Madness Explained

by Richard P. Bental

  71. R. Richards, D. Kinney, I. Lundy and M. Benet (1988) ‘Creativity in manic-depressives, cyclothymes, and their normal first-degree relatives’, Journal of Abnormal Psychology, 97: 281–8.

  72. Some studies have attempted to demonstrate similar styles of reasoning in psychotic patients and creative people. See, for example: N. J. C. Andreasen and P. S. Powers (1975) ‘Creativity and psychosis: an examination of conceptual style’, Archives of General Psychiatry, 32: 70–3; M. Dykes and A. McGhie (1976) ‘A comparative study of attentional strategies in schizophrenic and highly creative normal subjects’, British Journal of Psychiatry, 128: 50–56; J. A. Keefe and P. A. Magaro (1980) ‘Creativity and schizophrenia: an equivalence of cognitive processing’, Journal of Abnormal Psychology, 89: 390–98; H. J. Eysenck (1993) ‘Creativity and personality: suggestions for a theory’, Psychological Inquiry, 4: 147–78.

  Other studies have demonstrated, in psychiatrically healthy individuals, a positive correlation between scores on questionnaire measures of schizotypy and psychological measures of creative thinking. Examples of this kind of research can be found in: P. K. Chadwick (1997) Schizophrenia: A Positive Perspective. London: Routledge; D. Schuldberg (1990) ‘Schizotypal and hypomanic traits, creativity and psychological health’, Creativity Research Journal, 3: 218–30; T. O’Reilly, R. Dunbar and R. P. Bentall (2001) ‘Schizotypy and creativity: an evolutionary connection?’, Personality and Individual Differences, 31: 1067–78.

  73. Claridge, ‘Creativity and madness’, op. cit.

  74. S. Freud (1926/1959) ‘The question of lay analysis: conversations with an impartial person’, in Collected Works. London: Hogarth Press. See also B. Bettelheim (1983) Freud and Man’s Soul. London: Hogarth Press.

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

  76. R. D. Laing (1960) The Divided Self. London: Tavistock Press; R. D. Laing (1961) The Self and Others. London: Tavistock.

  77. R. D. Laing and A. Esterson (1964) Sanity, Madness and the Family: Families of Schizophrenics. London: Tavistock; R. D. Laing (1967) The Politics of Experience and the Bird of Paradise. London: Penguin Press.

  78. For an account of Laing’s life, see J. Clay (1996) R. D. Laing: A Divided Self. London: Hodder & Stoughton.

  79. T. S. Szasz (1960) ‘The myth of mental illness’, American Psychologist, 15: 564–80; T. S. Szasz (1979) Schizophrenia: The Sacred Symbol of Psychiatry. Oxford: Oxford University Press.

  Chapter 6 Them and Us

  1. ‘We and They’, from Rudyard Kipling: The Complete Verse, London: Kyle Cathie Ltd.

  2. S. Butler (1872/1970) Erewhon, Or Over the Range. London: Penguin. For a discussion of the social context of Butler’s utopian fiction, see A. L. Morton (1969) The English Utopia. London: Lawrence & Wishart.

  3. H. Fabrega (1993) ‘A cultural analysis of human behavioral breakdowns: an approach to the ontology and epistemology of psychiatric phenomena’, Culture, Medicine and Psychiatry, 17: 99–132.

  4. J. H. Orley (1970) Culture and Mental Illness. Kampala: Makerere Institute of Social Research.

  5. E. Kraepelin (1904/1974) ‘Comparative psychiatry’, in S. R. Hirsch and M. Shepherd (eds.), Themes and Variations in European Psychiatry. Bristol: Wright, pp. 3–6.

  6. Quoted in H. Fabrega (1989) ‘On the significance of the anthropological approach to schizophrenia’, Psychiatry, 52: 45–65.

  7. My account of the work of Carothers is drawn from Jock McCulloch’s fascinating book Colonial Psychiatry and ‘the African Mind’. Cambridge: Cambridge University Press, 1995.

  8. World Health Organization (1973) International Pilot Study of Schizophrenia. Geneva: WHO.

  9. World Health Organization (1979) Schizophrenia: An International Follow-up Study. New York: Wiley.

  10. A. Kleinman (1980) Patients and Healers in the Context of Culture. Berkeley: University of California Press.

  11. A. Jablensky, N. Sartorius, G. Ernberg, M. Anker, A. Korten, J. E. Cooper, R. Day and A. Bertelsen (1992) ‘Schizophrenia: manifestations, incidence and course in different cultures’, Psychological Medicine, Supplement 20: 1–97.

  12. To appreciate this point it is necessary to consider briefly the purpose of statistical testing in studies of this sort. Such tests are used to decide whether the differences observed between the sites could be caused by random variations in the data. For example, a very small difference (say, an annual incidence rate of 0.80 per 10,000 population at one site and a rate of 0.81 per 10,000 at another) would not be interesting, because it would probably be the result of chance processes (for example, random fluctuations in the number of people becoming ill in different periods and at different places). If statistical calculations show the probability that an observed difference is due to chance is less than 1 in 20 (probability = 0.05) the convention is to assume that the difference is a real one. However, this strategy creates a risk that a true difference will be rejected as statistically non-significant. Studies that have insufficient sample sizes to distinguish between large differences that are genuine and similar sized differences that are due to chance factors are said to be ‘underpowered’. This is most likely to happen when, as in the DOSMD, many different sites are compared, as the number of participants required per site to achieve adequate power increases as the number of sites increases.

  13. A. Kleinman (1987) ‘Anthropology and psychiatry: the role of culture in cross-cultural research on illness’, British Journal of Psychiatry, 151: 447–54.

  14. See E. F. Torrey (1987) ‘Prevalence studies in schizophrenia’, British Journal of Psychiatry, 150: 598–608; and also J. Thakker and T. Ward (1998) ‘Culture and classification: the cross-cultural application of the DSM-IV’, Clinical Psychology Review, 18: 501–29.

  15. J. S. Allen (1997) ‘At issue: are traditional societies schizophrenogenic?’ Schizophrenia Bulletin, 23: 357–64.

  16. L. Hemsi (1971) ‘Psychiatric morbidity in West Indian immigrants’, Social Psychiatry, 2: 95–100; I. Carpenter and I. Brockington (1980) ‘A study of mental illness in Asians, West Indians and Africans living in Manchester’, British Journal of Psychiatry, 137: 201–5.

  17. G. Kirov and R. M. Murray (1999) ‘Ethnic differences in the presentation of bipolar affective disorder’, European Psychiatry, 14: 199–204; J. van Os, N. Takei, D. J. Castle and S. Wessely (1996) ‘The incidence of mania: time trends in relation to gender and ethnicity’, Social Psychiatry and Psychiatric Epidemiology, 31: 129–36.

  18. R. Littlewood and M. Lipsedge (1989) Aliens and Alienists: Ethnic Minorities and Psychiatry (2nd edn). London: Unwin Hyman.

  19. F. W. Hickling, K. McKenzie, R. Mullen and R. Murray (1999) ‘A Jamaican psychiatrist evaluates diagnoses at a London psychiatric hospital’, British Journal of Psychiatry, 175: 283–5.

  20. D. Pilgrim and A. Rogers (1993) A Sociology of Mental Health and Illness. Buckingham: Open University Press.

  21. G. Harrison, D. Owens, A. Holton, D. Neilson and D. Boot (1988) ‘A prospective study of severe mental disorder in Afro-Caribbean patients’, Psychological Medicine, 18: 643–57.

  22. D. Bhugra, J. Leff, R. Mallett, G. Der, B. Corridan and S. Rudge (1997) ‘Incidence and outcome of schizophrenia in Whites, African-Caribbeans and Asians in London’, Psychological Medicine, 27: 791–8.

  23. D. Bhugra, M. Hilwig, B. Hossein, H. Marceau, J. Neehall, J. P. Leff, R. Mallett and G. Der (1996) ‘First contact incidence rates of schizophrenia in Trinidad and one-year follow-up’, British Journal of Psychiatry, 169: 587–92.

  24. D. Bhugra, J. Leff, R. Mallett and G. E. Mahy (1999) ‘First-contact incidence rate of schizophrenia on Barbados’, British Journal of Psychiatry, 175: 28–33.

  25. Harrison et al., ‘A prospective study’, op. cit.; G. Hutchinson, N. Takei, T. A. Fahy, D. Bhugra, C. Gilvarry, O. Moran, R. Mallett, P. Sham, J. Leff and R. M. Murray (1996) ‘Morbid risk of schizophrenia in first-degree relatives of white and Afro-Caribbean patients with psychosis’, British Journal of Psychiatry, 171: 776–80; P. A
. Sugarman and D. Crawford (1994) ‘Schizophrenia in the Afro-Caribbean community’, British Journal of Psychiatry, 164: 474–80.

  26. World Health Organization, Schizophrenia: An International Follow-up Study, op. cit.

  27. K. M. Lin and A. M. Kleinman (1988) ‘Psychopathology and clinical course of schizophrenia’, Schizophrenia Bulletin, 14: 555–67.

  28. E. Susser and J. Wanderling (1994) ‘Epidemiology of nonaffective acute remitting psychosis vs schizophrenia: sex and sociocultural setting’, Archives of General Psychiatry, 51: 294–301.

  29. R. B. Edgerton and A. Cohen (1994) ‘Culture and schizophrenia: the DOSMD challenge’, British Journal of Psychiatry, 164: 222–31.

  30. Fabrega, ‘On the significance of the anthropological approach’, op. cit.

  31. I. Al-Issa (1978) ‘Sociocultural factors in hallucinations’, International Journal of Social Psychiatry, 24: 167–76; I. Al-Issa (1995) ‘The illusion of reality or the reality of an illusion?: hallucinations and culture’, British Journal of Psychiatry, 166: 368–73.

  32. D. M. Ndetei and A. Vadher (1984) ‘Frequency and clinical significance of delusions across cultures’, Acta Psychiatrica Scandinavica, 70: 73–6.

  33. J. Mitchell and A. D. Vierkant (1989) ‘Delusions and hallucinations as a reflection of the subcultural milieu among psychotic patients of the 1930s and 1980s’, Journal of Psychology, 123: 269–74.

  34. For discussions of culture-bound syndromes, see C. Helman (1994) Culture, Health and Illness. London: Butterworth & Heinemann; and M. MacLachlan (1997) Culture and Health. London: Wiley.

  35. For example, see A. Kiev (1972) Transcultural Psychiatry. Harmondsworth: Penguin.

  36. R. Littlewood (1986) ‘Russian dolls and Chinese boxes: an anthropological approach to the implicit models of comparative psychiatry’, in J. L. Cox (ed.), Transcultural Psychiatry. Beckenham: Croom-Helm.

  37. D. Sperber (1982) On Anthropological Knowledge: Three Essays. Cambridge: Cambridge University Press.

  38. Littlewood, ‘Russian dolls and Chinese boxes’, op. cit.

  39. Sperber, On Anthropological Knowledge, op. cit.

  40. L. A. Sass (1994) The Paradoxes of Delusion: Wittgenstein, Schreber and the Schizophrenic Mind. Ithaca, NY: Cornell University Press.

  41. American Psychiatric Association (1994) Diagnostic and Statistical Manual for Mental Disorders, 4th edn. Washington, DC: APA.

  42. Littlewood and Lipsedge, Aliens and Alienists, op. cit.

  43. E. Bourguignon (1970) ‘Hallucinations and trance: an anthropologist’s perspective’, in W. Keup (ed.), Origins and Mechanisms of Hallucinations. New York: Plenum.

  44. Al-Issa, ‘The illusion of reality’, op. cit.

  45. W. S. McDonald and C. W. Oden (1977) ‘Aumakua: behavior direction visions in Hawaiians’, Journal of Abnormal Psychology, 86: 189–94.

  46. Helman, Culture, Health and Illness, op. cit.

  47. R. B. Edgerton (1971) ‘A traditional African psychiatrist’, Southwestern Journal of Anthropology, 27: 259–78.

  48. A. Honig, M. A. J. Romme, B. J. Ensink, S. Escher, M. H. A. Pennings and M. W. De Vries (1998) ‘Auditory hallucinations: a comparison between patients and nonpatients’, Journal of Nervous and Mental Disease, 186: 646–51.

  49. S. Krippner and J. Achterberg (2000) ‘Anomalous healing experiences’, in E. Cardena, S. J. Lynn and S. Krippner (eds.), Varieties of Anomalous Experience: Examining the Scientific Evidence. Washington, DC: American Psychological Association, pp. 353–95.

  50. J. M. Murphy (1976) ‘Psychiatric labelling in cross-cultural perspective’, Science, 191: 1019–28.

  51. R. Noll (1983) ‘Shamanism and schizophrenia’, American Ethnologist, 10: 443–59.

  52. Fabrega, ‘A cultural analysis’, op. cit.

  53. K. Kutchins and S. A. Kirk (1997) Making us Crazy: DSM – the Psychiatric Bible and the Creation of Mental Disorders. New York: Free Press.

  54. K. Hyams, F. S. Wignall and R. Roswell (1996) ‘War syndromes and their evaluation: from the U. S. Civil War to the Persian Gulf War’, Annals of Internal Medicine, 125: 402. See also P. Bracken (1998) ‘Hidden agenda: deconstructing post traumatic stress disorder’, in P. J. Bracken and C. Petty (eds.), Rethinking the Trauma of War. London: Free Association Books.

  55. Kutchins and Kirk, Making us Crazy, op. cit.

  56. See M. Romme and S. Escher (eds.) (1993) Accepting Voices. London: MIND Publications.

  57. J. Jaynes (1979) The Origins of Consciousness in the Breakdown of the Bicameral Mind. London: Penguin.

  58. The main evidence that Jaynes cites to support this unlikely hypothesis is from the language of the Ancient Greeks as revealed in the Iliad. Apparently, the Ancient Greeks made no reference to mental states as we would think of them today. The late Professor Henry Blumenthal, a distinguished classicist at the University of Liverpool, confirmed to me that Jaynes’ observation is correct, but doubted his explanation for it. However, my colleague Ivan Leudar and his collaborator Phil Thomas (Voices of Reason, Voices of Insanity: Studies of Verbal Hallucinations. London: Routledge, 2000) have suggested that Jaynes may have misread the Iliad, and that indirect evidence that the Greeks knew of their own mental states can be inferred from the text.

  In this context, it is helpful to note that some modern languages represent mental states in ways which differ strikingly from English (see K. Wilkes, ‘——, yishi, duh, um, and consciousness’, in A. J. Marcel and E. Bisiach (eds.), Consciousness in Contemporary Society. Oxford: Oxford University Press, 1988).

  59. M. Romme and A. Escher (1989) ‘Hearing voices’, Schizophrenia Bulletin, 15: 209–16; M. Romme and A. Escher (1996) ‘Empowering people who hear voices’, in G. Haddock and P. D. Slade (eds.), Cognitive Behavioural Interventions with Psychotic Disorders. London: Routledge; Honig et al., ‘Auditory hallucinations’, op. cit.

  60. J. E. Mezzich, H. Fabrega and A. Kleinman (1992) ‘Cultural validity and DSM-IV’, Journal of Nervous and Mental Disease, 180: 4.

  61. S. R. Lopez and P. J. J. Guarnaccia (2000) ‘Cultural psychopathology’, Annual Review of Psychology, 51: 571–98.

  62. A. Kleinman (1978) ‘Concepts and a model for the comparison of medical systems as cultural systems’, Social Science and Medicine, 12: 85–93.

  63. Social constructionists (sometimes called postmodernists) argue that there is no such thing as a ‘reality’ beyond the descriptions made by the observer. Scientific knowledge is thereby seen as nothing more than a product of a particular cultural stance, and hence no more valid than witchcraft. For an example of this kind of approach to psychopathology, see I. Parker, E. Georgaca, D. Harper, T. McLaugh-lin and M. Stowell-Smith (1995) Deconstructing Psychopathology. London: Sage.

  A thoughtful philosophical critique of social constructionist approaches to psychology can be found in J. D. Greenwood’s book Realism, Identity and Emotion (London: Sage, 1994). Greenwood agrees with social constructionists that it is important to examine the way that cultural and historical forces have misshapen our scientific theories, but argues that we should use the insights gained to improve our scientific knowledge and develop better theories. The approach taken in this book is consistent with his critical realist approach.

  64. H. D. Ellis and K. W. de Pauw (1994) ‘The cognitive neuropsychiatric origins of the Capgras delusion’, in A. S. David and J. C. Cutting (eds.), The Neuropsychology of Schizophrenia. Hove: Erlbaum, pp. 317–35.

  65. G. L. Klerman (1978) ‘The evolution of a scientific nosology’, in J. C. Shershow (ed.), Schizophrenia: Science and Practice. Cambridge, MA: Harvard University Press.

  66. D. Bannister (1968) ‘The logical requirements of research into schizophrenia’, British Journal of Psychiatry, 114: 181–8.

  More recent papers and books advocating this approach include: C. G. Costello (1992) ‘Research on symptoms versus research on syndromes: arguments in favour of allocating more research time to the study of symptoms’, British Journal of Psychiatry, 160: 304–8; C. D. Frith (1992) T
he Cognitive Neuropsychology of Schizophrenia. Hillsdale, NJ: Lawrence Erlbaum; J. Persons (1986) ‘The advantages of studying psychological phenomena rather than psychiatric diagnoses’, American Psychologist, 41: 1252–60; P. D. Slade and R. Cooper (1979) ‘Some conceptual difficulties with the term “schizophrenia”: an alternative model’, British Journal of Social and Clinical Psychology, 18: 309–17.

  Earlier attempts by myself to outline the symptom-orientated strategy include: R. P. Bentall, H. F. Jackson and D. Pilgrim (1988) ‘Abandoning the concept of schizophrenia: some implications of validity arguments for psychological research into psychotic phenomena’, British Journal of Clinical Psychology, 27: 303–24.

  R. P. Bentall (1990) ‘The syndromes and symptoms of psychosis: or why you can’t play 20 questions with the concept of schizophrenia and hope to win’, in R. P. Bentall (ed.), Reconstructing Schizophrenia. London: Routledge.