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

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Summary

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.

Introduction

During the 20th century, attempts to explain madness were guided by a set of assumptions first made by early German psychiatrists, particularly Emil Kraepelin [1], who introduced a number of diagnostic concepts that are still widely used today. This framework of ideas is a ‘paradigm’ in the exact sense of the term articulated by the philosopher Thomas Kuhn [2]; it has constituted a theoretical framework that until recently has gone largely unquestioned, and which has guided research and the construction of theoretical models of psychopathology. However, it is now being challenged by a new paradigm, which is sometimes called a ‘symptom-orientated’ approach, but which might be better described as a ‘complaint-orientated’ approach.

Consistent with Kuhn’s analysis of the structure of scientific progress, the core assumptions of the Kraepelinian paradigm have often been embraced unconsciously, so that it has been extremely difficult for researchers and clinicians to ‘think outside the box’ formed by them. Occasionally, however, scientific investigators have embraced these assumptions self-consciously, as when Gerald Klerman [3] (one of the informal school of American psychiatrists who designed the influential third edition of the American Psychiatric Association’s Diagnostic and Statistical Manual [4]) wrote a manifesto for ‘the neoKraepelinian movement’.

In retrospect, Klerman’s manifesto marked the high-water mark of the Kraepelinian approach. Over the 25 years since its publication, the limitations of the paradigm have become increasingly obvious, particularly to patients, their carers, and those mental health professionals who have not endured a medical education. Nonetheless, the paradigm continues to influence psychiatric practice and research for a number of reasons, some of which are more political than scientific (the vested interests of organized psychiatry and pharmaceutical companies). However, one important impediment to progress has been the lack of a valid alternative framework for understanding severe psychiatric disorders. The complaint-orientated approach is now beginning to provide this framework.

In this editorial, I will try and give a brief outline of this new understanding of psychosis. The argument I will present will be in three parts. First, I will show the assumptions made by Kraepelinian researchers have led to serious misunderstandings about the nature of madness and must therefore be abandoned. (They have also led to coercive, abusive and occasionally lethal practices towards patients, but this is a part of the story that I cannot review here for reasons of space. The interested reader is referred to Robert Whitaker’s book Mad in America: Bad science, bad medicine and the enduring mistreatment of the mentally ill [5]). Second, I will show that the complaints of psychotic patients (experiences and behaviours such as hallucinations and delusions, phenomena that psychiatrists refer to as ‘symptoms’) can be understood in terms of relatively well-understood psychological mechanisms that have been extensively studied in ordinary people. Third, I will show that the aetiology of the psychoses can be explained in the same way – by exploring how different biological and environmental forces influence the development of the psychological mechanisms that give rise to complaints.

The arguments I outline here are developed at much greater length in my book Madness explained: Psychosis and human nature [6]. Inevitably the account I will give here will focus, somewhat egocentrically, on my own research, but I want to emphasise that the new view of psychosis is the product of efforts by many investigators. At this stage I would also like to emphasise that, in contrast to previous attempts to critique conventional psychiatry (for example, the philosophical criticisms of Thomas Szasz [7], or the insightful clinically-based objections of Ronald Laing and his colleagues [8], [9]) the account I will give is heavily supported by research. Indeed, the main claim I make for the new approach is that it is much more scientific than the Kraepelinian paradigm that preceded it.

Section snippets

The Kraepelinian paradigm in modern psychiatry

When Gerald Klerman [3] attempted to articulate the fundamental elements of the Kraepelinian paradigm, he listed 10 propositions that he believed marked out the main assumptions of the approach. A few were uncontentious (for example, proposition 2 that, “psychiatry should use modern scientific methodologies and base its practice on scientific knowledge”) but the two that were particularly questionable from the perspective of the present argument were that: 4, “there is a boundary between the

Post-Kraepelinian psychopathology

Psychiatrists and psychologists have responded to these criticisms of the Kraepelinian paradigm in a number of ways. Some have simply stuck their head in the sand, insisting that, “Surely we should improve our system of diagnosis and classification by enhancing the quality of research” [34]. However, given the enormous sums and efforts already committed to designing categorical diagnostic systems, without any tangible benefits to researchers, clinicians or their patients, further research of

From cognitive formulation to aetiology

A common response to the complaint-orientated (sometimes called symptom-orientated) approach to psychopathology is that it fills in some missing details about the nature of severe mental illness, but does not address questions of aetiology [105]. After all, the cognitive models of individual complaints concern only the proximal causes – the final common pathways – that lead to experiences such as hallucinations, delusions and thought disorder.

I think that this perception of the new approach’s

Is the new paradigm useful?

It is sometimes objected that the complaint-orientated approach to psychopathology may be all very well for the purposes of research, but it has no utility for clinical purposes. The most obvious response to this objection is that any utility of Kraepelinian diagnoses is purely illusory. Indeed, it can be claimed that many of the abuses suffered by psychiatric patients at the hands of psychiatric services during the 20th century have been an unintended but direct consequence of the Kraepelinian

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