Madness Explained

by Richard P. Bental

  Positron emission tomography (PET) A technique used to image activity in the brain, in which radio-labelled substances are injected into the body. On reaching the brain, the substances release positrons which almost immediately decay, releasing photons that travel in opposite directions and which are then detected by a scanner.

  Post-traumatic stress disorder A cluster of symptoms often experienced by survivors of life-threatening events. These include constant re-experiencing of the traumatic event (in the form of intrusive memories, flashbacks or dreams), avoidance of stimuli associated with the event, and persistent emotional over-arousal (for example, as indicated by irritability).

  Prefrontal leucotomy A crude brain operation devised by the Portuguese neurosurgeon Egas Moniz and inflicted on many psychotic patients, especially in the 1950s. It involves severing neural pathways from the frontal regions of the brain to the anterior regions. Often performed quickly under local anaesthetic, by inserting a knife in a hole drilled towards rear of the forehead, with little care about the precise location of the lesions created. A version developed by Walter Freeman involved displacing the eyeball downwards and thrusting an ice-pick-like instrument through the bone of the orbit behind the eyes. There is no evidence that this operation affects symptoms, but it may leave patients more passive and easier to manage.

  Prevalence The proportion of a population suffering from a condition at a particular point in time. Not to be confused with incidence (the number of new cases in a particular period).

  Prodromal symptoms Symptoms that precede the appearance of full-blown psychosis. Typically, these include disturbances of mood, but may also include subtle cognitive (thinking) and perceptual abnormalities.

  Psychiatrist A medical doctor who specializes in the treatment of psychiatric problems. After receiving the basic medical qualification, the doctor receives a further four or more years of training which mostly consists of supervised clinical work. Psychiatrists often use psychiatric drugs as their main line of treatment, but many also acquire training in psychological techniques. Because psychiatrists have important legal responsibilities (they can have patients compulsorily admitted to hospital), because they are the only profession currently allowed to prescribe psychiatric drugs, and because doctors have a long history of telling other health professionals what to do, they are usually the leaders of multidisciplinary psychiatric teams.

  Psychoanalysis This has two meanings: the theory about the mind and the origins of mental illness developed by Sigmund Freud, and the particular type of psychotherapy that he invented. Psychoanalysis as a theory has often been criticized as woolly and untestable by modern scientific psychologists, but there is no doubt that Freud was an astute observer whose sometimes bizarre ideas are peppered with acute insights into human nature. Psychoanalysis as a treatment is long (often several years), intensive (often several times a week), extremely expensive, and has never been shown to be of benefit to psychotic patients. However, it remains fashionable and is even regarded as a gold-standard therapy in some intellectual quarters. More recent brief psychodynamic therapies, which draw on Freud’s ideas to some extent, have been shown to be effective for some non-psychotic conditions.

  Psychoanalyst ‘Analyst’ for short. One who practises psychoanalysis. Although Freud was a doctor, he came to believe that medicine was a bad initial training for those wishing to be psychoanalysts. However, this did not stop the American Psychoanalytic Association from restricting training to doctors until they were successfully sued by a group of disgruntled psychologists in 1965. Now psychoanalytic associations in most countries will take on trainees from a wide range of backgrounds. The training includes a personal analysis, in which the trainee is analysed by a qualified analyst. The length of training is usually long and indeterminate and is completed when the supervisor and his/her colleagues think the trainee is ready. Why anyone would wish to undertake an expensive training in this old-fashioned and ineffective treatment is another matter.

  Psychopharmacology The scientific study of the effects of drugs (including psychiatric drugs) on the brain, behaviour and experience.

  Psychosis A term which has undergone dramatic changes of meaning since the end of the nineteenth century, when it was used to describe mild psychiatric problems with presumed psychological causes. It now refers to the most severe psychiatric disorders, in which the individual to some extent can be said to be out of touch with reality, which many psychiatrists and psychologists have presumed to be biological diseases. In practice, this means disorders in which the individual suffers from delusions and/or hallucinations.

  Puerperal psychosis A psychotic reaction experienced by a mother soon after (usually within three months of) the birth of her child.

  Reinforcement and reinforcers Technically, stimuli that, when consequent on a behaviour, increase the likelihood that the behaviour will occur again in the future. In lay terms, a reward (although it is important to recognize that some things which we think are rewarding may not actually be powerful reinforcers). Primary reinforcers reflect basic biological needs and include food, contact with an attachment figure (caregiver) and sex. Secondary reinforcers acquire their power by virtue of our learning history, and include social reinforcement (praise for our achievements) and, of course, money.

  Reliability The first test that must be passed by a diagnostic concept if we are to say that it is scientifically valid. Reliability refers to the consistency with which diagnoses are made, either by different clinicians or on different occasions. Reliability can be measured by having independent clinicians attempt to diagnose the same patients and then measuring their level of agreement with the kappa statistic, which varies between 0 (agreement at chance level) and 1 (perfect agreement). It can also be measured by making diagnoses at one point in time and then repeating the procedure at a later date, again using the kappa statistic to assess agreement between the two time points. (Obviously this kind of test–retest reliability is only meaningful in the case of measurements which we expect to remain fairly stable across time.)

  Although a diagnosis must be reliable to be scientifically valid, reliability is no guarantee of validity. For this purpose, additional validity tests must be passed.

  Ruminative response (coping) style A response to dysphoric mood, in which the individual focuses excessively on the mood and its causes, asking questions such as, ‘How did I get in this mess?’ and ‘Will I ever feel better?’ This response seems to prolong dysphoric episodes.

  Self Cognitive representation of who you are; roughly what is meant when saying ‘I’. It has been argued that the self consists of many domains (for example, the self as it actually is, the ideal self, the self as it ought to be, the self that might be possible in the future) and also different perspectives on the self (for example, my beliefs about what sort of person my mother thinks I am, and so on).

  Self-discrepancy Discrepancy between one domain or perspective on the self and another. So, for example, an actual–ideal discrepancy is a discrepancy between beliefs about the self as it actually is, and the ideal self.

  Self-esteem Global evaluation of the self. Typically regarded as a unidimensional scale running from self-loathing to self-satisfaction. However, this is an oversimplification, and there may be several different types of self-esteem. For example positive self-esteem (positive beliefs about the self) may be relatively independent of negative self-esteem (negative beliefs about the self).

  Self-guides Self-representations that have motivational properties, for example the ideal self and the ought self, which are two different kinds of standards for self-evaluation.

  Self-schema Core assumptions or beliefs about the self, often barely articulated, including enduring standards of self-evaluation.

  Self-serving bias The tendency to attribute positive events or experiences to one’s own actions and characteristics and negative events to causes external to the self. This bias is found in ordinary people, is exaggerated in paranoid patients and is abs
ent or even reversed in depressed people.

  Signal detection theory (SDT) As much an experimental method as a theory. SDT presumes that an individual’s decision that he or she has detected a stimulus – or signal – is a function of two separate factors: the sensitivity of the individual’s perceptual system (the more sensitive, the more likely that the signal will be accurately detected, or that the individual will correctly realize that it is not present) and perceptual bias, which can be roughly understood as the individual’s willingness to guess that a signal is present under conditions of uncertainty (the greater the bias, the more likely that the individual will correctly detect stimuli, but this gain is made at the risk of falsely detecting signals which are in fact absent).

  SDT experimental methodology allows these two factors to be measured separately. This has been useful in the study of hallucinations.

  Social brain hypothesis The hypothesis that the brain has evolved specific mechanisms for dealing with the demands of complex social relationships.

  Sociotropy A type of self-schema in which there is a tendency to judge one’s value in terms of relationships with other people. People high in sociotropy tend to be very sensitive to rejection or relationship problems.

  Source monitoring The process of determining the likely source of a cognition. One type of source monitoring involves discriminating between cognitions (thought, image or memories) and perceptions (especially things heard). It is believed that this skill may be compromised in people who hear voices. Another involves telling the difference between things one has thought, and things one has said. It is believed that people with thought, language and communication disorder have difficulty with this skill.

  State-dependent memory Material which is memorized while in a particular state (physiological condition or context) is more likely to be recalled when the individual is in the same state than when the individual is in some other state. This state-dependent memory effect has been shown to be true for a variety of circumstances, for example, when material in learned under conditions of intoxication (in which case, re-intoxication may improve recall) or when the individual is scuba-diving (in which case, recall is better in the water than on dry land). These observations show that even cognitive psychologists can devise fun experiments.

  Stress-vulnerability models Models of psychopathology that assume that some people are especially vulnerable to developing psychiatric symptoms by dint of possessing particular biological or psychological characteristics, but that exposure to stressful experiences is required for a full-blown psychiatric disorder to develop. It follows from these assumptions that many people who are vulnerable to psychiatric disorder may be spared as a consequence of living in a stress-free environment.

  Stroop effect The tendency to experience difficulty when naming the ink colours of words that grab attention. The effect is particularly evident when colour words are printed in incongruent ink colours (for example, ‘RED’ printed in green, or ‘BLUE’ printed in pink). Under these conditions, the individual experiences competition between the urge to name the word (‘Red’) and saying the ink colour (‘Green’), which slows down the latter response. A similar but slightly less strong effect is found for any emotionally salient words and, under these circumstances, is known as the emotional Stroop effect.

  Psychologists can use the emotional Stroop effect to show that certain themes are troubling to patients. The effect is strongest (that is, colour-naming is slowest) for the most troubling words.

  Structural imaging/scanning A type of neuroimaging (using, for example, CAT or MRI) that reveals the structure of the brain. Used to make anatomical comparisons between psychotic patients and ordinary people.

  Subvocalization Micro activations of the speech muscles that occur during inner speech. These can be recorded by means of electromyography. Subvocalization typically occurs when we are thinking about demanding or emotionally challenging problems.

  Tardive dyskinesia An extrapyramidal side effect of neuroleptic medication, now thankfully rare. The patient experiences spasmodic movements of the jaw and tongue, which are unsightly and, once established, are sometimes irreversible even after the medication has been discontinued.

  Theory of mind (skills) A misleading term for the ability to understand the mental states (beliefs, desires, wishes and intentions) of other people. People who can do this are said to possess a theory of mind, in contrast to autistic children, who seem unaware that others have mental states. Theory-of-mind (perhaps better called mentalizing) skills are often tested using problems that can only be solved by understanding that others have false beliefs.

  A typical example used with children concerns two individuals, Sally and Ann, who watch something (perhaps a sweet or toy) being placed in one of two boxes. Sally leaves the room and Ann moves the object to the other box before she returns. The child is asked which box Sally looks in when attempting to find the object. To answer correctly, the child must know that Sally believes the object is in the wrong box.

  Psychotic patients tend to be impaired on more complex theory-of-mind tests. It has been argued that their inability to understand the mental states of others contributes both to paranoia and to speech and communication disorders. However, the evidence on this is not clear cut.

  Thought disorder A misleading term for psychotic speech, which is incoherent to the listener and, in extreme cases, forms a kind of ‘word salad’. The term was introduced by early psychiatrists and psychologists who assumed that incoherent speech reflected incoherent thinking. However, modern research has established that this is generally not the case.

  Thought, language and communication disorder A rather unwieldy term introduced by Nancy Andreasen as an alternative to ‘thought disorder’.

  Unipolar depression A mood disorder in which only episodes of depression occur (i.e. mania is absent).

  Validity The extent to which a set of measurements or a diagnostic system fulfils the purpose for which it is designed. Not to be confused with reliability. There is no single test of validity. For example, the validity of a diagnostic concept might be assessed by seeing whether it corresponds to a naturally occurring cluster of symptoms, by seeing whether the diagnosis runs in families or is associated with any particular type of pathology, or by seeing whether it usefully predicts what happens to the patient in the future or which types of treatment are likely to be effective.

  Ventricular enlargement Enlargement of the cerebral ventricles, reported in some psychiatric conditions.

  Verbal community The community of competent language-users.

  Working memory A relatively brief (tens of seconds) memory store, used in everyday tasks such as comprehending speech. When we repeat telephone numbers to ourselves when walking from the telephone directory to the telephone, we are continually refreshing the working memory store.

  Zeitgeber A clock-setting stimulus. Any regular event (for example, dawn) or activity (for example, eating breakfast) that has the effect of resetting the circadian clock, and thereby keeping circadian rhythms in step with the natural 24-hour light–dark cycle.

  Notes

  Chapter 1 Emil Kraepelin’s Big Idea

  1. L. Wittgenstein (1980) Culture and Value (trans. P. Winch). Oxford: Blackwell.

  2. A few years before I arrived at Denbigh, a series of articles in the Guardian newspaper (reprinted in T. S. Szasz (ed.) (1975) The Age of Madness. London: Routledge & Kegan Paul) had revealed that many elderly female psychiatric patients in Britain had been incarcerated in their youth after giving birth to illegitimate children, a form of behaviour deemed to be evidence of psychiatric disorder in the 1920s and 1930s. Although there was speculation that this might be true of some of the elderly women in Denbigh, no evidence was uncovered to suggest that any of the patients on the ward fell into this category.

  3. The experiment, together with some further work, actually appeared in a paper that I wrote up, partly out of bloody-mindedness, many years later. The full reference is: R.
P. Bentall, P. Higson and C. F. Lowe (1987) ‘Teaching self-instructions to chronic schizophrenic patients: efficacy and generalisation’, Behavioural Psychotherapy, 15: 58–76.

  4. See Richard Warner (1988) Recovery from Schizophrenia: Psychiatry and Political Economy. New York: Routledge & Kegan Paul.

  5. Quoted in E. J. Engstrom (1991) ‘Emil Kraepelin: psychiatry and public affairs in Wilhelmine Germany’, History of Psychiatry, 2: 111–32. The mission referred to in the poem was apparently Kraepelin’s fight against the evils of alcoholism.

  6. E. Shorter (1997) A History of Psychiatry. New York: Wiley.

  7. The English-language literature on the life of Emil Kraepelin is relatively limited. I have used the following as the basis for my own account: E. Kraepelin (1987) Memoirs (trans. H. Hippius, G. Peters and D. Ploog). New York: Springer-Verlag; Franz G. Alexander and Sheldon T. Selesnick (1966) The History of Psychiatry: An Evaluation of Psychiatric Thought from Prehistoric Times to the Present. New York: Harper & Row; Edward Shorter (1992) From Paralysis to Fatigue: a History of Psychosomatic Illness in the Modern Era. New York: Free Press; and also A History of Psychiatry. op. cit.