Thursday, November 29, 2012

Suckling Pigs, Stray Dogs, and Psychiatric Diagnoses

By defining the unknown, and classifying psychopathology, we bring an element of knowability to that which we do not know.
In The Order of Things, Michel Foucault, the great French philosopher cites a ‘certain Chinese encyclopedia’ that notes ‘animals are divided into: (a) belonging to the Emperor, (b) embalmed, (c) tame, (d) suckling pigs, (e) sirens, (f) fabulous, (g) stray dogs, (h) included in the present classification, (i) frenzied, (j) innumerable, (k) drawn with a very fine camelhair brush, (l) et cetera, (m) having just broken the water pitcher, (n) that from a long way off look like flies’. The contemporary reader may look on at this classification of animals with amusement and bewilderment or contempt and derision. Yet, the same level of sophistication bedevils our classification of morbid mental life today, as cataloged in the Diagnostic and Statistical Manual of Mental Disorders, the official psychiatric bible. This cultural document, its current permutation a product of fin-de-siècle America, holds up emotions, behaviors, and beliefs deemed pathological as if they exist in external nature as timeless, universal ‘things’ and aims to define and classify them. Attempting to avoid any reference to the causal basis of the disorders listed within, it also ignores the values, meanings, and assumptions imbued within the system of classification or the context in which these ‘disorders’ are experienced. About to enter its fifth revision, the DSM has been encircled in debates regarding which elements of mental life should be recognized as morbid, which disorders should bow their farewell, and where the disorders that are included should be classified. These debates miss the point. Without acknowledging the inherent meaning making in any system of classification, and the context in which mental life is defined as disorder and then categorized, the book is not only not valid, it is not useful.

A Brief History of Psychiatric Classification

Attempts at classifying elements of morbid mental life are not new. The first known system dates back to 1400 BCE India, and the Ayurveda, which regarded aberrant mental states as resulting from different forms of possession. In the West, Hippocrates, Arataeus of Cappadocia, and Galen also tried their hand at categorizing madness. Nor were they the only ones. Throughout the intervening years a number of physicians, philosophers and theologians delineated their own classifications of mental disorder. It was not until the 19th century, however, that classifications of mental disorder came from careful observation of the apparent causes, clinical course, and prognosis to differentiate different forms of madness. Esquirol, more than anyone ushered in this era and noted five types of madness including lypemania (melancholy), mania, monomania, dementia, and idiocy. It was the German Psychiatrist Emil Kraepelin though that made the most detailed study of the classification of mental disorder, which was his life’s work and he refined his classification over eight editions of his famous Textbook of Clinical Psychiatry. The final classification included mostly medical problems including traumatic brain injury, epilepsy, syphilis, intoxication, infection, thyroid disease, and abnormal mental states in the context of brain disease. His most enduring contribution to psychiatry was taking the “amorphous mass of madness”* that existed before and separating it into manic-depressive insanity (which includes depression and bipolar states today), and dementia praecox (today’s schizophrenia). Dementia praecox was further divided into the hebephrenic, catatonic, and paranoid types. Amazingly, Kraepelin’s classification is the basis for our current psychiatric classification some 90 years later.

Why this long trend in classifying pathological mental states? By defining the unknown, and classifying psychopathology, we bring an element of knowability to that which we do not know. Further, we create the illusion and indulge in the deception of knowing more about that which we do not know than we do. It is only natural that humans should try to reason with unreason, to order to disorder, to dispassionately delineate the boundaries between sanity and madness. It is ironic then, that this attempt at understanding and demystifying abnormal mental states, should have compounded the sense of otherness and alienation endured by those experiencing mental distress.

Is depression even a mood disorder?

The DSM attempts to catalog different aspects of mental life together that share some element of commonality. For example, depression and mania are classified as mood disorders, whilst generalized anxiety disorder, specific phobia, and social phobia are classified as anxiety disorders. It would seem to make intuitive sense to file major depressive disorder under the rubric of mood disorders, and generalized anxiety under the rubric of anxiety disorders. It’s in the names after all. When we come to closer inspect the experience that is labeled as depression in the DSM, we discover that one does not even need to experience depressed mood to be diagnosed with depression. For many people, the experience is instead characterized by the inability to derive any joy from their existence, from persistent feelings of stress and worry, endlessly ruminating about the past, feelings of inadequacy, self-loathing and worthlessness. It is almost as if the experience of ‘depression’ for these individuals is summed up by thinking too much. Indeed, the concept of depression does not exist for the Shona people of Zimbabwe. Instead, what would get labeled as depression in the West is called Kufungisisa in Zimbabwe, which means, “thinking too much”. For others the experience of depression is not characterized by thinking too much or depressed mood. It is instead felt as a profoundly visceral sapping of the
vital forces, of unending fatigue, heaviness, nausea, malaise, tinnitus, and unexplained aches and pains. The appetite has waned, sleep sparse and fitful. It is an extremely physical experience. In China, the concept of depression does not exist, and despite attempts to make the diagnosis, it is not accepted. Instead, what would be understood as depression in the West is diagnosed as neurasthenia. Once regarded as an American disease, today it has been expunged from the American psychiatric classification as if it never existed. Even the selection of a particular aspect of mental experience as a hallmark as a whole category of disorders is a cultural act, laden with assumptions.

That generalized anxiety disorder should be grouped with other anxiety disorders and not depression is also more puzzling than might appear. For the Shona people of Zimbabwe, the idea of “thinking too much” might equally be diagnosed as generalized anxiety disorder or major depression in the West. It turns out there is so much overlap between the two experiences, that the idea of mixed-anxiety and depression is a common one in primary care. Intriguingly, this overlap was not always the case. In the previous edition of the DSM, generalized anxiety disorder had different diagnostic criteria altogether. Instead of focusing on symptoms of worry, or constructing anxiety in cognitive terms, generalized anxiety disorder was a fear-based diagnosis, constructed in somatic terms. The experience was seen as characterized by persistent sweating, shakiness, tremulousness, being on edge, experiencing palpitations, breathlessness, a sinking sensation in the stomach, a sense of impending doom. Just as neurasthenia (a physical experience and diagnosis) was supplanted by the more psychologically experienced depression, a somatically or fear-based anxiety disorder, has been supplanted by a more psychologically experienced anxiety disorder. As we become more psychologically minded, the way we experience distress is transformed from a somatic idiom to a psychic one.

The Problem with Psychiatric Classification

The process of psychiatric classification is weaved together with the assumption that with each new edition some new truth has been discovered, a new disorder unveiled, the boundaries between mental health and mental illness more firmly delineated, that the process is the result of scientific progress. But as Foucault demonstrated throughout his life, what appears as progress in seeing the world are merely different ways of seeing, they are not necessarily better. In the pursuit of scientific progress, our system of psychiatric classification has attempted to uniformly describe the acceptable ways in which one can go mad, as if to lose one’s mind was a uniform, discrete experience discontinuous from the experiences of sadness, joy, fear, disgust, and terror we experience in our daily lives. A psychiatric classification that ignores the wider sociocultural forces at work rather than taking these to the heart of the matter is woefully misguided. A psychiatric classification that attempts to homogenize madness, rather than accept the enormous variation in the experience of mental distress and the process of meaning making has missed the point. I will continue to dutifully document my multi-axial diagnoses in my notes. But like the DSM, my notes will be most salient not for what has been written, but for what has not been written. 

*Brockington, I. F. & Leff, J. P. (1979) Schizo-affective psychosis: definitions and incidence. Psychological Medicine, 9, 91-99.

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