There have been a couple of interesting articles relating to mental health that have caught my eye recently. They both highlight a longstanding trend within psychiatry (and, unfortunately in some parts of the psychoanalytic world) to redefine various forms of human suffering and disturbance as ‘disorders’. This seems to directly correlate with what might be best described as the demise of the clinic, by which I mean the move away from the individual case history (of which Freud’s case studies were exemplary examples) and an attempt to remove the doctor/analyst/therapist from the scene altogether.
Take for example this recent Guardian article on ‘depersonalisation disorder’ which begins with account of young woman who describes waking up one day and feeling she was not herself – a feeling which lasted for three years:
It was a feeling of being fundamentally wrong in your own body…..It was a constant, continuous otherworldly experience…….It’s a feeling that, if you’re feeling this way, you shouldn’t be existing at the same time. The feeling was of having left myself completely, constantly trying to grasp on to reality, trying to claw back what I’d had a few days ago. Yesterday I had a life, and now I’ve got nothing.
The article then goes on to cite two other people who have had similar experiences of depersonalisation – one a man who is now in his early seventies, and another young woman.
The article also looks at the fact that although depersonalisation disorder (DPD) appears to be widespread, with as many sufferers as those with a diagnosis of schizophrenia or obsessive compulsive disorder, there also appears to be widespread ignorance of the condition amongst the psychiatric profession.
And then there is this Independent article on ‘conversion disorder’ which centres on the recent decision by British Canoeing to bar the paralympian canoeist Charlotte Wilkinson-Burnett from competing in the 2016 Brazilian Paralympics because her disability is now considered to be ‘psychological’ rather than physical.
According to the article, tests by doctors “have shown that she has ‘conversion disorder’, which causes people to suffer from symptoms such as paralysis with any identifiable physical cause”.
What’s interesting about both these stories is that they are describing phenomena that are well documented in the history of psychiatry and psychoanalysis, but which in the past would have been regard more as symptomatic of some underlying problem, rather than being ‘disorders’ or ‘conditions’ in their own right.
If we take ‘conversion disorder’ first, in the past this was often associated with hysteria, although as I will argue below, things are not quite that simple. However, hysteria, as a psychiatric condition, now seems to have fallen way out of favour. As for ‘depersonalisation disorder’, feelings of estrangement from reality and from one’s own body can occur in both neurotic and psychotic illnesses. But although the terms ‘neurosis’ and ‘psychosis’ are still used in psychiatry, they seem to have lost the diagnostic precision that they once had.
So what happened? Why is the discourse of mental health now awash with umpteen numbers of ‘disorders’, ‘syndromes’, and various other forms of classification which are essentially descriptions of symptoms rather than attempting to address any underlying clinical structures?
To put this in a historical context, I would recommend reading Katrien Libbrecht’s brilliant and comprehensive study of the hysterical psychosis, which explores the emergence, trajectory and fate of this particular form of psychotic illness.1 In the process Libbrecht gives a fascinating account of the development of psychiatry and psychoanalysis from the late nineteenth century until the 1990s, in both the Franco-German and Anglo-American psychiatric milieux. In particular it becomes clear that the focus was more on classification and description than developing a coherent theory of psychopathology, in spite of Freud’s (and Lacan’s) best efforts to the contrary. This culminated in the development of the broad sweeping classificatory systems such as the DSM (now in its fifth edition) and the ICD.
So there is nothing particularly new in this focus on classification and description at the expense of theory. This is not to say that (some) psychiatrists and psychoanalysts were not interested in aetiology, i.e. the causes of particular forms of psychopathology. The irony, however, is that the ones who were most interested tended to posit a neurobiological basis for such illnesses. Even Freud, until the end of his life, still believed that ultimately a neurobiological basis would be found for all the psychopathologies that he had encountered and treated (non-biologically) during his long career.
Putting such arguments to one side, it seems to me that one of the attractions of classification and description is that it gives the appearance of rationality, objectivity and of ‘being scientific’ without having to think too much or do any of the heavy lifting that true science demands. If various phenomena, various symptoms, can be described and classified, and if the psychiatric community can agree on such descriptions and classifications, then no-one has to worry anymore about the singularity, the uniqueness, of each case, of each human being (or of each practitioner for that matter). Rather they can reach for their manuals and ‘look up’ the particular symptoms and give them a name – which usually has the suffix ‘disorder’ or ‘syndrome’.
But this is pseudo-science at its worse; it combines naive empiricism with a stamp collecting mentality, which is then constituted into a bureaucratic template that all patients have to ‘fit’ into. Then again, in the absence of any coherent theory, what else do you expect?
Then there is the problem, which I alluded to earlier, of treating the symptom rather than the cause. As I mentioned above, feelings of depersonalisation and (somatic) conversion are symptoms of something more underlying. However, with conversion things get more complicated because some ‘conversion’ is actually somatisation, which is where traumatic memories are enacted directly in the (physical) body; whereas with conversion ‘proper’, the trauma is mediated symbolically – what Freud referred to as ‘the body joining in the conversation’.
Of course, there is another way….
- Katrien Libbrecht. Hysterical Psychosis: A Historical Survey. New Brunswick: Transaction Publishers, 1995. [↩]