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Deliberating the science of madness: DSM-5 and the polytechtonic rhetorical economy of psychiatric nosological controversy
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DELIBERATING THE SCIENCE OF MADNESS:
DSM5 AND THE POLYTECHTONIC RHETORICAL ECONOMY OF
PSYCHIATRIC NOSOLOGICAL CONTROVERSY
by
Laurance Paul Strait
A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(COMMUNICATION)
August 2014
Copyright 2014 Laurance Paul Strait
ii
DEDICATION
To Laura, my raison d'être, who taught me
about the fourth kind of madness.
iii
ACKNOWLEDGMENTS
Over the past seven years, I have received support, encouragement,
and guidance from a great number of individuals. Without inspiration from
my family, friends, and mentors, I would have been like the man, who,
“having been persuaded that competent written work comes from technical
knowledge, reached the temple doors without the creative madness of the
Muses; both he himself and his work were deficient, and his sober writing
will be eclipsed by the art of those driven to madness” (Plato, 1903, sec. 245a,
my translation).
1
I am indebted to the members of my committee, whose guidance has
made this a rewarding and thoughtful journey. They include: Tom Goodnight
(director), Randy Lake, Andy Lakoff, and Larry Gross. In addition, I would
like to thank Sandy Green, a true polymath, for his brilliant insights and
helpful feedback as a member of my qualifying exam committee. Larry Gross
very generously offered his wisdom and time and, among other things, taught
me the difference between a research question and a complaint. Andy Lakoff
transformed my curiosity about mental health and psychiatry into actual
knowledge by directing my attention to the appropriate literature and always
emphasizing the importance of conceptual rigor. I was helped by Randy Lake
1
“ μ , ὃςδ᾽ἂνἄνευ ανίαςΜουσῶνἐπὶποιητικὰςθύραςἀφίκηται πεισθεὶςὡςἄραἐκ
μ , τέχνηςἱκανὸςποιητὴςἐσό ενος ἀτελὴςαὐτόςτεκαὶἡποίησιςὑπὸτῆςτῶν
μ μ .” αινο ένωνἡτοῦσωφρονοῦντοςἠφανίσθη
iv
to assiduously—for the most part—avoid composing sentences as terrible as
this one—his unflagging, perhaps Sisyphean, efforts to improve my style is
one thing which he is thanked for and, I am earnestly hopeful that a seizure
will not be induced by this momentary reversion to my old habits. I also
thank him for almost singlehandedly teaching the graduate rhetoric
curriculum to me, which is only a slight exaggeration, as I took seven of his
seminars (in some cases more than once). He is an amazing mentor, role
model, and friend. Finally, I must thank my advisor, Tom Goodnight, for his
tutelage, patience, and insightful supervision, which proved indispensable
both for this thesis and for my years of doctoral training at the University of
Southern California. Beyond guiding my work to fruition, he taught me
about the joys of intellectual labor and the importance of the academic
vocation. I agree wholeheartedly with the sentiment expressed by Stephen
O'Leary, and, no doubt, by countless other students of Tom's over the years,
that he is unequaled in either genius or generosity.
I profited greatly from working within the scholarly milieu engendered
by the Annenberg School, and I am deeply grateful for the years of financial
support and copious teaching and research opportunities afforded to me.
Imre Meszaros has been especially supportive of my efforts by making it
possible for me to teach a wide variety of subjects. I thank Anne Marie
Campian for helping me navigate the university bureaucracy cheerfully and
v
with nonpareil competence. The faculty's broad approach to the field of
communication dramatically expanded the horizon of my thoughts. I have
learned a great deal from countless conversations with other students, and I
am especially indebted to the rhetoricians with whom I completed
coursework: Shoko Barnes, Patrick Belanger, Beth Boser, the inimitable
Omri Ceren, Ryan Gillespie, Zoltan Majdik, Steven Rafferty, Don Waisanen,
and Diana Winkelman, who are all dear friends.
While completing my doctoral studies, I served the Trojan Debate
Squad as an assistant coach and, in that capacity, worked with Gordon
Stables, an incredible rolemodel. His dedication to the wellbeing and
growth of his students is remarkable, and he has nurtured a culture that
ought to be the envy of every debate team. I thank him for his years of
support and valuable advice, for holding me accountable for my mistakes,
and for challenging me to be a better professional. I also learned quite a bit
working with Brian McBride, whose cynical wit has brought many smiles to
my face. I thank my fellow assistants, Noah Chestnut, Liz Lauzon, Joel
Lemuel, Jim Maritato, and Shawn Powers, for their example, their insight,
and their solidarity. Finally, I owe debts of gratitude to my debate students,
especially Monica Do, Sean Hernandez, and Garry Padrta, for all that they
have taught me, which almost certainly exceeds what I taught them.
I am indebted to all the wonderful teachers that prepared me for
vi
doctoral studies. Don Boileau, who advised my M.A. thesis, introduced me to
the field of communication and has been a constant source of encouragement
over the years. Richard Velkley introduced me to German philosophy and
inspired me to become an academic. Steve Mancuso gave me a voice and
taught me how to listen. Deb Plummer introduced me to formal
argumentation, taught me how to write and support a thesis statement, and
impressed upon me the importance of primary sources. Carolyn Dusenbury
instilled in me a love of the written word, and, having no tolerance for
nonsense, she inspired me to hold myself to a higher standard. Additionally,
Joseph Capizzi, Warren Decker, Les Fortune, Wayne Froman, Tim Gibson,
Sr. Margarita IgricziNagy, Bob Lichter, Tim Miller, Timothy Noone, and
Cindy Rinehart each played a key role in my intellectual formation and
collectively inspired me to become a teacher.
I would be remiss not to acknowledge Patrick Waldinger for his
perspicacity about the nature and importance of policy deliberation and his
years of friendship. I thank Michael Gales for working tirelessly to keep me
relatively sane, and for helping me refine many of my raw ideas. I also thank
the many friends who, in a different way, helped me stay sane, especially
Nick Barabach, Dan Cerulo, Steve D'Amico, Michael Holman, Paul
Huntington, Stephen Kowalski, and Trevor MackessyLloyd. Over the past
several years, they fostered my creativity while offering sage (and sometimes
vii
very spirited) advice about conflict and cooperation, data management,
perspectivetaking, probability, procedure, and the roles social actors play.
I extend a very personal thanks to my family, especially my parents
Bob and Lauran, my siblings Kyle and Annabelle, and my grandmothers
Carolyn and Marianne, who have supported me financially, emotionally, and
spiritually. My mother helped me directly by proofreading an early draft of
Chapter 3. John and Karen Greathouse opened up their Santa Barbara
home to me during holidays, which made being three thousand miles from
home endurable. I have always been able to count on Ann and Mike Weber,
who helped me at the age of ten obtain an amateur radio license and
certification in CPR, providing my first formal education in communication
and medicine.
Finally, and, most crucially, I owe an eternal debt of gratitude to my
partner and fellow rhetorician, Laura Alberti, for her unceasing love and
support: I truly would be lost without her. If I were to attempt to expatiate
on the sundry and diversiform ways in which she enriched this project, my
professional and personal development, and my life, I would run into the
same problems that troubled apophatic theologians contemplating the
quidditative properties of the divine essence. Simply put, there are no words
with which I could sufficiently and accurately characterize her manifold
contributions. Illa est condicio sine qua nihil sum.
viii
TABLE OF CONTENTS
DEDICATION.......................................................................................................ii
ACKNOWLEDGMENTS.....................................................................................iii
TABLE OF CONTENTS....................................................................................viii
LIST OF TABLES..............................................................................................xiv
LIST OF FIGURES.............................................................................................xv
LIST OF ABBREVIATIONS..............................................................................xvi
ABSTRACT.........................................................................................................xix
CHAPTER ONE: THE CONCILIAR DSM..........................................................1
Context............................................................................................................10
Excursus on L'Affaire Arius.....................................................................11
DSMIII and the Scientific Psychiatry Revolution.................................19
Agonistic Marking of Terms..............................................................28
DiAgnostic or DiaGnostic: Esotericism in the DSM......................32
From DSMIII to DSM5..........................................................................36
Method to My Madness..................................................................................49
Grounded Theory......................................................................................50
Rhetorical History....................................................................................52
Rhetoric of Inquiry...................................................................................56
Rhetorical Subjectivity.......................................................................59
Rhetorical Objectivity........................................................................59
ix
Rhetorical Intersubjectivity...............................................................61
Social Study of Science.............................................................................62
Materials...................................................................................................65
(1) Popular Media...............................................................................66
(2) The “DSM5 Development” Website............................................67
(3) Primary and Secondary Institutional Media..............................69
(4) Advertisements for Psychiatric Treatments...............................73
Outline of the Study.......................................................................................74
Polytechtonic Rhetorical Economy....................................................79
Rhetorical Histories of Psychosis......................................................80
Psychosis Risk Society.......................................................................82
That Commodified Supplement.........................................................85
CHAPTER TWO: POLYTECHTONIC RHETORICAL ECONOMY................87
Rhetoric as Epistemic....................................................................................93
Memory as Epistemic Function of Rhetoric............................................94
Rhetoric as Technical Art.........................................................................97
Rhetoricity of Symbolic Form................................................................106
Rhetoric and Institutions............................................................................113
Rhetorical Institutionalism....................................................................113
Social Knowledge....................................................................................115
Connecting System and Lifeworld.........................................................120
x
Institutional Canon................................................................................124
Rhetoric and Practice...................................................................................133
Ideas Market...........................................................................................135
Signification Exchange...........................................................................140
Epistemic Bubbles..................................................................................142
Rhetoric as Polytechtonic Art......................................................................146
Social Systems........................................................................................150
Rhetorical Reproduction........................................................................153
Evolution or Revolution?........................................................................154
CHAPTER THREE: RHETORICAL HISTORIES OF PSYCHOSIS.............162
The Humoral Model of Pathology...............................................................168
Humoral Rhetoric from Antiquity to Modernity..................................176
Why did Humorism Succeed?................................................................201
Why did Humorism Fail?.......................................................................206
The Rise of Scientific Medicine...................................................................212
The Ontological Interpretation..............................................................213
Evolution of Hysteria.............................................................................216
The Physiological Interpretation...........................................................227
Reconciliation of Ontology and Physiology...........................................233
Psychiatric Antecedents.........................................................................237
The Emergent Assembly of Psychiatry......................................................243
xi
Inventional Visual Rhetoric...................................................................249
Neurosis and Psychosis..........................................................................261
Dementia Praecox: Prognosis as Diagnosis..........................................267
Schizophrenia: A Continuum of Discontinuity.....................................278
AntiPsychotics and History..................................................................288
Phenothiazines as the Discontinuous New....................................291
Phenothiazines as the Continuous Old...........................................299
Schizophrenia & Psychosis Today.........................................................304
Conclusion....................................................................................................315
CHAPTER FOUR: PSYCHOSIS RISK SOCIETY..........................................324
Risk in Antiquity and Early Modernity.....................................................330
Risk and Unknown Fate........................................................................332
Risk as Dangerous Opportunity............................................................333
Risk and Fortune....................................................................................336
Risk as the Management of Uncertainty..............................................340
Psychiatric Rhetoric in a Risk Society........................................................353
Risks of Modernity: Degeneracy and the Rise of Hygiene...................355
Risk and Latent Danger.........................................................................364
Medicalization and Criminalization......................................................368
Sluggish Schizophrenia....................................................................369
Pedohebephilic Disorder..................................................................382
xii
Coercive Paraphilia..........................................................................386
Parental Alienation Syndrome........................................................398
Risk (Factors) and Susceptibility..........................................................401
Risk Production and Risk Society.........................................................405
Early Intervention Research.......................................................................408
Freud's Views on Early Diagnosis.........................................................408
Diagnostic AntiFatalism: Schizophreniform Disorder.......................412
Early Intervention for Psychosis...........................................................414
Theoretical Perspective of Patrick McGorry.........................................422
Psychosis Risk Syndrome and DSM5........................................................428
Psychosis Risk Syndrome Formalized..................................................429
Psychosis Risk Syndrome as Representative Anecdote.......................432
Terministic Screen, Interpellation, and Stigma...................................433
Risks of Psychosis Risk Syndrome........................................................437
False Positives and the Rhetorical Ontology of Risk...........................438
(1) Risk Factors Interpretation.......................................................443
(2) Vulnerability Interpretation......................................................446
(3) Prodrome or Prodromal Phase Interpretation..........................449
(4) 'At Risk Mental State' (ARMS) Interpretation.........................451
Brief Excursus on Melancholia..............................................................454
Changes in the DSM5 Draft Revisions................................................458
xiii
Controversy During DSM5 Revision Process......................................466
Conclusion....................................................................................................478
CHAPTER FIVE: THAT COMMODIFIED SUPPLEMENT..........................483
Key Findings................................................................................................485
1. Rhetorical Economy of Science..........................................................485
2. Residues of the Past Remain.............................................................486
Conceptual Cacophony.....................................................................487
Kuhnian Paradigms?.......................................................................490
Polytechtonic History of the Present..............................................492
3. Configurations of Knowledge Transcend Psychiatry.......................498
4. DSM5 Anxieties: Pharma and the Medicalization of Normality...504
Politics of the Supplement...........................................................................507
Humoral Supplement for the Inhuman................................................510
Writing as Supplement..........................................................................513
Diagnosis as Supplement.......................................................................516
Rhetorical Commodities.........................................................................518
Postpsychiatric Rhetorical Inquiry.............................................................525
REFERENCES..................................................................................................531
xiv
LIST OF TABLES
Table 1: Interpretations of Psychosis Risk Syndrome....................................442
Table 2: Revision History for Psychosis Risk Syndrome Criteria..................459
Table 3: Final Version of Attenuated Psychosis Syndrome in DSM5..........460
xv
LIST OF FIGURES
Figure 3.1: Structural relationships between the humors.............................169
Figure 3.2: Humoral rhetorical appeals in ‘naturopathic’ marketing...........195
Figure 3.3: Brain imaging and naturopathic marketing................................197
Figure 3.4: Esquirol channels Linnaeus..........................................................250
Figure 3.5: Linnaeus invoked to emphasize specificity of 'Librium'..............252
Figure 3.6: SPECT images of schizophrenia...................................................257
Figure 3.7: SPECT image of oppositional defiant disorder [ODD]................258
Figure 3.8: The Treachery of Neuroimaging...................................................259
Figure 3.9: 'Thorazine' compared to totemic objects.......................................292
Figure 3.10: Lifting the 'mask' of psychotic withdrawal.................................294
Figure 3.11: 'Thorazine' compared to colonial 'surprise bath'........................296
Figure 3.12: 'Stelazine' compared to Beethoven's Fifth Symphony...............300
Figure 3.13: 'Stelazine' compared to Homer's Iliad.........................................301
Figure 3.14: Anthropomorphized disordered brain molecules.......................309
Figure 3.15: Illustration of apocalyptic free radical production.....................310
Figure 3.16: Excitotoxicity, cell death, and psychotic symptoms...................311
Figure 3.17: Donepezil as molecular straitjacket............................................313
Figure 4.1: The risk of medication noncompliance as iceberg (reef).............343
Figure 4.2: Noncompliant schizophrenic as saboteur....................................377
Figure 4.3: Securing cooperation with 'Haldol'...............................................378
Figure 4.4: Undetectable medication for paranoid patients...........................379
xvi
LIST OF ABBREVIATIONS
5HT 5Hydroxytryptamine (serotonin)
AAPL American Academy of Psychiatry and the Law
ADHD Attention Deficit/Hyperactivity Disorder
APA American Psychiatric Association
ARMS AtRisk Mental State
BE Bereavement Exclusion
CBD Compulsive Buying Disorder
CBT Cognitive Behavioral Therapy
CPR Cardiopulmonary Resuscitation
c/s/x Consumer/Survivor/ExPatient Movement
DD Dissociative Disorders
DID Dissociative Identity Disorder
DNA Deoxyribonucleic Acid
DSM Diagnostic and Statistical Manual of Mental Disorders
DST Dexamethasone Suppression Test
DTI Diffusion Tensor Imaging
ECT Electroconvulsive Therapy
EI Early Intervention in Psychosis
EPPIC Early Psychosis Prevention and Intervention Centre
FDA Food and Drug Administration
xvii
FGA FirstGeneration ('Typical') Antipsychotic
fMRI Functional Magnetic Resonance Imaging
ICD International Classification of Diseases
IED Intermittent Explosive Disorder
KGB Committee for State Security (Soviet Union)
LDOPA L3,4Dihydroxyphenylalanine
LSD Lysergic Acid Diethylamide
MBD Minimal Brain Dysfunction
MDE Major Depressive Episode
MHMIC Mental Health MedicalIndustrial Complex
MPD Multiple Personality Disorder
MRI Magnetic Resonance Imaging
NAMI National Alliance for the Mentally Ill
NIMH National Institute of Mental Health
NMDA NmethylDaspartate (glutamate receptor)
NOS Not Otherwise Specified
ODD Oppositional Defiant Disorder
OED Oxford English Dictionary
PAH Phenylalanine Hydroxylase
PAS Parental Alienation Syndrome
PCP Phencyclidine
xviii
PET Positron Emission Tomography
PKU Phenylketonuria
PMDD Premenstrual Dysphoric Disorder
PRS Psychosis Risk Syndrome
PTSD Post Traumatic Stress Disorder
RDC Research Diagnostic Criteria
RDoCs Research Domain Criteria
SCID Structured Clinical Interview for DSMIIIR
SGA SecondGeneration ('Atypical') Antipsychotic
SPECT SinglePhoton Emission Computerized Tomography
SSRI Selective Serotonin Reuptake Inhibitor
STS Science, Technology, & Society
SVP Sexually Violent Predator
TCA Tricyclic Antidepressant
TIPS Treatment and Intervention in Psychosis Study
TMS Transcranial Magnetic Stimulation
UCLA University of California, Los Angeles
UHR UltraHigh Risk
US United States
USSR Union of Soviet Socialist Republics
WHO World Health Organization
xix
ABSTRACT
This study examines the rhetorical features of psychiatric nosological
controversy. The locus of inquiry is the recent controversial revision of the
American Psychiatric Association's (APA) Diagnostic and Statistical Manual
of Mental Disorders, now in its fifth edition (DSM5). The dissertation seeks
to answer the following research question: When the field of psychiatry
assembles to revise itself, how do previous rhetorical arrangements organize
into new vectors, evolve, and cluster together into what becomes a new
network consensus (or quasiconsensus)?
This dissertation contributes to debates in the social study of science
and the rhetoric of inquiry about the development and evolution of scientific
fields. It contends that as psychiatric knowledge advances, discursive forms
embodying old institutional logics and theoretical paradigms leave residues
that retain their suasive character. These sedimented rhetorical residues
play a significant role in many of the developments and impasses in the
controversies surrounding DSM5. Our contemporary concepts of psychosis
are the result of the projection of tensions between discrete and continuous
terminologies, ontological and functional interpretations of health and
sickness, and psychodynamic and neurobiological descriptions of the mind
into the temporal dimension. This study argues that the inability of
psychiatry to resolve a set of internal dilemmas combined with its
xx
temporizing can be understood in contemporary terms as a politics of the
supplement.
Several major DSM5 debates are analyzed, with special focus on the
controversy over psychosis risk. Chapter 1 introduces the direct and indirect
contexts of DSM5. Chapter 2 works out a theoretical toolkit and a model of
polytechtonic rhetoric capable of appreciating the historical dynamics of
interfield and public controversy. Chapter 3 examines the rhetorical history
of 'psychosis,' which requires a larger rhetorical history of psychiatric
nosology. This includes an account of the humoral model of pathology, which
remains present in contemporary medical rhetoric. Chapter 4 examines the
rhetorical history of risk and the evolution of research on early interventions
for psychosis to contextualize the contemporary controversy over psychosis
risk syndrome. Chapter 5 concludes the study by discussing the implications
of these different lines of inquiry for an understanding of the rhetoric of
psychiatry in our contemporary late modern epoch. It argues for a reading of
DSM5 in terms of the 'politics of the supplement,' a field of contestation
concerning the risks and benefits of the new technologies of the self with
which we (re)define our human nature.
Word count (excluding front matter, footnotes, and references): 109,251.
Keywords: Biopolitics, DSM, epistemic rhetoric, medical humanities,
nosology, pharmaceutical marketing, poststructuralist institutional analysis,
psychiatric diagnosis, psychosis risk syndrome, rhetorical history, rhetoric of
science, risk society, scientific controversy, supplementarity.
1
CHAPTER ONE: THE CONCILIAR DSM
“Some people are born mad... others achieve madness, and others have madness thrust upon
them by the Diagnostic and Statistical Manual [of Mental Disorders].” – Phillip Elias
2
“Science is not... a single concrete entity speaking with one authoritative voice... The whole
force of the word nevertheless depends upon a bland assumption that all scientists meet
periodically in synod and there decide and publish what science believes. Yet anyone with
the slightest scientific training knows that this is very far from a possibility.” – Richard
Weaver
3
“Though this be madness, yet there is method in't... [of] which reason and sanity could not so
prosperously be delivered.” – Polonius
4
***
Rhetoric permeates psychiatric discourses of madness, exerting a
powerful, but largely unseen, influence on the institutional development of
scientific knowledge. Persuasive deliberative appeals mediate the boundaries
that divide varieties of madness into discrete disease entities and distinguish
between what is mad and what is sane. These appeals circulate through a
rhetorical economy of technical discourse and social criticism within the
context of public controversy. As knowledge advances, scientists discard
outdated appeals, but discursive forms embodying old institutional logics
leave residues that retain their suasive character. I argue that these
sedimented rhetorical residues play a significant role in many of the
developments and impasses in contemporary psychiatric nosological
controversy.
5
2
Phillip Elias (2010, para. 1).
3
Richard Weaver (1970c, p. 92).
4
Hamlet, Act 2, Scene 2 (Shakespeare, 1904, p. 48).
5
'Nosology' is derived from the Greek words nósos ( ), meaning 'disease' or 'sickness,' νόσος
and lógos ( ) meaning 'word.' λόγος Nosology thus denotes 'words about disease,' and more
2
The locus of inquiry is the recent controversial revision of the
American Psychiatric Association's (APA) Diagnostic and Statistical Manual
of Mental Disorders, now in its fifth edition (DSM5).
6
More than a decade of
technoscientific deliberation about how best to classify mental illnesses
culminated in the May 2013 publication of DSM5, “one the most anticipated
events in the mental health field” (American Psychiatric Association, 2010b).
Its development drew scientists, mental health professionals, professional
societies, patients, and the general public into a web of controversies sitting
at the intersection of the public, technical, and personal spheres of argument
(Goodnight, 1982). These public scientific controversies “embed
epistemological disputes over knowledgeclaims within pragmatic contexts of
public opinion formation in order to achieve intersubjective consensus on
broadbased policies” (Crick & Gabriel, 2010, p. 203). They rise to the level of
“rhetorical crisis” when institutional discourse “fails to fulfill ordinary
specifically refers to the study of the classification of diseases (Brock, 2002).
6
The first four editions of the DSM are distinguished by Roman numerals (e.g., DSMIV). In
a move somewhat reminiscent of Catholic Church's decision to abandon the exclusive use of
Latin in its liturgical celebrations in order “to adapt more suitably to the needs of our own
times those institutions which are subject to change” (Paul VI, 1963, sec. 1), the APA
eschewed Roman numerals for DSM5, offering the scarcely credible explanation that “in the
21st century, when technology allows immediate electronic dissemination of information
worldwide, Roman numerals are especially limiting” (American Psychiatric Association,
2010c). This decision should be understood in light of the criticisms—in which the fifth
edition is almost always referred to as 'DSMV,' incidentally—proffered by individuals closely
associated with the development of DSMIII and DSMIV. This is supported by the timing of
the decision: The APA referred to the revision as 'DSMV' for more than eight years, choosing
to change the name after significant criticism from the former editors appeared. Though
minor, the change supports the position that the older editions contain a nosology that is
limiting, especially given recent scientific and technological developments.
3
epistemological and axiological expectations” (Farrell & Goodnight, 1981, p.
272).
As the world's largest psychiatric association, the APA regards itself as
“the voice and conscience of modern psychiatry” (American Psychiatric
Association, 2011a). Since 1952, the APA has assumed responsibility for the
publication and maintenance of the official formal criteria of psychiatric
nosology, i.e., the classification and diagnosis of mental disorders. The
frequent references in both the popular and scientific media to the diagnostic
handbook as the “Bible of psychiatry” underscore its status as an
authoritative text (Geppert, 2006, p. 14). The APA's deliberative process
infuses the DSM with technical ethos, as the final text codifies the
compromises reached by committees of experts after years of debating the
state of scientific knowledge. The endorsed diagnostic categories and criteria
provide a frame of reference for clinicians, patients, scientists, regulators,
and the members of the public to communicate about mental disorders.
The scope of the manual's influence extends internationally due to its
integration with the International Classification of Diseases, the eleventh
edition (ICD11) of which the World Health Organization (WHO) plans to
publish in 2017. As a matter of public health, the diagnostic criteria
contained in DSM5 directly and indirectly influence the courses of treatment
for hundreds of millions of people around the globe. 'Neuropsychiatric
4
disorders' (the category in which mental illness currently is placed according
to the dominant biological paradigm) are far and away the leading cause
worldwide of healthy life lost due to disability, and make up more than 13%
of the global burden of disease—ahead of cancer, heart disease, and
HIV/AIDS (Collins et al., 2011; McGorry, 2011; World Health Organization,
2008). Health is at “the center of Western politics and culture... Where race,
creed, and class divide us, health offers the possibility of a common language”
(Healy, 1997, p. 1). A good deal of the vocabulary and grammar of that
common language is institutionalized in DSM5.
The creation of a common diagnostic language, however, does more
than merely facilitate a certain form of medical communication. By
institutionalizing a powerful symbolic order that circulates through the
discourses of public policy, scientific research, journalism, mass culture, and
everyday conversation, the DSM facilitates the social distribution of
knowledge about the boundaries between “abnormality and normality,
disease and deviance, symptoms of illness and natural feelings, and states
deserving of sympathy or of stigma” (Grob & Horwitz, 2010, p. 111). The
schemata and worldview embedded in the vocabulary and grammar of the
DSM nosological universe deeply penetrate public consciousness, “[seeping]...
into our art, fiction, theater, movies, language, humor, and our view of
ourselves and our neighbors” (Kirk & Kutchins, 1992, p. 8). Datta (2013)
5
suggests that as “a cultural document whose influence transcends not only
psychiatric practice but also the Western civilization from which it
originates,” the DSM reflects upon and informs our human nature, and every
time it is revised, it “rescripts and reimagines how we make sense of our
experiences, reinterprets what thoughts, feelings and behaviors are socially
sanctioned, and ultimately what it means to be human” (para. 1, my
emphasis).
Federal and state governmental bodies, along with the pharmaceutical
and health insurance industries, the medical research community, and
clinical mental health professionals all rely on the DSM to delimit the
domain of mental illness and thereby make judgments about the medical
status of deviant behavior, subjective distress, and dysfunctional
communication. Attorneys and courts look to DSM diagnostic criteria to
inform their arguments and judgments about a defendant's criminal liability
and mental competence to stand trial. In short, the DSM, and the consensus
it represents, is of great social importance. Threats to that consensus are, in
one way or another, threats to the institutional functioning of society.
In order to examine the controversy surrounding DSM5, I first lay out
the context in this chapter, as this document was produced as an open
successor to the closed biocentric (yet, paradoxically, also etiologically
agnostic) nosology of DSMIII/DSMIV, which itself was an attempt to resolve
6
the dilemmas of mind and body, prognosis and diagnosis, measurement
reliability and construct validity. Once the context is described, I will
identify a range of resources for the interpretation of the document and its
debate. These resources should enable a reading in the complex contexts of
institutional, systems, and lifeworld work that are difficult to unify. This
reading will pay special attention to the roles of diagnosis and the DSM in
the context of risk society, late modernity, and scientific research, clinical
intervention and therapy.
The development of DSM5 provided an exigence that called the field of
psychiatry into a reflexive conversation about its institutional identity. The
need to revise the DSM arose out of an array of historical trajectories in
tension with one another. Those involved in the contested revision process
needed to make use of the terminologies, rhetorical forms, and interpreted
observations that together constituted the field of psychiatry as it was, in
order to advance arguments about what it should become. To argue about
revising an historical trajectory entails developing a narrative relationship
with the past, a consciousness of the historicallysituated nature of one's
rhetorical situation. It also requires legitimation from society at large, which
necessitates the articulation of any new institutionalized categories and
logics in terms compatible with society's selfunderstanding, ideals, anxieties,
rhythms, and prevailing symbolic forms. This dissertation therefore seeks to
7
answer the following research question: When the field of psychiatry
assembles to revise itself, how do previous rhetorical arrangements organize
into new vectors, evolve, and cluster together into what becomes a new
network consensus (or quasiconsensus)?
My major contention is that the inability of psychiatry to resolve a set
of internal dilemmas combined with its temporizing can be understood in
contemporary terms as a politics of the supplement: Such politics are framed
by Derrida (1974) and Lyotard (1991) as ultimately residing within lacunae
in the reflexive projects of the self that individuals, institutions, and society
as a whole pursue. These gaps are ineffable, defined (and thus filled)
imperfectly by the supplement, and are constituted historically: “The already
there of what is lacking [fait défaut], of this unnameable Default [Défaut
innommable] (whether one names it God or not) passes through the unlived
alreadythere of those who once lived and bore witness” (Stiegler, 2001, p.
260). The supplement gives rise to politics because it mediates institutional
power: Foucault (2006) suggests that the “function of psychiatric knowledge”
is “to give the psychiatrist's power a particular stamp, to give it an
additional, supplementary distinction; in other words, the psychiatrist's
knowledge is one of the components by which the disciplinary apparatus
organizes the surpluspower of reality around madness” (p. 233).
The DSM supplements what is lacking in psychiatry's ability to
8
produce knowledge relative to other fields of medicine. It consists of
psychiatric diagnoses, which supplement imperfections in the individual,
attempting to correct the disparity between society's ideal healthy subject
and a patient's lived experience and capacity to function. These diagnoses
signify the biological imperfections that psychopharmacological medications
supplement. Revisions in diagnostic practice supplement the adverse
consequences of these material interventions. And so on:
Everything is supplementary, and yet no supplement can stand in
general for what is supplemented and what supplements... Only the
program—supplementarity—can give the necessity, after the event
[aprèscoup], of the absolute past and the absolute future; only the
program can both compel and interrupt belief just as it can both
compel and forbid the calculation of belief. This “both” has a history, it
is never given except in the singularity of epochs that are traced by the
history of supplementary specificities, notably those of contemporary
technology. (Stiegler, 2001, p. 261)
In other words, the rhetoricity of any formulation of the supplement, the
degree to which it facilitates efforts to compel or interrupt belief (or its
calculation), is situated in a history that leaves its trace in the discursive
residues of past appeals that find reuse in the present.
So, before foregrounding my discussion of DSM5 against the historical
9
backdrop of DSMIII, I shall first examine another important historical
context: an ancient religious synod in which a field of experts set out to revise
its supplemental categories. The leading social institution of the day charged
with managing and mediating technologies of the self required a
standardized and reliable text deriving from consensus and directed toward
maintaining consensus. I shall move from this indirect context to the direct
context of DSMIII. I then discuss the methodological presuppositions that
guide this study.
At the end of this chapter, I provide an outline of the study, which I
preview now. The second chapter takes up the the question of the
relationship between rhetoric and knowledge. There, I argue that a
rhetorical economy provides structure to scientific fields, enabling their
growth and reproduction. As the old means of producing meaning
accumulate, knowledge workers reassemble them into hybrid rhetorical
forms, maintaining a continuity with the past amidst the discontinuous
present. This is less a study of the "hidden rhetorics in knowledge claims"
than of those that are out in the open, in marketing appeals and in public
debate about the benefits and risks of legitimating certain scientific theories
(Ceccarelli, 2001, p. 168). The third and fourth chapters examine the
rhetorical development of two objects of knowledge, psychosis and risk, that
inform the controversy over psychosis risk syndrome, which I argue is a
10
“representative anecdote” of both DSM5 and of late modernity (Burke,
1969a, p. 59). The final chapter summarizes the findings and implications for
the politics of the supplement, discusses limitations of this study, and
suggests future lines of inquiry that might supplement what this study lacks.
Context
Though DSM5 is firmly anchored in the world of late modernity, in
recognition of the “futurity of the past,” I shall pursue a brief excursus on an
institutional crisis that rocked the world of late antiquity (Habermas, 1994,
p. 66). It may seem peculiar to begin a study of a contemporary psychiatric
controversy with an analogy to a premodern religious debate. Psychiatry
today has more in common with yesterday's Christianity than might be
apparent at first glance – just as priests exorcised demons, heard confessions,
and dispensed edible substances with soulhealing properties, psychiatrists
treat psychosis, provide psychotherapy (though this is becoming increasingly
rare), and prescribe psychoactive medication. In a society characterized by
an everincreasing preoccupation with health, psychiatry plays a similar role
as Christianity played in a society concerned with salvation. This may help
to explain why commentators so often refer to the DSM as the 'Bible of
psychiatry.' Direct and indirect references to religious concepts, terms, and
symbols fill the network of discourse produced by psychiatrists about
psychiatry. For example, Geppert (2006) cites “stigma research [indicating]
11
that to be labeled as an 'anorexic' or a 'schizophrenic' may not be all that far
from being branded a sinner or damned in terms of its detrimental effect on
selfimage and future possibilities” (para. 9). I shall develop the broader
analogy between psychiatry and Christianity in greater detail throughout the
dissertation, beginning with the specific historical analogy in this section that
provides important context about the revision process that lead to DSMIII.
At certain times in history, an institutional controversy among
specialists about a highly technical matter manages to set off a societywide
conversation, the topic of which seems somehow to transcend its own scope.
By studying these controversies, it is possible to gain insight about the
historical episteme in which they occur. Each of these controversies provides
society a means to reflect upon its understanding of human nature, society,
and communication. Contemporary psychiatric nosology and ancient
dogmatic theology overlap barely at all, and yet they both provoked
significant controversies characterized by the same level of vehemence and
intensity. I begin with this analogy, therefore, to call attention to the
possibility that the DSM5 controversy can tell us something more general
about the contemporary nature of humanity and the ongoing development of
multiple modernities.
Excursus on L'Affaire Arius
In the first quarter of the fourth century of the Common Era, a grave
12
doctrinal dispute known to historians as the Arian crisis threatened to tear
Christianity in half.
7
The issues debated include the relationship between
God the Father and Jesus, the validity of baptisms performed by heretics, the
status of those Christians who had renounced their faith in the face of torture
and death, and the proper date for the celebration of Easter. At stake was
the institutional legitimation of the Universal Church, which was in
ascendancy in the Roman Empire due to the support it had recently drawn
from the emperor. Two factions, the Arians and the Homoousians, engaged
in a heated theological conflict. The Arians were associated with a presbyter
named Arius who emphasized the difference between God the Father and
Jesus Christ. The Homoousians, whose name derives from the Greek homos
( μ ), meaning 'same,' and ὁ ός ousia ( ), meaning 'essence' or 'being,' οὐσία
insisted that the Father and the Son were consubstantial. At the request of
Emperor Constantine I, approximately 300 bishops (each accompanied by
several priests and deacons) converged upon a small city in Asia Minor
(modern day Turkey) in the summer of 325 to convene the First Council of
Nicaea (Rubenstein, 1999).
Constantine was not driven by a particular theological agenda; indeed,
modern historians (e.g., Williams, 1995) have increasingly emphasized the
7
This controversy has been ignored entirely by argumentation scholars, despite its status as
“the most interesting debate in the West until the struggle between Stalin and Trotsky,”
according to no less an authority than Michel Vovelle (as cited in Rubenstein, 1999, p. xii).
13
importance of his nontheological political and institutional motives. Rather,
he simply wanted the bishops to determine which side was correct and then
agree on a consistent set of beliefs so that there would be unity. In a letter to
Alexander, the first Archbishop of Constantinople, Constantine suggested
that disunity was a threat to public mental health:
Indeed, when an intolerable madness had seized the whole of Africa
because of those who dared with illconsidered frivolity to split the
worship of the population into various factions, and when I personally
desired to put right this disease, the only cure sufficient for the affair
that I could think of was that, after I destroyed the common enemy of
the whole world, who had set his own unlawful will against your holy
synods, I might send some of you to help towards the reconciliation of
those at variance with each other. (Eusebius, 1999, sec. 2.66)
8
For the first time in the history of the Church,
9
an assembly of bishops
8
The quoted text is from a letter preserved by the historian Eusebius, whom modern
historians frequently judge to be unreliable; e.g., Burckhardt (1983) famously called him “the
first thoroughly dishonest historian of antiquity” (p. 283). Caveat lector.
9
I am excluding the most likely nonhistorical 'Council of Jerusalem' described in chapter 15
of the Acts of the Apostles and, most likely, in the second chapter of Paul's Epistle to the
Galatians. Even if the council were an historical event about which we have meaningful
knowledge, it would have taken place long before the emergence of the monarchical
episcopate, and certainly would not have involved temporal authorities (Walker, 2013).
Before the Edict of Milan provided Christianity with official legal recognition in 313, there
were other preecumenical councils, but they were all more or less provincial in scope, and no
reliable records of their written acts were preserved (Wilhelm, 1908). Their significance to
the Church as a whole was roughly analogous to the significance of DSMI and DSMII to the
global institution of psychiatry. Prior to DSM III, according to Robert Spitzer, many
psychiatrists “hadn't the slightest interest in the DSM,” and some prominent psychiatrists
had not even heard of it (R. L. Spitzer, 2000, p. 423). The sporadic anachronistic references
to the DSM in movies and television shows set before 1980, often uttered by nonpsychiatrist
characters, reflect the widespread tendency in our culture to read the present into the past
14
representing all of Christendom, working in cooperation with temporal
authorities, came together to form a consensus about the critical theological
issues of the day and, after a long debate, produced a standardized doctrinal
creed backed by both the official leaders of Christianity and the state
(Ehrman, 2014; Rubenstein, 1999).
In the decades that followed, the council seemed to provoke as many
questions as it resolved. As the council had been silent about the Holy Spirit,
theologians were not yet able to arrive at a comprehensive doctrine of the
Trinity. Leaving it as an open question, teams of theologians working with
the Nicene terminology and schemata produced several lines of research that
appeared to be productive, but in fact were later determined to be heretical
and, thus, epistemic deadends, e.g., the Homoiousian
10
school that taught
that the Son is of a 'similar substance' to the Father, or the Homoian school
that taught that the Son and Father are 'similar in all things,' without taking
a stance about the divine essence (Heather & Matthews, 1991).
Christianity had long been challenged by external critics (both Jewish
and pagan), but the very public denunciations of recognized church
(Syrjamaki, 2011). For example, in the second season of the television show American
Horror Story, set in 1964, four years before DSMII was published, a lesbian journalist says
to a psychiatrist: “According to your bible, the Diagnostic and Statistical Manual of Mental
Disorders, I'm sick” (Uppendahl, 2012). Not only was DSMI not regarded as a 'bible' by
anyone, the suggestion that a nonpsychiatrist with no special interest in mental health in
1964 would have heard of it, let alone that idiom, is risible.
10
The intensity of the conflict between the Homoousian Trinitarians and Homoiousian
heretics suggests that 'one iota of difference' can be significant.
15
authorities by other recognized church authorities that became common
during this period signified a novel historical development. In the process,
what was once in the domain of expert theologians (and before that, strictly
in the personal sphere of private faith) became a public matter, as “debates
on Christian dogma [were drawn] out of the seclusion of churches and made...
a regular topic of discussion in the imperial consistory, in the salons and in
the marketplace” (Sághy, 1999, p. 151). Gregory of Nyssa gives us a sense of
how public (and, in his opinion, insane) this controversy was in
Constantinople in the fourth century:
All the city is full of the controversy—in the public squares, the
markets, the streets, and the alleys; among clothing merchants,
moneychangers, and vendors of food and drink. If you ask someone
for change, he philosophizes to you about the begotten and the
unbegotten. If you ask about the price of bread, the baker replies: “The
Father is greater, and the Son subordinate.” Or if you ask: “Is the bath
serviceable?”, the attendant says that the Son was made out of
nothing. I do not know by what name one should call this malady,
whether it be frenzy, or madness, or some evil epidemic of this sort,
which causes such a derangement of reason.
11
(Gregory of Nyssa, 1863,
11
“ Πάνταγὰρτὰκατὰτὴνπόλιντῶντοιούτωνπεπλήρωται͵οἱστενωποὶ͵αἱἀγοραὶ͵αἱ
μ ? μ πλατεῖαι͵τὰἄ φοδα οἱτῶνἱ ατίωνκάπηλοι͵οἱταῖςτραπέζαιςἐφεστηκότες͵οἱτὰ
μ μ μ . ἐδώδι αἡ ῖνἀπε πολοῦντες Ἐὰνπερὶτῶνὀβολῶνἐρωτήσῃς͵ὁδέσοιπερὶγεννητοῦ
? μ μ καὶἀγεννήτουἐφιλοσόφησεν κἂνπερὶτι ή ατοςἄρτουπύθῃ͵ΜείζωνὁΠατὴρ͵
. ἀποκρίνεται͵καὶὁΥἱὸςὑποχείριος Εἰδὲ͵Τὸλουτρὸνἐπιτήδειόνἐστιν͵εἴποις͵ὁδὲἐξ
16
sec. 557b, my translation)
Participants in this public theological controversy even became reflexively
aware of what we now might call 'conflicts of interest,' as various theological
parties challenged the propriety of their opponents' involvement one way or
another with the secular authorities.
All of this eventually was settled in 381 in the First Council of
Constantinople (Hanson, 1988; Rubenstein, 1999). This, the second
ecumenical council, completed the work Constantine initiated more than 50
years earlier, and produced a set of decrees by which Nicene Christianity was
adopted as the official religion of the Roman Empire, at which point the
ascendance of catholic orthodoxy became official. Genuine advancements in
the development of Christian doctrine followed, as dogmatic theologians were
able to move on from the basic Trinitarian doctrine to pursue higher
Christological questions (Sheldon, 1895). More than 1500 years later, the
doctrinal canons pronounced in Nicaea and Constantinople still provide a
common language and a set of key terms that frame the way in which
Christians profess their faith and discuss matters of religious doctrine. The
recent national conversation about whether Mitt Romney (as a member of the
Church of Jesus Christ of Latter Day Saints, which does not accept the
. μ οὐκὄντωντὸνΥἱὸνεἶναιδιωρίσατο Οὐκοἶδατίχρὴτὸκακὸντοῦτοὀνο άσαι͵
μ μ μ φρενῖτινἢ ανίαν͵ἤτιτοιοῦτονκακὸνἐπιδή ιον͵ὃτῶνλογισ ῶντὴνπαραφορὰν
.” ἐξεργάζεται
17
traditional doctrine of the Trinity) is a “real Christian” testifies to the
enduring historical significance of these two ancient ecumenical councils
(Debevec, 2011).
What is entailed in the claim that Jesus Christ is, to use the words of
the Nicene Creed, “begotten, not made, one in being with the Father,” and
what difference would it make instead to claim that, for example, Jesus
Christ was at one point created? In the fourth century, this was more than a
mere matter of life or death – the implications were sufficiently profound to
attract the attention of the Emperor of the (known) world. Society has
always rested on certain shared takenforgranted but unprovable
assumptions. In the ancient world, they included humanity's epistemic
capacity to know with confidence certain things about the nature of God and
the relationship between God and humanity. These assumptions form the
hidden backbone of the lifeworld, which “for us who wakingly live in it, is
always already there, existing in advance for us, the 'ground' of all praxis
whether theoretical or extratheoretical” (Husserl, 1970, p. 142). Though the
questions taken up in the two ecumenical councils of the fourth century
barely seem meaningful as questions today, they were able to serve as a focal
point for the configuration of important political, economic, and institutional
relationships, because their open and unresolved status threatened to tear
the fabric of the lifeworld. Failure to resolve the Arian controversy meant
18
facing an existential crisis, “the prospect of being overwhelmed by anxieties
that reach to the very roots of [their] coherent sense of 'being in the world'
[and]... the frameworks of existence” (Giddens, 1991, p. 37).
In light of Durkheim's (2001) famous insight that 'God' signifies a
society's apotheosized projection of itself, it becomes perhaps easier to see
some of the sociological and epistemic stakes entailed in a premodern
controversy about the doctrine of the Trinity, which posits that God consists
of three persons. The first of these is associated with “all that is seen and
unseen,” the external objective world (English Language Liturgical
Commission, 1997, l. 4). The second is a human subject who, personifying
language, is known as “the Word,” and accordingly, “through him all things
were made” (l. 12). The third personifies the relationship between the first
two (that is, between the object world and the subject world) while at the
same time, having “spoken through the prophets” (l. 28), represents the
intersubjective world by mediating the relationship between God (society)
and humanity (also society).
12
In this way, I contend, the Arian crisis
precipitated a societywide discussion about itself, the nature of identity,
subjectobject relations, and intersubjectivity that touched every major
institution of the known world. Then, as now, the ontological security of the
12
Kenneth Burke argued that all metaphysics is in fact “coy theology” (1966, p. 45). Though
Durkheim (2001) never deals with the subject of theology in his study of religion, it seems to
me to imply that theology could be reframed as 'coy sociology.'
19
lifeworld depends upon assumptions about the nature and stability of the
objective world, the subjective self, the relationship between subject and
object, and intersubjective relationships. Descartes's (1998) project of radical
doubt later embedded these assumptions in the selfcertain, selfidentical,
rational, and sovereign subject of early modernity. Each of these attributes
has been rendered problematic in our current epoch of late modernity, a
“posttraditional order... [that] institutionalizes the principle of radical doubt”
(Giddens, 1991, pp. 2–3). Just as religion was tasked with these problems in
late antiquity, psychiatry has been tasked with them today.
DSMIII and the Scientific Psychiatry Revolution
Many of the themes and events surrounding the First Council of
Nicaea reappeared in the second half of the twentieth century, as psychiatry
faced a looming institutional legitimation crisis. Criticisms of orthodox
psychiatry became increasingly salient in the public sphere, bringing the
cultural credibility of psychiatric diagnosis into question. One of the most
outspoken critics was the psychiatrist Thomas Szasz, who had achieved some
notoriety among his physician peers for arguing that mental disorders only
are medical illnesses in a metaphorical sense; mental illness, he provocatively
maintained, is a “myth whose function it is to disguise and thus render more
palatable the bitter pill of moral conflicts in human relations” (Szasz, 1960, p.
118). Critical sociologists, particularly those associated with symbolic
20
interactionism, social constructionism, and related theoretical perspectives,
began producing critiques of psychiatry in which they suggested that mental
illness serves as a conceptual apparatus for managing social deviance
(Foucault, 2001; Scheff, 1966; S. P. Spitzer & Denzin, 1968). These critiques
undermined the institutional selfidentity of psychiatry as a medical
discipline, an identity that was “historically weak and vulnerable,” yet served
as the basis for an institutional order in which psychiatry, visàvis other
mental health professions like clinical psychology and clinical social work,
was preeminent (Kirk & Kutchins, 1992, p. 21).
The construct validity of mental disorders as medical illnesses was
further challenged when several meetings of the APA were disrupted by
protesters enraged by the inclusion of homosexuality as a mental illness in
DSMII. Further calling into question the scientific reliability of psychiatric
diagnosis, the scandalous Rosenhan experiment demonstrated that twelve
psychiatric hospitals were incapable of distinguishing between real and fake
patients (Rosenhan, 1973). More than just a scientific problem, the use of
unreliable diagnoses constituted “morally questionable labeling that
stigmatized patients, resulting in negative overall effects” (Wilson & Skodol,
1994, p. 341). Regulatory changes governing the practice of randomized
clinical trials amplified the institutional relevance of the problem of
reliability, which led to the development of specific diagnostic criteria (the
21
Research Diagnostic Criteria [RDC]) written in language stripped of
psychodynamic etiology (Healy, 1997; R. L. Spitzer, Endicott, & Robins,
1978).
In 1974, Robert Spitzer was chosen to chair a committee that would
revise DSMII. He had been involved in the production of DSMII, albeit in a
trivial role. As Spitzer tells it, Ernest Gruenberg, chair of the APA's
Committee on Nomenclature and Statistics, approached him in 1967 (the
year before the APA published DSMII) and asked: “We're finishing work on
DSMII and we need somebody to take notes at committee meetings and
maybe help in editing some of the stuff, would you be interested?” (R. L.
Spitzer, 2000, p. 416).
13
A chance conversation with an activist led to his
organization of a symposium about homosexuality at the the APA's 1973
annual conference. That same year, Judd Marmar, who had publicly come
out against pathologizing homosexuality, became president of the APA.
Marmar knew of Spitzer from his involvement with the symposium. While
Spitzer “had some reputation as a researcher, ...I think he mainly saw me as
somebody who knew the DSM committee stuff. You have to realize also that
at that time it wasn't regarded as that important a job” (p. 418). In 1974,
Spitzer's committee officially declassified homosexuality as a mental disorder
13
His answer betrays the state of field's worldly innocence at the time: “I said to him, 'Well,
is there any money involved?' and he said, 'No, there's no money.' So I had to make a quick
decision and I made the right choice – not to worry about the money” (p. 416).
22
(replacing it with 'sexual orientation disturbance,' which was in turn replaced
by 'egodystonic sexual orientation' in DSMIII and 'sexual disorder not
otherwise specified' in DSMIV), and in the same year, the APA convened its
first ecumenical council of sorts: the DSMIII Task Force.
Two competing factions—the psychoanalytic Freudians and the
biological neoKraepelinians—differed both in the way they conceived of
mental illness and in the technical vocabularies with which they each
classified and diagnosed mental disorders. As the psychodynamic symbolic
universe declined, the biomedical perspective ascended and increasingly
dominated the institutional order that structured the everyday world of
psychiatric practice. In line with Berger and Luckmann's observation that
the “appearance of an alternative symbolic universe poses a threat because
its very existence demonstrates empirically that one's own universe is less
than inevitable,” this conflict called attention to the arbitrary nature of many
psychiatric concepts, about which Szasz famously noted: “If you talk to God,
you are praying; if God talks to you, you have schizophrenia. If the dead talk
to you, you are a spiritualist; if you talk to the dead, you are a schizophrenic”
(Berger & Luckmann, 1966, p. 108; Szasz, 1973, p. 113). The APA explicitly
recognized the RDC in 1980 with the publication of DSMIII, which “was to
be a kind of diagnostic machine, the reliable performance of which would
liberate psychiatry from the idiosyncrasies of subjective judgment” (Lakoff,
23
2000, p. 159).
Those involved frequently characterized the sweeping changes wrought
by DSMIII in terms of Enlightenmentera political insurrection, the
overthrow of psychiatry's psychodynamic Ancien Régime. DSMIII was not
necessarily the subversive agent—that honor went to 'science' itself—but
“perhaps more than any other single event, the publication of DSMIII
demonstrated that American Psychiatry had undergone a revolution”
(Maxmen, 1985, p. 35). For the new psychiatric regime, DSMIII functioned
as a “charter document,” a text that
establishes an organizing framework that specifies what is significant
and draws people's attention to certain rules and relationships. In
other words, the charter defines as authoritative certain ways of seeing
and deflects attention from other ways. It thus stabilizes a particular
reality and sets the terms for future discussion. DSMIII is a charter
document in psychiatry, and the particular reality that it stabilizes is
the biomedical conceptual model of mental illness. (McCarthey, 1991,
p. 358).
As the instrument by which “the ascendance of scientific psychiatry became
official,” DSMIII radically divorced theory from praxis, for “the old
psychiatry derives from theory, the new psychiatry from fact” (Maxmen,
1985, pp. 35, 31, my emphasis).
24
What was the nature of this 'new psychiatry'? Textually, DSMIII was
a monumental change from DSMII. It was 494 pages long, with 265
diagnostic categories, and was later revised in 1987 as the DSMIIIR to be
567 pages long with 292 diagnoses. But changes to specific diagnoses, on
their own or in the aggregate, were not what made DSMIII revolutionary.
For that, we must look to the social drama in which the production of DSM
III served as the central act and examine the motives of its agents.
Robert Spitzer, whose past involvement in the revision of DSMII
secured the institutional ethos of tradition, led the DSMIII task force, which
had a few overarching goals. The first was to standardize diagnostic
practices with other countries, as recent evidence showed marked differences
in diagnostic practices between the United States and Europe, which not only
suggested poor reliability, but also interfered with the international
regulatory process through which a pharmaceutical company can bring drugs
to the market (Gurland et al., 1970). For this, criteria were taken from the
RDC—which Spitzer coauthored—and the Feigner Criteria, and developed
more by consensus during meetings of the committee (Lakoff, 2005). These
criteria left little room for creative interpretation, which had more or less
served as the central diagnostic modus operandi prior to DSMIII. The
second was to remove symptoms and disorders that performed an interpretive
function with respect to etiology and pathogenesis, e.g., “depressive neurosis,”
25
which is the result of “an excessive reaction of depression due to an internal
conflict or to an identifiable event such as the loss of a love object or
cherished possession” (American Psychiatric Association, 1968, p. 40).
Instead, all listed symptoms are descriptive, in colloquial English language, of
behavior or feelings expressed by the patient.
While this latter feature is frequently cited as an innovation of DSM
III, the framers of DSMII believed that they had been guided by that same
principle: “The Committee accepted the fact that different names for the
same thing imply different attitudes and concepts. It has, however, tried to
avoid terms which carry with them implications regarding either the nature
of a disorder or its causes,” although they were “explicit about causal
assumptions when they are integral to a diagnostic concept” (American
Psychiatric Association, 1968, p. viii). The framers of DSMIII would have
preferred to eliminate all diagnostic concepts tied to essential causal
assumptions, but they did retain one: “300.11 Conversion Disorder (or
Hysterical Neurosis, Conversion Type),” the definition of which “is unique in
this classification in that it implies specific mechanisms to account for the
disturbance” (American Psychiatric Association, 1987, p. 257). The real
difference between the way the two manuals implemented this ideal is that
the framers of DSMIII had an ulterior motive: a desire to promote a
biomedical approach by marginalizing psychodynamic nosology. In contrast,
26
when dealing with “diagnostic categories about which there is current
controversy concerning the disorder's nature or cause,” the framers of DSMII
“attempted to select terms which it thought would least bind the judgment of
the user,” not trying “to reconcile [conflicting] views but rather to find terms
which could be used to label the disorders about which they wished to be able
to debate” (American Psychiatric Association, 1968, pp. viii–ix).
DSMIII endorsed an approach to psychiatric nosology grounded in a
biomedical model, in which mental illnesses were understood to be
real, generic entities which cause distress or impairment in
functioning. Further, there is an implication of underlying behavioral,
psychological, or biological dysfunction; that is, the disturbance is not
just in the relationship between the individual and society.
(McCarthey, 1991, p. 361)
This was more than just a new list of disorders to diagnose. It entailed an
institutional logic of practices operating according to a nosological rationality
common to other fields of medicine but new to psychiatry. One of the neo
Kraepelinian reformers, Samuel Guze, described (2000) the basic premise
and implications of this new rationality:
We insisted that psychiatry would make the greatest progress by being
viewed as a medical discipline. This viewpoint has all kinds of
implications as to how patients are thought about and approached. In
27
addition, as in the rest of medicine, research offered the only hope for
the future of our field and it had to include clinical studies, basic
laboratory work and basic epidemiological work. Our basic outlook on
psychoanalysis was that there appeared to be no way to test it and
there were such limited data to support it. (pp. 398399)
A psychiatrist employing the nosological rationality endorsed in DSMIII
classifies a patient by listing his or her basic symptoms, most of which will be
nonspecific, and then gives a diagnosis based on their clustering pattern.
DSMIIIR reinforced this mode of practice by promulgating the 'Structured
Clinical Interview for DSMIIIR' (SCID), an instrument for administering “a
clinical assessment procedure that would not only be linked to DSMIII but
would incorporate several features not present in previous clinical diagnostic
instruments” (R. L. Spitzer, Williams, Gibbon, & First, 1992, p. 624).
As Guze's remark about psychoanalysis suggests, the biomedical
nosological rationality starkly contrasted with psychodynamic nosological
rationality, according to which “each mentally ill patient is seen as an
individual whose symptoms have meaning particular to him or her,” and
which are then interpreted according to the “constructs of intrapsychic
workings and theories of etiology developed by Freud, Adler, or Jung”
(McCarthey, 1991, pp. 361–362). Quite often, the psychoanalyst sees the
patient's symptoms as symbolic artifacts of conflict within his or her
28
unconscious mind. The two rationalities appear to have certain terms and
concepts in common, but they are in fact “incommensurable epistemic
systems” (Lakoff, 2005, p. 164).
Agonistic Marking of Terms
The framers of DSMIII marginalized psychoanalytic rationality by
targeting its key terms. Considerable controversy surrounded the term
'neurosis.' I discuss its relationship to 'psychosis' extensively in Chapter 3.
For now, it is enough to note that their relative meaning, especially in the
nineteenth century, was constantly in flux, as was which of the two terms
was preferred, or 'unmarked.' Chandler explains the semiotic concept of
markedness:
The unmarked form is typically dominant (e.g., statistically within a
text or corpus) and therefore seems to be neutral, normal, and natural.
It is thus transparent – drawing no attention to its invisibly privileged
status, while the deviance of the marked form is salient... Unmarked
marked may thus be read as normdeviation. (Chandler, 2002, p. 112)
By the time DSMIII was in production, 'neurosis' had become the marked
term. While it remained a key term in psychoanalytic theory, proponents of
biological psychiatry believed that it was too vague and unscientific (Bayer &
Spitzer, 1985). Early drafts of DSMIII lacked the word altogether, resulting
in a political backlash from the newly marginalized psychoanalytically
29
oriented psychiatrists.
The conflict was not resolved through recourse to scientific data.
Instead, as historian of psychiatry Hannah Decker tells it, what happened
was more a political power struggle between metaphorically warring parties
than a collaborative scientific research endeavor:
Spitzer's... plan was to propose a “neurotic peace treaty” ...to deal with
the array of challenges on the neurosis issue. The treaty was a
complex threepart measure that would involve changes and additions
to the classification (Axis I and II), the Introduction, and the Glossary
of Technical Terms... To complicate his negotiations further, Spitzer...
faced... rebellion from the Task Force. He had tried to convince them
that his “neurotic peace treaty” was not capitulation or undoing vital
progress, but not all were persuaded... In a memo to the entire Task
Force, [Donald] Klein accused Spitzer of “usurping the authority of the
task force” …[and] charged that Spitzer was weakening in the face of
those who wanted a psychoanalytic influence in DSMIII. Those
arguing for a descriptive treatment of the neuroses in reality wanted
“the term reinserted because they wish a covert affirmation of their
psychogenic hypotheses.” This is “all too painfully obvious,” Klein
went on. He accused Spitzer of engaging in a political maneuver that
was “unworthy of the scientists who are attempting to advance our
30
field via classification and reliable definition.” (Decker, 2013, pp. 283–
284)
This conflict was apparently so significant that there was concern over
whether the APA Board of Trustees would approve the manual.
Chandler's (2002) analysis of marked terms suggests that if the term
'neurosis' could not be “simply subsumed,” then it would be “foregrounded –
presented as different; it is out of the ordinary – an extraordinary deviational
special case which is something other than the standard or default form of
the unmarked term” (p. 112). In the end, that is precisely what occurred:
'Neurosis' was kept in a few instances of diagnostic special pleading,
sometimes following the word 'disorder,' and always in parentheses, e.g.,
“300.40 Dysthymia (or Depressive Neurosis),” a disorder created for this
purpose and retained in DSMIIIR and DSMIV (American Psychiatric
Association, 1987, p. 230). In most other diagnoses in which 'neurosis' had
appeared in DSMIII, the marked term vanished without a whimper. In
DSM5, the term 'dysthymia' was marked in just the same manner as the
discarded term 'neurosis' had been: Diagnosis 300.4 is now called “Persistent
Depressive Disorder (Dysthymia)” (American Psychiatric Association, 2013,
p. 168).
At the time, in a memo outlining his proposal to add the marked terms
'neurotic,' 'neurosis,' and 'psychoneurosis' in various places in the text,
31
Spitzer claimed that it was “not merely a compromise, but is, in fact,
preferable to the previous approach taken by the Task Force toward this very
difficult problem” (as cited in Decker, 2013, p. 284). Years later, however, as
Spitzer explained to David Healy in an interview, he actually thought those
terms were meaningless and his only objective was to pacify his opponents:
A lot of what I had to do was diplomacy. I had to meet with these
people. I came up with all kinds of ways of muting their concerns...
But eventually all these things meant nothing. When DSMIIIR came
out, we dropped the parentheses. Can you imagine that somebody
would now say obsessivecompulsive neurosis? It would just be
absurd. I think history has proven what we did. (R. L. Spitzer, 2000, p.
424)
Spitzer's conclusion relies on the metonymic substitution of effect for cause in
the reduction of the emergence of scientific consensus to 'history,' and it
implies that the marginalization of analytic perspectives in DSMIII was
more of a falsifiable prediction than a determinant of future psychiatric
practice (Lanham, 1991; Vickers, 1988). By the same rhetorical topic, petitio
principii, one might argue that history has proven that the Church made
wise decisions about which books belong in the New Testament canon—after
all, one can find all of them in the Bible! Could anyone imagine that
somebody would now talk about the Apocryphon of James in a sermon?
32
It should be clear by now that the DSM is not the collected results of
impersonal processes of neutrally testing claims against reality. The
militaristic metaphors psychiatrists sometimes use to characterize the
struggles surrounding the DSM suggest that reality is tested only within the
context of a discursive field of battle, which, once captured, must be defended
by an everexpanding epistemic 'military'industrial complex:
Fatefully, perhaps, the victors... withdrew, leaving the defeated
analysts to reposition themselves. Some of the analysts' efforts to
regroup led to their containment behind the sanctions of evidence
based medicine, legal precedents, protocols, and guidelines, which
established substantial “no fly” zones. (Healy, 1999, p. 949)
Having won the battle, the victors built institutional battlements on the
conquered land. I suggest that the DSM is an agonistic instrument that
institutionalizes both a domain of discourse and a set of motives – in other
words, “an act or body of acts... done by agents... and designed (purpose) to
serve as a motivational ground (scene) of subsequent actions, it being thus an
instrument (agency) for the shaping of human relations” (Burke, 1969a, p.
341, emphasis in the original).
DiAgnostic or DiaGnostic: Esotericism in the DSM
DSMIII eliminated the problem of diagnostic unreliability, which had
become “symbolic of the profession's selfdoubts and of its vulnerability to
33
public and scientific criticism,” through a process of mystification that
transformed the unreliable categories and the statistics with which their
reliability was measured (Kirk & Kutchins, 1992, p. 13). Diagnostic
unreliability, which as a cultural problem posed a potential institutional
legitimation crisis, was by DSMIII
transformed from a seriously threatening conceptual and practical
problem into a technical problem, best left to experts who promised
technical solutions. Redefined as a technical problem, diagnostic
reliability lots its simple, intuitive meaning to practitioners and
became, in the hands of a few teams of research psychiatrists, complex
and mystified. (p. 14)
Mystification is not unusual in scientific discourse, but nosological discourse,
because of the nature of its subjectmatter, needs to be accessible to lay
audiences, or at least appear to be accessible.
Psychiatric nosological discourse simultaneously attracts and excludes
public participation, as was noted by Walter Lippmann in an essay on lay
reactions to Freud:
It is clear why we who are laymen [sic] cannot remain entirely passive
about Freud... We ourselves are the subject matter of his science, and
in the most intimate and drastic way. The structure of matter can be
left to objective analysis, but these researches of Freud challenge the
34
very essence of what we call ourselves. They involve the sources of our
character, they carry analysis deeper into the soul of man [sic] than
analysis has ever been carried before... We live in a world where
knowledge is becoming more and more highly specialized, and as
laymen [sic] we cannot hope to have the equipment for adequate
judgment... We are called on to make decisions we are not trained to
make. This is almost the central problem in modern intellectual life.
(Lippmann, 1970, pp. 298–300, emphasis in original)
Georges Clemenceau's famous (though perhaps apocryphal) dictum about war
being too important of a matter to leave to the generals seems especially apt
here.
14
We, all of us, who have human natures, are stakeholders in any
debate about psychiatric nosological discourse.
The neoKraepelinian nosological orientation of DSMIII satisfied this
complex rhetorical exigence. It institutionalized a set of terms that
“permitted communication between experts and... [practitioners], while at the
same time allowing the [practitioner] to communicate with the public,” and
succeeded in holding the field together
by virtue of combining the right measure of simplicity and ambiguity...
[The new nosological terms] succinctly conveyed a meaning that people
thought they could grasp but that in actual fact was like a Rorschach
14
“La guerre! C'est une chose trop grave pour la confier à des militaires” (as cited in
Constable, 2004, p. 79).
35
test, something into which different groups could read whatever
meaning they wished to see. (Healy, 1997, p. 160)
The theoretical development of psychiatry as a scientific field requires a set of
terms that can simplify a very complex matrix of phenomena without
straightforwardly resulting in error or nonsense. They must be rigid enough
to allow for measurements that are scientifically meaningful and reliable, yet
flexible enough to survive the new meanings developed through the processes
of scientific discovery and pharmaceutical marketing.
An authoritative but mysterious text lures its audience in, and
acquires new layers of mystification as that audience presses the text to
disclose its secrets, for a “sacred text... never completely yields up its secrets.
The shadows may be pushed back, but they are never finally dissipated, for
every revelation creates another mystery” (Black, 1992, p. 55). This is true
particularly for texts that present themselves as accessible, both to the lay
public and to scientists. Such epistemic openness widens both apparent
knowledge and mystery, and grants further authority to the institution that
claims expertise at interpreting the text's secrets:
Once a text is credited with high authority it is studied intensely; once
it is so studied it acquires mystery or secrecy. The tradition undergoes
many transformations, but is continuous; revivals of learning did not
destroy but fostered secrecy... The belief that a text might be an open
36
proclamation, available to all, coexisted comfortably with the belief
that it was a repository of secrets. And this quality of sacred books is
inherited by counterparts in the secular canon. Shakespeare is an
inexhaustible source of occult reading... yet at the same time he is
believed to speak plainly, about most of human life, to any literate
layman. Like the scriptures, he is open to all, but at the same time so
dark that special training, organized by an institution of considerable
size, is required for his interpretation. (Kermode, 1979, p. 144)
Much like Shakespeare's corpus, the DSMIII nosology managed to combine
plain language about everyday human experiences, while mystifying
reliability problems and also facilitating esoteric scientific research.
From DSMIII to DSM5
The model of psychopathology established in 1980 with the publication
of DSMIII maintains its institutional hegemony to this day. When “certain
domains of discourse are institutionalized, ...discursive conversations will be
initiated... [that] become a systematically relevant mechanism of learning for
a given society” (Habermas, 1973, p. 25). As an institutional technology for
the regulation of a domain of discourse, DSM provides a terministic screen
that reveals some objects while concealing others. Burke (1969a) insisted
that humanity is constantly searching for “vocabularies that will be faithful
reflections of reality. To this end, they must develop vocabularies that are
37
selections of reality. And any selection must, in certain circumstances,
function as a deflection of reality” (Burke, 1969a, p. 5). No longer primarily
thought of as maladaptive psychological processes, mental disorders have
been transformed into specific medical disease entities that are “defined and
legitimated in terms of characteristic somatic mechanisms” (Rosenberg, 2006,
p. 407). These disorders are illnesses of the brain, rather than the mind.
Since DSMIII, psychiatric diagnostic variables are almost exclusively
categorical, and the function of diagnosis is to identify the presence or
absence of a specific mental disorder, determined by whether the patient
exhibits a minimum number of symptoms. Under this system, for example, if
and only if a patient displays five or more symptoms of depression over a two
week period that cannot be explained by the loss of a loved one,
15
he or she
15
This socalled 'bereavement exclusion' (BE) was very controversially eliminated in DSM5.
Critics argued that it is “normal” for people grieving the death of a loved one to exhibit the
symptoms of depression (Gutting, 2013, para. 4). Supporters of the change countered that a
helpseeking individual should not be denied treatment simply because their symptoms can
be explained as an expression of grief. Further, they argued that most studies in the past 30
years have shown that depressive syndromes in the context of bereavement are not
fundamentally different from depressive syndromes after other major losses — or from
depression appearing “out of the blue.” ...DSM5 rightly recognizes that grief does not
immunize the bereaved person against the ravages of major depression—a potentially lethal
yet highly treatable disorder (Pies, 2013, para. 3, 16).
Importantly, supporters contend that there is a significant difference between bereavement
that looks like a major depressive episode (MDE) and other (perhaps more 'normal')
exhibitions of grief:
MDE and grief are fundamentally different constructs. The former is a medical
condition that is life threatening and often requires treatment; the latter is thought
to be an adaptive, instinctual response to loss that generally does not require
treatment. Although bereaved individuals may feel terribly sad and like “a piece of
themselves” is missing, most do not experience MDE. But just as in the context of
any number of other serious life adversities, some bereaved individuals do experience
MDE. When that happens, the individual may simultaneously experience grief and
MDE. But acknowledging that bereavement can be a severe stressor that may trigger
38
suffers from major depressive disorder. As with diseases like lung cancer or
tuberculosis, there is understood to be a sharp division between the healthy
and the sick. In contrast, a dimensional model of psychopathology would
treat mental disorders as continuous variables. Rather than identifying
whether the patient suffers from a disorder, the diagnostician determines the
degree to which one suffers, under the assumption that the symptoms of the
mental disorder in question are continuously distributed throughout the
general population.
Although a categorical nosology was useful in providing further
contrast with the more dimensional psychodynamic nosology, there is nothing
inherent about the biomedical model that calls for a categorical approach.
The categorical approach does resemble the way in which most non
psychiatric diseases, e.g., lung cancer or tuberculosis, are classified (there are
exceptions, however, like high blood pressure). But those diagnostic
categories are much more mutually exclusive and grounded in physiology
than psychiatric categories. It seems that the primary reason for adopting
the categorical approach was less about science than political economy.
an MDE in a vulnerable person does NOT medicalize or pathologize grief! (Zisook et
al., 2012, p. 441)
Notice the capitalization of the word 'not' and the exclamation point at the end—this is fairly
emphatic prose for its genre (a review article in a refereed scientific journal). I tend to agree
with the change: Would the same critics of the BE oppose a diagnosis of post traumatic stress
disorder (PTSD) for rape victims if they believed that the symptoms of PTSD were 'normal'
for someone who has gone through such a traumatic experience? In any event, removing the
BE furthers the basic project started in DSMIII to eliminate etiological concerns from the
manual.
39
Among the neoKraepelinians involved in the DSMIII Task Force, Samuel
Guze favored excluding many problematic categories, replacing them with a
“label that would indicate what the diagnostic problem was... [which] would
put us on a stronger scientific basis.” His proposal was not embraced:
[The other members of the task force] said we have enough trouble
getting the legitimacy of psychiatric problems accepted by our
colleagues, insurance companies and other agencies. 'If we do what
you're proposing, which makes sense to us scientifically, we think that
not only will we weaken what we are trying to do but we will give the
insurance companies an excuse not to pay us.' ...I bring up this story
because you have to recognize that any classification system is of the
moment. If you look at the rest of medicine, diagnostic systems are
always being sharpened, certain things are being lumped together,
certain things are being pulled apart... I have always taken the
position that when we understand everything about them, some
psychiatric disorders will end up as distinct qualitatively different
conditions and others will be on some sort of continuum. (Guze, 2000,
p. 407)
When DSM5 was conceived, one hope was that it would produce a nosology
similar to what Guze had described, a hybrid of categorical and dimensional
constructs, due to the prevailing belief that “reliance on categorical diagnoses
40
in past research studies may be a major factor in how little we yet know of
the causes and cures of mental disorders” (Kraemer, Shrout, & RubioStipec,
2007, p. 263).
Advocates of dimensional constructs appeal more to the failures of
psychiatric research using categorical constructs than to any positive
evidence in support of dimensional validity. Kupfer, First, and Regier (2002)
argue that the search for specific laboratory markers that could identify any
of the DSMdefined disorders has been fruitless. To the contrary:
Epidemiologic and clinical studies have shown extremely high rates of
comorbidities among the disorders, undermining the hypothesis that
the syndromes represent distinct etiologies... [as well as] a high degree
of shortterm diagnostic instability for many disorders.... Lack of
treatment specificity is the rule rather than the exception. (p. xvii).
Making a similar point, Rounsaville et al. (2002) note that ever since the
publication of the DSMIII, “evidence has accumulated that prototypical
mental disorders such as major depressive disorder, anxiety disorders,
schizophrenia, and bipolar disorder seem to merge imperceptibly both into
one another and into normality” (p. 12). As the assumption of specificity
associated with the germmodel of disease has become increasingly difficult
in psychiatry to justify on scientific grounds, it has also been displaced for
marketpragmatic reasons. Psychiatric disorders and their treatments are a
41
form of knowledge formerly consumed primarily by doctors, but with direct
toconsumer marketing, the patient is becoming the consumer, and as Healy
(1997) notes, “lay views of mental disturbances are more generally
dimensional” (p. 216).
As I've suggested, DSMIII's endorsement of a biomedical model was in
tension with its intentional avoidance of etiological language. Basically,
“DSMIII and its subsequent editions served an essential promissory function
in that they were framed as providing the foundation for future
breakthroughs in psychiatry” (Whooley & Horwitz, 2013, p. 80). This was a
project that had to be completed in multiple stages. Psychiatrists desired
what Freud, in a letter to Jung, called the “indispensable 'organic
explanations' without which a medical man can only feel ill at ease in the life
of the psyche” (1974, p. 68).
16
The psychiatrists behind DSMIII did not trust
such explanations to be forthcoming without first wiping the slate clean,
eliminating all of the psychodynamic baggage that was preventing the
reliable statistical research that could lead to an understanding of
neuropathology. The publication of DSMIII did manage to spur a “research
explosion [that] has raised many more questions than it has answered”
(Michels & Marzuk, 1993, p. 552). Yet, the diagnostic criteria that motivated
16
Freud explained that this is why he remained so preoccupied with “sexual processes,”
which he believed provided that organic foundation, and was “rather annoyed with Bleuler
for his willingness to accept a psychology without sexuality” (p. 68).
42
all of this research in the first place have more or less stayed the same since
1980. Although DSMIV, published in 1994, contained a few important
changes, Allen Frances, the chair of the DSMIV Task Force, described it as a
“mere [footnote] to DSMIII” (Frances, 2010b, para. 4).
The leaders of the DSM5 Task Force believed that the disconnect
between the DSMIII diagnostic criteria and the last 30 years of research
required remedy:
The DSMIII categorical diagnoses with operational criteria... are now
holding us back because the system has not kept up with current
thinking. Clinicians complain that the current DSMIV system poorly
reflects the clinical realities of their patients. Researchers are
skeptical that the existing DSM categories represent a valid basis for
scientific investigations, and accumulating evidence supports this
skepticism. Science has advanced, treatments have advanced, and
clinical practice has advanced since Dr. Frances’ work on DSMIV.
The DSM will become irrelevant if it does not change to reflect these
advances. (Schatzberg, Scully, Jr., Kupfer, & Regier, 2009, para. 7)
Similar sentiments led the National Institute of Mental Health (NIMH) to
propose formal Research Domain Criteria (RDoCs) to foster research that
will
(1) define the pathophysiology of disorders from genes to behavior, (2)
43
map the trajectory of illness to determine when, where, and how to
intervene to preempt disability, (3) develop new interventions based on
a personalized approach to the diverse needs and circumstances of
people with mental illnesses, and (4) strengthen the public health
impact of NIMHsupported research by focusing on dissemination
science and disparities in care. (Insel, 2009, p. 128)
Given the “limited state of evidence in support” of the proposed criteria, Paris
(2013a) argued that “the adoption of RDoCs by the NIMH can only be
described as ideological... Rushing ahead to doubtfully valid spectra that are
not yet rooted in data shows a lack of patience and a lack of judgment” (p.
40).
The given rationale for the radical changes proposed for DSM5 was
scientific progress. One of the core values of science is openness (although, as
we have already seen, sometimes a situation calls for mystification). The
issue of openness and transparency is not simply about including non
experts. It also entails the inclusion or exclusion of various groups within
psychiatry, or more largely within the field of mental health. J. Robert
Oppenheimer, a physicist who played a key role in the development of
nuclear weapons, delivered a magnificent encomium to openness in science
upon resigning in 1945 as director of Los Alamos Laboratory. “Secrecy,” he
argued,
44
strikes at the very root of what science is, and what it is for... It is not
good to be a scientist, and it is not possible, unless you think that it is
of the highest value to share your knowledge, to share it with anyone
who is interested. (Oppenheimer, 2006, p. 51)
This ideal is deeply rooted in Enlightenment ideas about the role of science
and rationality in building an open society.
The scientists selected by the APA for the DSM5 Task Force either did
not share this ideal or were engaged in some (also secret) exercise in special
pleading. In his first public statement about DSM5, Spitzer attacked the
Task Force for its opaqueness, which he contended was incompatible with the
Task Force's scientific aspirations:
I found out how transparent and open the DSMV process was when in
a February email to me from Darrel Regier, M.D., vice chair of the
DSMV Task Force, he informed me that he would not send me a copy
of the minutes of DSMV Task Force meetings as I had repeatedly
requested over the past year. He explained that he and David Kupfer,
M.D., chair of the DSMV Task Force, had come to this decision
because the Board of Trustees believed it was important to “maintain
DSMV confidentiality.” ...I didn't know whether to laugh or cry.
Laugh—because there is no way task force and work group members
can be made to refrain from discussing the developing DSMV with
45
their colleagues. Cry—because this unprecedented attempt to revise
DSM in secrecy indicates a failure to understand that revising a
diagnostic manual—as a scientific process—benefits from the very
exchange of information that is prohibited by the confidentiality
agreement. (R. L. Spitzer, 2008a, p. 26)
The APA found it difficult to defend against such poignant criticism from
such an esteemed critic, which spawned a very public controversy, filled with
action and conflict between protagonists and antagonists. As Decker
observed: “Rarely has the medical world—and the general public, for that
matter—been witness to an open drama such has taken place... in response to
a medical association’s [decision] to revise its diagnostic categories” (Decker,
2010, para. 1).
The APA's justification for the secrecy, that it was necessary to prevent
the pharmaceutical industry (or anyone else) from stealing the APA's
intellectual property rights, raised more questions than it answered.
17
To
what nefarious ends would these nosological pirates put their illicitly
obtained knowledge, if not scientific research? And aren't 70% of the Task
Force members on Pharma's payroll in one way or another anyway (Collier,
17
Darrel Regier also claimed that it would just take too much time to deal with every public
response, many of which would undoubtedly be trivial or premised upon a misunderstanding.
Spitzer found this argument scarcely credible: “Making the DSMV process transparent by
posting the minutes on a public web site, as the WHO does for the ICD11 revision groups,
does not obligate the APA to respond to 'every spontaneous response.' How much time does
it take to ignore a crackpot blog posting?” (R. L. Spitzer, 2008b, p. 2).
46
2010)? It did not take long for the APA to determine that this was an
unwinnable fight, and so they shifted gears, and published thousands of
pages of information about the thenongoing development of DSM5 online
(dsm5.org), though they maintained the confidentiality agreements.
In 2010, amidst concerns about transparency and openness, the APA
published preliminary draft revisions, along with notes and other details
from the DSM5 Task Force and Work Groups, on the Internet (dsm5.org),
and solicited public comment over three twomonth periods. During this
time, more than 500,000 people visited the website, and the APA received
more 13,000 signed responses (American Psychiatric Association, 2013;
Moyer, 2010). Then, in an article defending his decisions, DSM5 Task Force
Chair David Kupfer suggested that the development process “has been highly
visible, transparent to an unprecedented degree, and inclusive” (Kupfer,
2012, para. 4). The DSM5 development webpage echoed the claim that the
DSM5 development process is 'open and inclusive' in several places. The
high level of interest DSM5 has garnered reflects the controversial nature of
its subject matter and the scope of its influence: “The power of DSM
throughout the world should not be underestimated, and it is the problem for
all the psychiatrists of the future—at least until the DSM6 is written” (Fink,
2010, p. 6).
I suggest that the digital public space in which the nosological
47
controversies surrounding DSM5 took (and continue to take) place should be
understood as a 'hybrid forum.' As described by Callon, Lascoumes, and
Barthe (2009), hybrid forums are
open spaces where groups can come together to discuss technical
options involving the collective, [and] ...the groups involved and the
spokespersons claiming to represent them are heterogeneous,
including experts, politicians, technicians, and laypersons who
consider themselves involved... [The] questions and problems taken up
are addressed at different levels in a variety of domains. (Callon et al.,
2009, p. 18)
While it is not uncommon for scholarship on scientific controversy to take a
negative view of its objects—pitting experts against commercial actors or lay
publics (apologetically defending the legitimacy of one group's concerns over
and against those of its interlocutors), or viewing the dissensus either
tragically (e.g., the product of deception) or comically (e.g., a benign
communication failure)—the concept of hybrid forum calls attention to a
more appreciative view:
When scientific expertise and political voluntarism adopt the form of
an authoritative discourse, they fail to respond to the questions of
concerned citizens... [Controversies] are not just a useful means for
circulating information. Nor are they reducible to simple ideological
48
battles. With the hybrid forums in which they develop, they are
powerful apparatuses for exploring and learning about worlds... [and]
overflows engendered by the development of science and techniques.
Overflows are inseparably technical and social, and they give rise to
unexpected problems by giving prominence to unforeseen effects... The
controversy carries out an inventory of the situation that aims less at
establishing the truth of the facts than at making the situation
intelligible. This inventory focuses first on the groups concerned, on
their interests and identities... The distribution is not known in
advance but is revealed as the controversy develops, and it is precisely
for this reason that the latter is an apparatus of exploration that
makes possible the discovery of what and who make up society.
(Callon et al., 2009, p. 28, emphasis in original)
The digitally contested development of DSM5 represents more than just a
potential legitimation crisis for the institution of psychiatry, but an overflow
through which citizens, science, and therapeutic institutions established a
new relationship with one another, restructuring the way in which scientists
and practitioners produce and understand psychiatric knowledge.
Although psychiatric diagnostic controversies are older than
psychiatry itself, the debates surrounding DSM5 are unique in that they
have been unfolding in a digital public sphere. In contrast to past
49
controversies that were either primarily driven by institutional outsiders
(e.g., the antipsychiatry movement) or motivated by ideological divisions,
two of the loudest and most influential critics of DSM5 were (and are) the
lead editors of the previous two editions of the DSM, Robert Spitzer and,
especially, Allen Frances.
Method to My Madness
This study is antisystematic by design.
18
It proceeds via an
interdisciplinary theoretical synthesis punctuated by rhetoricalcritical
vignettes of relevant texts. By the end of the study, the narratives dissolve
into a few very specific arguments, but there was no specific theory I set out
to prove, or hypothesis to test, before examining the data. Instead, I took an
iterative approach, studying the relevant texts inductively, and appealing to
theory to facilitate description and interpretation. The theoretical contents of
this dissertation constitute means rather than ends.
The DSM5 controversies consist of public texts, my readings of which
are rhetorical. I am guided by Gaonkar's (1997a) proposal to view
public discourse as if it were a turnstile, with speaking subjects rapidly
18
I have eschewed the alltoocommon practice of including a separate chapter or extensive
prologue on 'methodology,' which usually functions as “something of a ritual, an invocation to
the presiding deities of scientific method, serving to ensure an appropriately 'scientific'
status for what follows, and avowing the proper concern with meeting standards of scientific
acceptability” (Kaplan, 1964, p. 20). I burn no incense at the altar of methodology, which “is
no more the precondition of fruitful intellectual work than the knowledge of anatomy is the
precondition for correct walking” (Weber, 1949, p. 115). In my judgment, what sometimes
goes under the name of 'methodological rigor' is, in fact, intellectual laziness.
50
entering and exiting, bearing dead metaphors, usable traditions,
fragmented arguments, recycled images, and worn emotions. In this
mobile economy of public signs and affects, innovation is
indistinguishable from bricolage and every attempt at individual
voicing gets effaced by the imploding heteroglossia. (Gaonkar, 1997a,
p. 352)
Gaonkar's suggestion points to the idea of a rhetorical economy in which
market dynamics trump the individual judgments of epistemic analysts and
opinionleaders. He also suggests a methodological principle for this study,
namely, to search “the public text not to ascertain the authorial signature,
but to map the condition of its existence, the mode of its dissemination, and
the force of its articulation” (p. 352). The surface of a public text is “a layered
and sedimented space, where the visible and the invisible are continuous” (p.
351). I maintain that the rhetorical residues left by the articulations of a
text's historical predecessors constitute the conditions of its existence, supply
the terministic resources with which it may be disseminated, and enable
rhetors to deploy the text persuasively.
Grounded Theory
Gaonkar cautions that “in the humanities one has to worry about how
one's critical probes might become estranged and vagrant by a mere contact
with the object of analysis” (p. 352). I therefore attempt to ground my
51
theoretical interpretations of rhetorical dynamics in the hermeneutic insights
proffered by the actors who are engaged in the controversies. The
interlocutors in the DSM5 controversy offer a rich supply of speculative
theoretical explanations for the developments about which they argue. My
primary goal is to describe the controversies, and to provide an opportunity
for the actors involved to explain themselves. While I delve into debates
about specific diagnostic controversies here and arguments over procedure or
nosological theory there, I do not attempt to discuss every single DSM5
controversy, nor do I devote equal time to the controversies I do discuss.
When I focus deeply on specific controversies (e.g., over psychosis risk
syndrome in Chapter 4), it is because it has become clear that the controversy
functions as a representative anecdote or synecdochic signifier of a key
coalescing global issue or constellation of issues.
I largely view the DSM5 controversy as a substrate of a psychiatric
'actornetwork,' to use Latour's (2005) term. I follow Habermas' (2005)
synthesis of conceptual nominalism with epistemic realism. With respect to
mental illness, though my beliefs are largely irrelevant, I should state them
for the record: The constellations of behaviors and experiences categorized as
mental illnesses all have some objective material biological basis (I regard
the Cartesian division between mind and body as epistemic rather than
metaphysical), but, as specific disease entities, they are socially constructed.
52
I have no strong opinion in either direction about whether the ongoing move
toward a nosology grounded in neurobiological explanations will lead to
better treatment outcomes, though I suspect it depends upon the particular
disorder.
One feature of the DSM5 controversies is that identity of the
argumentation field in which the controversy occurs is contested. Defenders
of DSM5, particularly institutional authorities, argue that the controversies
are fundamentally scientific in nature. Psychiatry as a field of science
functions both as a symbolic order, with a fairly clear hierarchy of values and
dialectical terms, and as a terministic screen, in which some aspects of the
controversy are revealed while others are rendered invisible. Many critics of
DSM5 view psychiatry through the lens of political economy, and accordingly
prioritize forces of production and market relations in their argumentative
narratives. This goes beyond focusing discussion on the literal
pharmaceutical drug market. For example, Healy argues that “drugs are
clearly commodities to be traded in the marketplace, but scientific ideas are
also tradable commodities” (Healy, 1997, p. 180). Similarly, Allen Frances
warns that “DSM5 will further inflate the ADD Bubble” (Frances, 2011b, l.
1).
Rhetorical History
The schizophrenic patient, the “paradigmatic figure” of psychiatry, has
53
a relatively short history as an object of knowledge (Foucault, 2006;
Lagrange, 2006, p. 361). Ever since the term ‘schizophrenia’ was coined in
1911—or perhaps even earlier, when the disorder was known as ‘dementia
praecox’—the diagnosis has served as a nosological exemplar, the archetypal
reduction of some varieties of madness to a unified formal clinical syndrome
(Bleuler, 1911b). If depression (qua ‘neurosis’) is the common cold of
psychiatry, schizophrenia (qua ‘psychosis’) is its cancer. My description of the
nosological scene in which schizophrenia (or its equivalent) acts follows from
a close reading of the constitutive features of the disorder, along with the
periodic controversies that have surrounded efforts to formalize those
features.
Critical communication inquiry requires the analysis of the
contradictions and trajectories of history. Adorno (1976) suggests that society
is neither consistent, nor simple, nor neutrally left to the discretion of
categorical formulation. Rather, on the contrary, it is anticipated by its
object as the categorical system of discursive logic. Society is full of
contradictions and yet determinable; rational and irrational in one; a
system and yet fragmented; blind nature and yet mediated by
consciousness. The sociological mode of procedure must bow to this. (p.
105)
These contradictions are the source of public controversy. They arise when
54
symbolic forms, i.e., relationships between communicative action and its
object, come into conflict with one another. These conflicts occur after the
relationships become taken for granted as 'things' in the world, their
historical nature concealed. To counter this, Pryor (1981) suggests that
critical communication inquiry requires an historical approach:
Any critical analysis of communication would have to be historical and
developmental in nature; it would have to consider particular forms of
communication within a framework of movement... Critical analysis
would see communication as the practice of interacting persons who
are socially and biologically determined... As a form of historical
analysis, the critique of communication would account for the
development of structures which give rise to the particular
communicative encounter and the actors' interpretations or definitions
of that encounter... Analysis, then, would focus on the emergence of
phenomena and the determination of objects over time, as they are
formed and decay. (p. 28)
Therefore, I must examine the history of our categories of psychosis, risk,
health, and medicine. To support my claim that contemporary scientific
appeals hybridize and recirculate past rhetorical forms, I will move from
historical narrative to present controversy whenever I hit upon a critical
juncture in the rhetorical history of a present diagnostic controversy. For
55
example, in Chapter 3, I begin my historical analysis of psychosis by
examining the humoral model of pathology, which dominated the field of
medicine for the vast majority of its existence. This provides insight into the
contemporary marketing appeals of alternative medicine. The historical
origins of hysteria is the starting point of an analysis of the controversy over
conversion disorder (or functional neurological disorder, as the Somatic
Symptoms Work Group would have preferred). The first psychiatric
nosological textbook, written by JeanÉtienne Dominique Esquirol,
established a framework for visual rhetoric used today in both
pharmaceutical advertising and brain imaging discourses. In this way,
Chapter 3 moves back and forth between dialectical history and
contemporary controversy.
I suggest that our representations of psychosis and risk at any given
time bear the signature of the phase of modernity (or premodernity) from
which they proceed. To support this claim, I read psychosis both
synchronically and diachronically. The synchronic analysis of a controversy
about terminologies for psychosis can produce larger insights about the
contemporary symbolic orders and material relations at work in society at the
time of the controversy, just as a diachronic analysis of such controversies
can produce larger insights about the temporal arc of modernity. The inverse
is also true; macrosocial understandings can shed light on the particularities
56
of the microcosmic controversies themselves.
Rhetoric of Inquiry
In addition to examining heated rhetorical texts about the DSM, this
dissertation examines the DSM as a rhetorical text. The DSM is produced
within a larger conversation about psychiatric diagnosis, and so these texts
reflexively relate to one another. Scientific classification is an epistemic
process by which “our mind or our brain transforms physical facts into
mental entities” (Hayek, 1955, p. 48). Inverting this formula, the
classification of the disorders of our mind or our brain becomes a rhetorical
process by which the DSM apparatus transforms mental entities into
physical facts. Due to the limited understanding of etiology (causes) and
pathogenesis (processes) of mental illness, “the concept of psychiatric
diagnosis is an especially thorny one... and, in fact, in no other field of
medicine are there as many endless controversies about diagnosis as there
are in psychiatry” (Paris, 2008, p. 38).
These controversies inseparably fuse episteme and phronesis into
rhetorical trajectories, which flow out of, and are designed to suture, ruptures
within standing practice. In this context, 'practice' refers to
any coherent and complex form of socially established cooperative
human activity through which goods internal to that form of activity
are realized in the course of trying to achieve those standards of
57
excellence which are appropriate to, and partially definitive of, that
form of activity, with the result that human powers to achieve
excellence, and human conceptions of the ends and goods involved, are
systematically extended. (MacIntyre, 2007, p. 187)
Revising DSM entails reformulating an institutional logic that underwrites
standards of psychiatric practice.
This institutional logic governs what Schiappa calls “definitive
discourse—discourse that defines, whether in an explicit discourse about a
definition, discourse that argues from a particular definition, or discourse
that stipulates a view of reality via an argument by definition” (2003, p. xi).
Schiappa argues:
[Definitional] disputes should be treated less as philosophical or
scientific questions of “is” and more as sociopolitical and pragmatic
questions of “ought.” ...Definitions put into practice a special sort of
social knowledge—a shared understanding among people about
themselves, the objects of their world, and how they ought to use
language. Such social knowledge typically takes the form of an explicit
and often “authoritative” articulation of what particular words mean
and how they should be used to refer to reality... [The] difference
between those definitions that are accepted and used and those that
are not is a matter of persuasion; hence, many arguments concerning
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definitions are open to rhetorical analysis. (Schiappa, 2003, p. 3)
Robert Spitzer, who directed a major revision to DSM in 1980, suggested that
psychiatric nosology “defines what is the reality. It's the thing that says this
is our professional responsibility, this is what we deal with. Once it means
something, it's bound to have importance” (2000, p. 427). Particularly in
psychiatry, definitional disputes are inherently biopolitical, as the “struggle
for definition is veritably the struggle for life itself” (Szasz, 1973, p. 121).
Kenneth Burke (1969a) argues that the rhetorical function of
definition is to establish boundaries: “To tell what a thing is, you place it in
terms of something else” (p. 24). Definitions also place objects of knowledge
strategically within a dramatic narrative, which for Burke consists of five
basic elements: “Act, Scene, Agent, Agency, [and] Purpose” (p. xv). These are
the places within a drama in which rhetorical motives are expressed.
Redefinition allows people to formulate new attitudes toward a situation,
changing “not only recognizable patterns of behavior, but also our
understanding of the world” (Schiappa, 1993, pp. 406–407). Critically, this
bears on the status of psychiatry as a science, for many empirical
observations “are but implications of the particular terminology in terms of
which the observations are made” (Burke, 1966, p. 46). Palczewski (1994)
argues that when the key definitions of a field “become the explicit subject of
public argument,” a rhetorical movement forms in the “space between the
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system and lifeworld... [challenging] traditional distinctions between
objective, subjective, and intersubjective” (pp. 3941).
Rhetorical Subjectivity
Psychiatric practice is a collection of simultaneously scientific,
political, market, and cultural phenomena. Further complicating the matter,
psychiatry's multiple personalities are deeply interconnected. One cannot
elucidate its operation as a scientific system without first considering how it
works as an institution situated within both market and lifeworld (or, even
better, within a series of markets and lifeworlds). And yet each of these
natures carries different (and mutually exclusive) systemic imperatives, as
well as distinct modes and capacities to invent and evaluate arguments.
These insights should draw our attention to arguments that invoke
particular institutional identities for psychiatry.
Rhetorical Objectivity
I also pay close attention to appeals to the real. Realities “are the
product of social definitions and as such far from equal in status. Realities
are contested, and textual representations are sights of struggle” (Chandler,
2002, p. 65). Among the sea of syntagmatic substitutions and transpositions
that constitute the formal elements of a rhetorical economy, pairs of terms
positioned in binary opposition are of special importance:
The oppositional tensions that ferment within a universe of discourse
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are signaled by its vocabulary, especially its antonyms. Public/private,
liberal/conservative, radical/moderate, individual/societal: such pairs of
antonyms are the matrices of rhetorical activity. They signify fields of
judgment. They designate the topoi—the places—where commitments
of political and moral significance are made and unmade... The “places”
where rhetorical activity may occur are marked by the presence of
linguistic antonyms. They are symptoms of the capacity of language to
support both an affirmation and a denial—a contradiction, either
moiety of which is a linguistic possibility... Because antonymity may be
a locus for rhetorical activity, the thorough explication of an antonym
would include an inventory of the argumentative configurations
possible to it. The ways in which commitments are solicited and given
—the structures of persuasion and conviction—should be illuminated
by such an examination. (Black, 1992, p. 52)
Many linguistic antonyms are loadbearing features of the polytechtonic
rhetoric of psychiatric nosology. The opposition of psychosis/neurosis, which I
have already touched upon and will discuss extensively in Chapter 3, is an
important example. Other linguistic antonyms of note include mind/body
(and variations like psychological/biological), categorical/dimensional,
deficiency/excess, balance/imbalance, ontological/physiological,
melancholia/mania, and normophilic/paraphilic. Linguistic antonyms
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indicate where the rhetorical action is, and they can also serve as reference
points when charting a symbol's dynamically changing meaning. For
example, as I detail in Chapter 4, the term 'risk' is synonymous with 'danger'
at one time, and antonymous at another.
Rhetorical Intersubjectivity
If the meanings of psychiatric terms, concepts, and theories are
constantly in flux, how do different institutional actors communicate with one
another coherently? Action coordination depends on the ability of the
complicated network of actors involved in psychiatric practice to
communicate with one another (Baxter, 1987). Some scholarship in the field
of the rhetoric of science grapples with this problem. For example, Galison
(2000) studied the way in which theoretical physicists, experimental
physicists, and nonacademic engineers working in the field of high energy
physics communicate with one another. Despite working within different
epistemic paradigms, the scientists were able to communicate with one
another – at least sufficiently enough to coordinate action successfully,
though often they could not fully understand one another despite using the
same terminology. Galison argued that their patterns of communication
resembled what anthropologists call a ‘contact language,’ a pidgin language
that emerges when, for example, members of two distinct cultures without a
shared language need to communicate in order to facilitate trade. Cooper
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(2007) argues that the DSM is the lexicon for a contact language that
“facilitates interparadigm communication by enabling professionals to
bracket off much of what they believe for particular purposes” (p. 95).
Social Study of Science
As such, the nosological system presented in DSM is a communication
technology. Though conceptual, it is no less a technology than any material
feat of engineering. In order for a medical technology to transform into a
consumer product, it must “travel from the medical domain, relinquishing its
cultural script as a measured, controlled, specific and potent therapy, to enter
other social worlds. In this process, new cultural meanings must accrue...
'rescripting' and/or 'resculpting' the technologies' purpose” (Coveney,
Williams, & Gabe, 2011, p. 379). This process is rhetorical, and in it lies a
great deal of inventional potential, although the potential for
miscommunication and unintended consequences is ever present. To help
elucidate what is going on, I will draw on scholarship from the fields of
science, technology, and society [STS] and the rhetoric of science.
The social study of science and technology is a fairly young field.
Historically, scholars focused on the ‘macroenvironment’ in which science
occurs, emphasizing the contingency of scientific discovery by focusing on
external material and institutional historical contexts that shaped the
production of scientific knowledge. More recently, scholarship has turned to
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the 'microenvironment,' analyzing the material items that mediate the
scientific process. Rhetorical studies of science in this vein strove to
demonstrate the many ways in which the objects of science, i.e., “epistemic
things... [consisting of] unstable concatenations of representations,” are also
symbolic (Rheinberger, 1997, pp. 28–29). In this study, macro and micro
converge, because DSM5 institutionalizes a particular understanding of the
objects of psychiatry in order to facilitate communication across a network of
diverse actors. Psychiatric discourse is both suasive and epistemic, and
diagnosis is both a scientificallyinformed medical judgment and a
commodity.
The arrangement of objects institutionalized by DSM5 accords with a
neurobiological paradigm of mental illness, in which all mental disorders are
understood to “[reflect] an underlying psychobiological dysfunction”
(American Psychiatric Association, 2010d). Daston (2000) identifies four
important concepts in the rhetorical study of scientific objects: emergence, the
process by which new scientific phenomena come into being as objects of
inquiry; salience, the process by which old scientific phenomena that have
acquired a marginalized status regain the attention of science; productivity,
the degree to which an object of science can be used to produce scientific
knowledge; and embeddedness, the quality of being situated in material
networks of practice. Each of these concepts is relevant to the development of
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this modern paradigm. In examining the productivity of the paradigm, I do
not limit myself to its scientific productivity. Instead, I describe all of the
strategic results of the paradigm, which has been productive commercially in
facilitating the marketing of pharmaceuticals; productive ideologically in
helping institutional apologists engage the arguments of critics; productive
politically—in the sense of Giddens's (1991) notion of life politics—in helping
individuals and groups define their identities, as well as build solidarity with
one another; and productive culturally, effecting in the lifeworld changes in
the way people conceptualize human nature and the mind.
In line with Shea's observation that “metaphors that are central (or
fundamental) to a scientific discipline are less obviously figurative and more
likely to be taken literally,” I examine the role of metaphors in the rhetoric of
neurobiological psychiatry (Shea, 2008, p. 125). To do this, I draw on the
work of Rosenman (2008), who cataloged several important psychiatric
metaphors. In addition to metaphors that appear directly in DSM5, I look for
prominent metaphors in pharmaceutical advertising and categorizing as well
as in the lay theorizing of those diagnosed with a mental disorder.
As rhetoric is the counterpart to dialect, so is 'biomythology' the
counterpart to the neurobiological scientific paradigm. In order to study
biomythology, I examine what Healy calls “biobabble,” which
refers to things like the supposed lowering of serotonin levels and the
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chemical imbalance that are said to lie at the heart of mood disorders,
ADHD, and anxiety disorders. This is as mythical as the supposed
alterations of libido that Freudian theory says are at the heart of
psychodynamic disorders. While libido and serotonin are real things,
the way these terms were once used by psychoanalysts and by
psychopharmacologists now—especially in the way they have seeped
into popular culture—bears no relationship to any underlying
serotonin level or measurable chemical imbalance or disorder of libido.
What's astonishing is how quickly these terms were taken up by
popular culture, and how widely, with so many people now routinely
referring [to] their serotonin levels being out of whack when they are
feeling wrong or unwell. (Lane, 2009, para. 1–2)
This form of discourse appears in a variety of places, reinforced by the
appearance of scientific authority.
Materials
This study examines how changes in psychiatric nosology are
discussed in the rhetoric of social movements, the mass media, public
hearings, and in the internal institutional discourse. I aim to explain how
the artistic (ethos, logos, pathos) and inartistic (statistics, metaphors, etc.)
proofs circulate alongside the rhetorical motives to which they are attached,
and how they change when recirculated. I also pay careful attention to how
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the rhetorical contours of institutional discourse privilege or constrain the
various speakers. In order to understand the attendant controversies from a
variety of angles, especially DSM5's importance in facilitating
communication among diverse social actors, I examine the following textual
sources, in addition to DSM5 itself and books written by the DSM5 Task
Force members:
(1) Popular Media
With the publication of Peter Kramer's (1993) Listening to Prozac,
along with coverpage articles about Prozac in the New York Times (Rimer,
1993) and Newsweek (Begley, 1994; Cowley, 1994; Cowley, Springen,
Leonard, Robins, & Gordon, 1990), hailing Prozac as a 'wonder drug,'
Prozac had become a media event, a subject for public debate and for
inclusion in screenplays. Far from being unique in this, however, it
was following a trail blazed by the bromides, the barbiturates,
Miltown, and Valium before it. The mythology wheeled out—that its
creation was a rational process, that it was a designer drug—had
echoes in the 1955 reception of Miltown as the penicillin for anxiety.
(Healy, 1997, p. 226)
This tradition continues with DSM5. Opeds about the controversy have
appeared in dozens of major newspapers. As of January 2014, there are 203
articles in the LexisNexis news database in which the phrase “DSMV” or
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“DSM5” appears 5 or more times, with titles like “Bad behavior isn't an
illness: The manual that psychiatrists use to diagnose mental disorders is too
quick to classify moral lapses as fullblown pathologies,” (Los Angeles Times,
November 5, 2013), “Psychiatry in crisis: Infighting, boycotts, resignations
mark fierce debate over diagnoses” (The Vancouver Sun, May 18, 2013),
“Debate hot on bible of psychiatry” (Chicago Times, August 9, 2011), “The
fight over a new edition of psychiatry's 'bible' reveals a field out of balance:
Addicted to dealing drugs and deluded about its grasp of the mind, Ian
Brown makes a diagnosis” (The Globe and Mail, July 9, 2011), “Psychiatry
trying to get its disorders in order; Guide's scope will decide how – or even
what – to treat” (Chicago Tribune, May 31, 2009), etc. An analysis of these
texts illuminates the ways in which the arguments in the institutional media
are reconfigured and realigned.
(2) The “DSM5 Development” Website
During the development process, the APA presented its preliminary
draft revisions (over several iterations), rationales, and public comments on
the DSM5 on an official “DSM5 Development” website (dsm5.org), which
was taken down shortly before publication in 2013 (to protect the APA's
intellectual property after final decisions were made). The way in which the
website framed the DSM5 is of particular importance. For example, there
was a list of criteria one must meet in order to be qualified to join the DSM5
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Task Force or any DSM5 Work Group. Given the explicit scientific
justification for the DSM5 project, one might expect this list to include
necessary scientific credentials. On the contrary, the criteria are as follows:
• Serve without remuneration for their services with the exception of
the DSM5 Task Force Chair. • Not serve on a work group with a
spouse, domestic partner, or firstdegree family member. • Receive no
more than $10,000 annually in the aggregate from pharmaceutical
companies/device makers/ biotechnology companies and similar
industry entities for direct services, such as consultancies, advisory
committee positions, forensic assistance, speakers’ bureau services, etc.
(These “industry entities” do not include clinical practices, hospitals,
nonprofit organizations, managed care organizations, universitybased
lectures, and similar activities.) • Not hold stock or shares worth more
than $50,000 in the aggregate in pharmaceutical companies/device
makers/biotechnology companies and similar healthcare related
commercial ventures or receive more than $10,000 annually in the
aggregate in dividends from such sources. Stock and shares held in
mutual funds, pension or retirement funds, blind trusts, and similar
arrangements do not count toward these limits. • Abstain from
participating in any capacity in Industry Sponsored Symposia at an
APA Annual Meeting during their task force and/or work group tenure
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after 2007. (American Psychiatric Association, 2010a)
This list clearly constitutes an argument about the propriety of the DSM5
procedures. It implies the existence of a particular criticism about the undue
influence of the pharmaceutical industry in the process. Likewise, a
discussion of the possible new diagnoses begins with the following statement:
“The goal of DSM is to establish clear criteria for diagnosing mental
disorders, not to create medical conditions out of the full range of human
behavior and emotions” (American Psychiatric Association, 2010c, para. 34).
Though the website presents itself as informative rather than polemical, its
framing of the issues betrays a heated dispute, as argument “presupposes
two distinguishable participant roles, that of a 'protagonist' and that of a—
real or imagined—'antagonist'” (van Eemeren, Grootendorst, Johnson,
Plantin, & Willard, 1996, p. 277).
(3) Primary and Secondary Institutional Media
As it turns out, the APA's real antagonists published heavily in
institutional media, which include the two publications of the APA, the
American Journal of Psychiatry and Psychiatric News, along with other
important outlets like Psychiatric Times, Psychology Today, the British
Journal of Psychiatry, and The Journal of the American Academy of
Psychiatry and Law. Of particular importance are the criticisms of DSM5
offered by Robert Spitzer and Allen Frances, who chaired the task forces that
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developed DSMIII and DSMIV, respectively. Describing this conflict as an
historic crisis of legitimacy for psychiatry as an institution, Decker observed:
A war broke out with unlikely sides: Two former editors of the
American Psychiatric Association’s (APA) Diagnostic and Statistical
Manual (DSM) on the one side and, on the other, the officers of the
APA and the leaders of the APA’s current Task Force that is revising
the DSM. Because of the Internet, the battle has been very public, and
the APA has found itself on the defensive as it became repeatedly
bombarded by open letters and columns in various media outlets.
These missives were immediately seized on by multiple bloggers. The
hallmark of the campaign by the former editors has been marked by
unrelenting, inescapable repetition, which has added strength to their
broadsides. (Decker, 2010, para. 1)
As the lead developers of DSMIII and DSMIV (respectively), Spitzer and
Frances represent powerful critical voices in the controversy. Spitzer,
Frances, and other DSM5 critics have raised a variety of issues, including
concerns about the undue influence of the pharmaceutical industry (70% of
the DSM5 Task Force have industry ties), amplified by the lack of
transparency in the development process, as well as concerns about the
increasing medicalization of society (Cosgrove & Bursztajn, 2009; Elias, 2010;
Moran, 2008). The intensity of the controversy can be seen in their attacks,
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which are at the same time highly inflammatory and deeply personal.
The strategic maneuvering in DSM5.org referred to earlier could
sensibly be read as responding to warnings about
...the wholesale imperial medicalization of normality that will trivialize
mental disorder and lead to a deluge of unneeded medication
treatments—a bonanza for the pharmaceutical industry but at a huge
cost to the new falsepositive patients caught in the excessively wide
DSMV net. They will pay a high price in adverse effects, dollars, and
stigma, not to mention the unpredictable impact on insurability,
disability, and forensics.” (Frances, 2009, para. 24)
Perhaps channeling Szasz, the infamous heresiarch, our former psychiatric
Pope Frances, straightforwardly attacked the basic presupposition of DSM5,
that it is possible to arrive at a more scientific definition of mental illness:
“There is no definition of a mental disorder. It’s bullshit. I mean, you just
can’t define it... these concepts are virtually impossible to define precisely
with bright lines at the boundaries” (cited by Greenberg, 2011, para. 1). His
confessor, Gary Greenberg, later reported that Frances himself was furious
about how the published interview came out: “The thing I don't understand,
he tells me, ...is that you think the words in the DSM are capable of great
harm. So why aren't you worried about the harm your words can do?”
(Greenberg, 2013a, p. 332).
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Much to his chagrin, antipsychiatry groups attempted to appropriate
Frances' rhetoric, forcing him to fight his war of words on two fronts:
The Alliance for Human Research Protection is attempting to draft me
as an unwilling soldier in its dangerous campaign to discredit
psychiatry and to discourage psychiatric patients from staying in
treatment and taking medication. In a recent posting, they make the
ludicrous claim that Dr. Frances' “publicly expressed criticism of
psychiatry's grandiose ambition—demonstrated by its ever expanding
list of unvalidated disease designations and reliance on demonstrably
harmproducing chemical interventions—essentially validates the
criticism expressed by the Alliance for Human Research Protection for
more than a dozen years.” No! I must strongly disclaim this incorrect
and misleading attribution. At a fundamental level, I could not have a
more opposite view of psychiatry than that expressed by the Alliance.
My critique of diagnostic inflation and over treatment in no way
“validates” the Alliance and its reckless antipsychiatry rhetoric.
(Frances, 2011a, para. 1–2)
For the next two years, he published at least two articles a week criticizing
the DSM5 process (most of which appear in his two blogs, “DSM5 in
Distress” and “Couch in Crisis”). Expressing contrition, perhaps, Frances
later told Greenberg that the “controversy stirred by my critique of DSM5 is
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a terrible moment in the history of psychiatry,” and “the worst thing to
happen to the field's credibility since Rosenhan—and psychiatry is a a field
that especially requires credibility to be effective. I know I have done grave
harm” (Greenberg, 2013a, p. 329).
(4) Advertisements for Psychiatric Treatments
I examine the way in which pharmaceutical marketing has guided the
rhetorical trajectories that surround the development of DSM5. As Healy
suggests, the psychiatric marketplace of ideas is indeed a marketplace: “The
selection of scientific ideas according to their coincidence with commercial
interests is becoming an increasingly important factor in shaping the
academic marketplace. Put another way, drug companies obviously make
drugs, but less obviously they make views of illness” (1997, p. 181). Andrew
Lakoff (2005) coined the term “pharmaceutical reason” to refer to “the
underlying rationale of drug intervention in the new biomedical psychiatry:
that targeted drug treatment will restore the subject to a normal condition of
cognition, affect, or volition” (p. 7). As the biomedical model has become more
firmly established over time, the categories of mental illness have
increasingly aligned with the categories of pharmaceutical treatment.
This is also the case for the marketing of alternative 'naturopathic'
treatments, which I argue borrows stasis points and topics from
pharmaceutical reason even while ostensibly adopting a position in
74
opposition to that form of rationality. I suggest that this supports Toulmin's
(1972) hypothesis that a scientific field develops through a somewhat
continuous evolutionary process—because one can contest the validity of
fielddependent warrants only from within the argument field in which they
operate—over against Kuhn's (1962) position in favor of discontinuous
revolutionary 'paradigm shifts.'
Outline of the Study
This study proposes a rhetorical reading of psychiatric discourse that
accounts for both the internal logic of the DSM revisions and the public logic
of nosological controversy. My aim is to examine the scientific psychiatric
diagnostic rhetoric and to provide rhetorical diagnosis of psychiatric science.
That is, on one hand, I aim to understand the current array of nosological
controversies as a rhetorical movement. What are the conditions that make
these controversies possible? What is significant about the topics and stasis
points around which discursive dissensus has coalesced? What resources are
available to the interlocutors invested in these controversies, and what
accounts for their persuasive capacity? Then, on the other hand, looking at
the contested discursive field of psychiatry as an intersubjective psychic
system emerging out of the materiality of late modern institutional life, what
can be said about its 'mental health'? Do the rhetorical pathologies that I
shall identify proceed from some sort of neurotic collective anxiety brought on
75
by unresolved conflicts in our persuasive appeals, root metaphors, nosological
models, or institutional logics? In other words, is this epistemic “world.. so to
speak, dissociated like a neurotic” (Jung, 1964)? The situation would be
worse if psychiatry, as a psychotic science, has lost its capacity to test reality
(or is atrisk of losing this capacity). Perhaps we can attribute any rhetorical
problems to material causes—that is, the realities of clinical practice and
regulated forprofit psychopharmacology are like lesions interfering with the
epistemic functioning of the field.
These two categories of questions are at once distinct and yet
interdependent, for the diagnostic terms we would apply can be trusted only
to the extent that they do not apply (a psychotic science is, precisely, a
pseudoscience). Furthermore, our judgments about the rhetorical conditions
of controversy depend upon an accurate diagnosis of the field. By seeing the
problem this way, I am embracing the radical selfreferentiality of late
modernity (Giddens, 1991). The theoretical model I shall outline shortly
reflects this. Additionally, the metaphor of 'diagnosing' psychiatry is not my
own, but appears over and over in the popular and professional literature.
Michael Taylor invokes this idea by suggesting that his psychiatric colleagues
are as deluded as the patients they treat:
When a patient sticks to an idea that all the data indicate is false and
rejects efforts by others to change his mind, the patient is said to be
76
delusional. When a chairman of a prominent academic department
who is wellconnected with the psychiatric establishment sticks to a
clearly false idea, the false idea is accepted and the data are tossed out.
(Taylor, 2013, p. 60)
I have already cited several examples of this in the popular literature: the
claims that psychiatry is addicted to drugs, deluded about the state of its
knowledge, and obsessed with pathologizing normal problems of living. An
article about the DSM in the Wall Street Journal very succinctly adopts this
metaphor in its title: “How Psychiatry Went Crazy” (Tavris, 2013).
The first set of questions—those concerned with the contested field of
psychiatric nosology as a rhetorical movement—are justified by the failure of
previous studies to take up these questions with a sophisticated
understanding of the rhetorical production of knowledge. Stuart Kirk and
Herb Kutchins (1992) made the closest attempt to tackle this task in their
book The selling of DSM: The rhetoric of science in psychiatry, which looked
at the making of DSMIII. This is an important study, but it does not have
much to say about rhetoric. As Lewis (2006) suggests, the study essentially
positions rhetoric in binary opposition to 'good science' – rhetoric is how the
DSMIII task force got away with all their 'bad science':
[Rhetoric] for them means something external to the facts: an
embellishment or perhaps a commentary on scientific data, rather
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than something integral to the data itself... [The] brightline
distinction between the “facts” of the DSMIII field trials and the
“rhetoric” used to describe these facts... hurts Kirk and Kutchins as
much as it helps them. It prevents them from stepping back from the
details to see how the DSMIII developers' rhetorical frame
significantly affected the facts the developers “discovered.” And
furthermore, it prevents them from recognizing that alternative
rhetorical frames would have produced alternative facts. (pp. 106).
A richer view of rhetoric informs this dissertation, and motivates the basic
questions it asks.
Lewis suggests that these questions be directed toward 'models of
madness,' because of their rhetorical nature:
[A] deeper rhetorical critique of the DSM involves teasing out the
rhetorical frame of the current manual and comparing that frame with
alternative rhetorical options. The best way to do this is to connect a
rhetorical discussion of DSM with the literature on 'models of
madness,' ...[which] operate very much like a rhetorical frame: they
work as an underlying organizing structure that guides the perception,
selection, and methodological manipulation of psychic data. Models of
madness frame and select certain aspects of a perceived human reality
and make them more salient than others. Each model promotes its
78
own problem definitions, explanatory concepts, research methods, and
treatment recommendations. (p. 107)
Since these models of madness develop over time, this study has a strong
historical focus. But as critics of DSM5 argue, contemporary models of
madness are everexpanding, encompassing more and more of what formerly
was not regarded as mental illness (Frances, 2013; Greenberg, 2013a).
In a variety of different ways, risk has long been for psychiatry both an
object of inquiry and a methodological attribute. Psychiatric nosology is a
risky field of knowledge. Its validity conditions go beyond correspondence
with reality—the knowledge that psychiatrists produce is invalid to the
extent that it brings harm to the patients (perhaps simply by classifying
them as patients). Therefore, the rhetorical resources that enable one to
justify claims about uncertainty and risk are of critical importance and must
be read alongside those that justify claims about the nature of psychosis.
These issues all come together in the controversy about diagnosing 'psychosis
risk syndrome,' which Allen Frances called “the most ill conceived and
potentially harmful” disorder proposed for DSM5 (Frances, 2010c, para. 1).
For these reasons, this study focuses on the controversy over psychosis
risk more than any other diagnostic category. This study contains three
preliminary steps. I first work out a theoretical toolkit with which I can
explain how the rhetoric of inquiry in a field develops over time (Chapter 2).
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Next, I examine the rhetorical history of 'psychosis,' which requires a larger
rhetorical history of psychiatric nosology (Chapter 3). Then, I examine the
rhetorical history of risk, before directly examining the contemporary
controversy over psychosis risk syndrome (Chapter 4). Along the way, I will
examine a variety of other diagnostic controversies. I conclude the study by
discussing the implications of these different lines of inquiry for an
understanding of the rhetoric of psychiatry in our contemporary late modern
epoch (Chapter 5). I shall conclude this chapter by introducing the basic
argument of each of these subsequent chapters.
Polytechtonic Rhetorical Economy
This dissertation examines the relationship between rhetorical
invention and the production of knowledge. I contend that psychiatric
nosology, the systematic classification of mental illnesses, develops within a
wider rhetorical economy of symbolic forms (Cassirer, 1944, 1957),
ideographs (McGee, 1980), signifiers (Saussure, 1959), subject identities
(Goux, 1990), and topics of invention (Aristotle, 1984; Cicero, 2009).
Knowledge workers produce, consume, trade, borrow, hybridize, and invest as
“epistemic capital” (Maton, 2003, p. 62) these discursive objects through
processes of “tropological exchange” (Lundberg, 2012, p. 74) and
“communicative labor” (Greene, 2004, p. 189, 2007, p. 328). These epistemic
transactions depend upon the “reflexive claims of iconic associations, when
80
system signals split, multiply, and render symbolic and material connections
selfconfirming, unstable, or conflicted” (Goodnight & Green, 2010, p. 119).
Chapter 2 provides the details about the theoretical commitments and
presuppositions I hold in advancing this argument. It explores the
relationship between rhetoric and knowledge, and incorporates concepts from
several different fields of social science that will prove helpful in explaining
the rhetoric of psychiatric nosology. Of particular importance are the
concepts of symbolic form, institution, lifeworld, system, selfreference, and
architectonic. I suggest that bodies of scientific knowledge develop through
the craft (techné) of rhetoric, because the “processes of knowing are processes
of making and doing” (McKeon, 1975, p. 730). In late modernity, this craft
has become “polytechtonic” (Goodnight, 2014, p. 2). I describe a polytechtonic
model that incorporates and integrates ideas from rhetorical, sociological,
cultural, and economic perspectives, reflecting the conceptual hybridity that
characterizes late modernity. These ideas serve as grounding for the
historical inquiry of the next two chapters.
Rhetorical Histories of Psychosis
Chapter 3 examines the humoral model of pathology developed by
Hippocrates and Galen, a model that is discontinuous with present medical
thinking and yet still serves as a rhetorical resource both within mainstream
medical thinking and in popular discourse about health. I investigate the
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flows and ruptures of meaning that led from antiquity to the modern models
of madness, and in particular the concept of psychosis. I then show how
modern 'biobabble' and related popular rhetorics of mental health and
madness derive from a series of symbolic residues of history which have
matured into a few distinct models of madness. These rhetorics show up in
discourses which align with the neuropsychiatric model, as well as those
which align with subaltern psychodynamic or alternative 'naturopathic'
models.
The currently hegemonic neurobiological model has its immediate
origins in the nineteenth century but involves discursive forces that have
been developing dialectically since the time of Hippocrates. I trace the
rhetorical history of modern models of madness through which psychosis has
become an object of knowledge. Through the various twists and turns of
material history, alongside adjacent rhetorical moves, a perspective on the
selfgenerating processes of discursive formations becomes visible. I show
how our contemporary concepts of psychosis are the result of the projection of
tensions between discrete and continuous terminologies, ontological and
functional interpretations of health and sickness, and psychodynamic and
neurobiological descriptions of the mind into the temporal dimension.
Over the course of the chapter, I bring into focus the elements of the
various models of madness operative in contemporary controversies, and
82
show how, in every case, their development and persuasive validity derives
from the repurposing and hybridization of the topics, tropes, and forms of
alreadyestablished models. Furthermore, I show that these remain
available as rhetorical resources today. Certain patterns in the cyclic
alternation between terminologies that prioritize continuity and those that
prioritize discontinuity also become clear. In particular, I show the
importance of visual rhetorical forms in the dissemination of new scientific
configurations of knowledge.
Psychosis Risk Society
The rhetorical history of the concept of psychosis with which Chapter 3
concludes leads into Chapter 4, which focuses on the medicalization
controversy surrounding the diagnosis of psychosis risk syndrome. I
investigate how such controversies motivate action, and tease out the
rhetorical motives that animate the polemical discourse such controversies
inspire. More specifically, I examine the controversy surrounding the
proposal to officially recognize a 'psychosis risk syndrome,' a diagnosis that
would apply to those people (primarily adolescents) judged to be at an
increased risk of becoming psychotic at some future point, at a sufficient level
of certainty to justify some sort of medical intervention.
Psychosis risk syndrome exemplifies a wider contemporary
phenomenon, the medicalization of risk, which entails conceptualizing some
83
probable problematic future situation as a kind of illness or disease.
Medicalization itself is a risk phenomenon, and the medicalization of risk is a
phenomenon in the very image of reflexive modernity. Ivan Illich (1976)
famously described the situation that gives rise to the question of whether
some problem by its nature belongs to the domain of health: “Each
civilization defines its own diseases. What is sickness in one might be
chromosomal abnormality, crime, holiness, or sin in another” (p. 37). Once
formulated as a health concern and pathologized, a putative disease entity is
on course to fall under the technical gaze of expertise, which will occur when
acceptable subjective and objective criteria are developed and
institutionalized.
The concept of medicalization is relatively recent—the term entered
discourse in the 1960s, and first appeared in a dictionary (of jargon) in 1987
(Aronson, 2002). Medicalization has been defined as “a process by which non
medical problems become defined and treated as medical problems, usually in
terms of illness and disorders” (Conrad, 2007, p. 4). Fairly recent examples
include baldness (alopecia), bad breath (halitosis), impotence (erectile
dysfunction), overactive bladder (detrusor instability), shyness (social
anxiety), and too much plastic surgery (body dysmorphic disorder), to name
just a few (Conrad, 2005, 2010; Conrad & Leiter, 2004; Conrad & Schneider,
1992; Ghigi, 2009; Lane, 2007; Maturo, 2009; Payer, 1992). There are two
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primary pathways to medicalization: “the pathologizing of normal biological
or social variation and... the portrayal of the presence of risk factors for
disease as a disease state itself” (Heath, 2006, p. e146). Some examples of
diseases constructed from risk factors, sometimes called “prediseases” or
“preconditions... a medical label [for] people who are at risk of being at risk,”
include 'high' blood pressure, 'high' cholesterol, menopause, obesity, pre
diabetes, and preosteoporosis (Gambrill, 2012; Moynihan, 2010, p. 485).
Market dynamics drive the process by exerting a downward pressure on the
severity thresholds of the newly medicalized phenomena:
Due to the shape of the typical disease bell curve, lowering the severity
threshold at which people think they have a 'real' disease and need
drug treatment typically expands the potential market by a factor of
ten or more. It is only with a low severity threshold that a PR firm can
whip up a proper scare campaign about a hidden epidemic of disease
that affects ten, twenty, or fifty million people. (Brody, 2008, p. 241)
Industry is only one side of the issue: The neoliberal structuring of academia
also encourages researchers to carve out new pet conditions and promote
them to the public (Moynihan, 2011). The rampant medicalization of the
problems and risks of modern life has left us increasingly intolerant of
relatively mild complaints and increasingly anxious about risk (Barsky &
Borus, 1995; Conrad, Mackie, & Mehrotra, 2010; McCormick, 1996).
85
I argue that psychosis risk syndrome and the surrounding controversy
are synecdochic of macrolevel dynamics occurring in our late modern society.
To establish this, I first trace the historical development of the modern
concepts of risk, and I argue that at each stage of its conceptual development,
a residue is produced that shows up in some manner in the discourses of
psychiatry. I then sketch out the argumentative landscape of the controversy
over psychosis risk syndrome. I analyze how the interlocutors approach and
utilize risk, and distill out several apparent risk ontologies that serve to
background these approaches. I also examine how risks flow through the
systems world, moving from deliberative to forensic contexts, and I examine
how the DSM makes use of the rhetorical forms of secrecy and disclosure in
an attempt to regulate the rhetorical risk market. After investigating what
the rhetorical contest over the medicalization of risk can tell us about our
contemporary risk society, I examine the intersections of episteme and
phronesis entailed in the medicalization of crime.
That Commodified Supplement
Chapter 5 concludes the study. It explores the way in which diagnosis
as instantiated by the DSM apparatus factors into emerging politics of the
supplement. Politics of the supplement engage a cluster of concerns that
regulate the risks inherent in the rhetorical commerce that enable an
individual to pursue a “reflexive project of the self” (Giddens, 1991, p. 5). I
86
argue that a cluster of institutional, political, social, and rhetorical forces
have changed the very meaning of a psychiatric diagnosis. Once thought of
as a medical technology with usevalue, I suggest that a psychiatric
diagnosis' exchangevalue now dominates. As I trace the dynamics of this
transition, I investigate the ways in which the commodification of diagnosis
and the associated reification of mental illness can promote alienation, on one
hand, and solidarity, on the other.
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CHAPTER TWO: POLYTECHTONIC RHETORICAL ECONOMY
“Each speech must be put together like a living creature, with a body of its own; it must be
neither without head nor without legs; and it must have a middle and extremities that are
fitting both to one another and to the whole work.” – Socrates
19
“But their method is just as if one were to take hands, feet, a head, and other body parts
from diverse places, each constructed very well indeed, but not fitting to a single body, and
neither in any way proportionate to one another, so that a monster rather than a man would
be composed from them. ” – Nicholas Copernicus
20
“Verbal rhetoric... should not make technology the operation of a machine, in which the
message is a massage; it should not take its form from its medium and it should not be
adapted to use to communicate established judgments (which are jostled commonplaces) or
revolutionary convictions (which are repeated dogmas) in the supposition and intimation
that they might be related to traditional ends or novel objectives and that they are somehow
means to those ends... It should be positive in the creation, not passive in the reception, of
data, facts, consequences, and objective organization.” – Richard McKeon
21
“They build on sense, then reason from th'effect, On wellestablish'd truths their schemes
erect; By these some new Phaenomena explain; And light divine in every prospect gain.” –
Samuel Bowden
22
***
This chapter adumbrates the role of rhetorical activity in the
institutional production of knowledge. My framework is interpretive, rather
than positivist, seeking to explain rather than to predict. Although rhetoric
exhibits a systematic element, it yields no master narrative or ultimate order.
Rhetoric is explained in terms of a variety of contingent models that
19
“... μ , δεῖνπάνταλόγονὥσπερζῷονσυνεστάναισῶ άτιἔχοντααὐτὸναὑτοῦ ὥστε
μ μ , μ , ήτεἀκέφαλονεἶναι ήτεἄπουν ἀλλὰ έσατεἔχεινκαὶἄκρα πρέπονταἀλλήλοιςκαὶ
μμ ” τῷὅλῳγεγρα ένα (Plato, 1997c, sec. 264c).
20
“...sed accidit eis, perinde ac si quis e diversis locis manus, pedes, caput aliaque membra
optime quidem, sed non unius corporis comparatione depicta sumeret, nullatenus invicem sibi
respondentibus, ut monstrum potius quam homo ex illis componeretur” (Copernicus, 1873, p.
5, ln. 1823, my translation).
21
Richard McKeon (1987, p. 24).
22
Samuel Bowden wrote 'A poem on the new method of treating physic' in praise of Thomas
Morgan's (1725) treatise on the Philosophical principles of medicine (quoted in W. P. Jones,
1966, p. 125, emphasis in original).
88
underwrite psychiatric rhetoric as a practice. Although the approach is
informed by several canonical sociological theories, to which I intend to be
faithful except where I note otherwise, hermeneutic utility trumps theoretical
fidelity. Thus the chapter lays out social structures that invite vectors of
influence, but each has a unique constitution and outcomes which need
attention. Before attending to the chapter, I will lay out its structure and
define key terms. This is necessary to appreciate rhetoric in the complex
maneuvers to articulate, justify, and defend a public debate over mental
health. Terms include the relationship of rhetoric to epistemics, institutions,
practice, and polytechtonic discourse.
1. Rhetoric as Epistemic. The central, general question to be
addressed in this chapter: What is the role of rhetoric and the production and
transmission of technical knowledge? Although the epistemic nature of
rhetoric has been the subject of much debate over several decades
(Brummett, 1976, 1990; Cherwitz & Hikins, 1986; Farrell, 1990; Harpine,
2004; Herrick, 1997; Leff, 1978; McKerrow, 1977; Railsback, 1983; R. L.
Scott, 1976, 1967), my interest is in the classical conceptions of rhetoric that,
as my thesis suggests, have been unfolding throughout history and remain
relevant today. The models to which I attend are those debates over health
and medicine that are less about how either rhetoric or the production of
knowledge works in practice per se, and more about defining epistemic
89
boundaries (Gaonkar, 1997b; McCloskey, 1997). Contestation over
boundaries has always brought into question the norms, standards, and
problems of knowledge production in contexts of practice. Practice is
continually challenged by contingent matters with positive and negative
outcomes. Decisions have to be made under the pressures of time,
uncertainty, and circumstance. Over time, the ongoing practice of judgment
is translated into an epistemic inheritance that guides or regulates conduct.
State of the art practices themselves are subject to extension, revision, or
scrapping. I examine three epistemic functions of rhetoric: mediating the
communication of knowledge through time (memory), inventing new
arguments (technical art), and expanding the range of signification (symbolic
forms). These aspects contribute to the life of institutions.
2. Rhetoric and Institutions. Institutions are rhetorical organizers,
containers, and sites of invention. Powerful modern institutions deploy
resources that persuade nonexperts to trust experts, supplying symbolic
tokens that experts and nonexperts alike may use as surrogate reasoning
media. Scholarship in rhetorical institutionalism, which emphasizes the
importance of discourse and meaning in institutional processes, suggests that
institutions constrain and enable the agency of actors who would make use of
specialized knowledge and deploy symbols strategically (Giddens, 1991;
Green & Li, 2011). An institution guides the development of social
90
knowledge by supplying myths that legitimate the practices and beliefs with
which it is associated (Alvesson, 1993). Institutions anchor instrumental
systems within which experts produce technical knowledge to the lifeworld.
In so doing, they shape the development of knowledge within the systems
world. One mechanism by which this occurs is by curating texts in the
institutional canon. By developing and managing the symbols (both
linguistic and nondiscursive) that signify units or categories of specialized
knowledge, institutions regulate the way individuals in a society think and
communicate about the problems they face.
3. Rhetoric and Practice. Institutions may offer stable platforms to
regulate practice. However, they also provide sites for “institutional
entrepreneurs” who “use language to manipulate meaning and thus theorize
and create endogenous change” (Green & Li, 2011, p. 1670). Further, in the
increasingly complex world of late modernity, attention, comprehension, and
signification are limited resources that actors must manage and optimize
(Simon, 1978). They do so “through persuasion, or the deployment of
symbols, to construct and manipulate meaning” (Green & Li, 2011, p. 1670).
These processes occur in what I call a rhetorical economy. This economy
contains an ideas market, in which institutional entrepreneurs attract
investors in their research and sell their ideas to other knowledge workers or
to public consumers (DiMaggio, 1988). A rhetorical economy also governs the
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forces of signification exchange. Symbolic strategies for coming to terms with
social relationships can be exchanged for material resources and legitimation.
Actors secure the cooperation of others by accepting the symbolic order
within which the cooperative relationship has a fixed meaning. Justification
governs epistemic valuation. As these processes play out, guided by
emergent market logics, I suggest that 'epistemic bubbles' may form under
certain conditions. An epistemic bubble occurs when speculation drives
actors to systematically overvalue an idea or cluster of ideas, leading to a
characteristic rise and crash.
4. Rhetoric as Polytechtonic Art. The mix of stable practitioners
and entrepreneurs producing partnered change constitutes a polytechtonic
art. This idea integrates the epistemic functions of rhetoric discussed in the
first section with rhetorical institutionalism and the concept of a rhetorical
economy. Richard McKeon suggests that as “an architectonic art relating and
directing arts, sciences, and actions by principles,” rhetoric organizes
institutions and integrates fields of knowledge (1981, p. 431, my emphasis).
Using McKeon's architectural metaphor, I examine the 'building' of
psychiatric nosology. I suggest that the disconnected and competing
constructs that constitute this building point to the shift from architectonic to
polytechtonic rhetoric (Goodnight, 2014). To explain how psychiatric
nosology developed into its current polytechtonic form, I turn to Luhmann's
92
theory of social systems, retaining part of his model while updating his
impoverished view of communication with the concept of polytechtonic
rhetoric. Of particular interest is Luhmann's account of how a social system
reproduces itself and changes in the process. Considering a scientific field as
an epistemic social system, I examine two competing theories: Kuhn's
suggestion that change occurs through sudden, revolutionary shifts between
incommensurate paradigms, and Toulmin's contention that the process is not
revolutionary but evolutionary due to the importance of common field
dependent warrants. I hypothesize that Toulmin's theory better explains the
development of psychiatric nosology and is more consistent with the notion of
a polytechtonic rhetorical economy.
The definition of rhetoric as polytechtonic paves the way for an
understanding of the complex, often contradictory demands on extension,
justification, and defense of new criteria for diagnosing and recognizing
mental illness. Due to the great reflexivity and interdisciplinarity of late
modernity, contemporary psychiatric nosological discourses invoke concepts
from these different fields. Although the logic of epistemic labor within the
academy aims toward increasing specialization, I suggest that the field of
rhetoric is an antispecialty, conversant across many fields of expertise: a
polytechtonic art for a polytechtonic age. The chapter elaborates the key
terms defined above in order to construct a robust notion of a polytechtonic
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rhetoric capable of appreciating the dynamics of interfield and public
controversy.
Rhetoric as Epistemic
Rhetoricians have long concerned themselves with understanding and
articulating the relationship between language and knowledge. Ever since
rhetoric emerged as an object of inquiry, scholars have been divided about its
nature and scope. Broadly speaking, the various interpretations of rhetoric
can be divided into two groups. The first limits rhetoric to public
communication, which includes public deliberation, forensic (courtroom)
debates about guilt and innocence, and ceremonial oratory that either praises
or blames a specific person, community, object, or concept. In its strongest
form, rhetoric is further limited to political discourse, upon which the
functioning of any democratic order depends. This category roughly
corresponds with McCloskey's (1997) notion of 'Little Rhetoric.' The second
category, which corresponds to the notion of 'Big Rhetoric,' tends to see
rhetoric as encompassing all aspects of culture. In its strongest form,
rhetoric mediates all human communication, or at least all symbolic action,
without which no meaning is possible. Theories in the first category tend to
associate rhetoric with persuasion, while theories in the second category
either expand the scope of rhetoric beyond persuasion to include at least the
entirety of semantics, or expand the scope of persuasion to encompass all of
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human communication.
Memory as Epistemic Function of Rhetoric
In ancient Greece, the Sophists (responsible for the first formalized
rhetorical education schools) adopted a wide view of rhetoric that included
anything capable of communicating knowledge (Wardy, 1996). Some sophists
believed that through rhetoric, one could communicate knowledge that did
not exist prior to the communication. Working in the same classical milieu,
Plato has been credited with developing the view that knowledge is “justified
true belief” (Gettier, 1963, p. 121; Southerland, Sinatra, & Matthews, 2001).
While some sophists (e.g., Gorgias)
23
quibbled about whether there was such
a thing as 'truth,' they believed that justifying beliefs and persuading others
to accept them as true was firmly within the province of rhetoric.
23
In his nonextant treatise ‘On the NonExistent,’ Gorgias advances three claims: nothing
exists; even if something does exist, it cannot be known; and even if something can be known,
it cannot be communicated. Instead, the only kind of knowledge possible is that of belief and
opinion. To support the claim that nothing exists, Gorgias first argues that if something
exists, it would have mass and take up space. Further, it must be either one thing or many
things. If it has mass and takes up space, it must be divisible, and yet if it is divisible it
cannot be one. But if nothing unitary exists, then certainly no combination of unitary things
can exist. Therefore, nothing can exist. Gorgias supports his second claim by noting that it
is possible to have thoughts about fictional objects. If we may also have thoughts about non
fictional objects—that is, knowledge about objective reality—there must be some way to
distinguish those thoughts from those concerning the nonexistent. Our only manner of
distinguishing thoughts is through thought itself—we think that some thoughts are true
while others are not. Yet we have no way of verifying if those distinguishing thoughts are
themselves true; in other words, we have no objective external criterion against which the
veracity our thoughts may be confirmed. Since objective knowledge (as opposed to belief)
must be both true and known to be true, it is impossible. For his third claim, Gorgias argues
that if one can acquire knowledge about the objective world, it is by means of the senses. If
knowledge can be acquired by means of communication, then our ability to understand
communication is like all of our other senses. Yet we cannot see tone, or hear color—likewise,
speech, which uses symbols as a code to refer to various things, can refer to an experience,
but it cannot transmit it (Guthrie, 1969, p. 195).
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While Plato's relationship with rhetoric was complex,
24
he maintained
that dialectical rhetoric constituted a valid epistemic technique. According to
Plato's theory of knowledge, all learning is in fact remembering, which always
involves some measure of dialectical reasoning. Thus, his discussion of types
of memory is important because it is really a discussion of different ways of
acquiring knowledge through communication. This is important to my thesis
about the recurrence of rhetorical residues in scientific discourse, which
suggests that the discovery of new knowledge occurs through the
hybridization of the rhetorical forms that embodied nowforgotten knowledge.
In the Phaedrus, Socrates refers to two types of memory: hypomnesis, by
which one recalls fixed events directly, and anamnesis, a living memory by
which we recall “the things our soul saw when it was traveling with god,
when it disregarded the things we now call real and lifted up its head to what
is truly real instead” (sec. 249c).
Hypomnesis, by which Phaedrus has mentally stored a verbatim
transcript of the speech he heard the famous sophistic lawyer Lysias deliver,
suffers from the inability to distinguish between what is actually true and
what is only apparently true. When the mind directs its attention toward the
image of a text, the focus remains on maintaining all of the details of that
24
Besides authoring one dialogue against (the Gorgias) and one in favor (the Phaedrus) of
rhetoric, there are other textual complexities that make interpreting Plato difficult. For
example, in the Gorgias, Socrates gives speeches detailing his defense of dialectic and critique
of rhetoric, and is dialectically crossexamined by his rhetorical opponents.
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text, rather than on a critical evaluation of its meaning and implications.
This kind of memory is not trustworthy because it is alienated from the thing
remembered. At best, it “can only serve as [a] reminder to those who already
know” (sec. 278a). The example of memories falsely recovered under
hypnosis is apt here (Spanos, Burgess, Burgess, Samuels, & Blois, 1999).
Anamnesis, in contrast, works when one identifies enough aspects of
the truth, which indirectly is present in everything (which is why Socrates
listens to Lysias’ speech), that one becomes aware of a true insight about the
soul. 'Anamnesis' contains the root of our word 'amnesia,' and can be
thought of as a form of 'antiamnesia.' Bindé (2000) speaks of anamnesis as a
“memory of the future,” that is, a “living memory, anchored in the present
and focused on the future” (p. 70). This kind of memory, Socrates argues,
requires one to distinguish between truth and conventional wisdom—though
there is truth in all conventional wisdom, it can only be discovered when the
conventional wisdom is questioned, rather than taken into the mind
uncritically.
Psychoanalytic theorists took up this same notion millennia later. For
Plato, we have access to the Forms before we are born, forgetting what we
know of them when we are born into the material realm. For Freud, our
forgetting occurs over time as we emerge from childhood, and what we forget
leaves “the deepest traces on our minds and [has] a determining effect upon
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the whole of our later development,” and sometimes can make us mentally ill:
Hysterical amnesia, which occurs at the bidding of repression, is only
explicable by the fact that the subject is already in possession of a store
of memorytraces which have been withdrawn from conscious disposal,
and which are now, by an associative link, attracting to themselves the
material which the forces of repression are engaged in repressing from
consciousness. (Freud, 1924b, p. 260)
Just as Freud argued that “psychical acts and structures are invariably
overdetermined” by these residues of the past, I suggest that our epistemic
acts and structures are overdetermined by our vast rhetorical unconscious
(Freud, 1913b, p. 482). Contemporary narratives that are ignorant of the
past suffer from amnesia. Our historical narratives that fail to understand
how the past operates in the present are hypomnestic. To be anamnestic,
epistemic communication must lead to a new (true) understanding about
human nature, which is then inspired among others and retained by all.
When this occurs, we have “[come] to terms with the past” (Adorno, 1986, p.
115).
Rhetoric as Technical Art
In contrast to the abstraction of Plato, Aristotle took a more pragmatic
approach to rhetoric and knowledge. Persuasion occurs through the use of
pístis ( ), named after of the god of good faith, trust, and reliability, πίστις
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usually translated as 'proof.' There are two types of rhetorical proofs:
inartistic, or atechnic, from atechnoi ( ), and artistic, or entechnic, ἄτεχνοι
from entechnoi ( ) ἔντεχνοι (Aristotle, 1984, sec. 1355b). Aristotle further
distinguishes between two terms I discussed in Chapter 1: technē ( ), τέχνη
meaning craftsmanship or art, and epistēmē ( μ ), meaning knowledge ἐπιστή η
or science. This distinction follows Plato, who associated rhetoric with technē
and dialectic with epistēmē, but, for Aristotle, the difference between the two
is that episteme refers to the disinterested discovery of objective knowledge
(either logical truths like the Principle of NonContradiction or the Law of the
Excluded Middle, or of natural truths like the existence of various types of
fish), while technē refers to the practically motivated production of
knowledge. His Organon deals with episteme, while the four books of
practical philosophy (the Nichomachean Ethics,the Politics, the Rhetoric, and
the Poetics) concern technē.
Practical matters of public concern—e.g., the choice between war and
diplomacy, or judging the killing of a child to be murder or selfdefense—are
contingent rather than necessary, and their 'truth' is relative to the norms
and attitudes of the community facing the decision. For example, whether or
not someone who probably is guilty, but may very well be innocent, should be
punished, depends in part on the degree to which his or her behavior is
repugnant to the public. Additionally, because error is always possible in
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contingent matters, another relevant factor is the public's relative tolerance
for Type I and Type II errors.
The 'entechnic' artistic proofs consist of persuasive arguments that a
speaker can create in the audience. They are of particular importance to
Aristotle, as can be seen in the definition of rhetoric he provides in Book II, to
wit, that rhetoric is the ability in any particular case to see the available
means of persuasion. Rhetoric requires the speaker to have knowledge about
the audience, and to use that knowledge to create in the audience knowledge
about how to respond to some exigent contingent problem. There are three
types of artistic proofs: ethical appeals, in which the speaker creates in the
audience trust and the belief in his or her credibility, and accordingly are
speakerfocused; pathetic appeals, in which the speaker creates in the
audience an emotional involvement in the speech, and accordingly are
audiencefocused; and logical appeals, which create in the audience the
logical connections between arguments in the speech that are necessary for
the speech to be understood as reasonable, and accordingly are message
focused.
25
In contrast, the inartistic 'atechnic' proofs do not create knowledge on
their own—rather, they are attached to the artistic proofs in order to justify
25
This tripartite division reflects an early awareness of the three categories of faculty
psychology (ethosvolition; logoscognition; pathosaffect) that were later identified by
Thomas Reid in the Scottish Enlightenment. Their contribution to contemporary psychiatric
nosology is discussed in Chapter 3.
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their claims. Unlike the artistic proofs, which are expressly created by the
speaker through the process of rhetorical invention, the inartistic proofs exist
beforehand. Some examples of inartistic proofs are statistical facts,
examples, quotations from a trusted authority, germane documents such as a
legal statute or a signed contract, and, importantly, logical premises that
already have been accepted by the audience and can be taken for granted.
Whether or not an inartistic proof is persuasive depends on the rules of
argumentation that have been accepted by the community. I am more likely
to persuade a Christian than an atheist to accept a claim backed by scripture.
The last type of inartistic proof I mentioned is especially powerful,
however, because it is always persuasive by its very nature. Unlike the other
inartistic proofs which are explicitly presented in the speech, a takenfor
granted premise or assumption is powerful when it is unstated. Speakers
employ this proof through enthymemes, usually understood to mean an
informal version of a syllogistic argument in which the minor premise is
unstated. Indeed, Aristotle refers to the enthymeme (from enthýmēma
[ μ μ ], which literally means 'within the soul') as a 'rhetorical ἐνθύ η α
syllogism.'
Enthymemes are central to Aristotle's rhetorical theory. The
enthymeme is the counterpart to the syllogism, just as rhetoric is the
counterpoint of dialectic. An enthymeme can take the audience’s
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understanding as the starting place, and, taking advantage of its
assumptions and prejudices, transform a virtually incomprehensible (to the
audience) dialectical argument into a persuasive rhetorical argument. An
enthymeme bolsters ethical appeals because it shows that the speaker is so
aligned with the audience that she takes for granted the same assumptions
that they take for granted. A preacher does not remind his or her
congregation of the trustworthiness of scripture every time scripture is
quoted—to do so is both unnecessary and potentially offputting.
Enthymemes also bolster logical appeals because they cause the audience to
make logical connections themselves, and it is difficult to find one's own ideas
unpersuasive. When the implied minor premise concerns a matter with
which audience members are emotionally involved, an enthymeme can
bolster pathetic appeals.
In this sense, Aristotle reverses Plato's contention that dialectic, rather
than rhetoric, is required to arrive at true knowledge. For Aristotle, when
dealing with a lay audience, it is rhetoric, rather than dialectic, that can
bring new knowledge to the audience. Weaver (1970a) explains that through
an enthymeme, “the rhetorician enters into a solidarity with the audience by
tacitly agreeing with one of its perceptions of reality” (p. 173). The
enthymeme involves premises which are merely probable, rather than true
by necessity, and the degree to which the audience finds them likely depends
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upon the strength of that solidarity created between speaker and audience.
If the argument rests on an implied assumption about reality that is
essentially the same in the mind of the speaker as it is in the audience, then
the audience tends to regard the premises as extremely likely.
No division akin to Aristotle's three categories of artistic proof appears
in Plato's dialogs, probably as a consequence of his belief that the ultimate
underlying nature of reality is ideal, and one characteristic of the ideal world
is its unity. Aristotle's realist approach, in contrast, recognizes the existence
of both material objects and ideals, and along similar lines led him to a more
nuanced understanding of the unity of reality, distinguishing between things
like substance and accident; matter, form and purpose; analogical and
equivocal relationships; different orders of true knowledge, etc. Though all
kinds of oratory involve all three basic kinds of appeals, each appeal speaks
to a different kind of communicative need, and some situations call for the
emphasis of one kind of appeal over another.
Further, Aristotle identifies the three broad genres of rhetoric I briefly
introduced above: the deliberative, which seeks to establish the expediency of
a particular course of action and which is oriented toward the future; the
forensic, which seeks to establish the justice of some behavior, personal act,
or event, and which is oriented toward the past; and the epideictic, which
seeks to establish the honor or dishonor of a person, thing, or ideal, and
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which is oriented toward the present. Each genre must make use of each
kind of appeal, but in some cases there is a natural association. For example,
deliberative rhetoric tends to rely heavily on appeals to ethos, for if the
speaker can convince the audience that he or she is an expert who has the
audience’s best interests in mind, it stands to (the audience’s) reason that the
advocated proposal is a good idea. The best way for a speaker to convince an
audience that their best interests are in mind, of course, is to demonstrate
that he or she is in the same boat, so to speak, as the audience, and therefore
has selfinterested reasons to desire the best for the audience. This is done
rhetorically by moving oneself to the audience, identifying with their political
interests. Forensic rhetoric tends to emphasize appeals to pathos, as the
audience typically considers itself disinterested and impartial, and so
persuasion tends to work when the audience is moved to the position of the
victim (when prosecuting) or the alleged criminal (when defending). The
audience is moved only when their emotions are invoked, as “the emotions
are all those feelings that so change men as to affect their judgments”
(Aristotle, 1984, sec. 1378a).
The classical conception of rhetoric as a technical art contrasts with an
idea that has some currency in certain far right and far left political circles,
namely, that words are simply epiphenomenal of material reality, which is
regarded as the only reality worthy of the name. From this follows a sharp
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distinction between a science's subjectmatter and style of expression.
Contemporary advocates of 'neuropsychiatry' sometimes express this view in
the same breath that they curse the Cartesian mindbody split that, they
insist, is the root of the errors of psychoanalysis. In Chapter 3, I explicate a
specific instance of this: the hysteria surrounding hysteria.
Richard Weaver criticizes this approach to social science, which he
identifies with positivism. Invention, he insists, belongs to the domain of
rhetoric—the novel arguments made by social scientists are developed
rhetorically rather than empirically. Indeed,
rhetoric is... a process of coordination and subordination which is very
close to the essential thought process... [and] in any coherent piece of
discourse there occur promotion and demotion of thoughts... [which]
involve matters of sequence, of quantity, and some understanding of
the rhetorical aspects of grammatical categories. (Weaver, 2011, p.
210)
McCloskey (1998) compares the inability of her fellow economists to
understand this to mental illness, and concludes:
A rhetorical cure for these mental disabilities... is literary and
rhetorical. The cure would not throw away the illuminating
regression, the crucial experiment, the unexpected implication
unexpectedly falsified. These too persuade reasonable scholars.
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Nonargument is the alternative to narrow argument only according to
the dichotomies of modernism. The cure would restore the health of
economics, disguised now under the neuroses of an artificial
methodology of science. (pp. 184185, my emphasis).
Her arguments about economics apply equally to psychiatry, and her
'psychiatric treatment' is remarkably similar to the one proposed by Dewey.
Dewey's (1954) proposed cure for this sort of psychosis is the
instantiation of a 'Great Community,' which should be “saturated and
regulated by mutual interest in shared meanings, consequences which are
translated into ideas and desired objects by means of symbols” (pp. 153154).
These new symbols could be invented and propagated through art, as “the
function of art has always been to break through the crust of
conventionalized and routine consciousness” (p. 183). Over against the
suggestion that art exists for art's sake, Burke (1974) suggests that literature
is “equipment for living” (p. 492). Along these lines, McCloskey avers:
If translated into English, most of the ways economists talk among
themselves would sound plausible enough to poets, journalists,
business people, and other thoughtful noneconomical folk. Like
serious talk anywhere... the talk is hard to follow when one has not
made a habit of listening to it for a while. (p. xvii)
She contends that the difference between art and science is smaller than is
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commonly supposed. For example, statistics are “figures of speech in
numerical dress” (p. 56). Likewise, Renaissance literary criticism relies on
“the logic of probability and the counting of frequencies” (p. 56). McCloskey
explicitly is not challenging the claim that economics is a science; rather, she
contends that “all science is humanism (and no 'mere' about it) because that
is all there is for humans. Economics is scientific, then, but literary too... one
can talk of it in ways that sound a lot like the things people say about drama,
poetry, novels, and the study of them” (p. 57).
Rhetoricity of Symbolic Form
The language of reasoning and of persuasion is clearly a symbolic form
that serves an epistemic function, but where did it come from? Cassirer
(1944) suggests that when prehistoric humans first began to use symbols to
communicate, the symbolic form available to them was very limited in its
ability to refer to objects. Symbolic action can only produce knowledge about
the objects that can be signified symbolically. The epistemological
implications of this are profound: it is not merely that one cannot learn about
a potential object of knowledge, but that one cannot even think about that
object. Nothing that is not an object of knowledge lies within the
circumference of the lifeworld. As a result, the development of symbolic
forms is slow—without a symbolic form capable of referring to a specific kind
of object, humans cannot see any need for developing such a symbolic form.
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Cultural evolution is driven by the development of more epistemically
powerful symbolic forms. Beliefs or practices that dominate a particular
culture can be explained in terms of the symbolic forms available to members
of that culture. Along with Aristotle, Cassirer argued that the drive to
experience meaning is an innate feature of human nature. Since the
experience of meaning is mediated by symbolic communication through a
symbolic form known to members of a culture, the drive to experience
meaning entails a drive to participate in cooperative social activities that
facilitate symbolic communication. This is the source of rituals, shared
beliefs, and just about every behavior that is a characteristic of a culture that
those outside of that culture would regard as bizarre.
Psychiatric nosology is a symbolic form.
26
It provides us with the
ability to refer to certain patterns of observed behavior and relayed subjective
experiences as discrete disease entities. In order to make use of it, one also
needs a language for describing those patterns of behavior, and the broader
idea that certain similar observed actions can be made into behavioral
categories. The patient also needs a language for describing his or her
subjective experiences, with the understanding that they belong to a broader
category of sicknessrelated experiences, and that they are medically (and
not, say, religiously) relevant. The entire enterprise can only occur within a
26
I must note, however, that it is not a symbolic form on the order of Cassirer's.
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symbolic universe that provides the capacity to draw inferences about causal
relationships. Chapter 3 will explore how this symbolic form came into
existence, what symbolic forms preceded it, and how they all relate together.
The available symbolic forms function as the ‘uncaused cause’ of a
culture's worldview. Just as Aristotle’s (1941b) 'unmoved mover' is
indivisible, unalterable, and in an eternal state of contemplating itself
contemplating, so is this fundamental assumption of communication. It is
indivisible because communication ceases to be communication if there is no
one with whom one may come to an understanding, or if nothing exists about
which one person might come to an understanding with another. It is
unalterable because no two communicators can come to a mutual
understanding about the undesirability of coming to mutual understandings,
for the orientation toward mutual understanding characterizes
communicative action. The symbolic constitution of a culture eternally
contemplates itself, for an act of communication implicitly contains a
judgment about its own capacity to facilitate contemplation among those
moved by that judgment.
During the Enlightenment, distinct forms emerged that could refer to a
wide array of distinct objects, further expanding the circumference of
symbolic reference. The new forms include science, art, secular ethical
discourse, and history. The culmination of the Enlightenment corresponded
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with the expanding circumference of referential facility such that it included
itself. Selfreference and reflexivity emerged as major problems in so many
distinct domains of knowledge. Selfreference introduces a certain epistemic
problem whereby an act of measurement is part of the system of phenomena
being measured. Facts are in a certain sense made as much as they are
discovered. Every modern field of knowledge deals with this problem in one
way or another. In psychiatry, this problem manifests in a variety of ways,
one of the most significant of which is the central problem taken up in
Chapter 4, i.e., the diagnosis of psychosis risk syndrome, in which a
measurement that aims at disclosing the future is used in order to change the
future. The debate is so heated in part because of the profound consequences
of distinguishing between the 'weird' and the 'mentally ill.'
The expansion and universalization of symbolic form after the
Enlightenment paradoxically diminished the epistemic power of symbolic
action (or, more precisely, made us aware that we had been overestimating
our epistemic abilities). Furthermore, we started to become skeptical of the
Cartesian subject of the Enlightenment, and in particular the metaphysical
division of mind and body. Given our new abilities to use symbols to refer to
every object of reality, both symbolic and material, as well as our discovery
that the experience of symbolic meaning is mediated materially (according to
material phenomena occurring in our brains), the idealist orientation lost a
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fair bit of ground to the materialist orientation.
Furthermore, a relativistic understanding of truth began to replace a
more absolute one. During the medieval era, the whole world (as far as we
knew about it in the West) was part of the same culture, with the same
rituals, metaphysical beliefs, and epistemic practices. This inclined us to
adopt an absolutist conception of truth, and it was so strong that we thought
nothing of doing things like burning heretics (i.e., people with an alternative
metaphysical picture of the world) at the stake. The Enlightenment
overturned the unifying but unwarranted beliefs that characterized the
medieval era, but medieval universalism was replaced with modern
universalism in the form of a universal subject with a universal faculty to
discover truth through reason. Yet in the aftermath of the Enlightenment,
when the whole world came under our gaze, we discovered alien and bizarre
cultures with strange worldviews resulting from the differences between
their symbolic universes and our own. To the extent that a particular form of
reason was posited to be a universal symbolic form, that belief had to be
surrendered, having been falsified empirically. What was still residually in
the cultural memory of classical Greece was finally being rediscovered, and
just as it motivated the sophists to adopt a materialist and relativistic stance,
so too did it motivate us to adopt a philosophical outlook that tends toward
what is sometimes called the postmodern, proper to the age of late
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modernity.
Martin Heidegger profoundly expressed the new conception of truth
and its relationship to previous symbolic orders. With respect to
metaphysics, Heidegger (2008) claimed that our culture had lost the ability to
contemplate Being as such, because we had lost our ability to conceive of
Being's inverse, Nonbeing. Ever since Plato equated Being as such with a
being (in his case, the good; in the Aristotelian/Thomistic case, God; and even
in Nietzsche's case, the eternal recurrence of the will to will), the only sort of
nonbeing we could understand is a metaphysical order without that being
(which periodically happened, as for example is apparent in Nietzsche's
observations about the event known as the death of god). As a consequence,
we cannot ask the fundamental question that enabled philosophical inquiry
in the first place: Why is there Being at all, rather than Nothing? By in effect
conceiving of a metaphysical order without (postPlatonic Western)
metaphysics, Heidegger hoped to enhance our ability to understand reality.
Heidegger (2000) also provided philosophical elaboration of the the
changing attitude toward truth resonating throughout our culture.
Heidegger challenged the correspondence theory of truth, by which a
proposition is regarded as true if and only if it corresponds with reality. It is
easy to see why ancient philosophers gravitated toward this conception of
truth—the propositional symbolic form was still new, its epistemic potential
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untapped, and the purpose of philosophy was to discover what it is capable of
doing epistemically. With a couple thousand years of distance, Heidegger
noted that this understanding of truth supplanted an older understanding of
truth. Philosophy ever since the classical period had been asking the same
questions over and over, and the rate of its production of knowledge had
steadily declined ever since antiquity. Heidegger hearkened back to the
symbolic state that preceded the emergence of philosophy (and was thus the
environment in which people first decided to start asking philosophical
questions). This is the reason he was so concerned with discovering long lost
understandings of metaphysics and epistemology.
Heidegger discovered what he believed was a more originary
conception of truth by way of an etymological analysis of its Greek signifier,
alētheia ( ). He noted that the word consisted an alpha prefixed to a ἀλήθεια
derivative of the word lēthō ( ), a verb which means to be concealed. In λήθω
Greek, as in English, when the first letter of the alphabet is used as a prefix,
it is usually privative, signifying the absence of what follows (e.g., atypical,
amoral, etc.). Thus, before truth was understood in terms of propositional
correspondence, according to Heidegger, it was understood as disclosure or
unhiddeness. One reason why Heidegger preferred this understanding of
truth is that our experience of so many different symbolic orders and
corresponding worldviews forced us to abandon the notion that reality is
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ultimately composed of signified entities that exactly and exhaustively match
our signifiers. Consequently, our attempts to create a symbolic mirror image
of everything we know about the world can only lead us to distorted
perceptions of the world (for example, viewing sanity or insanity as opposed
categories instead of as ends of spectra).
Rhetoric and Institutions
Heidegger's concept of truth as disclosure is important to
understanding the unfolding of meaning in psychiatric knowledge. The
ongoing unconcealment of truth offers a way to understand how the
rhetorical residues of the past become hybridized with contemporary symbols
to disclose new meanings. Meaning is an infinite and inexhaustible surplus
that is limited only by the symbolic forms we have at our disposal. Of course,
sometimes symbolic forms are incompatible with one another. As a field of
knowledge develops, it requires the development of new symbolic forms as
well as the redactive integration of old symbolic forms into a cohesive scheme.
Rhetorical Institutionalism
The institutional structure of a field of knowledge depends upon the
integration of symbolic forms. In modern societies, institutions play a crucial
role in this integration. In other words, institutions perform an architectonic
function. Just as speech was formalized into writing, both of which are
rhetorical, speech and writing developed into formal social structure, the
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institution, which too is a rhetorical form. Institutions serve as the sites of
interaction between the material and symbolic worlds within which humans
cooperate with one another. Institutions are traditionally studied by
sociologists, the “science of institutions, their genesis and their functioning”
(Durkheim, 1982, p. 45). Although an institution is a structure of social
order, and can manifest in physical buildings and written documents, an
institution qua institution has no physical/material existence, nor is it
symbolically represented ideas or concepts (although in some cases they are
formally organized in law). Rather, as Mead (1967) explains, an institution is
“nothing but an organization of attitudes which we carry in us, the organized
attitudes of the others that control and determine our conduct... The
institution represents a common response on the part of all members of the
community to a particular situation” (pp. 211; 261). According to Giddens
(1979), institutions “form a consensual backdrop against which action is
negotiated and meanings formed... Institutions...may be regarded as
'standardized modes of behavior' which play a basic part in the timespace
constitution of social systems” (pp. 50; 96). Furthermore, “every competent
member of every society knows a great deal about the institutions of that
society” (p. 71).
Is the DSM an institution? If it is, it is of a fixed kind, changing only
when formally revised. Yet institutions are always changing:
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Nothing comes from nothing: new institutions can only be created from
old ones... True institutions live, that is, change incessantly; the rules
of action are neither understood nor applied in the same manner at
successive moments, even though the formulae in which they are
expressed remain literally the same. (Mauss, 2005, p. 11)
This suggests that the DSM is an institutional canon (from the Greek kanōn
[ ] κανὠν , meaning measure, standard, or rule), that contains the formulae
that express the rules of action, the meaning of which in practice constitutes
the actual institution. Additionally, while many people have heard of the
DSM and have a passing familiarity with, if nothing else, the names of some
of the most common disorders, it would not be accurate to say every
competent member of our society knows a great deal about the DSM. I
suggest that the DSM serves as an institutional anchor into two distinct
lifeworlds: one common to most in society, and the other common to clinicians
—a clinical lifeworld. While the activities of the clinic are part of the medical
system and thus part of the systems world, medicine is a practical art, and
clinicians themselves are not usually engaged in the same enterprise as
medical researchers.
Social Knowledge
As I've explained, the emergence and mutation of symbolic forms were
integral to the development of culture. Culture consists of the set of
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knowledge from which a collective of communicating people can develop ways
to interpret their experiences meaningfully so that they can understand the
world of objects, as the “natural world, as we experience it, is not identical to
the one known to physics but is culturally constructed” (Sonesson, 2001). In
that sense, culture helps people satisfy their need for meaning and
understanding, which I have explained before is innate. Humans have other
needs, of course. First and foremost is the biological imperative to survive
and reproduce. For that reason, communities come together to form society
so that they can cooperate to solve their material goals. Like culture, a
society can only come about through communication. Without
communication, individuals would not be able to cooperate to solve mutual
goals, for several reasons. First, they must be able to trust one another. In
primitive communities, individuals could trust each other because they were
bound together by kinship relations. In order for nonbiologically related
individuals to trust one another, they needed to demonstrate to one another
that their behavior was guided by a consensual agreement about normative
rules of behavior.
An animal in the wild must always be fearful of strange animals,
because any unknown animal could pose a danger. If they had some way to
predict whether certain other animals would not attack them, they could let
their guard down. Humans are the same way – but by means of
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communication, humans can express to one another that they will not behave
violently toward one another. The cooperative act of communication initially
instantiates this because, in order to communicate, all parties must follow a
set of shared rules. In other words, there must be a collective pool of social
knowledge, which
comprises conceptions of symbolic relationships among problems,
persons, interests, and actions, which imply (when accepted) certain
notions of preferable public behavior... Social knowledge... acquires its
rhetorical function when it is assumed to be shared by knowers in their
unique capacity as audience (Farrell, 1976, p. 4, emphasis in original).
Both social knowledge and the shared assumption that it is shared—
awareness of shared values and norms, of the objectively real world of
objects, and of individual personalities in which occurs similar subjective
experiences of the world—exist in and constitute the lifeworld, the “horizon
within which communicative actions are 'always already' moving, [which] is...
limited and changed by the structural transformation of society as a whole”
(Habermas, 1987, p. 119). There is no meaning outside the lifeworld, for the
ways in which we are aware of ourselves and the world depend entirely on
this collectively constructed lifeworld. Only having access to the subjective
world of experience, one's awareness of material objects is limited to
interactions mediated by instinct and sense perception.
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The development of symbolic communication made it possible for
humans to comprehend material objects that exist within “one and the same
world for a community of speaking and action subjects” (Habermas, 1984, pp.
12–13). This occurs within the lifeworld, a shared horizon of understanding.
The concept of the lifeworld was first defined by Husserl:
In whatever way we may be conscious of the world as a universal
horizon, as a coherent universe of existing objects, we, each “Ithe
man” and all of us together, belong to the world as living with one
another in the world; and the world is our world, valid for our
consciousness as existing precisely through this ‘living together.’ We,
as living in wakeful worldconsciousness, are constantly active on the
basis of our passive having of the world... Obviously this is true not
only for me, the individual ego; rather we, in living together, have the
world pregiven in this together, belong, the world as world for all, pre
given with this ontic meaning... The wesubjectivity... [is] constantly
functioning. (Husserl, 1970, pp. 108–109)
Although everything we perceive arranged throughout time and space is
filtered through the lifeworld, we are not conscious of its operation, as it is
the completely takenforgranted experience of the world.
To us, the world seems objective, which is to say that it exists outside
of ourselves, not within our minds but out there for everyone to see. But even
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this
anticipated unanimity of experience... presupposes a community of
others who are deemed to be observing the same world, who are
physically constituted so as to be capable of veridical experience, who
are motivated so as to speak ‘truthfully’ of their experience, and who
speak according to recognizable, shared schemes of expression. (p. 47)
Though it feels like a subjective process, it is actually intersubjective because
it is shared with everyone in our society. This lifeworld is “the world as we
immediately experience it prereflectively rather than as we conceptualize,
categorize, or reflect on it” (van Manen, 1990, p. 9). In other words, the
lifeworld is the constant everyday experience that all humans have and take
for granted; it is a common horizon of knowing (Todorov, 1984).
The lifeworld does not represent a prelinguistic reality; even basic pre
reflective sensory experience is culturally dependent, which has been
demonstrated dramatically by Henrich et al. (2010), who compared people
from WEIRD societies (that is, societies that are western, educated,
industrialized, rich, and democratic) to people from nonWEIRD societies,
and found that WEIRD people are “frequent outliers” in terms of “visual
perception, fairness, cooperation, spacial reasoning, categorization and
inferential induction, moral reasoning, reasoning styles, selfconcepts and
related motivations, and the heritability of IQ” (p. 61). We don't even
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perceive optical illusions in the same way, a powerful demonstration of the
way in which every experience we have comes to us within the lifeworld.
This is true even of our experience of ourselves—without the lifeworld, there
is no world of differentiated objects, and so there are no individuals. Within
the lifeworld, however, individuals have an internal subjective experience of
the world, recognizing themselves as subjects, an 'I.' Through a series of
language games with other members of her society, the individual recognizes
herself as an object, a 'me' (Mead, 1967).
Connecting System and Lifeworld
This extended discussion of the lifeworld may seem like a tangent, but
it is absolutely critical to understanding psychiatric institutions in the late
modern world. These institutions structure our lifeworld by regulating our
behavior and infusing our perceptions of events with normative judgment.
As will become clear in Chapter 3, this is something that contemporary
institutions inherited from past social structures of expertise: The humoral
model of pathology that dominated Western medicine from Hippocrates to the
end of the eighteenth century systematically structured the lifeworld of the
West. Subjects do not experience the institutional logics that structure their
lifeworld simply as pressures to act one way or another to avoid punishment
or violating a taboo. Rather, the horizon of potential decisions and behaviors
is limited: “Compliance occurs in many circumstances because other types of
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behavior are inconceivable; routines are followed because they are taken for
granted as 'the way we do these things'” (W. R. Scott, 2014, p. 57).
Institutions come from our need to cooperate. Cooperation requires
that the actions of individuals be coordinated in an organized fashion, and
action coordination requires linguistic communication. As some people are
better suited to do certain tasks than others, a society must divide up the
tasks. Durkheim (1997) observed: “Social life is derived from a dual source,
the similarity of individual consciousnesses [the lifeworld] and the social
division of labor” (p. 172).
Initially, communities function as singular instrumental systems in
which all action is steered by linguistic communication within their
lifeworlds, which were coextensive with their systems. As they grow,
however, they begin to divide into groups with different functions. This
trend toward differentiation must be balanced by measures of integration
that keep the community from breaking into pieces. The norms of behavior
that brought the community together in the first place must be codified into
laws that are binding on all members. Further, as people differentiate into
separate groups, the functions of and relationships between these groups also
must be codified into law. Durkheim suggested that the role of law in a
society was similar to the role of a nervous system in an organism:
That system, in effect, has the task of regulating the various bodily
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functions in such a way that they work harmoniously together. Thus it
expresses in a very natural way the degree of concentration that the
organism has reached as a result of the physiological division of labor...
[We] can ascertain the measure of concentration that a society has
reached through the social division of labor, according to the
development of cooperative law with its restitutory sanctions. (p. 83).
In this way, even though system and lifeworld decouple, the consensual
norms of the community are institutionalized into law.
As the community continues to enlarge and become more complex, the
amount of linguistic effort necessary for each system of organizations to steer
itself becomes too great a burden. A very small group of people faced with
the task of allocating scarce resources can accomplish this by talking it out in
order to figure out who needs what resources, and with them what they are to
accomplish for the society. A larger social system of exchange cannot talk
this sort of thing out, and instead must develop a delinguistified medium of
communication—money. As members of the society accomplish tasks for
others, they receive money from them, which they then can use to get from
others what they need; use value becomes exchange value. In order for this
to work, people have to trust one another to honor systemic interactions
mediated by money. Norms must emerge and become codified into law.
At this point, the society now has a basic market within which people's
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behavior, and the behavior they expect from others, are regulated
institutionally. The basic function of an institution is to anchor the steering
media of systems to the lifeworld, which at this point is divided structurally.
Habermas (1987) explains:
Under the functional aspect of mutual understanding, communicative
action serves to transmit and renew cultural knowledge; under the
aspect of coordinating action, it serves social integration and the
establishment of solidarity; finally under the aspect of socialization,
communicative action serves the formation of personal identities... The
process of reproduction connects up new situations with the existing
conditions of the lifeworld; it does this in the semantic dimension of
meanings or contents (of the cultural tradition), as well as in the
dimensions of social space (of socially integrated groups), and historical
time (of successive generations). Corresponding to these processes of
cultural reproduction, social integration, and socialization are the
structural components of the lifeworld: culture, society, person. (pp.
137138, emphasis in original)
The legal institution functions as a metainstitution because through
codification in law, new institutional relationships become legally binding. A
consequence of the institutional relationship between system and lifeworld is
that whenever there is a new problem requiring a new subsystem (or any sort
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of increased systemic complexity), the new systemic development must be
anchored institutionally in the lifeworld, where it becomes rationalized.
Institutions embody 'rationality structures' developed within culture
which opens space for new forms of rationalizing action to be discovered. In
this way, society becomes an evolutionary learning process, as institutions
become engines of progress within which technical systems can incorporate
aspects of cultural products—initially worldviews—into systemic innovation
aimed at a major goal of society. This marks the emergence of the modern
world.
Institutional Canon
While less formalized systems can be slow to adapt to the rhetorical
challenges they face, formal systems make use of canonical texts that
buttress the system's authority, and which can be changed in an instant if
necessary. Canonical texts are renewable resources in which one may find
backing for appeals to authority and to the 'normal' or the 'natural.'
Normalization only works when it is understood well enough to regulate
behavior and belief while remaining perfectly invisible. The canonical texts
work best when lay members of the public can understand them well enough
to know what is required of them—one must understand a text at least
enough to know what it justifies—but not well enough to understand the
reasons for their declarations, or the means to challenge them on their own
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ground. This balancing act, being sufficiently clear to attract diffuse public
support (achieved communicatively in the public sphere) while preventing
outsiders from participating in the systems' internal deliberation about the
operation of its institutions (located almost entirely in the technical sphere),
can be difficult to achieve, particularly during the process of amending one's
canonical text, an act that requires greater legitimation.
Were the public able to participate fully in the technical discourse of a
system, contradictions in the prevailing social logic would become apparent.
To militate against this outcome, “the administrative system must be
sufficiently independent of legitimating willformation” (Habermas, 1975, p.
36). The challenge in psychiatry is made much more difficult by the
communicative nature of its treatment: Both psychotherapy and the
prescription of psychoactive drugs work much better when the patient thinks
he or she understands how they work. Social systems must accomplish both
social integration and systemic integration, and their survival depends on
their “capacity to maintain their boundaries and their continued existence by
mastering the complexity of an inconstant environment” (p. 4).
A social movement can provoke a legitimation crisis by successfully
demonstrating the contradictions of the otherwise takenforgranted
institutions. If the legitimacy of a particular order can be justified by
appealing to its authoritative text, so can the delegitimation of that order if
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countervailing social movements can explain why the text supports their
critique. It is no surprise that the Protestant Revolution centered around
sola scriptura, a doctrine that challenged the nature and authority of the
Bible as read and interpreted by the Catholic Church. Likewise, atheists
often appeal to scripture when they proselytize.
27
In any event, authoritative
texts and the discourse surrounding their production are battleground sites
among internal forces in a system. The contradictions do not need to derive
from entirely internal conflicts (e.g., in psychiatry, the conflict between the
psychoanalytic and biological approaches, discussed in Chapter 1).
Systems often deal with steering problems by soliciting the aid of other
systems which have distinct and even somewhat conflicting imperatives. A
social movement can critique an institution effectively by demonstrating that
its legitimacy is derived from an external system. Like all systems in late
capitalism, psychiatry is deeply connected to other instrumental systems. It
is regulated by the FDA, which manages the definition of an illness and the
means by which it may be treated, by the market, which produces new
treatments in order to make a profit, and by clinicians, who translate and
apply the definitions and treatments to individual patients. Psychiatry is
more a network of systemic interactions and an environment housing a
rhetorical economy than a system proper.
27
See, for example, (Matthew, 2008).
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Psychiatry enlists the aid of these other systems to prevent an identity
or steering crisis: Government regulation of the same sort applied to other
medical fields provides it with a great deal of authority, as do the biological
explanations of mental disorders provided by scientists who are enabled by
the pharmaceutical industry, which also enables clinicians to use the newly
developed treatments 'effectively.' But psychiatry also helps these systems
achieve their own imperatives by providing their actors with social capital: to
pharmacologists, a justification for their work and their status as experts; to
pharmaceutical companies, a market within which its goods may be sold; to
society at large, which has become increasingly secular and correspondingly
more and more focused on health.
Healy (1997) argues that the medicalization of the 'problems of living'
has performed a legitimation function in supporting this move, and as a
result, scientific crises in psychiatry have the potential to contribute to
biopolitical legitimation crises in society at large. During the 1970s, the use
of minor tranquilizers to treat anxiety was a frequent topic of discussion in
both art and in mass media, often appearing in news stories clustered with
discussions of the unhealthy (pun intended) relationship between the
scientific basis of psychiatry and the pharmaceutical industry. In the 1990s,
the use of fluoxetine and other SSRIs became culturally significant,
especially with publications like Listening to Prozac.
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Stable texts provide social movements with an opportunity to
demonstrate contradictions because, if a canonical text is meaningful at all,
it is likely that there are internal contradictions as well as contradictions
between the text and actual practice. It is more difficult to demonstrate that
a moving target contradicts, but for the same reasons it is difficult to appeal
to an instable authority. Likewise, if an authoritative text can be changed on
a whim, appeals to it become less persuasive as it seems to be little more
than a contingent set of opinions. For this reason, canonical texts tend to be
most effective when there is a formalized mechanism with which they can be
amended that is simple enough that it can be understood by the public to not
be completely arbitrary, but complex enough that the opponents of the
institution have little to no ability to access it themselves.
One may speak of the U. S. Constitution as a 'living document,' which
for the sake of posterity establishes a process of amendment that is difficult
but not impossible to use. Similarly, the Christian Bible is open to revision,
though less openly: It can be retranslated or modified (as when Martin
Luther removed the deuterocanonical books from the Old Testament).
Barring that, the church also may alter its meaning as an institutional text
by calling ecumenical councils that can be doctrinal or pastoral. Successful or
not, a powerful institution facing a powerful social movement, their
interactions and strategies for coopting one another's rhetoric while
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defending themselves from the same, are all reflected in the change over time
in a canonical text and the discourse surrounding those changes.
In A Grammar of Motives, Burke (1969a) discusses at length the way
in which a constitution works, and is well aware of the danger posed by
linguistic contradiction:
[Let] us assume some body of men living in a complex but relatively
stable political and economic order. And let us suppose that the
philosophy advocated by one of the schools became “implemented” as
the authoritative vocabulary for rationalizing the culture's acts,
institutions, relationships, and expectancies. Here a new kind of
ambiguity would arise. For the vocabulary of the unofficial schools
would implicitly or explicitly contain different programs of action with
respect to political and economic issues than would the official
vocabulary. (In brief, the grammatical resources would take on
rhetorical implications.) And such doctrinal differences, when
sharpened by their direct or indirect bearing on the political and
economic agon, would in time come to be felt not simply as differences,
but as antitheses. (p. 103)
Though Burke dismisses the importance of formal amendment rather
flippantly (“We need not complicate matters by considering amendments”) he
argues that one way in which a symbolic order protects itself from its
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contradictions is by lending itself to reinterpretation by a competent
impartial actor, as the Supreme Court can do “without waiting for the
unwieldy process of amendment prescribed in the Constitution” (p. 197, 387).
Just as a social movement can challenge an institution by demonstrating its
contradictions, so can an institution defend itself from a social movement by
capitalizing on its contradictions. The more specific the contradictions are,
the more they serve the social movement, while the more vague they are, the
more they can be used effectively by the institution to defend itself (though
obviously the authority of an institution must not be so vague that it cannot
be used credibly to prescribe or proscribe). One can accomplish this by
valorizing two seemingly opposed dialectical terms. Indeed the Supreme
Court derives its legitimacy from “the ambiguities and contradictions arising
from the nature of the Constitution itself” (p. 388).
The psychiatric medical system is instrumental. One of its functions is
to regulate the way in which individuals subjectively experience society and
behave according to its norms. It controls the supplement, which it
administers according to its expertise. The definition and treatment of
mental disorders enables psychiatry as a system to steer society. This relies
primarily on two institutions: the concept of 'mental illness,' and the methods
of its treatment, primarily the authority to prescribe psychoactive drugs.
Through these institutions, it produces a standardized response to a
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situation it defines: mental illness. By producing the terms with which one
may communicate about mental illness, psychiatry controls to some extent
the way in which society thinks about mental health and the treatment of
mental disorders. It is coercive in several ways. Though very uncommon and
extremely limited now, psychiatrists historically have been given by the state
the authority to incarcerate people who they regard as mentally ill, forcing
them to ingest consciousnesschanging psychoactive drugs, and disciplining
them by compelling them to selfidentify with a mental health diagnosis.
This is the primary type of coercion resisted by the antipsychiatry
movement. A further way in which psychiatry is coercive is that it serves as
the gatekeeper of psychiatric medicine: One may only have access to an
antidepressant, for example, with the blessing of a psychiatrist. This is one
coercive power around which the consumer or expatient movement is
constituted. Both forms of coercion rely on the power to define; psychiatrists
treat 'patients' who they diagnose with a 'mental disorder.' To a large extend,
psychiatrists require that those 'patients' agree with those definitions before
they permit them to accomplish some goal (e.g., obtaining release from
incarceration, obtaining a prescription for Prozac, etc.).
The language of an institution is technical. It is difficult for the public
to resist its presence without fluency in an institution's internal
communication. It is difficult to convince the public to oppose a system that
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they cannot understand. People need reasons to oppose powerful systems,
and it helps if those reasons are good reasons, reasons they can defend
despite their inability to comprehend their technical complexity. Who am I to
argue with a scientist about science? Although institutions have a public
dimension, they legitimate systems by serving as a site of interaction
between the technical sphere and the private sphere, a deeply personal
relationship to that system that cannot be challenged publicly.
In the case of psychiatry, the privacy of the doctorpatient dyad is
untouchable, with sufficient legal protection that not even a judge can compel
doctors to discuss their interactions with their patients publicly. In pre
modern times, the Church enjoyed mass loyalty by virtue of its putative
ability to overcome sins, which it defined. Sin in general was a matter of
public discussion, but one's particular sins were discussed only in the private
confessional. Both sin and the sacrament of confession were institutions by
which the Church as an instrumental system embedded itself in the
lifeworld. The various contradictions associated with sin—the problem of
evil, the seemingly Godgiven inclination to sin, the sinful nature of fallible
church leaders, conflicting moral duties, etc.—were difficult to point out
without being able to discuss the contradictions between the public and
private functions of sin. In any event, psychiatric social movements, like
many social movements, can undermine an institution by drawing what was
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once technical along with what was once personal into the public sphere (K.
M. Olson & Goodnight, 1994).
Rhetoric and Practice
Traditionally, financial economists have focused on the material at the
expense of the symbolic (R. H. Brown, 1987; Goodnight & Green, 2010; Graff
& Birkenstein, 2007; McCloskey, 1994, 1997, 1998, 2002, 2010; Szenberg &
Ramrattan, 2004). The opposite error is committed when the material is
neglected in the study of human symbol use. Sahlins (1972) advanced this
argument in support of his rejection of the “procrustean opposition of
'idealism' and 'materialism' by which the discussion customarily proceeds” (p.
ix). This suggests the desirability of speculative interdisciplinary work that
examines material economic phenomena in terms of their symbolic and
communicative components, as well as work that examines symbolic and
communicative phenomena in terms of their material economic components
(Aune, 2001, 2003, 2006, 2009; Cloud, 1994, 2002; Cloud, Macek, & Aune,
2006; Greene, 1998, 2004, 2007).
A market is an instrumental system of action in which scarce resources
are allocated as efficiently as possible. To do so, its rationality is mediated by
a delinguistified medium of communication—money. That is, scarce
resources are allocated through the exchange of money. Left to its own
devices, the market would steer social intercourse divorced from the shared
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norms and values that constitute and integrate modern society. However, it
is anchored to the lifeworld institutionally. Thus, it can be seen to have two
modalities: system (various interlinked markets) and institution (legal,
financial, professional, etc.). Institutions themselves operate in an
institutional environment inhabited by other institutions. Market actors
(both individuals and organizations) are driven by the need to survive and
reproduce, and to do so, they must accomplish material ends in markets
while establishing and maintaining legitimacy within and through
institutions.
Thus, a market is an action systems steered by the exchange of money
between individuals whose behavior is standardized and regulated by an
organized set of attitudes shared by all market actors. In the late modern
world, this organized set of attitudes and predictable behaviors comprises the
global economy as an institution. Within this institution the material
technical operation of the market merges with the symbolic rationalization of
culture and the norms of society. A market and its corresponding institution
are similar in that they both do their work through communication. Markets
operate according to a logic (or sometimes competing logics) dictated by their
steering medium and oriented toward accomplishing technical goals
(Friedland & Alford, 1991; Lounsbury, 2007; P. H. Thornton, 2002).
Although individuals intentionally set up markets and create formal
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organizations called 'institutions,' by and large both markets and institutions
are emergent phenomena. They develop intersubjectively, selforganizing
their functions well beyond the conscious intentions of any of the individuals
involved.
Their differences, however, are significant. A market is an action
system, while an institution is essentially a framework within which the
lifeworld can influence a market (by forcing market actors to obey societal
norms and by orienting market production and consumption toward the
shared values of society) and the market can influence society by distorting
the communicative action that steers the lifeworld. The institutional
arrangement is the product of systemic interaction between the state and the
economy, as the legal constitution of the institution is backed by the power of
the state. Institutions operate according to institutional logics, according to
which interactions within the institution function.
Ideas Market
A market is an open system that cannot be understood inductively,
which is to say its behavior cannot be predicted with certainty. This is
particularly the case now, as its systemic complexity is growing at a rate too
fast to be rationalized by individuals through their institutional economic
relationships. Markets stay relatively stable when there is a high degree of
trust among and between their actors, which also entails trust in the
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market's steering medium. Too much uncertainty in these areas can cause
individuals to behave decidedly irrationally, as they lack any institutional
logic to govern their economic decisions and behavior. All of this is amplified
by the reflexivity of late modernity – institutional knowledge produced by
economists designed to predict future market behavior on the basis of
interactions in the past becomes embedded in the market itself, rendering the
prediction void, further restricting the circumference around which they
make act rationally. The increasing number and complexity of institutional
linkages between market participants amplifies this effect. The more the
outcome of one actor's actions is connected to those of others, the more
vulnerable the market is to swings. The negative consequences of error can
spiral out of control, leading the market toward disequilibrium. There is a
maximum safe amount of leveraging beyond which economic disaster is
inevitable. Furthermore, structural disincentives associated with short
selling favor isomorphisms between bullish investors over those between
bearish investors.
This is a danger posed by coordinating regimes like the DSM.
Psychiatry, as a scientific field, is a market of ideas. Good ideas, ideas which
are productive of knowledge, are valuable. If someone believes an idea is
undervalued – that is, it has a lot of potential to produce new knowledge but
currently is not being pursued by any major research program – then they
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should invest (time, financial resources, intellectual energy) in that idea by
initiating a line of research around it. When scientists write grants, they
have a lot in common with fundamentals analysts on Wall Street. Their
rhetorical efforts must be directed at convincing funding authorities and
colleagues that the idea they want to pursue has potential. In a free market
of ideas, bad ideas lose to good ideas. Unfortunately, there is no such thing
as a free market.
The recent financial crisis suggests that uncertainty and confusion are
in some way built into markets. Buchanan (2008) explains that financial
instrument complexity prevented market participants, whose rationality was
constrained by inadequate banking regulations, from accurately calculating
the risk inherent in those instruments. Moreover, the market was structured
in such a way that separated the shortterm benefits achievable by single
influential actors from the risks associated with those benefits, risks that
nonetheless were taken by organizations, against their own interest (but in
the interest of single individual decisionmakers within the organization).
Those risks were further obscured by ‘collateralized debt obligations,’ which
were then bought and sold by market actors who were not able correctly to
calculate the risk associated with those assets. A third way in which
uncertainty about risk became built into the market is through the process of
leveraging—hedge funds borrow money from banks in order to capitalize on
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market inefficiencies. Banks charge interest on those loans in order to make
a profit, and that interest has to be proportional to the risk that the loan will
not be repaid, which is why individuals with poor credit can only get loans
that come with extremely high interest. The more that hedge funds leverage
their investments, the more risk banks become exposed to – and when banks
lose money in the aggregate, it becomes more expensive for anyone in the
market to borrow money. Buchanan (2008) points to recent models that
suggest that when leverage reaches a certain critical point, the market
becomes completely unstable, as single mistakes (which are inevitable) ripple
through the market, creating cascades of failures throughout the entire
system.
The field of psychiatric nosology has encountered similar problems.
The DSMIII revolution I described in Chapter 1 resulted from the
widespread belief that the complexity of psychodynamic etiological theories
had advanced beyond the capacity of psychiatrists to deploy them reliably.
An institutional legitimation crisis is like a market crash in this analogy.
The new market order created by DSMIII, however, led to a great deal of
leveraging, as theoretical constructs were homogenized into a multiaxial
categorical system, and collateralized disease entities emerged that covered
over heterogeneous phenomena, like the decision in DSMIIIR to fold all
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variants of depression into one major depressive disorder.
28
It is in this
context that Allen Frances could speak of diagnostic 'bubbles' like attention
deficit / hyperactivity disorder (ADHD) or childhood bipolar disorder
(Frances, 2011b, 2013).
Classical economics assumed that market actors were rational
optimizers. As it turns out, market actors often merely copy one another
mimetically, and rather than optimize, they are willing to accept less than
optimal performance as long as it satisfies certain minimum needs. Simon
(1991) suggested that there are “limits upon the ability of human beings to
adapt optimally, or even satisfactorily, to complex environments” (p. 132).
Against the hypothesis that humans always attempt to maximize utility
based on the knowledge available to them, Simon (1978) maintained that any
theory of rationality “must be quite as much concerned with the
characteristics of rational actors – the means they use to cope with
uncertainty and cognitive complexity – as with characteristics of the objective
environments in which they make their decisions” (pp. 89). What is
particularly surprising is that this behavior happens even when uncertainty
is minimized. According to Levine and Zajac (2007), in times of complete
informational certainty, individual market actors take behavioral cues from
others, and when asked to explain the reasons behind their positions, they
28
A proposal to reintroduce melancholia to DSM5 failed for reasons having little to do with
science, as discussed in Chapter 4.
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seemed unaware of this mimesis. Likewise, isomorphisms develop in
institutional environments as organizations mime one another's structure,
management techniques, and strategies (DiMaggio & Powell, 1983). As a
result, the success or failure of each organization becomes correlated with
that of others, increasing the possibility of great swings.
Signification Exchange
The behavior of any member of society is influenced by the structures
of that society, structures which are continually reproduced by the actions of
individuals. Values play a role in both sides of this reflexive loop—on the
micro level, values motivate the conduct of individuals (the values can
include artificial 'needs' mediated communicatively from the market through
art into the consciousness of individuals), while, at the macro level, values
work as institutionalized norms (which regulate the market) to form a moral
consensus that integrates individuals and structures into a social unity. The
signification of value is linguistically structured, and as Giddens (1993)
notes, “language at the same time expresses aspects of domination; and the
codes that are involved in signification have normative force” (pp. 106107).
In addition to signification and domination, legitimation also structures
institutional relationships. Giddens divides institutions into four categories:
symbolic orders or modes of discourse, political institutions, economic
institutions, and legal institutions and other modes of sanction. Of course,
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these institutional forms are all integrated together, and together they
mediate system structure and language.
Symbolic orders and modes of discourse are institutional forms that
organize signification, assigning meaning to cultural needs and to market
products. Symbolic orders provide a surplus of meaning, as symbols can
relate terms literally or through a variety of tropes, e.g., metaphor,
metonymy, synecdoche, irony, etc. Linguistic signification influences and is
influenced by forms of domination and legitimation. Political institutions and
economic institutions organize domination, which shares an interdependence
with signification. As an example, consider the situation when two
individuals exchange money for work. This could be signified in terms of
exploitation or free exchange. Additional signifiers like contract, wage, and
labor further enable and constrain the meaning of the situation. Those
significations then are interdependent with legitimation, as they each entail
rationalized relationships regulated by social norms (codified into law) that
guide the behavior of both parties. Legal institutions organize legitimation,
which is interrelated with domination, as when one entity dominates another
through a lawsuit that all parties agree to accept. Legal institutions
essentially contain a web of intersecting codified norms, which may be
appealed to by one attempting to dominate another through a relationship
that everyone in the society living under the law will accept. As meaning is
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produced culturally, it is constituted and communicated into normative
sanctions. Both meanings and norms can be attached to transactions of
power, through which a member of society can sanction the behavior of
another, resist the efforts of another attempting to sanction him, or infuse his
actions with meaning to which others must yield.
Epistemic Bubbles
I would like to make a final point about late modern technical systems
and the associated institutions that anchor them into the lifeworld within a
broader rhetorical economy. Though other instrumental systems are not
organized around the production of wealth, they all have an instrumental
end. In order to achieve that end efficiently, actors search for strategies of
action that can accomplish the end with the least amount of time and
resources. Once they discover such a strategy, they need to communicate its
value to other actors in the system, so that they can 'invest' in it. This
communication occurs in two ways. First, within the system, it occurs
through its delinguistified communication medium with which it is steered.
Second, within the institution, value is signified within discourse, as actors
try to convince one another to trust them.
The promotion of a specific psychiatric or nosological theory requires
the accumulation of confirmatory data, as well as rationalization among
other system actors (that is, other psychiatrists) and by members of the
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public, who form mental models of the theories. On the basis of those mental
models, individuals will decide how they ought to behave given the new
knowledge, including the decision materially or ideologically to support or
oppose the scientists behind it. In any event, new theoretical and
methodological development requires an investment related to the system's
steering media, provided with the hope that it will deliver a large return (in
the case of psychiatric science, this is in the form of knowledge about the
varieties of madness and their treatment).
I'd like to describe this ‘activity’ as a rhetorical search activity. This
keeps it general and tied to the literature on bounded rationality, as well as
to Kuhn's (1962) theory of paradigmatic revolutions in science. In terms of a
‘search,’ both the borrower and the lender bet that the borrower will find a
technique permitting her to pay back the loan before the money runs out.
When the cost of borrowing is low, the lender takes on more risk, predicting
that this technique will be found. When it thinks that the technique will be
harder to find, it pushes risk onto the borrower by raising rates. Thus, an
expansion in the money supply can be seen as the source of a special, macro
economic case of an institutional belief that new discoveries are forthcoming.
This belief is marked by the distribution of discovery risk away from
discoverer and onto lender/patron of discovery. Necessarily, when this risk is
shifted, borrowers respond. When the money supply expands, borrowers can
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afford to take more risks. But whether this leads to bubbles has to do with
what kinds of things, if any, they find with their searches, rather than simple
fact that they search more. I would hypothesize that expansions in the
money supply lead to bubbles when what is found by borrowers are rhetorical
techniques for exploiting information asymmetries (between borrower and
lender) rather than productive techniques that increase knowledge. A
pyramid scheme is just one such rhetorical technique. Noprinciple loans are
another (note, the asymmetry here is between mortgage broker as borrower
and Wall Street as lender, with homeowner as an evidentiary pawn in the
rhetorical game). Bubbles would occur when the money supply expands and
the ratio of discoverable information asymmetries to productive techniques is
high. Instead of investing capital in a productive way, people instead use it
to search for superior strategies of effective deceit.
Thus, we may casuistically stretch the money supply concept to
generalized epistemic institutional contexts, and with it, we can stretch the
concept of asset bubbles to generalized “epistemic bubbles” (Strait, 2012, p.
5). In order to do so, we must discover parallels to the linkages entailed in
markets that contain high amounts of leveraging. Interconnectedness is
problematic for markets when the negative consequences of investing in poor
search strategies are felt too widely across the entire market. Since this in
and of itself does not require the steering media of money, this phenomenon
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can occur in institutions in which organizational actors are so closely
connected that the mistakes of one actor result in negative downstream
consequences for the entire institution. Just as with markets, we should
expect this process to be nonlinear.
With each new edition of the DSM, the psychiatric nosological 'money
supply' expands, as the market is flooded with a plethora of institutionally
recognized but underresearched objects of knowledge. Pharmaceutical
companies can have a field day in this environment, which is what occurred
after DSMIII gave them several new diseases to brand (Gambrill, 2012;
Healy, 1997). Changing the DSM provides the rhetorical resources to exploit
information asymmetries between market participants, particularly between
industry affiliated researchers, on one hand, and physicians, patients, and
regulators, on the other. Interconnectedness makes the nosological idea
market vulnerable to swings in either direction. If the coordination provided
by DSM hits on fruitful concepts, the idea market will swing upward; if it
contains epistemic deadends or overly risky diagnoses, the result can be
negative. Of course, other factors at play prevent the market from becoming
overly leveraged, like the NIMH's decision to pursue the dimensional
diagnostic concepts they had hoped would be included in DSM5 (Datta, 2013;
Paris, 2013a). The DSM offers just one nosological perspective within an
“economy of DSM alternatives,” though it has a competitive advantage due to
146
the “mental health medicalindustrial complex (MHMIC)” (Sadler, 2013, p.
21). Sadler is hopeful that “NIMH's interest in the RDoC idea signals a new
responsiveness to other and more alternatives to the DSM. Perhaps the
DSM5 idea about a 'living document' may lead to support for 'open source'
classifications of disorder... Only time will tell” (p. 34).
Rhetoric as Polytechtonic Art
In Chapter 1, I proposed the concept of a polytechtonic rhetorical
economy, which integrates the various lines of sociological, anthropological,
economic, and rhetorical theories that I have been discussing in this chapter.
The idea begins with McKeon's concept of rhetoric as an “architectonic
productive art” that “relates form to matter, instrumentality to product,
presentation to content, agent to audience, [and] intention to reason”
(McKeon, 1987, p. 24). In the context of modern institutions, architectonic
rhetoric "provides grounding for the intersubjectivity of communications of
persons and groups and for the objectivity of conclusions of inquiry and
action”; within this deliberative field, “possible worlds, which are discussed in
plans and policy, are constructed, and theses which are posited are stabilized
into principles” (p. 23). The idea that a scientific field is like a building under
construction can be found in an etymological metaphor, the Greek word for
knowledge, epistēmē ( μ ), which combines the verb ἐπιστή η histēmi ( μ ), ἵστη ι
meaning 'to make to stand,' and the prefix epi ( ), meaning 'upon.' This ἐπί
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provides context for understanding the famous words of the ancient physicist
Archimedes, who, while reflecting on the concept of leverage and the
transformative potential of science, said: “Give me a place to stand [stō], and I
will move the world” (as cited in Regnault, 2012, p. 243).
29
From this Greek
word for standing, “one could build a whole philosophical universe... it would
have stables, staffs, staves, stalls, stamens, stamina, stanchions, stanzas,
steeds, stools, and studs” (Burke, 1969a, p. 21). Given the proper topoi, or
rhetorical places,
30
the art of rhetoric makes a constellation of signifiers stand
upon one another. By linking them together within a internally referential
persuasive network, rhetoric builds a scientific field with an architectonic
communicative structure.
The architectural metaphor is useful both for what it does and does not
explain. I contend that a neat structural conception of knowledge fails to
characterize contemporary psychiatric science accurately. In contrast to a
single wellordered building, the field of psychiatry built by the architectons
of mental health
resembles the Tower of Babel. Our psychiatric situation is perhaps
even more chaotic than that of the legendary tower, for in that famous
29
“δός μοι ποῦ στῶ καὶ κινῶ τὴν γῆν.”
30
“To refer to a rhetorical 'place' is to mean, simply, that there are some locations in the field
of thought where verbal controversy can occur through the instrumentalities of rhetoric, and
other locations where the mode of discourse must be of some character other than rhetorical
or where, as Wittgenstein has advised, one would incur an obligation to be silent” (Black,
1992, p. 52).
148
example of failed communication, each person was presumably
speaking one language consistently, although not the same language
as his fellow towerbuilders. What we have in psychiatry is worse:
each person uses a hodgepodge of bits and pieces of ideas, theories,
notions, and ideologies in order to engage in a supposedly common
enterprise with others similarly confused. (Siegler & Osmond, 1974, p.
11)
Written six years before the publication of DSMIII, these words remain true
today. While the DSM functions as an organizing institution, I contend that
contemporary psychiatric nosological discourse has “no center, ...no privileged
locus of growth, ...and no stable patterns of interconnection among its
elements” (Bogue, 2007, p. 127). Put another way, “in an age characterized
by digital material exchange, networks of assembly, and global circulation,”
the rhetoric of psychiatry is not architectonic, but “polytechtonic” (Goodnight,
2014, pp. 9, 2). This corresponds with the shift from early modernity's
concern for “the stability and uniformity of Science” to a late modern need to
“to protect diversity and adaptability” (Toulmin, 1990, p. 183, emphasis in
original).
The concept of a polytechtonic rhetorical economy encompasses theory,
model, argument field (Toulmin, 2003), and paradigm (T. S. Kuhn, 1962), but
is less extensive than an episteme (Foucault, 1994). In contrast to Cassirer's
149
idealism and Kuhn's nominalism (Hacking, 1999), my approach follows
Aristotle (1941b) and Habermas (2005) in presupposing epistemic realism
(while remaining agnostic with respect to metaphysical questions). My
approach breaks with Toulmin, who positions fields of argument in hierarchy,
and with Foucault, who sees epistemic structures as assemblages of control.
Instead, I see scientific discourse as a hybrid body of arguments with
material outcomes that require justification for the expenditure of wealth
capital (Boltanski & Thévenot, 2006). Miscommunications occur in the
justification process due to ripples and dissonances in the lifeworld:
Rational expressions have the character of meaningful actions,
intelligible in their context, through which the actor relates to
something in the in the objective world. The conditions of validity of
symbolic expressions refer to a background knowledge
intersubjectively shared by the communication community. Every
disagreement presents a challenge of a peculiar sort to this lifeworld
background. (Habermas, 1988, p. 13)
This is where the testing and countertesting of validity claims comes in, as
the restoration of a shared understanding “necessary for reasoned agreement
requires working through the bases for concern and objection... an exchange
of reasongiving and criticism – argumentation” (Goodnight, 2007, p. 96).
150
Social Systems
Much like Niklas Luhmann's (1995) conceptualization of a
communication system, a rhetorical economy is autopoetic and self
referential. There are two primary differences between my theory and
Luhmann's. First, my view of rhetoric is less mechanistic than Luhmann's
view of communication, and it can account for suasive forms ('information')
unrelated to their substantive content ('information'). Luhmann's sociological
instincts led him to see the social aspects of communication at the expense of
the individual subject, which for Luhmann is not involved in communication
qua communication, for “only communication can communicate and... only
within such a network of communication is what we understand as action
created” (Habermas, 1975; Knodt, 1994; Leydesdorff, 2000; Luhmann, 1992,
p. 251, emphasis in original, 1995; Ståhle, 2009). Second, where Luhmann
(like Talcott Parsons [1951] before him) detaches social systems from their
materiality, my view of rhetoric is irreducibly material both in terms of its
mediation and in terms of the underlying reality that is signified by and
invested with meaning through rhetoric (Cesaratto, 2013; de Moraes Netto,
2007).
The basic problem guiding Luhmann's inquiry concerned the
reproductive dynamics of social systems. In this context, reproduction refers
to temporal continuity, that is, a system's ability to maintain a continuous
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and stable identity over time despite changes in and turnover among its
members. How do social systems reproduce? Vilfredo Pareto (1935)
suggested that a social system's reproduction is a consequence of the
reproduction of its members. Talcott Parsons (1951) rejected this solution
because, following Émile Durkheim (1951), he argued that sociological
phenomena cannot be reduced to aggregated individual phenomena. Instead,
Parsons suggested that a social system reproduces when its characteristic
patterns of action—the social roles available to its members—reproduce.
These patterns of action are “implementations of perspective points,
interests, values, and – more generally, of meanings” (Poli, 2010, p. 2).
Luhmann (1986) thus argued that the reproduction of social system is a
function of the reproduction of meaning, which happens in communication.
Luhmann's model of communication is peculiar in that it does not
include subjects. Following Bühler (1934), Luhmann conceives of
communication as a trinity of information (the object that is communicated),
utterance (the mechanism of communication), and understanding (the
audience's reception of the uttered information). “Communication,”
Luhmann (1995) suggests, “can be conceptualized as a kind of selfexcitation
that inundates the system with meaning” (p. 171). A communication system
is selfreferential because “there is nothing outside of the text” (Derrida,
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1974, p. 158).
31
Meaning is a distinctive property of communication, and so
communication must refer to communication in order to participate in a
semiotic chain of meaning. A selfreferential communication system is
therefore a relational system.
I want to distinguish between nosological structures, like those
proposed and maintained by the DSM, and the semiotic systems involved in
their assembly, transformation, and deconstruction. Luhmann (1995) argues
that the difference between structures and systems is that the latter “have
boundaries... [which] cannot be conceived without something 'beyond'; thus
they presuppose the reality of a beyond and the possibility of transcendence”
(p. 28). We can bracket off the question of whether this distinction is
meaningful (it is plainly absurd—a structure is built on the ground, from raw
materials and by agents, and is meaningful qua structure by comparison to
its disordered or differentlyordered environment).
32
Burke (1969a)
suggested that a thing's substance, that is, its “characteristic and essential
components,” is actually outside of it: “Yet etymologically 'substance' is a
scenic word. Literally, a person's or a thing's substance would be something
that stands beneath or supports the person or thing” (pp. 2122).
33
So, a
31
“Il n'y a pas de horstexte.”
32
Needless to say, this is an example of one of my favorite tropes, proslepsis. I should also
mention at this point that the word 'system' comes from the Greek word sýstēma ( μ ), σύστη α
literally 'standing together,' generally used to denote a composite structure or apparatus
(Liddell & Scott, 1940).
33
He goes on to discuss—in a single paragraph that makes passing references to the Arian
crisis, the humoral model of pathology, and Freud—a variety of different ways this paradox
153
nosological structure (or system—two different words to describe the same
thing with a slightly different emphasis) stands on its essential elements,
clusters of meaningful associations, transacted through a rhetorical economy,
in which those possessing epistemic capital (perhaps after having raised it by
pitching it to semiotically wealthy insiders or outsiders) invest in ideas,
research programs, and symbols.
Rhetorical Reproduction
Luhmann borrowed the concept of 'autopoesis' from the biologists
Humberto Maturana and Francisco Varela, who argued that a living cell is
an “autopoietic machine,” that is,
a machine organized (defined as a unity) as a network of processes of
production (transformation and destruction) of components which: (i)
through their interactions and transformations continuously
regenerate and realize the network of processes (relations) that
produced them; and (ii) constitute it (the machine) as a concrete unity
manifests in the realm of ideas: “The same structure is present in the corresponding Greek
word, hypostasis, literally, a standing under: hence anything set under, such as a stand,
base, bottom, prop, support, stay; hence metaphorically, that which lies at the bottom of a
thing, as the groundwork, subjectmatter, argument of a narrative, speech, poem; a starting
point, a beginning. In ecclesiastical Greek, the word corresponds to the Latin Persona, a
person of the Trinity (which leads us back into the old argument between the homoousians
and the homoiousians, as to whether the three persons were of the same or similar
substance). Medically, the word can designate a suppression, as of humours that ought to
come to the surface... When we are examining, from the standpoint of the Symbolic,
metaphysical tracts that would deal with 'fundamentals' and get to the 'bottom' of things,
this last set of meanings can admonish us to be on the lookout for what Freud might call
'cloacal' motives, furtively interwoven with speculations that may on the surface seem wholly
abstract. An 'acceptance' of the universe on this plane may also be a roundabout way of
'making peace with the faeces'” (p. 23, emphasis in original).
154
in space in which they (the components) exist by specifying the
topological domain of its realization as such a network. (Maturana &
Varela, 1980, pp. 79–80)
Like a living system, a social system manufactures what it needs for
reproduction. Autopoiesis literally means a process of making (poiésis
[ ], creation) oneself ( ποίησις auto [ ], self). For Luhmann, a social αὐτό
system's reproduction is coequal with its selfreference, by which social
systems “define their specific mode of operation or determine their identity by
reflection to be able to regulate which internal meaningunits enable the self
reproduction of the system and thus are repeatedly to be reproduced”
(Luhmann, 1995, p. 34). Since a system of meaning can only refer to itself, it
“must adhere to the type of element that the system defines. To this extent,
it is reproduction. Thus action systems must always produce actions... This
is what the selfreference of the elements guarantees. Certain limits are
placed on variation” (p. 35). But social systems evolve; they do not always
stay the same. This raises another question: how do social systems change?
Evolution or Revolution?
Autopoietic reproduction of a system of action does not mean that the
same actions are repeated continuously—rather, reproduction only requires
“production out of what has been produced; for autopoietic systems this
means that the system does not end through its actual activity, but goes on...
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[which depends] on the fact that actions (whether intentionally or not) have
communicative value” (p. 169). New ideas and practices are not created ex
nihilo, but in the process of reproduction, change gets introduced into a social
system.
Stephen Toulmin suggests that useful innovations essentially come
into being randomly. Like Luhmann, Toulmin and Goodfield (1965) see a
parallel between social and biological systems, particularly regarding their
evolutionary paths:
[The] most profound lesson of Darwin's work is that new creations of
great functional significance often come into existence as byproducts
of processes, all of whose manifest goals lie in quite other directions;
and the merits of these novelties depend, not on their conformity to
any longterm historical tendency, but on their immediate
appropriateness to the particular situation in hand. This is equally
true for both organisms and institutions. If there is a key to the
understanding of all history, it consists in recognizing not its single
directedness, but rather its multiple opportunism. (Toulmin &
Goodfield, 1965, p. 235)
In other words, the history of ideas is more a polytechtonic flow than a
unidirectional arrow. On the other hand, the terminologies of science “are
not made at random; they follow a definite principle of classification”
156
(Cassirer, 1944, p. 209). What is random is the rhetorical productivity that a
particular form will have in some future hybrid context, as is whether such a
context, and not a different one, will present itself.
Toulmin (1972) argues that the development of scientific systems
occurs through a process of evolution, rather than revolution, as Kuhn (1962)
maintained. Toulmin bases his criticism of Kuhn's theory, which posits
incompatible paradigms competing with one another for hegemony, on his
theory of fielddependence and fieldinvariance. If, Toulmin argued, outside
of 'normal science,' two paradigms are truly incommensurate, then they have
no basis on which to compete. This is because interlocutors only may
compare conflicting claims that are part of the same field of argument. For
example, if one argues that abortion is impermissible because of the
universal patristic witness against the practice, and another argues that it is
permissible because of Roe v. Wade, there is no procedure by which the two
could weigh the relative merits of those two claims. Toulmin argued that,
just as absolutism overestimates the degree to which warrants are field
invariant, Kuhn's relativism overestimates the degree to which warrants are
fielddependent. There are always elements of both at work in any body of
discourse—though we would not expect the “standards of argument relevant
in a court of law” and those “relevant when judging a paper in the
Proceedings of the Royal Society” to be identical, we would expect them to
157
share some logical features and to contain some similar kinds of arguments
(Toulmin, 2003, p. 15). The development of knowledge involves both
continuous and discontinuous flows, as new findings, ideas, and symbols from
the “intellectual ecology” of a disciplinary field make their way into a larger
epistemic structure once place has been made through the culling of
“entrenched concepts,” all of which occurs within “forums of competition” in
response to forces of symbolic supply and contingent “demand” (Toulmin,
1972, p. 140).
My view is essentially Toulmin's, with a few modifications. I follow
Foucault's (1994) insight about the parallel nature of the configurations of
knowledge across fields, as well as Luhmann's (1986, 1995) conceptions of
multiple interlocking systems that refer to one another and of a self
referential system of meaning. I see the latter essentially as an “ideological
cultural system,” that is, an ordered lifeworld of “interacting symbols… [with]
patterns of interworking meanings… [that] transform sentiment into
significance and so make it socially available” (Geertz, 1964, pp. 56–57). For
Geertz (1973), rhetoric provides connections between the different
dimensions of culture, which he defines as “a system of inherited conceptions
expressed in symbolic forms by means of which men communicate,
perpetuate, and develop their knowledge about and attitudes toward life” (p.
89). Culture integrates three psychological dimensions: a cognitive
158
dimension, consisting of a thoughtworld of collective representations
networked together in a way that makes communication possible; a moral
dimension, consisting of our convictions about what is just and unjust, right
and wrong, important and trivial, which guide value judgments, goals,
choices, evaluations, and norms of action; and an affective dimension,
consisting of sentiments like love, fear, anger, loyalty, hate, gratitude, and
disgust, which define and orient our emotional responses to people, events,
and actions.
Their refusal to learn anything about rhetoric has, in Geertz's (1964)
scathing judgment,
reduced sociologists to viewing ideologies as elaborate cries of pain.
With no notion of how metaphor, analogy, irony, ambiguity, pun,
paradox, hyperbole, rhythm, and all the other elements of what we
lamely call “style” operate—even, in a majority of cases, with no
recognition that these devices are of any importance in casting
personal attitudes into public form, sociologists lack the symbolic
resources out of which to construct a more incisive formulation. (p. 57)
These tropes are the points at which the different dimensions of culture
intersect. These different dimensions permit meanings to flow both
continuously and discontinuously at once. Concepts, symbols, and rhetorical
forms can, like “nomads,” go into temporary exile from one field, or even from
159
the cognitive lifeworld altogether, biding their time in the affective or moral
realms (Noyes, 2004, p. 159). The “rhizomatic multiplicities” of systems,
fields, structures, and environments reflect the polytechtonic nature of the
late modern world (Deleuze & Guattari, 1987, p. 370).
In Chapter 3, I examine the roots of modern medicine in the humoral
theories of Hippocrates and Galen. Although the modern science of medicine
has moved far beyond these theories, I will show that traces of their former
existence are visible in the appeals used in both mainstream and alternative
medicine. Pieces of an ancient rhetorical system still exist, within which
certain symbols, and certain kinds of grounds, contain the ability to persuade
audiences of certain kinds of claims. The transformation of medical theory,
particularly over the last two hundred years, provides an opportunity to look
at how a rhetorical system reproduces, and what happens to those processes
after that rhetorical system seems to have been replaced.
As I will show in the next two chapters, contemporary psychiatric
diagnostic entities have a temporal element. This is true across different
nosological schemes: Psychodynamic perspectives locate present distress in
past trauma, and neuropsychiatric definitions of schizophrenia and bipolar
disorder depend, in different ways, on a sequence of syndromal features
presenting over time. More generally, patients and even populations of
patients change over time. Even more generally, science is a technique for
160
producing knowledge that is necessarily temporal, as new findings and
inventions update and supplement old knowledge. The rhetorical economy of
psychiatric science involves “temporalized complexity,” and thus depends on
“constant disintegration” (Luhmann, 1995, p. 48). Under this condition,
“reproduction is a continuous problem,” because:
All elements pass away. They cannot endure as elements in time, and
thus they must constantly be produced on the basis of whatever
constellation of elements is actual at any given moment. Reproduction
thus does not mean simply repeatedly producing the same, but rather
reflexive production, production out of products. (p. 49)
Dynamic stability in rhetorical systems therefore will involve a change in
elements over time, and the systems that successfully reproduce are those in
which rhetors can repurpose terms and strategies operative in one case to
another, either in the same form or in a hybridized combination with other
elements (symbols, warrants, evidence, topoi, etc.) of the system. Often this
entails retaining the form but not the content of past persuasive appeals.
The principal means of rhetorical production are identification and
division (Burke, 1969b, 1984b). A rhetorical economy facilitates scientific
thought by creating continuity and discontinuity at the right points,
connecting or distinguishing old ideas and new, integrating or disentangling
separate findings, embedding or disembedding different fields and subfields
161
of knowledge. As a consequence, ruptures and revolutions occur in the
history of scientific theories, but the tropes and topoi of the past can remain
even after a radical rupture occurs, for “in tearing down an old house, one
usually saves the wreckage for use in building a new one” (Rene Descartes,
1998, pp. 16–17).
That a cultural structure born in antiquity is alive in contemporary
arguments (be they personal, technical, or public) implies the existence of
mechanisms of rhetorical reproduction, since “in order to exist, every social
formation must reproduce the conditions of its production at the same time as
it produces” (Althusser, 1994, p. 101). Understanding these mechanisms
allows us to see nosological debates in a different light. This inquiry also
reveals certain periodic rhetorical trends in the history of medicine—for
example, the prominence of appeals to individual case reports rather than to
appeals to theory, or the relative stress placed on continuity or discontinuity
within a terministic model—and their significance in contemporary
discourse. More generally, this sort of study offers insights into the ways in
which an old symbol’s “surplus of meaning” can serve as an effective (and
affective) inventional resource, particularly for a discursive formation that is
traveling the path from emergence to formalization, to reformalization
(Foucault, 1972; Ricoeur, 1976, p. 45).
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CHAPTER THREE: RHETORICAL HISTORIES OF PSYCHOSIS
“You see, here’s the problem. You don’t know the history of psychiatry. I do.” – Tom
Cruise.
34
“Science, unlike art, is a system of derivative ideas filtered through centuries. Consequently,
originality in science is not only infrequent but unwelcome, and even the most original ideas
have a history, often a much longer one than their authors suppose.” – Miriam Siegler &
Humphry Osmond
35
“Direct selfobservation is not nearly sufficient for us to know ourselves: we require history,
for the past continues to flow within us in a hundred waves; we ourselves are, indeed,
nothing but that which at every moment we experience of this continual flowing… [To]
understand history we have to go in quest of the living remnants of historical epochs – we
have to travel, as the father of history, Herodotus, traveled, to other nations – for these are
only earlier stages of culture grown firm upon which we can take a stand… But there exists
a subtler art and object of travel which does not always require us to move from place to
place or to traverse thousands of miles. The last three centuries very probably still continue
to live on, in all their cultural colors and cultural refractions, close beside us: they only want
to be discovered. In many families, indeed in individual men, the strata still lie neatly and
clearly one on top of the other: elsewhere there are dislocations and faults which make
understanding more difficult… He who, after long practice in this art of travel, has become a
hundredeyed Argos, will in the end be attended everywhere by his Io
36
– I mean his ego –
and will rediscover the adventurous travels of this ego in process of becoming and
transformation.” – Friedrich Nietzsche.
37
“Let the credulous and the vulgar continue to believe that all mental woes can be cured by a
daily application of old Greek myths to their private parts.” – Vladimir Nabokov
.38
***
The public discussion and controversy over DSM5 takes place in the
context of the progressive development of modern medicine generally and the
emergence of modern psychiatry in particular. This chapter draws forward
this context by examining a number of key moves in the histories of medicine
34
Tom Cruise, interviewed by Matt Lauer on NBC’s ‘Today Show’ (“Tom Cruise discusses his
views on antidepressants and psychiatry,” 2005, para. 14).
35
Miriam Siegler & Humphry Osmond (1974, p. 1).
36
According to Greek mythology, Hera sent Argos Panoptes (a primordial giant with 100
eyes) to watch over the cownymph Io in order to guard against any illicit encounters with
Zeus (E. Hamilton, 1940).
37
Friedrich Nietzsche (1986, sec. II:223, emphasis in the original).
38
Vladimir Nabokov (1973, p. 66).
163
and madness. The arc of the chapter is to situate the contemporary context
concerning psychosis risk syndrome (a topic I take up directly in Chapter 4).
The controversy over predictive and diagnostic understandings of risk
syndrome raises a critical issue central to the DSM5 debate: What is the
nature of mental illness and its status as a “real, recognizable, unitary and
stable object of history”? This question raises issues that concern the
ordering of prevention and treatment within a hierarchy of medical values,
the role of likely course and prognosis in psychiatric nosology, and the
importance of (and attributed confidence in) scientific knowledge about the
etiology and pathogenesis of psychotic disorders. Analysis of the issue will
offer insight into the ways in which continuity and discontinuity are
performed rhetorically, the relationship between diagnosis and recommended
treatment, and the perseverance of cultural systems and epistemic
assemblages well beyond their putative abandonment by apparent consensus
(Luque, Berrios, & Villagrán, 2003, p. 111). I explore several interrelated
historical discursive movements that are germane to each of these issues, yet
can be difficult to see in contemporary biomedical discourses without the
right tools.
The chapter is a study in rhetorical history. It moves from what are
regarded as dated theories of pathology to explain contemporary stateofthe
art medical appeals. This critical history shows the contemporary relevance
164
of the residues of thinking which still retain the capacity in some manner to
“organize the chaos” within and around us (Nietzsche, 1874, p. 122).
Through the various twists and turns of material history, alongside adjacent
professional and clinical languages, a perspective on the selfgenerating
processes of discursive formations becomes visible. By the end of the chapter,
the diverse observations made along the path through the dislocations,
faults, and neatly lying strata of the discourses of madness and medicine
should coalesce into themes that set forth the context in which nosological
positions become advocated and contested. My history has three discursive
episodes, each of which I shall preview briefly in order to show the
progressive, cumulative developments of contexts within which DSM5
debates occur.
1. The Humoral Model of Pathology. Humorism (sometimes
'humoralism' or the 'humoral model') constitutes a model that dominated the
articulation of medicine for more than 2,500 years. This discourse offers the
earliest definitions of pathology in the Western medical tradition. Humorism
was for all purposes coequal with medicine as a field of knowledge, into which
all medical discoveries for millennia were integrated. This chapter identifies
basic premises of this model and reads select, foundational texts of medical
science in the Hippocratic corpus and the writings of Galen. Additionally, it
examines nonmedical authorities writing about medicine, especially the
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Roman Epicurean philosopher Lucretius. His radically material and
biological account of mental illness shares much in common with
contemporary biomedical views. From the very beginning, Hippocrates made
both epistemic and institutional moves as he formulated medical practice.
Modern medicine featured similar rhetorical strategies in defining medicine
and madness. These feature a wide array of relevant discourses, including:
Mesmerism (a protopsychotherapy developed to treat what are now known
as dissociative identity disorders); categories adopted by alienists like
melancholia and mania; twentieth century theories about personality
structures and types; contemporary constructs like Attention Deficit /
Hyperactivity Disorder (ADHD); recurrent institutional squabbles between
psychiatrists and psychologists; the marketing of alternative 'holistic' or
'naturopathic' dietary supplements; and the presentation and rhetorical use
of scans produced with brain imaging technologies. The chapter shows how
traditional concepts were carried forward into modern times.
2. The Rise of Scientific Medicine. For the purposes of this study, I
examine the transition to a 'scientific' approach to medicine as a phenomenon
stretching from the seventeenth century, when the therapeutic effects of the
bark of cinchona trees (which contains quinine, an effective malaria
treatment) were discovered, to the early twentieth century. The
achievements most relevant to the DSM5 debate come from the emergence
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(and subsequent convergence) of ontological and physiological interpretations
of pathology. Thomas Sydenham, called the 'English Hippocrates,' offers an
example of departure to the modern. His approach to medicine was at once
neoHippocratic and protobiopolitical, retaining certain humoral beliefs.
These beliefs informed his decisions about the variables he included in the
first ever epidemiological study involving data collection and statistical
analysis. Sydenham crafted an ontological distinction, dividing illness into
discrete disease entities that each present as a syndrome with characteristic
clinical signs and symptoms. His empiricist approach (distinguished from
rationalist humorism) was concerned with “semeiosis” rather than diagnosis
(Coulter, 1975, p. 247).
39
Sydenham's classification of 'hysteria' as a mental
illness anticipated the contemporary conflict between psychological and
biological explanations in psychiatry. A later generation of physicians
revised this view, arguing that disordered bodily 'vapors' were the source of
hysteria. In turn, twentieth century psychoanalysis reformulated these class,
gender, and sex based outlooks into 'conversion disorder,' an illness that
features psychic tensions giving way to somatic distress. Rudolf Virchow
argued that biological terminology and conceptualization should replace the
ontological understanding of illness. The relationship between
39
Originally, semiotics was a field of medical knowledge concerned with the interpretation of
clinical signs, only later acquiring its more generalized identity as the study of signification
and meaningmaking (Baer, 1988).
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psychoanalysis and pharmaceutical intervention thus became contested.
Although its terms were worked out early in the twentieth century, the
modern setting for defining and diagnosing disorder still broadly shapes the
context for DSM5 contestation.
3. The Emergent Assembly of Psychiatry. The final section of this
rhetorical history describes the genesis of psychiatry. JeanÉtienne
Dominique Esquirol, a French alienist, produced the first comprehensive
nosology of mental illness based on the patients he observed while working in
an asylum. Visual representations played a critical role in Esquirol's efforts
to persuade his colleagues of the merits of his classification scheme. Esquirol
appropriated the visual rhetoric of Linnaeus, the father of modern taxonomy.
Esquirol's representations are followed by the semiotic dialectic of 'neurosis'
and 'psychosis,' which unfolded alongside Emil Kraepelin's diagnostic
category 'dementia praecox.' Dementia praecox was a revolutionary
pathological entity because it was defined by its temporal course and
prognosis. This concept of psychotic illness evolved into Bleuler's
'schizophrenia,' which reimagined dementia praecox as a loosening of
associations and a splitting of the mind. The sharp material turn of the last
fifty years gave biological meaning to these two ideas: a loss of associations
between neurons and neurological lesions in gray and white matter.
Developments in psychopharmacology and in brain imaging techniques
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continue the material turn, which pharmaceutical advertising has carried to
publics. The mixed development of psychiatry combined with public
representations of disease form the context in which DSM5 finds controversy
attributed to the wellbeing of a profession and its publics.
The Humoral Model of Pathology
Humorism is a model of pathology that explains variance in human
health, personality, and drive as a function of the deficiencies and excesses of
four distinct bodily fluids, the humors. Hippocrates compiled humorism into
a system in the fourth century before the Common Era, and some five
centuries later, Claudius Galen integrated it with Aristotelian philosophy
into a comprehensive theory for the science of medicine, defined as “the
knowledge of what is healthy, what is morbid, and what is neither” (Galen,
2004, p. 1).
40
Mapped onto the four classic elements that Empedocles (2012)
had described a century before Hippocrates, the humors were structurally
organized in relation to one another according to the qualitative binaries of
hot/cold and wet/dry (Figure 3.1).
40
Galen goes on to clarify that it “makes no difference if one uses the term ‘diseased’ instead
of ‘morbid.’ The term ‘knowledge’ is to be understood in its common, not its technical, sense”
(2004, p. 1).
169
Source: (Magner, 2002, p. 25)
Figure 3.1: Structural relationships between the humors,
temperaments, elements, and qualities
170
While it might seem paradoxical to describe a liquid as ‘dry,’ these
qualities were simultaneously metaphorical and physiological. Hippocrates
observed, for example, that one could become dehydrated as a result of
drinking too much wine.
41
Further, he observed that the consumption of wine
often brought a feeling of warmth. Hence, Hippocrates thought of wine as
being both hot and dry. Noting that the sweetness of a wine inversely
correlates with its suppressive effect on salivation, acrid wines were
described as more ‘dry’ than sweet wines, a distinction that persists today
(Norrie, 2003). In a similar manner, we make use of humoral terminology
when we speak of comedy as ‘dry’ (as a deadpan delivery lacks the outward
signs of cheer associated with ‘moist’ sanguine humor) or ‘dark’ (associated
with the melancholy of black bile).
Physicians understood the humors to be “lifegiving moisture,” liquid
incarnations of the vital forces that govern all of the rhythms of life, from the
seasons and the weather all the way down to human health, “a proper
mixture of the humors being as necessary to bodily growth and functioning as
that of the elements to the creation of permanent substances” (Tillyard, 2011,
p. 69). These vital forces deeply penetrate our corporeal nature, circulating
through and ‘coloring’ human bodies, both literally and (as we understand it
41
The various writings attributed to Hippocrates are not all believed to have been authored
by him, but rather by subsequent students (King, 1993). Citations of Hippocrates in this
chapter should be understood as citations of the Hippocratic corpus, rather than necessarily
as direct attributions to the historical Hippocrates.
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today) metaphorically, as in the reddening of the face associated with both a
sanguine complexion and a sanguine disposition. In other words, they are
visibly present in one’s complexion (the literal result of a ‘complex’ of
humors), level of activity, mood, posture, speech, and temperature (derived
etymologically from the Latin temperare, ‘to mix’). Each humor further
corresponds with a distinctive temperament (also derived from temperare)
and prevailing affective state: black bile (the hidden fluid responsible for
darkening blood and stool, thought to be produced in the spleen or bowel)
with the sad melancholic; choler (yellow bile or gastric juice, thought to be
produced in the liver) with the angry choleric; phlegm (mucus, sweat, tears,
and other colorless secretions, thought to be produced in the brain) with the
sluggish phlegmatic; and blood (a hot red liquid thought to be produced in the
heart) with the cheerful sanguine (Galen, 2004; Gottfried, 1983; Healy, 2008;
Magner, 2002; Noll, 2011).
Though not terribly controversial at the time, the notion that our
personality and behavior are at least partially (if not entirely) determined by
physiological factors was repressed deep within the Western cultural
unconsciousness for millennia, and its return in the nineteenth century
ironically was instrumental in the final rejection of humorism by the medical
establishment in favor of a model of discrete disease states based on
pathological anatomy. The four temperaments, protoWeberian ideal types of
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characterological dispositions, signify clusters of character tendencies (later
conceptualized as personality traits), the consequences of the humors
tempering one another such that one of the four humors completely
dominates the other three in an individual's body and, thus, character
(Strelau, 2002; Weber, 1949).
In a physically and mentally healthy person, all four humors are in a
state of eucrasia (literally a ‘good mixture’) or balance. Accordingly,
dyscrasia (‘bad mixture’), the acute (sometimes chronic) imbalance of humors,
is the direct cause of most disease. ‘Cause’ here refers to susceptibility, a
disposition or tendency (‘habitus’) toward some specific manifestation of
disease; “habitus phthisicus,” for example, is the Latinized Hippocratic term
used to describe someone who is especially susceptible to what was later
known as pulmonary tuberculosis (R. J. Campbell, 2009, p. 440). Hippocrates
notes:
If the brain is corrupted by phlegm the patients are quiet and silent, if
by bile they are vociferous, malignant and act improperly. If the brain
is heated, terrors, fears, and terrifying dreams occur; if it is too cool the
patients are grieved and troubled. (cited by Diethelm, 1971, p. 16)
Another form of imbalance, either in some singular extrahumoral disposition
or in a crisis associated with an inner conflict between dispositions, produces
an illness state known as ‘distemper,’ paralleling our contemporary notion(s)
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of the disordered personality (e.g., borderline personality disorder),
distinguished from the acute clinical syndrome (Healy, 2008).
42
In some cases, the pathogenic imbalance is not within an individual
human body (agent), but rather the surrounding environment (scene), which
may be a source of some bad odor (‘miasma’) or of contagion, a disease
substance that, unlike miasma, was produced within a human body before
beginning to circulate through corrupted or polluted air (Gottfried, 1983;
Noll, 2011). When predisposition to a particular illness runs in a family, the
imbalance is not a humoral excess or deficiency per se, but rather an intrinsic
imbalance within a single humor—‘bad blood,’ in which the inherited trait, or
perhaps rather heredity as such, is metonymically reduced to the sanguine
humor (Ciobanu, 2012). Infectious disease was communicable even across
the barrier of metaphor, as an imbalance in the ‘body politic’ was known to
render individual human bodies susceptible to leprosy (Douglas, 1992).
Humoral pathology served as a logic that unified the various medical
techniques of diagnosis and intervention. The model provided explanations
of the mechanisms of ancient pharmacotherapy. These explanations spread
to other domains of thought through figures of speech. For example, the
sophist Gorgias of Leontini invoked humoral pathology in his famous
observation about the power of rhetoric:
42
In DSMIV, this is a difference between the second and first axes (respectively) of
disorders.
174
The effect of speech upon the soul is comparable to the power of drugs
over the nature of bodies. For just as different drugs dispel different
secretions from the body, and some bring an end to disease and others
to life, so also in the case of speeches: some distress, others delight,
some cause fear, others make the hearers bold, and some drug and
bewitch the soul with a kind of evil persuasion. (Gorgias, 1972, para.
14).
This may be the first articulation of the 'talking cure,' written 2,300 years
before Freud was born, formulated as an argument by analogy to humoral
medicine.
We can see traces of the humoral architectonic in our everyday
language today, as when a chronically irritable person, prone to outbursts of
anger, is said to have a ‘bad temper’ (and is perhaps ‘hotheaded,’ unlike
people who can ‘keep their cool’ when the unexpected occurs) or when a
moody, sensitive, and perhaps erratic individual is said to be
‘temperamental.’ An almost opposite type of character is signified by
‘temperance,’ which invokes notions of moderation and selfcontrol, the result
of a balanced character. Etymologically, the difference between
‘temperament’ and ‘temperance,’ both noun derivatives of the verb temperare,
is that the former contains the Latin suffix –mentum while the latter
contains the Latin suffix –antia. The suffixes –mentum and –antia are
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extremely similar, both functioning to convert a verb into a noun
representing a state associated with, produced by, or instantiated in the
action signified by the verb. The difference is that –mentum converts the
verb into a concrete state, generally the subject (as in government) or object
(as in firmament) of the verb, while –antia converts the present participle
form of the verb into a noun, emphasizing process rather than source or
outcome (Luschnig & Luschnig, 1982). Temperamental is simply an adjective
derived from temperament. Hence, ‘temperamental’ describes someone prone
to concrete states of character or affect, the outcomes of distinctive humoral
mixtures that are imbalanced in one way or another. In contrast, temperate
(the adjectival form of temperance) describes someone whose character is
moderated by a steady, balanced process of humoral mixing (as well as a
steady, balanced climate). This is how two nearly identical words generated
within a robust semiotic system came to have nearly opposite meanings.
43
The difference between concrete states and dynamic processes may
seem merely semantic, but will come to be the pivot point for multiple
revolutions in psychiatric nosology as the conflict between categorical and
dimensional approaches to diagnosis. Indeed, Theodore Millon, a
psychologist who served on both the DSMIII and DSMIV committees, and
43
This also helps to explain how a powerful eighteenth to twentieth century American social
movement thoroughly united in opposition to mixed beverages could perhaps paradoxically
come to be known as the ‘Temperance Movement.’
176
Erik Simonsen, past president of the International Society on the Study of
Personality Disorders and past chairman of the World Psychiatric
Association section on personality disorders, argue that, while
debates on these issues often degenerate into semantic arguments and
theoretical hairsplitting, it is naïve to assume that metaphysical
verbiage and word quibbling are all that are involved. Nevertheless,
the language that we use, and the assumptions such language reflects,
are very much a part of our scientific disagreements. (Millon &
Simonsen, 2010, p. 50)
How one defines pathology determines how one thinks of individual
disorders: how to measure their presence or absence, what it means to treat
them, and how to distinguish one from another.
Humoral Rhetoric from Antiquity to Modernity
In contrast with certain mystical or religious orientations in which
madness (possession by a demonic or divine force) and physical ailments
(manifestations of the corrupting or defiling nature of sin) are seen in moral
terms as two incommensurate elements of a cosmic theological drama, the
humoral orientation seems strikingly modern. Its concepts of mental and
physical illness both are ‘seen’ (literally and metaphorically) as natural
processes best explained physiologically and, thus, falling within the domain
of medical science. This is very clear in Hippocrates’s treatment of the so
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called ‘sacred disease,’ today known as epilepsy, in which he presents a
thoroughly secular understanding of mental illness (as epilepsy was regarded
from antiquity until very recently) along with some very prescient claims
about the role and functions of the brain:
I do not believe that the ‘Sacred Disease’ is any more divine or sacred
than any other disease but, on the contrary, has specific characteristics
and a definite cause. Nevertheless, because it is completely different
from other diseases, it has been regarded as a divine visitation by
those who, being only human, view it with ignorance and
astonishment… It is my opinion that those who first called this disease
‘sacred’ were the sort of people we now call witchdoctors, faithhealers,
quacks and charlatans. These are exactly the people who pretend to be
very pious and to be particularly wise. By invoking a divine element
they were able to screen their own failure to give suitable treatment
and so called this a ‘sacred’ malady to conceal their ignorance of its
nature… The brain is the seat of this disease, as it is of other very
violent diseases… It ought to be generally known that the source of
our pleasure, merriment, laughter and amusement, as of our grief,
pain, anxiety and tears, is none other than the brain. It is specially
the organ which enables us to think, see and hear, and to distinguish
the ugly and the beautiful… It is the brain too which is the seat of
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madness and delirium, of the fears and frights which assail us, often
by night, but sometimes even by day; it is there where lies the cause of
insomnia and sleepwalking, of thoughts that will not come, forgotten
duties and eccentricities. All such things result from an unhealthy
condition of the brain… This socalled ‘sacred disease’ is due to the
same causes as all other diseases… Each has its own nature
44
and
character and there is nothing in any disease which is unintelligible or
which is insusceptible to treatment… The physician… could cure this
disease too provided that he could distinguish the right moment for the
application of the remedies. He would not need to resort to
“purifications” and magic spells. (Hippocrates, 1995, pp. 139–144)
This line of argument was centuries ahead of its time, and not only on
account of the “astonishingly prescient” insights about the material nature of
conscious experience located in the brain, for which it justifiably is celebrated
(Zeman, 2006, p. 2).
45
This jurisdictional polemic is also evidence that, from
the very beginning, Western medicine has been the site of a discursive
struggle over the politics of medical expertise.
While admitting that the ‘sacred disease’ certainly may seem
supernatural to a nonexpert, Hippocrates positions himself as an expert who
44
The word for nature is physis ( ), φύσις emphasizing that the basis of disease is
physiological, not supernatural.
45
Aristotle, a virtual contemporary of Hippocrates, suggested that the mind was located in
the heart and that the only purpose of the brain was to keep the body from overheating by
cooling the blood (Klein & Thorne, 2006).
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knows better, because he understands that, like other physiological diseases,
the ‘sacred disease’ is caused by organic dysfunction. Further, causal
knowledge should be privileged over other kinds of knowledge because one
cannot effectively treat disease without it. By this justification, Hippocrates
defines the ‘sacred disease’ as a physiological phenomenon.
46
The tactic of
arguing from definition “is a very persuasive way to stake out expertise, since
it distinguishes what is within the purview of a particular expert from what
is not” (Hartelius, 2011, p. 113). By embedding a causal argument within an
argument from definition, Hippocrates further strengthens his position by
demonstrating that there is a rational basis for privileging the physiological
expertise of a physician over the theological expertise of a faithhealer.
This novel interpretation of reality became part of medicine's origin
myth, giving rise to a rhetorical form that physicians have employed at
various points in history. In the eighteenth century, the many individuals
who displayed multiple personalities “were understood, within the
explanatory paradigms of their era, to be afflicted with the various Judeo
Christian forms of possession, and were approached therapeutically with the
culturallysanctioned JudeoChristian rituals of exorcism” (Kluft, 1993, p.
87). Franz Mesmer challenged this in 1775 by offering the 'scientific'
46
An unfortunate counterpoint to this line of reasoning, which became evident during the so
called ‘witch craze’ in Europe (spanning the fourteenth to seventeenth centuries), is that if a
disease does not respond to medical treatment, that might be evidence that the patient is a
victim of witchcraft (Barstow, 1995; R. Porter, 1991).
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explanation that the phenomenon and its apparent treatment by exorcism
were in fact both the result of 'animal magnetism.' Mesmer advocated a new
technique “to cure patients for very high fees by assembling them around a
container filled with magnetized water” (Ellenberger, 1970, p. 186).
Mesmer's theory, connecting physiology and cosmology, was based on a
universal principle of fluid matter, which occupies all space; and that
as all bodies moving in the world, abound with pores, this fluid matter
introduces itself through the interstices and returns backwards and
forwards, flowing through one body by the currents which issue
therefrom to another, as in a magnet, which produces the phenomenon
we call Animal Magnetism. This fluid consists of fire, air, and spirit,
and like all other fluids tends to an equilibrium... Philosophers have
compared the human body to an electrical machine, they have
supposed the arms the conductors, the fingers the pointers, which any
one may experience by trying. Hold the fingers of both hands for some
time towards the patient's pericardium, and you may easily perceive
all the effects of electricity on the invalid's body. (Wonders of animal
magnetism displayed, 1791, pp. 11–13)
The various magnetic treatments worked best on “thin bilious persons of a
sanguine constitution whose nervous system is irritable” (de Veaumore, 1785,
p. vi).
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By reinterpreting supernatural possession according to humoral theory
(in a modified form: illness was the result of an imbalance of a magnetic fluid
that circulated through the body), Mesmer echoed Hippocrates'
reinterpretation of the 'sacred disease.' Mesmer slightly modernized the idea
by appealing to a recent technological invention, the Leyden jar, a type of
capacitor that had been invented thirty years earlier (Riskin, 2002). With the
simple addition of magnets, a humoral system could simultaneously possess
the glow of the stateoftheart and the mystique of a received esoteric
tradition: The anonymous author of the 1791 treatise I quoted above reports
that he, speaking of himself in the third person, “is one of the few instances of
exception from the general mysterious oath of secrecy; yet he has the
happiness of being fully instructed in this wonderful system, by a professor of
the first rate abilities” (p. 15).
Even though his theory was quickly rejected as physically and
physiologically absurd, Mesmer's appropriation of the Hippocratic drama in
which modern science triumphs over myth and superstition made it
persuasive, and its persuasiveness persisted after its formal rejection.
Followers of Mesmer explained that the efficacy of his treatment was the
result of suggestion, giving birth to hypnosis, in which one is 'mesmerized' (C.
L. Hull, 1929). In this case, a psychological interpretation replaced an earlier
physical, biological etiology for mental illness. Understood as a mysterious
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form of persuasion, animal magnetism provided a language in which the
dynamics of political revolution could be expressed: Porter (1985) notes that
“the French Revolution begot 'political Mesmerists,' who hoped the waves of
animal magnetism would radiate a politics of peace, liberty, and health” (p.
23).
The association of magnetism and health continues today in the form
of magnetic therapy. An alternative medicine website (through which
various magnetic products are available for purchase) suggests that magnetic
therapy
is recognized as a nonevasive [sic] natural therapy... [Magnets] are
used in hospitals and clinics... Magnetism is the very foundation of life
on earth. The human body has developed over millions of years within
this magnetic field. Our body is “electric,” it resonates within a
frequency range and is constantly being altered by poor diet, injury,
illness, accidents and the effects of electromagnetic fields. Magnet
therapy products can help to readdress [sic] this imbalance by allowing
the body to repair itself, from within. (MAGNETiC, 2007, para. 2–4)
The website (which is a typical example of this kind of discourse) attempts to
build ethos by referencing the use of magnetism in orthodox medicine,
specifically, magnetic resonance imaging (MRI) and transcranial magnetic
stimulation (TMS). We will see this phenomenon again in the next section,
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which examines the role of humoral rhetoric in 'naturopathic' marketing
appeals.
A more contemporary reappearance of an Hippocratic rhetorical form,
similarly employing an argument from definition that implicitly is backed by
a claim to superior knowledge about cause and effect, appears in the APA’s
official response to legislation proposing to extend prescribing rights to
clinical psychologists:
The American Psychiatric Association deplores [proposed legislation
that would] permit clinical psychologists to prescribe potent
medication… Psychologists have always had a clear path to prescribing
privileges: medical school. No psychologydesigned and administered
crash course in drug prescribing can substitute for the comprehensive
knowledge and skills physicians achieve through medical education
and rigorous clinical experience… We pledge to continue to oppose all
efforts to jeopardize the public health by allowing persons without a
medical education to practice medicine. (Harding, 2002, para. 1–4, my
emphasis)
Then, as now, disciplinary boundary disputes were contests between
competing theories about the causes and remedies of disease. If madness is
caused by the gods, then its treatment should be the domain of priests; if
instead madness is caused by humoral disturbances, then physicians and
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their remedies should enjoy privileged status.
In accordance with Hippocrates' physiological model, from antiquity
through the beginning of the nineteenth century, physicians believed that
madness (whether presenting with seizures, delirium, sleepwalking, or any
other ‘very violent’ disease of the brain) was a unitary phenomenon
characterized by a total insanity that interfered with every function of the
mind (generally understood to be unitary in substance), a “delirious and
raving state” that robbed one of all awareness, judgment, and free will
(Healy, 1997, p. 29). Madness could manifest as mania, characterized by
frenzied overactivity, or melancholia, characterized by lugubrious
underactivity, but in either case the insane person was completely dissociated
from reality, whether catatonic or maniacal. This entails many conditions
that would not fall today under the domain of psychiatry, e.g., amnesia,
cerebellar ataxia, delirium, dementia, encephalitis, epilepsy, narcolepsy,
peduncular hallucinosis, stroke, stupor, tertiary syphilis, etc. (Fear, Sharp, &
Healy, 1995).
Hippocrates and Galen both left written ‘case’ descriptions of mental
illnesses, a genre of medical rhetoric which has only recently receded in
prominence in the discourses of institutional psychiatry in favor of the
randomized controlled clinical trial, in which an anonymous sample of
patients stands in for a population (Berkenkotter, 2011). These case
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descriptions superficially resemble modern constructs of mental illnesses,
which enables the modern practice in which disease constructs as we
understand them today are placed into narratives that project them into the
past, so that their modern development appears natural and inevitable
(Healy, 2008). Against the background of ancient and obscure medical
theories, anything resembling something we can make sense of stands out
and is particularly susceptible to anachronistic misreading.
This tendency may be less pronounced with texts not principally
concerned with the techne of medicine. Titus Lucretius Carus, a Roman
philosopher writing some three centuries after Hippocrates (and about two
centuries before Galen), crafted an argument symptomatic of the orientation
toward mental health and the mind engendered by ancient humoral thinking.
In a polemic against the notion of an afterlife, Lucretius describes an acute
state of frenzy (with features of delirium, psychosis, and the ‘sacred disease’)
grounded in an explicitly material understanding of cognition and the mind
as a natural, nonunitary biological object so deeply interconnected with the
rest of the body as to give rise to something resembling a somatoform
disorder:
When… the mind is upset by some more overwhelming fear, we see all
the spirit in every limb upset in sympathy. Sweat and pallor break out
all over the body. Speech grows inarticulate; the voice fails; the eyes
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grow dim; the ears buzz; the limbs totter. Often we see men actually
drop down because of the terror that has gripped their minds… The
same reasoning proves that mind and spirit are both composed of
matter. We see them propelling the limbs, rousing the body from
sleep, changing the expression of the face and guiding and steering the
whole man – activities that all clearly involve touch, as touch in turn
involves matter. How then can we deny their material nature? …[As]
the body suffers the horrors of disease and the pangs of pain, so we see
the mind stabbed with anguish, grief, and fear… Often enough in the
body’s illness the mind wanders. It raves and babbles distractedly. At
times it drifts on a tide of drowsiness, with drooping eyelids and
nodding head, into a deep and unbroken sleep… Since the mind is
thus invaded by the contagion of disease, you must acknowledge that it
is destructible… Or it may happen that a man is seized with a sudden
spasm of epilepsy before our eyes. He falls as though struck by
lightning and foams at the mouth. He groans and trembles in every
joint. He raves. He contracts his muscles. He writhes. He gasps
convulsively… The cause of the foaming is that the spirit, torn apart
by the violence of the disease throughout the limbs, riots and whips up
spray… The raving occurs because mind and spirit are dislodged and,
as I have explained, split up and scattered this way and that by the
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same poison [that is, the excess of the offending humor]. Then, when
the cause of the disease has passed its climax and the morbid secretion
of the distempered body has returned to its secret abode, then the man
rises, swaying unsteadily at first, and returns bit by bit to all his
senses and recovers his vital spirit… Conversely, we see that the
mind, like a sick body, can be healed and directed by medicine… When
you embark on an attempt to alter the mind or to direct any other
natural object, it is fair to suppose that you are adding certain parts or
transposing them or subtracting some trifle at any rate from their
sum. But an immortal object will not let its parts be rearranged or
added to, or the least bit drop off… [Spirit] and mind are held in by
the whole body, intermingled through veins and flesh, sinews and
bones, and are… kept together so as to perform the motions that
generate sentience. (Lucretius, 1994, pp. 70–81)
Early modern anxieties about the distinction between body and mind, the
unitary and/or immortal nature of the latter, and the existence of powerful
affective passions within a morally responsible and rationally sovereign
subject all seem absent in the humoral lifeworld as exemplified in this text.
Despite the Epicurean metaphysical orientation that sees reality as
fundamentally composed of indivisible, discrete atomic units, this discourse
consistently stresses continuity—between illness and health, mind and body,
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mental and physical disease—along with a radical materialism according to
which all mental and physical pathologies share a proximate biological
pathogenesis. This tension appears in the basic structure of the argument
against the immortality of the soul. Though Lucretius and Hippocrates have
very different objectives, both of their arguments depend on establishing an
identity between mental and physical illness. For Lucretius, this equation
provides evidence that the soul or psyche is entirely material, and, because
the material body evidently is destructible, the soul, therefore, is destructible.
The passage begins with an argument by sign, noting the physiological
changes that accompany intense fear or anxiety. Lucretius points to three
binary clusters of signs: skin disturbances with speech disturbances,
dimming eyes with failing voice, and buzzing ears with tottering limbs. Each
pair contains a spiritual component and a somatic component. The first
cluster is external, visibly evident; the second cluster is relational, a
disturbance in the sick patient’s ability to perceive the outer world and in the
outer world's ability to observe the spirit within; the third is internal,
auditory hallucinations and nonresponsive muscles. The body responds this
way to mental anxiety because the spirit (energy animating body and mind)
is upset in ‘sympathy’ with the mind. Galen further developed this basic idea
when he discovered and named the sympathetic nervous system, which he
believed was the medium for vital energy that has become decoupled from the
189
humors. The connection goes both ways: Just as mental anguish can
manifest in somatic form, so too can physical illness produce mental
symptoms.
The same clustering pattern recurs again in the description of the man
seized with epilepsy. Just before this section, Lucretius associates vocal
utterances with mental activity by positioning the mind as the speaking
subject who ‘raves’ and ‘babbles’ during somatic illness. Lucretius then
presents the symptoms of the ‘sacred disease’ in four clusters of voice (a
movement of the mind) with body motion. The man falls and his mouth
foams; groans while his joints tremble; raves as his muscles contract; and
finally, writhes and gasps. When the seizure ends, physical swaying mirrors
the recovery of senses. Physical motion, Lucretius explains, generates
sentience. The explanation of the common causes of mental and somatic
suffering amplifies their verbal association. The man’s spirit, as physical as
mind and body, has been lacerated by the ‘violence’ in the limbs caused by the
poisonous humoral excess, which also splits his psyche (a complex of mind
and spirit). As we shall see, this metaphor—intended literally—is a
conceptual prodrome of the modern disease entity schizophrenia, a loosening
of associations in the psyche accompanied by neurobiological deficits that
imply a splitting of the mind.
Though Lucretius describes the human body in terms of its discrete
190
parts, made all the more discontinuous as they fissure and separate over the
course of the seizure, the force of the argument comes from the contrast
between this disjunction, on one hand, and the greater underlying unity in
substance and action, on the other. This is expressed in a different way in
the argument from definition at the end of the passage. Immortality may be
predicated only of a composite substance that absolutely resists change, i.e.,
addition, subtraction, or rearrangement of its component parts. Because the
mind can be healed by medicine, it cannot have this property. In this form,
the argument seems redundant, because the fact that the mind can become
sick in the first place also proves it is subject to change. But its minor
premise, the similitude between sick body and sick mind, expresses explicitly
what was implied in the copia of mental and somatic symptom clusters.
Understood as a terministic screen, the humoral model overpowers the
atomistic tendency of Epicureanism to direct attention away from the
continuous. Kenneth Burke explains that “there are two kinds of terms:
terms that put things together and terms that take things apart”;
accordingly, “some systems stress the principle of continuity, some the
principle of discontinuity… All terminologies must implicitly or explicitly
embody choices between the principle of continuity and the principle of
discontinuity” (1966, pp. 49–50). This is what distinguishes a categorical
nosology, which emphasizes differences in kind, from a dimensional nosology,
191
which emphasizes differences in degree. In Lucretius' image of wholebody
madness, we can see not only that the humoral terminology stresses
continuity, but that it does so forcefully, perhaps overwhelmingly, relative to
another terminology. The representations of health and disease manifest
this same ratio of continuity to discontinuity that characterizes the rhetorical
assemblage by which they are produced.
Like body and soul, rhetorical models of health and sickness are
mortal. Their direction or alteration occurs by adding to, subtracting from, or
transposing their component parts. But in the process of change, the parts
are conserved. What is added comes from somewhere, and what is
subtracted goes somewhere, and in this sense they achieve a restricted form
of immortality. For most of history, the process of change occurs through the
informal formation of consensus among members of a rhetorical community.
The DSM, with its formal revision process, institutionalizes the consensus
approved rhetorical model and explicitly defines its component parts and
their arrangement. But however a model is changed, its parts live on as
vestiges of the prior unity, carrying with them the model’s unique tropes and
ability to persuade.
Though humoral pathology has been thoroughly discredited and
explicitly rejected by modern medical science, it maintains a powerful
cultural presence to this day. Humoral tropes, logics, and aesthetics
192
continually show up in modern medical rhetoric. ‘Holistic’ and ‘naturopathic’
medicine today is often marketed in the humoral idiom. As we will see in
subsequent chapters—especially in the next chapter's discussion of ‘disease
branding’ and 'preillnesses'—the effective marketing of a new therapy or
treatment modality often must include constructing a health problem that
the new product can treat. This is simply an application of the more general
strategy in deliberative rhetoric to define or frame a problem in a way that
implies the appropriateness of the advocated solution.
47
To market vitamins,
herbs, and other ‘nutritional supplements,’ one also must sell a corresponding
model of pathology. This rhetorical situation is constrained, however, by
FDA rules that strictly regulate the marketing of therapeutic agents
“intended to diagnose, treat, cure, or prevent any disease” (Code of Federal
Regulations, 2012). The naturopathic marketer does not need to make such
claims, however, if instead the product is intended to rectify some sort of
imbalance which may, among other things, contribute to some disease. This
presents an interesting opportunity for interdisciplinary collaboration
between lawyers and marketers as they seek to craft a narrative that
includes everything but the illicit therapeutic claim (upon which the entire
advertisement depends). As the FDA does not regulate the use of
47
Nixon’s ‘Vietnamization’ speech, for example, deploys this strategy to great effect, although
his creative reading of the historical record was not appreciated by all critics (K. K.
Campbell, 1972; Hill, 1972).
193
enthymemes, presumably this is not illegal.
48
An example of this tactic appears in the marketing copy of one
nutritional supplement that relies extensively on the rhetorical resources of
humorism, substituting dietary elements and ‘brain chemistry’ for bodily
fluids. The potential consumer/patient is informed that Attention
Deficit/Hyperactivity Disorder (ADHD) is in fact a group of disorders of
“certain mechanisms in the central nervous system,” and that various food
additives, which can “throw off the balance in the chemistry of the brain,”
often are to blame (2013, para. 1–2). The curious logical jump between these
two sentences underscores the enthymematic status of the therapeutic claim:
Researchers have found that a lack of these nutrients to the brain can
cause from minor to serious mental and emotional imbalances, which
are common symptoms in Adult ADHD. Using a liquid form is
preferable here for best absorption. (The Balance You Need, 2013,
para. 4)
The humoral architectonic provides an organizing rhetorical logic that brings
together a disparate constellation of concerns: the preoccupation with
deficiencies, excesses, and balance (particularly of the neurohumoral 'brain
chemistry'); the references to vital life forces; the observation that the
recommended course of action promotes 'health overall'; and the semiotic
48
Disclaimer: This should not be read as legal advice.
194
pairing, both semantically and iconically, of balance and fluid (Figure 3.2).
195
Figure 3.2: Humoral rhetorical appeals in ‘naturopathic’ marketing
Source: (The Balance You Need, 2013).
196
While antimodern tropes about the hazards of technology frequently
appear in naturopathic discourses, it is clear that these discourses have a
catholic nature. Advertisers can incorporate humoralized technoscientific
medical appeals to build credibility. For example, a subpage devoted to
explaining the causes of ADHD contains an image with two sidebyside brain
scans, most likely produced by positron emission tomography (PET) on
subjects who have received injections of radiolabelled raclopride, used to
measure dopamine receptor density (Köhler, Hall, Ögren, & Gawell, 1985;
The Balance You Need, 2012). None of this is explained—indeed, the image
is not even mentioned in passing. The image itself contains no internal
caption or explanation aside from a key by which we can see that certain
areas of the control subject’s brain are variously ‘higher’ and ‘lower’ in some
unspecified respect than the matching areas of the ADHD subject’s brain
(Figure 3.3).
197
Source: (The Balance You Need, 2012).
Figure 3.3: Brain imaging and naturopathic marketing
198
The average member of the public, particularly one who might be
shopping for a ‘natural’ ADHD medicine, probably cannot read PET scans, so
the inclusion of details or some context might not have added anything
meaningful to the message, but with their conspicuous absence the image
clearly must be understood as an enthymeme. This image functions as a
prop that conveys the idea that ADHD is ‘real,’ which is to say a
neurobiological disorder. This was less of a problem when the disorder was
known as 'minimal brain dysfunction' (MBD) or 'minimal brain damage,' a
disease construct based on certain observed similarities between encephalitis
survivors with brain lesions and the wider group of poorly behaved children
(Lakoff, 2000). Physicians diagnosed MBD so frequently that, by the middle
of the 1970s, it had
become an allencompassing, wastebasket diagnosis for any child who
does not quite conform to society's stereotype of normal children...
Children are labeled as such by school psychologists who find
“organicity” on psychological testing or even by teachers who find
certain vague symptoms that they relate to MBD. Labeling troubled
children as having MBD has almost become a national pastime.
(Schmitt, 1975, p. 1313)
Lacking reliable evidence that the disorder was in fact caused by “some
underlying unobservable etiological mechanism in the brain,” and concerned
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about the stigmatizing effect of labelling children as brain damaged, the
American Psychiatric Association renamed the disorder “attention deficit
disorder (with or without hyperactivity)” in DSMIII and then “attention
deficit hyperactivity disorder” in DSMIIIR (American Psychiatric
Association, 1987, p. 50; Barkley, 2006, p. 8).
If the disorder is nonorganic, parents are less accepting of biological
treatments. This is the attitude that the appeal to brain imaging militates
against. Even though “some people think” that problems with attention and
hyperactivity are caused by bad parenting or television, they are in fact
symptoms of this neurobiological disorder (The Balance You Need, 2012,
para. 5). Additionally, the image reinforces the connection to modern medical
science and its prestige, which makes the website less likely to be read as
quackery. We are also told that the information offered here, which
culminates in a product testimonial for some redacted “liquid organic
product” produced by the also redacted “Company X,” is simply for
educational purposes. Presumably the name of the product ‘Body Balance’
was not included so as to maintain the farcical suggestion that this subpage
of the Body Balance website is for “information purposes only,” though this is
undermined by the fact that the words “liquid organic product” contain a
hyperlink to the main product page. Crucially, nothing on the page is
intended to help anyone treat the medical disorder ADHD, but rather “simply
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[to] offer some opinions as to how to possibly help with ADHD symptoms.”
Besides recommending the Body Balance product, these opinions also include
the suggestion to perform a “colon cleanse” four times annually; conveniently,
a colon cleansing supplement is also available for sale elsewhere on the
website.
49
The discrete disease entity ADHD seems particularly wellsuited to a
humoral reading, given that its defining features are characterized as a
deficiency in ‘attention’ and a surplus of ‘activity.’ Lay explanations of the
supposedly ‘paradoxical’ efficacy of its conventional medical treatment,
psychostimulant therapy—i.e., amphetamine ('Adderall,' 'Dexadrine,'
'Vyvanse'), methamphetamine ('Desoxyn'), or methylphenidate ('Concerta,'
'Focalin,' 'Ritalin')—often resemble the Galenic notion of sympathy.
50
This
parallels the biomedical understanding that stimulants are
‘sympathomimetic,’ i.e., capable of arousing the sympathetic nervous system,
increasing blood pressure, body temperature, and heart rate (Grohol, 2012).
Despite universal expert rejection of humoral theory’s scientific validity, its
rhetorical validity depends upon whether potential consumers find such
appeals persuasive. In the world of late capitalism, Body Balance (in liquid
49
Unlike the laundry list of potentially dangerous chemicals—including sugar—that could be
the cause of their child’s ADHD, parents are comforted with the incredibly spurious
suggestion that “[all] of these products are safe for children since they are all made from
plant sources” (The Balance You Need, 2013).
50
The outmoded idea that the therapeutic effect of amphetamine in ADHD is “paradoxical”
was first suggested by Bradley (1937).
201
commodity form) can be purchased over the internet. Similarly, the ongoing
suasive force of the therapeutic logic of ‘sympathy’ enables the homeopathy
industry today to market biologically inert placebo remedies to the tune of
more than three billion dollars in annual revenues in the United States alone
(Nahin, Barnes, Stussman, & Bloom, 2009).
51
Finally, explanations of the
action of pharmacological agents in terms of ‘sympathy’ (and its inverse,
‘antipathy’) persisted well into the nineteenth century, and physiologists
have retained Galen’s name ‘sympathetic nervous system’ to refer to the
anatomical branch of the autonomic nervous system responsible for
mediating the ‘sympathoadrenal’ (‘fightorflight’) response (Ackerknecht,
1974).
Why did Humorism Succeed?
According to the standards of modern scientific positivism, humorism
is nothing more than pseudoscience, no more legitimate than astrology or
phrenology. It particularly fails the falsifiability criterion, an essential
realitytesting procedure according to which a scientific theory is valid to the
extent that it can make successful predictions (Popper, 1935). It is somewhat
surprising that humorism held sway with the bulk of medical authorities
from the time of Hippocrates through the first part of the nineteenth century.
51
Homeopathy is based on the doctrine proposed by Samuel Hahnemann (1833) that 'like
cures like’ – essentially, the theory posits that a substance known to cause a particular
symptom can heal that same symptom once it is so severely diluted that not even one
molecule of the original substance remains.
202
How is it possible that so few noticed an imbalance between humorism's
theoretical sophistication and its practical failures in developing effective
cures for disease? This was no innocuous form of quackery, merely
promoting harmless absurdities or ineffective but cheap placebos: Many sick
people were given dangerous diaphoretics, laxatives, purgatives, and
diuretics, or needlessly subjected to bloodletting (sometimes with fatal
consequences) in misguided attempts to restore humoral balance. This
mystery can be attributed partly to external causes: persistent confirmation
bias, pervading trust for traditional sources of expert knowledge, and the
fact, as Kuhn (1962) observed, that “once it has achieved the status of
paradigm, a scientific theory is declared invalid only if an alternative
candidate is available to take its place” (p. 77).
52
But the primary source of
its suasive persistence, I contend, consists internally in its coherence as an
ideological cultural system (Geertz, 1964). Its preoccupation with
maintaining the proper quantity of each humoral liquid must be understood
in light of the Lacanian dictum concerning the absence of lack in the real—
that is, “every perception of a lack or a surplus (‘not enough of this,’ ‘too much
of that’) always involves a symbolic universe” (Lacan, 1988, p. 313; Žižek,
1994, p. 11, emphasis in original). Humorism has little to no epistemic
52
I say this without necessarily agreeing with Kuhn's idea of how that transition takes place
(i.e., revolutionary paradigm shift). See the discussion in the previous chapter on Toulmin's
criticism of Kuhn's hypothesis, a criticism which I argue finds considerable support in this
study.
203
validity to the extent that its objects of knowledge belong to the order of the
real, but the calculus is much different if its knowledge claims are confined to
symbolic or imaginary objects. Its rhetorical effectiveness as a cultural
system depends upon its ability to obscure this constraint on its referential
capacity while remaining ever faithful to it.
In such cultural systems, the prereflective experience of reality occurs
through, with, and in (recalling the Eucharistic doxology: per ipsum, et cum
ipso, et in ipso) a shared, socially constructed, symbolic order in which
cognitive, normative, and affective registers of meaning are integrated by the
figures of rhetoric into a unitary (perhaps hypostatic) conceptual framework
structured by a grammar of symbols and social facts (Durkheim, 1982; Lévi
Strauss, 1963). The tropes of analogy and metaphor are particularly
important to the overall coherence of a lifeworld conceived in this manner
53
because they work structurally to identify the abstract, arbitrary, strange,
and uncertain with the familiar, observable, realitytested, and shared,
providing an underlying basis for common sense, judgments of validity,
legitimation, and persuasiveness. To the extent that distinct bodies of
knowledge—fields like herbalism and nutrition, along with more distant
fields like meteorology and astrology—were integrated into the humoral
symbolic universe, an epistemic ‘multiplier effect’ came into play such that a
53
That is, I am not attempting to be completely faithful to Husserl (1970) in my usage here.
204
modest symbolic outlay may stimulate a great deal of meaning production
mediated through aggregate processes of cultural exchange.
54
The mastery of
new knowledge that is epistemically anchored in the humoral symbolic order
serves as a kind of validation of that order (unless the new knowledge turns
out to be a complete flop). Even if the epistemic content of the humoral order
were reduced to mere scholarly custom, this alone might explain its cultural
stability insofar as “the person who does not adapt himself to it is subjected
to both petty and major inconveniences and annoyances as long as the
majority of people he comes in contact with continue to uphold the custom
and conform with it” (Weber, 1978, p. 30). Some annoyances are more
blatant than others; in the sixteenth century, for example, the faculty of
medicine at the University of Leipzig persuaded civil authorities to ban books
written by the medical heretic Paracelsus, whose attempts to overthrow the
traditional humoral orthodoxy often drew comparisons to his contemporary,
Martin Luther (Pagel, 1982). Other inconveniences in the realm of science
communication are more subtle. By failing to use the accepted terminology
and concepts, clarity suffers, there are fewer opportunities for publication or
collaboration, and it becomes more difficult to promote one’s ideas to the
wider public.
54
My aim with this Keynesian subtext is simultaneously to explain and demonstrate (there
is an inverse relationship between my success and the degree to which this explanation is
necessary) an epistemic process Burke called “verbal ‘atom cracking.’ That is, a word belongs
by custom to a certain category—and by rational planning you wrench it loose and
metaphorically apply it to a different category” (Burke, 1984a, p. 308).
205
Humorism's robust longevity is thus a testament both to its ubiquitous
embeddedness in other cultural systems (just as, for Lucretius, the psyche
innervates and is embedded in the body), enabling social actors of all levels of
theoretical nuance or expertise to work toward mutual understanding by
means of its symbolic network (reproducing the symbolic order in the
process), and to its casuistic flexibility, i.e., its hermeneutic power to
incorporate and explain a very wide range of phenomena, giving it an
enormous capacity to employ common observations of reality as inventional
resources for encompassing new situations (Burke, 1984a). For example, in
the definitive medical textbook of the medieval period, Avicenna used
humoral concepts to elaborate a theory of “emotional aspects, mental
capacity, moral attitudes, selfawareness, movements and dreams” (Rastogi,
2012, p. 81).
55
Similar efforts continued into the twentieth century, notably
including Hans Eysenck’s (1947) fourfactor model of personality in which the
dimensions of extraversion and neuroticism stand in for temperature and
dryness, respectively. Perhaps the epistemic distance between the world of
validated psychometric scales and computerassisted statistical techniques
like orthogonal factor analysis, on one hand, and the 2,500 yearold pre
scientific humoral model, on the other, is smaller than it first seems.
55
Avicenna was also one of the rare few scholars during the medieval period who recognized
that both consciousness and behavior are products of organic processes in the brain, and that
some somatic symptoms may have psychological explanations (Preul, 1997; Vakili & Gorji,
2006).
206
Why did Humorism Fail?
To explain how humoral pathology eventually came to be rejected, I
would like to extend my earlier analogy between the health of a person and
the health of a model. In cancer, the same physiological processes and
anatomical elements that allowed one to live and thrive become the vehicle of
one’s mortality. In a similar manner, the same features and capacities that
explain the persistence of humorism also facilitated the model’s rhetorical
fragmentation and downfall. The persistence of humorism was due in part to
its capacity for doctrinal development, enabling it to accommodate, explain,
or otherwise account for new, seemingly inconsistent, discoveries. As the
model was challenged by new empirical observations and material social
practices, its adaption process became disordered, leading to an
uncontrollable heterogeneous complexification. Its widespread cultural and
epistemic integration required that the model’s growth be even and
consistent so that changes could diffuse into the general body of social
knowledge. Theoretical developments provoked by different challenges
became inconsistent, slowly splitting the humoral psyche, leading to its
progressive epistemic deterioration.
The serendipitous discovery by Catholic missionaries in 1630 that a
bitter substance in the bark of the cinchona tree, called quinine, can treat
effectively the high fever associated with malaria (from the Italian mala aria,
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‘bad air,’ once thought to be its source) is one significant example of the kind
of challenges the humoral order faced. At the time, medical authorities
believed that all fevers resulted from an excess of bile, which was thought to
cause fermentation in the blood, for which the (rather ineffective) treatments
of bleeding and purging were indicated.
56
Making matters more confusing,
the apparently effective extract is a dry powder derived from a tree native to
the hot climate of Peru. One might expect such a substance to amplify,
rather than ameliorate, the suffering brought about by a surplus of the
quintessentially hot and dry humor. As it turned out, according to leading
seventeenthcentury authorities in humoral medicine, the socalled ‘Jesuit’s
Powder’ stimulated the flow of bilious secretions through the nervous system,
an example of the phenomenon Galen called ‘sympathy,’ which effected a
cure by pushing the malarial fever to its conclusion (Berdoe, 2006).
The plot further thickened when it was discovered that quinine’s
therapeutic efficacy was specific, limited to fevers associated with the discrete
disease entity malaria. Why shouldn’t the same sympathetic process resolve
other forms of fever? Is the category of ‘discrete disease entity’ part of a larger
category that also includes pathology conforming to the old unitary disease
concept, or does this new category conceptually replace the old? Both
56
The new treatment’s effectiveness relative to the then current standard of care was
sufficiently impressive that its advocates were able to overcome widespread antiCatholic
persecutory delusions that quinine was the first phase of some “Popish plot” against the
Protestant nations (Rocco, 2004, p. 103).
208
possibilities would raise new, difficult questions. Left unanswered, these
questions threatened the humoral order with legitimation crisis just as other
historical social forces seemed to be aligning against orthodoxy in general
(e.g., widespread and frequently violent religious partisanship; sweeping
changes in society’s mode of production associated with industrialization;
mass dissatisfaction with the institutions of aristocracy and monarchy;
exposure to new cultural forms of knowledge about health and remedies
associated with the Age of Exploration; an intellectual climate associated
with the Enlightenment that favored radical breaks with tradition, etc.).
Remarkably, the humoral symbolic order managed to avert the crisis
and preserve its hegemonic cultural position by successfully performing the
ideological functions of “hiding real contradictions and of reconstituting on an
imaginary level a relatively coherent discourse which serves as the horizon
of… experience” (Poulantzas, 1973, p. 207). In doing so, however, it
sustained serious damage, as the necessary legitimating discourses and
conceptual elaborations were “[reminiscent] of the epicycles used by
astronomers to explain variances within the Ptolemaic universe… [and
which] did not so much overthrow the wobbling paradigm of Galenic humoral
concepts as they supported the ancient edifice with more ‘modern’ knowledge”
(Haller, 1994, p. 18, my emphasis). The epistemic disorder was not cured; it
was simply in remission. Haller’s metaphorical characterization of the order
209
as ‘wobbling’ is particularly insightful because it highlights the degree to
which humoral theory was out of balance, in total variance with its own
ultimate values. The humoral order did not so much neutralize the external
substantive contradiction between theory and observation as transform it
into an internal performative contradiction entailed in the imbalanced and
fragmented form in which the values of balance and unity were defended as
ultimate terms. The first contradiction was constituted by a rupture between
the registers of the Symbolic and the Real; the second contradiction
represented a conflict entirely within the Symbolic, “between a meaning
conveyed explicitly and a meaning conveyed by the act itself of conveying” (D.
Turner, 1983, p. 26).
The hegemonic grip of humorism on the institution of medicine began
to recede as a result not of theoretical development, but rather of changes in
material productive practices and relationships; in other words, base
determined superstructure (Marx, 1904). A vast market existed for new
treatments, including herbs discovered in recently colonized parts of the
world, as well as the purified chemicals and metals promoted by Paracelsus
(1657). These highly profitable treatments could be rendered intelligible only
retrospectively, as medical treatments within the humoral framework.
Medical theory thus “followed the money” (Healy, 2008, p. 15). As more and
more of these treatments were adopted, the medical literature gradually
210
became less focused on pure theory and more interested in empirical
observations (Maehle, 1999). The genre of the ‘case history’ as a medical
topos reappeared. As I shall demonstrate later, the prevalence and emphasis
of the ‘case history’ in medical rhetoric as a ‘place’ to look for substantiating
evidence at any given time can be seen as a barometer of tension between
medical theory and practice. Appeals to the case are relatively more
persuasive to an audience suspicious of the available theoretical paradigm;
their suppression is a rhetorical move made by defenders of an orthodoxy, as
when the editorial board of the American Journal of Psychiatry, following the
promulgation of the new DSMIII nosology, decreed that “single case reports
should be published as Letters to the Editor rather than as Clinical Research
Reports” (Edelson, 1985; “Single Case Reports,” 1984, p. 852).
The ascent of appeals to the case rather than to humoral theory
pointed to the discontinuous nature of disease. From the drama concerning
the introduction of quinine, we can see that a radical discovery alone is
insufficient to bring about a change in intellectual order. Before the
introduction of a powerful new architectonic, the old regime of knowledge
must be delegitimized:
The real revolution in medicine, which set the stage for antibiotics and
whatever else we have in the way of effective therapy today… did not
begin with the introduction of science into medicine. That came years
211
later. Like a good many revolutions, this one began with the
destruction of dogma. It was discovered, sometime in the 1830s, that
the greater part of medicine was nonsense. (Thomas, 1995, p. 159)
How was this aporia achieved? The cacophonous proliferation of cases was
coupled with emerging technologies that facilitated novel ways of ‘seeing’ the
signs of illness, both in human patients and in the old theoretical orthodoxy.
Physicians had long had the ability to look inside the bodies of individuals
postmortem (though were often prohibited from doing so by religious
authorities), but the microscope, the stethoscope, and the practice of histology
opened up a whole new vista of morbidity, “[plunging] the gaze of the
doctor… into the interior of the body,” a shifting of horizon that would be
repeated again in the twentieth century, when new genetic and statistical
techniques allowed scientists to ‘see’ in populations a new array of
pathological objects (Hacking, 1975; Hedgecoe & Martin, 2008; N. S. Rose,
2007, p. 193). A new perceptive technology can show the continuous to be
discontinuous and visaversa, potentially producing terministic rupture,
“since all laboratory instruments of measurements and observation are
devices invented by the symbolusing animal, [and thus] they too necessarily
give interpretations in terms of either continuity or discontinuity” (Burke,
1966, p. 49). Novel technological modes of observation not only enables new
objects of knowledge to be seen, but also reveal the contradictions,
212
limitations, and absurdities of the old theoretical orthodoxy (Hogle, 2008).
The Rise of Scientific Medicine
Like water coming to a boil that is preceded by rising bubbles, this
sudden and dramatic revolution in the nineteenth century was preceded by
nascent microconfigurations of knowledge. These epistemic fragments were
not full models of pathology but, rather, terministic sonograms through
which one can glimpse the modern concept of disease in an embryonic stage.
Two of these emergent frameworks, one emphasizing discontinuity and the
other continuity, were of particular importance: an ‘ontological interpretation’
of disease, and a ‘physiological interpretation’ of disease (KräuplTaylor,
1982). According to the ontological interpretation, the vista of pathology is
subdivided into discrete disease entities that are distinct from the signs and
symptoms revealing their presence. The physiological interpretation instead
focuses on morbid processes as they manifest in the body. Both
interpretations provided important insights necessary for the development of
modern medical science. As medicine moved dialectically from one
interpretation to the other, the conceptual integrity of humoral concepts
became strained, and with each new rearticulation, shifts in meaning were
accompanied by the introduction of emerging modern concepts. Many ideas
and concepts that would become central to modern medical science emerged
centuries before their time, but in combination with archaic vestiges of the
213
old order. These concepts were sometimes discarded or remixed into new
discursive assemblages before being taken up in modern form.
The Ontological Interpretation
Thomas Sydenham (1682), who was heavily influenced by the findings
about quinine and the putative disease entity ‘malaria,’ as well as by the
Methodist school of biological classification that began with Italian physician
and botanist Andrea Caesalpino (1583), made an articulate case for an
“ontological view of disease… [affirming] the existence of natural and
unwavering disease entities, separable from the person, and whose
presentation was uniform across sufferers” (Boyle, 1990, p. 8). In no small
part due to his novel ontological approach to pathology, Sydenham, the so
called “English Hippocrates” (Noll, 2007, p. x), contributed greatly to
medicine. Before Sydenham, many medical authorities had a difficult time
grasping the idea of a discrete disease entity, conflating it with a discrete
disease expression. An illness state involving several distinct symptoms
implied a holistic pathology, especially in the absence of any distinctive
pathological features (e.g., Koplik spots, uniquely characteristic of measles).
Sydenham’s approach to nosology was built around the “presupposition that
clinical findings fall into easily identifiable constellations of signs and
symptoms that can be recognized through their natural histories” (Cutter,
2003, p. 37). Avicenna had hinted at the concept of syndrome (unaltered from
214
the Greek syndromē [ μ ], meaning συνδρο ή a disorderly crowd running
together), but Sydenham explicitly articulated and significantly developed it
(Millon, 2004).
57
The basic idea is that, by closely observing a large number
of patients and keeping precise records of their cooccurring pathological
characteristics, it is possible to identify distinctive forms of disease that share
a common set of causes and, presumably, should respond to the same
treatment (as with malaria and quinine) (Blashfield, 1984).
Sydenham’s views caught on in part because they were popular with
physicians who, transformed into scientists by his revolutionary
methodology, were eager to take up the important job of systematically
recording the wide range of elements that work together to produce the
disease processes in their patients (Boyle, 1990). This shift in medical
research and training resulted in new institutional and professional norms
emphasizing careful, detailed clinical observations (KräuplTaylor, 1979).
These developments prompted a biopolitical reading of the Hippocratic
corpus. Sydenham collected data on major disease outbreaks in London from
16611675 and detected an association between specific syndromes and the
time of year, providing empirical support for an ancient hypothesis, revived
by his contemporary, Robert Boyle, that the seasons (relating to the humors)
57
Having worked out a synthesis of Galenic medicine and the Stoic theory of signs, Avicenna
proceeded “to schematize a conditional with multiple antecedents and a common consequent:
‘If this man has a chronic fever, hard cough, labored breathing, shooting pains, and rasping
pulse, he has pleurisy.’ Here Avicenna lays a groundwork for the idea of a syndrome as he
pioneers in the diagnosis of a specific disease” (Goodman, 2003, p. 155).
215
were epidemiologically significant (D. Porter, 1998).
58
The idea of studying
populations to identify risk factors for disease influenced the development in
the following century of an emergent mode of governance involving “the
dramatic expansion in the scope of government, featuring an increase in the
number and size of the governmental calculation mechanisms” (A. Hunt &
Wickham, 1994, p. 76).
As distinctive as Sydenham’s position was, he did not abandon
humorism, routinely resorting to humoral explanations whenever necessary,
particularly for acute conditions that, he posited, often resulted from
atmospheric ‘miasmata’ disturbing the humors (KräuplTaylor, 1979).
Though the discrete disease entity represented a distinct move away from
holistic pathology, Sydenham believed its manifestation as a syndromal
complex pointed to a multifactorial etiology and pathogenesis, with multiple
simultaneous influences acting on a patient and influencing the course of the
morbid process (KräuplTaylor, 1982). Neither an imbalance in the humors,
an invasion of a pathogen (i.e., some inorganic corpuscular substance
originating underground), a distressing life event, nor any other lone
stimulus was sufficient to trigger the onset of an illness, though each could
contribute to one’s susceptibility. Similarly, though the outbreak of
epidemics eluded reliable prediction, he identified several risk factors he
58
The term ‘epidemiology’ first appeared a little more than a century later in Joaquín de
Villalba’s (1802) Epidemilogía Española.
216
believed to be significant: excessive humidity or dryness, extremely cold or
hot temperatures, and the presence of “vapors” emanating from “the inward
bowels of the earth” (cited by Dewhurst, 1966, pp. 66–67).
Evolution of Hysteria
These neoHippocratic sources of disease were discarded by subsequent
physicians, only to be rearticulated less than a hundred years later in slightly
revised form. The principles of modern chemistry were applied to the old
humoral framework, fusing moral judgment and somatic pathology within
vaporous imagery:
[In] acid vapors the particles are mobile, and even incapable of rest,
but their activity is weak, without effect; when they are distilled,
nothing remains in the alembic but an insipid phlegm… [One] would
consider the vapors that rise from the blood to the brain and that have
degenerated into an acid and corrosive vapor… [to be] a chemistry of
the humors. …Certain particularly volatile animal spirits are alkaline
salts that move with great speed and transform themselves into vapors
when they become too tenuous; but there are other vapors that are
volatized acids; the ether gives these latter enough movement to carry
them to the brain and the nerves where, ‘encountering the alkalis, they
cause infinite ills.’ Strange, the qualitative instability of these
[vaporous] illnesses; strange, the confusion of their dynamic properties
217
and the secret nature of their chemistry! …The space in which [the
vaporous] assumed its dimensions was…that of the body, in the
coherence of its organic values and its moral values. (Foucault, 2001,
pp. 122, 142–143)
Just as the people of London in Sydenham’s time suffered from an epidemic
brought on by vapors from deep underground, many wealthy and urbane
women living in Paris suffered from an epidemic brought on by vapors that
emanated from their own inward bowels (or furor uterinus, an agitated
womb):
For more than a century, the vapors have been endemic in large cities;
most women who take pleasure in the comforts of life are vaporous,
and one might say that they purchase a series of languid infirmities
with the vast riches that they so enjoy.
59
(Raulin, 1758, p. viii, my
translation)
Men were less often afflicted, but when they were it was usually their fault
as well: “Men become vaporous just like women when their nerves lose their
natural firmness;
60
it sometimes happens that they were born with their
feeble temperaments, but more often than not they become weak through
acts of debauchery, exhaustion, idleness, mental strain, etc.” (Raulin, 1758, p.
59
“Il y a déja plus d'un siécle que les vapeurs sont endémiques dans les grandes Villes; la
plupart des femmes qui jouissent des commodités de la vie sont vaporeuses, on peut dire
qu'elles achetent par un suite de langueurs l'agrément des richesses” (Raulin, 1758, p. viii).
60
Not just their nerves, as the vapors usually brought on impotency in these effete men (Vila,
1998).
218
42, my translation).
61
Some commentators suggested that this epidemic was a form of
disease unique to capitalist modernity: “We have few good books on the
vaporous diseases…[and] the reason is simple; it is that these diseases are
new, their progress having followed that of the vast population of Paris and
its heart of luxury” (Beauchêne, 1783, pp. 8–9, my translation).
62
Others
linked the outbreak to older disease states (e.g., melancholia, hysteria), while
still emphasizing its novel epidemic status:
Melancholy is not exactly a new disease, but in no other century was it
so widespread, nor did it have the same level of intensity; thus we can
look at it as a new plague. It is necessary to bring all efforts to destroy
it, as was done successfully for venereal diseases. (Bressy, 1789, pp. ii–
iii, my translation)
63
All agreed that this was a bourgeois ‘plague,’ afflicting women whose “mode
of life [was seen by] physicians…as overrefined and soft,” as well as
effeminate men “who had ‘degenerated’ to a similarly delicate temperament”
61
“Les hommes deviennent vaporeux tout comme les femmes lorsque leurs nerfs perdent leur
fermeté naturelle; il arrive quelquefois qu'ils sont foibles par une suite du temperament, mais
ils le deviennent le plus souvent par la débauche, par l'épuisement, par l'oisiveté, par la
contention d'esprit, etc.” (Raulin, 1758, p. 42).
62
“On a peu de bons livres sur les maladies vaporeuses… La raison en est simple, c'est que ces
maladies sont nouvelles; leurs progres ont suivi coeur du luxe, ceux de l'immense population
de Paris” (Beauchêne, 1783, pp. 8–9).
63
“La mélancolie n'est pas précisément une maladie nouvelle, mais dans aucun siècle n'avoit
été aussi général, & n'avoit eu autant d'intensité; de maniere qu'on peut la regarder comme
un fléau nouveau: il faut donc réunir tous les efforts pour l'anéantir, comme on le fait avec
succès pour les affections vénériennes” (Bressy, 1789, pp. ii–iii).
219
(Vila, 1998, p. 229). The couches of the Victorian era were designed with the
vaporous woman in mind, as even the slightest stimulus could cause her to
become faint, overwhelmed with emotion; other prominent symptoms
included “edema or hyperemia, …nervousness, insomnia, sensations of
heaviness in the abdomen, muscle spasms, shortness of breath, loss of
appetite for food or sex with the approved male partner, and [a general]
tendency to cause trouble for others” (Maines, 2001, p. 23).
The connection between Sydenham and the pathologically feminine
Parisians of the eighteenth and nineteenth centuries goes far beyond the
suggestion that vapors (of some sort) cause illness. The eighteenth century
vaporous diseases were based on a syndrome Sydenham identified as
hysteria in the seventeenth century, a name it would regain in the nineteenth
century as a focal point of study for JeanMartin Charcot, Pierre Janet, and
Sigmund Freud (Breuer & Freud, 2000; Charcot, 1971; Janet, 1920).
Hysteria is as old as Western medicine itself, but Sydenham was the first to
conceive of hysteria as a disease of the mind (Bronfen, 1998). The
conventional wisdom in 1600 was that it was caused by a malpositioned
womb (Rousseau, 1993). The name ‘hysteria’ comes from the Greek word for
uterus, hystera ( ). ὑστέρα The Hippocratic corpus lists a variety of symptoms
thought to be related to the movements of an excessively dry womb. Sexual
intercourse, in order to add moisture to the womb, was the recommended
220
treatment: Nubat illa et morbus effugiet, ‘let her marry and the disease shall
disappear’ (Kerber, 2005, p. 275, my translation; King, 1993).
Sydenham’s (1682) careful study (particularly his observation that
men and women equally exhibited the constellation of hysterical symptoms)
led him to believe that the problem was not in the womb, but rather in the
brain.
64
Nevertheless, the concept could not escape its gendered roots, and
has invited feminist readings, according to which the hysterical women of the
nineteenth century “epitomize universal female oppression” (Showalter, 1998,
p. 10). On the other hand, Herndl (1988) suggested that hysteria “has come
to figure a sort of rudimentary feminism and feminism a kind of articulate
hysteria” (p. 54). The tensions and ambivalences entailed in gendered
diagnoses recur, for example, in the DSM5 diagnoses of compulsive buying
disorder (CBD) and premenstrual dysphoric disorder (PMDD), which some
suggest present women as irrational, with poor impulse control and monthly
episodes of emotional instability (Saedi, 2012).
Sydenham noted that hysteria (understood metaphysically as an
independent disease entity) could simulate the symptoms of several organic
diseases, e.g., convulsions, heart palpitations related to anxiety, paralysis
64
Nevertheless, as we have already seen, the ‘wandering womb’ hypothesis persisted in one
form or another through the twentieth century, and directly led to the invention of the
vibrator, which began as a device used by physicians to administer socalled ‘medical
massage’ (designed to induce ‘hysterical paroxysm,’ a euphemism for orgasm), a standard
treatment for hysteria and several eating disorders still common as late as the 1920s
(Maines, 2001).
221
similar to that produced by stroke, and unexplained pain similar to kidney
stones. The ontological assumptions that the same symptoms could have
different causes and that the same cause could present with different
symptoms enabled Sydenham to identify and catalogue the various forms of
this disorder as had never been done before (Schneck, 1957). Sydenham
focused less on individual symptoms than the overall syndromal complex,
and his ontological interpretation of disease allowed him to distinguish
between the symptoms and the disorder. Before Sydenham, a physician
observing one case of syncope caused by orthostatic hypotension and another
case of hysterical fainting would not have been able meaningfully to
distinguish between the two manifestations of illness. A recent encomium
testifies to the prescience of Sydenham’s clinical pictures of hysterical
syndromes, and more broadly to the enduring significance and influence of
Sydenham’s approach on contemporary nosological debate in psychiatry:
The careful and systematic manner of his descriptions of hysterical
phenomena was so comprehensive that little can be added today to
what he said three centuries ago. He recognized that hysteria was
among the most common chronic diseases, and… he also suggested
that differential diagnosis between real biological diseases and those
generated by the mind could only be made if the patient’s psychological
state could be thoroughly known. He was among the most successful
222
in illustrating that emotions can generate and simulate physical
disorders. In his efforts to formulate a syndromal pattern for
numerous disorders, he extended the range of his observations to
include not only the patient’s dispositions, emotions, and defenses, but
the family context within which they arose… [in order] to determine
the overall pathogenesis of certain syndromes, largely through the use
of both physical and psychological phenomena. (Millon & Simonsen,
2010, p. 23)
Hence, the concept of vaporous diseases that appeared after Sydenham was a
throwback to a previous era, leading physicians away from the psychogenic
nature of hysteria.
Charcot was less than prescient when he wrote in an 1888 letter to
Freud: “Rest assured, hysteria is coming along, and one day it will occupy
gloriously the important place it deserves in the sun” (cited by Micale, 1993,
p. 496). Nonetheless, the syndrome once associated with the signifier
‘hysteria’ is still a source of diagnostic controversy, and the array of issues
currently under discussion was almost entirely anticipated by Sydenham in
the seventeenth century. There is certainly some truth to Guillain’s (1949)
suggestion that “in reality, the patients have not changed since the time of
Charcot—only the words used to describe them have changed” (p. 147, my
223
translation).
65
In the DSMIV and ICD10 nosologies, hysteria is known as
‘conversion disorder’ (classed with the somatoform disorders in the former
and with the dissociative disorders in the later), and is characterized by
“unexplained” symptoms such as (nonepileptic) seizures, unusual
movements, fainting, weakness, and sensory disturbances. While the
symptoms “suggest a neurological or other general medical condition,” in fact
“psychological factors are judged to be associated with the symptoms or
deficits” (American Psychiatric Association, 1994, p. 445). Diagnosis requires
a “thorough medical investigation… to rule out an etiologically neurological
or general medical condition,” as the symptoms of conversion disorder
“typically do not conform to known anatomical pathways and physiological
mechanisms, but instead follow the individual’s conceptualization of a
condition” (1994, sec. 300.11).
The name ‘conversion disorder’ itself refers to the basic hypothesis that
the symbolic resolution of unconscious psychological conflicts can manifest
somatically—in other words, a psychological conflict that cannot be resolved
consciously is ‘converted’ into a complex of physical symptoms (Nicholson &
Kanaan, 2009). The DSM5 Somatic Symptom Disorders Workgroup
65
“Ces malades étaient exactement les mêmes que ceux qui se présentaient aux consultations
du temps de Charcot. En réalité, les malades n'ont pas changé depuis Charcot, ce sont les
mots pour les désigner qui ont changé” (Guillain, 1949, p. 147). The claim is certainly not
absolutely true; patients can and do change, sometimes even because of changes in the words
used to describe them. Obviously bored wealthy housewives no longer need fainting couches
to make it through the day.
224
recommended that the disorder be renamed ‘functional neurological disorder’
(American Psychiatric Association, 2011b).
66
Apparently, the name
‘conversion disorder’ is too closely associated with the old psychoanalytic
heresy:
Although long dominant, the conversion hypothesis… has little
supportive empirical evidence. Even the notion that the etiology of
these symptoms is wholly psychological may be scientifically incorrect.
For example, functional brain imaging studies showing findings such
as contralateral thalamic hypoactivity in hemisensory conversion
encourage us to understand conversion symptoms from a brain as well
as a mind perspective… [The] name “conversion disorder” has not been
widely accepted by either nonpsychiatrists or patients. We therefore
need a name that sidesteps an unhelpful brain/mind dichotomy… For
the majority of patients psychological factors can be identified, but not
for all… In practice, conversion disorder is usually diagnosed after a
neurologist has identified a symptom as “nonorganic” because of
66
The final name of this disorder was “still under active discussion” as of the time that the
APA made the draft revisions unavailable in anticipation of the imminent publication of the
new edition (American Psychiatric Association, 2011b). In the final draft, as an apparent
compromise, the disorder was named “Conversion disorder (functional neurological symptom
disorder)” (American Psychiatric Association, 2013, p. 318). According to the explanation of
the disorder's diagnostic features: “Many clinicians use the alternative names of 'functional'
(referring to abnormal central nervous system function) or 'psychogenic' (referring to an
assumed etiology) to describe the symptoms of conversion disorder (functional neurological
symptom disorder)” (p. 319). It is unclear why the authors believe that the suggestion that
the disorder is caused by “abnormal central nervous system function” is less “etiological”
than the suggestion that the disorder is “psychogenic.”
225
clinical findings of incongruity with disease or internal consistency…
[We] suggest that conversion disorder be renamed “functional
neurological disorder” and that the requirement for the exclusion of
feigning and identification of associated psychological factors be
relegated to the accompanying text... Together these changes have the
potential to foster collaboration between psychiatrists and
neurologists. (J. Stone, LaFrance, Levenson, & Sharpe, 2010, pp. 626–
627)
A few brief observations about this official line of reasoning are in order. The
authors take for granted that ‘psychological’ phenomena are nonorganic, as
if the activities of the mind could be wholly independent of the activities of
the brain. Otherwise, the observation that ‘functional brain imaging studies’
show activity of some sort in the brains of patients with conversion disorder
could not serve to refute the claim that the etiology of the symptoms is
“wholly psychological.” This is a vulgar strawperson argument—not even
René Descartes, and most certainly not Freud, would accept the premise that
some “wholly psychological” phenomenon could occur without any
corresponding material/organic activity.
67
This reasoning mistake means
that, instead of seeking to elucidate the neurobiological basis of psychological
phenomena, this hypermaterial turn is made seemingly for its own sake.
67
The positions of Descartes and Freud on this matter are discussed in greater detail below.
226
The irony in the subsequent comment concerning the need to sidestep an
“unhelpful brain/mind dichotomy” is almost overwhelming. Over against the
approach of DSM5, Sydenham had strongly resisted the urge to reduce the
syndromal complex to either organic or psychological morbid processes
(Schneck, 1957).
The concern for the patients’ acceptance of the diagnosis is interesting,
although, if the ‘conversion’ hypothesis is correct, attempts to over
accommodate the patients in this regard may be antitherapeutic, as the
incidence of hysteria dramatically declined once the conversion hypothesis
became well known to the public (Micale, 1993). There are many ways to
interpret this finding, but the most parsimonious is that a population is less
vulnerable to hysteria when the latter is understood in psychodynamic terms
than when it is commonly believed to be a neurological disorder. Finally, it is
somewhat strange that a neurologist's failure to discover a neurological
problem would be a defining characteristic of a ‘neurological disorder,’
functional or otherwise.
68
In any event, the various twists and turns through
which ‘hysterical affection’ has been ‘converted’ into a neurofunctional
disorder were possible only because of Sydenham’s careful studies, and
though the DSM5 approach rejects a strict ontological interpretation
68
The authors also suggest that the name ‘functional neurological disorder’ would constitute
a “return to an older terminology” (p. 626). As evidence for this claim, they cite Wessely,
Nimnuan, and Sharpe (1999), who indeed use this terminology, which, they contend, is a
better way to discuss the symptoms of conversion disorder and other somatoform disorders.
Given the context, the referent for the comparative word ‘older’ is very unclear.
227
pointing toward some vague ineffable physiology, the differences between
Sydenham’s hysteria and the contemporary form are more cosmetic than
substantive.
69
The Physiological Interpretation
Why did the seventeenth century mental illness of hysteria change into
a collection of neurological vaporous diseases in the eighteenth century?
There were many factors, but perhaps most important was a growing interest
in and understanding of functional physiological processes that resulted from
the introduction of scientific methodology to medicine. The material practices
that Sydenham inspired gave rise to a terministic screen focused on morbid
physiological processes. A physiological interpretation of pathology appealed
to the postmetaphysical sensibility of the Enlightenment, expressed
famously in 1748 by David Hume:
If we take in our hand any volume; of divinity or school metaphysics,
for instance; let us ask, Does it contain any abstract reasoning
concerning quantity or number? No. Does it contain any experimental
reasoning concerning matter of fact and existence? No. Commit it then
to the flames: for it can contain nothing but sophistry and illusion.
(Hume, 1993, p. 114, emphasis in the original)
69
The biggest difference between Sydenham’s clinical picture and those represented in DSM
IV and ICD10 is that Sydenham also included hypochondriasis and melancholia as clinical
forms of the hysterical syndrome (Dewhurst, 1966).
228
Ontological interpretations in general were no longer in vogue with the
intelligentsia by the eighteenth century. Thirteen years after Hume
published his Enquiry concerning human understanding, Giovanni Morgagni,
now regarded as the father of anatomical pathology, identified lesions in the
organs, rather than humoral imbalance, as the cause of disease (Morgagni,
1903). In 1761, he published his pathbreaking text De sedibus et causis
morborum, in which he aggregated the physiological data extant in the
literature along with the anatomical observations he and his teacher, Antonio
Valsalva had made in the preceding decades.
70
Its publication revolutionized
medicine: By placing anatomy at the foundation of general pathology,
“medicine was elevated to the rank of a natural science” (Virchow, 1958a, p.
178).
In 1858, less than a century later, after cataloging the various kinds of
tissue and their cellular natures, Rudolph Virchow delivered a series of
famous lectures in which he established a new model of disease based on
cellular pathology that quickly became dominant within the new modern
institution of clinical medicine (Turk, 1993). In his early days, Virchow
explicitly rejected the ontological view of disease in favor of a physiological
conception. According to this essentially nominalist view, diseases do not
70
Antonio Valsalva, a physician and anatomist from Bologna whose research predominately
focused on the ear, is known today for inventing the ‘Valsalva maneuver’ whereby with a
closed mouth and a pinched nose one attempts to exhale in order to equalize the pressure
between the ears and sinuses, a technique commonly performed today by divers and airplane
passengers.
229
exist independently, but, rather, subsist in dysfunctional bodily processes.
The old humoral model was essentially physiological, though not scientific.
Instead of seeing discrete disease entities with their own unique course and
treatment, a physiologist sees somatic processes that deviate from the norm,
lying in a continuous spectrum from healthy to diseased. For the 26yearold
Virchow, seeking in 1847 to define ‘scientific medicine,’ disease entities are
“neither selfsubsistent, circumscribed, autonomous organisms, nor entities
which have forced their way into the body, nor parasites rooted on it, but…
[rather] they represent only the course of physiological phenomena under
altered conditions” (Virchow, 1958b, p. 26). When he reached the age of 73,
however, Virchow felt less of a need to militate against ontological readings of
his cellular model:
Aside from cells, there are no histogenetic or organopoietic substances.
This conception is expressly ontological. That is its merit, not its
deficiency. There is in actuality an ens morbi [disease entity], just as
there is an ens vitae [living entity]; in both instances a cell or cell
complex has the claim to be thus designated. (Virchow, 1958a, p. 207)
Essentially, then, Virchow read realism into the nominalist ontological
interpretation. Discrete disease entities exist and are coequal with
physiological disordered processes.
To understand how Virchow was able to advance these seemingly
230
contradictory positions about pathology, one must take note of his ultimate
driving concern, precisely the same concern held by the developers of DSM5:
the development of a conceptual framework of pathology best suited to “pave
the way for muchneeded scientific progress” (Hyman, 2011, p. 5). If disease
is understood ontologically, where is it located and what is its nature? The
elder Virchow in 1895 drew a connection between serum therapy (in which a
serum from an immunized animal is used to treat a disease) and the old
humoral model:
Enthusiasts see here a final triumph of humoral pathology, although a
humoral pathology quite different from any preceding it. The old
humoral pathology cannot come into question at all, but only one of the
later forms—hematopathology [i.e., a branch of cellular pathology that
focuses on hematopoietic cells, which originate in bone marrow and
give rise to red and white blood cells and platelets], to be precise… The
doctrine of putrid infections (septicemia) had gradually passed over
into general knowledge; everyone assumed that putrescent substances
exerted a harmful effect and sometimes caused new putrefactive
processes in the body. But no one had the right to conclude from this
doctrine that the tissues of the body—let us say the cells for brevity—
could be disregarded, and that a putrid infection was nothing more
than an abnormal condition of the blood. The blood only contains the
231
causes of the tissue disturbance; the disease is not the blood, but is
rather the effect of the cause on the cells or tissues. (1958a, p. 213)
The humoral (functional) pathology had located disease in the fluids of the
body, while the anatomical (ontological) pathology had located disease in the
body’s solid parts. The physical properties of solidity and fluidity seem to
stand in respectively for the concrete discontinuity of the ontological
perspective and the dynamic continuity of the physiological perspective.
Virchow reconciled these conflicting views by first locating life within
the cell, composed of solid organelles immersed in cytoplasmic fluid and
surrounded by a membrane. The cell is thus the scene of a biological drama
in which cellular components are agents engaging in the various acts that
constitute and sustain life. Its entelic ‘purpose,’ understood as an
Aristotelian final cause, is to continue living, and thus the acts must proceed
in an orderly fashion consistent with the ‘normal’ vital mode of operation for
a cell of its type. When, for whatever reason, the dynamic cellular processes
or structures of the cell deviate from this norm, that deviation constitutes
disease. Disease is directly identified with the disordered cell, rather than
depicted as a pattern of various signs and symptoms. Instead of ‘tobacco
smoking syndrome,’ we have a cancerous lung. Though it becomes a bit more
complicated when applied to behavior rather than apparent cellular
structure, this interpretation of pathology provides a relatively objective
232
criterion with which one can detect the presence of disease: dysfunctional
deviancy.
71
According to this perspective, life is simultaneously a process and a
concrete material entity (that is, the living cell, which comes from a pre
existing cell). Thus, the disordered (unordentliche, sometimes translated as
‘deranged’) cell serves as the concrete representation of disease (Virchow,
1958b, p. 37). The pathological cellular condition comprised for Virchow the
disease entity, and the point of diagnosis was to identify and name the
cellular abnormality. This contrasts with the bacteriological view that had
emerged by the end of the nineteenth century, according to which a disease
entity was defined by the cause of pathological changes—invading bacteria—
regardless of the particular presentation of the illness. This model of
pathology, which is ontological in nature, introduced the idea that a single
disease entity could produce an array of pathological changes, such that in
two individual patients, the same disease might present with completely
different symptoms or even be asymptomatic. As we will see in the next
section, these various terministic screens influenced those attempting to
make sense of madness, even though there was no corresponding way to
differentiate forms of madness on the basis of cellular abnormalities (and
even today mental illness by and large cannot be diagnosed on the basis of
71
It was not yet known that cells could be quite deviant without actually presenting any
medical problem, as can often be the case with some benign tumors.
233
physiological testing).
Reconciliation of Ontology and Physiology
As advances in medical science changed the way we measured and
observed disease, an ontological interpretation was applied whenever disease
could be linked to an external referent—either etiological, e.g., an invading
microbe, or pathogenetic, e.g., a characteristic course over time (as its
temporal extension is external to its manifestation physiologically at any
single point in time). Its usefulness depends on how well a given disease
entity seems to fit its external anchor given the constraints of state of the art
medical technology. The less physicians could predict about the cause or
course of an illness, the more carefully they attended to the observed
physiological phenomena. It has often been the case that a successful
ontological interpretation points to a new physiological area of interest to
study, and a successful physiological interpretation leads to an ontological
interpretation of the same disorder based on the newly grasped knowledge.
As a terministic screen with an expansive circumference, the
ontological interpretation today pervades everyday speech:
Usually, we do not give it a second thought, when we talk of ‘catching’
a disease, of being ‘attacked’ by it, ‘struck’ by it (‘stroke,’ ‘apoplexy’),
‘seized’ by it (‘seizure,’ ‘epilepsy’). We speak of disease ‘carriers’ who
are not ill themselves, of diseases which are ‘transmitted’ from person
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to person or parent to child, which move as ‘epidemics’ from place to
place or lurk as ‘endemic’ dangers waiting for the unimmunized
traveler. (KräuplTaylor, 1979, p. 6)
These idioms are so appealing in part because they helps us ‘order the chaos’
caused by medical ailments, providing some psychological comfort by offering
“a reassuringly simply solution to the apparent chaos of physical suffering: a
number of seemingly disparate phenomena can be accounted for and perhaps
abolished by reference to one underlying cause” (Boyle, 1990, p. 9). No
matter how advanced our knowledge of physiology becomes, it will be difficult
to stray too far from an ontological understanding of disease because of how
embedded it is in our linguistic lifeworld. On the other hand, advances in our
understanding of human biological processes at the molecular and genomic
levels make the physiological interpretation equally entrenched. Changing
paradigms in modern medicine is therefore less about adopting an ontological
or physiological interpretation than choosing which of the two to prioritize.
Scientific discussions of novel disease constructs can shift back and forth
between an ontological or physiological emphasis, often without any apparent
insight about this indeterminacy on the part of the discussants. We will see
this phenomenon in the next chapter, as those debating early interventions
in psychosis cannot seem to decide if they are discussing a psychosis risk
syndrome or the prodromal phase of a psychotic disorder. Both terministic
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screens are required to navigate the contemporary discourses of medicine.
The most successful paradigms in medicine integrate both ontological
and physiological terminologies. This is true even more generally: The
discovery of calculus by Newton and Leibniz, for example, brought the
continuous and discrete together in a single terminology, solving Zeno’s
paradoxes and providing the mathematical framework for modern Newtonian
physics (Kondratieva, 2007). Similarly, continuous and discrete physical
terminologies are integrated in the theories of quantum physics. At the risk
of drawing Alan Sokal's (1996) ire, I would suggest that, notwithstanding the
objective physical reality of particlewave duality, there is a discursive
phenomenon at work that is operating at an even more general level of
abstraction than the physical or mathematical. Reality, whether physical or
social, is neither discrete nor continuous until it is rendered so in language.
Our terminologies come into being not as a result of discovering
significant objects (that is, objects to be signified) that actually are
continuous or discrete in themselves, but rather as a result of humanity's
invention of the negative (Burke, 1963). As eighteenth century naturalist
Charles Bonnet put it, “If there are no cleavages in nature, it is evident that
our classifications are not hers” (as cited in Lovejoy, 1936, p. 230). Similarly,
Cassirer (1944) suggests, “Nature as such only contains individual and
diversified phenomena. If we subsume these phenomena under class
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concepts and general laws we do not describe facts of nature. Every system is
a work of art—a result of conscious creative activity” (p. 209). Either kind of
terminology might be more or less ‘accurate’—that is, capable of
encompassing a situation in a way that satisfies the rhetorical motives giving
rise to the symbolic action in the first place (Burke, 1974). While noumenal
objects are neither discontinuous nor continuous, phenomenal objects obey
the structure we give to them. An account of some phenomenon that is
produced wholly within a single terminology is bound to be an incomplete,
partial reading. Therefore, epistemic revolutions tend to come at times when
rhetors have discovered a new terminology that accounts for and reconciles
two distinct terminologies by which discontinuous and discrete approaches
had been divided.
Any successful integration must organize the symbolic field clearly and
efficiently so that the terminologies are appropriate to the situations that call
for their use without redundancy. It must find a way around the confusion
and miscommunication associated with incompatible epistemologies. The
integrated terminologies must be made to enrich and complement, rather
than cancel, one another. The new terminology certainly will still emphasize
either continuity or discontinuity, but in a way that transcends the
differences of the older terminologies, a “dialectical resolution by reduction to
an ultimate order” (Burke, 1969b, p. 207). What is needed is a new way of
237
understanding the world that can be condensed, if only metaphorically, into
some ultimate symbol under which the previous terminologies can organize.
The new terminology must be clear to all parties, something that everyone
can access for the first time at once, and which promises to be epistemically
productive. As this chapter continues, we will see how these criteria apply to
later epistemic developments on the road to psychiatric modernity.
For biological medicine in the nineteenth century, cellular pathology
provided a terminology that reconciles the ontological and physiological
interpretations. It is not merely a variant of the old humoral order with an
updated empirical grounding; rather, it is a new model in which disease is a
disturbance not of the whole body but of one discrete part. Any present
humoral rhetoric circulates around an ontological terminology of discrete
disease entities, and though a disease is not defined by its cause or course, it
is recognized that diseases have specific causes and courses. The signs and
symptoms of a syndromal complex were joined with a physiological
understanding of morbid processes within the unifying image of the deranged
cell.
Psychiatric Antecedents
Despite the achievements of cellular pathology, it seemed more or less
inapplicable to mental illness. The Cartesian mind was unitary and
immaterial; that madness could result from disordered brain cells was
238
inconceivable.
72
Two major historical developments produced the epistemic
shift that facilitated the birth of psychiatry. First, an alternative view of the
mind emerged from the Scottish Enlightenment in the form of faculty
psychology. Developed by Thomas Reid as an epistemological theory, faculty
psychology was based on the assumption that each individual operation of
the mind (e.g., perception, emotion, memory, will, appetite, etc.) was driven
by an independent mental faculty (Reid, 1785). These ideas were taken up by
French alienists and were influential in discussions about the nature of
madness in the early 19
th
century, in addition to forming the basis of the
phrenology movement (Boutroux, 1897; Brooks, 1976; Marková, 2005). Both
alienism and the phrenology movement also were influenced by the growing
physiognomic tradition, according to which one could infer an individual's
personality and character systematically from his or her external appearance
(Lavater, 1789).
The phrenologists suggested that different mental functions were
located in different regions of the brain (primarily around its outer surface),
and that variations of these functions corresponded to the external
72
It must be noted however that Descartes contributed significantly to the modern
understanding of neuroanatomy, including particularly his suggestion that the soul was
materially connected to the body via the pineal gland, and his assumption that the
organization and material structure of the nervous system, which mediated the connection
between the intentions of the will and the behavior of the body, reflected established habits
of behavior (LeDoux, 2003; G. Murphy, 1956). His neuroanatomical instincts were incorrect,
for the most part, but the very fact that he conceived of the problem in these terms was
highly significant.
239
topography of the skull (Kosslyn & Andersen, 1995). Though the latter
assumption was discredited, phrenology was “the first ‘scientific’ effort made
to analyze the underlying brain structure from which character and
personality might be derived” (Millon & Simonsen, 2010, p. 21). In a series of
lectures throughout Europe at the beginning of the nineteenth century, an
early exponent of phrenology, Franz Joseph Gall, introduced to a wide
audience the idea that cognitive functions are localized in neuroanatomy
(Breidbach, 2001). A few decades later, anatomical discoveries about the
structure and function of the dorsal and ventral roots of the spinal nerve led
to an anatomical exegesis of the reflex arc, demonstrating that the nervous
system was the source of at least some human behaviors (Hall, 1843). Two
decades later, with the discovery that the destruction of a specific region of
the brain causes aphasia, this finding was extrapolated to brain function
(Sechenov, 1863). The functionally differentiated mind of faculty psychology
and the efforts by alienists and phrenologists to study its physiological
implications lined up with the discovery of the functionally localized central
nervous system to forge a new category of epistemological figures and objects
of knowledge.
The second major development was institutional, namely, the
“establishment at the beginning of the [nineteenth] century of a new mode of
exclusion and confinement of the madman in a psychiatric hospital”
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(Foucault, 1972, p. 40). This development had its roots in the seventeenth
century, when those deemed to be mad (that is, unemployed) were
imprisoned and forced to labor so that they would not remain ‘idle’ (Foucault,
2001). Madness was regarded as a source of danger and a sign of
inhumanity, understood neither medically nor morally, for “the disturbance
of his reason restored the madman to the immediate kindness of nature by a
return to animality” (p. 75). At the end of the eighteenth century, the first
hospitals came into existence, spurred by the moral movement in medicine
that sought to transform “hostels where the sick went to die [into]
institutions dedicated to providing a therapeutic milieu” (Healy, 1997, p. 32).
Corresponding to this development, Philippe Pinel is usually credited with
unchaining the inmates of l'Hôpital Bicêtre (an asylum near Paris), though
this was actually the work of JeanBaptiste Pussin, who was superintendent
in 1797. Pinel, after having apprenticed himself to Pussin at Bicêtre, became
superintendent of the Hospice de la Salpêtrière in 1795 and in 1800, shocked
by the inhumane treatment of the mentally ill (so the typical narrative goes),
followed in Pussin’s footsteps by banning the use of chains as restraints
(Cousin, Garrabe, & Morozov, 2008; Gerard, 1997; Pinel, 2008; Walsh,
1913).
73
73
Inversely, Pussin also followed in Pinel’s footsteps by joining him at Salpêtrière a few
years later as his special assistant. Pussin’s interest in treating asylum inmates began not
in medical school—he was not a physician, but a tanner by trade—but rather during his own
experience as patient at Bicêtre suffering from scrofula (lymphadenopathy of the neck
related to tuberculosis). After his recovery, he took a staff position at Bicêtre in 1771, and 13
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The new institution of the psychiatric hospital facilitated the
transformation of the asylum inmate into a new object of medical knowledge,
the mentally ill patient. Rose and AbiRached (2013) suggest that these
institutions “seemed to confer some homogeneity upon those disparate
individuals—displaced, desolate, despairing, deranged—who were collected
within its walls” (p. 115). Two important features of the new clinical gaze
allowed madness to be seen differently than ever before. First, asylums
enabled alienists to observe pathological processes temporally, drawing
attention to another aspect of disease: its course over time. Second, observing
the mad alongside one another revealed clearly that insanity manifested in
many distinct ways (Healy, 1997; N. S. Rose, 2007). For the first time, it
became possible to observe the symptoms, course, and outcome of a large
sample of mentally ill patients, leading Pinel (1807) to advocate the use of
data driven experimental methods and statistical analysis in medical
research:
years later he became superintendent of the mental ward, despite his lack of medical
education. His social status perhaps explains why he was insufficiently credited for his role
in the founding of psychiatry. Despite Pinel’s explicit crediting of Pussin in the 1809 second
edition of his Treatise on Insanity, his contemporaries insisted on crediting Pinel for Pussin’s
initiative. Various etchings and a painting in 1876 by Tony RobertFleury, in which Pinel
was depicted as “singlehandedly unchaining the mentally ill,” almost certainly helped to
promote this myth (Noll, 2007, p. 56). Subsequent historians have for the most part passed
on the error without correction. Michel Foucault in Madness & Civilization notes (with some
irony) that “Pinel, according to tradition, had ‘liberated’ the insane of Bicêtre” (2001, p. 240),
and David Healy reports that “Philippe Pinel, one of the first physicians to work in a lunatic
asylum, unlocked the chains binding the lunatics in the Bicêtre” (2004b, p. 10). In fact, in
1797, two years after Pinel left Bicêtre, Pussin instituted a reform that permanently banned
the use of chains as restraints, and three years later, once Pussin had joined Pinel at
Salpêtrière, a similar reform was instituted (Gerard, 1997; Pinel, 2008).
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In medicine it is difficult to come to any agreement if we do not attach
a precise meaning to the word ‘experiment,’ since everyone praises his
own results and more or less only cites the facts in their favor. For an
experiment to be genuine and conclusive and serve as a solid basis for
any method of treatment, it must be carried out on a large number of
patients following the same general rules and a predetermined order.
It must also be based on a consistent series of observations made with
extreme care and repeated for a number of years with some kind of
regularity. Finally, it should report all of the findings, assigning as
much weight to results that are favorable as to results that are not.
74
Suffice it to say a medical experiment must be founded on the theory of
probabilities, which has already been applied so successfully to civil
life, and on which the methods of treating the sick must henceforth
rely if they are to be established on a solid foundation.
75
(pp. 169–170,
my translation)
74
Selective publication of positive results is still a major problem for private sector
pharmaceutical research (Goldacre, 2013; Healy, 2000b, 2004a; Washington, 2011).
75
“Il est difficile de s'entendre en médecine si on n'attache un sens précis au mot expérience,
puisque chacun vante les résultats de la sienne propre, et qu'il cite plus ou moins de faits en
sa faveur. Une expérience, pour être authentique et concluante, et servir de fondement solide à
une méthode quelconque de traitement, doit être faite sur un grand nombrr de malades,
asservia à des règles générales et dirigés suivant un ordre déterminé. Elle doit être aussi
établie sur une succession régulière d'observations constatées avec un soin extrêmè et répétées
pendant un certain nombre d'années avec une sorte de conformité. Enfin elle doit rapporter
également les événemens favorables comme ceux qui sont contraires, assigner leurs nombres
respectifs, et instruire autant par les uns que par les autres. C'est assez dire qu'elle doit être
fondée sur la théorie des probabilités déjà si heureusement appliquée à plusieurs objets de la
vie civile, et sur laquelle doivent désormais porter les méthodes de traitment des maladies, si
on veut les établir sur un fondement solide” (Pinel, 1807, pp. 169–170).
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These four changes—the new idea that disease was varied in kind and could
be classified on the basis of deranged anatomy (down to the cellular level);
the new understanding that the mind was differentiated in function and,
anatomically, so was the brain; the realization that at least some (if not all)
behaviors were mediated by activity in the central nervous system; and the
ability repeatedly to observe large numbers of mentally ill patients whose
symptoms over time appeared quite varied, regularly record the findings, and
compare data over time—converged to inspire the first modern systematic
attempts to articulate a nosology of madness within the framework of
institutional practices that “came to be known as clinical medicine” (T. D.
Murphy, 1981, p. 308, emphasis in the original).
The Emergent Assembly of Psychiatry
The first major classification system to emerge from this convergent
set of factors was Pinel’s 1806 Treatise on Insanity, which divided madness
into five categories: dementia, idiocy, mania with delirium, mania without
delirium, and melancholia (P. J. Cowen, Harrison, & Burns, 2012). In all
cases, however, Pinel thought the patient completely insane. This changed
with the nosological system produced by Pinel’s student JeanÉtienne
Dominique Esquirol. After distinguishing madness from the humoral
temperaments that were not pathological (although they might increase one’s
susceptibility to psychopathology), Esquirol (1838b) divided mental illness
244
into two categories, insanity and partial insanity. The latter group included
monomania (‘partial delirium’) and lypemania (‘melancholy with delirium’),
chronic cerebral affections, unattended by fever, and characterized by
a partial lesion of the intelligence, affections or will. At one time, the
intellectual disorder is confined to a single object, or a limited number
of objects. The patients seize upon a false principle, which they pursue
without deviating from logical reasonings, and from which they deduce
legitimate consequences, which modify their affections, and the acts of
their will. Aside from this partial delirium, they think, reason and act,
like other men… [Among those suffering from affective monomania,
by] plausible motives, [and] by very reasonable explanations, they
justify the actual condition of their sentiments, and excuse the
strangeness and inconsistency of their conduct… In a third class of
cases, a lesion of the will exists. The patient is drawn away from his
accustomed course, to the commission of acts, to which neither reason
nor sentiment determine, which conscience rebukes, and which the will
has no longer the power to restrain. The actions are involuntary,
instinctive, irresistible… The monomaniac is gay, petulant, rash,
audacious. The lypemaniac is sorrowful, calm, diffident, fearful... The
course of monomania is more acute, its duration shorter, and its
termination more favorable, unless there are complications. The
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contrary holds true in lypemania. In this, the delirium seems to
depend more particularly upon some abdominal lesion; while in the
other, it appears to be caused more immediately, by the anormal
condition of the brain… [We] need not confound these two pathological
conditions, nor impose upon them the same name, if we desire
precision in medical language… Partial delirium is a phenomenon so
remarkable, that the more we observe it, the more we are astonished,
that a man who feels, reasons, and acts, like the rest of the world,
should feel, reason and act no more like other men, upon a single
point? (Esquirol, 1838b, pp. 320–321)
Several things about this division are noteworthy. Esquirol assumes that the
subvarieties of monomania correspond to psychic ‘lesions’ (the extent to
which this was meant metaphorically is unclear), and his division of intellect,
will, and affect match the original treble division of Reid’s psychological
faculties, and can be seen still in the contemporary categories of cognitive,
affective, and conduct disorders. Esquirol provides an early example of the
strained attempt to combine psychological and neurological objects in one
nosological system. The explicit rationale for this nosology, with its category
errors, is the need for ‘precision in medical language.’ Through this precision,
a form of illness that no one has been able to see before becomes remarkably,
even astonishingly, clear. Like the stethoscope, this classification is designed
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to be a technology for seeing a hybrid object of medical knowledge.
Second, Esquirol justifies the principle division between monomania
and lypemania on the basis of their course and prognosis. This represents a
significant development of the syndrome concept, which originally denoted a
synchronic semiotic pattern. This innovation will become very important in
the development of dementia praecox, to which I shall turn shortly.
Esquirol's treatment of the category of temporal course contains an echo of
humoral thinking:
After Hippocrates, Areteus and Celsus assure us, that summer and
autumn produce rage... Dementia appears in winter. Charles VI
became insane after having been exposed to the sun... Excess cold
causes the same disorders; a truth illustrated in the experience of our
troops during their disastrous retreat from Russia, when many French
soldiers were seized with phrenetic delirium, and even mania... Heat,
like cold, acts upon the insane, with this difference, that the
continuance of warmth augments the excitement, while cold prolongs
the depression. Great atmospheric commotions excite and exasperate
the insane. A house for the insane is most disturbed... at the period of
the equinoxes... The influence of the seasons extends even to the
course of the insanity. There are individuals who pass the summer in
a state of prostration or agitation; whilst in the winter they are in an
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opposite condition... Insanity, which appears in spring and summer,
has an acute course. If not speedily cured, it terminates in the winter.
The monomania and mania of autumn, terminate only in the spring.
Summer is more favorable to the cure of dementia... (Esquirol, 1838b,
pp. 31–32)
Esquirol based these conclusions on observational data recorded at the
Salpêtrière hospital over a nine year period by alienists following Sydenham's
suggestions to look for relationships between clinical signs and the time of
year.
Third, Esquirol implies that any behavior resulting from one of these
mental ‘lesions’ is beyond the patient's control. This remains the core legal
principle by which defendants can avoid culpability for crimes associated
with psychiatric illness (‘not guilty by reason of mental disease or defect’). So
many of the varieties of monomania Esquirol identifies are associated with
criminality, including murder, theft, and rape, or as the DSM5 Paraphilias
Subworkgroup proposed to call it, ‘coercive paraphilia,’ which I discuss
extensively in Chapter 4 (D. Thornton, 2010).
Fourth, the very idea of lypemania, literally a 'sadnessmania,' inverts
the traditional traditional binary opposition between melancholia and mania
that traces back to Hippocrates. In this way, it is stunningly modern. Healy
suggests that in proposing “a selective disorder of mood, Esquirol all but
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created modernity. This was the cornerstone on which the modern edifice of
depression has since been erected” (1997, p. 33). Although the concept of
monomania is no longer extant scientifically, it remains in the popular
culture in words like ‘pyromania,’ ‘kleptomania,’ and ‘nymphomania’: “[The]
survival to this day of this use of the mania suffix indicates where one of the
corpses on the road to modernity is buried” (Healy, 1997, p. 33). But as
radical as Esquirol's monomania concept was, traces of the humoral model
appear in his invocation of melancholy, along with the suggestion that
lypemania (‘sadnessmania’) involves some problem in the stomach.
Finally, Esquirol is aware of great epistemic tensions. He notices the
discordance between categorical and dimensional diagnostic concepts, a
distinction which was central to the DSMIII nosological revolution in 1980
and which animates many of the DSM5 controversies today. Furthermore,
Esquirol reveals the inner conflict he feels between honoring the received
wisdom of the past and embracing the empirical science of the present:
Does the moon exercise any influence upon the insane? ...The English,
and almost all the moderns, give to the insane the name of lunatics...
Certain isolated facts and phenomena observed in many nervous
diseases would seem to justify this opinion. I have been unable to
verify this influence, though I have been at some pains to assure
myself of it... At Hospital Salpêtrière, where practical truths have
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become, in some sort known, among the inmates of the house, they
have no longer any suspicions of lunar influence. The same is true of
the Bicêtre... Nevertheless, an opinion which has existed for ages,
which is spread abroad through all lands, and which is consecrated by
finding a place in the vocabulary of every tongue, demands the most
careful attention of observers. (pp. 3233, my emphasis)
This hardly seems like the writing of a revolutionary, though that he was.
Inventional Visual Rhetoric
Alongside a description of the characteristic symptoms and their
observed course, Esquirol provided an illustrative case history for each
diagnostic category in his textbook. Each of these histories includes a
description of how the patients typically appear physically, including such
features as posture and skin color, and a handdrawn image of a patient
exemplifying the physical ‘look’ associated with the diagnosis (Figure 3.4).
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Source: Illustrations in Esquirol's textbook, Mental Maladies. From top left,
clockwise: a sadnessmaniac ('lypemaniac'), a 'maniac,' an 'idiot,' and a
'demented lunatic' (Esquirol, 1838a, pp. 1.411, 2.162, 2.230, & 2.316).
Figure 3.4: Esquirol channels Linnaeus
251
These images were drawn in a style reminiscent of Linnaeus' (1735)
renderings of plant species a century earlier (Gilman, 1982).
76
Linnaeus's
classificatory illustrations have stood in for the specificity of modern medicine
in terms of both diagnosis and treatment, in contrast to the holistic nature of
the humoral model. An illuminating example of this is found in an
advertisement (Figure 3.5) in the American Journal of Psychiatry, which
compares the specificity of bee communication, as represented by Linnaeus,
to the specificity of the minor tranquilizer 'Librium' (Roche, 1981, pp. A36–
A37).
76
The link between Linneaus and psychiatric nosology is also apparent in the work of
François Boissier de Sauvages de Lacroix, a botanist and physician who created the first
nosological framework for disease by synthesizing the work of Sydenham and Linneaus in
his threevolume magnum opus, Nosologia Methodica, published in 1763, which incorporated
much of the substantive content from his 1731 Treatise de Nouvelles Classes de Maladies, a
work that focused on madness. His approach to madness strongly influenced Pinel’s
thinking, and more broadly, his Nosologia “was used as an orderly classification for decades,
if not centuries, to come” (Millon & Simonsen, 2010, p. 25).
252
Source: An advertisement in the American Journal of Psychiatry (Roche,
1981, pp. A36–A37).
Figure 3.5: Linnaeus invoked to emphasize specificity of 'Librium'
253
Influenced by Pinel, Esquirol considered physical features to be very
important in classifying ‘specimens’ of madness, a physiognomic epistemic
orientation shared with the phrenologists. This grounded psychopathology in
physical biology, helping to anchor primitive psychiatry in the larger
institutional domain of medicine. Subsequent alienists of the nineteenth
century continued to regard patients' physical appearance as diagnostically
relevant, to the extent that “the visual image was central to the clinical
practice of individuating the pathology” (N. S. Rose, 2007, p. 193).
Kenneth Burke provides a hint about the underlying rhetorical
motives when he suggests that a preoccupation with images can be associated
with a “mystical transcendence of the person in generalizing the concept of
role to the point where the realistic or dramatistic notion of people in
situations retreats behind the pure lyric of imagistic suggestion” (1969a, p.
300). Certainly, the visual always lies within a web of signification (Geertz,
1973). Images also seem especially wellsuited to be significant symbols upon
which a new, transcendent, ultimate order can be constructed. A new
organizing object is introduced within a visual epistemic field which has not
yet been reduced to either continuous or discontinuous terms. Its visibility,
accessible to all, announces the possible formation of a new epistemic
paradigm.
Along these lines, I contend that the prominent inclusion of images
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within the nosological text implies a dissatisfaction with a purely symbolic
level of signification, which Esquirol felt the need to supplement with
illustrations that are at once iconic, in that they are meant to resemble or
imitate the signified, and indexical, in that there is supposedly an actual
relationship between psychopathology and posture, facial expression,
complexion, and other similar physical attributes (Peirce, 1868). Each of
these levels of signification should be understood in light of the rhetorical
canon of elocutio, by which Esquirol ornamented his new epistemic objects.
During the nineteenth century, the teaching of rhetoric became scientized,
leading to the “elocutionary sciences of chironomia (descriptive gesturing),
chirologia (emotional gesturing), proxemics (body positioning), facial display,
and bodily action” (Gronbeck, 2008, p. xxiv). In Esquirol we have a
fascinating example of symmetry whereby the teaching of science becomes
rhetoricized along precisely the same lines: His illustrations emphasize
“appearance, complexion… posture, gestures, and movements of the entire
figure” (Gilman, 1982, p. 12). The strategy of elaborating a scientific concept
by means of visual copia is a common way to enhance a concept's sense of
reality (Burri & Dumit, 2008). Publication of Esquirol's images historicized
the new clinical gaze and the distinctive form in which psychopathology, in
all its varieties, appears to this gaze.
Humoral pathology also featured a strong visual component. Its
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therapies were, more often than not, worse than useless, but they were
persuasive nevertheless. Bleeding a feverish patient produced an immediate
change in complexion and body temperature that all could see and feel. This
may not have corresponded with a cure, but it did not need to. No one can
see a cure itself; it is always mysterious and hidden (just as causation was
accessible only intuitively, as Hume argued). The patient either gets better
or dies, and if either includes a visual change, our compulsively reasonable
(but often irrational) minds cannot help assigning meaning to the imagined
association between the two. The visual evidence that we have at least some
mastery over the natural world appeals to our gnostic desire for some secret,
ineffable knowledge by which we can be saved from the imperfection, flaws,
dangers, and evil embedded in the material world of disease and death. Our
cognitive biases belie a fantasy of mastery over an uncontrollable situation.
This is how the ‘functional neurological’ hypothesis of hysteria, which
explains nothing at all (quite explicitly) but involves visible fMRI evidence,
could become preferred over the conversion hypothesis, which provides a
complete explanation and suggests an invisible, but often successful method
of treatment. An explanation that makes sense but is invisible generally will
be suspect. Explanations can be wrong, especially those built on the premise
that our unconscious minds play tricks on us, intentionally deceiving us in
order to avoid staring into the abyss of our neuroses, preferring even bodily
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suffering over confronting an inner conflict.
Much like the cultural return of the humoral ultimate order in the
marketing of alternative medicine, visual displays of madness have made a
great return in the neurobiological discourses of psychopathology. For
example, psychiatrist Daniel Amen runs a clinic that specializes in single
photon emission computerized tomography (SPECT) imaging techniques,
with which he claims he can classify subtypes of mental disorders that are
not currently recognized by mainstream psychiatry. Amen also claims that
such images can aid differential diagnosis between accepted disorder
categories, as well as inform medication decisions and monitor treatment
outcomes. The website presents sample SPECT images for a variety of
disorders, accompanied by explanatory captions and adjoining case histories
(Figures 3.6 and 3.7). Much like Esquirol’s illustrations, captions tell the
reader what is supposedly evident in the image, though perhaps ‘Ce n'est pas
une maladie mentale’ would be better (Magritte, 1929; Figure 3.8).
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Figure 3.6: SPECT images of schizophrenia constitute a modern
day reenactment of Esquirol’s illustrated nosology
Source: (The Amen Clinics, 2012c, sec. SCHIZOPHRENIA).
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Figure 3.7: SPECT image of oppositional defiant disorder (ODD)
Given the case history, it is unclear (and left unexplained) how the image
contributed to either the diagnosis or the treatment plan (The Amen Clinics,
2013, sec. Anger/Severe ODD).
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Figure 3.8: The Treachery of Neuroimaging
260
In his gallery of SPECT images, Amen sees what Esquirol saw in his
asylum: specific patterns, diversity in what once was thought to be a unity,
and a corresponding new means of classification. Accompanying each of his
images are descriptions of the essential features of the putative diagnostic
category and the typical features one will ‘see’ in the SPECT images. Yet,
ambiguity pervades the pseudoprecision of this neophrenological exercise.
For example, in ‘Temporal lobe ADD,’ “SPECT imaging typically shows
decreased or increased activity in the temporal lobes with decreased
prefrontal cortex activity” (The Amen Clinics, 2012b, sec. Temporal Lobe
ADD, my emphasis). The ‘insights’ provided by the images are not always
very insightful; for example, SPECT imaging helped to diagnose a child
presenting with “angry outbursts and constant defiant behavior” with
oppositional defiant disorder (ODD), and helped select a medication that was
of a different class than the five drugs that had already been tried
unsuccessfully (The Amen Clinics, 2013, sec. Anger/Severe ODD).
The website of the Amen Clinics revealingly suggests that “SPECT can
specifically help people with ADHD by: Helping evaluate whether or not the
person is ADHD; Helping determine the type of ADHD to inform treatment
decisions; …Reducing emotional pain and stigma by demonstrating that
symptoms and behaviors are not imaginary; Increasing treatment compliance
by showing pictures of results; Helping families gain a better understanding
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of the illness through visuals” (The Amen Clinics, 2012a, sec. SPECT
IMAGING, my emphasis). Not only is the imaging technology said to
increase diagnostic precision, it can do so while reducing stigma, increasing
compliance, and facilitating public understanding.
Neurosis and Psychosis
Just as physicians during the nineteenth century began charting the
developments and changes of symptoms in the presentation of an illness over
time, critics can study the longitudinal course of terminologies of mental
illness. The terminologies at any given point during this period for the most
part stress discontinuity; similarly, these terminologies enact discontinuity in
their changes, interactions, and moments of selfreference. The terms
‘neurosis’ and ‘psychosis’ emerged in the eighteenth and nineteenth centuries
(respectively), but the relatively constant flux in meaning through the early
twentieth century makes it very difficult to read psychiatric discourses from
this period on their own terms.
At first, ‘neurosis’ designated any disease of the nervous system, while
‘psychosis’ initially referred to the psychic dimension of a brain disease and
entailed a total disorder of the personality coupled with an organic brain
pathology (Janzarik, 2003; Knoff, 1970; SchmidtDegenhard, 1988). Neither
Pinel nor Esquirol used the term neurosis, as neuroses were within the
general domain of the physician and distinct from insanity (and, for Esquirol,
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partial insanity). When the concept of neurosis first appeared in the late
eighteenth century, it signified a lesion of the nerves, in accordance with the
anatomical model of pathology. In contrast to ‘neuritis,’ in which one could
see visibly damaged nerves upon autopsy, the neurological damage associated
with neurosis was invisible but presumed, and the prevailing belief was that
“in due course scientific advances would locate the invisible pathology”
(Healy, 1997, p. 39). Epilepsy (explicitly defined as a neurosis in the late
nineteenth century) and neuropathy are diseases that capture the original
meaning of the term. Perhaps ironically, the best modern example of a
psychiatric disorder believed to be an invisible neurological disorder is
‘functional neurological disorder.’ The DSM5 conversion of hysteria into
functional neurological disorder brings psychiatry full circle, reintroducing
the original concept of neurosis for the historically important hysterical
condition (although the somatoform disorder work group would undoubtedly
be horrified by the suggestion that they reintroduced the concept of neurosis).
Karl Friedrich Canstatt introduced the concept of psychosis in 1841 as
a synonym for ‘psychic neurosis’ (Bürgy, 2008; Canstatt, 1841; Scharfetter,
1987).
77
Feuchtersleben (1845) stressed the importance of both the somatic
and the psychic in understanding psychosis, and deployed the term as a
subset of the larger category of neurosis:
77
Many sources incorrectly claim that Baron Ernst Maria Johann Karl Freiherr von
Feuchtersleben (1845) first introduced the term ‘psychosis.’
263
Every psychosis is, at the same time, a neurosis; because, without the
intervention of nervous action, no change of the psychical action
becomes manifest, but every neurosis is not a psychosis, of which
convulsions and pain afford sufficient examples. Agreeably to this
notion is the popular view that a madman is not called mad because
his brain is overexcited, but because he judges and acts absurdly.
(Feuchtersleben, 1847, p. 246)
During the second half of the nineteenth century, ‘psychosis’ frequently
appeared in the psychiatric literature, generally used as a “synonym for
terms such as mental disorder, mental illness, and insanity” (Bürgy, 2008, p.
1201). While efforts, following the discovery of the reflex arc, to locate
increasingly higher nervous system functions in the brain enjoyed much
success, belief lingered that nonmaterial sources of the highest functions
associated with conscious judgment would be discovered. The emerging
distinction between ‘psychosis’ and ‘neurosis’ reflects this belief in that the
former was a disorder of the mind while the latter was a disorder of the
nervous system (Beer, 1995, 1996). Of course, every disorder of the central
nervous system implicates the mind in some manner, and vice versa.
Classification of a disorder as one or the other unavoidably introduces
assumptions about etiology, implying the causal priority of either mind or
brain. These distinctions became more pronounced once the concept of
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neurosis narrowed, resulting in a discursive decoupling of the two into
distinct, mutually exclusive categories.
Freud (1893b, 1924a) reintroduced this same distinction within the
concept of neurosis itself, distinguishing ‘psychoneuroses’ (later, just
‘neuroses’ unqualified) that were psychological in nature from ‘actual
neuroses’ that entailed physical damage to the nerves. Freud suggested that
the most common cause of this damage was masturbation, which Esquirol
(1838b) referred to as “that scourge of human kind” (p. 41). With respect to
therapeutic outcomes, risk management, and preventive psychiatry, Freud
(1893b) viewed 'actual neurosis' very much as psychosis is understood today,
and regarded it as psychoanalytically untreatable. Freud’s understanding of
‘neurosis’ (qua ‘psychoneurosis,’ not ‘actual neurosis’) radically transforms
what was once a “rigid boundary” between the sane and the insane by
“creating a new class of neurotic behaviors and linking it with normal rather
than psychotic behavior” (Horowitz, 2002, p. 53). Freudian neuroses imply a
fluid and dynamic nosology in which the difference between normality and
neurosis is a matter of degree, not kind. Rather than the discontinuous
categories of healthy and diseased, we have a continuous spectrum arrayed
dimensionally. This nosological view came to dominate the psychodynamic
tradition in much of the twentieth century, although, as discussed in Chapter
1, it fell out of favor in mainstream psychiatry with the 1980 publication of
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DSMIII. In Chapter 4, we will see how this repressed perspective has
returned in contemporary psychiatric discourse about the nature, treatment,
and prevention of psychotic disorders.
The cyclic alternation of the meaning of ‘neurosis’ (actual or otherwise)
and ‘psychosis’ created some confusion: everyone meant something definite by
each term, but these meanings often were idiosyncratic, not shared. Since
Freud believed that only the (psycho)neuroses could be treated effectively
with psychoanalysis, the term came to be associated with the psychoanalytic
tradition and its dimensional nosologies. Psychosis was something more
extreme, left to the asylum psychiatrists who treated large confined groups of
mentally ill patients rather than spending six hours per week with individual
patients, as Freud did (Freud, 1913a). In part because of this division,
neuroses became associated with disordered psychological functioning, and
psychoses with gross nervous system dysfunction. Pierre Janet (1920)
identified a loss of la fonction du réel (‘the reality function’) as the defining
characteristic of neurosis; similarly, Freud suggested that neurotic patients
“turn away from reality because they find it unbearable—either the whole or
parts of it” (Freud, 1911, p. 301). Though both neurosis and psychosis were
associated with impaired reality testing, in psychosis this impairment was
absolute (Kantrowitz, Katz, Paolitto, Sashin, & Solomon, 1987). Freud, for
whom acute florid hallucination “is perhaps the most extreme and striking
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form of psychosis,” conceptualized psychosis as a state in which “either the
external world is not perceived at all, or the perception of it has no effect”
(Freud, 1924a, p. 151). In contrast, the loss of insight was milder in a
neurotic break with reality, although it could progress to psychosis,
suggesting more of a continuum than a strict etiological and pathogenic
division:
[At] a final stage in the evolution of a neuroses [sic], the feeling of
unreality may pass over into that falsification of reality which we label
delusion. Hypochondriacal fear, such as the common one of heart
disease, may evolve by quantitative increase into the feeling that the
heart is literally gone, or actually broken. In this case, fear and
anxiety have developed into delusion. Another example may be cited;
in groping for the cause of his illness, a sufferer may conclude that he
is sick because he has violated the rules, as he understands them, of
health. Later on, as he becomes hopeless concerning his recovery, he
may deny that he is ill and state that his sins have found him out or
even that he is being punished by God. (Myerson, 1936, p. 263)
Clearly, the psychotic patient suffers from a total disconnection from reality,
with a complete lack of insight. At the end of the nineteenth century, this
break with reality became associated with a new diagnostic category, the
emergence of which coincided with a nosological development that serves as
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the foundation for the modern (DSMIII) approach to the classification of
mental illness.
Dementia Praecox: Prognosis as Diagnosis
Unlike the forms of mental illness known in some manner since
antiquity (e.g., melancholia), dementia praecox did not become an object of
knowledge until the midnineteenth century, when alienists began noticing
among the masses of generally insane patients a group of predominately
young people who suffered from a chronic, progressive decline in mental
faculties with no apparent cause. Emil Kraepelin provided the first
systematic treatment of dementia praecox, literally precocious or premature
dementia, the precursor to what is now called ‘schizophrenia’ (Kraepelin,
1896). Kraepelin appropriated the basic idea for dementia praecox from
BénédictAugustin Morel, who in 1852 described (in passing) a disorder he
called ‘démence précoce’ occurring in young patients who were ‘stuporous,’
appearing at first to have a good prognosis but nevertheless descending
inevitably into incurable dementia (Morel, 1852). Thomas Clouston named a
similar disorder the “hereditary insanity of adolescence,” which he later
shortened to “adolescent insanity,” not to be confused with (for Clouston) the
closely related “masturbational insanity,” a diagnosis he continued to
champion well after it fell out of vogue (Clark, 2004; Clouston, 1891, p. 111).
Based on work by his student, Ewald Hecker, Karl Kahlbaum described a
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form of ‘jugendliche irresein’ (juvenile madness) that often developed into
catatonia, a syndrome he studied extensively, as well as hebephrenia, a
syndrome characterized by severely disorganized speech and behavior
(Hecker, 1871; Kahlbaum, 1863).
Kraepelin integrated these varied clinical pictures and their seemingly
unrelated categories of symptoms (e.g., catatonia, confusion, delusions,
disorganized behavior, grandiosity, hallucinations, impaired communication
ranging from strange to completely incoherent, unusual thought patterns,
etc.) into the unified nosological entity dementia praecox. The common
organizing feature of dementia praecox was a marked deterioration in
personal/social behavioral and cognitive functioning from which the patient
was unlikely to recover. Kraepelin accounted for the diverse phenotypes of
disease expression by positing nine distinct ‘clinical forms’ of his new disease
entity: “We meet everywhere the same fundamental disorders in the different
forms of dementia praecox… in very varied conjunctions, even though the
clinical picture may appear at first sight ever so divergent” (cited by
Jablensky, 2011, pp. 3–4).
78
In the foreword to the fifth edition of his revolutionary textbook,
Lehrbuch der Psychiatrie, Kraepelin emphasized the importance of the course
78
Kraepelin’s ‘clinical forms’ include ‘dementia praecox simplex,’ ‘hebephrenia, ‘depressive
dementia praecox (simple and delusional form),’ ‘circular dementia praecox,’ ‘agitated
dementia praecox,’ ‘periodic dementia praecox,’ ‘catatonia, paranoid dementia (mild and
severe form),’ and ‘schizophasia (confusional speech dementia praecox)’ (Kraepelin, 1896).
269
of disease progression over time to his new conception of psychiatric disease:
“What convinced me of the superiority of the clinical method of diagnosis…
over the traditional one, was the certainty with which we could predict, on
the basis of our new concept of disease, the future course of events” (cited by
Noll, 2011, p. 66). In the case of dementia praecox, the “importance of our
diagnosis would therefore consist in this: that we are now able, at the very
beginning of the illness, to predict its resulting in a characteristic state of
feebleness” (Kraepelin, 1917, pp. 28–29). The sixth edition culminated in a
major insight that would define his nosological system: There are ultimately
two categories of insanity, one that terminates in dementia (dementia
praecox was the classic exemplar of this category) and one that does not
(exemplified by manicdepressive insanity, based on the concept in French
alienism of folie circulaire, or ‘circular insanity’). The ability to observe the
course of the illness, made systematically possible scarcely fifty years earlier,
became central to the organization of Kraepelin’s nosology, later serving as
the ideological basis for DSMIII. Just as the ‘neoKraepelinian’ categorical
DSMIII is now giving way to the more dimensional DSM5, Kraepelin,
toward the end of his life, discussed the possibility of replacing his
dichotomous categorical nosology with a dimensional model in which the
syndromes associated with his two categories of insanity “do not represent
the expression of particular pathological processes, but rather indicate the
270
areas of our personality in which these processes unfold” (Kraepelin, 1974, p.
12).
Kraepelin’s approach was revolutionary for several reasons. First, he
replaced the Sydenhamian ‘syndrome’ (i.e., “a cluster of signs and symptoms
that would remain consistent regardless of outcome”) with ‘prognosis’ as the
key term under which disease entities were organized (Noll, 2011, p. 66).
79
This move made it possible, years later, for the term ‘syndrome’ to be
transformed such that the idea of a ‘risk syndrome’ was intelligible. Second,
his methodology involved statistical analysis of longitudinal data generated
from thousands of cases, setting the stage for the biopolitical turn in the 20
th
century. Third, he explicitly appropriated the clinical language of medicine
to fashion psychiatry as its own medical specialty that treated naturally
occurring (provisional) discrete disease entities, each of which was
understood to have an underlying (but as of yet unknown) biological aetiology
and pathophysiology. Appeals to imagery no longer were needed to serve this
institutional linking function. For dementia praecox, the “nature of the
disease process… is not known, but it seems probable, judging from the
clinical course, and especially in those cases where there has been a rapid
deterioration, that there is a definite disease process in the brain, involving
the cortical neurones”: indeed in a few cases, “anatomical lesions have been
79
Syndrome will indeed return, as we shall see shortly, but in a revised form that
incorporates the ideas of course and prognosis.
271
found which can be explained only upon such a basis” (Kraepelin, 1907, p.
221). This finding confirmed suspicions that Kraepelin had voiced a decade
earlier:
The real nature of dementia praecox is totally obscure… It is hard to
see why an organism which has hitherto developed in a healthy or
even energetic way should suddenly, and for no particular reason, not
only come to a standstill but even deteriorate into chronic sickness… I
consider it more likely that what we have here is a tangible morbid
process occurring in the brain… It is true that morbid anatomy has so
far been quite unable to help us here, but we should not forget that
reliable methods have not yet been employed in a serious search for
morbid changes. (Kraepelin, 1987, p. 23)
Kraepelin already had found evidence that such lesions constituted the
organic basis of what we now know as Alzheimer’s disease. As dementia
praecox was for Kraepelin essentially an earlyonset variant of the same
disorder (as they both develop the same putatively terminal course), he
assumed it was only a matter of time before the parallel organic brain
pathology would be mapped out for dementia praecox (Metzl, 2009).
One important caveat must be noted here. That mental diseases have
a biological basis does not imply that that their causes can be reduced
entirely to physical defects of the brain; Kraepelin dismissed attempts to do
272
so as brain mythology (‘hirnmythologie’).
80
Nor does it imply the irrelevance
of psychological factors: the appendix to Kraepelin’s lectures on clinical
psychiatry asserts that this field “must include a study of the personality
itself, the temperament and general reactions, and also an analysis of the
aspirations, wishes, and conflicts, which have preceded the outbreak of
definite mental disorder, and in a great measure determine its occurrence”
(T. Johnstone, 1917, p. 357).
81
Kraepelin believed it was important to chart
all observed clinical variants carefully, but he fiercely resisted ascribing
etiological significance to their division, and left open the question whether
these clinical variants manifested an underlying unitary pathogenesis or,
instead, represented multiple disease states (Jablensky, 2010). Still,
Kraepelin believed that the evidence justified provisionally “regarding the
majority at least of the clinical pictures which are brought together here as
the expression of a single morbid process, though outwardly they often
diverge very far from on another” (Kraepelin, 1919, p. 3). Unfortunately,
Kraepelin’s hopes of finding distinctive organic antecedents and
80
This approach was particularly associated with Theodor Meynert (1890) and Carl
Wernicke (1906), who attempted to build an overall system of organic and mechanistic
psychiatry. But they often supplemented their objective findings with hypotheses on the
anatomical and physiologic substratum of psychic activity… [formulating]
psychopathological disturbances in terms borrowed from brain anatomy” (Ellenberger, 1970,
p. 284).
81
Contrast this with what came to be known in the 1970s as the neoKraepelinian model,
which “disregards etiology and dismisses conflicting theoretical standpoints… The neo
Kraepelinians do not disregard etiology as much as history, whether personal or social. They
would most likely be satisfied with some form of genetic and biochemical etiology, which is in
fact what they aim for. The neoKraepelinians simply do not want to deal with any form of
social etiology” (P. Brown, 1990).
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neurobiological pathological mechanisms associated with behavioral clusters
never were realized (Boyle, 1990; Gottesman & Shields, 1982; Jaspers, 1963;
Kendell, 1975; Wing, 1978).
Like Esquirol, Kraepelin had identified a new way of looking at mental
illness, although unlike Esquirol, visual observation did not figure heavily in
this new technology of seeing. Kraepelin and Freud both
mark a move away from the eye. Each opens the interior of the patient
to medical knowledge by demoting observation in favor of
interpretation. Kraepelin… illustrated his textbook liberally with
illustrations, but they were just that—illustrations. Their diagnostic
role had been taken over by the case history: the chronology of
symptomatology, etiology, and prognosis that was the diagnostic key.
(N. S. Rose, 2007, pp. 193–194)
Just as Kraepelin rejects Esquirol’s prioritization of visual observation, Freud
disparages his teacher, JeanMartin Charcot, as “not a reflective man, not a
thinker: he had the nature of an artist—he was, as he himself said, a
‘visuel,’—a man who sees” (Freud, 1893a, p. 49). What Kraepelin (and Freud)
made visible was subtle, easy to miss – indeed, the “whole disturbance
[associated with dementia praecox] can be so very gradual and the symptoms
so illdefined that relatives see them only as the result of an unfortunate
development or perhaps a weakness in character” (Kraepelin, 1987, p. 13).
274
Further, the clinical pictures
82
of the different forms of dementia praecox
were so variegated that Kraepelin went on for some seventy pages outlining
the various psychic symptoms he had observed. Yet these symptoms could be
divided into two broad groups to form the “general psychic clinical picture” of
dementia praecox (Kraepelin, 1919, p. 74). The first roughly corresponds
with what we now consider ‘negative symptoms,’ primarily flat affect, alogia,
avolition, and anhedonia:
One the one hand, we observe a weakening of those emotional activities
which permanently form the mainsprings of volition. In connection
with this, mental activity and instinct for occupation become mute.
The result of this part of the morbid process is emotional dullness,
failure of mental activities, loss of mastery over volition, of endeavor,
and of ability for independent action. The essence of personality is
thereby destroyed, the best and most precious part of its being, as
[German asylum reformer, neurologist, and psychiatrist Wilhelm]
Griesinger once expressed it, torn from her… The rapidity with which
deepseated and permanent dementia sometimes develops in the
domain of intellectual work makes the suggestion easy, that it also
may itself be drawn by the disease into a sympathetic morbid state,
even though it is invariably encroached on to a much less degree than
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The ubiquity of the 'clinical picture' metaphor in medical literature also testifies to the
emphasis on the visual in diagnosis.
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emotion and volition. (Kraepelin, 1919, p. 74, emphasis in original)
One cannot fail to notice here the tripartite division of the psyche—intellect,
affect, and will—inherited from the faculty psychology tradition of the
Scottish Enlightenment.
Kraepelin’s second group includes much of what we now call ‘positive
symptoms,’ which include delusions, hallucinations, ideas of reference,
grandiose thinking, disorganized speech, bizarre thoughts, and bizarre
psychomotor behavior (e.g., catatonia). Rather than focus on the signs and
symptoms here, Kraepelin describes what he sees as their underlying psychic
basis:
The second group of disorders... gives dementia praecox its peculiar
stamp… It consists of the loss of the inner unity of the activities of
intellect, emotion, and volition in themselves and among one another...
This annihilation presents itself to us in the disorders of association…
in incoherence of the train of thought, in the sharp changes of moods
as well as in desultoriness and derailments in practical work. But
further the near connection between thinking and feeling, between
deliberation and emotional activity on the one hand, and practical
work on the other is more or less lost. Emotions do not correspond to
ideas. The patients laugh and weep without cause, without any
relation to their circumstances and their experiences, smile while they
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narrate the tale of their attempts at suicide: they are very much
pleased that they “chatter so foolishly,” and must remain permanently
in the institution, on the most insignificant occasions they fail into
violent terror or outbursts of rage, and then immediately break out
into a neighing laugh. It is just this disagreement between idea and
emotion that gives their behavior the stamp of “silliness.” (Kraepelin,
1919, pp. 74–75, emphasis in original)
Kraepelin was following an idea developed by Erwin Stransky, a Viennese
neurologist who devised an explanatory model of dementia praecox involving
“inaffectivity” due to the loss of “intrapsychical coordination,” i.e., loosening
of the connection between the “noopsyche” and the “thymopsyche”
(Kretzschmar & Petit, 1994, p. 377).
83
Kraepelin believed further in a
connection between negative and positive symptoms:
As it seems to me, there exists an inner connection between the two
groups of disorders, which are here distinguished. What fashions our
experiences into a firmly mortised building, in which each part must
fit the other and subordinate itself to the general plan, are general
conceptions and ideas. The even calm of our temper, the swift victory
83
Despite the conceptual richness of this model, Stransky later adopted an atheoretical
perspective that would later still come to be associated with neoKraepelinianism: “…the
mere fact that I have to work through the pompous, arrogant, and puffy language of most
mediocre philosophers [publishing in psychiatric journals]… causes considerable, almost
physical discomfort in me… Every totally mindless brain cobbler or spine cutter does more
research work than recent philosophers all taken together” (cited by M. Spitzer, 1991, p. 763;
Stransky, 1923, pp. 251–252, 259).
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over sudden shocks, are guaranteed by the higher general emotions; on
the one hand they give to the background of our mood a definite
coloring even when no emotional stimuli are caused by special internal
or external experiences. Lastly, the inner unity of our will is
conditioned by the general trend of volition which is always alive in us,
and which is the product of our racial and personal development. We
may therefore expect that a weakening or annihilation of the influence
which general conceptions, higher emotions, and the permanent
general trend of volition exercise on our thinking, feeling, and acting,
must draw after it that inner disintegration, those “schizophrenic”
disorders, which we meet with in dementia praecox. It seems to me
that the disorders observed in the patients and the complaints to
which they give utterance, point exactly to injury to the general
scheme of our psychic development, as it fixes the substance of our
personality. The general trend of volition and also the higher emotions
might form the first point of attack. But further the instrument of
general conceptions with its regulating influence on the train of
thought would then also become worthless, if the will were no longer
capable of using it. (Kraepelin, 1919, pp. 75–76, emphasis in original)
Here, we see the influence of Kantian psychology (according to which
concepts and sense perception are inseparably connected through intuition)
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on Kraepelin’s understanding of the psychopathology of dementia praecox
(Sedler, 1994).
Schizophrenia: A Continuum of Discontinuity
Dementia praecox underwent one more important transformation
under Paul Eugen Bleuler, who conceptualized the disorder as a ‘loosening of
associations,’ leading him to propose the name ‘schizophrenia’ (to which
Kraepelin refers in the passage quoted above). A decade after the publication
of Kraepelin’s classic text, Bleuler criticized the concept of dementia praecox
as antiquated and untimely:
The older term is a product of a time when not only the very concept of
dementia, but, also that of precocity, was applicable to all cases at
hand. But it hardly fits our contemporary ideas of the scope of this
diseaseentity. (Bleuler, 1911a, p. 7)
Scarcely a century earlier, 2,500yearold terms were still current; by the
beginning of the twentieth century, terms scarcely a single decade old were
seen as ancient and out of touch, historical artifacts from a bygone era. Just
as psychiatry became attuned to the continuous course of disease over time,
its diseaseconcepts seemed to follow a rather discontinuous temporal course,
a diachronic loosening of nosological associations. The discontinuous nature
of the knowledgeproduction process became reflected in the knowledge
produced, and dementia praecox became schizophrenia. This term combined
279
the Greek words for ‘to split’ (schizein, σχίζειν) and ‘mind’ (phrēn, φρήν),
because, while it is not “possible to find a perfect name for a concept which is
still developing and changing… the ‘splitting’ of different psychic functions is
one of its most important characteristics” (p. 8). In light of schizophrenia’s
role in establishing a psychiatric nosology in which insanity has been divided
into discrete disease entities, featuring a splitting mind, which, like insanity,
once had been regarded as unitary, seems fitting.
Historians of medicine usually attribute the notion that schizophrenia
is irreversible to Kraepelin, often as a way to distinguish him from Bleuler,
but this is backwards.
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In typically careful, measured scientific prose,
Kraepelin notes: “[The] possibility cannot in the present state of our
knowledge be disputed, that a certain number of cases of dementia praecox
attain to complete and permanent recovery, and also the relations to the
period of youth do not appear without exception” (Kraepelin, 1919, p. 4). For
Bleuler, however, a patient's seemingly permanent recovery is almost
certainly illusory:
[Whenever] I have been able to examine any of those who have been
pronounced cured I have found a residue of the illness. The diagnosis
of a cure has often been rash… I know patients whose achievements in
84
As a representative example, Jablensky suggests that “Eugen Bleuler… modified
Kraepelin’s original concept by adding to the scope of dementia praecox clinical illnesses that
did not evolve into a ‘terminal state’ of deterioration” (Jablensky, 2011, p. 4).
280
life have been outstanding… [including] business men who
independently build up large and successful businesses, civil servants,
parsons, a poet and a scholar of international renown. The last of
these had suffered two attacks of catatonia before writing a new
scientific work. It was a pleasure to discuss scientific matters with
him even when he was still suffering from genuine delusional ideas.
But when I finally considered him completely ready to resume work, he
was still making crude logical mistakes when one spoke to him about
the complexes which had played a part in his illness. I would not like
to accept as a genuine cure a state in which some parts of the mental
apparatus are permanently inaccessible to logic… When the disease
process flares up, it is more correct, in my view, to talk in terms of
deteriorating attacks, rather than its recurrence. Of course the term
recurrence is more comforting to the patient and his relatives than the
notion of progressively deteriorating attacks. (Bleuler, 1987, pp. 61–62)
In this passage we glimpse the totalizing character of Bleuler’s
schizophrenia, and the strict criteria with which he evaluates a patient's
sanity. Were a cure effected, the patient no longer make ‘crude logical
mistakes’ relating to some past traumatic event or subject of disordered
reasoning. Bleuler is able to take pleasure in discussing stateoftheart
science with a scholar whom he judges to be acutely psychotic. The final
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insight, that patients are troubled by the likelihood (in his opinion) that
deterioration is inevitable, raises the additional question whether to
prioritize epistemic or therapeutic values, particularly if providing hope and
comfort to a mentally ill patient improves treatment outcomes (Anthony,
1993; Kleinman, Eisenberg, & Good, 1978; Slade, 2010). Kraepelin is
agnostic regarding recovery. Bleuler, however, explicitly excludes the
possibility: “By the term ‘dementia praecox’ or ‘schizophrenia’ we designate a
group of psychoses whose course is at times chronic, at times marked by
intermittent attacks, and which can stop or retrograde at any stage but does
not permit a full restitutio ad integrum” (Bleuler, 1911a, p. 9).
Further, despite a clear nominal discontinuity between ‘schizophrenia’
and ‘dementia praecox,’ Bleuler stresses that they are different labels for the
same fundamental disease entity:
In using the term dementia praecox I would like it to mean what the
creator of the concept meant it to mean. To treat the subject from any
other point of view would serve no purpose, but I would like to
emphasize that Kraepelin’s dementia praecox is not necessarily either
a form of dementia or a disorder of early onset. For this reason, and
because there is no adjective or noun that can be derived from the term
dementia praecox, I am taking the liberty of using the word
schizophrenia to denote Kraepelin’s concept. I believe that the tearing
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apart or splitting of psychic functions is a prominent symptom of the
whole group and I will give my reasons elsewhere. (Bleuler, 1987, p.
59, emphasis in the original)
In other words: I am using the concept in the same way as Kraepelin did,
meaning what he meant, except that he got it entirely wrong and, even
worse, his neologism is not very catchy, so I have given it a new name and
supplied a new meaning. Of course, to some extent this is simply the
inevitable consequence of making sense of a text (for certainly a nosological
category and its accompanying diagnostic criteria constitute a text imbued
with a surplus of meaning ripe for interpretation) by putting it in other
words; as biblical scholar Bart Ehrman has observed, “to read a text is,
necessarily, to change a text” (2005, p. 217). Given Kraepelin’s emphasis on
prognosis, it is interesting that the title of Bleuler’s article is ‘Die prognose
der dementia praecox: Schizophreniegruppe’ (‘The prognosis of dementia
praecox: Group of schizophrenias’): this suggests that the concept of
schizophrenia developed over time just as the course of schizophrenia
develops in an individual case over time. Further, Bleuler uses the plural
‘schizophrenias’ because he does not view schizophrenia “as a disease in the
narrower sense but as a disease group, about analogous with the group of the
organic dementias, which are divided into paresis, senile forms, etc. One
should, therefore, really speak of schizophrenias in the plural” (Bleuler, 1924,
283
p. 373). This move, justified on the grounds that it facilitated newly possible
‘studies of heredity,’ presaged the later notion of schizophrenia spectrum
disorders (e.g., delusional disorder, psychotic depression, schizotypal
personality disorder, schizophreniform disorder, schizoaffective disorder, and
importantly for the next chapter, psychosis risk syndrome).
Today, schizophrenia often misleadingly suggests something akin to
‘multiple personality disorder’ to a lay audience (interpreting ‘splitmind’ to
mean a psyche divided between more than one personality, rather than
psychic functions undergoing a process of splitting).
85
In Bleuler’s time,
however, the name ‘schizophrenia’ hit the right cord as a psychiatric
ideograph (McGee, 1980), containing a powerful combination of precision and
ambiguity:
The term schizophrenia and the idea of a loosening of associations
caught on in part because people thought they knew what was meant
by a loosening of associations but also in part because an adjective
could be made of the term in a way that it couldn’t be made of
dementia praecox. Once coined, words like schizophrenia, neurosis,
85
This misunderstanding is particularly understandable in light of Bleuler’s explanation that
“[it] is not alone in hysteria that one finds an arrangement of different personalities one
succeeding the other; through similar mechanisms schizophrenia produces different
personalities existing side by side” (Bleuler, 1924, p. 134, emphasis in the original German).
this passage has sometimes been construed to claim that Bleuler included multiple
personality disorder within his broader concept of schizophrenia (Rosenbaum, 1980),
Bleuler’s italicization suggests this is a misreading, an argument made most persuasively by
Ian Hacking (1998) in a rather scathing criticism of Rosenbaum’s interpretation of Bleuler’s
work.
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and psychosis can be like harpoons; if they go in they can be very
difficult to get out. On such details can important aspects of the
history of medicine turn. (Healy, 1997, p. 35)
Something about the concept of loosening associations was easy for people to
see in others. Helpfully, Bleuler also incorporated the “imagery and
vocabulary of syphilology… [by writing about] ‘severe cases’ requiring
confinement, and ‘latent cases’ lurking about without the patient realizing
that he is ill” (Szasz, 1976, p. 11). Like other mental disorders of its day, as a
‘disease’ schizophrenia was a working hypothesis that may not meet the
criteria of a unified etiology or pathogenesis. The transformation of dementia
praecox into schizophrenia, however, entailed a subtle but very important
change: No longer fixed as a Kraepelinian provisional natural disease entity,
one could conceive of schizophrenia, like the various ‘clinical forms’ from
which it was constructed, as a clustering of signs and symptoms—that is, as a
syndrome (J. N. Morris, 1978).
Conceptually, Bleuler’s schizophrenia extended Kraepelin’s dementia
praecox fairly faithfully, while simultaneously integrating several important
psychoanalytic ideas about the nature of the illness. Three years after it was
published, Swiss psychiatrist and founder of analytic psychology, Carl Jung,
praised Bleuler's formulation as similar to his own:
It is particularly gratifying to me that a psychiatrist of Bleuler’s
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standing has fully accepted, in his great monograph on the disease, all
the essential points in my work. The chief difference between us is as
to whether the psychological disturbance should be regarded as
primary or secondary in relation to the physiological basis. (Jung,
1960b, p. 155)
Furthermore, Bleuler invokes concepts popularized by Pierre Janet (who, like
Freud, trained under Charcot at Salpêtrière) in order to explain the process
of psychic splitting (‘spaltung’):
In every case, we are confronted with a more or less clearcut splitting
of the psychic functions. If the disease is marked, the personality loses
its unity; at different times different psychic complexes seem to
represent the personality… one set of complexes dominates the
personality for a time, while other groups of ideas or drives are ‘split
off’ and seem either partly or completely impotent… It is the splitting
which gives the peculiar stamp to the entire symptomatology.
However, behind this systematic splitting into definite ideacomplexes,
we have found a previous primary loosening of the associational
structure which can lead to an irregular fragmentation of such solidly
established elements as concrete ideas. The term, schizophrenia,
refers to both kinds of splitting, which often fuse in their effects.
(Bleuler, 1911a, pp. 9, 362)
286
Here, again, the discontinuous gives way to a conceptual continuity, as
Bleuler (loosely?) associates the concept of 'complexes' with fragmented ideas,
and integrates psychodynamic concepts into the Kraepelinian disease
construct. Bleuler appears to have been influenced by Janet’s concept of
désagrégation (dissociation), a fragmentation of the psyche under sharp
affective stress that results in a fixed idea complex (Ellenberger, 1970; Janet
& Raymond, 1903). The term ‘complex,’ of course, is a throwback to a
humoral rhetoric in which disorders of the personality proceed from an
imbalanced complex of vital fluids; in modern times, it first appears in the
work of Karl Kahlbaum’s student, Georg Theodor Ziehen, as ‘gefühlsbetonter
vorstellungskomplex’ (‘emotionallycharged representational complex,’
roughly), and makes its way to Bleuler by way of Carl Jung in 1904 (Freud &
Jung, 1974; Moskowitz & Heim, 2011).
86
Though not introduced with a literal
illustration, Jung metaphorically invokes the inventional power of the image
in scientific discourse in his clearest exposition of the appropriated concept:
What then, scientifically speaking, is a “feelingtoned complex?” It is
the image of a certain psychic situation which is strongly accentuated
emotionally and is, moreover, incompatible with the habitual attitude
of consciousness. This image has a powerful inner coherence, it has its
own wholeness and, in addition, a relatively high degree of autonomy,
86
After his final mental break in 1889, Friedrich Nietzsche became Ziehen’s most famous
patient at the Jena psychiatric hospital (Wilkes, 2000).
287
that it is subject to the control of the conscious mind to only a limited
extent, and therefore behaves like an animated foreign body in the
sphere of consciousness… My findings in regard to complexes
corroborate [a] somewhat disquieting picture of the possibilities of
psychic disintegration, for fundamentally there is no difference in
principle between a fragmentary personality and a complex. They
have all the essential features in common, until we come to the
delicate question of fragmented consciousness. Personality fragments
undoubtedly have their own consciousness, but whether some psychic
fragments as complexes are also capable of a consciousness of their
own is a still unanswered question… We observe… in certain
psychoses… [that] the complexes get “loud” and appear as “voices”
having a thoroughly personal character. Today we can take it as
moderately certain that complexes are in fact “splinter psyches.” The
aetiology of their origin is frequently a socalled trauma, an emotional
shock or some such thing, that splits off a bit of the psyche. Certainly
one of the commonest causes is a moral conflict, which ultimately
derives from the apparent impossibility of affirming the whole of one’s
nature. (Jung, 1960b, pp. 96–98, emphasis in the original)
This explanation parallels Janet’s etiological account of the ‘subconscious
fixed idea’ (Ellenberger, 1970; Van der Hart & Friedman, 1989; Van der Kolk,
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Brown, & Van der Hart, 1989; Van der Kolk & Van der Hart, 1989). Bleuler’s
suggestion that a “loosening of associational structure” is behind the
“splitting into definite ideacomplexes” further parallels Janet’s suggestion
that a “weakening of the synthetic activity of the mind” is behind the mental
weakness of psychasthenia (Bleuler, 1911a, p. 362; Janet, 1930; Janet &
Raymond, 1903; Perry & Laurence, 1984, p. 33).
87
AntiPsychotics and History
The categories of continuity and discontinuity, as we have seen, can be
extended temporally. So far in this chapter, I have presented an historical
account of the development of psychosis. But that account would be
incomplete without considering how history appears within the rhetorical
economy of psychiatry. I therefore now turn to a brief discussion about the
various temporal orientations that the pharmaceutical industry articulated
through its marketing of phenothiazine antipsychotic drugs. The industry
has imagined and reimagined the history of contemporary psychiatry, along
with the temporal course of psychosis as an object of knowledge, in its efforts
to deal with the contradictions of continuity and discontinuity in the late
capitalist marketplace.
87
Psychasthenia, the disease entity Janet is most known for establishing, is to neurasthenia
as Freud’s psychoneurosis is to actual neurosis (Janet & Raymond, 1903). Ellenberger (1970)
argues that Bleuler’s schizophrenia is more or less a “transposition” of Janet’s psychasthenia
(p. 406). Moskowitz & Heim (2011) argue for an even closer affinity, noting parallel key
terms (e.g., ‘lowering,’ ‘leveling,’ ‘weakening,’ and ‘synthesis’) and the features of inherited
premorbid susceptibility and mental weakness resulting in the destruction of an individual’s
ability to restrain and order the more primitive and chaotic elements of the psyche.
289
As a selfreferential epistemic field, scientific legitimation depends in
part on temporal narratives. While progress in science “is widely recognized
as nonlinear,” and, moreover, only “in hindsight does the development [of
knowledge] appear to have the coherence that creates a sense of a linear,
inexorable path,” it is nevertheless the case that scientific discourses tend to
presuppose a linear flow of time (National Research Council, 2006, p. 73).
The arrow of epistemic progress almost always points toward the future (R.
Morris, 1985).
Time is an epistemic category with a social origin that arises from the
rhythms of our social interactions and institutional practices (Durkheim,
2001; Nowotny, 1992; Sorokin & Merton, 1937). The typical argument form
of scientific rhetoric is temporal—one establishes a link to the past by
summarizing the state of relevant knowledge prior to research, then explains
how the findings update that state, and finally suggests the next steps future
research might take (Fahnestock, 2004; C. R. Miller, 1992; Toulmin &
Goodfield, 1965). Furthermore, an epistemic logic that aims at elucidating
causal relationships entails specific temporal commitments. For these
reasons, scientific authority and institutional legitimation are bound up in
narratives that establish temporal ethos (Kisiel, 1997; Lenzo, 1995;
Suchman, 1995).
Specifically, I examine advertisements for these drugs published in
290
medical journals, and I address two complementary but distinct temporal
maneuvers guided by 'pharmaceutical reason' (Lakoff, 2005). First, I present
a series of advertisements by which the figure of the antipsychotic gets
deployed as a framing device that positions psychiatric modernity as a radical
rupture with the primitive past. 'Western psychiatry' made this sudden
break with the discovery of the antipsychotic properties of the phenothiazine
drug chlorpromazine ('Thorazine'). Everything coming before this discovery
was utterly 'primitive' and barbaric. Messages reflecting this move
metonymically use phenothiazine compounds, especially Thorazine, to
represent scientific progress and the birth of pharmaceutical reason. Kendall
(2011) notes that what was identified here was the “beginnings of the new
science of psychiatry... that married the chemists' laboratory with the
psychiatric ward,” adding a cautionary note: “It is easy to miss an important
fact here: this also marks the birth of a new industry” (p. 267).
Second, I examine how those same drugs get positioned temporally
three decades after their discovery, when other newer antipsychotics
complicated attempts to appeal to the stateoftheart. The central claim is
that the medications discovered in the 1950s by the 'pioneers' are timeless
classics that difficult to improve upon. The latter move is, for obvious
reasons, less commonly found in pharmaceutical marketing copy today, but
shows up in the discourses of psychiatrists. Though these two moves are
291
complementary, they are also in tension, as on one hand the emphasis is on
the discontinuous nature of scientific progress and the temporal ruptures it
produced, while on the other, progress seems to have stopped at the
beginning of the new golden era of scientific psychiatry. As pharmaceutical
reason is the “strategic logic... that links chemical intervention to diagnostic
representation according to the norm of disease specificity,” these rhetorical
embodiments of particular attitudes toward history recur in the context of
nosological controversy (Lakoff, 2005, p. 176).
Phenothiazines as the Discontinuous New
In a twopage advertisement for Thorazine (Figure 3.9), one of a
series, the leftpage caption, “Basic tools of Primitive psychiatry,” appears
above photographs of two museum artifacts: a totem from Zaire, “used to
'drive out' an illness,” and a mask from Nigeria that “honors dead ancestors
and enforces the law” (Smith, Kline, & French Laboratories, 1975a, pp. 406–
407). The opposing caption reads: “Basic tool of Western psychiatry,” under
which appears the name “Thorazine,” along with an abbreviated version of
the prescribing information insert for physicians in small print.
292
Source: Advertisement in Hospital & Community Psychiatry (Smith, Kline, &
French Laboratories, 1975a, pp. 406–407).
Figure 3.9: 'Thorazine' compared to totemic objects
293
A similar advertisement (Figure 3.10), part of a different series, for
another phenothiazine antipsychotic, trifluorperazine ('Stelazine'), features a
photograph of a painted mask found in Mexico on the left page (Smith, Kline,
& French Laboratories, 1975b, pp. 329–330). On the opposing page, the
slogan “Lift the Mask of Psychotic Withdrawal” appears above an abbreviated
version of the prescribing information sheet for Stelazine in small print. The
effect is to emphasize the 'transcultural' nature of the illness treated by
Stelazine, while playing on the dissonance between an image of a tribal mask
and the pageantry of modern psychopharmacological science. The
advertisement also illustrates how pharmaceutical reason reconfigured the
category of psychotherapeutic intervention: The audience is told that
“psychotic withdrawal,” treatable with Stelazine, “can make [schizophrenic
patients] inaccessible to therapy.” In this way, administration of an
antipsychotic is both a therapeutic technique and a “disciplinary technology”
which works “on the body, in order to help produce the subject as a speaking
being” (Lakoff, 2005, p. 84).
294
Source: Advertisement in Hospital & Community Psychiatry (Smith, Kline, &
French Laboratories, 1975b, pp. 329–330).
Figure 3.10: Lifting the 'mask' of psychotic withdrawal
295
Another advertisement for Thorazine (Figure 3.11), printed sixteen
years earlier, contains an image from a wood engraving depicting a “surprise
bath,” supposedly “used in colonial times 'to restore the distracted to their
senses'” (Smith, Kline, & French Laboratories, 1959, pp. 52–53). A second
illustration demonstrates how this 'treatment' worked: a lever is pulled,
which results in a presumably mentally ill man falling through a trap door in
the floor into a pool of water. The advertisement explains: “Less than 200
years ago, the mentally ill were bled, purged, beaten, and sometimes nearly
drowned in efforts to restore them to their senses. The treatment of mental
illness has progressed far beyond methods such as these.”
Thorazine is described as a “fundamental drug” and a kind of
“chemotherapy” for mental illness. It owes its significance to both its
unparalleled therapeutic efficacy and its role in “the development of related
drugs which offer the psychiatrist opportunities to help an even greater
number of patients.” This drug that now restores one's senses had been used
only a few years earlier as a general anesthetic, branded as 'Largactil,'
reflecting “initial perceptions of its likely large range of action” (Healy, 1997,
p. 181, emphasis in original). While in this advertisement, Thorazine is still a
general treatment for “mental illness,” it is just a few years from being
understood as a highly specific treatment for schizophrenia (or even more
specifically as a treatment for “psychotic agitation,” as in Figure 3.9).
296
Source: Advertisement in Mental Hospitals (Smith, Kline, & French
Laboratories, 1959, pp. 52–53).
Figure 3.11: 'Thorazine' compared to colonial 'surprise bath'
297
All three of these advertisements show how the pharmaceutical
industry cultivated an attitude toward antipsychotic drugs, the discovery of
which inaugurated an era profoundly discontinuous with psychiatry's archaic
past. Taking advantage of the emphasis in modern science on the linearity of
time, these advertisements exemplify a strategy by which one emphasizes the
novelty of some idea, technique, or product by dissociating it from its
historical antecedents.
88
This strategy is not without its hazards:
Because linear time is sequential and progressive, any ‘cracks’ in the
dissociative strategy, i.e., any lingering continuities between past and
present, may render current issues as outmoded as the history they
echo. That is, associations between past and present may cast the
88
This dissociative strategy is by no means unique to science, or even to the modern world.
St. Paul employed it in his conflict with James, Peter, and the Jerusalem church, concerning
Jewish dietary law and circumcision:
I want you to know, brothers and sisters, that the gospel I preached is not of human
origin. I did not receive it from any man, nor was I taught it; rather, I received it by
revelation from Jesus Christ. For you have heard of my previous way of life... I was
advancing in Judaism beyond many of my own age among my people and was
extremely zealous for the traditions of my fathers. But when God... was pleased to
reveal his Son in me so that I might preach him among the Gentiles, my immediate
response was not to consult any human being. I did not go up to Jerusalem to see
those who were apostles before I was, but I went into Arabia... I assure you before
God that what I am writing you is no lie. (Galatians 1:1120, New International
Version)
Paul establishes ethos by referring to his knowledge of the traditions which he now rejects,
and by emphasizing the novelty of his teaching, insisting, rather vehemently, that he did not
consult anyone who actually met Jesus for years. This break with the past was so radical
that it inspired one of Paul's secondcentury followers, Marcion of Sinope, to proclaim that
the god of the Torah is an evil demiurge, and Jesus (and his one and only apostle, Paul)
revealed the existence of a god who had previously been completely unknown. This in turn,
according to Tyson (2006), led secondcentury protoorthodox Christians to author the Acts of
the Apostles, which explicitly contradicts Paul's claims in his Epistle to the Galatians, quoted
here (see, for example, Acts 9:131). This example illustrates the wide range of the rhetorical
topics of historical continuity, and the discontinuity of ingenium.
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present as retrogressive as the past, rather than coloring the past as
progressive as the present. (Lake, 1991, p. 128)
Fear of the consequences of insufficient temporal dissociation almost led the
group of psychiatrists associated with 'neoKraepelinism' to reject that label:
We didn't like it for a long time. I think we were afraid it would seem
too oldfashioned an idea, even though we insisted that all our
residents read Kraepelin's monographs and emphasized his work with
the medical students. But we were worried that the label didn't point
in the right direction. (Guze, 2000, p. 405, my emphasis)
Similarly, I read the drive to root out lingering psychodynamic diagnoses
(e.g., conversion disorder) from the DSM in light of this concern. Their
presence seems archaic, and since a neuropsychiatric analogue has yet to be
discovered, the only option is to come up with new names.
Pharmaceutical companies faced a similar problem as new medications
accumulated. In the 1950s and early 1960s, psychopharmacologists
discovered an array of extraordinarily effective psychiatric medications. By
and large, the medications discovered since then have not exceeded their
predecessors in efficacy (Healy, 1997, 2004b; Hyman, 2013; N. S. Rose, 2007;
Taylor, 2013). This is not a fact generally highlighted by the pharmaceutical
industry, but it arose in the 1980s in the context of marketing some of the
older drugs.
299
Phenothiazines as the Continuous Old
Three decades after the discovery of the antipsychotic effects of
chlorpromazine, with newer antipsychotics on the market, advertisements for
the older drugs ceased emphasizing the importance of novelty. Marketers
rebranded the same drugs that once had been heralded as a radically
discontinuous break with a hopelessly primitive past as timeless classics.
Two similar advertisements in the American Journal of Psychiatry recast
'Stelazine' as classic, traditional, and perhaps even an historical masterpiece.
In one (Figure 3.12), a photograph showing a bust of Beethoven contains the
text: “Some things are hard to improve upon.” On the opposing page, the
message “'Stelazine' A Classic Antipsychotic” stands above a comparison
between trifluorperazine and Beethoven's Fifth Symphony (Smith, Kline, &
French Laboratories, 1981a, pp. A46–A47). One is tempted to take this as a
highly ironic affirmation of a point made almost four decades earlier by
Horkheimer and Adorno (2002), dismissing the phenomenon of 'metoo'
antipsychotics as a sort of “caricature of style” that contrasts with the
“genuine style of the... great [psychopharmacological] artists... who adopted
style as a rigor to set against the chaotic expression of suffering” (p. 103). An
advertisement (Figure 3.13) appearing a few months later similarly compared
trifluorperazine to Homer's Iliad (Smith, Kline, & French Laboratories,
1981b, pp. A30–A31).
300
Source: Advertisement in the American Journal of Psychiatry (Smith, Kline,
& French Laboratories, 1981a, pp. A46–A47).
Figure 3.12: 'Stelazine' compared to Beethoven's Fifth Symphony
301
Source: Advertisement in the American Journal of Psychiatry (Smith, Kline,
& French Laboratories, 1981b, pp. A30–A31).
Figure 3.13: 'Stelazine' compared to Homer's Iliad
302
Today, with the patents long expired on these drugs, pharmaceutical
companies are much less eager to come to the defense of these canonical
classics of modern medicine. Instead, they now champion the 'atypical' class
of antipsychotics, modeled after the dibenzodiazapine drug clozapine
('Clozaril'), a remarkably effective drug that was relatively less likely to
produce extrapyramidal symptoms (EPS) like tardive dyskinesia, the bane of
patients treated with traditional antipsychotics.
89
Psychiatrists today,
however, sometimes discuss the difficulty in improving on the classic
antipsychotics, as in Michael Taylor's jeremiad against the “malignant
influence of the pharmaceutical industry on the prescribing of psychotropic
agents”:
Another fiction is that medical psychiatric treatments are better today
than they were 40 years ago... The newer antidepressant medications,
mood stabilizers, and antipsychotic agents have no greater efficacy
than the older agents. The secondgeneration TCAs and lithium still
have the best efficacy data and side effect profile... Psychiatrists accept
the promotional fictions of industry and insist that unlike the rest of
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Unfortunately, a different sideeffect led to clozapine's quick withdrawal from the market
in 1975, when eight patients being treated with clozapine in Finland died from
agranulocytosis, a condition in which one's immune system becomes severely compromised
(Kendall, 2011). Clozapine was eventually reintroduced in 1989 in light of its reported
effectiveness in 'atypical' cases of schizophrenia in which the symptoms were “treatment
resistant” (Kane, Honigfeld, Singer, & Meltzer, 1988, p. 789). The emergence of 'treatment
resistance' as a diagnostic category is a clear example of the tendency, under the regime of
pharmaceutical reason, whereby “[illness] comes gradually to be defined in terms of that to
which it 'responds'” (Lakoff, 2005, p. 7).
303
human kind we are not influenced by advertising. We are. (Taylor,
2013, p. 146)
90
Similarly, referring to the genetic categories of 'firstgeneration
antipsychotics' (FGAs) and 'secondgeneration antipsychotics' (SGAs),
Kendall (2011) argues, on the basis of a metaanalysis of 150 studies
comparing antipsychotic drugs, that “there are no consistent differences
between atypicals and typicals, SGAs and FGAs... The story of the atypicals
and the SGAs is not the story of clinical discovery and progress; it is the story
of fabricated classes, money and marketing” (p. 267). His conclusion,
affirming that “they are all just plain antipsychotics,” reinforces the idea that
like, perhaps, epic lyric poetry, some things are just hard to improve upon (p.
268)
The pharmaceutical industry obviously has no need to maintain
consistency in its messaging and, as I noted, the messages do complement
one another in emphasizing the fundamental distinctiveness of the
psychiatric drugs discovered in the 1950s. “Rhetoremes” recirculate through
the historical discourses of pharmaceutical reason, rewriting psychiatry's
relationship with its past (Salazar, 2011, p. 103). Chapter 4 will explore the
negative effects of the temporal dislocation that accompanies the
reconfiguration of diagnostic categories for the controversy over 'psychosis
90
This problem is hardly unique to psychiatry. No pharmaceutical treatment for acute heart
failure developed over the last two decades has decreased mortality (Jauhar, 2014).
304
risk.' These advertisements reveal the ways in which modern psychiatry
views its own historical timeline, and illustrates how the forms of past
appeals can reemerge, presenting rhetorical liabilities and opportunities.
Schizophrenia & Psychosis Today
As the concept of schizophrenia developed over the course of the 20
th
century, it became closely paired with the concept of psychosis. In DSM5, it
appears in the section ‘Schizophrenia Spectrum and Other Psychotic
Disorders’ (American Psychiatric Association, 2012b). Like the DSMIV and
ICD10 classifications, the DSM5 classification of schizophrenia is firmly
within the (neo)Kraepelinian tradition, built upon the concept of the disease
entity, and with the basic assumption that clinical symptoms, longitudinal
course and prognosis, and brain pathology are closely linked. Furthermore,
the modern conceptual understanding of psychosis descends from Erwin
Stransky's notion of intrapsychical discoordination, which Eugen Bleuler
popularized as a loosening of associations within the psyche. Once the will,
emotions, and cognitions of a patient are disconnected in the context of a
‘formal thought disorder,’ the patient is fundamentally disconnected from
reality.
This break with reality is key to the modern understanding of
schizophrenia and psychosis. Bleuler’s formulation of schizophrenia resides
not in the contemporary psychotic disorders so much as in the dissociative
305
disorders, which are characterized by “a disruption in the usually integrated
functions of consciousness, memory, identity, or perception of the
environment” (American Psychiatric Association, 1994, p. 477). Whether by
perceiving objects that do not exist (hallucinations), believing things that are
manifestly false (delusions), speaking so incoherently that meaningful
intersubjective interaction cannot occur (disorganized communication), or
withdrawal from the world in emotion (flat affect) and intention (avolition),
psychosis manifests as a loss of contact with reality. The critical test is
whether an individual maintains ‘reality testing’ procedures. For example, if
a patient hears voices but attempts to verify whether the source is external
(recognizing the possibility that the ‘voices’ are in fact auditory
hallucinations), the patient is not psychotic; if, on the other hand, the patient
cannot be convinced (having ‘delusional conviction’) that his or her
hallucinatory perceptions are unreal, the patient suffers from 'frank
psychosis.'
This modern idea of psychosis is a rearticulation of the ancient idea of
madness. The psychotic patient is out of reach, disconnected from the
objective material world by delusions and perceptual disturbances, from the
intersubjective world by grossly disorganized communication, from the
subjective world by affective flattening and other negative symptoms, and
from the industrialized modern world by severe functional impairments.
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Before Hippocrates, such a disconnection was brought about by divine or
alien intrusion into the human body; for Hippocrates, by an imbalance of
liquids within the body creating a disturbance within the brain; and for
nineteenth and twentiethcentury alienists and psychiatrists influenced by
faculty psychology, by a loosening of intrapsychic associations. Today, the
pathophysiology of psychosis is understood largely as it was in the past,
albeit expressed in the technoscientific language of neurobiology and
materiality. Just as Hippocrates and Galen converted the spiritualized
accounts of disease into physiological ones, modern neurobiologists have done
the same to the older psychodynamic explanations that seemingly have
passed away. Instead of imbalanced humors, we see disturbed
neurotransmission postulated by the dopamine hypothesis (too much
dopamine) and the glutamate hypothesis (not enough glutamate) of
schizophrenia (Laruelle, Kegeles, & AbiDargham, 2003; Moghaddam &
Javitt, 2011; J. M. Stone, Morrison, & Pilowsky, 2007; Swerdlow & Koob,
1987).
91
91
These hypotheses, which I have dramatically oversimplified, are interestingly enough in
part the products of extreme substance abuse. The recognition that overactivity in the
mesolimbic dopaminergic pathway plays a role in psychosis came after observing the
psychosis associated with very large doses of stimulant drugs (e.g., cocaine,
methamphetamine) and certain treatments for Parkinson’s disease (e.g., LDOPA), both of
which facilitate the transmission of dopamine in the central nervous system. This discovery
led to the elucidation of the pharmacological mechanism of chlorpromazine and the other
neuroleptic drugs (namely, antagonism of the D
2
family of dopamine receptors). Neuroleptics,
especially the newer ‘atypical’ class that began with clozapine, also antagonize 5HT
2A
(a
subtype of serotonin) receptors, through which the effects of Lysergic acid diethylamide
(LSD) and psilocybin (the active hallucinogenic ingredient in socalled ‘magic mushrooms’ are
mediated. Likewise, observations of the psychotic states associated with phencyclidine (PCP),
307
As we have come to expect, these hypotheses lend themselves to iconic
representation:
[Molecular] brain processes had become accepted enough to be
represented in conventionalized visual simulations, ...replete with
images simulating the neuronal processes underlying different
pathologies... In Stahl’s iconography, each neurotransmitter is allotted
a distinct icon—norepinephrine, for example is a triangle—and each
receptor is illustrated with a reciprocal icon—in this case a rectangle
with a triangle shape cut out—into which the neurotransmitter fits
like a key into a lock… These powerful and compelling simulations
combine a matteroffact materiality, iconic character, and languid
truthfulness. They also diagram a molecular specificity of different
types of disorder. Once imagined in this way, pathologies can be
illustrated visually as variations from this “normal” state…
Schizophrenia can be…illustrated with a moving image of a synapse
with dopamine molecules jumping across it—clearly an excess of them
in the “schizophrenic brain.” (N. S. Rose, 2007, pp. 200–201)
These illustrations of madness lack any representations of the mentally ill
patient, but reintroduce a human element by anthropomorphizing some of
the molecular elements.
a drug that blocks the NmethylDaspartate (NDMA) glutamate receptors, led to the
glutamate hypothesis of schizophrenia.
308
Stahl’s (2008) illustration of a variant of the glutamate hypothesis
(Figure 3.14) provides a fascinating example of this kind of move. For
reasons that are not entirely clear, walking individuals each holding a sign—
politically ‘radical’ protesters, perhaps—stand in for “toxic free radicals” that
have been “generated in the neurodegenerative process of excitotoxicity”
(Stahl, 2008, p. 442). The “neuroprotective” drug—a “free radical
scavenger”—that comes to the rescue appears to be PacMan’s evil twin, a
yellow spherical monster with sharp teeth and eerie red eyes. The limp
corpse of one activist, still hanging from the jaws of one of these
neuroprotective agents, no longer capable of grasping the sign that has now
fallen to the ground, evidences the effectiveness of this “novel glutamatergic
treatment” supposedly depicted in the scene of carnage. All of this action
takes place presumably on the surface of a neuron, next to a massive
structure apparently representing the NmethylDaspartate (NMDA)
receptor protein and ligandgated ion channel. The small yellow circles
represent the ultimate source of the free radicals: calcium ions (Ca
2+
) flowing
into the neuron. Another illustration (Figure 3.15) signifies this process
whereby “dangerous enzymes... produce troublesome free radicals” (p. 306).
A third depicts a scenario in which free radicals are left unchecked (Figure
3.16). This illustration connects a molecular event to a lesioned neuron,
which is associated with nearby icons representing psychotic symptoms.
309
Figure 3.14: Anthropomorphized disordered molecular brain
processes, illustrated
Source: Illustration in the popular textbook Stahl's Essential
Psychopharmacology: Neuroscientific Basis and Practical Applications
(Stahl, 2008, p. 442).
310
Source: Illustration in the popular textbook Stahl's Essential
Psychopharmacology: Neuroscientific Basis and Practical Applications (Stahl,
2008, p. 306).
Figure 3.15: Illustration of apocalyptic free radical production
311
Source: Illustration in the popular textbook Stahl's Essential
Psychopharmacology: Neuroscientific Basis and Practical Applications (Stahl,
2008, p. 307).
Figure 3.16: Excitotoxicity, cell death, and psychotic symptoms
312
Ideas about the health of the individual and ideas about the health of a
society tend to be closely related, which is why healthrelated metaphors
show up so frequently in sociopolitical discussions. Paradigmatically, in his
Republic, Plato contrasts a ‘healthy’ city with a ‘feverish’ one (Plato, 1997d,
sec. 372e–373a). In Stahl's illustrations, we see the same move in reverse,
with a sociopolitical metaphor showing up in expert biomedical discourse
(specifically, in a technical textbook for medical students, physicians,
psychopharmacologists, and neuroscientists—not a lay audience). Are Stahl's
degenerate ‘radicals,’ walking a picket line or attending a political rally, a
toxic source of madness afflicting our society? The images certainly contain
authoritarian overtones that recall a time when, some believed, psychiatry
stood simply for the involuntarily confinement of social deviants. Other
illustrations in the text suggest that Stahl understands the molecular action
of pharmaceutical agents in disciplinary terms. For example, his icon for
donepezil ('Aricept'), a reversible acetylcholinesterase inhibitor used to
manage the symptoms of Alzheimer's disease, is a straitjacket marked with
the American and Japanese flags (Figure 3.17). The flags, which distinguish
donepezil from the other compounds also iconically reduced to straitjackets,
were presumably chosen because the Japanese pharmaceutical company
Eisai developed the drug, and the Americanbased multinational
pharmaceutical corporation Pfizer marketed it.
313
Source: Illustration in the popular textbook Stahl's Essential
Psychopharmacology: Neuroscientific Basis and Practical Applications (Stahl,
2008, p. 924).
Figure 3.17: Donepezil as molecular straitjacket
314
Just as humoral rhetoric finds contemporary application in the
representations of molecular neurotransmission dysfunction, the residues of
the rhetorical histories of medicine form an epistemic assemblage with
structural magnetic resonance imaging (MRI) technologies, which encourage
researchers to see the brain in terms of deficiencies and excesses of white and
gray matter and in terms of normal or abnormal anatomical structures. The
discursively constructed MRI imagery works to persuade the world that the
psychic ‘lesions’ of schizophrenia take the material form of deficiencies in the
volume of gray matter in the medial temporal lobe, heteromodal association
cortex, and superior temporal gyrus (Falkai, Schmitt, & Cannon, 2011).
Channeling Virchow, these deficits were conceived initially as cellular lesions
(E. C. Johnstone, Frith, Crow, Husband, & Kreel, 1976), but newer
developments in neuroimaging technology, including diffusion tensor imaging
(DTI) and in vivo functional MRI (fMRI), revealed problems with the myelin
or axonal membrane in cortical regions, as well as unusually low white
matter anistrophy, all of which suggested to neuroscientists that the neural
networks of psychotic patients were losing connections between neurons
(Davis et al., 2003; Jafri, Pearlson, Stevens, & Calhoun, 2008; Josin & Liddle,
2001; Kubicki et al., 2007; Vercammen, Knegtering, den Boer, Liemburg, &
Aleman, 2010). With this, a mechanistic physiological account—the
“disconnection hypothesis of schizophrenia”—of schizophrenia's conceptual
315
‘loosening of associations’ was born (Friston, 1998, p. 115).
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Conclusion
Before moving to the next chapter, I shall summarize this chapter's
key findings. First, we examined the enduring presence of old epistemic
models as the field of medicine developed, the first and primary example of
which was humorism. I argue that the humoral model's longevity was not
due to its 'accuracy,' in the positivist sense of enabling one to make falsifiable
predictions. Rather, I explain its success rhetorically. Humorism provided
an architectonic communicative structure to the field of medicine that
infiltrated linguistic structures and other fields of knowledge, effectively used
visual appeals to justify its claims, and was remarkably robust in adapting to
new findings, innovations, and situations through a process of “casuistic
stretching,” that is, “introducing new principles while theoretically remaining
faithful to old principles” (Burke, 1984a, p. 229). This capacity was not
unlimited, and, eventually, the model became so unbalanced that it no longer
was tenable. The modern 'scientific' approaches to medicine displaced the
humoral architectonic. As I argue, humorism survives today in fragmented
hybrid discourses that contribute to the overall polytechtonic rhetoric of
contemporary psychiatric nosology.
One major finding is that a persuasive epistemic model that manages
92
These issues will be discussed further in the next chapter in the context of psychosis risk
syndrome.
316
to stay persuasive from one generation to the next—i.e., that successfully
reproduces itself—does so by spreading through cultural channels, using
figures of speech to travel between contexts and fields. That the humoral
model of pathology was so successful speaks to the persuasiveness of the
rhetorical forms to which it gave rise. By embedding itself in the language of
everyday life, its forms continue to circulate today: when we frame pathology
in terms of imbalance, deficiency, and excess; when we speak of personality
as temperament; when we appeal to synechdochic imagery to communicate
ideas about new disease constructs; when we buy and sell the endless array
of dietary supplements available to the health consumer; when we sip a dry
wine while watching a dark comedy. In these examples we see some of the
substantive ideas of humoral pathology (illness is caused by chemical
imbalance), its ordering structure (health is holistic and continuous), and its
implications (a disordered personality is as much a health issue as a
disordered organ, and moreover, its cause is a disordered organ). It has
infiltrated our language to such a degree that we no longer have any idea
that words like temperature, temperament, and temperate have anything to
do with one another, let alone that they originate in humoral pathology.
As successful as humorism was (and is), it is even more remarkable
that the more mythical understanding of illness that it supplanted also
remains with us today. We refer, for example, to a convulsive episode as a
317
'seizure' even though we do not believe it to be the result of a supernatural
entity taking temporary possession of the body. The transition from this
mythical view to the more 'scientific' humoral model also remains as an ideal.
Yet what remains of the mythical are not merely the fossilized linguistic
remnants of a forgotten age, but an enduring point of contact. Consider, for
example, the history of the dissociative disorders (DD). We have already
examined the rise and fall of animal magnetism, which Mesmer positioned as
a 'scientific' alternative to possession and exorcism. As for the underlying
disorder, it made its way into DSMIII:
With a change in the dominant paradigms for understanding (and
expressing) mental illness, the possession states did not abruptly cease
to exist. Instead, what we now call MPD [multiple personality
disorder] and DDNOS [dissociative disorder not otherwise specified]
began to be described in the literature without a supernatural
explanation... [These] conditions are no more than the secular
expression of the same psychological structures that were found in the
JudeoChristian possession syndromes. MPD is the contemporary
demystified form of an anthropological commonplace. (Kluft, 1993, p.
88)
Noll (2014) suggests that this nosological move constituted an expansion of
“the jurisdictional boundary of 'scientific' psychiatry and [colonization of] the
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supernatural,” but “the blurring of this boundary” that allowed psychiatrists
to claim “superior therapeutic expertise for techniques that had formerly
been the province of magicoreligious practioners (exorcists)... would backfire,
pulling many of them into the rip tide of Satanic panic” (p. 2).
93
This 'Satanic
panic' came in the form of thousands of MPD patients who, through hypnosis,
'recovered' memories of Satanic ritual abuse from their childhood, which they
had 'repressed.' Institutionalizing the diagnosis of MPD did not supplant the
mythical notion that people could be possessed by evil spirits; to the contrary,
it simply created a hybrid scientificsupernatural construct which validated
the mythical idea along with the ensuing moral panic about Satanic cults. As
Allen Frances remarked in a comment on Noll's article on April 3, 2014,
“modern man has acquired remarkable knowledge but is still capable of
remarkably primitive thinking and cruel action.”
94
The early modern transitional period during which humorism lost its
hegemonic grip on medical science began with Thomas Sydenham, who
93
In a very heated reply, Richard Kluft argues: “While Dr. Noll accuses me of promoting the
colonization of the supernatural, an alternative explanation might be that I have studied the
literatures of anthropology and the history of psychiatry to appreciate the wisdom of
understanding DID [Dissociative Identity Disorder] as a secularized expression of possession
syndromes... What Dr. Noll excoriates may be understood, alternatively, as a crosscultural
sensitivity increasingly embraced by our profession” (Kluft, 2014, p. 4). In the same reply,
Kluft makes use of apophasis to respond to what he perceived as personal attacks: “In my
response I will not counterattack Dr. Noll for his egregious and regrettable ad hominem
remarks. Here I will simply state my aversion to attacks against individuals, and my
conviction that they distract from rather than enhance one's argument (p. 3).
94
Frances also explains here that his vocal opposition to DSM5 was partly motivated by
guilt about his failure to use his position as Chair of the DSMIV Task Force to oppose the
satanic ritual abuse false epidemic.
319
popularized quinine as a treatment for malaria, founded the field of
epidemiology, and introduced the ontological concepts of syndrome and
discrete disease entity. Sydenham challenged the prevailing association
between hysteria and the uterus. Equipped with the ontological
interpretation, Sydenham distinguished between symptoms and disease
entities, which led to his insight that hysteria was most likely a mental
illness. Later physicians, who rejected this view, reimagined the illness in
terms of bodily 'vapors.' The vapors became an immensely popular illness in
the eighteenth and nineteenth centuries, and the phenomenon attracted
epidemiological social critique that associated it with gender, sexual
behavior, and social class. Twentiethcentury psychoanalysts reformulated
the disorder again as 'conversion disorder,' an illness in which inner psychic
tension 'converts' into somatic distress. Finally, the DSM5 Somatic Distress
Disorders Work Group (later renamed the Somatic Symptoms Disorders
Work Group) attempted to rebrand the disorder as 'functional neurological
disorder.' Each transition point represents a major shift in substantive
theory and rhetorical form. The DSM5 controversy concerned how
psychiatry should come to terms with these accumulated theories and forms,
rather than any genuinely scientific matter.
Rudolph Virchow's physiological interpretation of pathology helps
explain how hysteria became vaporous. In the wake of major developments
320
in the science of human anatomy down to the cellular level, physiological
pathology represented a backlash against the metaphysical elements of the
ontological interpretation. Similar to humorism, the physiological
interpretation cast pathology as the result of disordered processes in the
body, which often manifested as visible organic lesions. Physicians looked for
physiological damage proximate to the clinical signs and symptoms. Hysteria
causes a wide range of symptoms in every area of body, so the unseen
physiological cause must be something that could move throughout the body
from one organ system to another. Hence, the vapors.
Rudolph Virchow had originally conceived of the physiological
interpretation as an alternative to the ontological interpretation, but by the
end of his career, he argued that the two interpretations were actually
compatible. Therefore, I analyzed the integration of the two terministic
screens, one emphasizing continuity, the other discontinuity. As this strange
discursive permutation came into existence, the influence of faculty
psychology enabled physicians to apply the physiological model
metaphorically to the mind. A greater understand of neuroanatomy partially
undid this metaphor by suggesting disorders of the mind were in fact
disorders of the brain. These developments coincided with the conceptual
transformation of the asylum from a prison to a hospital at the turn of the
nineteenth century. All together, I argue, these antecedents brought the field
321
of psychiatry into existence.
My analysis of psychosis reveals that it does not have a single
rhetorical history, but several. As an object of knowledge, psychosis only
came into existence in late modernity, and only after early psychiatrists
(alienists) realized that they could break down madness into nosological sub
categories. Physicians working in other specialties of medicine (which,
indeed, had only recently acquired multiple specialties) had fairly recently
carried out similar projects in their subfields. The first major systematizing
effort we examined was by Esquirol, who made extensive use of visual
rhetoric to persuade his colleagues that he had identified a useful new way of
'seeing' madness. After Esquirol, the varieties of madness continued to
proliferate. The next major systematizing effort we examined was by
Kraepelin, who joined together several disparate recently identified varieties
of madness into the common diagnosis of dementia praecox, a syndrome
unified by a new pathological category: prognostic course over time.
Psychosis thus was first fragmented into variants that then were re
associated with one another by reference to temporal deterioration. Finally,
Bleuler, focusing on the splitting of intrapsychic associations, rebranded the
quintessential psychotic disorder as schizophrenia.
A striking feature of this development is the blurring of form and
content. A new way of seeing becomes accepted as an innovation if
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knowledge workers in a field are persuaded of its worth. Thus, the
innovative theōria ( ) θεωρία becomes a epistemic stock upon which rhetorical
forms may trade. The microscope enables one to see a cell, but in that image
of the microscopic, the microscope itself is visible. So also with nosologies.
Longitudinal observation of the ill allows one to distinguish one form of
illness from another, but soon the idea of temporal course itself becomes a
category of illness.
The cases in this chapter highlight the importance of visual appeals in
epistemic rhetoric. Esquirol's illustrations of his patients were effective not
because they showed anyone anything about mental illness, but because they
worked enthymematically to suggest that, with the aid of this new epistemic
system, readers could now 'see' a new object of knowledge that had previously
been invisible. Subsequent advocates of nosological models in psychiatry
(including pharmaceutical marketing departments) over the past two
centuries made use of the same rhetorical form. I have provided several
examples of this phenomenon, the occurrence of which is all the more
remarkable because these visual appeals contain no useful scientific
information.
The analyses in this chapter suggest that as new scientific models and
theories develop, they supplement old theories rather than overturn them.
Like humorism, this is true of the modern posthumoral terministic screens
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of pathology, the ontological and physiological interpretations. Within
psychiatric nosologies, this is true of psychodynamic and biomedical
approaches. Each new model that reveals something that had been invisible
provides an enduring set of rhetorical forms through which advocates render
scientific (and pseudoscientific) theories persuasive. In this sense, the
accumulation of these rhetorical residues facilitates communication. But in a
different way, it inhibits communication by introducing incommensurate
objects of knowledge, often sharing a common name. As Lakoff's (2005) study
of psychiatric clinical practices in Argentina demonstrates, this can create
confusion when clinicians with very different nosological orientations come
together to discuss particular cases. By the same token, these points of
confusion also become the seeds of controversy. It is tough to find consensus
when the field teeters between two ends, but the contest gets worse when
aggressive or restrictive judgments are debated as to whether to name new
diseases or rename old ones.
As the next chapter will show, the strategic ambiguity needed to forge
consensus can later result in irresolvable dissensus if the meaning of a key
term remains unclarified. In the case of psychosis risk syndrome, sometimes
researchers will, in the same publication, express two mutually exclusive
understandings of the meaning of risk, a consequence of the etiological
nihilism introduced in DSMIII.
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CHAPTER FOUR: PSYCHOSIS RISK SOCIETY
“Sometimes, in order to see the light, you have to risk the dark.” – Dr. Iris Hineman
95
“[Calumny] and flattery have so prospered with some men, as to have given them the power
of making you believe, that in things of little consequence, as for instance, opthalmies, and
fevers, and intestine complaints, the gods condescend to act as your advisers, and sometimes
even your physicians; but that in matters wherein the interest of the state, and your own
individual security are concerned, these same gods [fail to provide] council... A wise man will
not wait till the earth sends forth vapor, or the atmosphere is infected, if evil comes from
above; but he will perceive such things are at hand, not so soon as the gods, yet sooner than
the generality of men. The gods see what is to come, men what is come, and wise men what
is coming.” – Apollonius of Tyanna
96
“You have to believe in fate—science can compel you to. What then grows out of this belief in
your case—cowardice, resignation, or frankness and magnanimity—bears witness to the soil
upon which that seedcorn has been scattered but not, however, to the seedcorn itself—for out
of this anything and everything can grow.” – Friedrich Nietzsche
97
“With rare exceptions... the natural sciences are content to study, to investigate, to establish
facts. But in our attempts to cope with ambiguity and uncertainty, we create facts... If this is
acceptable, then we must not be judged by the ordinary criteria of science, pure or applied.
We are engaged in a different sort of undertaking—a permanent experiment with risk
taking, a prolonged and loving engagement with uncertainty on behalf of the mentally
disabled. It is a proud and desirable calling. And, if we can contain ourselves comfortably
within its constraints, the world will continue to reward our efforts.” – John Spiegel
98
***
This chapter examines the category of disease as a rhetorical object. It
explores the ways in which defining some state of affairs as a disease or
illness—what I will call a medicalization controversy—motivates action. I
examine the rhetorical maneuvers of interlocutors engaged in a
medicalization controversy, and highlight some problems with the
95
Dr. Iris Hineman is the (fictional) lead researcher of the ‘PreCrime’ technology in the film
Minority Report (Spielberg, 2002).
96
As relayed by Flavius Philostratos (1809, pp. 434, 450).
97
Friedrich Nietzsche (1986, sec. II:363).
98
John Spiegel, discussing the role of risk in psychiatry as a field of practice in his
presidential address at the 128th annual meeting of the American Psychiatric Association
(Spiegel, 1975, p. 697, emphasis in original).
325
evaluations of the argumentation. According to a general deliberative
practice, benefits are weighed against known risks – but what happens when
the benefits are characterized as the management of known risks associated
with inaction, and the particularly dispositive risks of action are important
precisely because they are unknown?
The main controversy under review in this chapter concerns the
proposal to formalize a diagnosis of 'psychosis risk syndrome.' Though the
proposed diagnosis has been incredibly controversial, the idea of diagnosis a
risk syndrome for schizophrenia has been embraced by the mental health
profession, and over 100 clinics devoted to the cause have been set up over
the last decade (Kecmanović, 2011). As a syndrome, it is characterized by a
constellation of signs and symptoms that by their clustering together
suggests a medically relevant morbid unity, an underlying disease process
that can be called by name, with a prognosis that can be speculated on, and,
in an ideal world, that will respond to a specific indicated treatment. As a
risk syndrome, the underlying disease process is not necessarily present, but
its future presence is anticipated on account of the premonitory signs and
symptoms that constitute the syndrome. The very heated public battle over
including psychosis risk syndrome in DSM5 ended in somewhat of a draw, as
the Task Force did include the putative condition (as 'attenuated psychosis
syndrome'), but in a special section for 'conditions for further study,' with the
326
explicit disclaimer that the “proposed criteria sets are not intended for
clinical use” (American Psychiatric Association, 2013, p. 783).
99
I argue that psychosis has always been about risk, and that
schizophrenia is the quintessential psychosis risk syndrome. The diagnosis
of psychosis risk syndrome is an expected development of the schizophrenia
construct that matches with the contemporary societal orientations toward
risk. Further, I suggest that the final consensus about psychosis risk
reflected in DSM5 represents a temporary ceasefire between warring forces,
pausing to consider the possibility that a greater threat exists to the integrity
of psychiatric science. In order to unfold this position I will consider classical
views, indicate the configurations of world risk society, and then show how
the DSM5 becomes a contested space in which this issue is fought in terms of
the inevitability and unpredictability of risk. These moves are divided into
four major sections.
1. Risk in Antiquity and Early Modernity. In order to understand
the controversy about institutionalizing psychosis risk syndrome in DSM5,
we need to investigate how cultural resources were drawn forward from the
99
Though it has been rebranded 'attenuated psychosis syndrome' in DSM5 (Table 1), that
name is rather uncommon in the scientific literature and popular press, owing to its recent
creation. A plurality of the literature refers to the diagnosis as 'psychosis risk syndrome,'
including official sources during the DSM5 early development phase. Consequently, I
(except when noted) stick to 'psychosis risk syndrome' when referring to the diagnosis. The
other neames that are used in the literature to describe this proposed diagnostic category
include 'at risk mental state,' 'risk syndrome for psychosis,' 'ultra high risk state,' and the
'prodromal phase' of schizophrenia.
327
time where fate and commonsense informed judgment to those where risk
was understood as potential opportunity, lurking danger and, later,
calculated probability. In late modern epistemic efforts, risk no longer
measures actual dangers, but sets the parameters of likelihood for
populations. The classic and modern points of view entered into the DSM5
controversy through the distinct interpretations of risk that psychosis risk
syndrome simultaneously signified.
2. Psychiatric Rhetoric in a Risk Society. Preoccupation with risk
is pervasive across our late modern society, which Ulrich Beck (1992b) has
called a risk society. Sociologists use this term to describe a “society
increasingly preoccupied with the future (and also with safety), which
generates the notion of risk” (Giddens, 1999, p. 3). Our society is a risk
society not because there are more risks than there used to be (though there
are), or because the risks we face are of greater magnitude than in former
times and in some cases are existential (though this is the case as well);
rather, risk society is so called because risk as both a logic and an object of
knowledge has become a significant organizing principle of all major
institutions (Beck, 1992a, 1992b, 1999, 2000; Beck, Giddens, & Lash, 1994;
Danisch, 2010; Douglas, 1992; Giddens, 1991, 1999; Keränen, 2008, 2011;
Lash, 2000; Luhmann, 1996, 2005; A. Scott, 2000; Van Loon, 2002). Hence, a
study of risk society may be grounded in any significant modern institution
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(Ericson & Haggerty, 1997). This study of risk society visàvis psychiatry
(and more specifically psychiatric diagnostic controversy) examines “how
forms of rationality inscribe themselves in practices or systems of practices,
and what role they play within them, because... 'practices' don't exist without
a certain regime of rationality” (Foucault, 1991, p. 79). That is, I examine
how risk, as a kind of rationality (or really a cluster of rationalities developed
historically and reproduced discursively), has inscribed itself in the
diagnostic and nosological practices of psychiatry and in the argument
practices of those engaged in controversies concerning those practices. This
section examines a series of related diagnostic controversies (e.g., sluggish
schizophrenia, pedohebephilic disorder, coercive paraphilia) that lurk in the
shadows of psychosis risk.
3. Early Intervention Research. This section examines the
development of early intervention strategies to prevent psychosis. These
efforts occurred concurrently in different nosological frameworks. To a
greater or lesser degree, the various research programs shared three
presuppositions: First, it is possible to identify susceptible individuals
sufficiently early to allow time for intervention; second, it is possible to
develop interventions that in some cases can prevent psychosis from
developing; and third, there is an urgent need for such techniques because of
the irreversible damage that occurs during a first psychotic episode. The
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section begins with an exploration of Freud's views on the importance of early
diagnosis. It then turns to various twentiethcentury nosological moves
designed to better classify the prognosis of psychotic disorders. It then
examines the development of early intervention research programs, and
concludes with the research of Patrick McGorry, a key figure in the DSM5
controversy.
4. Psychosis Risk Syndrome and DSM5. This section introduces
the argumentative landscape of the controversy, identifying its essential
arguments, stasis points, topoi, and tropes, and the ways in which the
rhetorical agency of the key opinion leaders in the dispute is constrained and
enabled. Special attention is paid to how rhetors appeal to different
conceptions of risk. These arguments about risk, particularly those that
compare one risk to another, enabled novel articulations of psychiatric
illness. However, representations of risk did not flow smoothly and
consistently through the public and technical spheres. The accumulated
concepts of risk and ideas about preventive medicine recirculate in the
discourses of psychosis risk. On one hand, the notion of a psychosis prodrome
in individual patients gives a neurobiological form to a hybridization of fate
and danger. On the other, classical phronesis combines with late modern
Bayesian risk factors in a clinical population. Participants in the controversy
weigh the benefits of these interpretations with the costs, which they also
330
articulate in the language of risk. Some of these risks are known dangers
(stigmatization, medication sideeffects), while some are unknown risks about
what the diagnosis will become once it moves from the marketplace of ideas
to the marketplace.
Risk in Antiquity and Early Modernity
In this section, I trace the historical development of risk as an object of
knowledge and as a regime of rationality. I begin by examining notions of
risk or risklike concepts in antiquity and early modernity, following and
updating the traditional account given by Luhmann (2005) and Beck (1992b),
paying special attention to the rhetorical implications of risk. I then turn to
the ways in which these historical antecedents were transformed into the
contemporary object of knowledge and subject of deliberation we understand
as risk, focusing on the ways in which the concept coevolved with the
institution of psychiatry visàvis the diagnostic entity of schizophrenia. In
the process, I discuss the historically controversial diagnosis of 'sluggish
schizophrenia,' and the DSM5 controversies surrounding pedohebephilia,
coercive paraphilia, and parental alienation syndrome. Finally, I turn to the
specific question of preventive psychiatry and the efforts to develop and
legitimize early interventions in psychosis, an idea that slowly evolved into
the notion of psychosis risk syndrome. I situate the controversy over
psychosis risk syndrome that played out over the last halfdecade in the
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larger context of developments and debates in the field stretching back into
the 1980s and before, and I explain the key arguments and their implications
in light of the larger issues of risk society and the rhetorical evolution of
psychosis discussed in the previous chapter.
The history of the concept of risk is closely intertwined with the history
of modernity, yet has only recently appeared as an object of social scientific
inquiry. The development of risk as an object of knowledge serving as a
motivator and product of human action is necessarily intertwined with the
cluster of historical and sociological configurations that have characterized
modernity, e.g., industrialization; secularization; capitalism; the nationstate;
and the emergence, development, and rationalization of institutions that
effect “the regularised control of social relations across indefinite timespace
distances” (Giddens, 1991, p. 16). In this section, I shall examine the pre
modern understanding of risk and contrast it with its modern conception, so
as to highlight the aspects of risk that are distinctive features of modernity.
This analysis will clarify the extent to which the diagnosis of schizophrenia
bears the signature of modernity. Building on the arguments and themes
developed in Chapter 2 and Chapter 3, I contend that the development of
psychosis risk syndrome, and the surrounding controversy, is an artifact of
the development of risk as an object of knowledge that occurred as early
modernity gave way to its more reflexive second stage.
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Risk and Unknown Fate
In an important early study of the sociology of risk, Luhmann
(1993/2005) argues that while humanity has always been concerned about
the uncertain nature of the future, premodern societies tended to
understand the future in terms of fate, over which their control was limited
to divination rituals and practices of piety:
Older civilizations had…no need for a word covering what we now
understand by the term risk… For the most part…one trusted in
divinatory practices, which—although unable to provide reliable
security—nevertheless ensured that a personal decision did not arouse
the ire of the gods or of other awesome powers, but was safeguarded by
contact with the mysterious forces of fate. In many respects the
semantic complex of sin (conduct contravening religious instruction)
also represents a functional equivalent, inasmuch as it can serve to
explain how misfortune comes about. (Luhmann, 2005, p. 8)
Though risk as it is understood in modernity is novel, Giddens (1991) argues
that alternative conceptual variants have been a constant feature of history
and have always been of central importance in human society:
[There] is no nonmodern culture which does not in some sense
incorporate, as a central part of its philosophy, the notions of fate and
destiny. The world is not seen as a directionless swirl of events, in
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which the only ordering agents are natural laws and human beings,
but as having intrinsic form which relates individual life to cosmic
happenings. (p. 109)
In ancient Greek mythology, even the gods were subject to the Moirai
( ), Μοῖραι the Fates, whose name derived from the word moira (μ ), οῖρα
meaning a portion of the whole—the Fates were literally 'apportioners' of the
goods and dangers of life (Grimal, 1996; E. Hamilton, 1940; Harper, 2013).
At the same time, individuals could make decisions that would affect their
destiny, but that destiny would unfold by necessity according to an unknown
but preordained script. Every person was driven toward his fate and
inevitable death by Moros ( ), Μορος the spirit of doom, and the root of the
word 'morose' (Lawson, 1994).
Risk as Dangerous Opportunity
There were two words in ancient Greek that conveyed something akin
to the modern idea of risk: kindynos ( ), κίνδυνος a noun meaning danger,
risk, hazard, or venture, and peiraō ( ) πειράω , a verb meaning to attempt,
endeavor, or try one’s fortune. Though the etymology of κίνδυνος is unclear,
the prefix kin often indicates motion or action (as in the English words
kinetic and cinema), and the root dyn usually means power or force or ability
(as in the English words dynamic and dynamite). In practice, the word had a
dual meaning, with a sense both of danger and of opportunity. Consider the
334
discussion between Glaucon and Socrates in Book V of the Republic,
concerning whether children should be brought to war:
Socrates: …Every animal fights better in the presence of its young.
Glaucon: That’s so. But, Socrates, there’s a considerable danger
[κίνδυνος] that in a defeat—and such things are likely to happen in a
war—they’ll lose their children’s lives as well as their own, making it
impossible for the rest of the city to recover.
Socrates: What you say is true. But do you think that the first thing
we should provide for is the avoidance of all danger [κινδυνεῦσαι]?
Glaucon: Not at all.
Socrates: Well, then, if people will probably have to face some danger
[κινδυνευτέον], shouldn’t it be the sort that will make them better if
they come through it successfully?
Glaucon: Obviously.
Socrates: And do you think that whether or not men who are going to
be warriors observe warfare when they’re still boys makes such a small
difference that it isn’t worth the danger [κινδύνου] of having them do
it?
100
(Plato, 1997d, sec. V.467b–c)
100
[467b] S: . G: . , , μ παρόντωνὧνἂντέκῃ ἔστινοὕτω κίνδυνοςδέ ὦΣώκρατες οὐσ ικρὸς
, μ , σφαλεῖσιν οἷαδὴἐνπολέ ῳφιλεῖ πρὸςἑαυτοῖςπαῖδαςἀπολέσανταςποιῆσαικαὶτὴν
. S: , , . μ ἄλληνπόλινἀδύνατονἀναλαβεῖν ἀληθῆ ἦνδ ἐγώ λέγεις ἀλλὰσὺπρῶτον ὲν
μ ; G: μ . S: ; ἡγῇπαρασκευαστέοντὸ ήποτεκινδυνεῦσαι οὐδα ῶς τίδ εἴπου
, ; G: . [467c] S: κινδυνευτέον οὐκἐνᾧβελτίουςἔσονταικατορθοῦντες δῆλονδή ἀλλὰ
μ μ μ σ ικρὸνοἴειδιαφέρεινκαὶοὐκἄξιονκινδύνουθεωρεῖνἢ ὴτὰπερὶτὸνπόλε ον
μ μ ; παῖδαςτοὺςἄνδραςπολε ικοὺςἐσο ένους
335
In this passage, it is clear that the outcomes of the risk were not as important
as the experience of taking the risk. The future is not predictable, but it will
unfold by necessity as it is so fated. Risk is understood as a kind of action
antithetical to the avoidance of danger.
Likewise, in the Phaedo, Socrates, imprisoned and soon to be executed,
explains to his followers why he did not attempt to escape, arguing that while
suicide is not morally permissible (because no one owns their own body, as it
is the property of the gods), the opportunity to die by someone else's hand is a
risk worth taking. Here Socrates provides the first technical explanation of
his theory of the Forms, after which he sums up his position thusly:
Because of the things we have enunciated, Simmias, one must make
every effort to share in virtue and wisdom in one’s life, for the reward
is beautiful and the hope is great. No sensible man would insist that
these things are as I have described them, but I think it is fitting for a
man to risk [κινδυνεῦσαι] the belief—for the risk [κίνδυνος] is a
noble one—that this, or something like this, is true about our souls and
their dwelling places, since the soul is evidently immortal, and a man
should repeat this to himself as if it were an incantation, which is why
I have been prolonging my tale… Now you, Simmias, Cebes and the
rest of you, Socrates continued, will each take that tragic journey at
some other time, but my fated day calls me now, as a tragic character
336
might say, and it is about time for me to have my bath, for I think it
better to have it before I drink the poison and save the women the
trouble of washing the corpse.
101
(Plato, 1977, sec. 114c–115a)
Even though Socrates’s fate has already been set, his decision to drink the
poison and end his life is a manifestation of his risky belief in the immortality
of his soul. Taking this sort of risk was often signified by the verb πειράω,
probably related etymologically to the Latin word perīculum, meaning
danger, risk; trial, attempt, or test, and both words are likely related to the
English words peril and experiment (Lombroso, 2006; Skeat, 2013;
Traupman, 1966).
Risk and Fortune
Another ancient view of risk, fortune, united the ideas of risk as an
unknown fate and as a dangerous opportunity. With the future largely in the
hands of the goddess Fortuna (in Roman antiquity), the ‘unpredictable’
chance element of events was projected externally, so that human decision
making was largely a matter of prūdentia:
101
[114c] ἀλλὰ τούτων δὴ ἕνεκα χρὴ ὧν μ , διεληλύθα εν ὦ μμ , Σι ία πᾶν ποιεῖν ὥστε
ἀρετῆς καὶ φρονήσεως ἐν τῷ βίῳ μ : ετασχεῖν καλὸν γὰρ τὸ ἆθλον καὶ ἡ ἐλπὶς μ . εγάλη
[114d] τὸ μὲν οὖν ταῦτα διισχυρίσασθαι οὕτως ἔχειν ὡς ἐγὼ , διελήλυθα οὐ πρέπει
νοῦν ἔχοντι : ἀνδρί ὅτι μέντοι ἢ ταῦτ᾽ ἐστὶν ἢ τοιαῦτ᾽ ἄττα περὶ τὰς ψυχὰς μ ἡ ῶν καὶ
τὰς , οἰκήσεις ἐπείπερ ἀθάνατόν γε ἡ ψυχὴ φαίνεται , οὖσα τοῦτο καὶ πρέπειν μοι δοκεῖ
καὶ ἄξιον κινδυνεῦσαι μ οἰο ένῳ οὕτως ἔχειν—καλὸς γὰρ ὁ κίνδυνος—καὶ χρὴ τὰ
τοιαῦτα ὥσπερ ἐπᾴδειν , ἑαυτῷ διὸ δὴ ἔγωγε καὶ πάλαι μηκύνω τὸν μ ... ῦθον [115a]
μ ὑ εῖς μὲν , οὖν , ἔφη ὦ μμ Σι ία τε καὶ Κέβης καὶ οἱ , ἄλλοι εἰς αὖθις ἔν τινι χρόνῳ ἕκαστοι
: πορεύσεσθε μ ἐ ὲ δὲ νῦν ἤδη , καλεῖ φαίη ἂν ἀνὴρ , τραγικός ἡ μ μ , εἱ αρ ένη καὶ σχεδόν τί
μοι ὥρα τραπέσθαι πρὸς τὸ : λουτρόν δοκεῖ γὰρ δὴ βέλτιον εἶναι μ λουσά ενον πιεῖν τὸ
μ φάρ ακον καὶ μὴ μ πράγ ατα ταῖς γυναιξὶ παρέχειν νεκρὸν . λούειν
337
An increasing risk awareness apparently became neutralized by
attributing possible future successes and damages to an external
source… [which] explained, albeit in a metaphorical way, the
unpredictability of events and the unforeseeable choice between good
and bad outcomes. External attribution protected the decision maker
from responsibility in the field of future contingencies. Prudence was
viewed as the capacity of humans (as distinct from animals) to choose
between reasonable expectations, contingent on the actions of other
people. So prudence, not risk, was the term for the capability to cope
with temporal and social contingencies. (Luhmann, 1996, p. 3)
The approach to risk called for practical wisdom, using prudence (phronēsis,
φρόνησις) and selfcontrol (sōphrosynē, ; literally, 'healthy σωφροσύνη
mindedness')
102
in the ‘right way’ (eukairos, εὔκαιρος), and the apprehension
of kairos (καιρός), i.e., the supreme moment of opportunity in a situation, a
concept of particular importance to rhetoricians. Thus, with the two concepts
of prudence and Fortune, it was possible to attribute responsibility for the
outcome of uncertain events either internally or externally, respectively.
102
The word is notoriously difficult to translate; Plato σωφροσύνη (1997a) wrote an entire
dialogue in which Socrates and Plato's uncle Charmides (one of the notorious Thirty Tyrants)
attempt to figure out the exact meaning of the word; Socrates in the end thinks it is
something closer to 'selfknowledge' or 'selfpossession' than to 'moderation' or 'temperance,'
but the issue is never fully resolved. It was one of the four cardinal Greek virtues, along
with prudence (phronēsis, ), righteousness ( φρόνησις dikaiosunē, ), and piety δικαιοσύνη
(eusebia, – the root εὐσέβεια seb refers to a frightful danger, because the original sense of
piety was fear of the gods), all of which were important topics of rhetoric during the Second
Sophistic (Winter, 1997).
338
One rhetorician in particular who embraced these concepts was the
sophist Isocrates. In the Panathenaicus, Isocrates advanced a populist
approach to practical wisdom:
[Those] who excel in arts [tas technas, τὰς ] τέχνας , in sciences [tas
epistēmas, τὰς μ ] ἐπιστή ας , and in specialized abilities [dynameis,
μ δυνά εις]…[for the most part] do not manage their own affairs well,
are intolerable at private gatherings, have contempt for the opinions of
their fellow citizens, and are filled with many other serious faults…
Whom then do I call educated, since I exclude those in the arts…and
sciences…and [specialties]? …[Those] who manage well the daily
affairs of their lives and can form an accurate judgment [doxan,
δόξαν] about a situation [kairōn, καιρῶν] and in most cases can figure
out [stochazesthai, στοχάζεσθαι] what is the best course of action [tou
sympherontos, τοῦ μ συ φέροντος]… [as well as] those who are not
corrupted by their good fortune, do not abandon their true selves, or
become arrogant, but on the contrary, remain in the ranks of those
with good sense and do not rejoice more in the successes that come to
them by chance than in those that come through their own nature and
good sense [phronimous, μ ] φρονί ους .
103
(Isocrates, 2004b, sec. 29–32)
103
In this passage I have replaced the transliterated Greek words in parentheses back to
their original form, in a few cases correcting errors in the rendering of the word (e.g., doxan
for doxa, technas for techne, etc.) in the (otherwise acceptable) translated text.
339
There is a clear ethical dimension in one’s relationship with kismet, a sense
that the prudent man who exercises good sense in the face of uncertainty is
also a man of virtue. This is even more explicit in Nicocles, in which
Isocrates suggests that moral vice is inherently dangerous:
Understand that the unjust acquisition of property will not make you
rich but will put you at risk [κίνδυνον]. Do not think that taking is a
profit, and losing is a penalty. Neither of these always has the same
effect, but whichever of these should occur at the right moment
[καιρός] and with virtue benefits those who do it. (Isocrates, 2000,
sec. 50)
Similarly, in Archidamus, Isocrates connects this ethical component with
pragmatism, contending that neither “war or peace is entirely bad or good,
but how each one turns out must always depend on how someone makes use
of the situation [pragmata, μ πράγ ατα] and the opportunities [kairoi, καιρόι]
it presents” (Isocrates, 2004a, sec. 50). In all these cases, the human
decisionmaking element is understood in relation to the externalized and
uncontrollable whims of fate:
[Choosing] the propitious moment was entrusted to intuition, but was
also subject to rational decision making. Neither too early nor too late,
now or never – this pattern of thinking was applied in an effort to cope
with risk situations. And Fortuna had to help, but could also refuse or
340
only pretend to do so. She appeared only in close association with
Virtus, aiding and encouraging the diligent. Closely related thereto we
find warnings against carelessness and foolhardiness, against a
demonstrative use of courage and force incommensurate with the
situation. (Luhmann, 2005, p. 150)
For the most part, the outcomes of dangerous and unpredictable situations
was a matter of good fortune or bad fortune—the only thing that human
actors had complete control over was the ethicality of their responses,
understood in very practical terms.
Risk as the Management of Uncertainty
In a world of uncertainty, the ancient art of risk management was
rhetoric. This view can be seen in the thought of Philo of Alexandria, a
Hellenistic Jewish philosopher who engaged in many debates with the
sophists of his day, and who serves as our best firstcentury CE witness to
the emerging Second Sophistic period (Winter, 1997). Philo developed an
Isocratean view of rhetoric, prudence, and wisdom, in what I might playfully
call a protoFreudian direction. In his commentary on the Patriarch Joseph
(one of the twelve sons of Jacob/Israel, whose story, involving the
interpretation of several dreams, features prominently in the Book of
Genesis), Philo describes the art of rhetoric as being akin to the
interpretation of the dreams of the awake:
341
And men awake too, who, as far as the uncertain character of their
comprehension goes, are in no respect different from people asleep,
deceiving themselves, think themselves competent to contemplate the
nature of things with reasoning powers which cannot err... Since, then,
life is full of all this irregularity, and confusion, and indistinctness, it
is necessary... [to] approach the science of the interpretation of dreams,
so as to understand the dreams and visions which appear by day,
...being guided by probable conjectures and rational probabilities, and
in this way [the rhetor] must explain each separate one, and show that
such and such a thing is honourable, another disgraceful, that this is
good or that is bad; that this thing is just, that thing is on the contrary
unjust; and so on in the same way with respect to prudence, and
courage, and piety, and holiness, and expediency, and usefulness; and
in like manner of the opposite things, with respect to what was not
useful nor reasonable, what was ignoble, impious, unholy, inexpedient,
pernicious, and selfish. (Philo, 1993, pp. 446–447)
Though psychoanalytic approaches (particularly those of a Lacanian flavor)
to rhetorical studies have become popular recently (Lundberg, 2012), Philo
seems to have anticipated this development 2000 years in advance. The
management of uncertainty through the pursuit of rational probabilities is a
notion at the heart of the concept of risk as it emerged at the beginning of
342
modernity.
The modern term ‘risk’ appeared as a neologism at some point during
the transition from the Middle Ages to the early modern period. The Oxford
English Dictionary (“Risk,” 2012) provides a couple of possible etymological
histories of the English word ‘risk.’ Though noting that this theory is poorly
supported by documentary evidence, the OED suggests that the postclassical
Latin noun resicum, risicum, riscus may be derived from the classical Latin
verb for cutting (resecō, resecāre, resectum) suggesting a meaning of rock,
crag, or reef, drawing a connection to the thirteenthcentury Spanish noun el
risco, which means ‘the reef, the shallows, the cliff, the rock.’ Luhmann
suggests that in “the Middle Ages the term risicum was used in highly
specific contexts, above all sea trade and its ensuing legal problems in cases
of losses or damages” (Luhmann, 1996, p. 3). Reefs certainly posed a serious
hazard to the seafaring, and Luhmann notes that “maritime insurance is an
early instance of planned risk control” (1993/2005, p. 9).
The enduring association of risk with the reef can be seen in Figure
4.1, an advertisement by Janssen Pharmaceuticals appearing in Psychiatric
News that warns of the “serious consequences” posed by the “hidden danger”
of “partial compliance” to antipsychotic medication in schizophrenia.
343
Figure 4.1: The risk of medication noncompliance as iceberg (reef)
Source: Advertisement in Psychiatric News (Janssen Pharmaceuticals, 2006).
344
A list of risk factors for this behavior are provided, including “delusional
ideas or beliefs, such as thinking the medication is poison” and “a tendency to
discontinue medication when feeling better.” This specific kind of risk
representation is discussed in at length later in this chapter.
Slowly, from the beginning of the sixteenth century, the use of the
term risk diffused into other contexts like politics and religion, as in Pascal’s
wager (Reith, 1999). In one of the earliest works of modern political
philosophy, Machiavelli argued that “it may be true that fortune is the ruler
of half our actions, but... she allows the other half or a little less to be
governed by us” (Machiavelli, 1903, p. 99). The significance of the neologism
for Luhmann is that it marks a change in thought, a new discursive or
rhetorical motive that was unfulfilled by existing words: “we may assume
that a new term comes into use to indicate a problem situation that cannot be
expressed precisely enough with the vocabulary available” (Luhmann, 2005,
p. 10).
Though an understanding of risk is a central component of the
configuration of knowledge that characterizes a period of human history, the
ancient world was not quite as monolithic in its approach to risk as the
sociologists of risk make it out to be (e.g., Eidinow, 2007; Luhmann, 2005). In
the history of medicine, there are frequently efforts to read the present into
the past, especially in psychiatry—the differences between the modern ideas
345
of bipolar disorder and major depressive disorder and the ancient notions of
melancholia and mania are much larger than they are often portrayed
(Healy, 1997, 2008). With risk, the opposite phenomenon exists: Rather than
emphasize a supposed continuity with the past, the stress is on the putative
uniqueness of the present. Neither approach is, strictly speaking, incorrect,
insofar as one is interested in accurately representing some historical set of
facts. These kinds of comparisons between some present object of knowledge
and its historical counterpart, in which one’s central purpose is to represent
the past as especially similar or dissimilar to the present, are less about
establishing historical truths than about cultivating an attitude about the
object in its current form.
With respect to our selfunderstanding of risk in late modernity, the
characterization of its historical antecedents as radically different from its
present form enacts a basic feature of modern risk, which
reverses the relationship of past, present, and future. The past loses
its power to determine the present. Its place as the cause of present
day experience and action is taken by the future, that is to say,
something nonexistent, constructed and fictitious. (Beck, 1999, p. 137)
With respect to early intervention for psychosis, we will see the temporal
inversion of modernity manifest in several ways. One of these is the belief,
constantly expressed over a fiftyyear period, that preventive research has
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about a fifteenyear history. Another is the confused conceptual slippage
between a prodrome (in which present symptoms help establish the probable
existence of a disease process initiated in the past) and a risk syndrome (in
which present symptoms establish the probable existence of a disease state
that will emerge in the future). I shall discuss these issues in depth shortly.
Though there is certainly some basis in fact for the argument that risk
as an object of knowledge has fundamentally changed over time, some
aspects that we tend to regard as novel are traceable to a premodern era.
The closest example from Greek antiquity of the modern concept of risk can
be found in Xenophon’s last work, Ways and Means, written about 50 years
after Plato penned his final dialogue. Xenophon—like Plato, a student of
Socrates—was writing in the context of a Greek (specifically Athenian) fiscal
crisis. In Ways and Means, Xenophon outlines his plan to restore prosperity
to the citystate. In Book IV, Xenophon discusses the possibility of managing
the risks entailed in digging new silver mines:
[27]…It is as possible now to open new veins as in former times. Nor
can one say with any certainty whether the ore is more plentiful in the
area already under work or in the unexplored tracts. [28] Then why, it
may be asked, are fewer new cuttings made nowadays than formerly?
Simply because those interested in the mines are poorer. For
operations have only lately been resumed, and a man who makes a
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new cutting incurs a serious risk [κίνδυνος δὲ μέγας]. If he strikes
good stuff he makes a fortune; but if he is [29] disappointed, he loses
[ἀπόλλυσιν]
104
the money he has spent. Therefore people nowadays
are very chary of taking such a risk [κίνδυνον].
105
[30] However, I
think I can meet this difficulty too, and suggest a plan that will make
the opening of new cuttings a perfectly safe undertaking. The
Athenians, of course, are divided into ten tribes. Now assume that the
state were to offer each tribe an equal number of slaves, and that when
new cuttings were made, the tribes were to pool their luck
[ μ κοινωσά εναι τὴν τύχην].
106
[31] The result would be that if one
tribe found silver, the discovery would be profitable to all; and if two,
three, four, or half the tribes found, the profits from these works would
obviously be greater. Nothing that has happened in the past makes it
probable [ἐοικός] that all would fail to find. [32] Of course, private
individuals also are able to combine on this principle and pool their
fortunes [ μ κοινου ένους τὴν τύχην] in order to diminish the risk
104
ἀπόλλυσιν is the third person singular indicative active voice of μ ἀπόλλυ ι, which means
‘to destroy/ruin/lose utterly.’
105
An alternate translation of this sentence reads: “This consideration chiefly has
discouraged the adventurers from trying so dangerous an experiment” (Xenophon, 1855, p.
687).
106
μ Κοινωσά εναι is the middle voice aorist participle of κοινόω, which in the active voice
infinitive means ‘to make common’ or ‘to communicate.’ In the middle voice, it means ‘to
communicate one to another,’ ‘to put into communication with one another,’ or, when paired
with a noun in the accusative case as in this passage, ‘to take part or share in.’ This is the
only extant instance of μ κοινωσά εναι that I could find in the Perseus digital database of
classical texts (Crane & Department of the Classics, Tufts University, 2013).
348
[κινδυνεύειν]. Nevertheless there is no reason to fear [φοβεῖσθε] that
a public company formed on this plan will conflict with the interests of
private persons, or be hampered by them.
107
(Xenophon, 1925, sec.
4.27–32)
Here, we have an understanding of risk that is caused by human action—
indeed, human action undertaken in order to remedy the damage caused by a
previous collective human endeavor, the (second) Peloponnesian War. The
risk is somewhat catastrophic, though only primarily catastrophic to the poor
individuals who dig but fail to find silver, the indirect effect is to perpetuate
the poor economic conditions from which all Athenians were suffering. It is
also manageable through good governance, and understood as a function of
probability (though the word translated as probable, ἐοικός, means
something closer to ‘seeming’ than the modern concept of probability, which
had yet to be created). The final argument almost seems to anticipate an
107
[27] καὶ μὴν μ καινοτο εῖν γε οὐδὲν ἧττον ἔξεστι νῦν ἢ . πρότερον οὐ τοίνυν οὐδ᾽
εἰπεῖν ἂν ἔχοι εἰδὼς οὐδεὶς πότερον ἐν τοῖς μ μ κατατετ η ένοις πλείων ἀργυρῖτις ἢ ἐν
τοῖς μ ἀτ ήτοις . ἐστί [28] τί , δῆτα φαίη ἄν , τις οὐ καὶ , νῦν ὥσπερ μ , ἔ προσθεν πολλοὶ
μ ; καινοτο οῦσιν ὅτι πενέστεροι μὲν νῦν εἰσιν οἱ περὶ τὰ μ : έταλλα νεωστὶ γὰρ πάλιν
: κατασκευάζονται κίνδυνος δὲ μέγας τῷ μ : καινοτο οῦντι [29] ὁ μὲν γὰρ εὑρὼν ἀγαθὴν
ἐργασίαν πλούσιος , γίγνεται ὁ δὲ μὴ εὑρὼν πάντα ἀπόλλυσιν ὅσα ἂν . δαπανήσῃ εἰς
τοῦτον οὖν τὸν κίνδυνον οὐ μάλα πως ἐθέλουσιν οἱ νῦν . ἰέναι [30] ἐγὼ μέντοι ἔχειν μοι
δοκῶ καὶ περὶ τούτου μ συ βουλεῦσαι ὡς ἂν ἀσφαλέστατα μ . καινοτο οῖτο εἰσὶ μὲν γὰρ
δήπου Ἀθηναίων δέκα : φυλαί εἰ δ᾽ ἡ πόλις δοίη ἑκάστῃ αὐτῶν ἴσα , ἀνδράποδα αἱ δὲ
μ κοινωσά εναι τὴν τύχην μ , καινοτο οῖεν οὕτως , ἄν εἰ μία , εὕροι [31] πάσαις ἂν
λυσιτελὲς , ἀποδείξειεν εἰ δὲ δύο ἢ τρεῖς ἢ τέτταρες ἢ αἱ μ ἡ ίσειαι , εὕροιεν δῆλον ὅτι
ἔτι λυσιτελέστερα ἂν τὰ ἔργα ταῦτα . γίγνοιτο τό γε μὴν πάσας ἀποτυχεῖν οὐδενὶ τῶν
παρεληλυθότων . ἐοικός [32] οἷόν τε δὴ οὕτως καὶ ἰδιώτας μ συνιστα ένους καὶ
μ κοινου ένους τὴν τύχην ἀσφαλέστερον . κινδυνεύειν μηδὲ μέντοι τοῦτο , φοβεῖσθε ὡς
ἢ τὸ μ δη όσιον οὕτω μ κατασκευαζό ενον παραλυπήσει τοὺς ἰδιώτας ἢ οἱ ἰδιῶται τὸ
μ : δη όσιον
349
objection that a modern day Tea Partier might put forth. This is, as far as I
can tell, the closest the ancient world gets to a modern idea of risk.
Still, even if this example were representative (to the contrary, it
seems to be uniquely ahead of its time), the place and function of risk in the
social lifeworld, in everyday discourse and in more formalized deliberative or
forensic rhetorical contexts, has developed quite a bit over time. Though
noting the importance of kairos for recent events in world history—
Chernobyl, German reunification, Austria’s 1914 ultimatum to Serbia—
Luhmann contends that kairos is no longer the focal point of the relationship
between risk and society:
The assumption that choosing the propitious moment averts risk
nowadays nevertheless lost all justification… [Any] attempt to decide
rationally takes time, and thus entails the risk of letting favorable
opportunities go by or of missing the last chance to prevent inevitable
developments. No one believes any longer that time itself designates
favorable points in time. And when the spouse of an American
president seeks astrological advice, this is noted with astonishment
and displeasure by all. The choice of a propitious moment for a risk
decision has itself become a risky decision. (Luhmann, 2005, p. 151)
This change stems from a more totalizing conception of risk as the concept
transitioned from a predicate of human action to an object of human action.
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A risk is not something that one decides to experience or not, but rather
something that must be managed. The management (or mismanagement) of
risk occurs through both action and inaction. Risk cannot be eliminated
through caution, for “the cautious man, when it is time to act suddenly, does
not know how to do so and is consequently ruined; for if one could change
one's nature with time and circumstances, fortune would never change”
(Machiavelli, 1903, p. 101).
108
This presaged the late modern view that both
action and inaction entail risks, and moreover risks are largely the
consequence of prior human decisions.
In the early stages of modernity, it was assumed that with greater
knowledge concerning the mastery of nature, humans could precisely control
the future. The human subject, as selfidentical and selfcertain, was
grounded in a sort of personal confidence, and as rational and sovereign,
could project that confidence into the future by acting deliberately after
careful study (René Descartes, 1997). The world of early modernity had no
room for chance (Hacking, 1975).
Though determinism as fate was rejected by Machiavelli as a
constraint on human agency, in the early nineteenth century this radical
108
Using a bizarrely misogynistic metaphor, Machiavelli argues that instead of facing the
goddess of fortune with caution, one should rape her (because that's how women want to be
treated): “I certainly think that it is better to be impetuous than cautious, for fortune is a
woman, and it is necessary, if you wish to master her, to conquer her by force; and it can be
seen that she lets herself be overcome by these rather than by those who proceed coldly. And
therefore, like a woman, she is a friend to the young, because they are less cautious, fiercer,
and master her with greater audacity” (p. 102).
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denial of chance developed into a return of an extreme form of determinism,
posited as a fundamental feature of the universe:
All events, even those which on account of their insignificance do not
seem to follow the great laws of nature, are a result of it just as
necessarily as the revolutions of the sun. In ignorance of the ties
which unite such events to the entire system of the universe, they have
been made to depend upon final causes or upon hazard, according as
they occur and are repeated with regularity, or appear without regard
to order; but these imaginary causes have gradually receded with the
widening bounds of knowledge and disappear entirely before sound
philosophy, which sees in them only the expression of our ignorance of
the true causes... We ought then to regard the present state of the
universe as the effect of its anterior state and as the cause of the one
which is to follow. Given for one instant an intelligence which could
comprehend all the forces by which nature is animated and the
respective situation of the beings who compose it—an intelligence
sufficiently vast to submit these data to analysis—it would embrace in
the same formula the movements of the greatest bodies of the universe
and those of the lightest atom; for it, nothing would be uncertain and
the future, as the past, would be present to its eyes. (Laplace,
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1814/1902, pp. 3–4)
109
This intelligence, which came to be known as Laplace's Demon, was based on
the assumption in classical mechanics that all particles have a defined
position and velocity. Though humanity could never achieve the omniscience
of Laplace's Demon, uncertainty could be minimized and calculated precisely
through the emerging discipline of mathematics known as probability
(Crombie, 1994; Daston, 1988; Gigerenzer et al., 1989; Hacking, 1975, 1990;
Hald, 2005; Krüger, Daston, & Heidelberger, 1990; Prior, Glasner, &
McNally, 2000). Omniscient but not immortal, Laplace's Demon was led to
its doom by the developments of thermodynamics in the nineteenth century
and quantum mechanics in the twentieth century (Ulanowicz, 1986).
With Werner Heisenberg's famous uncertainty principle, uncertainty
moved from the realm of epistemology to ontology, as imprecision
(ungenauigkeit) was built into the very fabric of the universe. In this, the
science of probability was strengthened, as what was once merely calculated
ignorance joined what medieval philosophers had called the praedicamenta,
i.e., Aristotle's categories of being. This transition produced some conceptual
109
Though quite possibly apocryphal, there is an often cited exchange between PierreSimon
Laplace and Napoleon in which the latter asked about the Laplace's failure to mention God
in his most recent book on astronomy. Laplace had no more need for God than he did for
chance, and accordingly is said to have bluntly replied: “Je n'avais pas besoin de cette
hypothèselà” (“I had no need for that hypothesis there”). Napoleon, rather amused by this
line, relayed it to the Italian astronomer JosephLouis Lagrange, who replied “Ah! c'est une
belle hypothèse; ça explique beaucoup de choses!” (“Ah! [But] it is a beautiful hypothesis that
explains so many things!”) (Ball, 1888, p. 388). The same could be said, perhaps, for chance
in the physical sciences and for risk in the social sciences.
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confusion that is a source of miscommunication in the debate about psychosis
risk syndrome. Is the diagnosis epistemic, a prediction of future pathology,
or is it metaphysical, a pathological state characterized by its potential to
progress to psychosis? I shall take up this question shortly; for now, it is
enough to observe that the answer depends on the extent to which the events
of the future are thought to be preordained.
Psychiatric Rhetoric in a Risk Society
With this background, I now turn to risk in late modernity, and the
rhetorical climate in which the concepts of dementia praecox, schizophrenia,
and psychosis emerged and developed. The concept of dementia praecox was
born during the nineteenth century within a risk climate that was focused on
degeneracy. It then developed into schizophrenia during the epoch of mental
hygiene and eugenics, and adopted its modern form during the era of
preventive medicine. The rhetoric of risk during these periods profoundly
influenced the development of the concept.
The grandiosity of early modern science was radical, but its expression
was an echo of antiquity, which gave way as modernity matured. The idea of
“providential reason,” according to which increasing human knowledge
enhances and safeguards the human experience,
carries residues of conceptions of fate deriving from premodern eras.
Notions of fate may of course have a sombre cast, but they always
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imply that a course of events is in some way preordained... To accept
risk as risk, an orientation which is more or less forced on us by the
abstract systems of modernity, is to acknowledge that no aspects of our
activities follow a predestined course, and all are open to contingent
happenings. In this sense it is quite accurate to characterise
modernity, as Ulrich Beck does, as a 'risk society,' a phrase which
refers to more than just the fact that modern social life introduces new
forms of danger which humanity has to face. Living in the 'risk society'
means living with a calculative attitude to the open possibilities of
action, positive and negative, with which, as individuals and globally,
we are confronted in a continuous way in our contemporary social
existence. (Giddens, 1991, p. 28)
The emergence of this late modern risk society is closely tied to developments
in the practice of medicine (especially psychiatry), and the shifting meaning
over the last 150 years of risk, from dangerous predisposition within an
individual subject to a probabilistic risk factor within a population. The
concept of 'risk' in classical psychiatry referred to “the danger embodied in
the mentally ill person capable of violent and unpredictable action,” a danger
that implies “at once the affirmation of a quality immanent to the subject (he
or she is dangerous), and a mere probability, a quantum of uncertainty, given
that the proof of danger can only be provided for after the fact” (Castel, 1991,
355
p. 283).
Risks of Modernity: Degeneracy and the Rise of Hygiene
The concept of predisposition that emerged in the late eighteenth
century referred to “an inherited taint or flaw that would, in the right (or
wrong) circumstances, manifest itself in illness or pathology,” and became
especially popular in the psychiatric imaginary by the midnineteenth
century, when “all manner of problems of social pathology and danger
became understood in terms of degeneracy” (N. S. Rose, 2007, pp. 18–19). A
predisposition to insanity was a latent material dangerousness subsisting in
the body, and during the first half of the nineteenth century, preventive
psychiatry entailed such drastic measures as confinement and/or sterilization
on the grounds of public safety, for “all insane persons, even those who
appear calm, carry a threat, but one whose realization still remains a matter
of chance” (Castel, 1991, p. 283).
Eventually facing practical limitations on their ability to confine the
dangerous, during the second half of the nineteenth century, psychiatrists
shifted their preventive efforts toward the promotion of 'mental hygiene,'
defined as
...the art of preserving the mind against all incidents and influences
calculated to deteriorate its qualities, impair its energies, or derange
its movements. The management of the bodily powers in regard to
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exercise, rest, food, clothing and climate, the laws of breeding, the
government of the passions, the sympathy with current emotions and
opinions, the discipline of the intellect—all these come within the
province of mental hygiene. (Rossi, 1962, p. 78)
The physician who coined the phrase 'mental hygiene,' William Sweetser,
invoked the theological notions of predestination and sin to explain the
emerging understanding of the heritability of mental illness:
Can we, therefore, escape the conclusion that we may be physically
predisposed, I had almost said predestined, to happiness or misery?
Such, in fact, is implied in the familiar expressions of happy and
unhappy constitution or temperament. As, moreover, these vicious
constitutions are oftentimes inherited, and must, probably, in the first
instance, have grown out of infringements of the organic laws, it
becomes a literal truth, that the sins of the parents may be visited on
their unoffending children, even to remote generations. (Sweetser,
1850, p. 120 my emphasis)
By this sort of rhetoric, moral degeneracy was converted into a biological
phenomenon, though the understanding of heritability was not quite
Darwinian. Bénédict Morel, a prominent French psychiatrist who trained
under JeanPierre Falret (Esquirol's successor) as chief resident at the
Salpêtrière Hospital and who in 1857 penned a Treatise on the physical,
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intellectual, and moral degeneracy of the human race,
110
claimed that
degeneracy was caused by things like poor nutrition, chronic diseases like
tuberculosis or goiter, the consumption of intoxicants such as absinthe or
tobacco, and masturbation along with other sexually deviant behaviors
(Dowbiggin, 1991; Morel, 1860). Furthermore, he contended that this
degeneracy becomes amplified in families as it was passed down through
multiple generations, so that, for example, alcoholic parents might produce
epileptic children, neurasthenic or hysterical grandchildren, and criminally
insane or congenitally idiotic (and probably sterile) greatgrandchildren
(Dowbiggin, 2004).
Morel was the first to argue that mental disorders should be classified
by (presumed) etiological rather than phenomenological factors, and proposed
that many of the separate disorders identified by Pinel and Esquirol be
grouped together into a single nosological category he called hereditary
madness (Dowbiggin, 2004). Morel believed that hereditary madness was one
aspect of the larger phenomenon of degeneracy, which was also manifested in
physical deformities (a point which he established in part by describing the
“facial stigmata” of children who most likely were born with what would later
come to be known as Down Syndrome) (Carlson, 2001, p. 41). As I mentioned
in the previous chapter, Morel coined the term démence précoce—which
110
Traité des dégénérescences physiques, intellectuelles, et morales de l'espèce humaine: Et des
causes qui produisent ces variétés maladives.
358
became Kraepelin's dementia praecox and then Bleuler's schizophrenia—to
describe the state he believed was “in many cases, the catastrophic end of
hereditary madness.” He continues:
A sudden immobilization of all the faculties, a precocious dementia
[démence précoce], indicates that the young patient has reached the
end of the intellectual life at his disposal. He is at that point referred
to as imbecile or idiot. These sad representatives of degeneration in
humanity constitute the fourth class of our hereditary madness.
111
(Morel, 1860, p. 566; my translation, emphasis in the original)
Although it is unclear whether Morel's understanding of degeneration was
the source or result, the association of social, physical, and mental
degeneracy reflected imagery in the nineteenth century popular imaginary.
What was the source of this degeneration that could be found in
abundance everywhere one looked? In the popular imaginary, degeneracy
was sometimes understood geographically as related to urbanization. The
process of moving into cities from villages was thought to in some manner
damage “the constitution of the immigrants, the weakly offspring they gave
birth to, and the further deterioration of those offspring as they were afflicted
by all manner of pathologies” (N. S. Rose, 2007, p. 19). This easily lent itself
111
“...dans bien des cas, la funeste terminaison de la folie héréditaire. Une immobilisation
soudaine de toutes les facultés, une démence précoce, indiquent que le jeune sujet a atteint le
terme de la vie intellectuelle dont il peut disposer. Il est alors désigné sous le nom
d'imbécile, d'idiot. Ces tristes représentants des dégénérescences dans l'humanité forment la
quatrième classe de nos folies héréditaires.”
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to popular negative representations of social classes. Honoré de Balzac, for
example, described lower class politically radical Parisians in 1835 as “a
people fearful to behold, gaunt, yellow, tawny... men whose twisted and
contorted faces give out at every pore the instinct, the desire, the poisons
with which their brains are pregnant; ...its cadaverous physiognomy... has
but two ages—youth and decay” (Balzac, 2010, para. 1). The Parisian
bourgeoisie did not fare much better in Balzac's account, in which his
description of their occupational psychosis bears a striking resemblance to
Morel's clinical description of the arrested development of démence précoce:
They appear to be skeptics and are in reality simpletons; they swamp
their wits in interminable arguments. Almost all conveniently adopt
social, literary, or political prejudices, to do away with the need of
having opinions... Having started early to become men of note, they
turn into mediocrities, and crawl over the high places of the world. So,
too, their faces present the harsh pallor, the deceitful coloring, those
dull, tarnished eyes, and garrulous, sensual mouths, in which the
observer recognizes the symptoms of the degeneracy of the thought and
its rotation in the circle of a special idea which destroys the creative
faculties of the brain. (Balzac, 2010, para. 10; my emphasis)
With scientists and publics expressing concerns about an epidemic of
degeneracy getting ever worse with each generation and potentially
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threatening the national stock, the eugenics movement was not far off, and
“the idea of degeneracy would be central to the biopolitics of the first half of
the twentieth century” (N. S. Rose, 2007, p. 19). Given that the concepts of
psychosis and schizophrenia were developing during this period, they were
profoundly affected by concerns for managing the risk of degeneracy.
The idea of degeneracy is depressing, of course, but the discourses in
which it is advanced are not exclusively pessimistic. There are rhetorical
motives at work, as always. Within a traditionalist/conservative ideological
milieu, the whole world is plunging into madness:
One must take into account the deep psychic anxiety, the
extraordinary prevalence of neurosis, which make our age unique. The
typical modern has the look of the hunted. He senses that we have lost
our grip upon reality. This, in turn, produces disintegration, and
disintegration leaves impossible that kind of reasonable prediction by
which men [sic], in eras of sanity, are able to order their lives. And the
fear accompanying it unlooses the great disorganizing force of hatred,
so that states are threatened and wars ensue. (Weaver, 1948, p. 16)
The proposed solution often “depends upon recovery of the 'ceremony of
innocence,' of that clearness of vision and knowledge of form which enable us
to sense what is alien or destructive, which does not comport with our moral
ambition” (p. 11). The situation is no more pleasant from the left. In a
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speech published in the Pravda on May 24, 1959, Soviet Premier Nikita
Khrushchev argued:
Can there be diseases, nervous disorders among certain people in a
Communist society? Evidently yes. If that is so, then there will also be
offenses, which are characteristic of people with abnormal minds. Of
those who might start calling for opposition to Communism on this
basis, we can say that clearly their mental state is not normal. (cited in
Tomov, Voren, Keukens, & Puras, 2007, p. 402)
As we will see very soon, this line of thinking in the Soviet Union did not end
well. In either case, there is a solution that will root out and eliminate all
those terrible defilers of our fair society, but we must have the ability to
detect the aliens and traitors in our midst, and the 'moral clarity,' as some
(almost always ironically) say, to be utterly ruthless in our treatment of
them. In this, a restoration of the moral order that has been defiled by
progressives/reactionaries (depending on one's persuasion), there is hope.
The pattern involved is that of “descentascent,” which “reflects a recurrent
rhythm of life and, for humans, a form of consciousness, a form in which
human experience is often symbolized and made meaningful. Put differently,
the descentascent pattern is akin to an archetypal metaphor” (Lake, 1984, p.
426).
In the previous three chapters, I examined the development of the
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concepts of psychosis and neurosis within the context of the discourses of
medical science. The cyclic inversion of meaning, with ‘(actual) neurosis’
taking on the meaning formerly signified by ‘psychosis,’ followed by inversion
again, testifies to the fluidity of these concepts at this stage and the tensions
between rhetorical continuity and discontinuity. The discourses of hygiene
and degeneracy also influenced the longitudinal course of these signifiers, as
can be seen in Freud's writings. With science, there is always a hope that any
degeneration can be halted or reversed, and this feeling out of terminology
was in part a rhetorical contest over which group of patients constituted the
lost causes, or, worse, the intrinsically dangerous.
At first, Freud's primary concern was in preventing the 'actual
neuroses' (by which he means psychoses, as opposed to the psychoneuroses).
This entailed, of course, stopping the dangerous practices of masturbation
and coitus interruptus, which he believed wrecked their havoc by physically
degenerating the onanists' nerves:
[Actual] neuroses [i.e., psychoses] are entirely preventable as well as
entirely incurable. The physician’s task is wholly shifted on to
prophylaxis. The first part of this task, the prevention of the sexual
noxa of the first period, coincides with prophylaxis against syphilis and
gonorrhea, since they are the noxae which threaten anyone who gives
up masturbation. The only alternative would be free sexual
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intercourse between young men and respectable girls; but this could
only be adopted if there were innocuous methods of preventing
conception. (Freud, 1893b, p. 60)
Here it would appear that the widespread availability of oral contraceptives
was one of the greatest psychiatric advances of the 20
th
century. With respect
to the ‘actual neuroses,’ we see in this remark a particular kind of medical
appeal that appears when a diseaseobject is both preventable and difficult to
treat, and which we will see again and again once the era of preventive
medicine truly begins. Importantly, Freud considers these phenomena
serious social problems, pathologies of an entire class or population, rather
than of individuals:
In the absence of such a solution [i.e., innocuous contraception], society
appears doomed to fall a victim to incurable neuroses, which reduce
the enjoyment of life to a minimum, destroy the marriage relation and
bring hereditary ruin on the whole coming generation. The lower
strata of society know nothing of Malthusianism, but they are in full
pursuit, and in the course of things will reach the same point and fall
victim to the same fatality. (Freud, 1893b, p. 60, my emphasis)
The sense of determinism in this fatalistic rhetoric is pronounced, and the
notion of Lamarckian inheritance is fairly typical of the discourses of
degeneracy. The association between preventive medicine, populations, and
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quasiapocalyptic language is a key cluster that will appear again and again.
The “hygienist” and eugenics movements were both biopolitical
projects concerned with regulating risks posed to populations by dangerous
degeneracy within individuals (Donzelot, 1979, p. 55). The brutal totalitarian
regimes that emerged in the twentieth century developed programs of
political oppression that united the politics of death with the politics of life.
To these, one might also add philanthropy, which also “sought a prophylactic
mode of action, endeavoring to promote certain kinds of moral conduct by
coupling the provision of financial aid with conditions as to the future
conduct of recipients,” thereby stemming the tide of degeneracy (N. S. Rose,
1989, p. 129). What these all have in common is the idea that a hidden
element can lie within an individual body, and be passed down from parent to
child, that could pose a danger to society and that should be managed
through a process of classification, identification, and some form of coercion –
in short, biopolitically.
Risk and Latent Danger
In his original formulation of the disorder, drawing upon the ideas of
Morel, Bleuler (1911a) described a variant of schizophrenia that was hidden
and latent in its development, which he believed was the most frequent form
of schizophrenia:
There is also a latent schizophrenia, and I am convinced that this is
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the most frequent form, although admittedly these people hardly ever
come for treatment... In this form, we can see in nuce all the symptoms
and all the combinations of symptoms which are present in the
manifest types of the disease. Irritable, odd, moody, withdrawn,
exaggeratedly punctual people arouse, among other things, the
suspicion of being schizophrenic. Often one discovers a concealed
catatonic or paranoid symptom and exacerbations occurring in later
life demonstrate that every form of this disease may take a latent
course. (p. 239)
For some (e.g., Gaupp, 1938), this was understood as a kind of psychotic
disorder with a lengthy prodromal phase, in which the patient is remarkably
lucid all the while an insidious endogenous pathology developed that could, at
any moment, activate. The course of schizophrenia was understood as a
degenerating (splitting) mind, but the seeds of this degeneration were
thought to be latent in these cases. Bleuler's pathological concept of 'latent
schizophrenia' developed under several names: 'abortive schizophrenia'
(Mayer, 1951), 'ambulatory schizophrenia' (Zilboorg, 1941), 'borderline
schizophrenia' (Knight, 1954), 'chronic incipient schizophrenia' (Mace, Koff,
Chelnek, & Garfield, 1949), 'pseudoneurotic schizophrenia' (Hoch & Polatin,
1949), 'pseudopsychopathic schizophrenia' (Hoch, 1950), and, with a hint of
mockery, 'salon schizophrenia,' which stands in contrast “to the honestto
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goodness state hospital” form of the illness (Bellak, 1955, p. 63).
112
Writing thirteen years later, Bleuler seems ambivalent about whether
latent schizophrenia constituted a disease entity, placing the word disease in
scarequotes (possibly to distinguish between the putative disease entity and
its observable expression) and noting that the characteristics of latent
schizophrenia (i.e., that it is frequently basically asymptomatic) were such
that they enabled the affected patients to masquerade as “normal”
individuals:
Latent schizophrenias are very common under all conditions so that
the “disease” schizophrenia has to be a much more extensive term than
the pronounced psychosis of the same name. This is important for
studies of heredity. At what stage of anomaly any one should be
designated as only a “schizoid” psychopathic, or as a schizophrenic
mentally diseased, cannot at all be decided as yet. At all events, the
name latent schizophrenia will always make one think of a morbid
psychopathic state, in which the schizoid peculiarities are within
normal limits. (Bleuler, 1924, p. 437)
The emphasis on heredity here, as well as the idea of a premorbid state, turn
out to be rather prescient with respect to psychosis risk syndrome.
112
Bellak goes on to comment that he does “not mean to question the existence or validity of
'salon schizophrenics.' Rather, I wish to determine the difference between them and those
people who were always more or less vegetative. (Undoubtedly, many originally brilliant
schizophrenics may reach a terminal stage of deterioration resembling the patients who
always manifested an extremely low level of functioning)” (p. 63).
367
DSMII contained a diagnosis of “schizophrenia, latent type,” for
“patients having clear symptoms of schizophrenia but no history of a
psychotic schizophrenic episode. Disorders sometimes designated as
incipient, prepsychotic, pseudoneurotic, pseudopsychopathic, or borderline
schizophrenia are categorized here” (American Psychiatric Association, 1968,
p. 34). This category was not included in DSMIII.
In these different developing pathways of the original concept of latent
schizophrenia, we can see the roots of several later diagnostic categories. The
'schizoid peculiarities' to which Bleuler referred in his description of latent
schizophrenia came to characterize schizoid personality disorder, which is
predicated of individuals who are extreme loners with no desire for social
activities, friendships, or sexual partners, and who are indifferent to praise or
blame (Magnavita, 1990; Shedler & Westen, 2004). Similarly, 'borderline
schizophrenia' eventually became borderline personality disorder, which is
characterized by unregulated affect, cognition, and behavior, unstable
interpersonal relationships (with patterns of idealization and devaluation),
and extreme sensitivity to abandonment, whether real or perceived (Brask,
1959; National Institute of Mental Health, 2014).
As borderline schizophrenia was initially conceived, it was closest to
what is now known as schizotypal personality disorder, “a pattern of acute
discomfort in close relationships, cognitive or perceptual disturbances, and
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eccentricities of behavior” (American Psychiatric Association, 2013, p. 645).
The term schizotype was coined in 1953 by Sandor Rado:
For psychodynamic purposes I shall abbreviate the term schizophrenic
phenotype to schizotype. Can we diagnose the patient's inherited
predisposition before he develops an open psychosis or even if he never
develops an open psychosis? In other words, are we prepared to view
him as a schizotype from birth to death, or only during his open
psychosis? ...[When] we subject these gross manifestations of the open
psychosis to minute psychodynamic analysis, we discover an
underlying ensemble of psychodynamic traits which... is demonstrable
in the patient during his whole life. This finding will define him as a
schizotype from birth to death, and will allow us to view his life history
as a sequence of schizotypal changes. (Rado, 1953, p. 410)
Though clearly the meaning of schizotypal has drifted somewhat, its
relationship to psychosis risk has been constant and will be discussed below.
Medicalization and Criminalization
While western psychiatry generally sought to distance Bleuler's latent
schizophrenia from the more visible and acute variety, as can be seen in the
development of these personality disorder concepts, the course of latent
schizophrenia in the Soviet Union took a rather insidious turn.
369
Sluggish Schizophrenia
Though remarkably absent from the contemporary debate about
psychosis risk syndrome and the risks posed by this diagnosis, a diagnosis of
Russian providence known as 'sluggish schizophrenia' provides another view
of schizophrenia as a (political) risk syndrome (Smulevich, 1989; Wilkinson,
1986). Six years after Bleuler converted dementia praecox into
schizophrenia, the Bolsheviks dismantled the provisional government in
Petrograd and launched the Russian Civil War. Russian psychiatrists were
one of the earliest professional groups that threw their support behind the
Bolsheviks, and consequently, several psychiatrists managed to acquire
prominent positions in the new government at the conclusion of the war in
1922 (Lavretsky, 1998).
These psychiatrists were the progenitors of what came to be known as
the 'Moscow School' of psychiatry, which exerted immense influence on the
field in the Soviet world (psychiatrists with heterodox 'antiPavlovian' views
risked being sent to the Gulag) and became close partners with the governing
state regime (J. V. Brown, 1994; Popov & Lichko, 1991). At a pivotal
moment, psychiatrists conducting research in neuropsychiatry were ironically
labeled 'antimaterialist' and reactionary, were made to confess and had their
laboratories shut down, and in some cases were tortured after the infamous
October 1951 'Joint Session' (or 'Pavlovian Session') of the Academy of
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Medical Sciences of the USSR and the AllUnion Neurologic and Psychiatric
Association (Windholz, 1997). The older generation of psychiatrists having
been liquidated, the inquisitors of the Joint Session, chief among them
Andrei Snezhnevsky, took control of the Moscow School.
The nosological approach of the Moscow School was to combine
dimensional and categorical diagnostic entities into a unitary framework, not
unlike the approach taken by DSM5, though for entirely different reasons
(Snezhnevsky, 1968). Central to the nosology was Snezhnevsky's concept of
'sluggish schizophrenia,' a diagnostic entity that “lends itself more than
conveniently to a view of dissent as a kind of illness” (Bloch & Reddaway,
1985, p. 160). Sluggish schizophrenia was characterized by a very slowly
progressing course, although the prognosis was just as bad as the more rapid
'malignant' form of the disease (Lavretsky, 1998). In a way, this was the
logical culmination of Kraepelin's decision to define dementia praecox based
on its course over time; Kendell (1975) politely noted that “Russian
psychiatrists appear to be influenced more by the course of the illness and
less by its actual symptomatology... which has some bearing on recent
political controversies” (p. 80). Comments like Kendell's led Szasz to
complain that “the concepts and methods of the Russian psychiatric
gangsters who perpetrate [abuses] are legitimized and supported by their
colleagues in the West” (Szasz, 1976, p. 101). Despite the Soviet rejection of
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genetics as capitalist biology under Lysenko, Snezhnevsky advanced the
thesis that schizophrenia was a “biological disorder with a genetic etiology,”
which provided support for the hospitalization of dissidents and their family
members (A. A. Stone, 2002, p. 110).
The political nature of the diagnosis of sluggish schizophrenia was
readily apparent from its signs and symptoms, and it fit in well with state
propaganda. Many believed that sluggish schizophrenia was invented on the
orders of the KGB, although many Soviet psychiatrists apparently lacked
insight into its political character when they made their diagnoses:
[According] to Snezhnevsky and his colleagues, patients with this
diagnosis were able to function almost normally in the social sense.
Their symptoms could resemble those of a neurosis or could take on a
paranoid quality. The patient with paranoid symptoms retained some
insight in his condition but overvalued his own importance and might
exhibit grandiose ideas of reforming society. Thus, symptoms of
sluggish schizophrenia could be “reform delusions,” “struggle for the
truth,” and “perseverance.” While most experts agree that the core
group of psychiatrists who developed this concept did so on the orders
of the party and the Soviet secret service KGB... and knew very well
what they were doing, for many Soviet psychiatrists this seemed a very
logical explanation because they could not explain to themselves
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otherwise why somebody would be willing to give up his career, family,
and happiness for an idea or conviction that was so different from what
most people believed or forced themselves to believe. (Voren, 2010, pp.
33–34)
These “reform delusions” were diagnosed whenever a patient “develops a new
principle of human knowledge, drafts an academy of human happiness, and
many other projects for the benefit of mankind” (Styazhkin, 1991, p. 122).
Snezhnevsky's emphasis on the “negative axis” of psychotic symptoms
is an important theoretical innovation (although the idea of negative
symptoms preceded him) that has been embraced in the West and is featured
prominently in the DSM. For Snezhnevsky, this axis, which included
“conflict with authorities, poor social adaptation, and pessimism,” was
developed to justify a diagnosis made in the absence of the more dramatic
positive symptoms of frank psychosis (Ougrin, Gluzman, & Dratcu, 2006, p.
458). The distinction between negative and positive psychotic symptoms is
grounded in a humoral way of thinking, as symptoms
that suggest a surplus or exaggeration of normal functioning, such as
delusions, hallucinations, and ideas of reference, are usually referred
to as positive symptoms, and those that refer to interpersonal and
motivational deficits are often referred to as negative symptoms.
(Millon, Millon, Meagher, Grossman, & Ramnath, 2012, p. 404)
373
Modern psychiatrists increasingly focus on the socalled negative symptoms,
like catatonia, flattened affect, asociality, alogia (highly restricted or absent
speech), anhedonia (lack of the ability to feel pleasure), and avolition (lack of
motivation), as antipsychotic medications (especially the older typical anti
psychotics) tend to be more effective against the positive symptoms while
leaving the negative symptoms insufficiently treated in many cases; the
newer atypical class of antipsychotics as a whole tends to perform better on
these symptoms (R. J. Leo & Regno, 2000). For those who show only positive
psychotic symptoms, Hacking (1998) has argued that the diagnosis of
multiple personality disorder has taken the role formerly taken by
schizophrenia before the idea of the importance of the negative axis of
symptoms became taken for granted. Schizophreniform disorder 'with good
prognostic features,' which will be discussed shortly, also represents
schizophrenia (in an early stage) without negative psychotic symptoms (the
absence of which is an indicator of a good prognosis). In any event, it seems
clear that the diagnosis of sluggish schizophrenia was a brazen political
abuse of psychiatry (and it must be noted that it is still in use in Russia today
and in some Latin American countries formerly within the Soviet sphere of
influence).
But it is also clear that the concept in its historical arc of development
(beginning as dementia praecox) was well suited to this sort of expansive
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interpretation. Further, it reveals a certain kind of risk – social
dangerousness – that was thought (and is thought) to inhere in individuals
who at some later point might manifest clear symptoms of psychosis. To
some extent, the problem relates to a more general nosological issue:
[The] emotive use of language so sways the intellect that phrases
suggesting the 'real' existence of diseases as single objects of
perceptions lead doctors to think as if these diseases were to be kept
away by barbedwire entanglements, or 'stamped out' by physical
agencies ruthlessly employed. (Crookshank, 1923, p. 345)
This seems especially true with risk syndromes that signify possibly
dangerous individuals; morbid descriptors like 'insidious' and 'latent' make it
easy to not just reify but personify an abstraction, and then draw moral
inferences about the person to whom the diagnosis applies.
This was not uniquely a Russian phenomenon. Jonathan Metzl shows
how similar concerns were used in the United States, especially during the
deinstitutionalization period, with a nonetoosubtle racial animus:
Many [individuals who were involuntarily committed] were sent to
Ionia [State Hospital, in Michigan] after convictions for crimes that
ranged from homicide to armed robbery to property destruction during
periods of civil unrest, such as the Detroit riots of 1968... [Ward] notes
emphasized how hallucinations and delusions rendered these men as
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threats not only to other patients, but to the authority represented by
clinicians, ward attendants, and society itself. “Paranoid against his
doctors and the police.” Or, “would be a danger to society were he not
in an institution.” Ionia held these men using littleknown loopholes in
deinstitutionalization amendments that stipulated that the hospital
would continue to receive or contain patients... who posed
“dangerousness to the community” even after most other patients were
set free. The word NEGRO appeared on the upper right corner of the
face page in eight out of every ten of these charts. And schizophrenia,
paranoid type was overwhelmingly the most common diagnosis applied
to these men, these institutionalized black bodies that
deinstitutionalization left behind. (Metzl, 2009, p. 14, emphasis in the
original)
This resonates with contemporary concerns, frequently given voice after
school shootings and similar tragedies involving firearms, about the dangers
of failing to restrain in advance those who show signs of mental illness.
Further, the association between people with schizophrenia and acts of
political violence or sabotage can be seen in advertisements for formulations
of antipsychotic medication that have been designed to be difficult for
patients to resist them. In an advertisement for an injectable formulation of
chlorpromazine (Thorazine), noncompliant patients are depicted as
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saboteurs, though nonetheless deserving of help (Figure 4.2). These “mental
patients who fear or resent medication” sabotage their own treatment, the
progress of their fellow patients “by spreading fears and multiplying conflicts
on the hospital ward,” and the bottom line of the hospital by “[throwing] away
thousands of dollars of drugs each year.” In a similar vein, a twopage
advertisement in the Archives of General Psychiatry for the non
phenothiazine butyrophenone derivative antipsychotic haloperidol (Haldol)
features a drawing of a threatening looking character on the left page with
the caption “Assaultive and belligerent?” On the right page, the reader is
told that “Cooperation often begins with Haldol,” which “acts promptly to
control aggressive, assaultive behavior” (Figure 4.3). Another advertisement
for Haldol, formulated as a “tasteless and undetectable” but “potent” liquid
that can be added surreptitiously to a patient's food, features a similar
message: that the drug can be used to “gain patient cooperation” while
“reducing the disruption of ward life often associated with coercive modes of
administration” (Figure 4.4). These messages all have in common the idea
that a patient with psychosis is physically dangerous and presents the ever
lurking, hidden risk of noncompliance, all problems that can be dealt with
pharmacologically.
377
Source: Advertisement in Hospital & Community Psychiatry (Smith, Kline, &
French Laboratories, 1965).
Figure 4.2: Noncompliant schizophrenic as saboteur
378
Source: Advertisement in Archives of General Psychiatry (McNeil
Laboratories, 1974).
Figure 4.3: Securing cooperation with 'Haldol'
379
Source: Advertisement in Health & Community Psychiatry (McNeil
Laboratories, 1968).
Figure 4.4: Undetectable medication for paranoid patients
380
Schizophrenia has always been a risk syndrome. Controlling the
hidden threats posed by the afflicted, and identifying in them in the early
stages of the illness (or predicting its later appearance, depending on what
view of the illness one takes, a topic I shall turn to in the next major section),
has always been a project of risk management, or to be more precise, danger
management. However, the development of effective antipsychotic
medications, deinstitutionalization, and changes in public opinion have
limited the extent to which psychosis is used to legitimate coercive political
abuses. Why was it necessary in the first place? After all, a state could just
criminalize certain threatening political activities. Even in thoroughly
repressive systems, some evidence and formal process of prosecution is
required before a citizen is deprived of ordinary liberties, or else a
legitimation crisis becomes very likely. The diagnosis of 'sluggish
schizophrenia' permitted the state to incarcerate future criminals before they
committed any crime, by denying the sanity of those guilty of 'precrime.'
Their incarceration did not need to be legitimized by a formal judicial
process. In modernity, citizens have rights on the basis of their rationality,
and the insane are by definition not rational. Our methods of crime control—
incentives, disincentives, deterrence, education, etc.—all presuppose rational
actors. Disconnected from reality, the psychotic are dangerous and society
needs to be protected from such individuals.
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Even though the diagnosis of schizophrenia (or a related psychotic
disorder) is no longer, for the most part, used in this fashion, there is another
area, however, in which psychiatric diagnosis is being used, with some
controversy, to deny civil liberties traditionally afforded to all citizens: sexual
crimes. These kinds of crimes are considered so evil, so abnormally deviant,
so unthinkable for a normal, rational citizen, that all criminals who commit
one of these crimes are forever held under suspicion, even after their 'debt to
society' has been paid. People who have been found guilty of rape are more
likely than the average citizen to commit another act of rape; prudence
demands that we take steps to control this controllable risk. Hence, sex
offender registries and the strange paradoxes of sexual crime control, e.g.,
children who 'sext' one another are being prosecuted for distributing child
pornography (Lee, Crofts, Salter, Milivojevic, & McGovern, 2013), and in
some cases one can receive a larger penalty for passively viewing child
pornography than for actually raping a child (Crary, 2012; Jauregui, 2014).
In this section, I shall discuss two proposed disorders that would have
medicalized sexual crime in different ways—pedohebephilic disorder and
coercive paraphilia—as well as a third proposed disorder, parental alienation
syndrome, that illustrates the risks associated with developing diagnoses for
the courtroom. All three diagnoses were ultimately rejected for inclusion in
DSM5.
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Pedohebephilic Disorder
As Metzl's (2009) research shows, it is easy for certain social categories
that are associated with systematic prejudice, like race, to pervert the
operation of putatively objective judgment producing institutions. One of the
successes of the civil rights movement was the enactment of reforms that
somewhat standardized the prison sentences given for felonies, so that
someone who formerly would have received an especially light or heavy
sentence would now receive one closer to the average. One consequence of
this diminished discretionary power of judges in assigning punishments is
that criminals who for whatever reason seemed more likely to reoffend were
given shorter prison sentences. The solution to this problem came in the
form of a shift from 'needfortreatment' to 'dangerousness' criteria as the
standard for civil commitment (Testa & West, 2010). This led to the creation
of the “sexually violent predator” (SVP)
113
as a juridical object of knowledge,
an individual who could be made to undergo chemical castration or else be
forcibly 'treated' for his
114
sexual perversions in a mental hospital after the
term of his prison sentence was complete (Frances, 2013, p. 165). Civil
commitment of SVPs is a form of preventive detention.
113
Another term used in some jurisdictions is 'sexually dangerous person.'
114
SVPs almost always are male. Even though a survey of victims by the Bureau of Justice
Statistics reported that females were responsible for 6% of sexual assaults committed by
individuals and involved in 40% of sexual assaults committed by groups, they represent less
than .02% of offenders given the SVP classification (D’Orazio, Arkowitz, Adams, & Maram,
2009).
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A diagnosis of pedophilia, indicating a sexual preference or compulsion
for prepubescent children, is one of the ways one could qualify for such
treatment (Aviv, 2013). The failed proposal either to include the diagnosis of
'hebephilia'—Glueck's (1955) name for sexual attraction toward teenagers—
or to expand pedophilic disorder into a broader 'pedohebephilic disorder,' first
so named by Freund, Seeley, Marshall, and Glinfort (1972), would have
widened this category dramatically. This proposal by the Paraphilias
Subworkgroup was rejected by the APA Board of Trustees for reasons that
remain confidential. The leading argument against treating hebephilia as a
paraphilia, according to Frances, is that it is actually 'normal' for adults
(men) to feel sexually attracted to pubescent
115
children:
Numerous studies have proven the obvious—such attraction is
common and completely within the range of normal male lust... The
advertising industry, wise to the fact that many adults remain
sexually attracted to adolescents, cynically exploits their interest by
displaying younglooking models in provocative clothing and poses.
The assertion that sexual urges stimulated by sexy teenagers denote
mental disorder violates common sense, experience, and evidence from
research. It is not a crime or a mental disorder to lust after the newly
pubescent; it is human nature. But it is a very serious crime in our
115
More specifically, children developmentally in Tanner Stage 2 and Tanner Stage 3,
generally aged 1114 (Tanner, 1978).
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society to act on these impulses, one that deserves a long prison term.
(Frances, 2013, pp. 201–202)
One source of possible ambiguity in the debate over hebephilia is that the
category of disorders in question concerns disordered appetites/desires,
rather than disordered conduct.
Along these lines, after reminding his audience of the historical uses of
the category of paraphilic disorders to control deviant and taboo 'perversions,'
Wakefield (2011) sharply criticized the proposal, calling it the “most flawed
and blatantly overpathologizing paraphilia proposal,” and suggested that the
proposed diagnosis “violates the basic constraint that disorder judgments
should not be determined by social disapproval. This is a case where crime
and disorder are being hopelessly confused” (p 206). In response to this kind
of criticism, Ray Blanchard, the chief proponent, argued that if pedophilia is
a mental disorder, it must follow that hebephilia is a mental disorder for the
same reasons; any criticism of hebephilia along the lines offered by Wakefield
or Frances should equally provide reason to exclude pedophilia. Attempts to
distinguish between pedophilia and hebephilia on the basis of fecundity
would imply that homosexuality is paraphilic, Blanchard contended.
Blanchard acknowledged that the diagnosis would have serious
reliability problems, but did not find this to be a very compelling argument:
But so what? Should there exist no diagnosis for men who say they are
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most attracted to pubescents, who have committed repeated sexual
offenses against pubescents, and who respond most strongly to
laboratory stimuli depicting pubescents just because there are other
men who produce less consistent findings?
116
(Blanchard, 2009b, p. 332)
Furthermore, Blanchard argued that his critics missed the entire point:
Hebephilia would apply only to men who exclusively feel attraction for
adolescents; that is, an adult who is attracted to teenagers as well as adults
would not be regarded as a hebephile. While Blanchard is correct that his
opponents do not address this, he never explains why it is actually relevant.
Further, Blanchard relies on an alternative understanding of pedophilia than
used by the DSM since DSMIIIR, which defined pedophilia in absolute
rather than relative terms, as in the DSM5 image of a pedophile as an adult
who has “recurrent, intense sexually arousing fantasies, sexual urges, or
behaviors involving sexual activity with a prepubescent child or children,”
regardless of whether they do or do not have equal or greater feelings of
attraction to adults (American Psychiatric Association, 2013, p. 697).
Perhaps fittingly, his passiveaggressive and argumentative tone is
reminiscent of the manner in which adolescents argue with their parents,
and is rather striking for scientific discourse. For example, he remarks that
the validity of his position “should be obvious to anyone who has read our
116
His critics would have no problem answering this rhetorical question with an emphatic
'no.'
386
article” and comments that it was “ironic” that his opponents cited a
particular finding “when our laboratory was one of the first to report this,”
almost as if to declare ownership of the fact in question, the interpretation of
which was not even in dispute (Blanchard, 2009, p. 332).
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Coercive Paraphilia
The proposed diagnosis 'paraphilic coercive disorder' or 'coercive
paraphilia' would have applied to anyone who has “sought sexual stimulation
from forcing sex on three or more nonconsenting persons on separate
occasions” (American Psychiatric Association, 2010f). This was not a new
idea: In 1985 the DSMIIIR Workgroup proposed the diagnosis of 'paraphilic
rapism,' “which was extensively criticized at the time” (Fuller, Fuller, &
Blashfield, 1990; Krueger & Kaplan, 2012, p. 251). As explained in DSM5, a
paraphilia is sexual desire that is sufficiently deviant that it can almost be
thought of as a kind of arousal psychosis:
The term paraphilia denotes any intense and persistent sexual
interest other than sexual interest in genital stimulation or
preparatory fondling with phenotypically normal, physically mature,
117
Ray Blanchard was a member of the DSM5 Sexual and Gender Identity Disorders Work
Group and chair of the Paraphilias Subworkgroup, and while the Board of Trustees of the
APA voted not to accept the Subworkgroup's recommendations in favor of adopting
Blanchard's view of hebephilia, he did succeed in his efforts to change the definition of a
paraphilia adopted in the final manuscript so that it contrasts with what is 'phenotypically
normal.' The approach in DSMIV defined paraphilia by concatenation, enumerating a
variety of paraphilic fantasies, urges, or behaviors; in contrast, the DSM5 approach, which
had been strongly advocated by Blanchard, defines paraphilia by exclusion, i.e., in terms of
what it is not (Blanchard, 2009a).
387
consenting human partners... [The] term paraphilia may be defined as
any sexual interest greater than or equal to normophilic sexual
interests. (American Psychiatric Association, 2013, p. 685, emphasis in
the original)
Provoking reactions that range from outrage to humor, coercive paraphilia
remains highly controversial, and most of the discussion about its inclusion
focused on the question of its status as a medical problem. Debate about this
diagnostic category is not so much about whether a coercive sexual
orientation is 'disordered' but, rather, whether it is to be defined as a medical
disorder, i.e., an illness, or as a legal disorder, i.e., a crime. On this point,
Lombroso reminds us that “the distinction between crime and madness is
something constructed not by nature but by society” (2006, pp. 83–84).
That the diagnosis seems designed as a risk management tool struck
critics as too risky, in two opposing ways. On the one hand, there are
concerns about the possible use by defense attorneys presenting an insanity
or diminished capacity defense (Slovenko, 2011). In criticizing the disorder,
Frances noted that the “construct 'paraphilic coercion' has already
contributed significantly to a grave misuse of psychiatry by the legal system
in the handling of sexually violent predators,” and urged the DSM5 Task
Force to withstand the urge to “medicalize undesirable sexual behavior and
thereby provide a psychiatric excuse helpful to those who are attempting to
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evade personal responsibility” (Frances, 2010a, pp. 3–4). On the other hand,
critics alleged that coercive paraphilia was an “[invented] diagnosis for [the]
civil commitment of rapists” (Zander, 2008, p. 459). The critics maintained
that this should occur “only if the offender's dangerousness is caused by a
mental disorder and is not a manifestation of simple criminality... Being
dangerous is not enough, since released criminals are also potentially
dangerous” (Frances & First, 2011, p. 555).
It appears that Frances was just as (if not more) concerned with this
danger. In Saving Normal, he argued that “we lose constitutional stability
whenever we allow civil rights to be violated, even for those people we most
detest” (Frances, 2013, p. 203). So as to prevent any ambiguity, Frances and
First (who headed the DSMIV Paraphilia Workgroup) stated their opposition
unequivocally:
The evaluators, prosecutors, public defenders, judges, and juries must
all recognize that the act of being a rapist is almost always an aspect of
simple criminality and that rapists should receive longer prison
sentences, not psychiatric hospitalizations. (pp. 558559)
At the 2010 annual conference of the American Academy of Psychiatry and
the Law (AAPL), a group of forensic psychiatrists voted against endorsing
'paraphilic coercive disorder' by a vote of 31 to 2, citing “the dearth of
scientific reliability or validity... [and] the potential for misuse by partisan
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advocates in the forensic arena, especially in civil commitment proceedings”
(Franklin, 2011, p. 137).
This potential is not theoretical. Even though the DSMIV Paraphilia
Workgroup “definitively rejected the claim that rape should be considered a
mental disorder,” and, moreover, the entire section on paraphilia in DSMIV
was written “before the issue of SVP [sexually violent predator] commitment
arose and was written with clinicians, not forensic proceedings, in mind,”
Frances and First claim that “a misreading of the poorly worded paraphilia
section allowed evaluators to form just the opposite impression,” namely, that
rapists should be given the DSMIV diagnosis of 'paraphilia, not otherwise
specified (NOS)' (Frances & First, 2011, p. 556). As he often does when
criticizing fellow psychiatrists, Frances concedes that his opponents are “well
meaning and honorable,” but argues that even “the best intended misuse of
psychiatric diagnosis to curb risks to society is not worth the cost,” reminding
his audience that “mental health professionals in other countries have been
turned into statesponsored tools in the oppression of political dissidents” (p.
560).
Despite this ethotic concession of good faith, the criticism employs a
tragic frame in which SVP evaluators, who are either acting “naively or
purposefully,” have hubristically exceeded the appropriate limits of
psychiatry (p. 559). Burke suggests that, in tragedy, hubris is the “basic sin...
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[surrounded] with the connotations of crime,” in “conflict with established
values.” Yet at the same time, “tragedy deals sympathetically with crime,” so
that “we are made to feel that [the criminal's] offense is our offense,” and
ultimately the target of criticism is “admonished... to 'resign' himself to a
sense of his limitations” (Burke, 1984a, p. 39, emphasis in the original).
Critics of coercive paraphilia did not limit themselves to the tragic
frame. In some cases, critics took to open mockery in the public sphere.
While these criticisms sometimes retained the tragic character of the
criticisms presented in expert forums, the turn to the public opens up space
for the comedic frame. Both tragedy and comedy warn “against the dangers
of pride,” but in comedy, the
emphasis shifts from crime to stupidity... The audience... chastened by
dramatic irony... is admonished to remember that when intelligence
means wisdom (in contrast with the modern tendency to look upon
intelligence as merely a coefficient of power for heightening our ability
to get things, be they good things or bad), it requires fear, resignation,
[and] the sense of limits. (Burke, 1984a, pp. 41–42, emphasis in
original).
In other words, comedy is an especially useful frame when one is urging the
exercise of practical wisdom over against expert expressions of technical
rationality. Burke suggests that comedy used in this way “must develop
391
logical forensic causality to its highest point,” which entails “completing the
process of internal organization whereby each event is deduced
'syllogistically' from the premises of the informing situation” (p. 42).
For example, at the 2010 AAPL conference, Karen Franklin, a forensic
psychologist, argued that if coercive paraphilia is a medical disorder, then
apparent outbreaks should be treatable in the same manner as other
contagious medical disorders:
A shocking news story out of Australia makes me think that if Coercive
Paraphilic Disorder exists, it must be contagious. Not just contagious,
but virulently contagious in certain allmale environments. Of the 198
students at St Paul's College at the University of Sydney, a large
proportion were apparently infected with a highly contagious form of
the virus. If Paraphilic Coercive Disorder makes it into the next
Diagnostic and Statistical Manual of Mental Disorders, St. Paul's will
be Ground Zero for the epidemic. According to an article in today's
Sydney Morning Herald, men at the elite, allmale college proudly set
up a prorape Facebook group called “Define Statutory” that promoted
sexual aggression against women. But the elite students did not stop
with words. They fostered an alcoholfueled climate in which rapes
were common, most sexual assaults went unreported, and women
students felt so unsafe that they quit school, the story reports.
392
Reporter Ruth Pollard documented a series of rapes and sexual
assaults, including one incident in which about 30 drunk, naked men
broke into a college and surrounded a young woman, touching and
taunting her. The good news is that, if it's a contagious illness, there
could be an immunization like the one for the H1N1 virus. So, while
the DSM developers are frenetically
118
creating new diagnoses, let's not
forget to work on finding some cures, too. (Franklin, 2009, para. 1–5)
While the tone is mocking, the frame is one of acceptance of psychiatry, which
is mistaken rather than evil. Through the comic corrective Franklin gently
reminds psychiatrists that diagnosis is not for its own sake, and that, if they
are going to concern themselves with rapists as a patient class, then they
should be thinking about how to 'cure' them.
Coercive paraphilia did not make it into DSM5, though the definition
of paraphilia (quoted above) explicitly includes a reference to nonconsensual
sexual acts, and a diagnosis that did make it, frotteuristic disorder, is
characterized by “recurrent and intense sexual arousal from touching or
rubbing against a nonconsenting person, as manifested by fantasies, urges, or
behaviors,” which seems to contain coercive paraphilia within an even larger
discrete disease entity concept, since it is difficult to conceive of a scenario in
which one could commit rape without touching or rubbing the victim
118
In these kinds of criticisms, it is almost a pro forma requirement to make a pun in which
the production of the DSM is a display of madness.
393
(American Psychiatric Association, 2013, p. 691). As with coercive paraphilic
disorder, a diagnosis of frotteuristic disorder is warranted after three
instances: “'recurrent' touching or rubbing against a nonconsenting
individual... may, as a general rule, be interpreted as three or more victims
on separate occasions” (American Psychiatric Association, 2013, p. 692).
In case this were not enough, two catchall categories were included:
other specified paraphilic disorder and, even more ambiguous, unspecified
paraphilic disorder, for “situations in which the clinician chooses not to
specify the reason” (American Psychiatric Association, 2013, p. 705). The
chapter on paraphilic disorders explicitly cautions that the “listed disorders
to not exhaust the list of possible paraphilic disorders... The diagnoses of the
other specified and unspecified paraphilic disorders are therefore
indispensable and will be required in many cases” (American Psychiatric
Association, 2013, p. 685, my emphasis). This is all despite the fact that
Frances' criticisms of coercive paraphilia appear in the context of criticizing
the “inartful” wording of the DSMIV diagnosis of paraphilia NOS, which was
written at a time when “we were not aware of the consequential problems
that would later arise from the fact that the section lacked the clarity and
precision necessary for legal purposes,” and yet was duplicated in DSM5
(Frances & First, 2011, p. 556). Presumably, it would be possible to diagnose
both coercive paraphilia and hebephilia (provided one does not agree with
394
Frances' contention that hebephilia is normophilic) indirectly with either of
the catchall paraphilic disorder categories.
What is one to conclude from this? It appears that DSM5 was
stripped of this diagnosis by name, while the chapter on paraphilic disorders
was written in such a way that a trained (or just careful) reader would see
that it was still there. Black (1992) suggests that “attitudes toward secrecy
and disclosure are manifested not alone as articulated commitments, but also
as rhetorical forms... [as] commonplaces with uncommon powers of
implication and entailment” (pp. 5253). Giving a disorder a distinct, unique,
and officially named status certainly enhances its visibility—to critics, to
attorneys, to pharmaceutical executives. Keeping the disorder but depriving
it of its name is a way to manage and restrain the risks associated with the
surplus of meaning that overflows from powerful words. This aligns with
Burke's account of the premodern concept of “word magic,” which “has its
origins, paradoxically, not in a naïve belief in the power of words, but in
man's first systematic distrust of words” and which “began with the sense of
the ineffable” (Burke, 1969a, p. 304).
Providing the disorder with its name, a mantra to be recited by
nefarious individuals eager to harness its power, was judged to be too
dangerous; the elimination of coercive paraphilia from the official list should
be thought of as desanctification. Burke notes that “the need to 'desanctify'
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the world is essentially but an appreciation of the fact that all things possess
power... [and] the rights of desanctification are designed to mitigate the
intensity of these powers” (p. 304). Yet the disorder was not removed, but
only hidden to those on the outside in the parables of the other specified
paraphilic disorder and the unspecific disorder, seemingly “so that they may
be ever seeing but never perceiving, and ever hearing but never
understanding” (Mark 4:12, New International Version). When the text says,
as quoted above, that these two diagnoses “are therefore indispensable and
will be required in many cases,” one could imagine as the next line, “Whoever
has ears to hear, let them hear” (American Psychiatric Association, 2013, p.
685; Mark 4:9, New International Version).
The explicit rationale for listing the eight disorders is that they are
“relatively common” forms of paraphilia, and that “some of them entail
actions for their satisfaction that, because of their noxiousness or potential
harm to others, are classed as criminal offenses” (p. 685). The subtext seems
to be that the lawyers of the world can have at these eight, but the others are
for the true believers endowed with the (dia)gnosis of 'clinical judgment,' and
proper faith in the institution of psychiatry, just as Clement of Alexandria,
writing at the beginning of the third century of the common era, argues in
Book I of his Stromateis:
Nor is the word, given for investigation, to be committed to those who
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have been reared in the arts of all kinds of words, and in the power of
inflated attempts at proof; whose minds are already preoccupied, and
have not been previously emptied. But whoever chooses to banquet on
faith, is steadfast for the reception of the divine words, having acquired
already faith as a power of judging, according to reason. Hence ensues
to him persuasion in abundance... But secret things are entrusted to
speech, not to writing, as is the case with God... And we profess not to
explain secret things sufficiently – far from it... Some things I
purposely omit, in the exercise of a wise selection, afraid to write what
I guarded against speaking: not grudging – for that were wrong – but
fearing for my readers, lest they should stumble by taking them in a
wrong sense; and, as the proverb says, we should be found “reaching a
sword to a child.” (Clement of Alexandria, 2012, pp. 12–14, Bk. I, ch. 1)
Esoteric knowledge should be trusted least of all in the hands of those who
are trained advocates but who have no genuine understanding and no
orienting faith. Clement is concerned about the risks associated with the
written disclosure of secret knowledge. The Platonic distinction between
speech and writing here is important. In a written text, which is forced to
speak for itself as it were, the writer of esoteric truths must anticipate how
the uninitiated might interpret the text in a dangerous way.
This accords with the argument made by Frances and First against
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even including the disorder in an appendix (or what became section III of
DSM5). They suggested that, in DSMIV, including rejected diagnoses in the
appendix
seemed like a benignly obscure way to encourage future research. If
paraphilic coercive disorder were like the average rejected DSM
suggestion, it would similarly make sense to park it in the appendix...
This might facilitate the work of researchers and also provide some
guidance to clinicians in assessing the rare rapist who does have a
paraphilic pattern of sexual arousal... Including paraphilic coercive
disorder in the DSM5 appendix and suggesting it as a possible
example of the proposed other specified paraphilic disorder category
would confer an undeserved backdoor legal legitimacy on a disavowed
psychiatric construct... We did not include any reference to paraphilic
coercive disorder in DSMIV, and it should not find its way in any
form, however humble and unofficial, into DSM5. (Frances & First,
2011, pp. 559–560, my emphasis)
By this reasoning, even including the disorder in an appendix would be akin
to 'reaching a sword to a child.'
Perhaps due to the alleged misuse of paraphilia NOS, the first section
of DSM5 ends with a 'Cautionary Statement for Forensic Use of DSM5,'
which argues that in “most situations, the clinical diagnosis of a DSM5
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mental disorder... does not imply that an individual with such a condition
meets legal criteria for the presence of a mental disorder or a specified legal
standard (e.g., for competence, criminal responsibility, or disability),” and
accordingly the use “of DSM5 to assess for the presence of a mental disorder
by nonclinical, nonmedical, or otherwise insufficiently trained individuals is
not advised” (American Psychiatric Association, 2013, p. 25). This draws a
very careful line, as it does not say that DSM5 cannot be used for forensic
purposes, but rather that the text can be interpreted only by the authorized
priestly caste of experts. The text acquires a certain degree of scientific
eloquence through its ability to balance
withholding and disbursing to the point that they beget mystery.
Enough is disclosed to license the authenticity of the rhetor, but that
same disclosure signals its own fractionality, leaving the audience
aware that what it has come to know is not all there is to be known.
(Black, 1992, p. 95)
Mental health professionals may act as expert witnesses and offer testimony
in support of the judicial relevance of a DSM5 diagnosis, but the rhetorical
force of this testimony should not be unfairly boosted by the authority of the
DSM itself.
Parental Alienation Syndrome
One other extremely controversial disorder, also proposed by rejected,
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raises similar concerns. Parental Alienation Syndrome (PAS) would have
applied to a child who engages in a “campaign of denigration” against one of
his or her parents with “no justification,” and is at best able to offer only
“weak, frivolous, or absurd rationalizations” for the vilification, which occurs
in the complete “absence of guilt [regarding his or her] cruelty to and/or
exploitation of the alienated parent” (Gardner, 2001, p. 10). Formulated in
this way, PAS is conceived as a kind of psychosis. Like coercive paraphilia,
this diagnosis is much more relevant in the courtroom than in the clinic.
Accordingly, rhetorical concerns are even more relevant than scientific
concerns, although in general it seems that diagnoses that appear to serve
only a forensic purpose tend to have scant scientific backing (after all, justice
and the good tend to resist hypothesis testing). In the case of PAS, supposing
the described phenomena actually occurs, a diagnosis of delusional disorder is
available, so the inclusion of PAS would work primarily to legitimize the idea
that such kinds of delusions are so common that they deserve special
recognition.
One psychiatrist who opposed PAS's inclusion in DSM5 is Paul Fink,
a past president of the APA. His criticism of PAS's scientific basis was
explicitly framed as a rhetorical matter:
[Many] of the controversies [about what to include in DSM5] are and
will be political with proponents on each side of the issue. All of us love
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rhetoric that seems reasonable to the reader. One such area is parental
alienation syndrome (PAS). I am personally involved in opposing the
inclusion of this bit of junk science invented by a psychiatrist in the
1980s, the late Dr. Richard A. Gardner. All of his books and most of his
papers were published by his own publishing company. He protected
child sexual abusers in court and was very abusive to the mothers of
the children caught up in custody hearings. Many children and
mothers have been hurt by this man's beliefs, but over 15 years, he
developed many converts to his beliefs, including judges, lawyers,
guardians at litem, and psychologists who liked the neat packaging of
his ideas. In recent years, the ball has been picked up by "father's
rights" groups who don't like to be interfered with when they are
sexually abusing their children. This group has petitioned the DSM
task force to include PAS in the publication. This is a good example of
the political activity into which DSM is drawn. The task force members
want to be fair to all parties, so we are now involved in putting together
data around this issue to disprove it to the DSM task force. (Fink, 2010,
para. 29–34, my emphasis)
By combining science and rhetoric, emotion and reason, morality and
medicine, personal character and public credibility, this criticism is
representative of many DSM5related arguments. The legitimacy of a
401
particular forensic tactic (i.e., expert witness impeachment) is now a medical
question. Dr. Gardner is described as an effective rhetor who has managed to
persuade legal authorities to accept his “junk science” by means of the “neat
packaging of his ideas.” According to this depiction, Gardner has engaged in
a form of sophistry that Plato compared to pastry baking, which he defined as
the flattery that wears the mask of medicine... [It is] a mischievous,
deceptive, disgraceful... thing... that perpetrates deception by means of
shaping and coloring, smoothing out and dressing up... [What] pastry
making is to medicine, oratory is to justice. (Plato, 1997b, sec. 469b–
469c)
The diagnosis is not problematic merely because it is 'incorrect' or 'invalid,'
but because it is risky. The risks posed by this diagnosis derive from the way
it functions rhetorically, which Fink undermined by marshaling scientific
data that he believed “disprove” its medical validity. Fink viewed the DSM5
debate as an opportunity to challenge the validity claims implied in
Gardner's discourse before those claims could become unquestionable.
Risk (Factors) and Susceptibility
The next stage of the conceptual development of risk in late modernity
turned from risks (dangers) hiding inside individuals to risks hiding inside
populations, a move that was joined by the rise of advanced liberalism,
according to which the biopolitics of risk entail
402
a variety of strategies that try to identify, treat, manage, or administer
those individuals, groups, or localities where risk is seen to be high...
Risk here denotes a family of ways of thinking and acting that involve
calculations about probable futures in the present followed by
interventions in the present in order to control that potential future.
(N. S. Rose, 2007, p. 70)
Recognizing the costs and inefficiencies inherent in a diseasecontainment
model, the dominant paradigm in medicine began to shift toward health
promoting/illnesspreventing strategies and techniques. In his landmark
essay “From dangerousness to risk,” Robert Castel contends that the
fundamental characteristic of the new strategies of biopolitical risk
management utilized in advanced industrial societies (more or less
corresponding with Rose's concept of advanced liberalism) is that they
“dissolve the notion of a subject or a concrete individual, and put in its place a
combinatory of factors, the factors of risk” (Castel, 1991, p. 281, emphasis in
the original). These strategies also emphasize prevention, which is consonant
with a set of neoliberal values that place “a premium on individual
responsibility for one's own health and wellbeing” (Grob & Horwitz, 2010, p.
106).
Along with this came the modern notion of preventive psychiatry,
which Castel argues was a solution to the moral and technical difficulties
403
involved in attempting to confine or sterilize anyone who might contain a
kernel of dangerousness. The transition to preventive psychiatry was
something that Morel gestured toward by focusing on frequencies and other
objective measures of risk in populations, but was unable to fully realize
because “he did not have at his disposal the specific techniques... with which
to instrumentalize” the requirement to “act directly on the conditions liable to
produce risk,” which also had been the principal failing of the eugenics
movement (Castel, 1991, pp. 285–286). The transition required that “the
notion of risk is made autonomous from that of danger. A risk does not arise
from the presence of particular precise danger embodied in a concrete
individual or group,” but rather the “effect of a combination of abstract
factors which render more or less probable the occurrence of undesirable
modes of behavior” (p. 287, emphasis in the original).
With this conceptual shift in place, the new biopolitics of risk were
ushered in with the rise of population data and increasingly sophisticated
methods of statistical analysis, which drove new ways of thinking about the
measurement and management of mortality, morbidity, and risk (Hacking,
1975, 1982). Writing two years after its publication, which in large part was
driven by concern over reliability (Kirk & Kutchins, 1992; Kutchins & Kirk,
1997), Hacking argued that the categories in DSMIII “are as responsible to
the need to count uniformly as they are to any interest in 'correct' diagnosis...
404
the fetishism for counting... brings with it the need for easily applied
categories in terms of which to count” (Hacking, 1982, pp. 293–294).
Accordingly, the DSM serves as a biopolitical apparatus that enables
individuals to be assigned to risk pools based on factors identified by
probabilistic and epidemiological knowledge, which constitutes “a new mode
of surveillance: that of systematic predetection... in effect [promoting]
suspicion to the dignified scientific rank of a calculus of probabilities” (Castel,
1991, p. 288).
With this “conception of prevention,” underpinned by “a grandiose
technocratic rationalizing dream of absolute control of the accidental,
understood as the irruption of the unpredictable,” very little falls outside the
circumference of its gaze (Castel, 1991, pp. 288–289). The scope of the
surveillance suggests that everyone, despite being “existentially healthy, [is]
actually asymptomatically or presymptomatically ill. Technologies of life not
only seek to reveal these individual pathologies, but intervene upon them,” a
consequence of which is that “new forms of life” are emerging around the idea
of risk as susceptibility (N. S. Rose, 2007, p. 19). The danger in this approach
is that it fosters a set of institutional logics that are constantly generating
risks to manage without “a trace of reflection on the social and human cost of
this new witchhunt... [e.g.,] the iatrogenic aspects of prevention” (Castel,
1991, p. 289, emphasis in the original).
405
Risk Production and Risk Society
One very important change that has coincided with 'reflexive
modernization' or the emergence of a second modernity is the emergence of
risk production as the dominating logic of the systems world. In the first
stage of modernity, the mystifications of religion and privilege were
dismantled by the likes of Marx and Nietzsche. In the second stage, “the
same is happening to the understanding of science and technology in the
classical industrial society, as well as to the modes of existence in work,
leisure, the family, and sexuality” (Beck, 1992b, p. 10). Beck argues that the
productive forces of industrialization “have lost their innocence in the
reflexivity of modernization processes. The gain in power from techno
economic 'progress' is being increasingly overshadowed by the production of
risks” (pp. 1213). In the first stage, the logic of wealth production was a
driving force in urbanization; the degeneracy that seemed (in the popular
imaginary) to result was “legitimated as [a] 'latent side [effect]'” (p. 13).
Urbanization brought pollution, stress, dislocation of families and
alteration of their structure, nutritional changes, socioeconomic conditions
that produced an increase in nonreproductive sexual activities and the
spread of sexually transmitted diseases (including, importantly, syphilis,
responsible for the 'general paresis of the insane'), etc., all of which received
blame (in some cases fairly, in others unfairly) for the apparent epidemic of
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degeneracy and associated mental illness. Our efforts to manage these
hazards and 'side effects' of modernization give rise to secondorder risks,
with each intervention encompassing an increasingly wider scope. In the
beginning, social risks seem to live inside individual human beings. The
latent danger in these individuals can be medicalized and regulated through
strict coercive measures, some of which are more acceptable to those tasked
with enforcing them if they can be conceived as noncoercive, as in the second
Haldol advertisement (Figure 4.3, supra). This was somewhat more of an
issue in totalitarian regimes, in which classical ideas about the role of
sovereign authority continued to hold sway, modernized only insofar as they
were revised to incorporate novel methods of disciplining subjects, than in
liberal societies in which “governmentality,” that is, a focus on “maximizing
the forces of the population collectively and individually,” was the field within
which “the thematics of sovereignty, of discipline and of biopower [were] all
relocated” (N. S. Rose, 1999, p. 23).
During the twentieth century, following the impulse first expressed (as
far as I can tell) by Xenophon, “security against risk was socialized” (N. S.
Rose, 1999, p. 158). The old virtue of prudentia to which the individual was
exhorted, for the sake of providing for his own and his family's needs, at a
certain point came to involve the prudent move of contracting private
insurance policies, which in turn were made compulsory and nationalized.
407
As the insured expand to include institutions and corporations, the social
insurance perversely contributes to a 'too big to fail' kind of moral hazard, a
new risk that we created as a direct consequence of our efforts to manage an
old risk.
As our knowledge expanded and expands, so too does our uncertainty,
which can now be quantified and experienced with an unprecedented level of
precision, thanks to recently developed theories of probability and methods of
statistical analysis. There is risk in acting and in not acting; risks in
managing prior risks (or choosing not to); risks that we can predict in
advance and risks that we cannot foresee (except insofar as we can predict
that there might be unintended consequences about which we can only
guess). As we realize things are more complicated than we thought,
impersonal risk factors lying in measurable populations rise to our attention,
and the prevailing imperative is to prevent problems before they start, if
possible, rather than treating them after they have come to fruition. This led
to preventive psychiatry. But as with each preceding stage in the process of
reflexive modernization, this maneuver will create entirely new risks, and
the controversies that result will turn ultimately on stasis points relating to
the salience, predictability, and importance of old risks compared with the
new.
408
Early Intervention Research
With the advent of preventive medicine, and in particular preventive
psychiatry, we now have sufficient context to discuss the idea of early
interventions in schizophrenia, from which the controversy about psychosis
risk syndrome directly descends. This idea has a much longer history than is
evident in the contemporary controversy.
Freud's Views on Early Diagnosis
We have seen already that Freud was keenly interested in identifying
schizophrenia as early as possible, but this was not in the interest of
treatment. The kind of damage to the nervous system that he believed
precipitated psychosis was preventable (a simple matter of stopping
adolescent male masturbation) but once symptoms were observable, it was
already too late, if in fact the cause was schizophrenia and not a more
treatable ailment like hysteria or obsessional neurosis. Writing 20 years
later, Freud displayed a different kind of concern for risk that he tied with
diagnosis and which thoroughly inverts the modern understanding:
Often enough, when one sees a neurosis with hysterical or obsessional
symptoms, which is not excessively marked and has not been in
existence for long—just the type of case, that is, that one would regard
as suitable for treatment—one has to reckon with the possibility that it
may be a preliminary stage of what is known as dementia praecox
409
(‘schizophrenia,’ in Bleuler’s terminology; ‘paraphrenia,’ as I have
proposed to call it), and that sooner or later it will show a wellmarked
picture of that affection. I do not agree that it is always possible to
make the distinction so easily. I am aware that there are psychiatrists
who hesitate less often in their differential diagnosis, but I have
become convinced that just as often they make mistakes. To make a
mistake, moreover, is of far greater moment for the psychoanalyst
than it is for the clinical psychiatrist, as he is called. For the latter is
not attempting to do anything that will be of use, whichever kind of
case it may be. He merely runs the risk of making a theoretical
mistake, and his diagnosis is of no more than academic interest.
Where the psychoanalyst is concerned, however, if the case is
unfavorable he has committed a practical error; he has been
responsible for a wasted expenditure and has discredited his method of
treatment. He cannot fulfill his promise of cure if the patient is
suffering not from hysteria or obsessional neurosis, but from
paraphrenia, and he therefore has particularly strong motives for
avoiding mistakes in diagnosis. In an experimental treatment of a few
weeks he will often observe suspicious signs which may determine him
not to pursue the attempt any further. Unfortunately I cannot assert
that an attempt of this kind always enables us to arrive at a certain
410
decision; it is only one wise precaution the more (Freud, 1913a, pp.
364–365)
Here, the disorienting suggestion that psychoanalysis is the only psychiatric
treatment that works (or that carries possible side effects) reminds us that
this is a prepharmacological era.
119
In contrast to the recent trend in
psychiatry, his motivation was to avoid an early intervention, for
schizophrenia was hopeless and attempting to treat it could only discredit
psychoanalysis. Hence the early diagnosis of schizophrenia was about
reducing risk to the profession rather than to the patient.
It is clear that already by this point, practitioners of psychoanalysis
and their more biologicallyinclined colleagues had already started to draw
interdisciplinary battle lines, reflecting perhaps the “narcissism of minor
differences” (Freud, 1989, p. 72).
120
Risk and diagnosis are caught up
together, though not in the same fashion as in psychosis risk syndrome, but
119
By prepharmacological, I am referring to the time before modern pharmacological
treatments, i.e., (major and minor) tranquilizers, mood stabilizers, and antidepressants.
The discovery of an effective treatment for acute psychosis in chlorpromazine (Thorazine)
fundamentally changed psychiatry, but certainly did not introduce the use of pharmaceutical
treatments in psychiatry (Healy, 2004b). In the late nineteenth century, alienists made
extensive use of sedatives, including camphor, chloroform, chloral hydrate, ether, hemlock,
hyoscine, hyoscyamine, hypnal (which could refer to a wide variety of substances, most often
phenazone), marijuana, morphine, paraldehyde, and potassium bromide (and other bromide
salts, the hypnotic properties of which provide the basis for the metaphor of bromide as
verbal sedative), along with many more, detailed in Daniel Tuke’s (1892) Dictionary of
Psychological Medicine (Reynolds, 1894; Ringer & Sainsbury, 1892). As Noll observed, the
“pharmacological treatment of insanity was not an innovation of the late twentieth century
by any means” (2011, p. 32).
120
Freud uses this phrase in his explanation of the “phenomenon that it is precisely
communities with adjoining territories, and related to each other in other ways as well, who
are engaged in constant feuds and in ridiculing each other” (p. 72).
411
Freud does understand a certain kind of untreatable/incurable psychosis to
exist that follows a standard declining course.
Complicating the problem of differential diagnosis is that Freud’s
division of the psychoneuroses is dimensional, while Bleuler's schizophrenia
was very much part of a categorical nosological structure. The adoption of a
categorical nosology tends to provoke controversies about 'subthreshold'
disorders:
The controversy surrounding subthreshold disorders exemplifies the
way in which classification of mental disorders influences the
definition of the discipline of psychiatry. The existence of subthreshold
disorders is a byproduct of the use of operational criteria that define
categories of mental disorders on the basis of a consensus rather than
evidence... [Problems] related to subthreshold disorders are close to
problems related to states that show some similarity to mental
disorders but are considered different from them and therefore should
not receive psychiatric treatment, such as grief reactions as well as
excessive religious zeal and related behavior (e.g., selfflagellation and
even crucifixion). (Sartorius, 2011, pp. 64–65)
Given that Freud's psychodynamic nosology is noncategorical, however, a
subthreshold disorder, if the concept is meaningful at all, is apparently more
of an opportunity than a problem.
412
Diagnostic AntiFatalism: Schizophreniform Disorder
Schizophrenia has always signified a fatalistic course, even before it
was called schizophrenia. This semiotic identity has been rather immune to
falsification. Sometimes psychiatrists observe cases that seem like
schizophrenia, but resolve in less than half a year. This is a phenomenon (or
set of similar phenomena) now known as schizophreniform disorder, the
characteristic symptoms of [which] are identical to those of
schizophrenia... Schizophreniform disorder is distinguished by its
difference in duration: the total duration of the illness, including
prodromal, active, and residual phases, is at least 1 month but less
than 6 months. (American Psychiatric Association, 2013, p. 97)
Shorter still is brief psychotic disorder, which resolves in less than a month
(p. 94). It may seem odd to have a diagnostic category that has its own
resolution as its distinguishing clinical sign (since this sign cannot be
observed until after the expertise of a physician is no longer required), but in
practice it is diagnosed provisionally until the symptoms have lasted six
months, at which point the diagnosis is changed to schizophrenia: “the
diagnosis should be noted as 'schizophreniform disorder (provisional)' because
it is uncertain if the individual will recover from the disturbance within the
6month period” (p. 97). In other words, the diagnosis itself is a category
designed for targeting potentially schizophrenic individuals for early
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intervention. Apparently the diagnosis is accurate (i.e., a patient given the
diagnosis in fact recovers within six months) about onethird of the time,
while the “majority of the remaining twothirds of individuals will eventually
receive a diagnosis of schizophrenia or schizoaffective disorder” (p. 98).
121
Schizophreniform disorder was first so called by Gabriel Langfeldt,
who wanted to distinguish those whose apparent psychotic states were
precipitated by a stressful life event from those who exhibit psychosis without
any apparent exogenous cause (Langfeldt, 1939). This is the same distinction
as Freud made using slightly different terms, and the core idea seems to be
that etiologically endogenous illness must have a strictly biological
pathogenesis, while etiologically exogenous illness must have a strictly
psychological pathogenesis, and so the latter was treatable (with
psychoanalysis) while the former was not, a view that changed sharply with
the discovery of the antipsychotic properties of the phenothiazine compound
chlorpromazine (Thorazine) in the 1950s (Healy, 2004b).
This distinction repeated with depression (distinguishing 'endogenous
depression' from 'reactive depression,' where the word reactive refers to a
neurotic reaction of the kind described by Freud), and was rather obscure
121
Schizoaffective disorder is similar to schizophrenia except that the psychotic symptoms
are very often (though occasionally not) accompanied by the symptoms of a mood disorder. If
the psychotic symptoms are always accompanied by the symptoms of an affective disorder,
then the proper diagnosis is either 'depressive disorder with psychotic features' or 'bipolar
disorder with psychotic features' (American Psychiatric Association, 2013, pp. 105–110). The
meaningfulness of such distinctions has been questioned, but is generally upheld (Maier et
al., 1992, 1993; Taylor, 1992).
414
until the discovery of the first tricyclic antidepressant imipramine (Tofranil)
by Kuhn (1958), who indicated it was an effective treatment for endogenous
depression (Healy, 1997). For the most part, DSMIII eliminated diagnostic
terms that implied an etiological theory (though see the discussion of
conversion disorder in Chapter 3), and the current consensus is that mental
illnesses previously thought to be 'endogenous' are usually precipitated by
stressors, and conversely, mental illnesses preceded by stressors usually have
a biological pathogenesis of some sort (Keller, Neale, & Kendler, 2007;
Kendler & Gardner, 2010; Kendler & Halberstadt, 2013). Furthermore, most
of the states that Langfeldt identified as schizophreniform disorder would
now be diagnosed as mood disorders (P. J. Cowen et al., 2012). But the name
schizophreniform disorder remains, along with the basic idea of trying to
distinguish, in cases of recent first psychosis states, those with a good
prognosis from those with a bad prognosis.
122
Early Intervention for Psychosis
Frequently in recent discussions about psychosis risk syndrome in the
context of DSM5, it is asserted that research programs aimed at identifying
individuals at high risk of developing psychosis began in the late 1990s. For
example:
122
Though not sufficient to make twoway predictions with any reasonable degree of
confidence, it is apparent that the absence of symptoms from the negative axis, as well as
good eye contact when being interviewed, are “good prognostic features” (American
Psychiatric Association, 2013, p. 97; Troisi, Pasini, Bersani, Mauro, & Ciani, 1991).
415
For the past 15 years, wellintentioned research efforts have sought to
identify individuals at highest risk to develop a psychotic disorder
(usually based on the presence of transient or attenuated positive
symptoms) and to develop effective early interventions for adolescents
and young adults at risk. (Pierre, 2013, p. 115)
Defenders of these efforts seem to use this 'fact' to emphasize the cutting
edge nature of this research; detractors similarly use the assertion to
emphasize the novelty of the idea, which they contend is wellintentioned but
“not ready for prime time” (Frances, 2010d, para. 14). The suggested
chronology, however, is not precisely accurate.
123
More than 75 years ago, researchers were aware that it may be
possible to diagnose schizophrenia early, and concerned themselves with
questions about diagnostic criteria and early intervention strategies.
Cameron suggested that
antedating the clinically recognizable symptoms there is a group of
behavior changes which we refer to as nonspecific... These non
specific symptoms persist for periods ranging from weeks to years
before the onset of the specific schizophrenic symptoms and were
123
I say 'not precisely' because it is accurate to say that this research has been in progress for
the past 15 years, but it is inaccurate to imply that these efforts began only 15 years ago; the
true number is more than double that. Interestingly, at nearly every period of time going
back to the mid 1950s, when researchers indicated the length of time research into some
form of psychosis risk had been going on, the length invariably was between 15 and 20 years.
I can only speculate as to the causes of this observed trend.
416
described in 83 of our 100 cases... We have tried to see in what
environment the patient is during these early stages and how the
various people around him during this time—his relatives and friends,
his employer and his physician—react to his growing abnormality.
Finally we have considered the development of certain social trends—
the growing acceptance of routing health examinations and the
increasing utilization of general hospitals for psychiatric treatment—
which may be of immense importance in the satisfactory detection and
treatment of early schizophrenia. (D. E. Cameron, 1938, pp. 568–569,
577)
Two decades later, a study was announced in Detroit in which researchers
test[ed] and interview[ed] a group of normal children... From these
tests and interviews, we shall predict which of these children will
become schizophrenic... If our predictions prove to be supported, we are
then in a position to do research which is aimed at the prevention of
schizophrenia. (Mednick, 1960, p. 69)
Twenty years later, in May of 1980, the same year that saw publication of
DSMIII, the National Institute of Mental Health (NIMH) sponsored a
conference at the University of California, Los Angeles, entitled: “Preventive
intervention in schizophrenia: Are we ready?” (Goldstein, 1981, p. i). This
followed the establishment in 1979 of an 'Office of Prevention.' Herbert
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Pardes, then director of NIMH, in the foreword to the proceedings from this
conference, seemed to answer in the affirmative (in contrast to most of the
papers given):
For more than three decades, the National Institute of Mental Health
has conducted and supported a broad spectrum of research programs
to add to our knowledge and understanding of schizophrenia. A major
focus of this work has involved diagnostic issues... Research
emphases... have been directed toward... studies of individuals and
populations hypothesized to be at high risk for the disorder... While
the core mystery of schizophrenia continues to challenge researchers
and clinicians, the incremental advances... constitute impressive
overall progress As information accumulates, so does the possibility
that we can intervene earlier and more effectively, aiming at
prevention of the premonitory signs of the disorder rather than at
signs which indicate the disorder has taken hold. (Pardes, 1981, p. iii)
Notice that Pierre and Pardes, writing thirtytwo years apart, employ very
similar language. Also significant in this passage is the oracular rhetoric –
the 'core mystery' of psychosis is still intact, but our seers are divining the
'premonitory signs' of the disorder. Similarly, Cowen argues that like “moths
attracted to a flame, our relentless quest has been to solve the riddle of
profound psychological disorder... [Recent] 'advances' notwithstanding, the
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mysteries of extreme disorder are still not unraveled” (E. L. Cowen, 1981, p.
180). This kind of gnostic (or should I say prognostic) and esoteric mystery
tradition language is less common in recent discussions on the topic.
A variety of perspectives are expressed in the papers given at this
conference, and many of them can be read as epideictic praise of and
exhortation to primary prevention. Primary prevention was defined in the
following way:
(1) Identify something worth preventing, and develop reliable methods
to differentiate victims from nonvictims; (2) Through epidemiological
and laboratory studies, locate its most probable cause(s); (3) Mount
and evaluate programs to circumvent those causes... That model has
well served society's efforts to stamp out oncebaffling, devastating
disorders, such as smallpox, malaria, diphtheria, typhoid fever, and
polio... Indeed, the very successes of the model have sustained it, won
it recognition and plaudits, and helped to extend it to new domains in
which, unfortunately, it may be less applicable. (E. L. Cowen, 1981, pp.
178–179)
One author suggests that there “are probably few issues of greater scientific,
social, and humanitarian importance” (Holzman, 1981, p. 19). Samuel Keith
emphasized the exigence of the research by describing the “individual,
familial, and clinical despair” that this “heartbreaking condition” brings
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about: Even thirty years after the discovery of the antipsychotic properties of
chlorpromazine, there “is no term in all of mental illness that elicits more
fear, pessimism, or therapeutic nihilism than chronic schizophrenia” (Keith,
1981, p. 306). Michael Goldstein, the first director of the thenrecently
christened NIMH Office of Prevention, notes that primary prevention is of
particular importance for schizophrenia because “a schizophrenic episode is
so disorganizing and recovery so arduous and unpredictable” (Goldstein,
1981, p. v).
Warnings and admonitions on the subject were also offered. Asarnow
and Asarnow (1981) remind their audience about the failures of the Mental
Hygiene movement, emphasizing the “importance of deriving our attempts at
preventive intervention for schizophrenia from the best available research
evidence concerning the nature of the central deficits in schizophrenia” (p.
91). One participant bemoaned the emphasis on biology at the expense of
communication, arguing:
The studies of communication in families has [sic] revealed that there
appear to be certain simple, fundamental properties of transactions
which, when they proceed well across time, promote human growth
and wellbeing. When these communication properties go astray, the
cost is high. (Singer, 1981, p. 173)
Another participant warned that the DSM criteria pose a fundamental
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barrier to effective primary prevention research, and antiprophetically
suggested that “the identification of the psychiatrist and things psychiatric
with the DSM approach may be loosening” (Cromwell, 1981, pp. 119–120).
Keith suggested that “we are probably doing ourselves a disservice by
confining to schizophrenia the impact of the past 20 years of research in high
risk,” because the true object of preventive efforts ought to have been on the
psychosocial and institutional barriers that frustrate the efforts of chronically
mentally ill patients to become “fully functioning members of society” (Keith,
1981, pp. 305–306). He also noted a logical problem with the overall primary
prevention research program:
[The] more closely an individual behavioral item is related to
diagnosable schizophrenia, the more risk we run of creating a
tautology. Those people who have “symptoms” of incipient or
impending schizophrenia can be predicted to have a very high risk
indeed of developing the disorder. The challenge to prevention
programs will be in developing specific interventions to correct for
maladaptive behavior patterns before the fullfledged disorder becomes
manifest and to obviate the necessity for secondary prevention. (p. 307)
Finally, he admonished his colleagues to remember that “if our interventions
are powerful enough to create something good, then they are powerful
enough, if used inappropriately, to create something bad” (p. 309).
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With the exception of this last, brief point, none of the papers dwell on
the issues of the unnecessary stigmatizing and medicating of 'false positive'
individuals raised by current critics of psychosis risk syndrome. Perhaps this
was related to the fact that virtually all proposed interventions were psycho
social in nature, with the exception of a single paper (Friedhoff, 1981) that
discussed injecting high doses of haloperidol into pregnant rats and then
dissecting and measuring the brains of the newborn rats a week after they
were born (but even in this paper the objective was theoretical and the author
did not suggest or even gesture toward the idea that pharmaceutical
intervention was appropriate for humans).
At this point, it is important to note that specific intervention
strategies were still in their infancy, and the focus almost entirely placed on
thinking about how to identify people for targeted interventions. Preventive
intervention strategies can be subdivided into three categories: universal
interventions that target the general population (e.g., seat belts, general
vaccinations, sanitation, etc.); selective interventions that target a subgroup
at risk (e.g., mammograms for women with family history of breast cancer);
and indicated interventions that target individuals who can be identified on
the basis of some specific manifest sign(s) or symptom(s) that can be
measured on an individual basis and suggest the very early stages of a
disorder or illness (Gordon, 1983). The line between the latter two categories
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is blurry, but a key dividing line is that those in the 'selective' category are
for asymptomatic patients, while those in the 'indicated' category have
“minimal but detectable signs or symptoms foreshadowing mental disorder,
or biological markers indicating predisposition for a mental disorder”
(Mrazek & Haggerty, 1994, p. 8). This suggests that it is necessary to
carefully articulate what is meant when it is suggested that someone is 'at
risk' for a disorder.
Theoretical Perspective of Patrick McGorry
One individual in particular seems to be close to the center of much of
the development of research into psychosis risk during the last two decades,
prolifically publishing on the subject and frequently named as its chief
exponent: the Australian psychiatrist Patrick McGorry. Before beginning his
work on early interventions, McGorry published an article in which he
challenged the “dominant neoKraepelinian paradigm” and instead offered a
model of psychosis called the “loose linkage model” (McGorry, 1991, p. 43).
McGorry complained about the failure of researchers working within the
constraints of the current model to elucidate the etiology or pathogenesis of
schizophrenia:
With each passing year, it becomes more of a paradox that, despite
exponential growth in knowledge in the neurosciences, the
pathogenesis of this group of disorders remains obscure. Nevertheless,
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the expectation that a breakthrough is imminent has been with us for
some time and continues to build. The rise of biotechnology certainly
holds out the promise that, if such technology could be appropriately
deployed, it would merely be a matter of time before the psychoses
would be forced to yield up their secrets; yet there is a growing sense
that it is perhaps no longer the crudeness of the research techniques
which is causing the delay. (McGorry, 1991, pp. 43–44, my emphasis)
The esoteric rhetoric recalls that of Cowen (1981) a decade before, and the
emphasis on the sense of discontinuity between the crude or primitive past
and the advanced scientific present can also be seen in the ways in which
antipsychotics were marketed in the first three decades after their discovery,
as we saw in Chapter 3.
McGorry argues that the key assumptions of the neoKraepelinian
framework are problematic. One assumption in particular stands out: that
“clinical boundaries can be drawn reflecting specific underlying disorders of
pathophysiology, and it is assumed that we already have an accurate idea of
the location of these 'joints' at which nature should be carved” (McGorry,
1991, p. 45). This observation recalls a metaphor in Plato's Phaedrus, in
which Socrates discusses the use of rhetoric to account for the different kinds
of madness systematically, noting that the key task is to “cut up each kind
according to its species along its natural joints, and to try not to splinter each
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part, as a bad butcher might do... [Our speeches] placed all mental
derangements into one common kind” (Plato, 1997c, sec. 265e).
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The neo
Kraepelinian model identifies the location of these 'natural joints' by looking
at clusters of symptoms, which works rhetorically to persuade psychiatrists
implicitly that there is a “close linkage of symptomatology with underlying
disease process” (McGorry, 1991, p. 45). This process is implicit because, as I
discussed in Chapter 1, DSMIII explicitly disclaimed any connection
between diagnostic categories and aetiopathological knowledge.
This belief guided research into vulnerability factors, as the search
tried to find biological phenomena that varied more between (neo
Kraepelinian defined) groups than within groups. McGorry suggests that
this belief was reinforced by a story about the historical discovery of the
etiology of neurosyphlis which he regards as mythical and factually wrong.
He further subtly suggests that the neoKraepelinian nosological approach to
schizophrenia is itself schizophrenic, “displaying the 'splitting' tendency in
classification... [which] has been termed 'splitomania'” (p. 46). To return to
the Platonic metaphor, McGorry would see this 'splitomania' as missing the
'natural joints' and producing many 'splinters.' McGorry notes that “despite
supportive research findings... [a dimensional model] has failed to displace
124
μ , μ τὸπάλινκατ᾽εἴδηδύνασθαιδιατέ νεινκατ᾽ἄρθραᾗπέφυκεν καὶ ὴἐπιχειρεῖν
μ μ , μ μ : καταγνύναι έρος ηδέν κακοῦ αγείρουτρόπῳχρώ ενον ἀλλ᾽ὥσπερἄρτιτὼλόγω
μ ... τὸ ὲνἄφροντῆςδιανοίαςἕντικοινῇεἶδοςἐλαβέτην
425
the categorical approach in the psychoses” (p. 47). He discusses several
possible reasons, and then suggests that a hybrid categorical/dimensional
model is needed. His “loose linkage model” is based on previous theoretical
work by Jaspers (1963) and Brockington and Meltzer (1983). It posits that,
due to the complex relationship between the manifest symptoms of psychosis
and the underlying pathophysiology, “a close or constant linkage between
symptom patterns and changes at the anatomical or physiological level is
unlikely” (McGorry, 1991, p. 48). Finally, he predicted a very poor prognosis
for the concept of schizophrenia: “its days as a candidate for disease entity
status and diagnostic term are numbered, and its demise is merely a matter
of time” (p. 53).
Shortly after this theoretical work, McGorry initiated a vast research
program into secondary prevention of schizophrenia and other psychotic
disorders at his new clinic, the Early Psychosis Prevention and Intervention
Centre (EPPIC), informed by the prodrome interpretation of psychosis risk
(Lincoln & McGorry, 1995; McGorry, 1992, 1993, 1994, 1995). He argued for
a phaseoriented classification of psychosis rather than a prognosisbased
classification, arguing that the latter is worse than useless because
iatrogenic effects of applying a diagnosis which connotes in the mind of
the clinician, the relatives and the sufferer a prospect of prolonged
pervasive disorder, disability and even inevitable deterioration... can
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be appreciated by any clinician who has witnessed the impact of this
unnecessarily threatening diagnostic process on patients and families.
(McGorry, 1995, p. 556)
The phaseoriented classification is still coursebased to some extent, but
emphasizes the dimension of staging, and can allow biological research to
focus on the stage of 'early psychosis' and help to identify the
psychopathological mechanisms at work during the 'critical period' that
determines whether a patient is going to have prolonged psychosis or not.
Shortly after this study, McGorry began working with Alison Yung on
elucidating the nature and clinical features of the prodromal phase (Yung et
al., 1996; Yung, Phillips, & McGorry, 2004; Yung & McGorry, 1996a, 1997).
The two would continue to work together on this problem for the next two
decades. Two key research questions concerned how to define the beginning
of illness (the onset of the prodromal phase), which requires an analysis of
the difference between 'abnormality' and 'normality,' and how to define the
point at which the prodrome ends and the “definitive disorder” begins (the
onset of frank psychosis) (Yung, Phillips, & McGorry, 2004, p. 12). They
defined eight categories of prodromal symptoms: neurotic symptoms (anger,
anxiety, irritability, restlessness); moodrelated symptoms (anhedonia,
depression, guilt, mood swings, suicidal ideation); volitional symptoms
(apathy, boredom, fatigue); cognitive symptoms (attentional/concentration
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problems, daydreaming, neurocognitive deficits, preoccupations, reduced
abstraction, thoughtblocking); physical symptoms (appetite problems, sleep
disturbances, somatic complaints, weight loss); attenuated/subthreshold
psychotic symptoms (changes in affect, changes in motility, changes in sense
of self or others or the world, perceptual disturbances, suspiciousness); other
symptoms (dissociative phenomena, interpersonal sensitivity, obsessive
compulsive phenomena); and behavioral changes (aggressive or disruptive
behavior, deterioration in rolefunctioning, impulsivity, odd behavior, social
withdrawal) (Klosterkötter, Ebel, SchultzeLutter, & Steinmeyer, 1996, p.
149; Yung & McGorry, 1996a; Yung, Phillips, & McGorry, 2004, p. 21).
McGorry and his colleagues investigated an array of different
interventions, focusing predominantly on cognitivebehavior therapy (CBT),
omega3 fatty acid supplements (generally from fish oil), and, “in those who
fail to respond to initial intervention with gentler therapies,” pharmacological
therapy involving “broadspectrum antipsychotics with minimal side effects,
[which] ...may still have a place in delaying or preventing psychosis onset,”
especially risperidone (Larson, Walker, & Compton, 2010; McGorry et al.,
2009, p. 1210; Stafford, Jackson, MayoWilson, Morrison, & Kendall, 2013;
van der Gaag et al., 2012; Yung, Phillips, & McGorry, 2004). Other, less
commonly used interventions include glycine treatment (Woods et al., 2013),
family therapy (Bird et al., 2010), psychoeducation (Hauser & Juckel, 2012;
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McFarlane, Lynch, & Melton, 2012), and skills training (Kecmanović, 2011;
F. Singh, DeJoseph, & Cadenhead, 2014). Some of these proposals are
obviously more controversial than others, and it is sometimes difficult to
determine what enters into the 'clinical judgment' used to decide which
intervention is most appropriate. Nevertheless, McGorry and his colleagues
did not use or endorse antipsychotic interventions unless they were
warranted by the presence of some specific symptom or complaint for which
antipsychotic medication would be indicated, keeping in mind also that
everyone included in any of their studies was helpseeking to begin with (T.
Jones, 2011; McGorry, 2011; McGorry et al., 2009).
Psychosis Risk Syndrome and DSM5
In 2009, the Psychotic Disorders Work Group recommended the
diagnosis of ‘psychosis risk syndrome’ for inclusion in DSM5. This set off a
firestorm of controversy. Before the disorder was proposed for inclusion, the
hypothetical diagnostic category was largely uncontroversial: Research still
needed to be done, but just about everyone who was concerned enough to
publish on the subject seemed to be in favor of the idea of early interventions,
simply because the overriding sentiment across various nosological
paradigms was that disability accumulates as psychotic disorders progress,
creating a ceiling on the quality of the eventual recovery. In other words, it is
generally conceded by virtually all controversy partners that in the
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progression of psychotic disorders, the earlier one is treated, the better
chance they have a meaningful recovery, while, when a psychotic disorder
progresses long enough without treatment, they will reach a point where
recovery probably is impossible. The proposal to include psychosis risk
syndrome as an official diagnostic entity in DSM5, however, changed
everything, perhaps provoking more controversy than any other proposed
diagnosis. This is in spite of the fact that there is a consensus about the key
technical aspects of the controversy, i.e., how accurately we can predict future
psychosis and how effectively we can prevent psychosis through intervention.
Psychosis Risk Syndrome Formalized
As conceptualized by the Psychotic Disorders Work Group, psychosis
risk syndrome is “a condition with recent onset of modest, psychoticlike
symptoms and clinically relevant distress and disability” (American
Psychiatric Association, 2012c, para. 2). A patient so diagnosed is not frankly
psychotic: Though some psychotic symptoms may be present in milder form,
they would be recognized as such because the patient's capacity for reality
testing would be relatively intact (Paris, 2013b).
The official DSM5 diagnostic features of this “not officially recognized”
disorder lend themselves to two parallel readings due to inherently
ambiguous linguistic choices. On one hand, one could see the description of a
very disturbed individual whose connection with reality becomes increasingly
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tenuous by the day; on the other hand, one could just as plausibly read the
description as the typical weirdness of “midtolate adolescence or early
adulthood,” the syndrome's usual age of onset. The patient, and/or his or her
family and friends, have noticed “changes in experiences and behaviors...
suggesting a change in mental state.” These changes can take a few forms.
Regardless of the specific symptoms experienced, the patient “maintains
reasonable insight into the psychoticlike experiences and generally
appreciates that altered perceptions are not real” (American Psychiatric
Association, 2013, pp. 784–786).
The first general category of psychoticlike symptoms that the patient
may have are “attenuated delusions,” which differ from true delusions (fixed
beliefs that are maintained in spite of overwhelming evidence to the contrary)
in that “reality testing and perspective can be elicited with nonconfirming
evidence.” For example, the patient may have a “propensity for viewing the
world as hostile and dangerous,” or might “[harbor] notions of being gifted,
influential, or special,” perhaps resulting in “unrealistic plans and
investments,” though the individual can be made to express skepticism about
these attenuated delusions with “persistent questioning.” Second, the patient
might have “attenuated hallucinations,” possibly seeing some phantom
movement or false shadow in his or her peripheral vision, or perhaps hearing
some faint murmuring or rumbling, which the patient regards as “unusual or
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puzzling,” but which is not experienced with the full force of normal
perceptions and is not believed to be real (American Psychiatric Association,
2013, pp. 783–784).
The third psychoticlike symptom variant is an attenuated version of
the “disorganized communication” of psychosis. The 'disconnection from
reality' involved in this symptom differs from that in the first two, as they
constitute a disconnection from objective reality, while disorganized
communication constitutes a disconnection from intersubjective reality. In
acute schizophrenia, disorganized communication may manifest as catatonic
nonresponsiveness, or grossly illogical or incomprehensible speech that is
completely disconnected from attempts at conversation. For example,
Kraepelin (1917) described a patient who
when asked where he is, responds with “You want to know that too; I
tell you who is being measured and is measured and shall be
measured. I know all that, and could tell you, but I do not want to.”
When asked his name, he screams, “What is your name? What does he
shut? He shuts his eyes. What does he hear? He does not understand;
he understands not. How? Who? Where? When? …How can you be
so impudent? I'm coming! I'll show you! You don't turn whore for me...
How they attend, they do attend,” and so on. At the end he scolds in
quite inarticulate sounds... He speaks in an affected way, now babbling
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like a child, now lisping and stammering, sings suddenly in the middle
of what he is saying, and grimaces.” (pp. 77–78)
In contrast, a patient suffering from the attenuated “psychosislike” variant
of this symptom might use speech that is “vague,” “metaphorical,” “muddled,”
“off track,” or “meandering;” although clearly understandable, in “severe”
cases “the individual fails to get to the point without external guidance” or
may have trouble coming up with the right word, “especially when the
individual is under pressure, but reorienting questions quickly return
structure and organization to the conversation.”
Psychosis Risk Syndrome as Representative Anecdote
For many critics, psychosis risk syndrome was an exemplar case of all
the excesses of DSM5. Expressing a level of vehemence fairly typical of the
polemics on either side of the controversy, Allen Frances sharply denounced
the proposal, even while acknowledging his interlocutors' good intentions:
1) The “risk syndrome” would misidentify many (somewhere between
39) kids for every one correctly identified; and 2) the treatment most
likely to be offered has no proven efficacy, but can have extremely
dangerous complications. This is clearly the prescription for an
iatrogenic public health disaster. The goal of early identification and
proactive treatment in psychiatry is laudable—but elusive and not
currently attainable. Prevention requires having a happy combination
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of accurate identification and effective and safe treatment. Instead, we
now have the opposite dangerous combination: wildly inaccurate
identification with a likely ineffective but definitely risky treatment.
(Frances, 2010c, para. 9–10; my emphasis)
I contend that the firestorm surrounding this proposed disorder was due in
part to the wide range of contested issues that are entangled in the debate
about its risks and benefits. I conceptualize the disorder as a Burkean
representative anecdote, a case exemplifying a terministic screen in which a
special vocabulary is united with a motivational calculus “supple and
complex enough to be representative of the subject matter it is designed to
calculate. It must have scope. Yet it must also possess simplicity, in that it
is broadly a reduction of the subject matter” (Burke, 1969a, p. 60). Psychosis
risk syndrome entails all or nearly all of the concepts and assumptions
involved in the dominant view of psychosis in contemporary psychiatry, the
approach to risk management in preventive psychiatry, and as can be seen in
McGorry's corpus, the latent conflicts and unresolved ambiguities embedded
in the epistemic compromise on which DSM rests.
Terministic Screen, Interpellation, and Stigma
The terministic screen metaphor is visual in nature, referring to
optical filters that can be applied to photographs. Such filters make it
possible to modify images so that they represent reality as conceived by the
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photographer. Filters accomplish this by selecting some aspects of the
captured image (e.g., color balance, contrast, etc.) to be featured and other
aspects are excluded:
I have particularly in mind some photographs I once saw. They were
different photographs of the same objects, the difference being that
they were made with different color filters. Here something so
“factual” as a photograph revealed notable distinctions in texture, and
even in form, depending upon which color filter was used for the
documentary description of the event being recorded. (Burke, 1969a, p.
45, emphasis in the original)
Following Burke's metaphor, the relevant 'photographs' of adolescents being
evaluated for psychosis risk syndrome come in the form of case reports in
which biographical narratives are organized into 'symptoms' of the syndrome,
each of which is reduced to a numerical score representing the degree to
which the psychotic symptom is attenuated. Each symptom is conceived as a
continuous quantifiable continuum from 'normal' to 'psychotic' (the actual
scales used vary by clinic). Any quirky or unusual characteristic of the
'patient' is thus seen only as an attenuated expression of psychosis. If a
teenager views herself as especially creative or gifted, a psychiatrist looking
through the lens of attenuated psychosis sees very mild grandiosity (a subset
of delusional thoughts; a psychotic patient with delusions of grandeur, for
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example, might selfidentify as Jesus). Hence, the process of revealing a risk
factor involves the corresponding concealing of nonmedicalized
interpretations of the 'patient's' personality traits, beliefs, and subjective
experiences.
A diagnosis of psychosis risk is not simply a passive label that only
functions to indicate a clinical judgment about the probability that a
particular pathological course will present in the patient so diagnosed.
Following Althusser (1994), I contend that the act of psychiatric diagnosis is
a “ritual of ideological recognition…[that] hails or interpellates concrete
individuals as concrete subjects” (p. 130). Correspondingly, the DSM
functions as an ‘ideological state apparatus,’ a relatively autonomous
superstructural edifice that controls and regulates the working knowledge
necessary to navigate the concrete and material network of mental health
institutions. A diagnosis designates the subject identity that constitutes a
patient’s selfrepresentation for all social relationships and connected
practices within this network. By accepting a diagnosis, patients produce
imaginary accounts of their relationship to the real world, and the image of
those accounts makes up the currently dominant biopolitical ideology.
This has long been the case, and it certainly is not limited to the
domain of mental health. Furthermore, it is not necessarily a negative trend
in world history. As we will see in Chapter 4, a reified diagnosis can be
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alienating while simultaneously serving as a basis for solidarity formation.
Furthermore, most individuals who will receive a DSM5 diagnosis at some
point are suffering, and the diagnosis opens new opportunities for relief.
Nevertheless, the diagnosis of a risk syndrome extends the totalizing reach of
this ideological formation, for good or ill. There is a nonzero probability that
any given person is in the early, presymptomatic phase of some mental
illness. This is all the truer given the trend toward viewing the symptoms of
mental illness as falling on a relatively smooth continuum between normalcy
and insanity.
For Althusser, the act of interpellation by its very nature is never
recognized by the individual as a process of transformation by which they
receive their subject position. Instead, individuals misrecognize the event as
a confirmation of their “alwaysalready” status as subjects (Althusser, 1994,
p. 130). Upon receiving the initial diagnosis, the patient did not just become
‘depressed’ or ‘bipolar’ in her mind; that’s how she’s always been, and now she
has a name for it, a way to make sense of it and to relate to others. This new
identity and set of terms with which one can finally put into words the
heretofore ineffable psychic distress that led to the diagnosis are the
discursive mechanisms by which the misrecognition of interpellation occurs.
From the “evidentness of the subject” proceeds the “evidentness of meaning,”
which is further confirmed by the institutional checking of identity that
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occurs every time the patientsubject fills a prescription, makes an
appointment, or makes a health insurance claim (Pêcheux, 2012, p. 147,
emphasis in the original). The diagnosis of psychosis risk syndrome, then,
has the potential to transform the selfconcepts of patients according to
autobiographical narratives governed by the terministic screen of attenuated
psychosis.
Risks of Psychosis Risk Syndrome
The magnitude of the potential impacts on either side of the
controversy is high. All parties involved concede that all courses of action
will both help and harm, though they disagree on the ratios. These
differences are not quantitative, but qualitative. On one hand, with a three
year ‘false positive’ rate of 68%, treatment options that include the atypical
antipsychotic drugs aripiprazole (Abilify), olanzapine (Zyprexa), and
risperidone (Risperdal), and children as the target population, the diagnosis
is depicted as a recipe for drugging all the children not already on
psychostimulants for ADHD with major tranquilizers, with the full
knowledge that the vast majority of children treated would not have become
psychotic if left untreated. On the other hand, given that a diagnosis of
schizophrenia very often means a life of partial or full disability, early
interventions have been shown to be very effective in preventing psychosis,
and no patient can (currently) receive the diagnosis without first being help
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seeking, critics of the diagnosis are depicted as paranoid, vaguely Szaszian
opponents of medical progress. Both sides concede that there is a great deal
of uncertainty about how the diagnosis would be deployed by nonspecialist
clinicians and research departments of pharmaceutical corporations. Which
risk is the biggest?
False Positives and the Rhetorical Ontology of Risk
The issue of socalled false positives has been at the forefront of the
controversy. The predictive validity of the selection criteria for diagnosing an
ARMS or a psychosis prodrome has been one of the chief concerns of early
intervention researchers (Cannon, Cornblatt, & McGorry, 2007; Yung, Fusar
Poli, & Nelson, 2012; Yung, Nelson, Thompson, & Wood, 2010; Yung, Phillips,
& McGorry, 2004). A fairly consistent finding that, with the best criteria that
have been developed, about onethird of those identified will transition to
frank psychosis within two years, although one longitudinal study
determined that after eight years more than 50% of the identified individuals
had received a psychotic disorder diagnosis (Chuma & Mahadun, 2011;
Frances, 2010c; Kecmanović, 2011; Thompson, Nelson, & Yung, 2011; Yung &
Nelson, 2011; Yung, Phillips, & McGorry, 2004). Yung and McGorry also
conceded that “the onset of psychosis is arbitrarily defined and does not differ
qualitatively from subthreshold psychosis,” raising a fundamental epistemic
problem (Yung & McGorry, 2007, p. s1). Indeed, Parnas (2005) suggests that
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this is “not only a psychometric problem, but a theoretical issue intimately
associated with the conceptual validity of schizophrenia, that is what we take
schizophrenia to be in the first place” (p. s112).
It gets worse. It turns out that as time went on, the 'false positive' rate
of every clinic seemed to get worse, as they became more wellknown and
were referred more marginal cases (Yung et al., 2003). This points to the fact
that these clinics are all highly specialized and run by psychiatrists whose
careers have been devoted to psychosis risk. We know what happens when
those psychiatrists try to predict psychosis. What would happen if regular
psychiatrists, or worse, primary care physicians, were to try to apply the
same criteria? This gets at a basic distinction between risk and uncertainty.
For contemporary theorists, risk entails the quantification of probabilities,
while with uncertainty, “We know that we do not know, but that is almost all
that we know” (Callon et al., 2009, p. 21). Yet amidst the uncertainty, there
is calculation. If there is a problem in specialized clinics, then, a fortiori,
regular psychiatrists and general practitioners should be even less accurate
(bracketing off the question of what the pharmaceutical industry will do to
change the way the category is put into practice). Even the most ardent
proponents of early interventions concede that the risk is substantial
(McGorry, 2011). Frances suggests that “the false positive rate would jump...
to about 90 percent in general practice. This means that as many as an
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astounding nine in ten individuals identified as 'risk syndrome' would not
really be at risk for developing psychosis” (Frances, 2010c, para. 4). This
would expose a potentially large population to risks that “include
unnecessary fear of illness, restriction of life goals, use of medication and
their sideeffects” (Warner, 2005, p. s104).
But whether an individual case of nontransition to frank psychosis
within a set time period should be regarded as a 'false positive' depends on
the rhetorical ontology of the 'at risk state.' The issue rests on what Prelli
calls an 'interpretivedefinitional' stasis point – that is, “What does construct
y mean?” (Prelli, 1989, p. 146). One frequent topic of discussion at the UCLA
conference over thirty years ago was this metaphysical question: what exactly
is meant when an individual is said to be 'at risk' or 'at high risk' of
developing a psychotic disorder? I contend that there are essentially three
basic interpretations of psychosis risk, and an additional interpretation that
is a permutation of two: (1) a confluence of risk factors that are neither
necessary nor sufficient for psychosis but increase the probability that an
individual will later meet the diagnostic criteria for a psychotic disorder; (2)
vulnerability, a trait that makes an individual particularly susceptible to
developing a psychotic disorder; (3) a prodrome or prodromal phase that
precedes psychosis in those destined (barring an intervention of some sort) to
become psychotic; and (4) a combination of the prodrome and risk factors
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interpretations, which treats the phenomenology of the prodrome as a state
risk factor (an 'at risk mental state') for developing a psychotic disorder in the
future (Table 1).
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Table 1: Interpretations of Psychosis Risk Syndrome
Interpretation
of psychosis
risk syndrome
Risk factors Vulnerability Prodrome
'At Risk
Mental State'
Pathogenesis Exopathogenic Endopathogenic Endopathogenic Endopathogenic
Dominant
theory
of probability
Frequentist Propensity Evidential/
Bayesian
Evidential/
Bayesian
Object of
probabilistic
prediction
Population of
patients
Individual
patient
Individual
patient
Individual
patient
Will correctly
identified
individuals
become
psychotic
absent
treatment?
Not necessarily,
and probably not
Not necessarily,
but probably
Yes Not necessarily,
and probably not
What is the
inferential
object of
probability?
Likelihood that
someone
correctly
diagnosed
develops
psychosis
Likelihood that
someone
correctly
diagnosed
develops
psychosis
Likelihood that
the diagnosis is
accurate
Likelihood that
someone
correctly
diagnosed
develops
psychosis
Implicational
relationship to
the emergence
of psychosis
Neither
necessary
nor sufficient
Necessary, but
not sufficient
Sufficient, and
may or may not
also be necessary
Neither
necessary
nor sufficient
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I shall provide examples of each of these interpretations, discuss their
presence in the recent debate surrounding DSM5, and explain why the
failure of the majority of interlocutors to carefully define their terms or
acknowledge the existence of alternative interpretations made much of their
debate incoherent.
(1) Risk Factors Interpretation
Arnold Friedhoff introduces the issue and explains its importance,
mentioning as popular an interpretation grounded in frequentist probability:
Before addressing the issues of risk measurement and modification, it
is necessary to have a precise understanding of the word, “risk.”
“Highrisk group” generally is taken to mean a group in which some
members will eventually develop the condition in question, while
others will not. Thus, preventive intervention or risk modification
carried out with members of a highrisk group will invariably be
applied to some individuals who would not have developed the
condition in the first place, inasmuch as those actually at risk may not
be distinguishable from those potentially at risk until sometime after
the preventive intervention has been carried out. (Friedhoff, 1981, p.
39)
As basic and as reasonable as this seems, such a discussion is remarkably
underdiscussed in the current debate, even when the meaning left
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ambiguous directly bares on the arguments being made, as I will show
shortly.
Certainly, if one's definition of an atrisk state implies that pathology
is already present, then primary prevention is no longer possible, and efforts
directed toward the identified population are in fact “secondary prevention,”
i.e., preventing already present but unrecognized pathology from becoming
worse, or “tertiary prevention,” to slow down the progress of a disease that
has already very clearly initiated (Fish, 1981, p. 226). Holzman argues that
the “risk factors” interpretation
refers to statistical probabilities that some groups of people will become
affected by a particular disorder. Thus, being a child of a schizophrenic
parent puts that child in a group with a larger statistical risk than the
general population runs, although that child may not be at all
vulnerable because he or she may not have the specific—but as yet
unknown—structural underpinning that predisposes to schizophrenia.
Risk factors are neither necessary nor sufficient conditions for the
occurrence of a disease... They... are not intrinsically characteristic of
the person at risk. (Holzman, 1981, p. 20, my emphasis)
An example of a risk factor, which Holzman calls “exopathogenic,” is cigarette
smoking, which dramatically increases the risk that one will develop lung
cancer (p. 20).
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With this interpretation, one can make a diagnosis while remaining
fairly agnostic about the actual mechanisms involved. As that follows the
general ideology of DSMIII, it could be taken as a default position in the post
DSMIII era, though it is not used consistently or unambiguously by the vast
majority of participants in the controversy. Further, this interpretation is
grounded in a frequentist theory of probability, according to which the
probability of an event is conceived of as the likely frequency of that event's
occurrence were the situation repeated an arbitrarily large number of times.
This is wellsuited to describe the probability of events that are specific to
individuals in a population, because each individual within the population
provides a unique trial, and the overall frequency of the event in the
population can be measured directly (Venn, 1888). If n
rf
is the total number
of people in a population defined by a set of risk factors, and n
pd
is the
number of those individuals that developed a psychotic disorder within a
given time limit (two years is usually used), then the probability P(pd) of an
individual with the specified risk factors will develop a psychotic disorder can
be approximated according to this equation:
P(pd)=
n
pd
n
rf
Frequentist inferences are only approximations in the short run or for single
individuals, but provided that one is interested in populations rather than
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individual subjects, one can take a direct measurement. Since the risk factor
interpretation gives approximate estimates for individuals, an individual who
is diagnosed as having a relevant risk factor who does not end up with a
psychotic disorder is not a 'false positive' unless the criteria were incorrectly
measured.
(2) Vulnerability Interpretation
Friedhoff suggested a second interpretation, one he embraced in his
research, that more clearly embraces the notion of susceptibility:
Another way in which the notion of biological risk is often used is that
an individual carries a marker that is associated with vulnerability to
a condition or with the condition itself. The implication is that a
person so affected will get the disorder associated with the marker or is
more vulnerable to that disorder. (Friedhoff, 1981, p. 40)
This vulnerability interpretation was also distinguished from the risk factors
interpretation by Holzman, who stressed the troubles that can arise from
carelessnessdriven ambiguity, especially “when the disease processes
involved are poorly understood,” while articulating the meaning of
'vulnerability' more precisely:
[The] terms “vulnerability” and “risk factors” ...are not synonymous,
and using them interchangeably can lead to confusion among
conceptual and empirical issues. Vulnerability refers to a perceivable,
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palpable, or measurable variation in structure or function that
represents a predisposition to a specific disease process... All of these
[vulnerability] traits are identifiable prior to the onset of the disease
and place the person possessing such traits in a position of being
susceptible to the specific disorders, given certain known or as yet
unknown environmental conditions. These traits, moreover, are not
intrinsically the disease. They represent a necessary but not sufficient
condition for the disease to develop. (Holzman, 1981, pp. 19–20, my
emphasis)
An example of a vulnerability trait, which Holzman calls “endopathogenic,” is
a genetic mutation that prevents an individual from being able to
manufacture the enzyme phenylalanine hydroxylase (PAH), which would
make one vulnerable to phenylketonuria (PKU). One (humoral)
endopathogen that Holzman believes might be relevant to psychosis, studied
by Freud (1937) and Pavlov (1927), is temperament.
Holzman is explicit that vulnerability is distinct from the disease itself.
This is not mere metaphysical posturing – in the example of genetic
susceptibility to PKU, the process by which one is susceptible and the process
by which the disease itself proceeds are arguably distinguishable if not
clearly distinct. Classical PKU is caused by a mutation in a gene located on
the twelfth chromosome that is responsible for the enzyme PAH (Filiano,
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2006). The enzyme PAH converts an amino acid called phenylalanine into
another amino acid called tyrosine, which is necessary for the synthesis of
certain neurotransmitters called catecholamines (dopamine, norepinephrine,
and epinephrine). A small amount of the phenylalanine will be metabolized
through alternate pathways, but all the unconverted phenylalanine will
compete with other large neutral amino acids for transport across the blood
brain barrier (Pietz et al., 1999). The combination of insufficient tyrosine and
excess phenylalanine in the brain contribute to frontal lobe dysfunction,
which can produce severe intellectual impairments (Janke & KleinTasman,
2012; Michals & Matalon, 1985).
The question is whether the essence of the disease entity PKU is the
genetic mutation or is the processes by which intellectual impairments occur
that are caused by the genetic mutation. If the genetic mutation is identified
in a newborn, a combination of diet and medication will allow for normal
brain development; in untreated adults, the damage is beyond repair
(MacLeod & Ney, 2010). Is that intervention a way of preventing the disease
in someone who is vulnerable, or is it a way of treating the disease in
someone who is afflicted by it? This is not a question that is answerable by
science. Rather, it is an artifact of the human communication processes that
are enlisted to produce a nosological terministic screen.
The vulnerability interpretation dominated the discussion at the
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UCLA conference on preventive intervention in schizophrenia, but has
essentially disappeared from the discussion, except insofar as individual risk
factors or hypothetical prodromal mechanisms are elaborated in terms of
susceptibility—but the etiological nihilism of DSMIII has led to a repression
of this mode of argumentative reasoning.
(3) Prodrome or Prodromal Phase Interpretation
If one is inclined to view the genetic mutation as an integral
component of the disease entity, then its detection in asymptomatic newborns
allows for an early diagnosis, and barring that, early developmental
problems, along with seizures, certain skin problems, and other symptoms
could be thought of as a prodromal phase of PKU.
This is the language that is used by many who are involved in the
psychosis risk controversy and who understand the diagnosis to apply to
patients in the earliest stage of schizophrenia or a related psychotic disorder,
called the ‘prodromal phase’ or ‘prodrome,’ from the Greek pródromos
( μ ), meaning ‘forerunner’ πρόδρο ος (Fava, Grandi, Canestrari, & Molnar,
1990; Fava & Kellner, 1991; Jackson, Cavanagh, & Scott, 2003; Yung &
McGorry, 1996b). The word prodrome is used in migraine sufferers to
describe the constellation of signs and symptoms—mood changes; irritability;
thirst; yawning; an 'aura' of flickering light, or hallucinations, or partial
vision loss—that precede the onset of a migraine headache (Kelman, 2004).
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Like John the Baptist, whom Christians call the Prodromos ( μ ), Πρόδρο ος
the migraine prodrome in a sense testifies concerning the headache, that
through these symptoms, the migraineur might believe he or she is about to
suffer a migraine; the prodrome itself is not the headache, but comes as a
witness to the headache which is to follow.
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Prodromal symptoms are
described as “premonitory,” which is to say that they are like an oracle that
gives a warning in advance of some set of events which are fated to occur
(Kelman, 2004, p. 865).
If the cause of schizophrenia was something like a mutation to a
specific known gene (as with PKU), this might not make much of a difference.
The etiology of psychotic disorders is unfortunately still unknown, and while
some aspects of its pathophysiology are understood (some sort of excess of
dopamine and/or deficiency in glutamate, as discussed in Chapter 2), even
those are debated. Most people agree that there are usually some early signs
and symptoms that precede the onset of frank psychosis, but those signs and
symptoms are notably nonspecific and heterogeneous – the same symptoms
precede lots of other mental disorders or sometimes no disorder at all. Kline
indicated that “hysterical and and neurasthenic symptoms are the
commonest precursors, but we cannot assume that the 'neurasthenia'
developed into schizophrenia, but rather that in the beginning stages of
125
John 1:78. It is also worth noting that the eleventh century monk Psellos ('the
stammerer') called rhetoric the pródromos of philosophical conversion (Kaldellis, 1999).
451
schizophrenia, neurasthenic symptoms dominated the picture” (Kline, 1966,
p. 28). In this we can see an intentional commitment to the prodromal
interpretation rather than the vulnerability or risk factor interpretation.
There are two implications of the prodrome interpretation. First, the
individual is symptomatic during the prodromal phase, which is possible but
not necessarily true of the vulnerability interpretation (if, for example, the
vulnerability factor was a specific gene that infants could be screened for);
second, the individual “will develop a fullblown illness following the
prodrome” (Yung, Phillips, & McGorry, 2004, p. 6). This rests on an
evidential (or Bayesian) theory of probability, according to which
probabilities reflect the degree of certainty one has that a given outcome will
occur based on the state of the evidence (Erickson & Smith, 1988). That is
because any probability measurement is an estimation of how confident the
diagnostician is that the symptoms he or she is observing in a given patient
are in fact manifestations of a prodrome. Individuals diagnosed as prodromal
who do not develop a psychotic disorder are 'false positives,' and we can say
the diagnosis was objectively incorrect.
(4) 'At Risk Mental State' (ARMS) Interpretation
For this reason, it is only possible to diagnosis a prodrome
retrospectively. This fact was emphasized by Yung, Phillips, and McGorry
(2004), who argue:
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This issue is more than just semantics. The danger of labelling a
syndrome prospectively as a schizophrenia 'prodrome' (or of labelling
an individual crosssectionally as 'prodromal') tends to reify the
syndrome as a disorder or disease, with its own natural history and
prognosis (eventual transition to frank psychosis). Instead, the
syndrome, which seems like, or could be, a prodrome should be thought
of, not as a disease entity, but as a state risk factor for fullblown
psychosis. That is, the presence of the syndrome implies that the
affected person is at that time more likely to develop psychosis in the
near future than someone without the syndrome. However, if the
symptoms resolve then the danger of increased risk remits as well. In
an attempt to deal with these issues we have coined a new term, the 'at
risk mental state.' (Yung, Phillips, & McGorry, 2004, p. 25)
This approach is not limited to retrogressive analysis, which can tell you a lot
about the people who eventually developed frank psychosis, but nothing
about the people who seemed identical to the first group except that the
never developed frank psychosis. Instead, this interpretation suggests that
researchers should examine 'enriched samples' via a 'closein strategy' that
include people who are positive for multiple distinct risk factors (Bell, 1992;
Häfner et al., 1994; Poulton et al., 2000). Sometimes individuals so identified
are considered to be at 'ultra high risk' (UHR) (Yung et al., 2012, 2010; Yung,
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Phillips, Yuen, & McGorry, 2004). This permuted interpretation was the one
adopted by those conducting research on early interventions in psychosis risk
over the last two decades, though their interlocutors at various points adopt
different interpretations or no clear interpretation.
Several ideas of risk are combined in this interpretation. To be 'at' risk
implies that risk is a location that one can occupy. That it is conferred on
individuals implies that risk is a status, as it is often explicitly described. It
is also common to see risk in this context described as a possession, i.e., that
someone has increased risk. It is also common to see risk treated as an
attribute or quality, i.e., that someone is a 'high risk patient.' This all
suggests that risk is a term that can operate on multiple discursive
modalities at once. This flexibility can sometimes be a weakness in that it
increases the discursive space for misunderstanding and miscommunication.
Stephan Heckers (2009) suggests that the prodrome interpretation,
which he links with Bleuler's concept of latent schizophrenia, and the risk
factors interpretation are not actually compatible:
The period of subthreshold psychosis before the first episode of a
psychotic disorder is often referred to as the prodrome. The prodrome
is, by definition, the nascent stage of a disorder (hence the term latent
schizophrenia). In contrast, a risk syndrome is not necessarily linked
to a disorder. The value of a risk syndrome increases with the
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accuracy in predicting future outcomes (e.g., metabolic syndrome
leading to diabetes or cardiovascular disease; mild cognitive
impairment leading to dementia), but the conversion to disease is, by
definition, less than 100%. In short, a prodrome is part and parcel of
the disorder, [while] a risk syndrome is not. (Heckers, 2009, p. 849)
Because of the ambiguity involved in combining two basic interpretations,
and because debates often center around core issues like false positives (or
'false false positives,' in which “a true vulnerability exists though it has not
yet been fully expressed”) and specific statistical measures, this permuted
interpretation tends to promote muddled debates with essential concepts
poorly defined or never even considered (Yung, Phillips, & McGorry, 2004, p.
30). If the disorder is a risk syndrome, then the rate of transition to frank
psychosis really has nothing to do with the 'false positive' rate, but if the
disorder is a prodrome, it has everything to do with it.
Brief Excursus on Melancholia
Further muddling the issue is that the risk factors interpretation and
the prodrome interpretation are individually grounded in distinct nosological
assumptions, one reflecting the paradigm of DSMIII and DSMIV while the
other reflecting some of the ideas behind DSM5, which is another reason
why this diagnostic controversy is synecdochic for the larger set of
controversies surrounding DSM5. As I discussed in the Chapter 1, DSMIII
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came with a revolution of etiological nihilism designed to desanctify the
psychodynamic theories of the past. The unstated goal of course was not to
remain agnostic with respect to the underlying disease processes, but to move
toward a biological model. DSM5 was supposed to do that, although it
largely did not abandon the etiological nihilism of the previous two editions.
One example that illustrates the problem is 'melancholia.'
In 2010, a list of seventeen eminent mental health professionals,
including Robert Spitzer (DSMIII chair), Max Fink, David Healy, Edward
Shorter, Gordon Parker, and Michael Taylor – a collection that includes
psychiatrists, psychoanalysts, psychopharmacologists, historians, and critics
of the pharmaceutical industry – wrote an article in the American Journal of
Psychiatry advancing the case for DSM5 to include an independent diagnosis
of melancholia,
a syndrome with a long history and distinctly specific
psychopathological features... [which] possesses a distinctive biological
homogeneity in clinical experience and laboratory test markers, and...
is differentially responsive to specific treatment interventions. It
therefore deserves recognition as a separate identifiable mood disorder.
(Parker et al., 2010, p. 745)
The advocates of melancholia combined diagnostic data, treatment data, and
historical analysis to make an extremely convincing case that melancholia is
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an entirely distinct form of depression, and that there are in fact “two
separate depressions” (Shorter, 2007, p. 5).
This is exactly the kind of diagnosis that fit the DSM5 ideology. As
Greenberg observed:
Distinctive signs, symptoms, lab studies, course, and outcome—if
melancholia wasn’t the Holy Grail, it was at least a sip from the
chalice of science, one disorder that could go beyond appearances. You
would think that the committee would at least have been eager to
consider it as a partial remedy for ongoing concerns about the
profession’s lack of scientific rigor. (Greenberg, 2013b, para. 8)
Melancholia is a specific subtype of depression that can be identified with
biological tests – it measurably disrupts the sleep architecture of the patient
and causes hypercortisolism (i.e., excessive blood levels of cortisol), which can
be identified with a dexamethasone suppression test (DST). All of this
testing has a purpose, because unlike other variants of depression, it
responds best to the older, seldom prescribed tricyclic antidepressants as well
as electroconvulsive therapy (ECT) (Parker et al., 2010).
These apparent strengths were actually weaknesses, as William
Coryell, one of the members of the DSM5 Mood Disorders Work Group,
wrote in a private correspondence to Max Fink: “I agree there is more data to
support using DST for melancholia than for using any other measure for any
457
other diagnosis,” but it would be “very hard to sell since it would be... the only
biological test for any diagnosis being considered” (cited in Greenberg, 2013a,
p. 337). The diagnosis did not even make it into the draft proposals, which is
to say that it was not even considered. Greenberg argues that the reason is
clear:
[A] test for melancholia would make the lack of biological measures
elsewhere in the DSM that much more glaring. It was a success that
would only highlight the APA's failures... Offered a key to one of the
cells of its epistemic prison, the APA had decided that the cost of
freedom was too high. (pp. 337338)
As one blogger and professional scientist commented about the affair:
“Psychiatry finally encounters science—and rejects it” (Couch, 2013, para. 1).
What does this have to do with psychosis risk syndrome? It provides a
glimpse of a scientific field caught in between two paradigms, grasping hold
of each with one hand and falling through the middle. The confused
interpretation of psychosis risk syndrome as both a risk syndrome and a
prodrome is symptomatic of this problem – on the one hand, committed to
etiological nihilism, on the other hand reaching for biological etiology,
pathogenesis, tests, and treatments. And the failure of most of the most
vocal participants in the controversy to even bother to clarify the
interpretation of psychosis risk as they saw it is betrays an argument
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community in chaos.
Changes in the DSM5 Draft Revisions
In August of 2010, following the first round of public comments on the
manuscript, the work group renamed the proposed diagnosis ‘attenuated
psychotic symptoms syndrome,’ and in April of 2012, following the second
round of public comments, the work group again renamed the proposed
diagnosis ‘attenuated psychosis syndrome’ and recommended it be included
in Section III of DSM5 along with other “