ABSTRACT
HMP Grendon, a smallish prison half an hour’s drive from Oxford, stands as the bold 1960s solution to the dilemma posed by Pinel with his formulation of psychopathy as “manie sans delire.”1 All psychiatric services have to grapple with Pinel’s riddle: how to conceptualize patients who have “insanity without delusions.” In more up-to-date language these are patients who are clearly psychiatrically disturbed but who do not have a mental state disorder, perhaps crazy but not mad. Diagnostic conceptualization as “personality disorder” or the dimensional Diagnostic and Statistical Manual of Mental Disorders (DSM) model are helpful but do not resolve the dilemma of patients in psychiatric hospitals who have to be admitted and who are difficult to discharge on the grounds of risk but who have no formal mental illness.
