* The origin of this terminology is the paper that started this line of research, written by the distinguished American primatologist David Premack and his colleague Guy Woodruff, which was entitled ‘Does the chimpanzee have a theory of mind?’ (Behavioral and Brain Sciences, 4: 515–26, 1978).
* Intriguingly, this observation led Pavlov to what may seem a most unPavlovian conclusion: ‘On the one hand, numerous speech stimulations have removed us from reality, and we must always remember this in order not to distort our attitude towards reality. On the other hand, it is precisely speech which has made us human’ (I. P. Pavlov (1941) Conditioned Reflexes and Psychiatry (trans. W. H. Gantt). New York: International Publishers).
* The phenomenon of subvocalization does not imply that speech muscles are necessary for verbal thought. The subvocalization is an echo of activity occurring in the language centres in the brain. For this reason, if you are unfortunate enough to lose your speech muscles in some kind of dreadful accident, your intelligence will not be affected.
* This argument that names are learnt from others does not contradict the view, now widely held among linguists, that some aspects of language – particularly syntax – are wired into the architecture of the brain.
* According to Ciompi (‘Is schizophrenia an affective disease?’, in W. F. Flack and J. D. Laird (eds.), Emotions in Psychopathology. New York: Oxford University Press, 1998):
* When clinicians write about their work there is a tension between being truthful and preserving the anonymity of their patients. In all the brief case studies reported in this book, I have gone to some length to disguise patients’ backgrounds and circumstances in order to render them unrecognizable. However, without exception, I have tried to be accurate when describing their complaints. Inevitably, the result is an uneasy blend of fiction and reality.
* This theory is a revision of an earlier account of depression, known as ‘the theory of learned helplessness’, proposed by Seligman in his book Helplessness: On Depression, Development and Death (San Francisco, CA: Freeman, 1975). To confuse matters further, the revised model has undergone some further revisions, most notably by Lyn Abramson and her colleagues (see L. Y. Abramson, G. I. Metalsky and L. B. Alloy (1989) ‘Hopelessness depression: a theory-based subtype of depression’, Psychological Review, 96: 358–72). Details of the differences between the various versions of the theory are not important in the present context.
* The flip side to this observation is the claim that dysphoria often reflects a realistic appraisal of events. This idea, first proposed by Lauren Alloy and Lyn Abramson (see, for example, L. B. Alloy and L. Y. Abramson (1988) ‘Depressive realism: four theoretical perspectives’, in L. B. Alloy (ed.), Cognitive Processes in Depression. New York: Guilford), has become known as the depressive realism hypothesis. It suggests that depressed people are more in touch with reality than ordinary people but that, unfortunately, reality is a very unpleasant place to be in touch with.
There is plenty of evidence that seems to be consistent with this hypothesis. For example, depressed people seemto make more realistic appraisalsof other people’s opinions about them, and their attributions have sometimes appeared more even-handed. However, thesefindings can oftenbeinterpretedinways that are inconsistent with the hypothesis (see R. Ackermann and R.J. DeRubeis (1991) ‘Is depressive realism real?’, Clinical Psychology Review, 11: 565–84). My own view, for what it is worth, is that the hypothesis holds for moderately but not severely dysphoric patients.
* In fact, the data from the Temple–Wisconsin Project support this conclusion. Approximately 17 per cent of the 173 high-risk participants were subsequently diagnosed as depressed, yielding 30 ‘cases’ of illness. However, if we assume that about 1 per cent of the remaining 4827 participants became ill (the figure obtained for the low-risk group), we find that this yields 48 cases of illness. Therefore, more cases of illness probably occurred among the low-risk than the high-risk participants.
* Readers familiar with Freud’s theory will recognize this particular aspect of the self as the ‘superego’. One important general implication of the material covered in this section, which I hope to examine further at a later date, is that moral values play a direct and important role in human psychology.
† In Higgins’s terminology, the actual self, ideal self and ought self are described as different domains of the self. The ideal self and the ought self are also called self-guides because of their motivational properties.
* Gallinovular = chicken or egg. I am grateful to my good friend David Dickins for this contribution to the English language.
* It would be understandable if readers had some ethical qualms about this kind of experiment. However, it should be borne in mind that the failure experiences contrived in these experiments are always very mild, and that participants are always fully debriefed afterwards.
* I am grateful to my Ph.D. student Justin Thomas for suggesting some of the ideas in this chapter.
* A piece of laboratory equipment that separates out different components of a sample of blood (or other bodily fluid) by spinning it at high speed.
* The terms ‘paranoia’ and ‘paranoid’ have a confusing history. They were first used by the Ancient Greeks to mean crazy or mad but were reintroduced to describe a type of delusional disorder in the first half of the nineteenth century. As we have already seen, this usage was embraced by Kraepelin. During the post-Second World War era, when, under Adolf Meyer’s influence, psychiatric diagnoses became unfashionable among US psychiatrists, the term ‘paranoid’ was often used to describe persecutory beliefs that were not necessarily delusional; hence the ordinary-language definition given in the Shorter Oxford English Dictionary (1993): ‘A tendency to suspect or distrust others or to believe oneself unfairly used’. DSM-III used the term paranoia to refer to a pure delusional psychosis (Kraepelin’s concept) but the term delusional disorder was used in its place in DSM-III-R and DSM-IV. However, paranoid personality disorder remains in DSM-IV as an axis-2 disorder, and is defined in a way that closely matches the ordinary-language definition given in the SOED. For the purposes of the present discussion, I will use the term ‘paranoid delusion’ to describe any delusional system in which themes of persecution are prominent.
* This kind of complex theory-of-mind conundrum is called a second-order test because, in order to answer it correctly, you have to be able to work out what Bob thinks the policemen are thinking. Similarly, third-order ToM problems require you to work out what X thinks Y thinks X (or Z) is thinking. I used to believe that multi-order ToM skills are rarely used in real life, but recently changed my mind because of the following incident. I was standing in a supermarket close to a (presumably married) couple, when a very beautiful young woman walked past. The man glanced towards her, and then looked sheepishly towards his wife. Responding to his expression, she said, ‘You look as if you think that I’ll be irritated because I know you think she’s beautiful’ – a statement that clearly required higher-order ToM skills.
* Having discussed attributional processes with people in many countries, I can confirm that the traffic excuse is cross-culturally invariant.
* This kind of reasoning is sometimes called ‘Bayesian’, after the mathematician who proposed a theorem that describes the optimum way in which to change one’s conviction in a hypothesis in the light of new evidence. However, we will not consider the details of Bayes’ model here, or the mathematical treatment of the research findings from deluded patients.
* I sometimes think it would be helpful if researchers numbered different versions of their theories, in the same way that computer programmers number different releases of their software. The theoretical model of paranoia outlined in this chapter is, by my count, version 4.1.
* It is important to note that a dispositional attribution does not require ToM, as it does not involve taking someone’s point of view. Even a simple attribution of malevolent intent, for example ‘He hates me’, may require less use of ToM th
an the more complex situational accounts we often give when friends behave in an unexpected manner.
* Dissociative disorder is a controversial diagnosis in which different facets of the individual’s mind are supposed to become dissociated from each other, leading, in extreme cases, to multiple personalities. Unfortunately, the concept of dissociative disorder is often confused with the concept of schizophrenia, which has never included multiple personalities.
Cases of multiple personality were reported in the nineteenth century, for example by the French neurologist Pierre Janet and the American pioneer of abnormal psychology Morton Prince, but the diagnosis was used very rarely until recently. In a break from this historical trend, over the last decade large numbers of multiple personality cases have been reported by a small number of American psychiatrists and psychologists. It seems likely that many of these new cases are highly suggestible patients who have been encouraged to regard themselves as ‘multiples’ by their therapists. For a fascinating and sceptical account of the disorder, see Ian Hacking’s book Rewriting the Soul: Multiple Personality and the Sciences of Memory (1995) Princeton: Princeton University Press.
* It is easy to confuse the idea of a dimension of experience with the idea of a dimension ofpersonality, but they are not the same. The first suggests that different kinds of experience (for example, vivid daydreams and hearing voices) may be related to each other, whereas the second indicates that people differ in their propensity to have those experiences. Of course, both types of dimension imply that there is no clear dividing line between normality and abnormality.
* The most common and least difficult answer to the vehicle question is ‘car’. Suitable answers to the vegetable question are ‘onion’ or ‘ocra’. We know how difficult these questions are for English-speakers thanks to one of the most laborious studies ever carried out by psychologists, in which thousands of North Americans were asked to think of examples of each category (W. F. Battig and W. E. Montague (1969) ‘Category norms for verbal items in 56 categories: a replication and extension of the Connecticut category norms’, Journal of Experimental Psychology Monographs, 80: 1–46). The results of this study have proved immensely useful to other psychologists like myself, because they enable us to devise tests that vary in difficulty.
* Brodmann areas are locations on the cerebral cortex defined according to a map developed by the German anatomist Korbinian Brodmann during the first decade of the twentieth century.
* According to Eugen Bleuler ((1911/1950) Dementia Praecox or the Group of Schizophrenias (trans. E. Zinkin). New York: International Universities Press), ‘The fact that the peculiarities of the associative process usually manifest themselves in an identical fashion, regardless of whether they are expressed in oral or written form, is certainly of great, if as yet unrealized, significance to the theory of associative thinking.’
* This is, of course, the scientist’s standard lament when summarizing findings. It’s true, of course, but it also gives us a nice excuse for applying for more research funds.
* I thank Dr James McGuire of the University of Liverpool for helpful discussions about many of the issues discussed in this chapter.
* Most of the clinical literature on functional analysis has been written by psychologists who are sympathetic to behaviourism. However, as an organizing principle, functional analysis does not require a commitment to any particular school of psychology.
* To be more precise, these estimates give the proportion of variance in a characteristic which can be attributed to genetic variation as compared with the proportion attributed to environmental variation in a given population. This definition assumes a simple additive model of the two sources of variation, such that
† Nowhere has the debate between heredityversus environment been more contentious than in relation to measured IQ and its implications for racial differences. While this debate has raged, research has demonstrated massive IQ gains in different countries (an increase in the average IQ of as much as 20 points in 40 years). This phenomenon is known as the Flynn effect, after James Flynn, the New Zealand political scientist who first identified it. Accepting, for the sake of argument, heritability estimates of 75 per cent or more, Dickins and Flynn’s mathematical analysis demonstrates that there remains room for the very strong environmental influences on IQ that are necessary to explain the Flynn effect.
* Of course, other interpretations of this finding are possible. The astrologically minded might want to note that the star signs associated with a high-risk of psychosis are Capricorn, Aquarius and Pisces.
* Readers who are confused on this point might like to carry out a few simple calculations based on hypothetical data. Suppose 10 per cent of the normal population experience birth complications and that this increases to 30 per cent in the case of future patients. Also suppose that, out of a population of 1000 people, 10 (1 per cent) become psychotic. It follows that 3 of the future psychotic patients (30 per cent of the 10) will have experienced birth complications. However, out of the 990 non-psychotic members of the population, 99 (10 per cent of the 990) will also have experienced birth complications – 33 times more than patients with birth complications. Even if we assume that psychotic symptoms are experienced by, say, 10 per cent of the population on the basis of the evidence we considered in Chapter 5, ordinary people with a history of birth complications would outnumber the number of psychotic patients with birth complications by a factor of 3:1.
† For example, consider the data on the onset of schizophrenia symptoms shown in Figure 17.1. Half of the males in the sample first became ill after the age of 25 years and half of all females became ill after the age of 29. Similar proportions of ‘older’ patients can be calculated from nearly all comparable studies.
* One way in which sceptical clinicians might overcome any doubts they might have about the subjective effects of neuroleptics is to take one. Two British psychiatrists, R. H. Belmaker and D. Wald (‘Haloperidol in normals’, British Journal of Psychiatry, 131: 222–3, 1977), long ago reported the effects of taking 5 mg of haloperidol: ‘The effect was marked and very similar in both of us: within ten minutes a marked slowing of thinking and movement developed, along with a profound inner restlessness. Neither subject could continue work, and each left work for over 36 hours. Each subject complained of paralysis of volition, a lack of physical and psychic energy. The subjects were unable to read, telephone or perform household tasks of their own will, but could perform these tasks if demanded to do so.’
I was a participant in a similar experiment conducted by my friend and colleague David Healy, in which I received 5 mg of droperidol, and became restless and dysphoric to the point of being very distressed (I burst into tears and, for some reason, I felt compelled to tell David everything I had ever felt guilty about). I had a hangover for several days. Similar effects were recorded from the other volunteers in the study (D. Healy and G. Farquhar (1998) ‘Immediate effects of droperidol’, Human Psychopharmacology: Clinical and Experimental, 13: 113–20).
The doses in these experiments were far lower than those typically given to patients.
Table of Contents
Acknowledgements
Foreword by Professor Aaron Beck
Author’s Preface
Part One The Origins of our Misunderstandings about Madness
1 Emil Kraepelin’s Big Idea The origins of modern psychiatric theory
2 After Kraepelin How the standard approach to psychiatric classification evolved
3 The Great Classification Crisis How it was discovered that the standard system was scientifically meaningless
4 Fool’s Gold Why psychiatric diagnoses do not work
5 The Boundaries of Madness Why there is no boundary between sanity and madness
6 Them and Us Modern psychiatry as a cultural system
Part Two A Better Picture of the Soul
7 The Significance of Biology Psychosis, the brain and the concept of ‘disease’
8 Me
ntal Life and Human Nature Madness and the social brain
9 Madness and Emotion Human emotions and the negative symptoms of psychosis
Part Three Some Madnesses Explained
10 Depression and the Pathology of Self Core psychological processes that are important in severe mental illness
11 A Colourful Malady The psychology of mania
12 Abnormal Attitudes The psychology of delusional beliefs
13 On the Paranoid World View Towards a unified theory of depression, mania and paranoia
14 The Illusion of Reality The psychology of hallucinations
15 The Language of Madness The communication difficulties of psychotic patients
Part Four Causes and their Effects
16 Things are Much More Complex than they Seem The instability of psychosis, and the solution to the riddle of psychiatric classification
Madness Explained Page 82
