Madness Explained

by Richard P. Bental

  Inevitably, when constructing a self, the child internalizes historically and culturally determined values. It is therefore possible that the self as known to people of the past may have been quite different from the self as known to people living in the modern world. Roy Baumeister has argued that for medieval Europeans, the self was relatively transparent, and was equated with visible manifestations and actions. As life on earth was, at that time, believed to be a preamble to eternal bliss, there was no need to search for self-fulfilment.62 In modern Western societies, in contrast, the self is often viewed as a hidden territory that can only be known with difficulty, but which must be explored (perhaps with the technical assistance of a psychotherapist) if its special talents are to be fostered and self-actualization achieved.

  Although anthropological studies suggest that people across the globe today share a common preoccupation with the self,63 even modern human beings may think about the self in diverse ways. American psychologists Hazel Markus and Shinobu Kitayama have noted important differences between the way in which the self is construed in individualist societies such as North America, in which people tend to define themselves and evaluate their self-worth in terms of their achievements, and collectivist societies such as Japan, in which individuals tend to define their identity in terms of harmonious relationships with other people.64 In the former, people tend to describe themselves in terms of traits and the self is largely context-free whereas, in the latter, people tend to describe themselves by reference to particular social relationships or situations (for example, ‘I care for my sister’).

  Given that the self plays such a pivotal role in human life, it would not be surprising if thinking about ourselves were to involve the activation of specific neuroanatomical structures. Of course, we should avoid the error made by Descartes, who decided that the pineal gland was the communication gateway that linked the brain to the soul. It would be foolish to assume that the self has a specific physical embodiment of this sort. Nonetheless, when we contemplate ourselves in any of the ways that I have described above, we are clearly doing something ‘brainy’.

  In recent experiments, Professor Tony David and his colleagues at the Institute of Psychiatry in London have tried to determine whether particular regions of the brain are involved in self-recognition. They used computer techniques to blend photographs of ordinary people with photographs of strangers, creating a series of pictures running from ‘other’ to ‘self’ in twenty-one steps. The participants were then shown the pictures while lying in an fMRI scanner, and were asked to say at which point they believed that the pictures were of themselves. All of the pictures activated the posterior fusiform gyrus, a region of the brain known to play a role in the recognition of faces. More interestingly, when the participants recognized a face as ‘me’ neuroactivations were detected in the dorsolateral prefrontal cortex, an area of the brain known to play a role in complex semantic judgements.65

  The Social Nature of Psychosis

  The reader may be forgiven for thinking that much of the material covered in this chapter has been something of a digression from our main business of explaining madness. As we have covered quite a lot of ground, the reader might also be feeling a little breathless. I would like to finish off by attempting to draw from this diverse material a few simple but important implications.

  The findings we have considered in the last few pages paint a picture of the mind–brain that is dramatically different from that assumed by many psychologists investigating psychosis. Most of these researchers have been heavily influenced by the computer metaphor, which sees the brain as a machine that processes information in much the same way that a food processor processes food – without much regard to its meaning or significance for the individual. On the contrary, we have seen that the mind–brain is very unlike a typical computer. Indeed, the things that it does well (for example, recognizing faces, speculating about why other people act in the way that they do) are precisely those things that a typical computer does badly, whereas the things that most computers do well (for example, discovering the square-root of 5876.9) are things that the average human mind finds daunting. The mind–brain is a biologically evolved but flexible cognitive system, which adapts to its environment by learning from other mind–brains (notably its caregivers), and which prioritizes its current activities according to both short-term and long-term goals. To summarize these properties in a single statement that is as profound as it is blindingly obvious: the mind–brain is a living system.

  This picture is entirely consistent with an important conclusion that we arrived at towards the end of Chapter 7. Remember that, in that chapter, we found strong evidence that the brain is (literally) shaped by experience. The anatomical structures that form subcomponents of the adult central nervous system change in size according to the demands placed on them by events. The structure and function of the adult brain are not simply products of some pre-ordained genetic program (although genes must have an influence) but are the results of a complex series of interactions between the individual and the social environment. It follows that psychiatric theories that consider the brain in isolation from the social world are unlikely to lead to a proper understanding of the origins of psychosis. The neoKraepelinian project of an exclusively biological psychiatry has been doomed to failure from the outset.

  The failure of researchers working within the Kraepelinian framework to consider psychological mechanisms that are important in ordinary life has had at least two unfortunate consequences. First, a huge explanatory gap remains between observations of gross cognitive deficits in patients and an understanding of their symptoms. It is simply not obvious how attentional impairments, no matter how real, can lead to hallucinations, paranoid ideas or incoherent speech. Second, as we will see in a later chapter, the findings from studies of gross deficits have had few implications for treatment. Indeed, they have reinforced the neoKraepelinian prejudice that schizophrenia and bipolar disorder are nothing more than brain diseases, and so impeded the development of treatments that address patients’ psychological and social needs.

  By trying to give a more realistic account of the human mind than that assumed by the neoKraepelinians, I have attempted to provide the conceptual tools with which we will later fashion a more adequate account of madness. To elaborate too much on this point at this stage would be premature. However, even without considering specific complaints in detail, it is not very difficult to see the relevance of the topics we have discussed in the preceding pages.

  It is perhaps most obvious that there must be a close relationship between language and psychosis. The three psychotic complaints that have been most intensively investigated – delusions, auditory hallucinations and communication disorder – manifest themselves as forms of speech. (Although we may question Tim Crow’s speculative theory that psychosis is genetically associated with cerebral lateralization, there must surely be some truth in his assertion that language and madness are inextricably linked.)66 It may be less apparent that madness is inherently social in a broader sense. Of course, social cognitive deficits affect patients’ ability to negotiate the social world. (American psychologists David Penn, Patrick Corrigan and others have shown that the social competence of patients is better predicted by their performance on measures of social cognition than by their performance on tests of general deficits.)67 However, there is also good reason to suppose that abnormal social cognition is directly implicated in the behaviours and experiences that are the most obvious manifestations of madness.

  Invariably, psychotic complaints reflect concerns about the self, or relationships with other people. Psychotically depressed people, for example, often believe that they are inadequate, or guilty of imaginary misdeeds. Manic patients, in contrast, often feel that they are superior to others, and are capable of achievements that will amaze the world. The delusional beliefs usually attributed to schizophrenia are particularly redolent with social themes. Patients rarely profess bizarre ideas about
animals or inanimate objects. Instead they believe that they are being persecuted by imaginary conspiracies, that they have been denied recognition for inventing the helicopter or the pop-up toaster, that they are loved by pop stars or by their doctors, or that their partners are conducting numerous affairs despite compelling evidence to the contrary. Although some patients experience pleasant hallucinations, many report that their voices comment adversely on their actions, or goad them to perform acts that will harm themselves or frighten others. Michael Musalek, a psychiatrist at the University of Vienna, has suggested that psychotic symptoms therefore reflect the core existential dilemmas experienced by ordinary people.68 To put this observation another way, the unusual beliefs and experiences of psychiatric patients all seem to reflect preoccupations about the position of the self in the social universe.

  9

  Madness and Emotion

  Reason is, and ought only to be the slave of the passions, and can never pretend to any other office than to serve and obey them.

  David Hume1

  Emotions play a pivotal role in human nature. On the one hand they colour the moments when we feel most human – falling in love, witnessing birth or death, achieving our ambitions or accepting humiliation and defeat. On the other hand, because we share them with other species, they ground us in the biological world. Yet, curiously, they are not usually considered to be important features of some of the extreme forms of mental suffering that are the focus of this book. In this chapter, I wish to redress this neglect and argue that psychotic symptoms are above all emotional phenomena. This argument will entail an examination of what we know about the psychology of emotions, which will prepare the way for our more detailed examination of individual psychotic complaints in later chapters.

  Some readers may be surprised by this approach. When most psychologists and psychiatrists think about extreme emotions, they usually focus on the spectrum of neurotic disorders, perhaps because non-psychotic depressions and anxieties are among the most common symptoms reported by patients visiting general physicians.2 When research has been carried out into the role of negative emotion in psychosis, much of it has adhered to the Kraepelinian paradigm, and has therefore focused on patients with a diagnosis of bipolar disorder rather than schizophrenia. This is unfortunate because emotion probably plays as important a role in the experiences of schizophrenia patients as it does in the lives of patients diagnosed as suffering from manic depression.

  Some studies have shown that as many as 65 per cent of schizophrenia patients complain of being depressed.3 Others have observed comparable levels of anxiety.4 Canadian psychiatrists Ross Norman and Ashok Malla measured both depression and anxiety in a large group of schizophrenia patients and found that the two emotions were highly correlated. High levels of both emotions were associated with delusions and hallucinations but, surprisingly, not with negative symptoms such as apathy or social withdrawal.5

  Other studies have shown that negative emotions are prominent in the early stages of psychotic breakdown, often preceding the emergence of positive symptoms. American psychiatrists Marvin Herz and Charles Melville interviewed the relatives of schizophrenia patients in order to discover prodromal symptoms that typically occur before a full-blown episode. Depression was reported in 76 per cent of cases, and anxiety in 86 per cent.6 A similar study conducted in Britain by clinical psychologist Max Birchwood and his colleagues at All Saints Hospital in Birmingham found that depression was reported in 57 per cent of cases, and anxiety in 62 per cent.7

  Further evidence that emotion plays an important role in schizophrenia symptoms has recently been gathered by American clinical psychologist Nancy Docherty of Kent State University in Ohio. Docherty has pointed out that many (although perhaps not all) schizophrenia patients find that their symptoms worsen when they are emotionally stressed. Positive symptoms (hallucinations and delusions) and also symptoms of cognitive disorganization (psychotic speech) are particularly affected in this way. Negative symptoms, on the other hand, appear to be relatively unaffected.8

  Taken together, these observations have two important implications. First, the presence of negative mood in so many schizophrenia patients, especially those suffering from positive symptoms, is yet further evidence that the Kraepelinian distinction between schizophrenia and the mood disorders is misleading. Second, because negative emotions are usually present before a recurrence of hallucinations or delusions, it seems unlikely that they are mere consequences or by-products of psychosis.

  So, What is an Emotion?

  Surprisingly, although the problems treated by psychiatrists are often called ‘emotional disorders’, most textbooks of psychiatry have nothing to say about the nature of emotions. As British psychologists Mick Power and Tim Dalgleish have recently commented:

  A worrying truth about the psychology of emotion literature is that the majority of theories of normal, everyday emotions make little or no reference to emotional disorder. Similarly, there are a host of theories of emotional disorder, which are only loosely anchored, if indeed they are anchored at all, to theories of emotional order.9

  Two assumptions

  It is in fact quite difficult to distinguish between emotions and other feelings such as pain or hunger, or other types of mental contents such as attitudes and beliefs. Textbooks of psychology routinely observe that emotions have affective (feeling), cognitive (thoughts and beliefs) and behavioural components, which should alert us to the possibility that the ordinary language word ‘emotion’ does not refer to a single process. Two other assumptions about emotion commonly held by psychologists are worth noting before proceeding further.

  First, many psychologists have assumed that emotions involve some kind of evaluation or appraisal of events. We tend to be happy when we know that we are loved by someone special or when we believe that we have achieved something important, sad when we have lost someone or suffered a setback to our ambitions, and anxious when we anticipate that something unpleasant will happen in the future. During the 1980s, a protracted debate about the role of appraisals in emotion was conducted between two American psychologists, Robert Zajonc and Richard Lazarus. Zajonc argued that feelings are the primary component of emotion, and that emotional reactions can occur without a conscious appraisal of the environment. (An obvious example would be our sudden reaction when we catch a brief glimpse of a large object moving dangerously towards us.)10 Lazarus, on the other hand, argued that cognitive processes are primary, and that emotions are always triggered by the belief that something positive or negative has happened or is about to happen. According to Lazarus, each emotion therefore has a specific meaning or ‘core relational theme’ – an offence against the individual in the case of anger, or the experience of irrevocable loss in the case of sadness.11 To some extent this dispute was more semantic than substantial – not all cognitive processes are conscious and some kind of rapid appraisal of the environment is presumably involved even when we automatically throw ourselves out of the path of an approaching car.

  Mick Power and Tim Dalgleish have noted that, when emotional responses are triggered automatically, this is often because the appraisal process has taken place at some point in the past. For example, a man whose memories of childhood are shrouded with fear may immediately feel frightened on hearing his elderly father’s raised voice. In this case, the sound of the father’s voice automatically elicits fear because it has previously been appraised as signalling danger. They also note that emotions often involve cycles of appraisal, rather than a single appraisal event. The experience of anger when insulted by a friend may lead to reflections about the relationship, modulating further encounters with the friend, and thereby leading to further appraisals.

  A second, widely held assumption about emotions is that their behavioural manifestations have along evolutionary history, and serve important functions in our lives. Not surprisingly, people who are suffering from anxiety or depression often find this a difficult proposition to accept. However, it is o
bvious that at least some emotional states help us to respond effectively in emergencies. When we see the car moving towards us, the rush of adrenalin prepares us to make the physical effort that will save our lives and, when we feel anxious, we can brace ourselves for the calamities to come.

  It is less obvious that emotions have important cognitive benefits. We usually have to juggle many competing goals in life. Our emotions enable us to prioritize our mental resources rapidly in order to face the changing demands of our environment, so that we can focus on those goals that are most immediately pressing.12 The decisions we make in these circumstances are often influenced, not by a labour-intensive analysis of the likely outcomes of different actions, but by a much quicker anticipation of the emotional consequences of each choice. (People selecting between risky options choose the option that they think will lead them to feel better.)13 Mr Spock, the character in the science fiction television series Star Trek who hails from the planet Vulcan and who, in the absence of emotion, can only reason logically, would be mentally paralysed when faced with many everyday dilemmas.14

  Of course, extremely negative emotions do not appear particularly adaptive. However, the neural mechanisms responsible for emotional behaviour presumably evolved a long time in the past. Therefore, although the situations that typically elicit emotions – ‘fighting, falling in love, escaping predators, confronting sexual infidelity, and so on’15– have occurred innumerable times in evolutionary history, the most appropriate way of responding to these challenges today may differ from the ways that were most adaptive in the past. British psychologist Paul Gilbert has argued, for example, that many of the behaviours associated with depression (particularly reduced aggression to more dominant individuals and increased anger towards more submissive persons), although apparently maladaptive in a modern context, allowed our ancestors to adapt following a loss of rank in a simple hierarchical society.16