MAD Theory and Conservative Psychotherapy (Detailed Exposition) 2026-3-8
Date: 2026.03.08
Title: A Proposal for Conservative Psychotherapy Based on the M-Unit Injury/Regeneration Model: An Integrated Perspective of MAD Theory and Sickness Behavior
Author: Tadashi Kon :Shinagawa Psychosomatic Clinic
Keywords: MAD Theory, M-unit (Manie cell), Sickness Behavior (SB), Primacy of Mania, Conservative Psychotherapy, Self-elimination program
- Introduction: Re-evaluating “Intervention” in Modern Psychiatry
- Chapter 1: Redefining Pathology via MAD Theory
- Chapter 2: Diurnal Variation and the “Toxicity of Sleep”
- Chapter 3: Theoretical Basis of Conservative Psychotherapy
- Chapter 4: Ethical Intervention in the “Self-Elimination Program” (Suicide)
- Chapter 5: Application to the Bipolar Spectrum and Reset Therapies
- Conclusion: Redefining the Role of the Psychiatrist
Introduction: Re-evaluating “Intervention” in Modern Psychiatry
In modern psychiatric clinical practice, “active intervention” aimed at early social reintegration and cognitive modification has become the mainstream. However, in clinical settings, we frequently encounter cases where such interventions conversely prolong the morbid state and fuel the patient’s agitation. We must move beyond viewing the essence of psychiatric disorders through the subjective index of “mood” and instead redefine them through the dynamics of functional units within the brain.
In this paper, I present the “MAD Theory (M, A, D Unit Model)” as a framework to comprehensively describe the entire spectrum of psychiatric disorders. Based on this, I will provide the theoretical and ethical foundations for “Conservative Psychotherapy.”
Chapter 1: Redefining Pathology via MAD Theory
1.1 The Three Functional Units and the Primacy of Mania
Mental activity is established through the equilibrium of three systems: the M-unit (Manie cell), the A-unit (Anankastic cell), and the D-unit (Depressive cell).
This theory adheres to the “Primacy of Mania,” positing that every “depressive state” is preceded by some form of overactivity (an “Event”) of the M-unit. Whether it be a viral infection, psychological conflict, or endogenous elation—the M-unit (responsible for manic drive, optimism, and activity) operates at full capacity during such “Events.” The starting point of the disorder is the “Injury” sustained by the M-unit itself, resulting from this functional and physical overload.
1.2 The Dual Function of the M-Unit: Activity and Sleep
The M-unit does not only drive activity; it also supplies the “sleep-inducing component” required for brain repair. When the M-unit is injured or enters a “frozen” state, the drive for activity ceases, and simultaneously, the power to put the brain to sleep is lost. At this point, the D-unit (depression, defense, sickness behavior), having lost its inhibition, is laid bare. This is the true nature of clinical depression.
(Note: The distinction between insomnia in mania and insomnia in depression becomes clear here. The M-unit contains two functions: 1. Generating vitality and 2. Inducing nighttime sleep. The “sleep-inducing” component is maintained as long as the M-unit exists. However, if the “vitality-generating” component becomes too strong, it overrides the sleep component, leading to heat-of-the-moment absorption without sleep; this is manic insomnia. Conversely, once the M-unit has ceased to function, the sleep-inducing component also vanishes, resulting in depressive insomnia.)
1.3 Timeframe: The Regeneration Process
The regeneration of a damaged M-unit requires biological time, much like the healing of a skin wound. Clinical observation suggests that this regeneration period typically requires 2 to 4 months. During this time, the dominance of the D-unit serves as a “biological scab” (Sickness Behavior), an adaptive response to protect the injured M-unit. This can be understood through the framework of Sickness Behavior (SB).
Chapter 2: Diurnal Variation and the “Toxicity of Sleep”
The “morning dread” (the worst feeling upon awakening) in depression can be explained by the dynamics of the M-unit during sleep.
- Nighttime Damage (Autophagy/Self-destruction): Normally, sleep is a process that organizes and disposes of unnecessary M-units. However, during a depressive phase where the M-unit is already injured, this process acts as “further destruction” toward the M-unit. Consequently, the depletion of M-units progresses during the night.
- Morning Dread: As the M-unit is minimized overnight, the D-unit (pessimism/self-reproach) is relatively most exposed upon awakening.
- Daytime Recovery: Daytime external stimuli—such as sunlight, conversation, and social interaction—act as a catalyst to gradually regenerate the M-unit. Mood lightens in the evening because the day’s stimuli allow the M-unit to recover slightly, resulting in the suppression of the D-unit.
Chapter 3: Theoretical Basis of Conservative Psychotherapy
Based on the MAD theory above, I propose “Conservative Psychotherapy.” Its foundation lies in the ethical and biological imperative to “not interfere” with the regeneration of the M-unit.
3.1 The Active Choice of “Waiting”
The depressive phase is the “infrastructure construction period” for the M-unit’s regeneration. It is a period of cellular repair and network reconstruction. Attempting forced cognitive modification or encouragement during this stage is equivalent to rubbing skin that has not yet formed, thereby enlarging the wound. Conservative Psychotherapy is not mere abandonment; it is a highly active medical intervention of “enduring and protecting the 2 to 4-month biological timeframe required for the M-unit to regenerate, alongside the patient.”
3.2 Threshold Management of External Stimuli
Daytime external stimuli (light, conversation, activity) serve as “fertilizer” for the M-unit. However, if the intensity is excessive, there is a risk of “re-burning” (triggering manic switching or worsening) the M-unit mid-regeneration. The role of the psychiatrist is to act as a “tuner of the environment,” appropriately managing the threshold of these stimuli, preventing manic switches, and controlling mixed states.
3.3 Management of the A-Unit (Anankastic Maintenance)
The A-unit governs the homeostasis/constancy of the system. In the depressive phase, since the M-unit has vanished, the A-unit becomes relatively conspicuous. This can result in compulsive behaviors or obsessive thoughts. Conservative Psychotherapy aims to calm the “idling” of the A-unit and provide assurance that “it is currently the period to rest safely, following the guidance of the D-unit (the biological scab/Sickness Behavior).”
Chapter 4: Ethical Intervention in the “Self-Elimination Program” (Suicide)
In MAD Theory, suicidal ideation is positioned as a “bug in the social survival strategy” brought about by the D-unit.
- Social Animal Cost Calculation: Recuperation (SB) entails a cost in consuming the resources of others. In a brain where the M-unit (the optimism/suicide-stop signal) has vanished, the D-unit activates a ruthless, evolutionary “self-elimination program” based on the logic that “my departure will increase the survival probability of the group.”
- The Doctor’s Duty: This program is a “temporary bug” that will vanish once the M-unit recovers. Therefore, the psychiatrist bears the absolute duty to “physically and ethically stop the runaway of the D-unit until the M-unit regenerates.” This is the ethical pillar of Conservative Psychotherapy.
- Generally, suicide does not occur during the deepest peak of depression, but rather when the depression has lightened to some extent and the capacity for action has returned. From my standpoint, this is because a “manic-depressive mixed state” is temporarily established during the M-unit regeneration process. At that moment, the D-unit provides suicidal ideation while the M-unit provides the motivation for concrete action. When these two align, a suicide attempt occurs. It is vital for the therapist to navigate this period together with the patient.
Chapter 5: Application to the Bipolar Spectrum and Reset Therapies
Since MAD Theory is based on the Primacy of Mania, it can explain the entire spectrum.
- Bipolar Disorder: The pathogenesis can be understood through the lens of pre-morbid personality and the onset mechanism.
- The Position of ECT/Ketamine: These serve as “Reset Therapies” that forcibly interrupt the M-unit destruction loop during sleep and physically re-ignite (re-start) the frozen M-unit. However, in many cases, even if the M-unit recovers rapidly and temporarily, the environment and interpersonal relationships remain unchanged, and the patient’s personality tendencies do not change. Therefore, the risk of recurrence is high. As Conservative Psychotherapy, we adopt a conservative stance. While some patients desperately wish to “just get through this moment,” it is often the repetition of such “quick fixes” that has led to the current state.
Conclusion: Redefining the Role of the Psychiatrist
MAD Theory and Conservative Psychotherapy transform the role of the psychiatrist from a “mentor who corrects distorted cognitions” to a “Gardener who watches over and protects the regeneration process of life.”
The 2 to 4-month period of depression is a sacred sanctuary necessary for a human being to regain the “power to sleep (M)” and the “power to be optimistic (M).” We must respect this period, protect the individual from the runaway of the M and D units (suicide) in a mixed state, and wait for the natural regeneration of the M-unit while using daytime external stimuli as fertilizer. I am convinced that this is the most compassionate and scientific form of psychiatric medicine, backed by biological and evolutionary foundations.
(Author: Shinagawa Psychosomatic Internal Medicine – Private Notes – Tadashi Kon 2026-3-8)
