Madness Explained

by Richard P. Bental

  31. M. B. First (2002) ‘The DSM series and experience with DSM-IV’, Psychopathology, 35: 67–71.

  32. R. K. Blashfield (1996) ‘Predicting DSM-V’, Journal of Nervous and Mental Disease, 184: 4–7.

  33. S. Hyler, J. Williams and R. Spitzer (1982) ‘Reliability in the DSM-III field trials’, Archives of General Psychiatry, 39: 1275–8.

  34. G. Klerman (1986) ‘Historical perspectives on contemporary schools of psychopathology’, in T. Millon and G. Klerman (eds.), Contemporary Directions in Psychopathology: Towards DSM-IV. New York: Guilford Press.

  35. Kutchins and Kirk, Making us Crazy, op. cit.

  36. J. B. Williams, M. Gibbon, M. B. First, R. L. Spitzer, M. Davies, J. Borus, M. Howes, J. Kane, H. G. Pope, B. Rounsaville and H.-U. Wittchen (1992) ‘The Structured Clinical Interview for DSM-III-R (SCID): II. Multi-site test–retest reliability’, Archives of General Psychiatry, 49: 630–6.

  37. P. D. McGorry, C. Mihalopoulos, L. Henry, J. Dakis, H. J. Jackson, M. Flaum, S. Harrigan, D. McKenzie, J. Kulkarni and R. Karoly (1995) ‘Spurious precision: procedural validity of diagnostic assessment in psychotic disorders’, American Journal of Psychiatry, 152: 220–3.

  38. M. A. Taylor and R. Abrams (1978) ‘The prevalence of schizophrenia: a reassessment using modern criteria’, American Journal of Psychiatry, 135: 945–8.

  39. W. T. Carpenter, J. S. Strauss and J. J. Bartko (1973) ‘Flexible system for the diagnosis of schizophrenia’, Science, 182: 1275–8.

  40. I. Brockington (1992) ‘Schizophrenia: yesterday’s concept’, European Psychiatry, 7: 203–7.

  41. J. van Os, C. Gilvarry, R. Bale, E. van Horn, T. Tattan, I. White and R. Murray (1999) ‘A comparison of the utility of dimensional and categorical representations of psychosis’, Psychological Medicine, 29: 595–606.

  42. P. McGuffin, A. Farmer and I. Harvey (1991) ‘A polydiagnostic application of operational criteria in studies of psychotic illness’, Archives of General Psychiatry, 48: 764–70.

  Chapter 4 Fool’s Gold

  1. From J. Borges (1960) ‘El idioma analitico de John Wilkins’, in Otras inquisiciones, Buenos Aires: Emece. I am indebted to Michael Dewey for translating this quotation and drawing it to my attention.

  2. G. H. Gallup and F. Newport (1991) ‘Belief in paranormal phenomena among adult Americans’, Sceptical Inquirer, 15: 137–46.

  3. R. E. Kendell (1975) The Role of Diagnosis in Psychiatry. Oxford: Blackwell.

  4. For a review of research on comorbidity, and other defects of the DSM system, see L. A. Clark, D. Watson and S. Reynolds (1995) ‘Diagnosis and classification of psychopathology: challenges to the current system and future directions’, Annual Review of Psychology, 46: 121–53.

  5. L. N. Robins, B. Z. Locke and D. A. Reiger (1991) ‘An overview of psychiatric disorders in America’, in L. N. Robins and B. Z. Locke (eds.), Psychiatric Disorders in America. New York: Free Press.

  6. ibid.

  7. Although mathematically complex, the principles behind the technique are not difficult to understand. Symptom data from patients who have already been diagnosed as suffering from either schizophrenia or manic depression are fed into a computer. The computer program is also ‘told’ the diagnosis assigned to each patient. The program then attempts to determine which symptoms best discriminate between the two groups of patients, calculating a mathematical weight for each symptom according to how well it does this. (Symptoms assigned high values are found in only one diagnostic group whereas those with weights close to zero are found in both groups. Arbitrarily, positive weights are given to those symptoms found mostly in one of the groups whereas negative weights are given to the symptoms present mostly in the other group.) In this way, the program attempts to discover the symptoms that most influenced the clinicians to give one diagnosis or the other.

  In a second phase of the analysis the computer constructs an equation, which it uses to measure the balance of symptoms in each patient. This equation, known as a discriminant function, consists of the sum of the weights assigned to the symptoms experienced by the patient. A patient’s score on this function indicates the extent to which he or she is more or less schizophrenic, more or less manic-depressive, or somewhere in between. If the distinction between schizophrenia and manic depression is a real one, most patients should fall at the two ends of this scale (patients should have either mostly schizophrenia symptoms or mostly the symptoms of manic depression) and few patients should have scores close to zero. If, on the other hand, schizophrenia and manic depression are not separate disorders, most patients should have near zero scores, and should be located towards the centre of the scale.

  For a more detailed but remarkably clear non-mathematical account of this and other statistical methods I describe in this chapter, together with their advantages and disadvantages, see R. K. Blashfield (1984) The Classification of Psycho-pathology: NeoKraepelinian and Quantitative Approaches. New York: Plenum. For simplicity, I have not discussed a third technique, known as cluster analysis, also described by Blashfield. However, readers of Blashfield will discover that this technique has yielded results that are even less supportive of Kraepelin’s paradigm than the two approaches discussed in this book.

  8. R. E. Kendell and J. A. Gourlay (1970) ‘The clinical distinction between the affective psychoses and schizophrenia’, British Journal of Psychiatry, 117: 261–6.

  9. A study by Robert Cloninger and colleagues (‘Diagnosis and prognosis in schizophrenia’, Archives of General Psychiatry, 42: 15–25, 1985) claimed to have identified a separation between patients with four schizophrenic features (persecutory delusions, delusions of control, mood-incongruent delusions and auditory hallucinations) and other psychotic patients, but this group was so tightly defined that many patients meeting most definitions of schizophrenia would be excluded from it.

  Ian Brockington and his colleagues (‘Bipolar disorder, cycloid psychosis and schizophrenia: a study using “lifetime” psychopathology ratings, factor analysis and canonical variate analysis’, European Psychiatry, 6: 223–36, 1991) found some evidence of a separation between schizophrenia and mania, but not of a separation between schizophrenia and depression. Indeed, the patients diagnosed as suffering from schizophrenia according to DSM-III criteria appeared to belong to a clinical spectrum in which schizophrenia merged with schizoaffective disorder and schizoaffective disorder merged with non-psychotic depression.

  10. For a history of factor analysis which focuses on its use in studies of intelligence, see S. J. Gould (1984) The Mismeasure of Man. London: Penguin.

  11. T. V. Moore (1930) ‘The empirical determination of certain syndromes underlying praecox and manic-depressive psychoses’, American Journal of Psychiatry, 86: 719–38.

  12. Extensive studies of psychotic symptoms were undertaken between the early 1940s and the late 1960s, notably by American psychologists John Wittenbourne, Maurice Lorr and John Overall (see R. K. Blashfield (1984) The Classification of Psychopathology: NeoKraepelinian and Quantitative Approaches. New York: Plenum). The work conducted by Overall culminated in the creation of a standard instrument for measuring the severity of psychotic illnesses, known as the Brief Psychiatric Rating Scale, which provided detailed rules for rating symptoms, and which remains popular among researchers today because it is reliable and relatively simple to use. Factor analyses of BPRS ratings consistently revealed four main symptom clusters. Over all and his colleagues (‘Major psychiatric disorders: a four-dimensional model’, Archives of General Psychiatry, 16: 146–51, 1967) named these thinking disorder (consisting of conceptual disorganization, hallucinations and unusual thought content), anxious depression (anxiety, depression and guilt), hostile suspiciousness (hostility, suspiciousness and uncooperativeness) and withdrawal-retardation (emotional withdrawal, motor retardation and blunted emotions).

  13. T. J. Crow (1980) ‘Molecular pathology of schizophrenia: more than one disease process?’ British Medical Journal, 280: 66–8.

  14. P. F. Liddl
e (1987) ‘The symptoms of chronic schizophrenia: a reexamination of the positive–negative dichotomy’, British Journal of Psychiatry, 151: 145–51.

  15. See N. C. Andreasen, M.-A. Roy and M. Flaum (1995) ‘Positive and negative symptoms’, in S. R. Hirsch and D. R. Weinberger (eds.), Schizophrenia, Oxford: Blackwell, pp. 28–45.

  An Australian group has re-analysed previous studies of schizophrenia symptoms, also finding the three-factor solution. See S. Klimidis, G. W. Stuart, I. H. Minas, D. L. Copolov and B. S. Singh (1993) ‘Positive and negative symptoms in psychoses: re-analysis of published SAPS and SANS global ratings’, Schizophrenia Research, 9: 11–18.

  16. P. D. McGorry, R. C. Bell, P. L. Dudgeon and H. J. Jackson (1998) ‘The dimensional structure of first episode psychosis: an exploratory factor analysis’, Psychological Medicine, 28: 935–47; V. Peralta, J. de Leon and M. J. Cuesta (1992) ‘Are there more than two syndromes in schizophrenia? A critique of the positive–negative dichotomy’, British Journal of Psychiatry, 161: 335–43; J. van Os, C. Gilvarry, R. Bale, E. van Horn, T. Tattan, I. White and R. Murray (1999) ‘A comparison of the utility of dimensional and categorical representations of psychosis’, Psychological Medicine, 29: 595–606.

  17. R. Toomey, S. V. Faraone, J. C. Simpson and M. T. Tsuang (1998) ‘Negative, positive and disorganized symptom dimensions in schizophrenia, major depression and bipolar disorder’, Journal of Nervous and Mental Disease, 186: 470–76.

  For other studies finding that the three-factor solution applies to non-schizophrenia patients see: S. Klimidis, G. W. Stuart, I. H. Minas, D. L. Copolov and B. S. Singh (1993) ‘Positive and negative symptoms in psychoses: re-analysis of published SAPS and SANS global ratings’, Schizophrenia Research, 9: 11–18; M. Maziade, M. Roy, M. Martinez, D. Cliche, J. Fournier, Y. Garveneau, L. Nicole, N. Montgrain, C. Dion, A. Ponton, A. Potvin, J. Lavallee, A. Pires, S. Bouchard, P. Boutin, F. Brisebois and C. Merette (1995) ‘Negative, psychoticism, and disorganized dimensions in patients with familial schizophrenia or bipolar disorder: continuity and discontinuity between the major psychoses’, American Journal of Psychiatry, 152: 1458–63.

  18. S. S. Kety (1974) ‘From rationalization to reason’, American Journal of Psychiatry, 131: 957–63.

  19. S. Rose, L. J. Kamin and R. C. Lewontin (1985) Not in Our Genes. Harmondsworth: Penguin.

  20. See ibid. Detailed discussions of the limitations of genetic research into schizophrenia can befound in the following sources also: M. Boyle (1990) Schizophrenia: A Scientific Delusion. London: Routledge; R. Marshall (1990) ‘The genetics of schizophrenia: axiom or hypothesis?’ in R. P. Bentall (ed.), Reconstructing Schizophrenia. London: Routledge.

  21. S. Kety, D. Rosenthal, P. H. Wender, F. Schulsinger and B. Jacobsen (1975) ‘Mental illness in the biological and adoptive families of adopted individuals who have become schizophrenic: a preliminary report based on psychiatric interviews’, in R. Fieve, D. Rosenthal and H. Brill (eds.), Genetic Research in Psychiatry. Baltimore, MD: Johns Hopkins University Press; D. Rosenthal, P. H. Wender, S. S. Kety, J. Welner and F. Schulsinger (1974) ‘The adopted away offspring of schizophrenics’, in S. A. Mednick, F. Schulsinger, J. Higgins and B. Bell (eds.), Genetics, Environment and Psychopathology. Amsterdam: North Holland Publishing Co.

  22. Rose et al., Not in Our Genes, op. cit.

  23. For a collection of essays addressing these findings and their implications, see A. C. Sandbank (ed.) (1999) Twin and Triplet Psychology: A Professional Guide to Working with Multiples. London: Routledge.

  24. Rose et al., Not in Our Genes, op. cit.

  25. K. S. Kendler, N. L. Pederesen, B. Y. Farahmand, and P.-G. Persson (1996) ‘The treated incidence of psychotic and affective illness in twins compared with population expectation: a study in the Swedish twin and psychiatric registries’, Archives of General Psychiatry, 26: 1135–44; C. M. Hultman, P. Sparen, N. Takei, R. M. Murray and S. Cnattingius (1999) ‘Prenatal and perinatal risk factors for schizophrenia, affective psychosis, and reactive psychosis of early onset: case control study’, British Medical Journal, 318: 421–6.

  26. Rosenthal and his colleagues published many accounts of the Genain quadruplets. The account given here is based on D. Rosenthal and O. W. Quinn (1977) ‘Quadruplet hallucinations: phenotypic variations of a schizophrenic genotype’, Archives of General Psychiatry, 34: 817–27. All quotations about the Genains are from this paper.

  27. A. F. Mirsky and O. W. Quinn (1988) ‘The Genain quadruplets’, Schizophrenia Bulletin, 14: 595–611.

  28. A. F. Mirsky, L. A. Bieliauskas, L. M. French, D. P. van Kammen, E. Jonsson and G. Sedvall (2000) ‘A 39-year follow-up of the Genain quadruplets’, Schizophrenia Bulletin, 26: 699–708.

  29. Rosenthal and Quinn, ‘Quadruplet hallucinations’, op. cit.

  30. E. F. Torrey, A. E. Bowler, E. H. Taylor and I. I. Gottesman (1994) Schizophrenia and Manic-Depressive Disorder. New York: Basic Books.

  31. T. J. Crow (1986) ‘The continuum of psychosis and its implications for the structure of the gene’, British Journal of Psychiatry, 149: 419–29; T. Crow (1991) ‘The failure of the binary concept and the psychosis gene’, in A. Kerr and H. McClelland (eds.), Concepts of Mental Disorder: A Continuing Debate. London: Gaskell.

  32. M. A. Taylor (1992) ‘Are schizophrenia and affective disorders related? A selective literature review’, American Journal of Psychiatry, 149: 22–32.

  33. For example, K. S. Kendler, A. M. Gruenberg and M. T. Tsuang (1985) ‘Psychiatric illness in first-degree relatives of schizophrenic and surgical control patients: a family study using DSM-III criteria’, Archives of General Psychiatry, 42: 770–9. See review by Taylor, ‘Are schizophrenia and affective disorders related?’ op. cit., for further examples.

  34. For example, M. T. Tsuang, G. Winokur and R. R. Crowe (1980) ‘Morbid riskofschizophreniaandaffectivedisordersamongfirst-degreerelativesofpatients with schizophrenia, mania, depression and surgical conditions’, British Journal of Psychiatry, 137: 497–504.

  For a recent study finding the same result, see V. Valles, J. van Os, R. Guillamat, B. Gutierrez, M. Campillo, P. Gento and L. Fananas (2000) ‘Increased morbid risk for schizophrenia in families of in-patients with bipolar illness’, Schizophrenia Research, 42: 83–90.

  35. J. Angst and C. Scharfetter (1990) ‘Schizoaffective psychosen’, in E. Lungershausen, W. P. Kascha and R. J. Witkowski (eds.), Affective Psychosen Kongress Band DGPN. Stuttgart: Schattauer Verlag. Cited in Crow, ‘The failure of the binary concept’, op. cit.

  36. J. T. Dalby, D. Morgan and M. L. Lee (1986) ‘Schizophrenia and mania in identical twin brothers’, Journal of Nervous and Mental Disease, 174: 304–8; J. B. Lohr and H. S. Bracha (1992) ‘A monozygotic mirror-image twin pair with discordant psychiatric illness: a neuropsychiatric and neuro developmental evaluation’, American Journal of Psychiatry, 149: 1091–5; P. McGuffin, A. Reveley and A. Holland (1982) ‘Identical triplets: non-identical psychosis’, British Journal of Psychiatry, 140: 1–6.

  37. A. E. Farmer, P. McGuffin and I. I. Gottesman (1987) ‘Twin concordance for DSM-III schizophrenia: scrutinizing the validity of the definition’, Archives of General Psychiatry, 44: 634–41.

  38. J. S. Strauss and W. T. Carpenter (1974) ‘The prediction of outcome in schizophrenia: II. Relationships between predictor and outcome variables’, Archives of General Psychiatry, 31: 37–42.

  39. J. S. Strauss (1992) ‘The person – key to understanding mental illness: towards a new dynamic psychiatry III’, British Journal of Psychiatry, 161: 19–26.

  40. M. Harrow, J. F. Goldberg, L. S. Grossman and H. Y. Meltzer (1990) ‘Outcome in manic disorders: a naturalistic follow-up study’, Archives of General Psychiatry, 47: 665–71.

  41. F. K. Goodwin and K. R. Jamison (1990) Manic-Depressive Illness. Oxford: Oxford University Press.

  42. M. Maj, R. Priozzi and F. Starace (1989) ‘Previous pattern of course of illness as a predictor of response to lithium prophylaxis in bipolar patients’, Journal of Affective
Disorders, 17: 237–41.

  43. R. M. Post, D. R. Rubinow and J. C. Ballenger (1986) ‘Conditioning and sensitization in the longitudinal course of affective illness’, British Journal of Psychiatry, 149: 191–201.

  44. L. Ciompi (1984) ‘Is there really a schizophrenia? The long term course of psychotic phenomena’, British Journal of Psychiatry, 145: 636–40.

  45. M. Bleuler (1978) The Schizophrenic Disorders. New Haven, CT: Yale University Press.

  46. Goodwin and Jamison, Manic-Depressive Illness, op. cit.

  47. M. Tsuang, R. F. Woolson and J. A. Fleming (1979) ‘Long-term outcome of major psychoses: I. Schizophrenia and affective disorders compared with psychiatrically symptom-free surgical conditions’, Archives of General Psychiatry, 36: 1295–1301.

  48. World Health Organization (1979) Schizophrenia: An International Follow-up Study. New York: Wiley.

  49. Crow, ‘The failure of the binary concept’, op. cit.