Madness Explained

by Richard P. Bental

  Can Psychosis be Prevented?

  Increasing optimism about both drug and psychological treatments for psychosis, whether or not justified, has led to a debate about when treatment should be offered. Recently, clinicians and researchers have begun to consider the possibility of intervening very early in the development of an illness.71 One impetus for this has been the emerging understanding, discussed in the last two chapters, that psychosis is the end point of a long developmental pathway. Another has been the discovery that many psychotic patients experience distressing symptoms for long periods before either seeking or being offered psychiatric help, and that a long delay in receiving treatment can lead to a poor outcome.72 This discovery suggests that the early detection of psychosis might substantially benefit patients.

  A team of investigators in Melbourne, Australia, which includes Patrick McGorry, Henry Jackson and Alison Yung among others, deserves particular credit for pushing this idea to its logical conclusion. In one of their studies, they reported that they could use a combination of methods to identify an ultra high-risk group who were very likely to become ill in the near future.73 An amazing 40 per cent of their sample, who either had experienced subclinical or transient psychotic complaints, or who were suffering from non-psychotic distress and had a first-degree relative with psychosis, became floridly ill within six months of being identified. Clearly, at this rate of transition to psychosis, preventative intervention becomes a real possibility.

  Several prevention studies are ongoing at the time of writing. The first, carried out by the Melbourne team, has already found evidence that a combination of psychotherapy and low-dose drug treatment for people at very high risk can at least delay madness in some people.74 In another trial, currently being conducted in the United States, a similar high-risk group is being offered olanzapine, one of the new atypical neuroleptics.75 However, giving drug treatments to people who have not yet become ill raises some very real ethical problems.76 From the experience of the Melbourne investigators, it seems that this strategy will expose a large number of people who would never make the transition to psychosis to a risk of very severe side effects. It is for this reason that Tony Morrison, Shôn Lewis and I are now conducting a small trial of CBT without medication for a high-risk group of people identified using the methods developed in Melbourne.77

  Even the use of purely psychological interventions in this way is not without danger. There is a risk of stigmatizing people by entrapping them into psychiatric services that they might otherwise have managed to avoid (for this reason, in our ongoing trial, we offer treatment separately from already established psychiatric clinics). There is also the risk of inflicting unwanted treatment on people who are quite happily living with psychosis, or the prospect of becoming psychotic (which is why we ask our patients to decide which difficulties should be prioritized in therapy, and focus on problems other than psychosis if they so wish).

  Liberation or Cure?

  In Chapters 6 and 7 of this book I argued that diagnostic judgements in psychiatry always involve implicit reference to broader human values.78 It is therefore important to recognize that psychotic people may value their experiences differently from people such as friends, family or mental health professionals, who are observing the experiences at second hand. They may also appraise the effects of treatment differently. For some the hazards of psychiatric care may far outweigh any disadvantages conferred by madness itself, whereas, for others, the opposite may be the case. Whether for or against treatment, there is no obvious reason why patients’ own opinions should not be respected, especially if (as is usually the case)79 they present no danger to other people. Ironically, I have found myself supporting the wishes of psychotic patients who want to receive neuroleptic drugs (on one memorable occasion attracting considerable hostility from many of the delegates at a conference of psychotherapists) almost as often as I have found myself defending their right to refuse them.

  Some years ago, Marius Romme invited me to give a talk at a conference at Maastricht, in Holland. Romme, it will be recalled, is the psychiatrist who discovered that large numbers of Dutch citizens (and presumably citizens of other countries also) hear voices without needing psychiatric treatment. His conference had been planned as an opportunity for sympathetic professionals like myself to exchange ideas with members of Resonance, his organization for voice-hearers. As we walked through the pristine white corridors of the brand-new conference centre one morning, Romme and I discussed our different approaches and, in the middle of this conversation, he said something that I will never forget:

  ‘I really like your research on hallucinations, Richard. But the trouble is, you want to cure hallucinators, whereas I want to liberate them. I think they are like homosexuals in the 1950s – in need of liberation, not cure.’

  It took me a little time to recognize the power of this simple idea. If people can sometimes live healthy, productive lives while experiencing some degree of psychosis (and the evidence we considered in Chapter 5 suggests that they can), if the boundaries between madness and normality are open to negotiation (and the cross-cultural evidence we considered in Chapter 6 suggests that they are), and if (as we have seen in this chapter) our psychiatric services are imperfect and sometimes damaging to patients, why not help some psychotic people just to accept that they are different from the rest of us? Fear of madness may be a much bigger problem than madness itself.

  Of course, this suggestion does not imply that people in distress should not be offered the most effective treatment that is available (drug or psychotherapeutic). It also does not imply that steps should not be taken to protect society from the very small number of patients who behave dangerously towards others. However, it acknowledges that, for many people experiencing psychosis, treatment may not be the most helpful way forward in their lives.

  Putting this idea into practice would require a fairly major shift in society’s attitude towards eccentricity and madness. It would involve giving mad people some control over our asylums. It would probably win no support from drug companies or politicians. But it would almost certainly make the world a better place for mad and ordinary people alike.

  Appendix: A Glossary of Technical and Scientific Terms

  Unless otherwise stated, the following definitions are my own.

  Adoption study A type of study designed to tease out genetic and environmental influences, by examining what happens to children who are reared by adoptive parents to whom they are not biologically related. One method involves examining adopted-away children of parents who have a disease, and comparing them with adopted-away children whose biological parents do not have the disease. The alternative approach involves identifying adoptees who have a disease, and comparing their biological parents with the biological parents of adoptees who do not have the disease.

  Affective blunting See Flat affect

  Affective reactivity The extent to which symptoms are reactive to emotional stimulation. Affectively reactive symptoms, for example some types of communication disorders, become more severe when the individual is reminded of unpleasant events.

  Affective style The style of interaction between relatives or significant others and psychiatric patients, as observed in actual interactions. Relatives with a negative affective style make many critical and intrusive comments to patients, and also tend to score highly on measures of expressed emotion.

  Akathisia An extrapyramidal side effect of neuroleptic medication. The patient experiences a very unpleasant subjective feeling of restlessness, often accompanied by profound feelings of depression. There is some evidence that akathisia may be associated with suicide attempts in patients receiving neuroleptics.

  Alleles Different variations of the same gene. Thus, strictly speaking, all human beings have the same genes and genetic variation is a consequence of our having different alleles of those genes.

  Ambivalent attachment A type of insecure attachment. In young children, it is manifest in distress on separatio
n from the caregiver, and an inability to be comforted on the caregiver’s return. In adulthood, ambivalent attachment is associated with emotional over-responsiveness towards potential partners, often leading to clingy behaviours or even jealousy, often culminating in rejection.

  Anhedonia An inability to experience pleasure. It is sometimes subdivided into physical anhedonia (the inability to experience physical pleasures) and social anhedonia (the inability to experience social pleasures). Although anhedonia has been recognized as a negative symptom of schizophrenia, it is found in a wide range of other conditions, especially depression.

  Anti-cholinergic drugs Drugs that affect neural pathways that utilize the neurotransmitter acetylcholine; used to control the extrapyramidal side effects of anti-psychotic (neuroleptic) drugs.

  Attachment relationships The kind of close emotional bond formed with a parent figure early in life, which serves as a model for emotional relationships in adulthood.

  Attention The psychological processes involved in responding only to important environmental stimuli. Often a distinction is made between selective attention (the filtering out of irrelevant stimuli) measured by tests such as the digit span with distraction task, and sustained attention (or vigilance, involving maintaining a focus on one task over a period of time) measured by tests such as the continuous performance test.

  Attribution A causal statement; a statement that either includes or implies the word ‘because’. It has been estimated that, on average, ordinary speech contains an attribution in every few hundred words. The types of attributions that people make are thought to have an important impact on mental health, and play a role in depression, mania and paranoia.

  Attributional (explanatory) style An individual’s characteristic style of making attributions. Attributional style is often assumed to be a stable personality trait, and is thought to play a role in a variety of symptoms, especially dysphoria, paranoia and mania.

  Atypical neuroleptics A new class of antipsychotic drugs, which are said to have a kinder side-effect profile, and possibly to be more effective, than traditional neuroleptic medication. The evidence for these claims is equivocal, but these drugs are certainly much more expensive than the typical drugs.

  Autonomy A type of self-schema, by which the individual evaluates his or her worth according to freedom of choice and the achievement of goals.

  Avoidant attachment A type of insecure attachment. Avoidantly attached children are unmoved by the departure of a care-giver, and ignore the caregiver on her return. In adulthood, the avoidantly attached person avoids emotional closeness with others. This type of attachment style is associated with the positive symptoms of psychosis, especially paranoid delusions.

  Backward masking Visual information processed by the brain is first held in a brief store, sometimes known as ‘the iconic memory’. The immediate presentation of an unpatterned stimulus after an initial stimulus can displace information about the initial stimulus held in the store, preventing it from being passed on to other parts of the cognitive system for further processing. In these circumstances the individual does not have a conscious experience of the initial stimulus. This phenomenon is known as backward masking, and has been exploited to investigate information processing in psychotic patients.

  Basic emotions (theory of) The idea that there are a small number of distinct emotions.

  Behavioural activation system (BAS) A hypothesized neural system thought to be responsible for determining response to reinforcement (reward). According to some theorists, the BAS is overactive in bipolar disorder.

  Behaviourism A much misunderstood approach to psychology pioneered by the American psychologist John Watson, who argued that psychology should be the scientific study of observable behaviour. According to Watson (Behaviorism, New York: W. W. Norton, 1924), ‘Let us limit ourselves to things that can be observed, and formulate laws concerning only those things. Now what can we observe? We can observe behavior – what the organism does or says. And let us point out at once: that saying is doing – that is, behaving. Speaking overtly or to ourselves (thinking) is just as objective a type of behavior as baseball.’

  Bias See Cognitive bias

  Bipolar disorder Modern term for manic depression; a psychiatric illness in which the individual experiences episodes of depression and also of either mania or hypomania.

  Blood-oxygen-level-dependent (BOLD) response Areas of the brain that become active when we attempt some kind of task demand increased oxygen. Several seconds after we start to perform the task, there is therefore a surge of oxygenated haemoglobin (oxygen enriched blood) to those areas. This can be detected by the latest fMRI scanning techniques, which thereby reveal which parts of the brain are most active at any point in time. This technique can therefore be used to determine which areas of the brain are most involved in different types of tasks.

  Capgras syndrome A delusional system in which the individual believes that someone (usually a loved one) has been replaced by an imposter or doppelgänger.

  Cerebral lateralization The tendency for the left and right hemispheres of the brain to take on different functions. In most people, the left side of the brain is much more involved in generating and understanding language than the right, although some people are exceptions to this rule.

  Cerebral ventricles Fluid-filled cavities inside the brain; it is thought that these are enlarged in some psychiatric conditions.

  Circadian dysrhythmia Desynchronization of the circadian rhythm with the natural 24-hour light–dark cycle, brought about by a severe disruption of routine, which may play an important role in mood symptoms.

  Circadian rhythm The daily rhythm of bodily changes accompanying waking, sleeping and regular changes in activity.

  Circumplex model of emotions See Emotional circumplex

  Clinical psychologist A psychologist who has specialized in using psychological methods to assess and treat clinical problems. Training begins with the basic degree in psychology, followed by a postgraduate programme lasting at least three years which includes a large amount of supervised clinical work. In North America this has always led to the degree of Ph.D. (doctor of philosophy) or D.Psy. (doctor of psychology). Until recently, trainee clinical psychologists in Britain graduated with a masters degree, but in the early 1990s all universities offering training in clinical psychology upgraded the basic qualification to a doctorate (usually D.Psy. or D. Clin. Psy.) on the American model.

  After qualifying, clinical psychologists can learn to specialize in a number of areas, including child clinical psychology, adult mental health, learning disabilities, clinical neuropsychology and forensic clinical psychology. Clinical psychologists in Britain cannot prescribe psychiatric drugs. However, a small number in the United States have been trained to do so, and the question of whether this should become a routine part of the psychologist’s role is being extensively debated in that country.

  Not surprisingly, the American Psychiatric Association is not keen on the idea.

  Cognitive behaviour therapy A type of individual psychological therapy that is problem-focused and usually time-limited. The patient and the therapist work together collaboratively to define goals, to identify dysfunctional thinking processes that may prevent the patient from achieving those goals, and to find better ways of coping with life stresses.

  Cognitive bias A bias towards preferentially processing (attending to, remembering or thinking about) some kinds of information as opposed to others. For example, depressed patients tend to recall more easily negative than positive information. Because patients with abnormal cognitive biases can process some kinds of information perfectly well (for example, negative information in the case of depressed patients) biases must be distinguished from more general cognitive deficits.

  Cognitive deficit A gross, content-independent deficiency of a fundamental cognitive process, such as attention or memory. Often attributed to brain damage, cognitive deficits may also reflect general motivational deficits.r />
  Cohesive ties Parts of speech that serve the function of informing the listener that different segments of speech are meaningfully related. There is evidence that these are to some degree absent in thought-disordered speech.

  Cohort study A study in which an entire (unselected) cohort of the population (for example, all children born in a particular week) is followed up, often over decades.

  Communication deviance An unusual style of parental communication involving abnormal ways of handling attention and meaning, unusual ways of talking about relationships, and abnormal emotional responses.

  Comorbidity The occurrence of more than one illness in the same person. NeoKraepelinian researchers have often assumed that comorbidity reflects the fact that individuals, through some misfortune, really do suffer from more than one illness. Of course, apparent comorbidity often reflects the fact that two illnesses are not really separate and independent entities.

  Computer tomography (CT; sometimes known as computed axial tomography or CAT) A type of structural imaging, in which information from X-rays taken at different angles is integrated to produce a picture of a cross-sectional slice of the body.