The Madness Within Us: Schizophrenia as a Neuronal Process

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How do we make sense of abnormal mental states? How do we explain that a person can lose touch with reality and drift into psychosis? Some psychiatrists come across these questions when diagnosing and treating the person struggling with a psychotic disorder, arguably the most impairing mental illness we know.


The Madness Within Us: Schizophrenia as a Neuronal Process

by Robert Freedman, MD. Oxford University Press, New York, NY, 2010, 198 pages, $35.00 (hardcover).

How do we make sense of abnormal mental states? How do we explain that a person can lose touch with reality and drift into psychosis? Some psychiatrists come across these questions when diagnosing and treating the person struggling with a psychotic disorder, arguably the most impairing mental illness we know.

The prominent narrative of contemporary academic psychiatry tells us that we need to study the brain in order to understand the psychotic mind. One of the best storytellers is Robert Freedman, chairman of a psychiatry department and editor in chief of The American Journal of Psychiatry, who has championed the theory that schizophrenia is primarily an abnormality of attention and sensory gating.

He has a very good story to tell. Not only is he able to weave many scientific facts into his highly readable text, he also translates theory into the real-life stories of his patients, who have shared with him their experience of psychosis. Some additional sketches and diagrams might have helped, especially when explaining the details of synaptic organization and information processing in the hippocampus. Most impressive is that Freedman does not only tell the story, he has in large part written it. He has devoted much of his career to proving that sensory gating deficits are prominent in schizophrenia, that we can study them in patients as well as in animal models, and that we can develop treatment for such deficits to help patients with schizophrenia.

His story is one of scientific curiosity and determination to find scientific evidence. He does acknowledge that the foundation for his model was laid by others, especially Paul Meehl (with his concept of schizotaxia) and Peter Venables (who applied signal detection theory to the psychopathology of schizophrenia). He also brings in important contributions by Eugen Bleuler and Harry Stack Sullivan and, daringly, tries to restore Sigmund Freud’s contribution by pointing out that his psychosexual interpretation of the Schreber case was about paranoia, not schizophrenia.

The general reader will not appreciate that Freedman’s story is one of many in the competitive marketplace of neural models for schizophrenia. He states that he is telling his story, but it would have provided more balance (and ultimately better education) if he had acknowledged complementary or, even better, competing models. For example, he largely ignores the explanation of negative/deficit symptoms in schizophrenia. It is the prerogative of the author to construct reality and hold the reader’s attention for as long as possible—in large part, he succeeds.

However, Freedman does not convince me with the title of his book. At the start and end of his story, he asserts (with the help of George Berkeley, the largely forgotten philosopher of English idealism) that the human mind will never know the boundaries between delusional and normal reality. In essence, we are all capable of delusion. He goes so far as to claim that the absolute conviction of the delusional elicits envy in the nonpsychotic. This is a laudable attempt to decrease the stigma of schizophrenia, but it ignores philosophical progress after Berkeley and it limits schizophrenia to reality distortion. Fear, bias, and stigma in the mind of the nonpsychotic can be overcome only by active engagement with the person struggling with psychosis. Ultimately, we hope to understand and explain the reality of schizophrenia.

Stephan Heckers, MD

stephan.heckers@vanderbilt.edu

Author affiliation: Vanderbilt University School of Medicine, Nashville, Tennessee. Potential conflicts of interest: None reported.

J Clin Psychiatry 2011;72(7):1020

Volume: 72

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