Posts Tagged ‘Mental Illness’
Posted on January 24, 2011 - by David
Of the various writings, videos, and recollections of teachers, classmates, and former friends with which we are left to piece together a picture of Jared Loughner’s mind before the shooting, the most intelligible is a poem titled ‘Meat Head’ that he wrote for one of his classes at Pima Community College last fall.
Awaking on the first day of school
Pain of a morning hang over
Attending a weight lifting class for college credit
Attempting to exercise since freshmen year of high school
Crawling out of bed and walking to the shower
Warm water hitting my back
Thoughts of being promiscuous with a female again
Putting on a old medium red tee shirt, light brown cameo shorts, and black Adidas
For breakfast a glass of water, cold pepperoni pizza, and two Advil
Bringing my Nano Ipod with heavy metal music
Taking the local bus on a overcast morning
Waiting with crack heads after their nightly binge
Bus is cheap, two dollars for a ride anywhere in the city
Sitting in back against a hard plastic seat
Staring at stop lights, brand new cars, and graffiti
Coming to a slow halt in front of the school
Entering the gym as the glowing florescent lights are humming
Next to the treadmills, putting a green foam mat on the ground
Stretching for fifteen minutes, loosening the muscles in my legs, back and arms
Cleaning the mat with anti-bacterial spray and a paper towel
Jogging for ten minutes, my heart beating, beating, beating
Pain in my right side of the last minute of twenty
Looking around, the cute women are catching my eye
Probably waiting for their hot boyfriends wandering in the locker room
All the men are in shape with their new white tank shirts, basketball short, and Nike shoes
Confusing look on my face of no idea what to do
Deciding to copy other men’s routines of
Arm Curls, Leg presses, Rows, Squats, Military something’s, and Isolated whatever’s
Leaving the gym thinking
Waiting for the bus with alcoholics that are going to the bars early
Coming home for another shower
While grabbing the white towel, the eureka moment is lingering
Quick nap and lunch is on my mind
Setting the alarm one hour before getting ready for my next class
Getting into bed
The title already suggests a problematic identity; (for any who might not know), ‘meathead’ is a derogatory term for jocks, muscular men, athletes, etc., but the poem focuses on Loughner’s own time in the gym, so he is criticizing himself? He has been “attempting to exercise since freshmen year of high school,” (this “attempting” implies a lack of success), and yet the title and tone suggest he sees himself as different from, and possibly somehow superior to, those working out around him. He has trouble looking the part, as his gym clothes are mismatched and worn out (“old medium red tee shirt, light brown cameo [probably meant camo] shorts, and black Adidas”) while the others “are in shape with their new white tank shirts, basketball short, and Nike shoes.” Not only does he feel like he looks out of place, he’s not sure how to act (“confusing look on my face of no idea what to do”), so he ends up “deciding to copy” what others do. It seems Loughner relates his lack of romantic or sexual involvement with the opposite sex to his inability to be like these other men, and while there is clearly an element of sexual tension in the poem, I don’t think it is as simple as Loughner being some kind of sex-crazed pervert. In fact, a MySpace posting from November 17th (“It hurts to have been never sexually active at 22!”) reveals that it is not so much a lack of sexual activity that is the problem, but his consciousness that in this society, a 22-year old virgin would probably be deemed abnormal. The people Loughner connects himself to most closely are the “crack heads” and “alcoholics” with whom he waits for the bus, and even this mention of public transportation seems another to reflect upon his inadequacy – he notes the contrast as he views “brand new cars, and graffiti” from his “hard plastic seat” on the “cheap” bus.
When read, ‘Meat Head’ is more depressing than disturbing, especially if one forgets for a moment who wrote it. But apparently the style of his presentation in class didn’t quite match the overall flatness of the poem. According to Don Coorough, a classmate who provided copies of two of his poems to the media, Jared “had the poem memorized, and he stood up in class and performed it with great drama — at one point, grabbing his crotch.” This performance, along with his inappropriate emotional responses to others’ poems (he laughed and joked as a tearful female student read a poem about abortion), contributed to the complaints which resulted in his suspension from Pima.
Another poem, ‘Dead as a dodo,’ may be an attempt to paint an allegorical scene, though it’s anyone’s guess who the dodo is (is it Loughner? Giffords?) or what the other objects, creatures, and movements might symbolize.
Dead as a dodo
On the island of Mauritius a heavy storm is leaving.
In the fields of the ancient wild forest a wild field of mushrooms is growing.
Snails and grasshoppers are ready for the warmth.
The old grass growing with lizards are jolting for crickets while snakes looking for lonely mice.
Falcons are flying for pray.
Shallow light Blue Ocean shimmering at each wave as the black clouds are rolling.
Waves are lapping.
Fisherman on the reefs are casting their poles.
In warm water a pack of clown fish are floating.
Tiger sharks are swimming free.
Steel drums beating in the distance.
The full moon slowly setting for the sun is rising.
At the local cemetery there is weeping.
The dodo is finally dieing.
But one wonders, why was this kid taking a poetry class when the unanswered question which proved nearly fatal for Rep. Giffords was, “what is government if words have no meaning?” His friends, at 4:06 in the video below, describe Jared’s obsession with what he perceived as the meaninglessness of language:
“He was obsessed with how words were meaningless, you know, you could say, “oh, this is a cup,” and hold a cup, and he’d be like, “oh, is it a cup? or is it a pool? is it a shark? is it an airplane?”
While his friends, and others since the shooting, have interpreted these statements as nonsensical, he is on to something very real here, despite his difficulty in expressing it: Jared realized that words, as symbols, are arbitrary, given their meaning by the history of their (socially agreed upon) use. There is nothing in the physical composition of the object we call a “cup” that makes us use that sound and those letters to refer to it, and for Jared this arbitrariness was equal to unreality. This fact of culture, overlooked or taken for granted by most, seems to have been both exhilarating and terrifying for Loughner; exhilarating because it meant there was no good reason why he should be constrained by social conventions, and terrifying because he was, in fact, constrained – someone or something else was “controlling the grammar.”
In addition to discovering the arbitrary nature of symbols, Jared senses the importance of logic in our culture, and his attempts to make sense of his reality rest largely on a series of if-then syllogisms like those in the video above. He seems to think that by formulating his delusional beliefs, (which he takes as facts), into logical statements, he has proven these beliefs true to his (at the time he made the videos, probably imagined, but now very real) “listener.”
Of course, since the premises themselves are faulty, nearly all of Jared’s syllogisms fail, except perhaps the following:
All humans are in need of sleep
Jared Loughner is a human
Hence, Jared Loughner is in need of sleep
If we consider what Loughner does (or tries to do) when he sleeps, our image of him becomes even more interesting: according to his friends, Jared was an enthusiastic practitioner of lucid dreaming. His own writings refer to “conscience dreaming” by which he presumably meant “conscious dreaming” (another term for lucid dreaming. Apparently, he preferred the dream world to waking world, feeling a greater sense of freedom and control while asleep.
Examined in the light of Liah Greenfeld’s hypothesized mental processes, Jared Loughner’s struggle to determine his own reality demonstrates fundamental problems with his Identity which manifested in problems with the Will. But one of the most important questions – from a legal standpoint at least – will be whether or not Loughner fully understood and was in control of his actions when he opened fire on January 8th. The evidence indeed suggests this was a willful act – planned ahead of time, and executed according to plan, so how do we reconcile this with the image of a deranged mind? In my next post on the subject, I’ll look at how Loughner’s delusional beliefs and other psychotic symptoms fit into existing definitions of mental illness, and consider what this might tell us about Jared’s mindset the moment he pulled the trigger.
Posted on January 19, 2011 - by David
By now, the search for political or ideological motivations in the January 8th shooting in Tuscon has given way almost entirely to a search for signs of mental illness in Jared Loughner’s past, and while debates over gun control, inflammatory political rhetoric, and the responsibility of colleges when it comes to dealing with troubled students will certainly continue in the wake of this tragedy, agreement is pretty much universal that this was the work of a madman.
I’m a pretty big fan of Jon Stewart, and wasn’t surprised that in his first show after this all happened, he took a characteristically sensible view, drawing the focus away from the much discussed “vitriol” even before the overall tone of reporting had shifted. But his acknowledgment of the role of insanity contains a subtle, unquestioned assumption that may need to be challenged, as controversial as such a challenge may be; this is the idea that mental illness, or at least the kind of mental illness that plays into an attack like this, has always existed. At 3:33 into the opening, Stewart said:
“We live in a complex ecosystem of influences and motivations, and I wouldn’t blame our political rhetoric any more than I would blame heavy metal music for Columbine. And by the way, that is coming from somebody who truly hates our political environment – it is toxic, it is unproductive, but to say that that is what has caused this, or that the people in that are responsible for this, I just don’t think you can do it. Boy would that be nice. Boy would it be nice to be able to draw a straight line of causation from this horror to something tangible, because then we could convince ourselves that if we just stop this, the horrors will end. You know, to have the feeling, however fleeting, that this type of event can be prevented, forever. But it’s hard not to feel like it can’t. You know, you cannot outsmart crazy, you don’t know what a troubled mind will get caught on – crazy always seems to find a way, it always has…”
But has it always? And how would we know? We’ve become increasingly convinced that serious mental illnesses – especially psychoses usually classified as bipolar or schizophrenia – are caused genetically, even though what we actually know about these illnesses doesn’t justify this faith in the biological model. The assumption that mental illness has existed in generally the same form, at generally the same rate throughout history and across cultures deserves more scrutiny than it is normally given today. Liah Greenfeld has hypothesized that madness is a modern phenomenon, emerging in 16th century England simultaneous with the emergence of nationalism. Consider the parallels between Jared Loughner and the case of Peter Berchet, a “lunatic” and a “deranged Puritan,” as described in Greenfeld’s forthcoming book:
In 1573, Berchet, a law student, stabbed Sir John Hawkins, a very firm Protestant, whom he mistook for Sir Christopher Hatton, an advisor to the Queen and also a Protestant, accused by Berchet of being “a wylfull Papyst [who] hindereth the glory of God.” The incident taking place at the time of increasing Puritan agitation, Elizabeth wished Berchet to be questioned under torture to reveal the names of co-conspirators she suspected. On the testimony of two of his fellow students, however, Berchet’s examiners became convinced that he was not a political/religious extremist, but, rather, suffered from “nawghtye mallenchollye,” i.e., was stark mad…
The distemper expressed itself in “very strange behavior” at the Middle Temple which his friends attributed to overmuch study and which, shortly before the attack on Hawkins reached a stage we would consider psychotic. “He rarely slept and would pace up and down in his room, striking himself upon his breast, throwing his hands in the air, filliping with [snapping] his fingers and speaking softly to himself… while alone in his chamber, [he] would walk up and down reciting biblical verses and rhymes to himself, then suddenly he would race to the window. With a pointed diamond that he wore in a ring on his little finger, he would scrawl one of his own compositions upon the glass,” when asked by a friend whether he was all right, he responded that “there was ‘a thing at his hart wich noe man in the world showld knowe’ and … would throw his hands in the air and use other ‘frantic gestures’.” To distract him, his friends took Berchet to a wedding in the country, where he proceeded to inform the bride that “she was another man’s daughter, and that she had been born in London. Staring into her eyes while pounding his hands upon the table, Berchet declared that he had ‘seene the verrye same eyes but not the same face,’” punctuating his “outrageous monologue… with unspecified but insulting gestures.” Before his departure from the house of the friend with whom Berchet and his fellow students stayed in the country, he “for no apparent reason beat a young boy … sent to his room to build a fire” and then “Berchet came out of his room, filipping his fingers and talking very strangely, saying in a loud voice, ‘watche, shall I watche hark, the wynd bloweth, but there is neither rayne, wynd, nor hayle, nor the Deuyll hym self that can feare me, for my trust is in thee Lord.’” On the way back to London his companions thought that his “head was verrye muche troubled,” among other things, he “galloped away from the party, dagger in hand, determined to kill some crows that had offended him.” In London, one of Berchet’s friends warned him that, if he continued behaving so, “his position at the Temple would be jeopardized. Berchet reproached [the friend] and maintained that he had ‘a thing at my hart which them nor anye man alyue shall knowe.’ The day that Berchet performed the fateful act, he and a fellow student… had attended a lecture given by Puritan zealot Thomas Sampson. The lecture seemed to provide Berchet with a necessary inspiration to attack Hawkins, for later the same day [another friend] observed Berchet by peering at him through the keyhole of his room door and heard him, as he filliped with his fingers, remark, ‘shall I doe it and what shall I doe it? Why? Then I will doe it.’ Running quickly toward the Temple gate, Berchet hesitated for a brief moment, repeated the same words, then dashed into the Strand where he confronted Hawkins.”
The outraged Queen, as mentioned above, wished Berchet to be both questioned under torture and executed immediately. Instead, following the testimony of his friends, he was committed to the Lollards Tower for his heretical beliefs, where the Bishop of London promised him that, if he recanted, he would live. Berchet recanted and was transferred to the Tower, apparently for an indefinite term of imprisonment under relatively humane conditions, to judge by the fact that the room was kept warm and had light enough, allowing his personal keeper to stand comfortably and read his Bible by the window. At this, however, Berchet took umbrage, promptly killing this innocent with a piece of firewood supplied by the charitable state. Thus, in the end, he was executed – not because his original, and, from the viewpoint of the authorities, graver, crime was attributed to madness (which, in fact, could save him), but because his madness could not be contained.
(The description of this case is based on Cynthia Chermely’s “’Nawghtye Mallenchollye’: Some Faces of Madness in Tudor England,” The Historian, v.49:3 (1987), pp. 309-328.)
Of course, this historical comparison is not meant to somehow explain Loughner’s actions, but if we consider for a moment the possibility that mental illness serious enough to drive someone to murder might have a cultural cause, then we must also consider that this cause is not rooted in the specific content of any particular cultural conflict – neither Puritan vs. Catholics nor Tea Party vs. Progressives – but in the general conditions of modernity which make identity formation so problematic. In my next post, I’ll look at some of Loughner’s preoccupations, including logic, language, and lucid dreaming, and consider how they might make sense within Greenfeld’s cultural model of mental illness.
Posted on October 8, 2010 - by David
I am working directly from the unpublished text of Liah Greenfeld’s forthcoming book, Mind, Madness, and Modernity: The Impact of Culture on Human Experience. All the original ideas, and all interpretations and analysis of primary and secondary source materials used to support the ideas are attributable to Liah Greenfeld. Read the introduction to the exposition here.
part 3 – Madness: A Modern Phenomenon
In this last installment, we consider how Greenfeld’s theory of the mind makes it possible to see schizophrenia and manic-depressive illness (that is, major depression and bipolar disorder), which are usually considered distinct disorders, as diseases of the will, existing on a continuum of complexity of the will-impairment experienced.
Culture – the symbolic transmission of human ways of life- is an emergent phenomenon, a new reality with its own rules, that nonetheless operates within the boundary conditions of life. This symbolic reality is only alive, (the process can only occur), in individual brains, hence the understanding of the mind as “culture in the brain,” or “individualized culture.” As described in part 2, three important “structures” of the mind – (patterned and systematic symbolic processes which must be supported by corresponding patterned and systematic processes in the brain) – are identity, will, and the thinking self.
Identity - the relationally constituted self – is always a reflection of a particular cultural environment. Greenfeld hypothesizes that the lack of direction given by modern culture makes the once relatively simple process of identity formation much more complicated. A well formed identity is able to subjectively rank the choices present at any moment, giving the will, (or acting self), a basis for decision-making. It follows then that problems with identity formation lead to problems with the will. Malformation of identity and impairment of the will necessarily affect the functioning of the thinking self (the “I of self-consciousness”) – the part of the mind which is explicitly symbolic in the sense that it operates with formal symbols – above all, language. The thinking self may become fixed on questions of identity; it may have to stand in for the will, when a person has to talk him/herself into acting in situations which normally wouldn’t require self-conscious reflection (e.g going to the bathroom, eating, getting out of bed); or in the most severe cases, the thinking self may become completely disconnected from individualized culture, in which case all the cultural resources of the mind range free, without direction from identity and will.
The experiences of those who suffer from mental illness begin to make sense within this framework. In major depression, the will is impaired in its motivating function – the ability to force oneself to act or think as one would like to, or as would seem appropriate, is severely lessened. The mind at this stage remains individualized and one has a definite, though distorted and painful, sense of self. The thinking self becomes negatively obsessed with identity, and an incredible dialogue of self-loathing thoughts takes hold. It is insufferable to be oneself, and death naturally suggests itself as the only possibility of escape. Though tragically, as we all know, many depressed people do take their lives, for many even the will to take this action is not present. In bipolar disorder, the impairment of the motivating function of the will in depression mixes with the impairment of its restraining capacity in mania. One can neither move oneself in the desired direction nor restrain one’s thoughts and actions from running in every direction. The negative self-obsession of depression (which can still be justifiably considered delusional) alternates with (the often more noticeable to the outside observer) grandiose and exalted self-image and beliefs. Mania can either cycle back to depression or, through delusional tension, develop into acute psychosis.
The most characteristic symptoms of schizophrenia – hallucinations and elaborate delusions – are usually preceded by a prodrome which bears significant resemblance to certain aspects of depression and mania. This is often a period of social withdrawal, when the experience of the outside world seems to move from a sense of unreality to a sense of the profound yet ambiguous meaningfulness of all things. In healthy minds, identity provides a relatively stable image of the cultural world and the individual’s place in it, and thus the will directs thought and action towards relevant goals. Naturally, at each moment much of the environment is overlooked so that attention can be focused where it should be. In the prodrome, however, the thinking self becomes fixated on mundane aspects of reality, and things in the environment which are usually taken for granted become alternately senseless or imbued with special significance. This experience of the world as incomprehensible and inconsistent suggests a serious problem with identity. The will, (which in healthy cases is a largely unconscious process directed by identity), gets put on the shelf, so to speak, and the thinking self takes on the task of trying to piece together this unreal or hyperreal outside world.
The prodrome is usually only identified after the fact, since it is the appearance of hallucinations and delusions which allows the illness to be diagnosed as schizophrenia. Delusions, (often also present in patients diagnosed with bipolar), are the best known feature of schizophrenia. We can understand delusion as the inability to separate between subjective and objective realities, or put another way, the inability to distinguish between the cultural process on the individual level (the mind) and culture on the collective level. Thus internally-generated experiences are mistakenly thought to have originated outside. The elaborate delusions described by schizophrenic patients can be seen as a kind of rationalization of the experience of acute psychosis. It is important to distinguish between delusional accounts of the acutely psychotic phase, given after the fact in moments of relative self-possession, and the experience itself. In the midst of acute psychosis, a person is almost always incommunicative. Descriptions of this stage often mention the loss of the sense of self, as well as the sense of being watched by an external observer. The mental process, no longer individualized, is beyond willed control. Schneider’s first-rank symptoms, such as the belief that thoughts are extracted or implanted and that physical sensations and actions are controlled by an external force, clearly point to the experienced loss of will which runs underneath so many schizophrenic delusions. The sense of an alien presence is explained by the continued processing of the thinking self even after identity and will have (if only temporarily) disintegrated. Lacking this individualized direction, the “I of self-consciousness” becomes the “eye of unwilled self-consciousness,” – the defenseless sufferer necessarily experiences this free-ranging cultural process as foreign, and quite possibly terrifying, because it is beyond his control.
The formal abnormalities of thought which were so important to Eugen Bleuler’s diagnosis of schizophrenia also fit into the cultural framework. Schizophrenics are often unable to privilege conventional, socially-accepted associations in thought. Most of the time in our modern societies, normal associations follow the rules of logic, (in the strict sense of Aristotelian logic based on the principle of no contradiction). (However, it must be noted that logic is an historical, thus cultural phenomenon, so the inability to think logically should not be taken as evidence of brain malfunction). Of course, depending on the context, some other logic may be culturally appropriate, and arbitrating between contextual logics is one of the primary ways that the will directs thought. In schizophrenia, though, with the will impaired, thought is unanchored to any of these logics, and seems to jump from one to another at random. This becomes most evident in the use of language, which seems to speak itself, flowing without direction and often tied together by the sonic qualities of words or connections in meaning which would usually be overlooked as irrelevant. While the use of language will necessarily depend on the particular cultural resources present in the individual’s mind, it is impersonal in the sense that it draws it life from the associations inherent in language itself, rather than associations pertinent to individual identity or the objective cultural context.
Not only does Greenfeld’s continuum model better account for the huge overlap between the illnesses as currently defined, it also allows us to pay closer attention to movement along this continuum throughout the course of an individual’s illness. While anomie is presumed to be the initial cause of mental illness early in life through interference with identity formation, the various swings on the spectrum may become more comprehensible when we consider what is happening to the individual at the time when the change in symptoms occurs. It is possible that specifically anomic situations may lead to shifts in the already existing illness. (These considerations are explored in Greenfeld’s analyses of the well-publicized cases of John Nash, ( Nobel prize winner in economics), and Kay Redfield Jamison, co-author of the authoritative book on manic-depressive illness.)
The focus on the symbolic, mental processes at work in these “diseases of the will” should not be misunderstood as in any way taking away from the biological reality of major mental illness. Just as the activity of healthy minds corresponds to certain brain activity, so the abnormal processes of a sick mind would be expected to correspond to atypical patterns of brain function. Neither does the hypothesis that mental illness has a cultural rather than biological cause ignore potential genetic conditions that might make certain individuals more vulnerable than others. In fact, it is possible that mechanisms of interaction between culture and genes may become known with continued research in epigenetics – the study of changes in gene expression not caused by changes to the underlying DNA sequence. Some have already hypothesized that gene-environment interaction may lead to epigenetic changes that are central to the expression of mental illness. Of course, unless epigenetic research is specifically designed to take the symbolic nature of the environment into account, it will probably do little to help us to better understand mental disease and the mental process in general.
Part 1 of the exposition looks at the the mind/body problem which has stood at the center of Western Philosophy for over 2000 years, and considers Greenfeld’s proposed resolution – a 3 layer view of reality (matter, life, and culture/mind) in which the top 2 are emergent phenomenon. Greenfeld credits Charles Darwin with making it possible to view the world in terms of emergent phenomenon, which in turn makes possible her theory of culture and the mind which can put the mind/body question to rest. At the same time, she exposes the historical roots of the dogmatic bias of science (as it is normally practiced) towards materialism, and dismisses the notion that science has (or can) in any way empirically prove this position, thereby maintaining that there is no inherent conflict between faith and rigorous empirical study.
In part 2, the proposed solution to the dualist problem is developed – culture is a symbolic process emergent from biological phenomena and operating within the boundary conditions of life, yet fundamentally autonomous and governed by different set of rules. As life organizes the matter out of which it is composed into unlikely patterns, so the symbolic process of culture organizes the brain, (which at all times both supports and provides the boundary conditions for the process) to suit its own needs. Greenfeld logically deduces that the point of emergence for culture and the mind must have been the moment vocal signs were first intentionally articulated, and became symbols. The internalization of this intention creates the mental structure of the will. Yes, this means that in a single moment, culture, the mind, and “free will” as we know it appear together, forever separating homo sapiens from all other animal species and making humanity a reality of its own kind. This view of culture, as a symbolic process which not only structures social life but individual minds, has radical implications for the many disciplines which study the various aspects of humanity. This view also demands the attention of neuroscience, which will remain purely descriptive and not gain any ground in the attempt to understand and explain “consciousness” until it takes into account the symbolic reality – by far the most important aspect of the human environment.
Part 3 reiterates the ideas about nationalism developed in Greenfeld’s first two book and takes things a step further. She identifies nationalism, a fundamentally secular consciousness based on the principles of popular sovereignty and egalitarianism, as the defining element of modernity, responsible for massive changes in the nature of human experience. More specifically here, she claims that love, ambition, and madness as we know them today emerged out of this new consciousness in 16th century England and spread from there to other societies that adopted and adapted the nationalist culture.
Part 4 challenges the current psychiatric dogma that manic-depressive illness and schizophrenia are distinct illnesses with biological causes. The need to rethink this distinction is evidenced by the high degree of overlap in symptoms between two conditions and the failure to find consistent functional or structural brain abnormalities which would allow for accurate differential diagnosis. Not only have genetic researchers been unable to find individual genes that cause schizophrenia or mdi, their best work suggests a shared vulnerability to both illnesses. Epidemiological data seems to show that mental illness occurs at greater rates in modern nations with Western-derived culture, and studies within these nations suggest that the upper classes (i.e those individuals who fully experience the openness of society and have the greatest number of choices) are particularly affected. Both of these findings are consistent with Greenfeld’s hypothesis that anomie causes mental illness. Nevertheless, this data is consistently ignored or rejected as flawed, since it flies in the face of the currently accepted notion of mental illness as biologically caused and uniformly spread across cultures and throughout history. Likewise, the fact that no genetic cause of mdi or schizophrenia has been found has done little to dhake the faith that such a cause will one day be found. Unfortunately, this systemic materialist bias can only continue to impede progress in the understanding of these fatal conditions.
The theoretical view of mental illness as ultimately stemming from problems with the formation of identity is a new one, and thus it does not come packaged with some ingenious cure. However, the clear implication is that something must be done to help individuals in anomic modern societies to create well formed identities. Since this process begins very early in childhood, the intervention must begin then as well. Educating children about the multitude of choices they will face in their extremely open environment, and alerting them to the presence of the many competing and often contradictory cultural voices vying for their attention would become priorities. We should also be cautious (as the recent work of people like Ethan Watters suggests) of the potential side effects of exporting our culture to other societies.
While this exposition is in some sense finished, there is much more to say, and I will continue exploring these ideas and comparing them with other perspectives in my future posts. I realize this work is controversial, and can be difficult to take in all at once. Please, if any part (of the whole) of this seems unclear, unsupported, or simply outrageous, ask a question or give your critique. I’m eager to hear what others have to say.
Posted on October 1, 2010 - by David
I am working directly from the unpublished text of Liah Greenfeld’s forthcoming book, Mind, Madness, and Modernity: The Impact of Culture on Human Experience. All the original ideas, and all interpretations and analysis of primary and secondary source materials used to support the ideas are attributable to Liah Greenfeld. Read the introduction to the exposition here.
part 3 – Madness: A Modern Phenomenon
With all that has been written about schizophrenia and manic-depressive illness, the countless studies that have been conducted, and the growing list of medications used in treatment, it would be easy to mistakenly assume that we now understand the nature and cause of these ailments. The history of the separation of psychoses of unknown cause into these two categories leads us to Emil Kraepelin (1856-1926). This German psychiatrist believed that these were heritable brain diseases, and he led a revolution in classification in German-language psychiatry around the turn of the twentieth century, trying to discover just what kind of brain diseases he was dealing with. Kraepelin used a latin version (dementia praecox) of the French term demence precoce (coined in 1852 by Benedict Morel), to distinguish a form of insanity with an early onset and rapid development from the common geriatric dementia. Kraepelin then separated Dementia praecox from manic-depressive insanity (called by the French folie circulaire or folie a double forme). Up until that point, the two conditions were believed to constitute one general category of insanity.
Kraepelin’s use of the term dementia praecox, which suggested a progressive slowing of mental processes, to refer to a condition characterized largely by delusions and hallucinations, (which imply not mental lethargy but imaginative hyperactivity) may have contributed to the misinterpretation of schizophrenia, (still common today), as degeneration of cognitive/reasoning capacities. The evidence suggests that it is rather the strange character of thought, the inability to think in normal, commonly accepted ways, which distinguishes schizophrenia from geriatric dementia. The name “schizophrenia” (meaning “splitting of the mind”) was introduced to replace dementia praecox in 1908 by Swiss psychiatrist Eugen Bleuler. Bleuler saw the disease mainly in terms of four features: abnormal thought associations, autism (self-centeredness), affective abnormality, and ambivalence (inability to make decisions). Then in the 1930’s, another German psychiatrist, Kurt Schneider, contributed greatly to the diagnosis of schizophrenia by identifying “first-rank symptoms,” primarily related to hallucinations and delusions. Hearing voices speak one’s thoughts aloud, discuss one in the third person and describe one’s actions; feeling like an outside force is controlling one’s bodily sensations or actions and extracting, inserting, or stopping thoughts; believing that one’s thoughts are “broadcast” into the outside world – these are some of the experiences which Schneider found to be characteristic of the illness which Bleuler had recently renamed.
It should be noted that although Schneider’s first rank symptoms are essentially psychotic symptoms, (and schizophrenia is by definition a psychotic illness), very often those diagnosed with schizophrenia do not experience these symptoms. Diagnostic standards today distinguish between positive symptoms, (symptoms like hallucination and delusions which are not present in healthy individuals), and negative symptoms (e.g blunted affect, lack of fluent speech, inability to experience pleasure, lack of motivation). Anti-psychotic medications are often effective in treating some of the positive (i.e psychotic) symptoms of schizophrenia, but attempts to alleviate negative symptoms with medication have been largely unsuccessful, and the prognosis tends to be worse for sufferers who experience primarily negative symptoms.
By far the most authoritative and extensive work (over 1200 pages long) on that other half of madness is Manic Depressive Illness: Bipolar disorders and Recurrent Depression, written by Drs. Frederick Goodwin and Kay Redfield Jamison. The subtitle (Bipolar disorders and Recurrent Depression) added for the 2nd edition, (published in 2007), emphasizes the essential unity of all the major affective illnesses. In the introduction, the authors stress their reliance on Kraepelin’s model for their own conceptualization of mdi. (They, like Kraepelin, see it as a brain disease with genetics playing a significant causal role). But because Kraepelin’s major act of classification was to divide psychotic illness into two distinct disorders, any definition of mdi based on his work depends on having a clear definition of schizophrenia, which is clearly lacking. Kraepelin’s distinction between the two was based primarily not on differences in symptoms, but on course of illness and outcome, with schizophrenia (or in his terminology, dementia praecox) being much more malignant and causing significant deterioration over time. It was in fact Eugen Bleuler who first called mdi an “affective illness,” not because schizophrenia occurred without major mood disturbance, but because in mdi he saw it as “the predominant feature.” This characterization has proven to be extremely important for the current conception of major mental illness; the original distinction as between two psychotic illnesses has largely been obscured, and mdi is now viewed essentially as a mood disorder, with schizophrenia, by contrast, appearing to be essentially a thought disorder.
Though manic-depressive illness includes a variety of mood disorder diagnoses, the main distinction is between major depression and bipolar disorder (alternating episodes of depression and mania). A few decades ago, the bipolar label was split into bipolar-I and bipolar-II. Bipolar-I is the severe form of the disease in which both depressive and manic episodes are serious enough to require treatment. A diagnosis of bipolar-II may be given when a patient suffers from major depressive episodes and also experiences “hypomanic” episodes (meaning basically “mildly manic” and therefore lacking psychotic features). Even Goodwin and Jamison seem skeptical of the value of this and other divisions in classification.
In order to compare manic-depressive illness with schizophrenia, then, we should concentrate on descriptions of, (go figure), depression and mania. According to the DSM-IV, typical symptoms of depression include “loss of interest or pleasure in nearly all activity,” irritability, “changes in appetite and weight, sleep, and psychomotor activity; decreased energy; feelings of worthlessness or guilt; difficulty thinking, concentrating, or making decisions; [and] recurrent thoughts of death or suicidal ideation, plans, or attempts.” The description given by Goodwin and Jamison is along the same lines, though much more vivid:
Mood in all of the depressive states is bleak, pessimistic, and despairing. A deep sense of futility is often accompanied, if not preceded, by the belief that the ability to experience pleasure is permanently gone. The physical and mental worlds are experienced as monochromatic, as shades of gray and black. Heightened irritability, anger, paranoia, emotional turbulence, and anxiety are common. (MDI 66)
Further descriptions from patients and clinical observers add more layers to this general body of symptoms; among the most interesting, lack of facial expression, and a sometimes frightening sense of unreality. It is quite clear that depression is something altogether different from normal sadness, and even “abnormally low mood.” These descriptions show a huge variation in the level of emotion experienced, from almost no feeling at all, to unbearably acute anxiety. A depressed person’s thinking may be slowed almost to the point of paralysis, or he may alternately be unable to control an unending torrent of painful thoughts. All that seems consistent within descriptions and definitions of depressive episodes is that it is an extremely unpleasant experience.
There is such a diagnosis as psychotic depression, (featuring obvious delusions and hallucinations, in which case it is not clear how it can be diagnosed differently from schizophrenia) but even its more ordinary form, many of the symptoms of depression cannot be easily distinguished from the negative symptoms of schizophrenia, which include flat affect and paralyzed thought. And what good reason is there not to consider the firm belief in one’s utter worthlessness, the obsession with death, and the sense of the absolute necessity of ending one’s life as instances of delusion or thought disorder?
Just as depression is not just extreme sadness, mania is not an exaggerated form of joy. According to the DSM-IV, a manic episode is a period of “abnormally and persistently elevated, expansive, or irritable mood,” with typical symptoms being “inflated self-esteem or grandiosity, decreased need for sleep, pressure of speech, flight of ideas, distractability, increased involvement in goal-directed activities or psychomotor agitation, and excessive involvement in pleasurable activities with a high potential for painful consequences.” To be considered a manic (rather than merely “hypomanic) episode, “the disturbance must be sufficiently severe to cause marked impairment in social or occupational functioning or to require hospitalization or it is characterized by the presence of psychotic features.” Mood within a manic episode may be highly variable, and the frequent alternation between euphoria and irritability is noted.
Grandiose delusions are common – the extreme expression of the inflated sense of self-importance so typical in mania. (Again, one wonders why the beliefs which spring from the typical sense of worthlessness in depression – the polar opposite of the grandiose beliefs in mania – should not be considered delusions as well). Grandiosity often manifests in compulsive writing which the sufferer may believe has special significance but is usually characterized by “flight of ideas” and “distractability.” This behavior is not unique to mania, and has been well documented in patients diagnosed with schizophrenia.
Delusions may be not only grandiose, but, (as in schizophrenia), paranoid as well. In some severe cases, the sufferer may reach the stage of delirious mania, which the authors of MDI describe by quoting Kraepelin:
At the beginning the patients frequently display the signs of senseless raving mania, dance about, perform peculiar movements, shake their head, throw the bedclothes pell-mell, are destructive, pass their motions under them, smear everything, make impulsive attempts at suicide, take off their clothes. A patient was found completely naked in a public park. Another ran half-clothed into the corridor and then into the street, in one hand a revolver in the other a crucifix….Their linguistic utterances alternate between inarticulate sounds, praying, abusing, entreating, stammering, disconnected talk, in which clang-associations, senseless rhyming, diversion by external impressions, persistence of individual phrases are recognized. …Waxy flexibility, echolalia, or echopraxis can be demonstrated frequently. (36)
The descriptions of delirious mania provided by recent clinicians are similar to Kraepelin’s. Quite obviously, a patient in the condition described above is suffering from some of the most characteristic symptoms of schizophrenia. Of course for those following in Kraepelin’s footsteps, this similarity should come as no surprise, since (as was mentioned earlier) his distinction between the two psychotic disorders was not based on differences in symptoms. Indeed, the need to clarify the blurry boundary between psychotic mania and schizophrenia has resulted not in further distinction, but the creation of hybrid diagnostic categories like schizoaffective and schizo bipolar. In summarizing the findings of a number of studies over a thirty year span comparing thought disorder in schizophrenia and mania, Goodwin and Jamison are forced to conclude that there is no quantitative difference in thought disorder between the two conditions. Nevertheless, (needing to maintain the distinction between their area of expertise and the even more mysterious realm of schizophrenia) they maintain there are qualitative differences in thought disorder, though the studies used to support this claim point in a number of different directions. Of course, these studies were done only after patients received a particular diagnosis, so differences in thought disorder may also have been related to the effects of different medications. After considering the huge overlap between these two diagnoses, and the fact that differences seem to be more of degree than kind, it seems possible that perhaps they might not be two distinct diseases after all.
While the technological advancements of recent decades allow us to map the human genome and look at the brain on the molecular level, the enormous amount of data that has been amassed is virtually useless for psychiatrists trying to diagnose their sick patients because the assumed biological causes of schizophrenia and manic-depressive illness have not been found. No brain abnormalities that are specific to either illness or present in all cases have been identified. Nevertheless, the experts who study and treat schizophrenia and mdi keep the faith (quite literally) that a breakthrough is just around the corner.
For years, genetic research has appeared to be the most promising of the recently opened avenues, but the excitement seems unwarranted by the findings. The relatively large number of chromosomal regions which may be implicated in susceptibility for bipolar means that hope of finding a specific bipolar gene or even a small number of genes must be given up. Some researchers think the way to go is to narrow the search by looking for genes associated with specific aspects of the disease. Of course, this further refinement is only possible because of the huge variation in symptoms and experiences of those who fall under the mdi/bipolar umbrella, and we are once again reminded of the difficulty of defining what this illness or group of illnesses even is. Furthermore, even the distinction between schizophrenia and mdi seems to collapse in light of the genetic linkage data. Goodwin and Jamison write:
While the search for predisposing genes had traditionally tended to proceed under the assumption that schizophrenia and bipolar disorder are separate disease entities with different underlying etiologies, emerging findings from many fields of psychiatric research do not fit well with this model. Most notably, the pattern of findings emerging from genetic studies shows increasing evidence for an overlap in genetic susceptibility across the traditional classification categories. (49)
Genetic studies in the schizophrenia research community lead to pretty much the same hypothesis as with bipolar: genetic susceptibility is most likely polygenic, meaning dependent on the total number of certain genes which may contribute to vulnerability. It must be noted that genetic vulnerability is a condition, not a cause of schizophrenia and bipolar – something else must be acting on this vulnerability. In one way or another, this fact is usually noted in the literature that deals with genetic data, but it is often obscured by a tone of confidence which suggests the information may be more meaningful and explanatory than it truly is.
Even when a specific gene has been well studied across illnesses, its usefulness in understanding genetic susceptibility may be extremely limited. Some studies in both schizophrenia and mdi have found an increased risk of illness for those who possess the short form of the serotonin transporter promoter gene 5-HTT. The thing is, each of us has two copies of this gene, and over two-thirds of us have one long and one short form, meaning that having the normal variant of the gene is the risk factor! If most of us possess a gene which puts us at risk for an illness which only a small minority of people have, then this particular trait is obviously not much of a causal explanation.
Still today, the most important evidence for the heritability of schizophrenia and bipolar are traditional genetic-epidemiological studies – “genetic” research only in the sense that we know that relatives share genes. There is significantly greater lifetime risk of illness for people with a first degree relative who suffers schizophrenia, and studies of bipolar and major depression (i.e manic-depressive illness) have had parallel findings. However, the overwhelming majority of schizophrenics do not have parents or first-degree relatives with schizophrenia, and most of them do not have children themselves, making it difficult to establish the genetic component by looking at family history in a large percentage of cases.
Studies of twins are particularly important for the heritability argument. Calculations from these studies find a 63% risk of having bipolar disorder if an identical (monozygotic) twin has it. The risk for major depression is significantly lower. In schizophrenia the risk is under 50%. The ideal study design for attempting to separate the contributions of biology and environment involves identical twins, separated at birth, adopted, and raised apart, with at least one of them suffering from mental illness. As can be imagined, these cases are hard to come by (4 in mdi and 14 in schizophrenia), and the small number of cases makes generalization suspect (though generalizations are often still made). Another method, for which there is significantly more data, is to compare the risks of identical (monozygotic) and fraternal (dizygotic) twins. Because both kinds of twins are assumed to share the same environment, but fraternal twins only share 50% of their genes, the difference in risk between fraternal and identical twins is attributed to genetics. But this method depends on an extremely limited understanding of environment, reducing it to simply having the same parents. It’s likely that identical twins would be treated in very similar ways by their parents and society at large, but fraternal twins, being biologically different (perhaps even in gender) will likely be treated in very different ways. Therefore, it is highly doubtful that twin studies are able to separate the contributions of biology and environment to lifetime risk of mental illness to anywhere near the degree that is suggested. The fact that over one-third of identical twins are not affected by the disease from which their twin suffers reveals again that genetic susceptibility is at most a condition, and not a cause of schizophrenia and mdi.
The prevailing assumption that schizophrenia and mdi have biological causes naturally leads to the expectation of finding them distributed uniformly across cultures and throughout history. In the case of schizophrenia, this belief justifies the adoption of the standard worldwide lifetime risk of 1%, (a nice round number), extrapolated from an embarrassingly small number of studies – one from Germany in 1928, and two from the 1940’s in rural Scandinavian communities. However, there is a serious lack of evidence of the existence of these illnesses before the early modern period, and studies have consistently found significant differences in the rates of mental illness across cultures and between social classes within cultures. Nevertheless, (perhaps because the idea that serious mental illness may affect different populations at different rates does not sit well with us), variations are often explained away with charges of inaccurate reporting and under or over diagnosis. But epidemiological studies sponsored by the World Health Organization carried out over several decades have found that the illness identified as schizophrenia in poorer, “developing” countries tends to be less chronic (fewer psychotic episodes), causes less disability, and has a better prognosis than schizophrenia in more affluent, “developed” societies. Some of the data from Western nations suggests a lifetime risk of schizophrenia greater than 1%, while in poorer societies the number often appears lower. Multiple studies have found the rate of schizophrenia among Afro-Carribeans born in the UK to be higher than the prevalence in the islands from which their families immigrated. Both schizophrenia and mdi have been found to be less prevalent in Asian countries.
Overall, cross-cultural data supports the hypothesis that schizophrenia and mdi are diseases caused by modern culture, and more specifically, that the more anomic a society becomes, (i.e the more identity becomes a matter of individual choice and the less guidance is given by culture), the more mental illness will be found. Research in the U.S has shown a lower age of onset and higher rates of prevalence for manic-depressive illness in those born after 1944 compared to those born before, though this increase has been attributed to the inadequacy of earlier data-collection techniques, which systematically underestimated the true prevalence of affective disorders. Usually, when environment is allowed a causal role in mental illness, poverty and the stress of the urban environment is the safest target to blame, with studies as early as 1939 finding a higher incidence of schizophrenia in lower-class, urban areas. However, when studies began to consider social class of origin rather than merely the status of the patient when the illness was first recognized, the picture changed significantly. The social mobility of schizophrenic patients displays a “downward drift,” suggesting that their greater proportion among the lower class is due to the disability of the disease rather than the stress of this environment. Furthermore, it appears that the upper-class supplies more schizophrenics than could be predicted by the total upper-class share in the population. The majority of studies of manic-depressive illness show significantly lower rates in blacks compared to whites, but this, like so many other findings which make no sense within the biological framework, is dismissed for a variety of reasons as a mistake.
Finally, Goodwin and Jamison tell us that “the majority of studies report an association between manic-depressive illness and one or more measures reflecting upper social class.” (169) To explain this finding, they consider the possibility that certain personality traits associated with affective illness may contribute to a rise in social position. (One assumes they mean the occasionally “positive” aspects of mild mania, since it is unclear how crippling depression or delusional mania would aid in social climbing). A second hypothesis, that manic-depressive illness could be related to the particular “stresses of being in or moving into the upper social classes,” is deemed simply “implausible, because it assumes that, compared with lower classes, there is a special kind of stress associated with being in the upper social classes, one capable of precipitating major psychotic episodes.” Furthermore, they accuse such a hypothesis of ignoring genetic factors, though discounting genetic vulnerability as a condition for mdi is quite obviously not implied by this idea.
By now it should be quite clear that the belief that major mental illness is caused biologically has made it virtually impossible to reconsider what the empirical evidence actually tells us. Each time the research that is supposed to support this belief comes up short, it is another occasion for the reaffirmation of faith in a soon-to-come breakthrough. Where the data appears to blatantly contradict their hypothesis, they often simply discount its reliability. While many of the most important experts will freely admit how little we actually understand about mental illness, despite all efforts, it is hard to imagine the direction of these efforts will change much anytime soon. This is not a recipe for scientific progress.
The final post of this series will bring Greenfeld’s theory of the mind together with what we know about schizophrenia and manic-depressive illness, considering the two as one disease existing on a continuum of complexity of will-impairment.
Posted on September 24, 2010 - by David
I am working directly from the unpublished text of Liah Greenfeld’s forthcoming book, Mind, Madness, and Modernity: The Impact of Culture on Human Experience. All the original ideas, and all interpretations and analysis of primary and secondary source materials used to support the ideas are attributable to Liah Greenfeld. Read the introduction to the exposition here.
“Identity-formation is likely to be faster and more successful the simpler is the (always very complex) cultural environment in which it is formed – i.e., the fewer and the more clearly defined are the relations that must be taken into account in the relationally-constituted self.”
- from Mind, Madness, and Modernity: The Impact of Culture on Human Experience
For most of human history, in most societies, identity was not something one had to go searching for – it was given at birth. For most individuals, the socio-cultural space relevant to their lives was easy to map out, and directions for proper navigation were well understood from a young age. Life may have been extremely difficult in the physical sense, but at least it was not confusing – people knew their proper place.
As Greenfeld has demonstrated since her first major work, this changed in 16th century England following the War of Roses, which wrecked the nobility and left the rigidly stratified society of orders in disarray. In its place, a new consciousness emerged – nationalism – the modern consciousness, which redefined the possibilities for life in England and in the other societies to which it soon spread. We call this new consciousness nationalism simply because “nation” was the name given to the society in which it emerged by those 16th century Englishmen who first experienced its dignifying effects.
Nationalism is a fundamentally secular and humanistic consciousness based on the principles of popular sovereignty and egalitarianism. (Three distinctive features which most often take shape along with this consciousness are an open class structure, the state form of government, and an economy oriented towards sustained growth). At the beginning of the 16th century, someone among the newly elevated English aristocracy began equating the word “nation,” which had formerly referred to a political and cultural elite, with the word “people,” which referred originally to the lower classes. This equation of “nation” and “people” both reflected and reinforced the new reality of English society, where the principles of popular sovereignty and egalitarianism made the nation and all its members an elite. No longer confined to a particular station in life by a closed societal structure ordained by Divine Providence, man became his own ruler, the maker of his own destiny. This elevation in dignity for every member of the nation meant that life in the here and now gained much greater importance – eternity was no longer the realm of the meaningful. This is the source of the secularism of modern society – God was not consciously abolished, but was essentially replaced by man.
For the first time in history, identity-formation became the responsibility of each individual, and this has proven to be a mixed blessing. With the opportunity to rise above the position of one’s birth comes the possibility of failing to successfully make the climb, or falling suddenly and senselessly from whatever height one is able to reach. The abundance of options in every aspect of life lets in a nagging suspicion that one has not made the best choice. The presence of circumstantial, or worse, socially imposed, obstacles to one’s advancement clashes with the belief in one’s equality and right to self-governance. Belief in equality becomes the idea of equality with the best, making it difficult to tolerate the sense that another person is better, or better-off. This inability of culture to provide the individuals within it with consistent guidance is called anomie – recognized by the great French sociologist Emile Durkheim over 100 years ago as the most dangerous problem of modernity.
With the changes in the nature of existential experience brought on by the mixed blessing of modernity came changes to the English language. A new vocabulary was needed to express and reinforce the ideas behind this new reality. By following linguistic changes in 16th century English, we can actually observe the emergence of several aspects of this new experience – at once, so elevating and devastating for the individual mind. That is to say, we can see several specific sources of anomie, which, it is hypothesized, makes identity formation difficult and complicated, leading in some of the worst cases to the development of mental illness.
Of course, there are many who would react strongly to the idea that changes in language may reflect fundamental changes in the nature of human experience. The same materialist tendencies which have us assuming the universality of schizophrenia lead us to assume the universality of a whole range of human emotions and experiences. If human nature is reduced to a set of biological capacities, the idea that various emotions, (which we must feel are a very important part of being human), have emerged in different places and at different times in history seems outrageous.
But as was demonstrated in the previous post, it is culture – the symbolic transmission of human ways of life – which distinguishes our species from all others and makes humanity a reality of its own kind. Culture is a fundamentally historical process, which means that the possibilities for thought and emotion for an individual at any one place and time are dependent on context – the context of what has gone on before and what is going on around the individual, the infinitely complex history of connections and intersections of the variety of symbolic systems which collectively make up that individual’s cultural resources.
This doesn’t mean that emotions are purely cultural phenomena. At the most basic level, emotions are physical sensations – we feel them. We know we must share certain primary emotions with animals – pleasure and pain, fear, positive and negative excitement – which we assume they experience through neurobiological processes similar to ours. We can see also that certain animals experience secondary emotions like affection and sorrow, which are once removed from their physical expression, and usually serve to strengthen social ties within a group. Considering this, it is obvious that human emotional functioning depends to a large extent on biological capacities that we share with other species. But inevitably, culture interacts with these biological capacities, creating more complex emotions which are tied to particular beliefs and ideas – specific experiences of a symbolic nature – which cannot be reduced to a combination of physical sensations.
When a new idea/emotion/experience emerges, it is usually closely linked to a particular word or set of words – either new words, new derivatives of old words, or old words with new or increased significance, evidenced by changes in usage and context. Ignoring these cultural developments under the mistaken assumption that all human experience is essentially the same results in a few common problems of backwards translation:
- the new meaning of a word is attributed to earlier uses of the same word, obscuring the historical shift in definition (and lived experience)
- other words which denote phenomena which may be related or similar to, but are nonetheless distinct from, the phenomenon to which the new word refers, are taken to be synonyms of the new term.
In both of these cases, differences between cultures and over time are blurred, making it nearly impossible to use the history of a language as empirical evidence. But if language, the most important of the various symbolic systems which collectively make up culture, is off limits as evidence, then no meaningful argument about culture can ever be made.
The two new great passions of modernity – the ultimate expressions of the sovereignty of the self – were ambition and love. The opening of these two realms of choice, and their importance in the formation of individual identity is reflected in the growth of the vocabulary of related terms soon after the birth of the English nation.
While ambition was not a new word, before modernity it usually carried a negative connotation, meaning basically an overgrown (and therefore sinful) desire for honor. Over time, though, it became more neutral, meaning something like “a strong desire”. Thanks to the principles of nationalism, such a desire for attainment of an earthly goal was legitimized and even encouraged, making ambition in many instances a virtue rather than a sin. A positive or negative qualifier would introduce the word to denote which type of ambition was being referenced.
The language of ambition was bolstered by other shifts in meaning and new derivative words. The OED finds only one instance of the use of the word “aspire” in 15th century, with all its derivatives – aspiration, aspiring, and aspirer – appearing mostly in the late 16th century. The verb to achieve acquired a new meaning of gaining dignity by effort, (as in Shakespeare’s: “Some are born great, some atchieue greatnesse”), and from this were derived achievement, achiever, and achievance. The use of the verb to better, referring to improvement by human action, (e.g “bettering oneself), was another permanent addition to the language. Success, which was originally a neutral term meaning any outcome of an attempt, came to refer only to a positive or desired outcome, and its derivatives, successful and successfully, obviously carried this new meaning as well.
Love, (first defined as a passion by Shakespeare), became a calling, a means of defining, or perhaps more accurately, discovering, who one was. While the word love had been commonly used with a variety of meanings – from the ideal of Christian, brotherly love, to the divine love of God, to the essentially sinful sexual lust – the 16th century English concept of love — which is our concept – was dramatically different. “Romantic” love, as it is sometimes called, occurred between a man and woman – therefore it retained clear sexual connotations – but it was above all a union of two minds (or souls, for by this point, the words mind and soul were nearly synonyms). In love, one recognized one’s true self through identification with another, giving meaning and purpose to life in this strangely open world where God, formerly the source of meaning, was conspicuously absent.
The ultimate end of ambition and love was another modern concept: happiness. This word refers to a phenomenon distinct from many of the historically earlier ideas with which it is sometimes identified. It is not luck, which could be either bad or good and was beyond one’s control; not eudemonia, freedom from fear of death which depended in large measure on avoiding excessive enjoyment of life; not the Christian felicity of certitude of salvation, requiring denial of bodily pleasures up to the point of martyrdom. Happiness was rather conceived of as a living experience, a pleasant one, which was purely good and could be pursued. The OED shows the first instance of this general meaning for the word happy in 1525; the same meaning of the noun form – happiness – doesn’t appear until 1591.
Happiness was knowing who and what one was, being content with one’s place in the world – in other words, successfully creating a satisfactory identity. But what was to become of those whose ambitions were left frustrated and unfulfilled? Of those who lost, or failed to find true love, or were kept, either by circumstance or society, from experiencing true love once it was found? What happened to those sensitive minds for whom the responsibility of building an identity proved too great a struggle?
In the same 16th century England which brought the world ambition and love, a new form of mental disease – Madness – appeared. While previously known forms of mental illness were temporary, related perhaps to an infection, an accident damaging the brain, a pregnancy, a bodily illness like “pox” (syphilis), or old age, madness was chronic – usually appearing at a fairly young age (without evidence of an organic cause) and lasting till death. Another of its names, lunacy, reflected the suspicion of a physical cause – specifically implicating the waxing and waning of the moon in the periodic alterations in the character and symptoms of the sufferers. The word insanity entered English at that time too, apparently referring to the same phenomenon as madness and lunacy.
The chronic nature of madness made it a legal issue from the very beginning; the first provision in English law for mentally disturbed individuals — referred to, specifically, as “madmen and lunatics” — dates back only to 1541. Also in the middle of the 16th century, Bethlehem Hospital – more commonly known as Bedlam, the world’s first mental asylum – became a public institution, transferred to the city of London in 1547. While there was probably little to be praised in terms of humane treatment and comfortable accommodations, Bedlam continued to expand into the 17th century to meet what seemed to be a growing need to house the severely mentally ill.
Important for this argument is the fact that folly was separated from madness. Though it sometimes referred to a moral deficiency, folly was generally a synonym for idiocy – a mental dysfunction or deficiency but not a disease. In ‘An Essay on Human Understanding,’(1689) John Locke summarized the difference between madness and folly as such:
In fine the defect in naturals [fools], seems to proceed from want of quickness, activity, and motion, in the intellectual faculties, whereby they are deprived of reason, whereas madmen, on the other side, seem to suffer by other extreme. For they do not appear to me to have lost the faculty of reasoning, but having joined together some ideas very wrongly they mistake them for truths… as though incoherent ideas have been cemented together so powerfully as to remain united. But there are degrees of madness, as of folly; the disorderly jumbling ideas together in some more in some less. In short herein seems to lie the difference between idiots and madmen. That madmen put wrong ideas together, and so make wrong propositions but argue and reason right from them. But idiots make very few or no propositions, but argue and reason scarce at all.
Physicians of the day sought to describe and understand this new phenomenon, but their methods, sources, and interpretations were thoroughly mixed. Their reliance on classical Greek and Latin terms of mental disturbance resulted in a liberal blend of (their interpretation of) the old ideas with the new reality, and though they attempted to draw distinctions between conditions, they were far from clear. The cause was usually assumed to be organic. The common attribution of madness to an imbalance of the four humors shows the strong influence of the classical medical understanding. (The use of the term melancholy as a name for mental illness in general or a particular variety of it is a prime example). Insanity might also be explained by the stars under which one was born. Some authors distinguished between organic madness and spiritual madness caused by demonic influence. Still others focused on mental states that could in turn affect the body.
Obviously, early observers of madness were far from a uniform hypothesis as to its nature and cause. Nevertheless, these sources do contain some revealing descriptions and suggestions. Andrew Boorde recommended that the patient be kept from “musynge and studieng,” (implying very obviously a literate madman), and likewise Thomas Cogan, a physician and head master of a grammar school, advised against “studying in the night” deeming “wearinesse of the minde” worse than “wearinesse of the bodie.” Sir Thomas Elyot noted a “sorowe,” or “hevynesse of mynde” which affected the memory and the ability to reason properly, relating it to such experiences as the death of a child and even disappointed ambition. Christopher Langton saw “sorrow” as a chronic condition, the most serious of four “affections of the mynde” that could “make great alteration in all the body.” Philip Barrough’s description of melancholy, (which he calls “an alienation of the mind troubling reason..”), mentions mood swings, suicidal thinking, hallucinations, and paranoid delusions – in short, some of the most characteristic features of major psychosis which might be diagnosed alternately as bipolar or schizophrenia today. Timothy Bright’s ‘Treatise of Melancholie’ contains the idea that being “over-passionate,” put one at risk for mental disease.
By far the longest and most famous book on the topic in the early modern period was The Anatomy of Melancholy by Robert Burton, first published in 1621. It was essentially a collection all the information he could find on mental disease – both past and present - and therefore (unfortunately) contributed greatly to the confusion of terms, translating as “madness” a whole variety of words from Latin and Greek sources. Despite his mistake, which allowed him to find English madness scattered throughout history, it seemed to him a particularly pressing problem in his day. He noted among his “chief motives” for writing the book “the generality of the disease, the necessity of the cure, and the commodity or common good that will arise to all men by the knowledge of it.” Burton’s description of his society as a “world turned upside downward” is loaded with colorful yet tragic examples of apparent inconsistency and injustice – in a word, sources of anomie common to modern life. One can hypothesize that the inclusion of such a description of the contradictions within culture, in a work that is dedicated to the understanding of what is deemed a medical illness with an essentially organic cause, is related to Burton’s sense that the two phenomena – anomie and mental illness – are related. Indeed, some of the mental symptoms of melancholy “common to all or most” – “fear and sorrow without a just cause, suspicion, jealousy, discontent, solitariness, irksomeness, continual cogitations, restless thoughts, vain imaginations” – begin to make sense if mental illness is seen as stemming from fundamental problems with identity caused by anomie. Some of these symptoms appear identical to the causes of melancholy which fall under Burton’s general category of “passions and perturbations of the mind.” Ambition and related passions like envy and emulation figure prominently here, but most striking of all is the inclusion of love – the cause, apparently of a special madness called “love-melancholy” which afflicted primarily men of the upper classes.
But perhaps the greatest early chronicler of madness was William Shakespeare. Dr. Amariah Brigham and Dr. Isaac Ray, ( two of the most important figures in 19th century American psychiatry), each devoted an extensive article in the early years of the American Journal of Insanity (today the American Journal of Psychiatry) to the consideration of his work. They saw in his plays, (in particular King Lear and Hamlet), such accurate portrayals of insanity that they were certain he must have drawn his inspiration at least partly from first-hand observation. Whatever might be said today in criticism of the method of these doctors, who had no qualms about using literary study to supplement clinical observation, it is significant that the mental illness they observed in their asylums was the same as that which Shakespeare brought to life in his tragedies more than two and half centuries earlier.
Apparently, the medical understanding of madness, lunacy, insanity, melancholy – whichever name one chooses – had not advanced very far from the time of Shakespeare to the middle of the 1800’s. “But,” most of us would confidently assume and assert,”since then we have come a long way, we know so much more now.” But do we? Certainly at the time when Brigham and Ray were writing about Shakespeare , serious psychiatric establishments were already taking shape in a number of modern nations. The growth that has taken place since the 19th century within this medical specialization in terms of publications, practitioners, institutions, associations, research, and treatments would have been difficult to imagine. But are we really any closer to identifying a cause, or having a cure to offer to those who suffer from mental illness?
The next post will look at what we know about the schizophrenia and the range of diagnoses which fall under the category of manic-depressive illness.
Posted on September 12, 2010 - by David
In her forthcoming book, Mind, Madness and Modernity: The Impact of Culture on Human Experience, Liah Greenfeld presents a new framework for understanding mental illness. Readers of this blog may be familiar with some of these ideas from earlier posts, but her position is so distinct from all other theoretical approaches to mental illness that the central claim should be clearly stated from the outset :
Schizophrenia and Manic-Depressive Illness are biologically real diseases caused by modern culture.
Until now, most of what has been written from a “social science” perspective has focused on attitudes toward mental illness or the history of the psychiatric establishment, rather than the phenomenon of mental illness itself. This is because the theoretical approach usually involves either…
- A tacit acceptance of the dominant model, which holds that mental diseases are caused biologically and therefore occur at equal rates across cultures and throughout history
- A denial of the biological reality of these illnesses, which comes with the view that mental illness is a social construction (derived from the likes of Michel Foucault and Thomas Szasz)
- Some in-between version of the first two, (e.g the recent work of Allan Horwitz), emphasizing the medicalization of some normal human conditions, while leaving severe psychosis in the realm of the universal/biological
In light of these views, Greenfeld’s hypothesis that culture, a symbolic (and therefore non-material) reality, is capable of disrupting the normal functioning of the brain, appears quite unique, possibly to the point of seeming outrageous.
Precisely because this idea must seem unbelievable to so many people, I am happy to announce that it will no longer go unsupported. Over the next two weeks, I will be doing an exposition of the new book through a series of posts, outlining the major elements of the argument, and summarizing logical, empirical, and historical evidence to support the claims.
To be clear, I am working directly from the unpublished text of the book. All the original ideas, and all interpretations and analysis of primary and secondary source materials used to support the ideas are attributable to Liah Greenfeld.
Here’s the schedule:
9/24 – Madness: A Modern Phenomenon
Posted on May 19, 2010 - by David
Ethan Watters, author of Crazy Like Us (see my commentary), was on PRI the other day (listen to the audio here). I was pleased to get a prompt response to my comments, which I’ve copied below. Go here to follow the entire discussion in the PRI science forum.
Posted on March 22, 2010 - by David
81 Words, a 2002 episode of NPR’s This American Life that was recently rebroadcast, tells the story behind the removal of the homosexuality diagnosis from the DSM-II in 1973. You can download the audio or read a transcript of the show here: part 1, part 2.
The report is given by Alix Spiegel, whose grandfather, Dr. John P. Spiegel, was president-elect of the American Psychiatric Association in 1973 when this historic change took place. Alix describes the family myth – that grandpa had single-handedly changed the APA’s position on homosexuality and removed one of the major barriers to equal rights for homosexuals in America. The truth, she says, is actually much more complicated. Though he did play a role in this historic change, ‘grandpa’ was not the driving force his family believed him to be, nor were his motives simply those of dedicated psychiatrist and champion of human rights. In Alix Spiegel’s words:
… this version of events was discarded anyway. Discarded after the family went on vacation to the Bahamas to celebrate my grandfather’s 70th birthday. I remember it well. I also remember my grandfather stepping out from his beach front bungalow on that first day followed by a small well-built man, a man that later during dinner my grandfather introduced to a shocked family as his lover, David. David was the first of a long line of very young men that my grandfather took up with after my grandmother’s death. It turned out that my grandfather had had gay lovers throughout his life, had even told his wife-to-be that he was homosexual, two weeks before their wedding. And so in 1981 the story that my family told about the definition in the DSM changed dramatically.
According to Alix Spiegel, from the 40’s through the early 60’s, the APA was a very conservative organization, largely uninterested in “weighing in on the issues of the day.” In her interviews with psychiatrists who were members of the APA in 1970, when the forces behind the definition change began to take shape, she was told that the overwhelming majority of the APA believed that homosexuality was indeed a mental illness – “even the ones of us who were gay,” added Dr. John Fryer.
Fryer was not alone in the APA. Because homosexuals were not allowed to practice psychiatry, Fryer and others like him had to hide their sexual preference, but they began to meet informally at APA conventions, calling themselves the Gay PA. There may have been a sense of solidarity among them, but they were not questioning the official psychiatric stance on homosexuality. Fryer told Spiegel, “because of our own internalized homophobia, most of us probably agreed that it was OK to be a disease.”
The idea that homosexuality was a form of insanity rather than a ‘moral abomination’ was first put forth in the 19th century, and Spiegel notes that many homosexuals actually saw this as a step forward. In the early 70’s, psychoanalysis, Freud’s great gift to psychiatry, was still the dominant form of therapy and mode of theoretical understanding in the profession. The two psychoanalytic authorities on homosexuality were Dr. Irving Bieber and Dr. Charles Socarides. Bieber, who was later demonized by gay activists, actually became interested in the subject of homosexuality after working as an army psychiatrist during WWII, when soldiers who were found to be homosexual were dishonorably discharged. Bieber believed they should receive treatment instead of being discharged, and because of this position, he was never promoted from his rank of Captain during his four years of service. Returning home, he began to research and write about this topic, which culminated in the 1962 publication of Homosexuality: A Psychoanalytic Study. As Spiegel says, this book, which analyzes the work of 77 doctors and over 100 of their gay patients, “concluded that the cause of homosexuality was a combination of what they termed close-binding mothers – which is overprotective women who made their children weak and feminine – and detached, rejecting fathers.”
Of course, there was other data used to argue against the idea of homosexuality as a mental illness. Alfred Kinsey’s famous and highly controversial report on male sexuality, published in 1948, found that 37% of American men had had physical contact to the point of orgasm with another man. Some opponents of the diagnosis used Kinsey’s work to claim that an experience so common could not be reasonably considered pathological.
The work of Evelyn Hooker, a psychologist from UCLA, was first made public in 1956, and addressed one of the main criticisms leveled against psychiatrists like Dr. Irving Bieber, whose study subjects consisted only of homosexuals who were imprisoned, in mental hospitals, had been discharged from the military, or had otherwise sought treatment on their own. Hooker’s aim was to examine gay men who weren’t troubled by their own sexuality. She administered psychological tests to 30 homosexuals who had never sought therapy, as well as 30 heterosexuals who were matched for comparable age, IQ, and education. The disguised results were then given to three experienced psychiatrists who were asked to identify the homosexuals. They were unable to distinguish between the two groups, and categorized two-thirds of both groups as “perfectly well-adjusted, normally functioning human beings.”
In 1970, the APA held their convention in San Francisco, probably an ill-advised choice of location. Gay rights activists showed up, some of whom had apparently obtained press passes from people within the APA, and made their feelings known. Bieber was a particular target, and they effectively broke up the meeting where he was trying to give a talk. The ’71 convention was much the same story.
While there was obvious pressure coming from the gay community to change the DSM, there was also something happening inside the APA. It seems from Spiegel’s story that the psychiatrists of the Gay PA were for the most part content to gather in secret and accept the traditional designation of homosexuals as sick, but others had begun to mobilize. In Dr. John P. Spiegel’s Cambrige, MA home, a small group of psychiatrists, ‘the young turks,’ began to meet:
The young turks were all psychiatrists, all members of the APA and all liberal-minded easterners who had decided to reform the American Psychiatric Association from the inside. Specifically they had decided to replace all the grey-haired conservatives who ran the organization with a new breed of psychiatrist; more sensitive to the social issues of the day with liberal opinions on Kent State, Vietnam, feminism. They figured that once they got this new breed into office they could fundamentally transform American psychiatry. And one of the things this group was keen to transform was American psychiatry’s approach to homosexuality.
Spiegel is quick to clarify that this group and others like it by no means constituted a “homosexual cabal,” but “several of the key players were gay,” and the young turks were able to use their influential positions as members of the Committee for Concerned Psychiatry to propose candidates for office. Despite all the visible and colorful protests of the APA by gay activists, Spiegel maintains that if it weren’t for the internal changes set into motion by these psychiatrists, the DSM diagnosis would have gone untouched.
At the 1972 convention, the efforts of those working for change both inside and outside the APA were joined for the first time. Gay psychiatrist Dr. John Fryer, recently ousted from his job at UPenn and apparently unemployable due to the rumors of his homosexuality, was recruited by activists to give a speech about the damaging effects of the DSM diagnosis. Though he initially refused the offer, after being rejected by one university after another as he looked for a new job, Fryer accepted the second request on the condition that his identity remain a secret. He appeared as ‘Dr. Anonymous,’ wearing a loud suit several sizes too big, his face hidden behind a distorted Nixon mask, hair covered by a wig, speaking into a special microphone to alter his voice. “He explained to his fellow psychiatrists how these  words had harmed him, and others like him,” and when he was through, received a standing ovation.
Independent of the changes already underway on the inside, there was another chance encounter involving an APA psychiatrist and a gay activist which proved to be instrumental in this process. During a behavioral therapy conference in New York City in ‘72, Dr. Robert Spitzer, a member of the APA’s committee on nomenclature and subscriber to the standard psychiatric view of homosexuality, was sitting in a meeting when Ron Gold stood up and spoke out against psychiatry’s oppression of gays. Spitzer made a point of speaking to Gold after the meeting ; he wanted to express his annoyance at the inappropriateness of the interruption. But when Gold discovered that Spitzer was on the nomenclature committee – the group that first decides what should and shouldn’t end up in the DSM – the conversation went in a different direction. The two men parted ways with Spitzer agreeing to set up a meeting for Gold with the committee as well as a panel discussion at the next convention where gay activists could participate.
At the 1973 APA convention in Honolulu, a few months after the requested audience with the nomenclature committee left the psychiatrists at a loss as to what should be done about the diagnosis, “The old guard, Charles Socarides and Irving Bieber, publicly met the new school, Ronald Gold, Judd Marmor [a future president of the APA] and several other psychiatrists in front of a room filled to capacity.” The showdown was a resounding victory for the gay activists. Even Socarides admits that the reception to his speech, (which Gold referred to as “his ‘they’re betraying their mammalian heritage’ number”), hardly qualified as warm. “A lot of people booed,” he told Spiegel, “some people clapped.”
Perhaps the most surprising part of this story, the last shove leading to the change, came later that night in a Honolulu bar. Gold, as the hero of the day, was invited to a covert Gay-PA celebration, and decided to bring Spitzer, who still didn’t personally know of any gay psychiatrists, along with him. Spitzer was supposed to be playing the role of a closeted gay man, but when he realized some of the big names who had been part of this underground group for years, he was shocked, and started asking questions that gave his true identity away. A psychiatrist Gold described as “the grand dragon of the Gay PA” wanted Spitzer out of there, but Gold refused on the grounds that Spitzer was actually doing something to help homosexuals, while the Gay PA had done nothing. In the middle of this encounter, a man in full army uniform walked into the bar, looked around, and fell weeping into Gold’s arms. As Gold tells Spiegel:
Well I had no idea who he was. It turned out he was a psychiatrist, an army psychiatrist based in Hawaii who was so moved by my speech, he told me, that he decided he had to go to a gay bar for the first time in his life. And somehow or other he got directed to this particular bar and saw me and all the gay psychiatrists and it was too much for him, he just cracked up. And it was a very moving event, I mean this man was awash in tears. And I believe that that was what decided Spitzer, right then and there, let’s go. Because it was right after that that he said, ‘Let’s go write the resolution.’ And so we went back to Spitzer’s hotel room and wrote the resolution.
While obviously we don’t have the original text composed by Gold and Spitzer in Honolulu– perhaps scrawled on some long lost sheets of hotel stationary –I’m guessing that much of what was written that night ended up here, in this position statement proposing a change in diagnosis from homosexuality to ‘Sexual Orientation Disturbance’ with homosexuality bracketed. This change was to be put into effect for the 6th printing of the DSM II and read as follows:
302.0 Sexual orientation disturbance (Homosexuality)
This category is for individuals whose sexual interests are directed primarily toward people of the same sex and who are either disturbed by, in conflict with, or wish to change their sexual orientation. This diagnostic category is distinguished from homosexuality, which by itself does not constitute a psychiatric disorder. Homosexuality per se is one form of sexual behavior and, like other forms of sexual behavior which are not by themselves psychiatric disorders, is not listed in this nomenclature of mental disorders.
In this paper, Spitzer basically states that homosexuality is a normal variant of human sexuality. He writes that “for a mental or psychiatric condition to be considered a psychiatric disorder, it must either regularly cause subjective distress, or regularly be associated with some generalized impairment in social effectiveness or functioning,” and because many homosexuals do not meet these criteria, homosexuality should not be considered an illness. Spitzer clearly understood that this change was in part a political action, stating that “we will be removing one of the justifications for the denial of civil rights to individuals whose only crime is that their sexual orientation is to members of the same sex.” However, he writes that the removal of the homosexuality diagnosis does not amount to “saying that it is ‘normal’ or as valuable as heterosexuality,” and maintains that “this change should in no way interfere with or embarrass those dedicated psychiatrists and psychoanalysts who have devoted themselves to understanding and treating those homosexuals who have been unhappy with their lot.” The idea, in the end, was that if someone was bothered by their own homosexual thoughts, impulses, or behavior, the DSM still had them covered.
This initial change, officially announced by Dr. Alfred Friedman, president of the APA, on December 15, 1973, may have allowed psychoanalysts to continue treating gay patients for a time, but in less than 15 years, the DSM would be wiped clean of the last traces of the idea that homosexuality could be a mental illness. Spitzer’s original change had been rewritten as ‘ego-dystonic homosexuality’ for the DSM-III, but was removed altogether in 1987.
Dr. Charles Socarides, the most prominent player on the losing team, responded to the change in a 1978 article titled ‘The Sexual Deviations and the Diagnostic Manual,’ published in the American Journal of Psychotherapy. In protest of further proposed revisions for the soon to be published DSM-III, Socarides wrote, “these changes would remove from psychoanalysis and psychiatry entire areas of scientific progress, rendering chaotic fundamental truths about unconscious psychodynamics, as well as the interrelationship between anatomy and psychosexual identity.” In particular, Socarides objected to the fact that the heading ‘Sexual Deviations,’ under which the homosexuality diagnosis had once was fallen, was going to be entirely removed from the DSM-III. Proponents of this change pointed to reports like Kinsey’s, arguing that a phenomenon as common as homosexuality shouldn’t be understood as a deviation, but Socarides believed this was faulty reasoning:
To form conclusions as to the specific meaning of an event simply because of its frequency of occurrence is to the psychoanalyst scientific folly. Only in the consultation room, using the techniques of introspective reporting and free association, protected by the laws of medicine and professional ethics, will an individual, pressed by his suffering and pain, reveal the hidden (even from himself) meaning and reasons behind his acts.
When I read Socarides’ paper, I noticed that he repeatedly summons the name of science, even while his argument belies a dogmatic faith in psychoanalysis –an approach that has been waning in popularity for decades, suffering from the criticism that it lacks scientific validity. Regardless of who is right or wrong in this argument, (or any similar argument for that matter), what I find most interesting is how it is imperative for each party to claim the support of science. One of the last people Spiegel speaks to in her report is Ronald Bayer, a public health historian from Columbia who wrote a history of this change titled Homosexuality and American Psychiatry. Bayer tells Spiegel that “the nature of these controversies,” is that “both sides wrap themselves in the mantle of science and both sides charge that the other side is being unscientific.”
While developments in medicine and advances in genetic study and different brain imaging technologies have no doubt increased the importance of being aligned with “science” when it comes to psychiatric debate, this is not a new phenomenon, nor was it new in the ‘70’s. At the same time, stories like this one makes it plain that the progress of certain disciplines may be driven just as much by personal and political factors as it is by actual scientific progress. I wonder if the removal of the homosexuality diagnosis in 1973 wasn’t the beginning of the end for psychoanalysis, as well as the first move towards the more standardized, symptom-based diagnoses of the 1980 DSM-III. This seems reasonable, considering that Robert Spitzer was chairman of the task force responsible for creating the new edition and directed the development of the revised edition published in 1987 (DSM-III-R).
As the APA prepares for the publication of the DSM-V in 2013, I believe it’s worthwhile to keep this story in mind. Some of the proposed changes seem to have more to do with a desire to remove a stigmatizing label than real “scientific” evidence. And like homosexuality, the pathology of which was for a many years assumed but never proven, the scientific understanding of some of the older DSM diagnoses is not particularly strong. Studying the history of psychiatry can’t necessarily prove or disprove the validity of a diagnosis, but it may help us to remain cautious as we go forward.
Posted on February 24, 2010 - by David
I was happy to see that Dr. Sally Satel commented on Monday’s post which linked to her WSJ article about the proposed revisions for the DSM-V. She posted a link to this article, written two years ago, which is actually a review of The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder, by Allan Horwitz and Jerome Wakefield. Written from the perspective of a psychiatrist critical of the direction the field is moving in, it’s plenty more than a book review. Dr. Satel incorporates her own knowledge of the history of psychiatry and the difficulties of diagnosis and treatment as she considers the book’s contributions and shortcomings.
I realize that some of my criticisms are really directed at Horwitz and Wakefield, and I may be repeating some of things I wrote in my post on the Horwitz interview, but here goes anyway:
Satel gives some valuable history on the state of affairs in psychiatry during the 60’s and 70’s leading up to the publication of DSM-III. I’ll just say that Horwitz and Wakefield identify the publication of the DSM-III in 1980 with a shift towards symptom-based diagnosis which effectively eliminated considerations of context. The biggest problem they see resulting from this, (as the title of their book implies), is that the normal expression of sorrow in the wake of difficult life events is being diagnosed as depression. They believe this leads to unnecessary prescription of medication, inflated rates of mental illness, and a culture-wide loss of the ability to integrate hardship and sadness into a normal, healthy life.
The book seems to argue (as Horwitz stated in the contexts interview) that there are two types of real depression. 1. Depression that appears without cause or context, and 2. Depression which begins with an apparent cause or context but persists longer than appropriate with more severe symptoms than normal.
From Satel’s article:
In the classic form of uncaused depression — referred to in the pre-DSM-III days as endogenous depression or melancholia — symptoms arise mysteriously out of the blue when life is otherwise good. It seems clear that whatever biological mechanism that regulates mood has gone badly awry.
Yet clinical depression need not always have a spontaneous onset; it can also arise in the aftermath of loss. The important distinction between normal sorrow and major depression, the authors say, is that in the latter the symptoms triggered by circumstances eventually lose their contextual moorings. Either they persist long beyond the resolution of the stressful situation, or the point at which an otherwise healthy person would have adapted to a new condition; or they mutate into overt psychosis, suicidal impulses or actions, or physical immobilization. A patient in the pathological realm is beset by self-reproach and ruminations. He does not brighten when, say, a beloved grandchild visits, and he cannot imagine anything ever making him happy again.
While I would agree that this idea makes sense on the surface, I see a real problem. When someone reacts too strongly for too long to some loss or crisis, we might say something went wrong to make this person overly-sensitive to either loss in general, or the particular loss that was suffered. But this is still much different from depression which arises “mysteriously out of the blue when life is otherwise good.” Perhaps the way we look at context or what we consider “context” to mean leads us to see symptoms arising from nowhere which actually do have an explanation outside of a brain malfunction.
The argument presented in The Loss of Sadness seems to rest on the claim that real depression is the same today as it was over 2000 years ago – that culture has changed our understanding of mental illness but mental illness itself (assumed to be biologically caused) has not changed. To me, this implies that “normal sorrow” should look similar between cultures and over time, with some differences that can be accounted for by cultural and historical context.
I believe this view obscures the dramatic cultural change that modernity brings. We may take it for granted that a certain type of loss is difficult and a cause for deep sadness, but to extend this response to all of history and humanity is ignorant. (I think Ethan Watters chapter on PTSD in Sri Lanka is helpful in looking at cultural differences in response to tragedy). Sure, some depression might be easier for us (as modern people) to understand given the context or spark. But if our “normal responses” to loss closely resemble pathological states, perhaps Horwitz’s conclusion isn’t the only one that can be drawn. The authors are saying we have pathologized normal human emotions, but perhaps our responses to “normal life events” have actually become more pathological. Of course, if the broad cultural changes that accompany the rise of modernity are not considered important and human emotions and attitudes (or even Western emotions and attitudes) are seen as historically consistent, then this second possibility doesn’t even show up on the radar.
The principles inherent in nationalism provide the basis for modern culture – the only form of consciousness most people reading this blog have ever known. As defined by Liah Greenfeld, “nationalism is a fundamentally secular and humanistic consciousness based on the principles of popular sovereignty and egalitarianism.” For this discussion, it is important to recognize two aspects of modern culture: 1. It’s openness gives individuals great freedom, but very little guidance in forming identity 2. It changes what we hope for and what we expect out of life, therefore changing the nature of what constitutes “loss” and interfering with our ability to accept loss. Consider the following from Greenfeld’s essay, Nationalism and the Mind:
The focus on the life in this world dramatically increases the value of this life to the individual and inevitably leads to the insistence on a good life, however defined. One is no longer expected to submit to suffering or deprivation, unless one has special reasons to do so, for the general reasons for such submission – the expectation of rewards in the beyond, transmutation and migration of the souls, the duty to serve witness to the glory of God wherever one is called, or the sheer impossibility to change one’s condition – no longer apply.
Moreover, in a self-sufficient world, changeable and shaped by people, suffering is generally believed to be man-made. Even natural disasters are likely to be so interpreted: a famine, an earthquake, or an epidemic are as often as not attributed to some human agent’s withholding of the needed but available resources or negligence; personal misfortunes, such as debilitating, life-threatening, and incurable illnesses are blamed on artificially-created environmental conditions (second-hand smoke, lead paint, etc.) or on doctors’ incompetence. None of these natural disasters, it is said, “have to happen”: they are no longer believed to be in the nature of things. Of course, the right to a life free of suffering is most clearly asserted when suffering is caused – as it is mostly, in modern societies — by social evils: war, economic or political conditions, competition for precedence, and so forth. Humiliation, rejection, thwarted ambition are felt as unjust – as contrary to expectations and thus resulting from illegitimate intervention of malicious others.
Greenfeld’s argument is that modern culture causes problems with identity formation which can lead to “biologically real” mental illness. She is therefore arguing that diseases like schizophrenia, bipolar, and depression are not as old as humanity, but really began appearing about 500 years ago with the rise of nationalism.
Her work proceeds from the view that culture- the symbolic process by which human ways of life are transmitted historically, is an emergent phenomenon, logically consistent with the laws of physics and biology, but nonetheless autonomous. This is absolutely critical. It is this first view which distinguishes Greenfeld from the many biologists and anthropologists who see human culture as dictated by biologically evolved brain mechanisms and natural selection.
For Greenfeld, the mind is the individualized cultural process, or “culture in the brain.” The individualized cultural process is therefore dependent upon, but not determined by, the biological functions of the brain. Just as organic brain damage can cause symptoms of mental illness- problems with thought, mood, and speech for example – Greenfeld believes that problems with the mind (problems with culture, that is) can lead to problems with brain function.
Obviously, all I can do here is prevent a bare-bones, unsupported version of Greenfeld’s theory and set in against the dominant view of the day. She is well along in the process of writing a book on this very subject and I look forward to its publication. Her work is not meant to go against, but to complement and elucidate research on the biology and genetics of mental illness. Genetic susceptibility probably goes a long way in explaining why only certain individuals experience mental illness, but it is important to acknowledge, (as Dr. Satel’ article does) that the extensive research to date hasn’t revealed a genetic cause of mental illness:
Psychiatry, alas, has a long way to go. “Although the past two decades have produced a great deal of progress in neurobiological investigations,” notes a recent paper written to guide preparation of the forthcoming DSM-V, “the field has thus far failed to identify a single neurobiological phenotypic marker or gene that is useful in making a diagnosis of a major psychiatric disorder or for predicting response to psychopharmacological treatment.” Indeed, almost all of the recent genetic findings are not specific. A particular gene associated with bipolar illness was later discovered to occur in people with schizophrenia. The same goes for almost every other major finding — leading to the current hypothesis that these various genes confer risk for psychopathology, but not for any specific kind.
Nevertheless, the dogmatic view that true, serious mental illnesses are caused by a problem in the brain hasn’t lost any steam. Satel writes:
As brain-based etiologies of classic serious mental illnesses, such as schizophrenia and bipolar illness, are uncovered, psychiatry will probably lose those diagnoses to neurology. Perhaps one day psychiatry will cater only to patients suffering from existential crises. But not anytime soon.
Dr. Satel seems to feel that as a psychiatrist, her job is not to figure out the exact nature and cause of mental illness, but to provide the best patient-care possible, and I guess I can’t argue with this.
… in his essay the weary Dr. Spitzer admitted that, “I doubt that clinicians will ever be very concerned with what illness itself is…. Concerns with defining medical or psychiatric illness or disorder are generally left to sociologists, psychologists, philosophers of science, and members of the legal profession.” This is deeply true. Front-line clinicians will not be joining the fray anytime soon. The academic debate over the evolutionary history of their patients’ woes is irrelevant to everyday practice.
I suppose that so far, academic attempts to define mental illness have been “irrelevant to everyday practice” because they haven’t resulted in any understanding of etiology or pathogenesis that could be translated into treatment and prevention strategies. But just because nothing has been solved so far, doesn’t mean a radical new approach might not prove to be more than added noise in the “academic debate.”
Satel concludes that “in the end, the most we can say about mental illnesses is that they are the result of various interrelated causes unfolding at different levels of explanation: biological (genetic or cellular), cognitive (information processing), and psychological (the generation of meanings in contexts).” I believe Greenfeld’s view of the mind as the individualized cultural process can help put together this causal puzzle that Dr. Satel describes. But this can only begin if we allow for the possibility that human experience is not determined by our biology. If we persist in the hope, (which I believe Satel holds), that we will one day grasp “how those swirling galaxies of neurons and molecules make us who we are, both in sickness and in mental health,” we will never stop “struggling in the dark.”
Thanks again to Dr. Sally Satel for the comment that sparked this post. You can read more of her writing here.
Posted on February 22, 2010 - by David
I regret how spotty my posts have been lately, but if I’m not writing something new every day the best thing I can do is point you to someone else’s work. With the proposed changes for the DSM-V being made public last week, there are plenty of opinions floating around on the internet. I found this op-ed piece from the Wall Street Journal by Yale psychiatrist Dr. Sally Satel interesting.
She points out that many of the proposed changes, (as well as the opposition to those changes), have more to do with stigma, labels, and identity issues than actual advances in the understanding of mental illness. Satel also mentions the common overlap in symptoms and diagnoses within individual patients, and underlines our relative ignorance as to how genes are actually related to mental illness:
The other problem that confounds psychiatry is how to draw boundaries around diagnostic categories, given that we rarely know the cause of mental illness at the neural level. Mental illnesses are the product of numerous genes that interact with one another, with the environment and also with experience. (A recent study by the National Institute of Mental Health found that 80 genes could be associated with bipolar disorder.) Add to this the miasma of social and personal encounters that impinge upon the genetically vulnerable individual—stress, poverty, family instability, drug or alcohol use, and so forth—and the causal mechanisms of any mental illness become staggeringly complex and elusive. Moreover, the “psychopathological pie,” as a colleague calls it, is rarely divided up as tidily as the manual implies. Patients often have symptoms that sprawl across several diagnostic categories. For example, half of kids who receive the diagnosis of bipolar disorder also have ADHD.
Of course, if you’ve been a regular reader of this blog you won’t be surprised that I take slight issue with her explanation of mental illness, (even though it might not be totally fair to judge her based on one sentence in a WSJ op-ed piece). The inadequacy of her own definition is made clear when she mentions that “80 genes could be associated with bipolar disorder,” but says nothing about how these genes “interact with each other.” Also, what is meant by “environment” and “experience” is unclear and could be taken in a variety of ways. She seems to offer a broad explanation for mental illness and demonstrates well that there major issues with the way we classify symptoms as disorders which often overlap, but like a good psychiatrists she still locates cause with genetics or “at the neural level.”
MindHacks has an extensive summary of the DSM-V changes with links to other major media coverage. I found his comments on the restructuring of the schizophrenia diagnosis and the addition of ‘psychosis risk syndrome’ particularly interesting. His article suggests that a lot of the more subtle changes are aimed at “de-freuding” the DSM. Definitely worth your time to check this out.