Madness Explained: Psychosis and Human Nature

by Richard P. Bentall

In contrast to the more mechanistic framing of schizophrenia in terms of abnormal brain chemistry or anatomical lesions, the new approach views the patient as a whole person troubled by apparently baffling problems, but also having the resources for ameliorating these problems.

He and his co-workers have been able to demonstrate that the apparently mysterious, incomprehensible symptoms of the mentally ill are actually extensions of what many of us experience every day.

Beliefs in mind-reading, clairvoyance and alien possession are especially common in young people and a surprisingly large percentage of the population believe that they have received communications from God, the Devil and aliens.

These beliefs, however, become a problem when they come to dominate the patients’ thinking and especially their interpretations of their experiences.

the so-called ‘negative symptoms’ can be understood as a natural detachment from a stressful environment.

have attempted to highlight an important theme of this book, which is the vanishingly small difference between the ‘us’ who are sane and the ‘them’ who are not.

The law states that, by the time an experiment has been completed, the researcher will know how it should have been done properly.

on closer scrutiny, the overwhelming impression is one of inactivity and loneliness.

will argue that the main problem faced by modern psychiatric services is not one of personnel or resources (although these may be important) but one of ideas. I

The orthodox approach which I will show must be rejected is based on two false assumptions: first, that madness can be divided into a small number of diseases (for example, schizophrenia and manic depression) and, second, that the manifestations or ‘symptoms’ of madness cannot be understood in terms of the psychology of the person who suffers from them.

First, and most importantly, there was a loosening of the associations that linked together the stream of thought, so that the patient could no longer reason coherently.

ambivalence – the holding of conflicting emotions and attitudes towards others.

autism, a withdrawal from the social world resulting from a preference for living in an inner world of fantasy.

affect, the display of emotions that are incongruent with the pat...

Whereas for Kraepelin the mad were subjects of scientific interest and scrutiny, for Bleuler they were fellow human beings engaged in the same existential struggles as the rest of humanity, struggles that were made more difficult by their illness.

The originality of his approach first became evident to his colleagues in 1910, when he published a paper in which he considered whether paranoia should be regarded as an abnormal form of personality development or as an illness.14 Jaspers’ distinction between these two possibilities was novel in itself.

In it, Jaspers made a distinction between two apparently irreconcilable methods of comprehending mental symptoms: understanding and explaining. According to Jaspers, a patient’s experiences can be understood if they are seen to arise meaningfully from the person’s personality and life history. The key to a psychological analysis of a patient’s abnormal experiences is therefore the clinician’s empathetic understanding of the patient’s subjective world and life story. In some cases, however, symptoms arise in such a way that no amount of empathy can link them understandably to the patient’s background.

Ununderstandability was, of course, the hallmark of the psychoses, and allowed them to be distinguished from the less severe psychiatric disorders, which later became known as the neuroses.

First, they are held with extraordinary conviction. Second, they are resistant to counterarguments or contradictory evidence. Third, they have bizarre or impossible content.

Because Kraepelin’s paradigm remains the main organizing principle for psychiatric practice and research, any evidence that draws it into question has revolutionary implications for both the understanding and treatment of madness.

In the last chapter, we saw that one way of assessing the usefulness of a diagnostic system is to measure its reliability. However, the example of astrology illustrates the limitation of this approach. Star signs are highly reliable (we can all agree about who is born under Taurus), so reliability alone cannot ensure that a diagnostic system is scientific. Further tests of the validity of the system are necessary to determine whether it fulfils the functions for which it has been designed.

although reliability does not guarantee validity, it is obvious that a diagnostic system cannot be valid without first being reliable.

Hallucinations and delusions seemed to occur together (a finding that has been consistently repeated in later research).

Therefore, although the distinction between schizophrenia and bipolar disorder does not seem to survive examination with these techniques, we can be fairly confident that all psychotic symptoms cannot be explained in terms of a single underlying disease process. What Families

attempts to find out whether twins have an increased liability to psychosis compared to the general population have reported inconsistent results.

Whereas clinical outcome is determined by assessing the persistence of symptoms, occupational outcome is defined according to how well the individual maintains a steady job, and social outcome reflects the individual’s ability to maintain an adequate network of social relationships.

The first is that the course of psychosis is very unpredictable.

outcome is enormously variable between individuals with the same diagnosis.

patients who receive a diagnosis of manic depression have a better outcome on average than patients who receive a diagnosis of schizophrenia.

‘the fallacy of the excluded middle’, namely the tendency to focus on ‘textbook’ patients who appear to be clearly schizophrenic or clearly manic-depressive, while ignoring the large number of patients who have both types of symptoms.

The effects of controlling for this fallacy were explored in an important study conducted by Robert Kendell and Ian Brockington.

At the beginning of this chapter I suggested that astrological predictions provide a fool’s-gold standard against which to evaluate the predictions achieved by psychiatric diagnoses. We are now in a position to apply this standard. While diagnoses clearly are superior to star signs, this superiority is not striking and is only evident when large groups are studied. When the focus is on the individual, the clinician wanting to predict what will happen to her patients in the years ahead would do almost as well by resorting to horoscopes.

progress in psychopharmacology has nearly always been in the opposite direction – the accidental discovery of an apparently effective drug has led to speculation about its mode of action, and from there to research on the biological origins of mental illness.

In this chapter I have drawn on a wide range of research. None of the findings we have considered supports Kraepelin’s diagnostic system. Studies of patients’ symptoms, of the role of genes, of the course and outcome of illnesses over time, and of the response of symptoms to treatment, all point to similarities between schizophrenia and bipolar patients, rather than to differences.

Still others, mostly psychologists, have advocated the development of dimensional systems of classification, in which an individual is regarded as suffering more or less from different kinds of disorder.

A recent study by Jim van Os and his colleagues provides some empirical support for this approach. Using his sample of over 700 psychotic patients, van Os assessed the power of categories (DSM-III-R diagnoses) and symptom dimensions to predict illness course, employment history, suicidal behaviour, the patients’ perceived quality of life, and a number of other variables. For nearly all of these, the dimensions were more powerful predictors than the categories.60 None of these strategies has received

According to Kraepelin, people either suffer from mental illness or they do not, and we are not free to choose whether to regard some kind of unusual behaviour as evidence of madness or mere eccentricity.

I will address the suggestion (succinctly expressed in the above quotation from the philosopher Ludwig Wittgenstein) that psychosis should be seen as just part and parcel of human variation, rather than as an illness.

symptom of schizophrenia according to Kurt Schneider. Perhaps even more surprisingly, 5 per cent reported holding conversations with their hallucinations. Subsequent surveys of students in Britain (carried out by myself and others)6 and in the United States (carried out by Tim Barrett and his colleagues)7 have obtained comparable results.

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studies have provided broad support for Tien’s findings. Jim van Os and his colleagues conducted psychiatric interviews with over 7000 people randomly selected from the general population of Holland.

Although the members of the new religious movements were not ‘ill’ in the sense of wanting or appearing to need treatment, the two groups could not be distinguished on a measure of delusional beliefs.

I am aware of only one study in which an attempt has been made to assess the prevalence of different kinds of delusions. In June 1996, thirty-one family doctors in the Aquitaine region of southwest France asked over 1000 patients attending their clinics to complete a questionnaire measuring twenty-one commonly reported delusional beliefs. Only 11.5 per cent of those approached had attended their doctor because of psychiatric problems. The most common delusional ideas reported were that people were not who they seemed to be (69.3 per cent of those with no history of psychiatric disorder); that the individual had experienced telepathic communication (46.9 per cent); that seemingly innocuous events had double meanings (42.2 per cent); that the individual was being persecuted in some way (25.5 per cent); and that occult forces were at work (23.4 per cent).

Indeed, in the case of two categories of abnormal speech – derailment (a pattern of speech in which ideas seem to slip off one track on to another, obliquely related track) and loss of goal (failure to follow a chain of thought to its logical conclusion) – the eccentrics showed less evidence of abnormality than ordinary people.

only one study has reported a population estimate for psychotic speech. In Poulton’s study of people in Dunedin, the speech of the participants was rated by a social worker as they arrived to be assessed, and 17.9 per cent of the sample were rated as having disorganized speech.

‘markers’ or indicators of schizotaxia in the hope that these could be used to detect people at risk of schizophrenic breakdowns.

These questionnaires have been followed by many others, so that scales of schizotypy or psychosis-proneness, if not quite a dime a dozen, have now become commonplace instruments of psychological research.

there is some evidence that scores on these questionnaires predict future psychotic breakdown, although not with the kind of precision that would be useful to clinicians.

the same kinds of arguments that have been made about the continuum between normal personality and schizophrenia have also been made about mood disorders.

First, in a study by Robert Spitzer, psychiatrists were asked to evaluate their patients on the proposed DSM-III definitions of schizotypal and borderline personality disorder. It was found that about half the patients who met the criteria for one of the diagnoses also met the criteria for the other.

In general, these studies have found that hypomanic traits (presumably related to mania) correlate very highly with odd beliefs and perceptual aberrations (traditionally thought of as a characteristic of schizophrenia). This finding suggests that schizophrenia and bipolar personality characteristics overlap, and therefore further undermines Kraepelin’s assumption that there are two separate types of psychosis.