Book Review: Madness Explained - Psychosis and Human Nature
Its name certainly isn’t misleading and gives a very impressive account of both psychosis and human nature. Bentall spends a significant portion of the book explaining, and then arguing against, what he calls the Kraepelin paradigm. The view that dominates current psychiatry, started by Kraepelin, the founder of modern scientific psychiatry in the early 20th century, and who popularized dementia praecox (what we now call schizophrenia). Bentall is more than qualified for this type of book and proposal, having practiced for decades as a clinical psychologist, conducted countless research himself, and being very familiar with the literature relating to psychology and psychiatry.
He argues this paradigm is obsessed with categorizing patients into countless diseases and always working on an assumption of genetic aberrant biology. He isn’t against biological mechanisms, however, he feels that its importance has been vastly overrated without sufficient evidence, and instead offers a joined-up psychopathology, combining anthropology, sociology, developmental and cognitive psychology, developmental biology, genetics, and the neurosciences.
He focuses the most on schizophrenia but also touches on bipolar disorder, general delusion, and depression. He discusses several possible mechanisms and hypotheses, in order to make an overall schema of a possible framework for madness. He discusses each pathway individually, going to an excruciating level of detail. While some of his mechanisms are hypothetical, this is unavoidable when trying to offer a new paradigm as he is, and nevertheless, it’s based on solid research, with nothing feeling a huge extrapolation.
Some of his proposed mechanisms include neurodevelopmental impairment, parent attachment, quality of parental communication, parental attributions, environmental stressors, cognitive vulnerabilities (self-representation, theory of mind deficits, dysfunctional mega-cognition, etc), prodromal characteristics and triggering events. Each one with countless variables and interacts with each other. It is indeed quite complex, but it would be suspicious if that wasn’t the case given what’s it is dealing with.
He argues for a symptom-oriented approach (post-Kraepelin). Rather than diagnosing a patient with schizophrenia or bipolar disorder, psychiatrists should diagnose their patients as having delusions, mania, paranoia, etc. The complaints are simply the result of the combination of the pathways mentioned above. Also, while not the classical anti-psychiatry critique, he also argues that many psychotic symptoms reflect the core existential dilemmas of ordinary people, their preoccupations about the position of the self in the social universe, and the line between madness and satiety is very blurry.
While the book is very accessible, requiring little to no knowledge in psychology and psychiatry, sometimes the book was quite tedious to read, especially in the second half. He dives quite deep into some clinical trials, which while perhaps useful for someone who want to know the topic as deeply as humanly possible (like a psychiatrist), for someone more layman it feels overkill. I felt like giving up on the book several times and ended up skipping some parts of a few chapters. If you’re looking for something easy to digest and simply an overview of madness, this is definitely not the book for it.
Overall, it’s definitely a brilliant book. Provides plenty of evidence that the current model of diagnosing and treating psychosis leaves a lot to be desired, and offers some valuable insights for the field. Even outside of psychiatry, I finished the book with a feeling of having a deeper understanding of human nature.