A polluted puddle of poetry and psychosis

Both of these books explore the relationship between madness and creativity. In particular, the creative edge to madness is celebrated. This type of exploration is a counterbalance to a traditional social administrative approach to the management of the "burden" of mental illness. When the latter is seen only in terms of costs to society, its productive potential is obscured and we are limited to a paternalistic discourse of "mental health care" for a group, typically excluded from the labour market and full citizenship.

This point about mental disorder as virtue rather than deficit, could also be made about the heightened sensitivity of anxious people, the predictive accuracy of depressive reasoning and even the attractive brazen confidence of many politicians and the sparkle of light entertainers, some of whom we might otherwise call "psychopathic".

The more we can explore the ambiguity of mental abnormality, the better, and both authors are doing their bit. However, given the amount of heat frequently generated in debates about mental health, any contribution from protagonists has to face questions about the cogency of their concepts, how comprehensive they are in offering competing empirical claims and their capacity to reflect on their disciplinary self-interest. When these questions are applied to the contributions from David Horrobin and Daniel Nettle, vulnerabilities soon emerge.

A common cause of the authors is to marshal evidence, albeit selectively, about the temperamental nature of madness - its purported presence in, and contingent emergence from, a flawed gene pool that enables poetry and psychosis to be alternative life course outcomes in affected individuals. Horrobin goes further and claims (like the 19th-century eugenicists) that this gene pool not only underlies madness and some types of learning disability but also criminal and "sociopathic" outcomes.

Both authors are committed to this "tainted" gene hypothesis but Nettle is more aware and reflective about the political track record of a tradition that they seem to commend. For Nettle, Hitler's policy of the elimination of "life devoid of meaning" (including psychiatric patients), enthusiastically prompted and then supported by the German Medical Association, was an unfortunate aberration. Nettle laments the stultifying environmentalism this eugenic excess created in subsequent years. He mentions one pioneering psychiatric geneticist, Ernst Rudin, but not his protege Franz Kallmann. Their combined work was incorporated into, and thus made respectable by, postwar psychiatric genetic research. This continuity between current mainstream genetic determinism and a murky past is left unexplored.

Thus, madness may or may not emerge from a "tainted gene pool" but psychiatric genetics remains tainted by its roots in Nazi Germany. Nettle knows this bit of the social history of psychiatry, but it is not clear whether Horrobin has the same awareness. Although the latter does make it clear that, on pragmatic grounds, single gene carriers are irrelevant as, for him, deviance is a function of polygenetic influence, so that old eugenic solutions make bad social policy.

Because of the biodeterministic bias of both authors, their capacity to reflect on their selective evidence base in a critical way and to place madness in a social context is limited. For example, Horrobin's focus on "great" families having high rates of schizophrenia does not engage with the complex and unresolved debate within psychiatric epidemiology about social selection or social causation explaining the class gradient in mental health.

He alludes to psychotic patients being "forced onto the streets" and out of the old asylums. In fact, what research we have on this topic suggests that substance abuse (not psychosis per se) predicts homelessness. Also there is clear international evidence that the residents of the old asylums were fairly well resettled. It is a sub-group of new younger patients, who were never in the old large hospitals and who abuse substances, who are at heightened risk of street living.

This lack of sensitivity to the complexities of the social psychiatric literature finds Horrobin at times falling into a loose, tabloid style of reasoning. In his favour, he does make his theoretical assumptions explicit when rejecting psycho-dynamic and sociological accounts of madness. His declared and favoured holism is based on the individual body and he quite openly excludes the social from his model. Horrobin cannot be accused of not making his biological version of holism transparent. But such reductionism is bound to provoke critics from a social perspective.

Both authors may have paid the price of a desire to be accessible to a general audience. Waived are the standard academic conventions about citing evidence extensively in the texts. Horrobin offers a lengthy bibliography prefaced with the statement that it "provides references for most of the factual statements in this book". However, which "factual statements" have been warranted about madness and which have been silenced has varied over time and across professional groups.

Nettle is more reflective about madness being a site of academic contestation, but he then also appeals to the reader to accept his particular blend of truth claims on trust. For example, he advocates the position that psychoticism is a genetically determined personality trait, with psychosis being one possible outcome. This is a fair enough hypothesis but not all psychologists favour the line of reasoning. Moreover, Nettle is prone by his disciplinary background (psychology) to frame madness as a variant of personality. The notion of continuously distributed personality traits dates back to the work of Galton - a seminal figure in differential psychology and eugenics. Such a tradition has its detractors as well as advocates and so it is misleading to suggest that the study of personality is a solid science.

In contrast to Nettle, Horrobin, as a medical practitioner, spends many pages providing an explanation for the reader about fat metabolism in primates. This he links to a dietary hypothesis about "schizophrenia" being a function of an abnormality in fat biochemistry, which, he claims, affects neural functioning in "schizophrenics". He extends this to a claim that "schizophrenics" do not experience physical pain as much as those without the "disease" do. He even claims that "schizophrenics" have a lower incidence of arthritis (and that arthritics have a lower incidence of "schizophrenia"). This for Horrobin is confirmatory of "the schizophrenic's" deficit in neural functioning. It might, of course, be explained by differences in reporting styles of patients and non-patients. For example, those who are psychotic may feel disconnected from their body, which could be a psychological rather than neurological phenomenon.

Thus Horrobin's model is built up within a rhetorical frame of biomedical science. A selected article is offered in support from The New England Journal of Medicine , which we are told is "one of the most prestigious of medical journals". Horrobin opts to use this appeal to prestige in the context of a semi-academic text in much the same way that journalists at times bolster their "top scientists have just discovered" stories, which then turn out to be more complicated than the exciting first depiction. Horrobin does not rehearse in detail the competing biochemical theories about the cause of "schizophrenia", which have come and gone with the years, or concede the embarrassment of 150 years of highly funded biological psychiatric research that has still not delivered on its Victorian hopes and promises.

Both authors talk of "schizophrenia" (and more offensively "schizophrenics") as if the diagnosis has an unambiguous validity. Several critics have noted that this assumption is empirically unsupportable. The concept of "schizophrenia" is little more than a medical codification - a reification that adds little to the lay notion of madness. In his favour Nettle uses the term "madness" in his subtitle, but Horrobin pointedly offers us "schizophrenia". In the contested arena of mental health, pre-empirical conceptual analysis is as important as empirical findings. Neither author does justice to this conceptual work.

Both books make a useful contribution to a needed debate about the relationship between madness and creativity. However, intelligent lay readers should be aware that the authors are partisan and highly selective in their presentation. Summary texts, about complex topics aimed at non-academic audiences, are necessarily selective. But when this necessity is applied in a controversial area of study such as mental health, it is risky for authors to leap in with strong and unqualified claims. When the latter are not tempered by the rehearsal of counter-argument, conflicting empirical findings or reflexive efforts to place the author's own position in a disciplinary context, then the criticisms rehearsed in this review will predictably follow.

David Pilgrim is professor of mental health, University of Liverpool.