Psychological Masquerade by Taylor MD, Robert L. and Robert L Taylor - Read Online
Psychological Masquerade
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When faced with a patient whose psychological symptoms may stem from an organic, or medical, condition rather than psychology, how does the practitioner determine exactly which is the true case? To facilitate this process and give psychologists, social workers, and nurses a useable guide to assessment, Robert Taylor created Psychological Masquerade and has updated it to be the most complete handbook you will ever need in the field.

New chapters on violent behavior, amnesia and dementia, sex obsession, and Munchausen-by-Proxy fill out the guide and numerous case studies help clarify diagnostic criteria and provide a welcome hands-on approach to caring for clients in this delicate balance. As a further enhancement of the text as assessment tool, self-tests for hypothetical cases are included as are specific clinical tests that aid in clue gathering.

This is the perfect clinical guide for any practitioner who is likely to come into contact with psychological masquerade among their clients and will be a welcome addition to the practitioner's toolbox.

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ISBN: 9780826102478
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Psychological Masquerade - Taylor MD, Robert L.

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Personal encounters in everyday life cause striking changes in how we think, feel, and act. Such changes are not always the product of external events. Sometimes they result from physical disease. In these instances, despite their psychological appearance, emerging symptoms reflect problems in the body or brain itself.

Proper identification of these masquerading medical conditions is a challenge to all health professionals. Failure to recognize them causes patient frustration, inappropriate therapy, and, in the most tragic cases, residual disability or even death. It is distressing for any clinician to discover after the fact that symptoms he or she construed as expressions of psychological conflict resulted from an underlying organic disorder.

The passage of 16 years since the first edition of this book has not altered the basic premise: Psychological symptoms are not always best explained psychologically. A host of medical conditions have a nasty way of presenting as psychiatric disorders. Clinical recognition begins with sensitivity to the possibility. Without it, the clinician risks being blinded by the most compelling symptoms. If the masquerade is to be detected, the clinician must be able to suspend judgment long enough to consider other less attention-grabbing clues.

This book is a practical clinical guide, composed of illustrative clinical case histories and a set of basic principles that, if followed, reduce the chances of overlooking psychological masquerades.

I owe a special thanks to Larry Koran, who many years ago set me to thinking about this subject and who thoughtfully reviewed early draft chapters. I am also grateful to Barbara Arons and the staff of the inpatient psychiatric service at Santa Clara Valley Medical Center (San Jose, California) from whom I learned invaluable lessons about psychological masquerade. And for their published accounts of masquerading organic disorders, I am indebted to various authors, most of whom I have never met.

Finally, the book has been improved in response to comments from Frank Benson, Pat Jordan, Bev Abbott, David Lam, Linda Olvera-Perales, Lenore Morell, Merna McMillan, and my editor, Sheri W. Sussman. Thanks also to two most helpful research librarians—Barbara Tims and Amy Mashberg—and to my copyeditor, Bernice Pettinato.


Appearances Can Be Deceiving

Difficulties lie in our habits of thought rather than in the nature of things.

–André Tardieu

Psychiatric symptoms are not always best explained psychologically. The same mental, emotional, and behavioral changes associated with problems in living also arise from various medical conditions (Butler & Zeman, 2004). For the clinician, this dual origin of psychological symptoms creates an ongoing diagnostic challenge. Is the patient depressed because of problems at home, at school, or on the job, or is this depression the reflection of a disturbance in the body or brain itself?

Psychological masquerade is the flip side of psychosomatic. Just as individuals with psychological issues sometime translate their problems into somatic symptoms and seek help from physicians, persons with masquerading medical disorders often turn to psychotherapists and counselors. Because these misleading clinical presentations are common, these diagnostic challenges cannot be avoided. And to complicate matters, they often occur in the context of what turns out to be unrelated personal problems.

In the everyday world, the boundaries between medical and nonmedical are blurred. Psychological masquerades show up on the watch of all mental health clinicians. They need to be prepared to see these problems for what they are. They owe this to themselves as professionals and, more important, to their patients.

This is not to say that they need to become junior neurologists. The detection of psychological masquerades does not require highly technical medical knowledge. Arriving at a specific medical diagnosis remains the role of medical specialists. The challenge for the nurse, counselor, or therapist is to entertain the realistic suspicion of organicity so that further medical evaluation can be done.


Throughout this book, I have contrasted psychological reactions with organic mental disorders. At times, the distinction may seem overly simplistic. In reality, human problems are neither. It is the explanatory language we use that is organic or psychological. If our knowledge of human behavior were complete, one all-encompassing language would suffice. As it is, we are stuck with various partial languages (or models) to explain different kinds of human dysfunction. Primarily, we rely on two languages. For convenience, we will call them Language I and Language II.

Mechanistic in character, Language I is the descriptive medium of the physical and biological sciences. Language II is more subjective and metaphorical. It has a greater capacity for expressing subjective experience such as motivation, meaning, and feeling. It is more compatible with the demands of the arts, social sciences, and human interactions. Psychological reactions to problems in living are more easily described in Language II than in Language I. This makes them more amenable to psychological hypotheses as opposed to mathematical equations or mechanistic explanations. The person is depressed because the promotion he long anticipated at work failed to materialize. This kind of explanation suggests certain nonbiological remedies: finding another job, working through problems with authority, or exploring pent-up feelings of rejection in psychotherapy.

But with other kinds of problems, Language II is not nearly as useful. Consider the abdominal pain associated with acute appendicitis. Formulating this symptom in terms of childhood rejection is possible, but it is of little utility compared to a physiological explanation rendered in Language I that calls for surgical intervention as corrective treatment. Ultimately the choice of explanatory language should be determined by which one better fits the problem at hand.

Compare the demands of acute appendicitis and grief. Stated in biochemical terms (Language I), an explanation of human grief would be quite limited in the practical insights it generates. Not so with Language II. Its vocabulary lends itself to describing grief in ways that are much more amenable to intervention. In short, any human problem can be explained in either organic (Language I) or psychological (Language II) terms. The choice of how a problem is conceptualized should come down to which one provides the more productive solutions. This book focuses on symptoms that—though often best explained psychologically—on occasion demand biological explanation. Failure to apply the appropriate explanatory language to these masquerading conditions sets the stage for treating brain tumor as a personality disturbance, thyroid disease as an anxiety disorder, or brain seizure as psychosis. Consider the following case:

After seven months of unexplained tearfulness and hearing voices, a 14-year-old girl, the youngest of three daughters, was referred to a child psychiatrist for treatment of her psychosis. The patient had no previous psychiatric problems, but there was a history of depression and psychosis in the family.

Despite the history of months of tearfulness, a psychiatric evaluation failed to show evidence of depression. Although the patient had no idea what was making her cry so often, her mood seemed normal. As for the so-called voices, they turned out to be more like whooshing or whispering sounds than distinctive auditory hallucinations. Furthermore, the girl explained how they occurred only when she stood up abruptly or rushed around. When she was at rest, they disappeared. (She denied ever hearing actual voices.) Along with these strange sounds she experienced dizziness, shortness of breath, and heart palpitations. With physical exertion, she quickly became breathless, and much of the time, she felt lethargic. (Field, 2005)

As it turned out, this young girl was not psychotic. Her real problem was severe anemia, caused by a combination of heavy menstrual periods and a poor diet. Her doctor hypothesized that the noises arose from the resulting altered hemodynamics and cerebral hypoxia (low oxygen).


Over the years, various researchers have studied the frequency of psychological masquerade. One of the earliest studies looked at 395 patients with well-documented neurological disease. The researcher posed the following question: How many of these cases were initially mistaken for psychological reactions? For the answer, they conducted an extensive medical record review and found that 13% of these patients had been misdiagnosed. Mistaken diagnoses included hysteria, schizophrenia, hypochondriasis, psychopathic personality, obsessive compulsive neurosis, anxiety, and somatization. On average, these false diagnoses had been maintained for 4 years. At one time or another, all of these patients received psychotherapy for symptoms eventually determined to be neurological (Tissenbaum, 1951).

Another pioneering effort reviewed 658 consecutive outpatient psychiatric cases for evidence of medical disorders productive of psychiatric symptoms. Although all these patients initially sought help for what they believed were psychological problems, 9% turned out to have an organic cause. The researchers concluded, Psychiatric symptoms are nonspecific and commonly occur in medical as well as psychiatric disease (Hall, 1978).

A decade later, Lorrin Koran of Stanford University’s Department of Psychiatry and his colleagues used a mobile evaluation unit to examine 529 patients drawn from the state’s public mental health system (Koran, 1989). Underlying organic conditions that either caused or significantly exacerbated psychiatric symptoms were found in 173 cases. In their report of these findings, the researchers, summarizing their own and nine additional studies, concluded that the average occurrence of psychological masquerade was 19%.

More recently, Koran’s team studied 289 consecutive admissions to a public psychiatric hospital (Koran, 2002). Based on extensive medical evaluations, undiagnosed medical disorders were found in 8% of patients. Medical conditions thought to cause or exacerbate psychiatric symptoms were estimated at 3.5%. One possible reason for this lower figure (as compared to earlier studies) is the difficulty detecting masquerading conditions related to drugs, alcohol, and medication side effects. (In this report there was no indication that drug screens were used, and no cases of alcoholism or drug addiction were reported in the list of active and important physical conditions.) This conjecture is supported by a separate study detailed in the American Journal of Emergency Medicine where 64 patients with unrecognized medical emergencies were mistakenly admitted to psychiatric units. Over half of these cases turned out to result from drug or alcohol intoxication or withdrawal or from adverse reactions to prescription drugs (Reeves, 2000). As we shall see later, drugs and alcohol (including prescription and over-the-counter medications) are always suspect when it comes to psychological masquerade.

Certain symptoms traditionally characterized as psychological require particularly close scrutiny. Consider sexual impotence. A study published in the Journal of the American Medical Association showed roughly 75% of 105 men evaluated for sexual impotence had causative physical diseases. Diabetes mellitus, sex hormone imbalance, and various addictions ranked high on the list (Spark, 1980). Of the 34 men who had hormonal problems and accepted hormone replacement therapy, 33 had a return of sexual potency. Previously, 14 of these men had undergone psychotherapy, unsuccessfully, to correct the problem. A more recent study looked more specifically at honeymoon impotence. Even here, based on physiological studies, 32.3% of 90 patients had a demonstrable organic basis (Usta, 2001).

These and other studies provide compelling evidence that psychological masquerade is by no means rare. Conservatively, one can assume that among psychiatric outpatients, roughly 5% to 10% of persons suffer from a causative physical disease (Hall, 1990). The figure increases in certain settings such as medical emergency rooms and psychiatric inpatient services. Similarly, it is greater in high-risk populations such as the elderly and in certain diagnostic categories such as hysteria, substance abuse, and first psychotic episodes.

These findings do not change this basic fact: The majority of cases exhibiting mental or emotional symptoms are appropriately explained psy-chosocially. But they do suggest that all mental health clinicians should expect to encounter a significant number of psychological masquerades during their careers.


A sound approach to mental health assessment begins with this basic assumption: Organic mental disorders and psychological reactions are not distinguishable on the basis of mental and emotional symptoms themselves. It is the broader context—additional history and other clinical observations—that provides the best basis for detecting psychological masquerade. Failure to look beyond the often dramatic presenting symptoms sets the stage for misdiagnosis.

Without any prior psychiatric history, a young man in his early 20s started acting strangely. Over a 3-month period, he spoke increasingly of bizarre ideas and at times appeared to respond to imaginary happenings. Also, very much out of character, he became verbally abusive. He grew lax in his physical hygiene, and his work suffered because of inability to concentrate and difficulty reading. Reports from his employer suggested that he was having trouble remembering things. The patient had no history of drug abuse, and there were no obvious major stressors in his life.

Eventually he sought help. When medically evaluated, he appeared unsteady of gait, and his attention, judgment, and memory were severely impaired. Further history revealed that he frequently paid money for sex. Brain neuroimaging showed diffuse cortical and cerebellar atrophy. When his human immunodeficiency virus (HIV) serology test came back positive, he was diagnosed with acute immunodeficiency syndrome (AIDS) dementia complex. (Chacko, 2004)

Had this man been referred for mental health assessment, it would have been easy to focus mainly on his psychotic symptoms and personality changes. But other observations were there to be made—cognitive problems and an imbalance of movement. Attention to these other findings was all that was required to build the case for possible organicity.


Distinguishing between organic and psychological disorders is made difficult by fixed patterns of perception. To a large degree, we see what we look for. People who live most of their lives in snow country learn to distinguish many different kinds of snow, whereas a visitor from the Sun Belt has difficulty discerning more than a single variety. In similar fashion, as mental health clinicians, we evolve favorite explanations. They help organize information, but they also limit our clinical observations. If taken too far, this tendency causes us to see cases of repressed anger, or primary narcissism, or abuse everywhere while ignoring other important clues. Favorite clinical hypotheses do serve a valuable function, but they can also create blind spots.

In his story entitled The Invisible Man, the mystery writer G. K. Chesterton has one of his characters dispatch four men to keep watch over the home of an intended murder victim (Chesterton, 1972). Despite these precautions, the murderer enters the house unseen and carries out his homicidal plan. Each of the four observers failed to see anyone suspicious come and go. At the story’s conclusion, the postman is revealed as the killer. He managed to be invisible because the observers were too busy looking for a murderer to take notice of the man delivering the mail.

Clinical settings—the typical clientele, the consensus viewpoint of clinicians who work together, the latest explanations—fashion a powerful context capable of distorting our observations and preventing our seeing unanticipated findings. This effect was dramatically illustrated in a now famous research study of eight pseudopatients admitted to 1 of 12 mental treatment facilities (Rosenhan, 1973). The eight individuals who volunteered were a graduate student, a housewife, a painter, three psychologists, a psychiatrist, and a pediatrician, none with any history of psychiatric problems. Each of them presented to various treatment facilities with the standard complaint: I have been hearing voices. They go empty, hollow, thud. Real names and occupations were not given; otherwise, these eight pseudopatients were truthful in reporting their lives. Even so, all of them were admitted, and all but one received a diagnosis of schizophrenia.

The research protocol prohibited these individuals from expressing any further fictitious complaints after admission; in fact, they were required to describe their complaints as though they were in the past. This had little effect on length of hospitalization. As a group, these patients were retained for periods ranging from 7 to 52 days, with an overall average of 19 days. During the course of their various hospitalizations, collectively, they received 2,100 pills, which in most instances they managed to dispose of without detection. Upon discharge, all received the diagnosis of schizophrenia in remission.

The study’s most telling finding surfaced during follow-up interviews. Professional staff and patients were questioned about suspicions they might have had concerning the real identities of the pseudopatients. Whereas none of the professionals suspected, several patients had guessed these were not actual patients. Why? Because they observed them doing things other patients did not ordinarily do. The designer of the study concluded, The hospital itself imposes a special environment in which the meanings of behavior can easily be misunderstood (Rosenhan, 1973).

Psychological masquerade is no respecter of persons. It can happen to anyone.

In the late 1930s George Gershwin, the great American composer, suffered bouts of fatigue and pounding headaches. His friends found him uncharacteristically moody and critical of others. After early musical successes, he had made a film in Hollywood, Shall We Dance. It bombed. Additionally, Gershwin and his brother, Ira, had agreed to work on Samuel Goldwyn’s pet project, The Goldwyn Follies, a three-hour song-and-dance extravaganza. Gershwin found the project distasteful and detested having to cater to the whims of its strong-willed producer. At about the same time, Gershwin fell in love with a much younger woman and began to contemplate marriage. It all added up to considerable stress. His friends thought, as he did, that his headaches and moodiness were the outcome of a life that had become a little too frenetic.

But when his symptoms progressively worsened, Gershwin had himself admitted to the Cedars of Lebanon Hospital in Los Angeles. He was subjected to extensive medical testing by an army of specialists, but despite this exhaustive assessment, 26 days later he was discharged with the notation: most likely hysteria.

At home, Gershwin deteriorated. He found light painful to his eyes (photophobia), and he became unsteady on his feet. Still, his friends and acquaintances persisted in the belief that it was all in George’s mind. When on one occasion he fell, a woman companion was overheard to comment, Leave him there. All he wants is attention. His brother persisted in calling Gershwin’s problem a nervous disorder.

But eventually there was no denying something else was going on. Gershwin was readmitted to the hospital and within a few days fell into a coma. An x-ray showed a mass compressing the right ventricle of his brain. At surgery there was an initial sense of relief when the tumor appeared to be a benign brain cyst, but the elation quickly faded when a highly malignant glioblastoma was discovered underneath that proved to be inoperable. Gershwin died the following day at age 39. (Jablonski, 1987)

Our society’s increasing sophistication about psychosomatic reactions ironically sets the stage for overlooking psychological masquerade. It has become too easy to explain complaints as just in his head. The key to avoiding such mistakes lies in maintaining a clinical mind set that is porous enough to register unanticipated, telltale clues to organic mental disorders. We must see through the obvious in order to view the hidden. Given that psychiatric symptoms most often are best explained psychologically, we continually run the risk of being lulled into insensitivity with respect to masquerades. The prime objective of this book is to render the reader less susceptible.


In Chapter 2, we consider the design of the nervous system with an emphasis on the structural basis of organic mental disorders. Chapter 3 presents clinical misconceptions that create blind spots for the clinician. Basic guidelines are covered in Chapters 4 and 5, with brain syndrome serving as a starting point for looking at clinical clues to masquerade. Chapter 6 presents a practical approach to organizing the clinical search for psychological masquerade along with seven test cases. Four masqueraders are reviewed in Chapter 7. These four medical disorders—brain tumors, seizures, endocrine disorders, and brain infections—commonly give rise to psychological masquerade. Chapter 8 considers masquerades induced by drugs (including medications and alternative treatments). Chemical substances taken into the body are the number one cause of organic mental disorders. Somatization is taken up in Chapter 9 as a means of alerting readers to findings that are inconsistent with psychosomatic explanation. When applied too loosely, the clinical hypothesis that physical symptoms reflect psychological conflict produces tragic results. Chapter 10 focuses on psychological masquerade among the elderly and Chapter 11, the young. A brief summary of the book’s major points and a self-test section of 15 clinical case histories make up the last chapter.

Finally, an annotated bibliography with selected references relevant to the clinical detection of psychological masquerade is included.


Butler, C., & Zeman, A. (2004). Neurological syndromes which can be mistaken for psychiatric conditions. Journal of Neurology, Neurosurgery, and Psychiatry, 76, 31–33.

Chacko, S., Sudarsanam, T., & Tomas, K. (2004). A young man with organic psychosis. Journal of Postgraduate Medicine, 50, 70–72.

Chesterton, C. K. (1972). The invisible man. In Selected stories. London: Kingsley Amis.

Field, A., & Cottrell, D. (2005). Postural hallucinations? An unusual presentation of anaemia. Archives of Diseases of Children, 90, 1192–1193.

Hall, R., Beresford, T., Blow, F., et al. (1990). Differentiating physical from psychiatric disorders. In M. Thase et al. (Eds.), Handbook of outpatient treatment of adults. New York: Plenum.

Hall, R., Popkin, M., DeVaul, R., et al. (1978). Physical illness presenting as psychiatric disease. Archives of General Psychiatry, 35, 1315–1320.

Jablonski, E. (1987). Gershwin. New York: Doubleday.

Koran, L., Sheline, Y., Imai, K., et al. (2002). Medical disorders among patients admitted to a public-sector psychiatric inpatient unit. Psychiatric Services, 53, 1623–1625.

Koran, L., Sox, H., Marton, K., et al. (1989). Medical evaluation of psychiatric patients: 1. Results in a state mental health system. Archives of General Psychiatry, 46, 733–740.

Reeves, R., Pendarvis, E., & Kimble, R. (2000). Unrecognized medical emergencies admitted to psychiatric units. American Journal of Emergency Medicine, 18, 390–393.

Rosenhan, D. (1973). On being sane in insane places. Science, 179, 250–258.

Spark, R., White, R., & Connolly, R. B. (1980). Impotence is not always psychogenic. Journal of the American Medical Association, 243, 750–755.

Tissenbaum, M., Harter, H., & Friedman, A. (1951). Organic neurological syndrome diagnosed as functional disorders. Journal of the American Medical Association, 147, 1519–1521.

Usta, M., Erdogru, T., & Tefekli, A. (2001). Honeymoon impotence: Psychogenic or organic in origin? Urology, 57, 758–762.


Design of the Nervous System

Man seems to be a rickety poor sort of thing.... A machine that was as unreliable as he is would have no market.

—Mark Twain

The human nervous system is a vast communication network. Outside information in the form of light (vision), chemical reactions (taste, smell), and mechanical stimulation (touch, vibration, sound) are detected by specialized sensory detectors and then transmitted over peripheral channels to a central processing area for interpretation. In turn, return messages are generated and translated into various responses: muscle action, speech, emotional response, glandular activity, contemplation, and many others. Through this arrangement, the nervous system maintains contact with the outside world as well as with the other systems of the body on which it is vitally dependent. This communication network enables the brain to plan and direct the essential life activities of protection, maintenance, growth, and creation.

Skill in detecting psychological masquerade is enhanced by an appreciation of the design of the nervous system. Here we are more interested in the big picture rather than the biomolecular details of neurophysiology and neuroanatomy. Familiarity with the general architecture of the brain allows a clinician to anticipate a number of masquerading conditions. This review highlights major potential break points—those design elements most at risk for going awry and producing organic mental disorder.


Brain substance is slightly firmer than gelatin or tofu. It is not very durable. This is why a rigid, bony covering—the skull and spinal vertebrae—as well as three layers of soft coverings are essential for its protection. In addition, the brain and spinal cord are insulated by cerebrospinal fluid, contained within the surrounding coverings. In effect, the central nervous system is an island enclosed by its own private lake and stonelike casing.

Elaborate as it is, this arrangement is not invincible. While protecting the brain against external trauma, the rigid housing predisposes it to other dangers. For example, if fluid collects within the brain (as sometimes occurs with infection or bleeding) or if there is an expanding mass such as a tumor, pressure builds up and encroaches inward on the soft brain substance. Another potential problem relates to the fluid in which the brain is suspended. Cerebrospinal fluid not only surrounds the brain and spinal cord; it also flows through the brain by way of small canals known as ventricles. These passageways are relatively narrow. They can become obstructed by aberrant growth, swelling, or hemorrhage, with a resulting outcome similar to the damming of a river. Since the rise in pressure behind the obstruction cannot be dissipated outward, it is directed inward, compressing the brain substance until dysfunction or even death ensues. In newborn infants—because the skull has not yet ossified into bone—blockage of one of these fluid channels results in outward enlargement of the cartilaginous skull. This is the cause of the enormous head size seen in hydrocephaly. Even here, the limits of accommodation eventually are reached, and increased intracranial pressure is transmitted inward. Severe mental retardation is a common outcome.

As for the soft coverings (meninges) of the brain, although they provide a degree of protection, they are also susceptible to infection—meningitis. Characteristically manifest by a stiff neck and headache, this condition can also cause confusion, bizarre behavior, and even personality changes. The invading infectious agent may also attack the brain and cause encephalitis. The clinical picture ranges from subtle headache and fatigue to gross aberrations in consciousness, emotion, and behavior. Sometimes psychiatric symptoms are the first manifestation.

Two days before she would be admitted to a hospital, a 25-year-old woman underwent a major personality change. She talked incessantly of grandiose ideas and became increasingly irritable. At times her thoughts came so fast that what she said made little sense. When taken to an emergency room, she was found to have a low-grade fever. She appeared disoriented, unable to say where she was or to give the correct date.

When her neurological examination turned out normal, she was admitted to the acute psychiatric service of a university-affiliated general hospital as a manic episode. After the patient started an antipsychotic medication (olanzapine) and a mood stabilizer (sodium valproate), her manic mood improved, but her fever increased and she developed chills. She was transferred to a medical ward, where a lumbar puncture was done to secure cerebrospinal fluid.

Subsequently, the culture of the fluid showed Cryptococcus neoformans , an encapsulated yeast found in the soil. The patient was diagnosed with cryptococcal meningitis and started on amphotericin B. Her recovery was slow, but a year later she was well and free of manic symptoms. (Tang, 2005)

The risk for cryptoccoccal meningitis is particularly high among im-munocompromised patients with conditions such as acquired immunodeficiency syndrome (AIDS) or cancer.


The basic unit of the human nervous system is the neuron. Billions of these cells, intricately woven together, form an amazing communication network. Each neuron is composed of three elements: a cell body, an axon, and dendrites (multiple branching structures). Neurons do not make actual physical contact with one another; instead, they are separated by synapses. It is across these microscopic gaps that messages are transmitted from one neuron to another in the form of chemicals called neurotransmitters. These chemical messengers are released at the end of one neuron; through chemical diffusion and active pumplike mechanisms, they reach the adjacent neuron. They deliver