should not be made to feel guilty; they must find a way to understand [God’s] mysteries. . .

One approach to these mysteries—especially in some Asian religions and in existential psychotherapy—is to shift the focus of prayer from the narrowness of one’s ego to a wider vision of the self that encompasses empathy for the suffering of others. Religious leaders have urged the faithful to see the immense human anguish and economic dislocation the pandemic has wrought as an invitation to spiritual transformation. Thus, the Abbott of Wat Pasukato—a Buddhist monastery in Thailand, the Venerable Phra Paisal Visalo,

This situation has great potential to help each of us to reduce our selfish behaviors and attitudes and increase our generosity in support of each other. We need to stay connected and encourage people to express their goodness from within, which ultimately helps others.

Like any intervention with the power to effect emotional change, religious and spiritual approaches to serious illness have risks and benefits. As psychiatrists, we need to understand both the positive and negative interactions of religion and spirituality with the particular patient’s physical and emotional needs—and this will likely differ considerably from patient to patient. We can address maladaptive responses stemming from religious guilt and fear, while supporting beliefs and practices that foster hope and resilience. Finally, we believe that psychiatry can play a useful role in re-framing the distressing aspects of the current pandemic in the altruistic and prosocial terms so eloquently expressed by Phra Paisal Visalo.

is Professor, Department of Psychiatry, SUNY Upstate Medical University, Syracuse, NY and Tufts University School of Medicine, Boston, MA; he is Editor in Chief Emeritus of 

 is Professor, Department of Psychiatry and Internal Medicine, and Director of Ethics Education, University of New Mexico School of Medicine in Albuquerque, NM; she is also Health Care Ethicist, Ethics Consultation Service, VA National Center for Ethics in Health Care. She is also an Editorial Board Member of 

1. Kaur H. 4 reasons why the rush to reopen churches goes beyond politics. May 24, 2020. CNN. 

https://www.cnn.com/2020/05/24/us/churches-reopening-state-orders-trnd/index.html

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New Poll: COVID-19 Impacting Mental Well-Being: Americans Feeling Anxious, Especially for Loved Older Adults are Less Anxious

 [press release]. Washington DC; March 25 2020.

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7. Miller L, Wickramaratne P, Gameroff MJ, et al. Religiosity and major depression in adults at high risk: a 10-year prospective study. 

Worshippers go online, those at services keep at distance

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https://news.gallup.com/opinion/polling-matters/310397/religion-paradox.aspx

10. Mosqueiro BP, de Rezende Pinto A, Moreira-Almeida A. Spirituality, religion and mood disorders. In: Rosmarin DH, Koenig HG, eds. 

Handbook of Spirituality, Religion and Mental Health. 

11. Rosmarin DH, Malloy MC, Forester BP. Spiritual struggle and affective symptoms among geriatric mood disordered patients. 

12. NBS News, Bishop who preached “God is larger than this dreaded virus” dies of COVID-19. April 14, 2020.

revised ed. New York, NY: HarperCollins; 2005.

14. Marquez M. “Jesus is my vaccine” is one of the more colorful messages. 

https://twitter.com/miguelmarquez/status/1252262768591491072?lang=en

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The Rebirth of the Clinic: And Introduction to Spirituality in Health Care. 

Washington, DC: Georgetown University Press; 2006.

Senior Thai Monk Offers a Buddhist Perspective on Dealing with COVID-19

Clinicians may need to consider what happens to religiously oriented people when things go badly, despite their faith and prayer.

The Upside and Downside of Religion, Spirituality, and Health

In the midst of a frightening spike in COVID-19 

 how do we understand those who adamantly refuse to wear protective masks in public? Barring some (very rare) medical contraindication to wearing a mask, I can think of no ethical justification for such a refusal. Given that face masks help prevent asymptomatic spread of COVID-19 and may also 

 of anyone contracting the COVID-19 virus,

 wouldn’t any decent, responsible citizen put up with such a minor inconvenience?

It is tempting to write off the mask refusers as selfish, irresponsible yahoos, or as “COVID deniers”—those who simply don’t believe the pandemic is “real,” or that it represents a serious health threat. There may be some truth to those characterizations. But, in my view, the picture is more complex and provides a window into a cultural archetype that I call the 

 First, though, we need to deal with mask refusal and 

, I referred to a venerable tradition of tough-minded individualism that has marked this country from its very inception.

“The image of the self-reliant, iron-willed “loner” is an iconic American archetype, from the days of the lone cowboy, out on the range, to the novels of Ernest Hemingway. The motto, “

”—which arose during the years of the American Revolution—nicely sums up the feisty spirit of American individualism. Indeed, during recent anti-restriction protests, “

” appeared on numerous flags and banners.”

, this rugged individualism serves as a useful counterweight to the

 impulse—the belief that the community is a “bearer of rights,” to which an individual’s interests may have to be subordinated in some cases. But carried to an extreme—what I called, “hyper-individualism”—the “Don’t Tread on Me” mentality can become an insidious force for societal disintegration.

In my view, many mask refusers are acting out of a debased form of individualism that some would call “toxic masculinity,” and which I would call 

. I hasten to add that I am using the latter term in a broad, generic sense, and 

 as a trait endemic to “Latin” culture or society. A very useful definition of 

“Exaggerated pride in masculinity, perceived as power, often coupled with a minimal sense of responsibility and disregard of consequences.”

Please scroll below the references to read Letters to the Editor.

In my view, this brand of American machismo helps explain the behavior of many (though not all) mask refusers. In effect, refusal to wear a mask in public settings has become a mark of being “a man’s man”—someone who won’t be pushed around or “muzzled” by governmental “tyranny.” To be clear: I’m not saying anything new here. In April of this year, social scientist Prof. Peter Glick 

“Why the reluctance to model safe behavior? My 

research with Jennifer Berdahl and others

 suggest one critical reason, which is that appearing to play it safe contradicts a core principle of masculinity: 

 In short, wearing a mask emasculates . . . [mask refusers] prove their manhood by showing resistance to experts’ opinions, hypersensitivity to criticism and constant feuding with anyone who seems to disagree with them.”

But, in my view, machismo is just one piece of the puzzle. We now need to examine an archetype that, in academic circles, is called 

—Latin for the “eternal boy” or “eternal child”—and which I want to call, “The American Man-Child.”

“. . . is used in mythology to designate a child-god who is forever young; psychologically, it refers to an older man whose emotional life has remained at an adolescent level . . . He covets independence and freedom, chafes at boundaries and limits, and tends to find any restriction intolerable.”

from an Ohio state representative who refuses to wear a mask:

“I will not wear a mask . . . quite frankly, everyone else’s freedom ends at the tip of my nose. You’re not going to tell me what to do.”

How many frustrated parents have heard, “You can’t make me!” from their petulant, early adolescent child?

 archetype was popularized by the psychoanalyst, Dr Dan Kiley, in his 1983 book, 

The Peter Pan Syndrome: Men Who Have Never Grown Up

. Kiley describes men of this type as follows:

"Narcissism locks them inside themselves . . . pursuit of other people's acceptance seems their only way to find self-acceptance. Their temper tantrums are disguised as manly assertion."

 Now, add in a dollop of magical thinking—as in, “This whole virus thing is a big hoax!”—and we have the makings of the American 

 Tragically, we also have the makings of a resurgent American pandemic that threatens to overwhelm us once again.

 is Professor Emeritus of Psychiatry and Lecturer on Bioethics and Humanities, SUNY Upstate Medical University; Clinical Professor of Psychiatry, Tufts University School of Medicine; and Editor in Chief Emeritus of 

1. Knowles H, Wagner J, Shaban H, et al. Seven states report highest coronavirus hospitalizations since pandemic began. 

https://www.washingtonpost.com/nation/2020/06/23/coronavirus-live-updates-us.

2. Texas A&M University. Face masks critical in preventing spread of COVID-19. 

https://www.sciencedaily.com/releases/2020/06/200612172200.htm

3. Glick P. Masks and Emasculation: Why Some Men Refuse to Take Safety Precautions. 

https://www.psychiatrictimes.com/view/freedom-does-not-mean-being-loose

https://www.britannica.com/topic/machismo

5. Glick P. Masks and Emasculation: Why Some Men Refuse to Take Safety Precautions. 

 April 30, 2020. Accessed June 29, 2020. 

https://blogs.scientificamerican.com/observations/masks-and-emasculation-why-some-men-refuse-to-take-safety-precautions

https://frithluton.com/articles/puer-aeternus/

7. Polman D. Refusing to wear a mask is about the most un-American thing to do right now. Pennsylvania Capital-Star. May 11, 2020. Accessed June 29, 2020. 

Given that face masks help prevent asymptomatic spread of COVID-19 and may also reduce the chances of anyone contracting the virus, wouldn’t any decent, responsible citizen put up with such a minor inconvenience? Apparently not.

Author | Ronald W. Pies, MD

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