Madness explained: why we must reject the Kraepelinian paradigm and replace it with a ‘complaint-orientated’approach to understanding mental illness.

Abstract

This article is a synopsis of the argument outlined in my book Madness explained: Psychosis and human nature, in which I describe a new paradigm (which might be called a 'complaint-orientated' approach) for understanding the psychotic disorders, the most disabling forms of psychiatric illness. Despite extensive efforts to study the genetics, pathophysiology and neuropsychology of the psychoses, replicable findings have been rare. I argue that this is because the phenomena concerned have been poorly defined. Since the end of the 19th century, research into the psychoses has been dominated by the system of classification first proposed by the German psychiatrist Emil Kraepelin, which assumes that the severe mental illnesses fall into discrete types such as 'schizophrenia' and 'manic depression', and that there is a clear dividing line between madness and normal functioning. However, Kraepelinian diagnoses fail all empirical tests of their validity. For example, they do not identify patients with common symptoms, with common aetiologies, who respond to specific treatments. I suggest that we therefore need to abandon psychiatric diagnoses altogether and must instead attempt to explain the specific complaints ('symptoms') that patients bring to our attention. These include hallucinations, delusional beliefs, thought and communication disorders, which are much more widely experienced than was previously thought (for example, about 10% of the population have experienced hallucinations). I show that recent psychological research has revealed much about the mechanisms underlying each of these complaints. For example, auditory hallucinations occur when the individual mistakes inner speech for an external stimulus, and delusions appear to be the product of abnormal inferential processes. The new approach has implications for aetiology. For example, researchers working within the Kraepelinian paradigm have often assumed that the psychoses are endogenous. However, there is compelling evidence that the risk of experiencing psychotic complaints is influenced by adverse environmental factors such as insecure attachment relations and exposure to sexual and other kinds of trauma. These associations are relatively easy to understand once the psychological mechanisms leading to specific complaints are known. When all of the psychotic complaints have been explained, there will be no 'schizophrenia' or 'manic depression' left behind awaiting explanation. The approach that I advocate is not only more scientific than the Kraepelinian approach, but also more humane. In contrast to the Kraepelinian approach, which has encouraged disrespect for patients' experiences, it encourages us to treat patients as rational agents and to take what they say seriously.