Madness in civilisation

I'm not sure if it really works, as I did in my previous post, collecting together tweets of quotes or amended quotes from a book which I've sent when I'm reading it. Another book I've recently read is Andrew Scull's Madness in civilization: A cultural history of insanity from the Bible to Freud, from the madhouse to modern medicine. It has been reviewed by Phil Thomas on Madness in America. I don't think the book is as good as some of Scull's previous books, such as Madhouse (see my BMJ review). It's trying to provide a wide-ranging survey of the history of madness over the last 3000 years. 

What I tweeted about from Scull's new book was the way that we seem to need myths to understand madness and illness in general. For example, the theory of the four humours - blood, phlegm, black bile and yellow bile - remained a major influence in understanding the working of the body until well into the 1800s. But we haven't really advanced:-

DBDouble Biomedical hypothesis justifies modern psychiatric practice in same way as humoral theory justified bleeding, purging and use of emetics 29/03/2015 10:56

DBDouble Humoral theory of disease was immensely powerful, making sense of symptoms and pointing the way towards remedies for what had gone wrong. 28/03/2015 20:22

DBDouble Humoral theory provided reassurance to the patient and an elaborate rationale for the interventions of the physician 28/03/2015 20:24

This wasn't the only theory:-

DBDouble Religious and secular, supernatural and what purported to be naturalistic explanations of illness persisted down the centuries 28/03/2015 20:27

DBDouble Notion that madness might sometimes be a means to truth (divine madness, as some would have it) would resurface repeatedly 28/03/2015 20:27

Furthermore:-

DBDouble Anti-phlogistic physicians saw disease as fundamentally a problem of inflammation and fever. 28/03/2015 20:29

DBDouble Bleeding, purging and making use of emetics, all designed to counteract and to deplete the over-active, over-heated body 28/03/2015 20:30

DBDouble Religious and spiritual interventions might be tried alongside the bleeding, purging and emetics of the anti-phlogistic physicians 28/03/2015 20:31

So, the notion of chemical imbalance in the brain (eg. see previous post) even though it's wrong, like humoral theory, persists because it provides an 'aura of factuality' (see previous post). The historical perspective provided by books like Madness in civilisation helps us to realise that modern claims about brain dysfunction in mental illness are not really facts but part of a myth, even delusion, to suggest an understanding of mental illness and justification for its treatment.

Pathologist of the mind

As I have been reading it, I have been tweeting quotes or amended quotes from Pathologist of the mind: Adolf Meyer and the origins of American psychiatry by Susan Lamb (who I have already quoted in a previous post). I thought I would bring some of these tweets together to try and explain the importance of Adolf Meyer's work.

Susan's book (see her website) is a scholarly account that the literature has needed. Meyer himself failed to be explicit in getting across his theory of psychiatry, which was called Psychobiology (eg. see my article). Susan includes clinical material from his archives which also helps to relate his theory to his practice.

As Susan says in her conclusion, one of the key insights is that:-

DBDouble Meyer viewed mental activity and brain activity as a single biological response 24/04/2015 13:12

She goes on, "to overlook this principle is to risk misconstruing Meyer's thinking, practice, and teaching". Or, as she says in another tweet:-

DBDouble The tendency to equate the descriptor 'biological' with 'physical, bodily or somatic' can render anything Meyer said or did unintelligible 08/03/2015 20:15

The second key insight is "to appreciate the essentially medical orientation of Meyer's thinking, practice, and teaching". For Meyer:-

DBDouble Mental dysfunction, as much as brain disease, is a medical condition resulting from pathological processes 08/03/2015 17:34

This meant that:-

DBDouble Meyer framed prevalent forms of mental illness not as distinct brain diseases, as did majority of his peers, but as failed adaptation 08/03/2015 17:37

This is why I have emphasised the views of Adolf Meyer in discussions of psychiatric diagnosis on this blog (eg. see previous post). Meyer was also clear that:-

DBDouble Brain research is comparative neurology not psychiatry 08/03/2015 20:58

In other words, Meyer warned against going beyond statements about the person to wishful 'neurologising tautology' about the brain. Even though:-

DBDouble Kraepelin was part of first wave in the generational backlash against the hegemony of brain mythology in the late 19th century 26/03/2015 16:59

DBDouble Meyer lamented the Kraepelinian craze to diagnose, classify and to generate statistics 26/03/2015 17:11

Meyer took over the Huxleyan notion of science as being organised common sense. 

DBDouble Science is defined by application of rigour to observing, documenting, comparing and ordering data 08/03/2015 22:01

DBDouble Science is not defined by principles of physics or chemistry, nor by experimental techniques 08/03/2015 22:00

In summary:-

DBDouble Psychobiology provided basis to liberate psychiatry from dogma that explained mental activity in reductive, dualistic or deterministic terms 24/04/2015 13:09

To emphasise, Meyer was primarily interested in the implication of these ideas for clinical practice. 

DBDouble Meyer was no philosopher. He was a pathologist on a mission 17/03/2015 08:59

Susan also agrees with me in my spat with Nasser Ghaemi (see previous post) that:-

DBDouble The pluralism of psychobiology was neither arbitrary nor uncritical 17/03/2015 09:00

No one should believe the chemical imbalance theory

A post on Slate Star Codex argues that the idea that "depression is a drop-dead simple serotonin deficiency was never taken seriously by mainstream psychiatry". There may be some truth in this view, but there's no doubt that many people have been taken in by the theory (see eg. previous post). They're surprised that the theory hasn't been proven. They may even have been told by a psychiatrist that their depression is due to a chemical imbalance.

And there's no doubt that drug companies have taken advantage of these beliefs as shown in the Zoloft (sertraline) advertisement above. True, the commercial does say that the cause of depression is unknown. But it then goes on to suggest that sertraline corrects a chemical imbalance to which depression may be related. And Slate Star Codex doesn't want to totally abandon the idea that "it's very likely it [depression] will involve chemicals in some way".

Actually, the 'chemicals in depression' may not be much different from those that create normal feelings. It may not make much sense to view depression as a neurochemical disorder. The kinds of processes that underlie mental illness at the biochemical level may be no different from those that produce thoughts, feelings and behaviour amongst the 'normal'. We tend to assume that there must be a neuropathological basis for mental illness, as there is a pathological basis for physical illness. But 'mental illness' is very different from physical illness, if only because of the mind-body philosophical problem.

And, the sertraline advert is also misleading in that it says that sertraline "is not habit forming". Antidepressant discontinuation problems do occur with SSRI antidepressants, like sertraline (eg. see previous post). It's not surprising that people may get psychologically dependent on a drug which they think has improved their mood (see my book chapter).

Psychiatrists do believe psychosis is a brain disease

Ronald Pies (whose recent book I have reviewed) has criticised the BPS report on psychosis (see previous post) in a Psychiatric Times article for underestimating the potential seriousness of psychosis and misconceiving its nature by focusing on hearing "voices". I agree that the report, for example, does not try and distinguish psychosis from dissociative identity disorder, in which people may also hear voices.

Pies also says that the report's argument against descriptive diagnosis is "historically ill-informed and medically naive" for suggesting psychiatric diagnosis should provide an explanation of people's problems. Again, I agree that psychiatric diagnosis is primarily phenomenological, in that it involves assessment of a person's mental state. Nor, as Pies says, is the "existence of societal prejudice and discrimination" a valid argument against psychiatric diagnosis, as inevitably the implication of a psychiatric diagnosis is that something has 'gone wrong' with the person's psychosocial functioning.

As I have explained in my book review, where I do have a problem with Pies is that I do not think he sufficiently knowledges that minds are not reducible to brains. For example, in another Psychiatric Times article on the BPS report, he says that "schizophrenia is often associated with neuropathology". He deliberately highlights the word "associated" because he does not want to imply causation necessarily. However, he tends to imply just that and it's difficult to see that he means otherwise. Psychiatrists do believe schizophrenia and psychosis are brain diseases and I think Ronald Pies does as well.


(With thanks to Around The Web post on Mad in America)