Madness Explained

by Richard P. Bental

  Szasz’s error

  Some of the implications of the foregoing account of the relationship between the mind and brain may not be apparent until we consider psychotic phenomena in detail later. However, an immediate implication is that we should not accept the terms on which psychiatrists and anti-psychiatrists have debated the disease status of psychosis.

  The more carefully we examine the scientific evidence, the more difficult it is to decide which brain abnormalities are really ‘pathological’. What are we to make of increases in ventricular volume that may be the consequence of adverse life experiences? Or of dopamine abnormalities that come and go, and which are only present when an individual experiences hallucinations or delusional fears? Or of either of these abnormalities when we know that people experiencing voices or strange beliefs often suffer no detriment to their quality of life?

  These difficulties are resolved when were cognize that the distinction between the pathological and the non-pathological inevitably involves some kind of implicit reference to human values. As the British philosopher Peter Sedgwick pointed out two decades ago,80 it is not enough that a physical characteristic is shown to be statistically unusual in order for it to be regarded as pathological; it must also be perceived as undesirable, or at least to have consequences that are perceived as undesirable.* If this is not obvious in the case of physical disease it is because there is almost universal agreement that the consequences of particular kinds of biological abnormality are disagreeable. The pain ful death that can follow a rapid swelling of the appendix is bad by anyone’s standards. (If, instead, the only consequence of appendicitis was a doubling of the patient’s IQ, it might be regarded differently.) In the field of psychiatry, by contrast, the role of values in determining diagnostic judgements is made obvious by diverse opinions about the relevant behaviours and experiences, which might be attributed to illness, regarded as evidence of harmless eccentricity or creative energy, or described as spiritual phenomena.

  The implications of this analysis of the nature of diagnoses have recently been worked out in more detail by Bill Fulford, a British psychiatrist who is also a professional philosopher.81 Fulford has suggested that, far from threatening the scientific status of psychiatry, acknowledging the role that values play in psychiatric judgements would help to make psychiatric diagnoses more reliable and scientifically valid. He argues that the descriptive and evaluative components of each diagnosis should be explicitly separated out, so that, for example, a diagnosis of schizophrenia would require not only that the patient experiences certain symptoms, but also that the symptoms are experienced as distressing or unwanted. Such a step would make it clear that it is impossible to create a value-free theory of mental illness as hoped for by the neoKraepelinians, and would obviously go some way towards solving some of the cross-cultural disagreements about psychiatric disorders that we encountered in the last chapter.

  It follows from this argument that Thomas Szasz is correct in asserting that psychiatric diagnoses inevitably involve a degree of value judgement, but mistaken in assuming that this is a feature of diagnosis that is unique to psychiatry. It is perhaps ironic that Szasz accuses mental health professionals of using the concepts of ‘disease’ and ‘illness’ to justify coercive practices, when the right of patients to refuse unwanted treatments is widely recognized by practitioners of physical medicine.82

  The future of biological psychiatry

  Some years ago, I was invited to speak at a Dutch symposium about controversies in psychiatric research. My talk was followed by a presentation by a highly respected Spanish neurologist who responded angrily to my attack on the Kraepelinian paradigm. ‘Some people may say that schizophrenia is a myth, but we know that it is brain disease,’ she exclaimed. She did not quite strike the table with her fists, but everything else about her demeanour suggested that she found my analysis offensive. She then proceeded to talk about her own structural neuroimaging studies, as if these settled the matter for all time.

  Biological findings about madness have often been greeted by a dramatic suspension of the critical faculties of both researchers and bystanders. (In recent years, my enjoyment of the Sunday newspapers has often been impaired by articles claiming that biologists have at last found the cause of one psychiatric disorder or another.) New discoveries are announced triumphantly, but with the passage of time are often found to be either unreplicable or to be consequences of some aspect of psychiatric treatment (for example, drug therapy or a hospital diet). Of course, part of the problem is that investigators continue to labour within the framework of the Kraepelinian paradigm. As neoKraepelinian diagnoses group together individuals who have very little in common, it is no wonder that biological research has yielded inconsistent and confusing data. However, just as important is researchers’ unreflective hunger for the rewards and plaudits that go with genuine scientific progress. It is as if they are mesmerized by the scent of the Nobel Prize that will be given to the person who finally finds the real cause of schizophrenia.

  It would obviously be wrong to extrapolate from these criticisms to the conclusion that brain research is fundamentally misguided. The unravelling of the mysteries of the central nervous system remains one of the most challenging and exciting tasks for science in the twenty-first century. Almost certainly, this effort will eventually lead to dramatic improvements in the quality of human life and perhaps revolutionize the way that we think about ourselves as sentient beings. For this reason, it is especially disappointing that so many biological psychiatrists have approached this quest in a naive way. In order to fulfil the promissory notes now routinely handed out by neuroscientists in their scientific papers and public statements, future investigators will surely have to engage with other disciplines, and abandon the assumption that discoveries about the brain somehow obviate the need to understand individuals from a social or psychological perspective.

  8

  Mental Life and Human Nature

  The human being is the best picture of the human soul.

  Ludwig Wittgenstein1

  In the last chapter I established that research into the neurobiology of madness leaves ample room for psychological analysis. In this chapter I will develop this argument further by examining the long tradition of psychological research into psychosis that has been conducted from within the Kraepelinian paradigm. I will not deny that this research has led to useful discoveries. However, I will try to show that the insights that have been gained have been limited, not only by a misleading approach to diagnosis, but also by a failure to recognize the social origins of human mental life.

  Psychological Research from the Kraepelinian Perspective

  It has been known for many years that psychotic patients perform badly on most psychological measures. This much was understood by Kraepelin, who pioneered the use of psychological tests in psychiatric settings. A vast number of tests have since been devised for administration to psychiatric patients, the majority of this work being carried out with patients diagnosed as suffering from schizophrenia. (For reasons that are unclear to me, much less research has been carried out with patients with a diagnosis of bipolar disorder.) However, a number of problems have to be resolved before the data from these kinds of investigations can be interpreted properly.

  An obvious difficulty is that test performance can be affected by factors that have very little to do with patients’ symptoms. As early as the 1930s, psychologist David Shakow at the Worcester State Hospital in Massachusetts showed that the performance of schizophrenia patients on a range of psychological measures varied according to their co-operation, motivation and interest, so that, under optimum conditions, their scores sometimes equalled those of ordinary people.2 This effect of motivation on performance has recently become obvious in a number of experiments using the Wisconsin Card Sort Task (WCST), the measure of frontal lobe function briefly introduced in the last chapter. The WCST is one of a wide range of neuropsychological tests devised by psychologists to enable the
detection of damage to particular regions of the brain.*

  As we have already seen, the WCST has been used to test the hypothesis that the frontal lobes of schizophrenia patients are under-active, especially in response to environmental demands. Consistent with this hypothesis, numerous studies have shown that schizophrenia patients typically perform poorly on the test.3 There have also been reports that patients diagnosed as suffering from manic depression find the task difficult, although these have been less consistent.4 However, studies by Alan Bellack and his colleagues in Maryland, by Michael Foster Green and his colleagues in California, and more recently by Heidi Nisbet and her colleagues in New Zealand,5 have shown that the scores of psychotic patients on the WCST can be improved by paying them for performing well, or by simply giving them feedback on their performance. Clearly, therefore, the poor performance of patients on this test must be explained, at least in part, by motivational problems.

  The effects of medication on psychological test performance must also be considered. American psychologists Herbert Spohn and Milton Strauss have shown that these effects vary according to the type of medication prescribed and the type of tests administered.6 For example, the anti-cholinergic drugs used to control some of the side effects of neuroleptic medication adversely affect memory. On the other hand, there is consistent evidence that performance on tests of attention usually improves following the administration of neuroleptic drugs to acutely ill patients. In order to control for these effects, investigators sometimes try to administer tests to patients while they are free of drugs. However, this is often hard to achieve, as doctors usually give their patients medication at the earliest signs of illness.

  A further problem is that psychotic patients have performed poorly on just about every test that anyone has ever administered to them. For this reason, it is sometimes impossible to decide whether poor performance reflects specific psychological processes that are affected in the patient, general intellectual deficits, or the more general effects of demoralization and institutionalization. There is no simple solution to this problem. One approach is to administer several tests, in order to show that performance is more abnormal in some than others. For example, if the difference between patients and controls is greater on a test of perception than on a test of memory, this can be considered evidence that perception is specifically affected. Many years ago, Loren and Jean Chapman of the University of Wisconsin pointed out that this strategy is only reliable when the tests are equally difficult for normal individuals.7 To see why this is the case, imagine the consequences of administering a test (say a simple measure of general knowledge) that was so easy that almost everyone would do well on it. Such a test would fail to discriminate between patients and controls. The same would be true of a very difficult test (say a questionnaire measuring knowledge of the mathematical principles underlying quantum mechanics), which both patients and ordinary people would fail. In general, tests are most sensitive to differences between patients and control groups when they are designed so that normal individuals of average intelligence will make errors on 50 per cent of opportunities. Returning now to our hypothetical experiment in which patients and controls are administered a test of perception and a test of memory, imagine what would happen if the perception test was moderately difficult but the memory test was either very hard or very easy. Under these conditions, the patients would appear to be specifically handicapped on the measure of perception but not on the measure of memory. However, this result would be entirely an artefact of the relative difficulty of the tests.

  This problem is most severe when tests are designed to measure gross deficits in cognitive ability.8 A deficit is said to be present when there is a general failure in an individual’s mental processes. We will see, for example, that there is evidence that psychotic patients often have difficulty attending to things that are happening, irrespective of what those things are. It is often assumed that deficits are the product of some kind of general malfunction of the central nervous system, although this is not always the case, because, as we have seen, poor performance on general measures of mental functioning may be caused by poor motivation.

  It is very important to recognize that not all psychological abnormalities are deficits. A cognitive bias is said to be present when someone preferentially processes (attends to, remembers or thinks about) some kinds of information as opposed to others. For example, we will see that people who feel depressed generally remember positive life experiences less easily than negative experiences. Their failure to recall good events cannot be attributed to a deficit, or poor motivation, because they can recall bad events exceptionally well. Because there is no general malfunction of the nervous system, but rather a skew in the way that the mind is orientated towards the world, biases are sometimes assumed to be the products of adverse learning.

  For reasons that are not obvious (at least to me), psychological studies of psychosis have, until recently, focused almost entirely on deficits, whereas research on non-psychotic conditions has usually measured biases. In later chapters, we will see that both types of abnormality contribute to psychotic symptoms.

  Psychosis and attention

  In fact, although many different mental processes have been assessed in psychotic patients, the most consistent observations of deficits have been made using measures of attention, which can be thought of as the ability to focus on and respond to some stimuli in the environment in preference to others. Kraepelin provided the following strikingly modern account of the process of attention, and of the abnormal distractibility experienced by psychotic patients:

  The content of consciousness of the child is hopelessly dependent upon its chance environment; it only perceives the strongest stimuli, not taking into account the inner connection of things, for it is lacking those general conceptions which also distinguish the less obtrusive perceptions as essential links in the chain of experience. In the adult, on the other hand, the process of perception is increasingly controlled by the special inclinations which gradually develop from his personal life experience. We exercise ourselves chiefly in taking notice of certain impressions by a progressively increasing responsiveness of our imagination to these impressions, so that even slight suggestions suffice to meet with a vivid inner resonance. On the other hand, we become accustomed to disregard everyday stimuli and to deny them any influence whatsoever on the course of our psychic processes…

  The slightest degree of increased distractibility can be observed as a temporary phenomenon in the state of distraction as it occurs in progressive fatigue. In spite of all efforts we are no longer able methodologically to follow a series of coherent sensory impressions, but realize again and again that we are diverted by other impressions or ideas and that we can only grapple with the task in a fragmentary way. This disorder is developed to a higher degree in chronic nervous exhaustion, in the period of convalescence following severe mental or physical diseases, to an even higher degree in acute exhaustion psychoses strictly speaking moreover in mania, often also in paralysis and dementia praecox. Here in many cases, an exclamation, a single word, even the exhibition of an object suffices for immediately diverting the direction of attention and suggesting quite complex conceptions.9

  Interest in the attentional difficulties of psychotic patients was renewed sixty-two years after Kraepelin’s account, following the publication of a study by Andrew McGhie and James Chapman, who were working at the Royal Dundee Mental Hospital in Scotland.10 They interviewed twenty-six schizophrenia patients who had recently become ill, and found that the majority reported subjective cognitive difficulties such as problems of attention, increased distractibility, heightened sensory impressions, and awareness of processes and actions that would normally be automatic. For example: ‘My concentration is very poor. I jump from one thing to another. If I am talking to someone they only need to cross their legs or scratch their heads and I am distracted and forget what I was saying.’ And: ‘I have to do everything step by step, nothing is au
tomatic now. Everything has to be considered.’ Chapman and McGhie later reported that schizophrenia patients performed poorly on a variety of psychological measures designed to assess attention. Although other researchers criticized their methods,11 later studies broadly supported their conclusions.

  The assessment of attentional processes is a complex and technical field, and I will therefore limit the present discussion to the three most widely used tests. In the first and simplest, the Digit Span with Distraction Test (DSDT), the participant listens to recorded strings of numbers, which he then repeats. Sometimes a second voice in the background reads out distraction numbers, which the participant is required to ignore. To ensure that the conditions are equally difficult for ordinary people, the number of digits presented is greater in the non-distraction than in the distraction condition. In the late 1970s, American psychologists Thomas Oltmanns and John Neale studied the DSDT performance of patients who were classified according to a loose hospital diagnosis of schizophrenia and according to the Research Diagnostic Criteria. When patients with the hospital diagnosis were compared with those with other diagnoses, no differences were found. However, when the patients who met the narrower RDC for schizophrenia were compared with those who did not, they were found to perform particularly badly in the distraction condition, indicating that schizophrenia patients are unable to screen out stimuli that are irrelevant to their current needs. Oltmanns and Neale studied the symptom profiles of their patients and found that distractibility was specifically associated with disordered speech.12 Their observations have been replicated many times since, with various refinements. American psychologist Mark Serper and his colleagues have recently shown that performance on the DSDT usually improves when patients are given anti-psychotic drugs, and that this improvement precedes and correlates with later improvements in symptoms.13