Madness Explained

by Richard P. Bental

  these discrepancies may be impediments to the provision of adequate health care in the poorest regions of the world. In his opinion, Western-trained doctors must therefore attempt to work with indigenous concepts of disease and illness in order to achieve mutually respectful and effective relationships with their patients.

  Kleinman’s research has focused on explanatory models of psychiatric disorder that are indigenous to China and the Far East. For example, as we shall see later, he has shown that Chinese concepts of mood disorder differ markedly from Western concepts, placing less emphasis on psychological symptoms such as low self-esteem and more emphasis on physical symptoms such as fatigue. Because of this focus, it is all too easy to assume that Kleinman’s analysis applies only to non-Western cultures. However, the analysis is just as relevant to the European and North American context as it is to Africa or the Far East. The Kraepelinian paradigm, like the diagnostic system of the Baganda, is a product of a particular social and historical context (the period of German expansionism in the late nineteenth century) and has been moulded into its latest incarnation, DSM-IV, by North American psychiatrists imbued with the values of a powerful scientific and industrialized economy. (Leafing through DSM-IV, it is hard not to feel that the hand of Henry Ford has helped to shape it.)

  Towards a Post-Kraepelinian Psychiatry

  This chapter concludes the first part of this book, in which I have tried to show the limitations of the Kraepelinian approach to explaining and understanding psychiatric problems. I am sure that social constructionists or extreme cultural relativists, who regard ‘reality’ as nothing more than an invention of the dominant culture, will particularly welcome the conclusions I have reached in the last few pages. According to this kind of reasoning, a scientific account of madness could never be constructed because there are no facts, free of social interpretation, on which to build a theory.63

  My own view is that this kind of nihilism is self-defeating. All scientific theories, even those in the physical sciences, are developed in a particular cultural context. Although the context may help to explain the persistence of a theory in the face of apparently falsifying evidence,

  the fact that a theory arises from a particular context is not sufficient to condemn it. Theories and paradigms must be accepted, modified or rejected on the basis of evidence. Indeed, if we swallow the postmodernist dogma that any theory is as valid as any other, and thereby reject the assumption that standards of scientific evidence lead to the tangible advance of knowledge, it is difficult to see why the arguments I have so far marshalled against the Kraepelinian approach should carry any weight. The main purpose of criticizing outdated theories is not to abandon theories altogether but to replace them with theories that are more useful and more scientific.

  The persistence of Kraepelin’s paradigm in the face of such overwhelming negative evidence reflects the difficulty of finding an alternative. It is one thing to criticize a theoretical system and quite another to offer something in its place. Despite various proposals for an alternative system (by making diagnoses more sensitive to cross-cultural distinctions, by classifying patients using dimensions rather than categories, by lumping together the psychoses under an einheitspsychose concept) none has been enthusiastically embraced by large numbers of clinicians or researchers, mainly because practical versions of these systems have yet to be devised. Although we cannot entirely exclude the possibility that a future Linnaeus of psychiatry will achieve what others have so far been unable to accomplish, I am sceptical whether any new system will succeed where Kraepelin’s has failed.

  In the remaining chapters of this book, I will therefore describe a more radical alternative. The fundamental principle guiding this approach can be simply stated as follows: We should abandon psychiatric diagnoses altogether and instead try to explain and understand the actual experiences and behaviours of psychotic people. By such experiences and behaviours I mean the kinds of things that psychiatrists describe as symptoms, but which might be better labelled complaints, such as hallucinations, delusions and disordered speech. I will argue that, once these complaints have been explained, there is no ghostly disease remaining that also requires an explanation. Complaints are all there is.

  An advantage of this approach is that it does not require us to draw a clear dividing line between madness and sanity. Indeed, when constructing explanations of complaints it is not necessary to assume that they are always pathological. By ‘complaint’, I just mean any

  class of behaviour or experience that is singled out as sometimes troublesome and therefore worthy of our attention.

  The approach I am advocating has been given various names, none of which is entirely satisfactory. It is most commonly labelled the symptom-orientated approach; although I will occasionally use this name in the following chapters, I feel uncomfortable with it because of the medical connotations of the word ‘symptom’. The term cognitive neuropsychiatry has been suggested by British psychologist Haydn Ellis to describe the attempt to understand psychiatric symptoms using the theories and techniques of cognitive and neuropsychology64 (we will see what these are in later chapters). Although there is now a journal of this name, and although brains clearly play an important role in unusual behaviours and experiences, I think that the prefixes cognitive and neuro presume too much. If the new approach needs a label (and perhaps it does not) then post-Kraepelinian psychiatry is perhaps as good as any.

  Manifestos are probably best left to political parties, but Gerald Klerman’s attempt write one for the neoKraepelinian movement65 has tempted me into constructing one for my fellow post-Kraepelinians. The manifesto (which is given in Table 6.1, and which matches Klerman’s almost point by point) tries to accommodate the lessons we have learnt in the past few chapters, and anticipates some ideas that I will introduce later on. It is designed to stimulate debate, and perhaps should not be taken too seriously.

  An initial objection that I must overcome

  The fundamental idea that I am advocating in this book – studying complaints and abandoning psychiatric diagnoses – is hardly new. It was anticipated in the ideas of Adolf Meyer but, to my knowledge, was first clearly articulated by the British psychologist Donald Bannister in the late 1960s.66 When I first began to investigate hallucinations and delusions in the mid-1980s, many of my colleagues still seemed to feel that this approach was slightly batty. Recently, however, an increasing number of psychologists and psychiatrists in Europe and North America have begun studying complaints, and this kind of research has been in danger of becoming absorbed into the mainstream of psychiatry. One indication that an idea has arrived is the emergence

  Table 6.1 A post-Kraepelinian manifesto.

  1. The understanding and treatment of psychiatric problems must be approached from multiple perspectives, including those of the neurosciences, psychology, sociology and anthropology. None of these approaches alone provides a sufficient framework, or has precedence over the other. (Psychiatry is not just a branch of medicine, except in the trivial sense that laws in many countries allow only medical practitioners to call themselves psychiatrists.)

  2. Psychiatric practice should use modern scientific methodologies and be based on scientific knowledge.

  3. Psychiatric practice involves the treatment of people who are distressed by psychological complaints, or who are having difficulty coping with the demands of everyday life. In some circumstances, experiences such as hallucinations, unconventional beliefs, or thinking that appears bizarre to others, occur in people who are not distressed, and who are functioning well. Such people should not be encouraged to seek psychiatric treatment.

  4. There is no clear boundary between mental health and mental illness. Psychological complaints exist on continua with normal behaviours and experiences. Where we draw the line between sanity and madness is a matter of opinion.

  5. There are no discrete mental illnesses. Categorial diagnoses fail to capture adequately the nature of psychological complaints for eit
her research or clinical purposes.

  6. There is no inseparable gulf between the psychological and the biological. Adequate theories of psychological complaints must show how psychological and biological accounts are interrelated. (An exclusive focus on biological determinants of psychological complaints is bad science and leads to treatments that fail to meet the needs of psychiatric patients.)

  7. Research into psychological complaints must start from a detailed description of those complaints. Such descriptions should be reliable and valid.

  8. Efforts should be made to understand the psychological mechanisms underlying psychological complaints. Specification of those mechanisms is likely to lead to an understanding of the aetiological role of both social and biological factors.

  9. Psychological complaints must be understood as endpoints of developmental pathways, which are determined by complex interactions between endogenous and environmental processes.

  of a thoughtful critical response. As I was completing the first draft of this chapter, an article criticizing symptom-orientated research appeared in the British Journal of Psychiatry.

  Ramin Mojtabai and Ronald Rieder, two psychiatrists working at the College of Physicians and Surgeons at Columbia University in New York, make three general points.67 Their first concerns reliability – they argue that clinicians and researchers often show less agreement when deciding whether a patient has a particular symptom than when deciding whether a patient fits a particular diagnosis. Second, they argue that genetic studies show that the heritability of symptoms is less than the heritability of diagnoses (in other words, clearer genetic effects are found when patients are selected according to diagnoses rather than according to symptoms). Finally, they argue that studies of symptoms have revealed nothing about the aetiology of psychiatric disorders. The second and third of these arguments will be addressed in later chapters. However, it is important to deal with the question of reliability here because, if Mojtabai and Rieder are correct, this objection would be fatal to my argument. Obviously, an approach focusing on complaints will get no where if we cannot decide who is experiencing which complaint.

  Mojtabai and Rieder present data from three American studies in which the reliability of symptoms yielded average kappa values of 0.62, 0.40 and 0.49. At face value, these results are certainly disappointing. Fortunately, they almost certainly underestimate what can be achieved, even with conventional psychiatric interview schedules. A recent study using the Positive and Negative Syndromes Schedule, a widely used interview-based method for rating the severity of psychotic disorders, showed that the reliability of symptom ratings improves when clinicians are given appropriate training. After five sessions of training, kappa exceeded 0.90 for seventeen out of thirty symptoms, and exceeded 0.70 for all but one.68

  When instruments especially designed to measure specific complaints have been evaluated, high levels of inter-rater reliability have consistently been achieved. At the Mental Health Research Institute of Victoria, in Melbourne, Australia, a group led by Professor David Copolov has developed an interview schedule for assessing unusual perceptions, particularly hallucinations; a study showed that kappa values for each of the subscales (measuring different aspects of hallucinations,

  for example physical and emotional characteristics of hallucinated voices) varied between 0.81 and 0.98.69 In Britain, a somewhat simpler interview-based scale for rating features of hallucinations and delusions has been developed by Gill Haddock, a clinical psychologist based at the University of Manchester. In field trials, this instrument has been shown to yield levels of inter-rater reliability for its various subscales that reach a minimum of 0.79.70 Several instruments are available to measure the thought, language and communication disorders of psychotic patients, for example Nancy Andreasen’s Thought, Language and Communication Scale71 and Nancy Docherty’s Communication Disturbance Index,72 both of which have been shown to have acceptable levels of reliability. Mojtabai and Rieder’s pessimism about the measurement of complaints seems to reflect a biased reading of the evidence.

  No doubt many readers will be as sceptical about focusing on complaints as Mojtabai and Rieder, although perhaps for different reasons. In the following parts of this book I will therefore lay out the framework of post-Kraepelinian psychiatry in some detail, describing research on depression, paranoia, mania, hall ucinations and disordered speech. I will then explore the implications of this research for aetiological theories of psychosis. In this way, I will attempt to demonstrate that the approach that I am advocating leads to a richer understanding of the nature and origins of psychiatric disorder than has been possible within the Kraepelinian paradigm.

  Part Two

  A Better Picture of the Soul

  7

  The Significance of Biology

  We are not interested in the fact that the brain has the consistency of cold porridge.

  Alan Turing1

  In the first part of this book I have offered a damning portrait of Kraepelinian psychiatry. By examining the taxonomic assumptions that have underpinned modern theories of psychosis, I have argued that the conventional approach to understanding madness is deeply flawed. This is the reason why there has been so little progress in the treatment of psychiatric disorders since the time of Kraepelin. Most researchers and clinicians have been stuck at the end of the blind alley into which he led us over a century ago.

  It is now time for me to make good my earlier promise that I would demonstrate a workable alternative to the Kraepelinian system. In the remaining parts of this book, I will therefore show how psychological theories can be used to explain many of the strange behaviours and experiences (‘symptoms’) encountered both inside and outside the psychiatric clinic. As I have already stated, my approach will be to examine each of these behaviours and experiences in turn. I will therefore make no attempt to explain schizophrenia, manic depression or any of the other myths of twentieth-century medicine. Instead, I will show how psychological research can cast light on phenomena such as hall ucinatory voices, depressed mood, delusional beliefs, manic episodes and incoherent speech.

  Before we start, however, we should do some ground work. In earlier chapters I have argued that psychotic behaviours and experiences lie on continua with normal behaviours and experiences. One implication of this argument is that the processes that govern ordinary mental life may well play an important role in psychosis. Indeed, it seems very unlikely that we will be able to develop a useful account of madness unless we first have an adequate understanding of human nature. The purpose of the next few chapters is to provide the framework for such an understanding.

  Unfortunately, there is not space with in these pages to give the reader a comprehensive review of what is known about human psychology, a field that is in any case changing daily. However, what I can do is focus on a small number of topics that have important implications for the way in which we attempt to explain madness. In the process, I will demonstrate how some of the theories of schizophrenia and manic depression proposed by neoKraepelinians have often failed, not only because they have been based on an unworkable system of classification, but also because they have accepted, as self-evident, assumptions about the human mind that are in fact erroneous. The general theme that I want to address is that the brain, the mind and human emotions cannot be understood in isolation from their social context.

  We will begin by considering what many regard to be the most fundamental question in psychology: the relationships between brain, behaviour and experience. This topic is important because any coherent account of psychosis must accommodate both the findings from neurobiological research and the results of psychological investigations. That this is not a trivial problem is attested to by the fact that most researchers who have studied psychiatric disorders have treated these two types of explanation as irreconcilable.

  The Interminable Debate

  From the very beginnings of their calling, many psychiatrists have assumed that biological explanatio
ns of psychosis should somehow take precedence over psychological accounts. For example, when Wilhelm Griesinger founded the Archives for Psychiatry and Nervous Disease in 1867, he penned an opening editorial, which stated that:

  Psychiatry has undergone a transformation in its relation to the rest of medicine. This transformation rests principally on the realization that patients with so-called ‘mental illnesses’ are really individuals with illnesses of the nerves and brain.2

  Nearly a century later, in their famous account of Three Hundred Years of Psychiatry, published in 1963, psychiatrists Richard Hunter and Ida MacAlpine argued that: ‘The lesson of the history of psychiatry is that progress is inevitable and irrevocable from psychology to neurology, from mind to brain, never the other way round.’3 Similarly, in the 1975 edition of an influential British textbook of psychiatry, the following remarks can be found:

  It would be absurd to maintain that psychology can be to psychiatry what physiology is to medicine, not only because the claim would be exaggerated, but also because it implies that psychiatry and medicine are mere cousin-sciences… The primary concern of the psychiatrist is the morbid mental states; and however much is known about the psychology of the normal individual, in the pathological field new laws will be found to operate.4