A new logic to treating insanity

Justin Thomas

• Last Updated: December 09. 2008 9:30AM UAE / December 9. 2008 5:30AM GMT

For thousands of years people have struggled to understand the bizarre, frightening and sometimes tragic human experience that we call madness. Archaeologists have uncovered ancient human remains with large holes intentionally drilled into their skulls, a procedure now known as trepanning. One explanation for this antiquated phenomenon is that it served as an early form of psychosurgery, that is, the hole was drilled to release insanity-inducing spirits.

Human ideas about madness have varied widely across time and place, and theories of insanity have implicated the effects of the moon (lunacy), demonic possession and neurochemical imbalances, to cite just a few. But the dominant view of mental illness in the world today is rooted in the biomedical sciences. Madness is viewed ultimately as a consequence of biological malfunction, specifically, structural brain abnormalities. Madness – or more specifically, hearing voices, holding bizarre beliefs, exhibiting strange behaviours and being out of touch with reality – is technically referred to as psychosis, and is typically differentiated from milder forms of emotional and behavioural disturbance.

Despite the dominance of the biomedical approach and more than a century of research, little progress has been made in understanding the causes of psychotic illnesses such as schizophrenia and bipolar disorder. Many leading psychologists and psychiatrists believe that one of the key reasons for our lack of progress is the assumption that psychotic illness can be meaningfully divided into easily identifiable categories.

Our current systems of categorising types of madness can be traced back to Emil Kraepelin, a German psychiatrist, from the latter part of the 19th century. As Dr Kraepelin collected hundreds of case studies he concluded that symptom groups followed characteristically different courses. Kraepelin’s nosology (categorical system) was enticingly simple; there was manic-depressive insanity, dementia praecox (later known as schizophrenia) and there was paranoia. Although fiercely contested at the time, Dr Kraepelin’s system came to dominate psychiatric study. Some argue this was just on account of its simplicity rather than its accuracy or utility.

The clinical reality, however, is that there is significant overlap between these proposed categories of illness, in their clinical features, symptoms and response to treatment. Furthermore, the fuzziness of these proposed illness categories is manifested in their continual expansion and splintering in the major diagnostic guidebooks. Kraepelin’s manic-depressive insanity, for example, was eventually split into unipolar and bipolar depression. Unipolar depression became major and minor depressive disorders, while bipolar disorder became bipolar 1 and bipolar 2 disorder, and so on. The American Psychological Association’s Diagnostic and Statistical has gone from listing about 60 disorders in the 1950s to detailing more than 400 in its latest edition.

Systematic research has done much to shake faith in the notion of discrete categories of psychotic illness. One study found that two fifths of psychiatric diagnoses were changed over the study’s two year duration; that is, people initially diagnosed as suffering from, let’s say, schizophrenia or depression had their diagnosis changed to bipolar disorder or schizoaffective disorder or vice versa. Furthermore, studies have also found that 64 per cent of psychiatrists were in disagreement about specific diagnosis of the same patient.

Beyond clinical practice, the idea of a flawed system of classification also has damning implications for research. Consider for example attempting to investigate the causes of “schizophrenia”. How can we draw firm conclusions if we don’t have certainty in the accuracy and stability of the diagnosis assigned to the individuals recruited into the study? Such implications were alluded to as early as 1939 by a colleague of Dr Kraepelin, Robert Gaupp, who suggested that “the greater part of all genetic work in psychiatry would immediately collapse like a house of cards if Kraepelin’s theory was shown to be altogether mistaken”.

After more than a century of research there is still no firm evidence to support the Kraepelinian categorisation of psychotic illness. There is an increasing acceptance that the foundation of our current system for understanding psychotic illness is fatally flawed, and of the dire need for a radical rethink. One of those at the forefront of rethinking insanity is the British psychologist Richard Bentall, who advocates what has been termed the symptom-centric approach to mental-illness. Rather than hypothetical disease concepts, such as schizophrenia and depression, Dr Bentall argues it is more useful to focus on the specific symptoms common to psychotic experience, such as, hallucinations, delusions and dysphoria. In addition to collapsing the boundaries between the supposed illness categories, Dr Bentall also advocates viewing psychotic symptoms on a continuum within normal psychological functioning. In this way certain psychotic symptoms become explicable in terms of our everyday thinking errors and biases.

In a fascinating study, Dr Bentall and colleagues fixed a computer game so that players either won or lost; winning and losing was in reality always out of the player’s control. When “normal” individuals played the game and won, they were quick to believe it was their good skill (delusional), whereas dysphoric-depressed individuals who won were more likely to spot the ruse and correctly identify the artificiality of their victory. Such demonstrations illustrate the everyday psychological processes underlying psychotic symptoms, and in this case the self-congratulatory bias of the “normals” gives us an insight into the possible mechanics of grandiose delusions.

Rather than assume that hearing voices is primarily a consequence of aberrant biology, the symptom-centric approach explores why people hear voices and tries to tie this to the fairly well explored psychological processes of everyday life. This explanation of psychotic illness includes all levels of analysis – biological, psychological and social – without precedence being given to any specific level of explanation. Furthermore, this view acknowledges the long and often complex developmental pathway to psychosis.

One early benefit of the symptom-centric approach is its focus on preventive interventions. The emphasis on understanding the developmental pathways and the various psycho-social and biological risk factors for psychotic symptoms can help us to better identify individuals who will potentially benefit from early or even preventive interventions. A recent Australian study used such methods to identify ultra high-risk individuals; people who the research team predicted were likely to experience psychotic illness in the near future. Impressively 40 per cent of those categorised as “at risk” actually went on to experience a full-blown psychotic episode within six months of being identified.

Early identification of psychosis is valuable in that there is a wealth of evidence supporting the benefits of early clinical intervention; generally, the longer psychosis goes untreated, the worse the outcome. In fact many healthcare systems now insist on the development of early intervention services on the basis of both clinical and cost effectiveness. Psychosis prevention research is still in its infancy but the symptom-centric approach has much to offer in terms of increasing our understating of psychosis, contributing to the technology of early detection and the development of effective treatment and preventive intervention.

Dr Justin Thomas is a psychologist with the Department of Natural Science and Public Health at Zayed University in Abu Dhabi