8th European Social Science History Conference

Date 29 mars 2010 |

At the 8th European Social Science History Conference which takes place in Ghent (13 April - 16 April 2010), several papers are devoted to the history of psychiatry.

  • The institutionalized role of psychiatry in the punishment and rehabilitation of former national socialists in the Netherlands (1944-1954) by Bram Enning and Helen Grevers
  • Beyond containing: the First World War and the psychoanalytic theories of Wilfred Bion by Michael Roper
  • A change of perspective: integrating evolutionary psychology into the historiography of violence by John Wood
  • The turn inwards: Freud's theory of female sexuality as a psychologization of social practices by Geertje Mak
  • Child Psychiatry between scholarly traditions in Sweden 1945-1985. Medical conferences as an arena for defining the borders and content of an emerging disciplinar field by Bengt Sandin
  • Different Settings? Narrative interviews versus psychoanalytical interviews by Ela Hornung
  • Psychology against Medicine ? Mysticism in the Light of Scientific Apologetics by Agnès Desmazières

To get the complete program, click here.

Review on Lisa Mandel's "HP"

Date 27 mars 2010 |

Cet album est une contribution originale à la bande dessinée documentaire et historique. Originale d’abord par son objet, la psychiatrie, dont on n’imaginait pas nécessairement qu’elle serait un jour illustrée de cette manière. Originale, ensuite, car ce n’est pas la grande histoire qu’elle cherche à documenter, l’histoire des grandes figures et réalisations de la discipline, mais au contraire le quotidien de l’hôpital psychiatrique, vu par des acteurs auxquels on donne aujourd’hui encore rarement la parole, les infirmiers, et qu’elle s’attache à décrire ce quotidien dans ses aspects les plus banals et triviaux. Originale enfin car elle rompt avec le réalisme auquel a d’habitude recours la bande dessinée documentaire. Et c’est précisément ce qui fait la force de cet album, et singulièrement sa force documentaire : non pas ou pas seulement car cela permet à Lisa Mandel de faire sentir ou voir le fantasme, le délire, la folie en un mot, parce que le dessin et l’imaginaire la libéreraient des contraintes de la vraisemblance ; mais surtout car cela lui permet de représenter la folie dans sa dimension la plus sordide et de donner à voir une réalité dont il n’est pas certain qu’elle ait jamais été mise à l’écran ou sur papier : les corps dégradés des personnes souffrant de maladie mentale au long cours, que ce soit les corps nus d’hommes et de femmes âgés, gâteux et dément, dans leurs déjection dans leur lit, ou les corps bavant et agités de spasme, de tremblements des malades neuroleptisés. Ce faisant, ce réalisme à la fois objectif et abstrait situe cet album au-delà du romantisme mais aussi du misérabilisme qui caractérisent souvent les témoignages et histoires de la psychiatrie, et lui permet de restituer l’épaisseur d’une certaine expérience de la maladie mentale.

L’album se présente comme un témoignage brut, recueilli à la source par l’auteur auprès de ses parents et d’amis et collègues de ces derniers, tous entrés en psychiatrie au même moment dans le même établissement de la région marseillaise. Les premières pages dressent un portrait des protagonistes de l’album et des raisons qui les ont conduits à embrasser la carrière d’infirmier psychiatrique – raisons rarement motivées par un choix ou une vocation personnelle. Le corps de l’album est le récit de la découverte par ces – alors – jeunes infirmiers de l’hôpital où ils font leurs premières années de métier. Il est constitué d’une série de bandes d’une à trois pages qui sont à la fois une série de saynètes ou d’histoires et la description de différentes facettes de la vie hospitalière. Si certaines sont comiques et d’autres relèvent plutôt de l’humour noir, les plus nombreuses, et les plus nombreuses à mesure que l’on avance dans l’ouvrage, ressortissent plutôt au genre du conte moral, et visent à illustrer en de courts récits les dilemmes et les difficultés auxquels doivent faire face les infirmiers sans être le plus souvent armés pour y apporter une réponse.

L’hôpital que découvrent ces jeunes infirmiers, c’est « l’asile » et l’ouvrage s’ouvre de fait sur une citation du premier article de la loi de 1838 fondatrice du système asilaire en France, seule incursion dans l’histoire antérieure aux années 1970. Quelques pages décrivent les moyens thérapeutiques mis en œuvre – l’auteur résume en particulier de manière très didactique la philosophie du soin comme régression et reconstruction à l’œuvre en France à l’époque -, d’autres présentent certains patients types d’un hôpital de l’époque. La plupart s’attachent à décrire finement les différentes formes de violence ordinaire dont sont victimes les patients. Violence faite du manque de moyen lorsque l’absence de draps de rechange oblige à réutiliser ceux qui viennent d’être souillés pour faire un lit. Faite de la bêtise des infirmiers lorsque ceux-ci profitent de leur position pour humilier, battre, voire voler les patients. Nourrie de leur angoisse et de leur faiblesse lorsque face à un patient lui-même violent, non content de le maîtriser ils lui « passent » littéralement leur peur sous forme de coup ou d’humiliation. Violence pateline lorsque sans chercher à mal certains infirmiers développent pour passer le temps des jeux humiliants ou dégradants pour les patients qui en sont les victimes parfois consentantes – comme celui-ci, inventé par un prodige de la pétanque, consistant à déloger d’un jet de boule un cochonnet placé sur la tête d’un patient, protégée par un vieux casque militaire, faisant de cet infirmier le Guillaume Tell de l’hôpital pour le plus grand plaisir de tous, patients y compris…

Si la description se veut objective, sans chercher ni à condamner ni à justifier les infirmiers mais en restituant seulement leur quotidien et les questions que celui-ci soulève chez eux, l’hôpital est analysé comme un système dont les différents acteurs ne sont pas libre d’agir comme ils pourraient le vouloir. En cela, l’album garde la marque des théories de psychologie sociale en vogue dans la psychiatrie de l’après guerre, qui décrivaient l’hôpital comme un champ de relations sociales animé par certaines lois ou règles générales. A ceci près que cette dynamique de groupe est ici toujours négative, là où précisément les psychiatres pensaient pouvoir la détourner pour en faire un facteur de traitement des malades. Quoi qu’il en soit ces descriptions dessinent en creux une vision idéale de la psychiatrie : la distance cultivée par l’auteur avec les techniques et les savoirs psychiatriques – par exemple en insérant un glossaire de termes marseillais là où l’on attendrait un glossaire de termes psychiatriques – suggère de fait que la matière psychiatrique est d’abord faite de sentiments et de relations humaines avant que de techniques.

L’ensemble donne une vision à la fois riche mais aussi forcément partielle de la psychiatrie telle qu’elle se pratiquait dans un établissement psychiatrique français dans les années 1970. On peut par exemple s’étonner voire regretter la justification simple que l’auteur donne de l’hospitalisation psychiatrique, comme moyen d’écarter les malades : l’entrée en psychiatrie a toujours été un processus complexe, douloureux, pour les malades comme pour leurs proches, et les hospitalisations sous contrainte n’ont jamais été des décisions simples. Sans doute la position des infirmiers, éloignés du contact des familles lorsqu’ils étaient cantonnés à l’hôpital comme c’était le cas avant l’avènement de la psychiatrie communautaire – et encore pour un certain nombre d’entre eux après – ne leur permettait-elle pas d’appréhender cette réalité dans sa richesse. On peut surtout s’interroger plus profondément sur la morale que l’auteur commence à dégager à la fin de l’album. Les dernières vignettes annoncent l’avènement d’une autre psychiatrie à venir dans les années 1980, dans laquelle ces infirmiers ont pu élaborer leur vocation véritable. Ce faisant, ces dernières pages donnent une coloration spécifique à l’ensemble de l’album : en faisant des travers qui y sont décrits une série de déviations dont l’auteur suggère que le tournant des années 1980 les aurait renvoyées à un passé révolu. L’histoire de la psychiatrie regorge de ces moments charnières de sortie de l’asile, dont il faut toujours interroger la texture – on pense ici à l’analyse par Gladys Swain de la libération des fous par Pinel. Les années 1970 correspondent sans doute à une série de transformations profondes dans les pratiques de soin, qui ont pris effet à des rythmes différents dans les différents établissements de France : on pense au recrutement d’un grand nombre de médecins qui viendront renouveler les cadres et apporter de nouvelles manières de faire, l’arrivée de nouvelles générations de travailleurs sociaux et de psychologues, la mise en place de pratiques de psychiatrie communautaire. On peut se demander cependant si ces changements si massifs soient-ils ne contribuent pas à assombrir le tableau que les acteurs font de la psychiatrie précédente. Après tout le sentiment d’avoir vécu la période de l’asile n’est-il pas une reconstruction mémorielle, une défense personnelle face à la sensation d’avoir contribué à faire advenir un mieux par la suite ? Sans doute est-il encore trop tôt pour juger : on attend pour cela le second album. Dès à présent cependant ce volume apparaît comme un document original à verser à l’histoire de la psychiatrie.

Nicolas Henckes

Lisa Mandel, HP - L'asile d'aliénés (Paris: L'Association, 2009), ISBN: 978-2844143167, 13€

Bonjour tout le monde !

Date 25 mars 2010 |

Welcome to Hypothèses, plateforme de carnets de recherches. This is your first post. Edit or delete it, then start blogging!

New Issue of History of the Human Sciences

Date 25 mars 2010 |

The most recent issue of History of the Human Sciences has Scott Vrecko as guest editor and is dedicated to Neuroscience, Power and Culture Contents. Two articles adresses more specifically the use of drugs inside psychiatry.

The persistence of the subjective in neuropsychopharmacology: observations of contemporary hallucinogen research by Nicolas Langlitz (Department of Anthropology, New School for Social Research). The abstract reads:

The elimination of subjectivity through brain research and the replacement of so-called ‘folk psychology’ by aneuroscientifically enlightened worldview and self-conception has been both hoped for and feared. But this cultural revolutionis still pending. Based on nine months of fieldwork on the revival of hallucinogen research since the ‘Decade of the Brain,’this paper examines how subjective experience appears as epistemic object and practical problem in a psychopharmacological laboratory. In the quest for neural correlates of (drug-induced altered states of) consciousness, introspective accounts of test subjects play a crucial role in neuroimaging studies. Firsthand knowledge of the drugs’ flamboyant effects provides researchers with a personal knowledge not communicated in scientific publications, but key to the conduct of their experiments. In many cases, the ‘psychedelic experience’ draws scientists into the field and continues to inspire their self-image and way of life. By exploring these domains the paper points to a persistence of the subjective in contemporary neuropsychopharmacology.

Profitable failure: antidepressant drugs and the triumph of flawed experiments by Linsey McGoey (Saïd Business School, University of Oxford). The abstract reads:

Drawing on an analysis of Irving Kirsch and colleagues’ controversial 2008 article in PLoS [Public Library of Science]Medicine on the efficacy of SSRI antidepressant drugs such as Prozac, I examine flaws within the methodologies of randomized controlled trials (RCTs) that have made it difficult for regulators, clinicians and patients to determine the therapeutic value of this class of drug. I then argue, drawing analogies to work by Pierre Bourdieu and Michael Power, that it is the very limitations of RCTs — their inadequacies in producing reliable evidence of clinical effects — that help to strengthen assumptions of their superiority as methodological tools. Finally, I suggest that the case of RCTs helps to explore the question of why failure is often useful in consolidating the authority of those who have presided over that failure, and why systems widely recognized to be ineffective tend to assume greater authority at the very moment when people speak of their malfunction.


The History of Health Insurance and Mental Illness

Date 23 mars 2010 |

The historical branches of German social insurance

The successful passage of health insurance reform legislation in the United States moves me to wonder about the extent to which scholars have looked into the role of health insurance in mental health care.  About ten years ago, a number of us historians examined the impact of mental illness on social insurance in Germany around the years 1880-1930.  Perhaps not surprisingly, the rise of shellshock in World War I and the killing of 200,000 psychiatric patients by the Nazis under their T-4 program provided the backdrop and inspiration for much of this research.   In my own study of disability within early German social insurance (Making Security Social), I found that providing health care benefits to those suffering from work-related nervous illnesses prompted a vocal, organized, and persistent backlash from those who contended that the system was only rewarding malingering.  The fact that some claimants contended that their nervous symptoms were caused, not by a factory accident, but rather by the torturous process of applying for a pension itself only seemed to confirm the view that social insurance and mental illness did not mix well.   In fact by the 1920s and 1930s, "pension neuroses" – as they were called – were publicly pilloried by conservatives, liberals, and the Nazis as emblematic of a social insurance system that bred whining and undermined productivity and masculinity.  Interestingly enough, however, the Nazis found it politically impossible to dismantle the social insurance system, despite the fact that many reformers in their party wished to do so.  So, there is certainly historical evidence indicating that, indeed, insurance systems do create new constituencies that provide powerful support for the system's continuation.

So, I have some questions for others.  Are there good historical studies out there (articles or monographs) which examine insurance's impact on mental illness and mental health and vice versa?  What role has health insurance played in reinforcing or undermining professional, institutional, and social trends and practices?  For instance, to what extent was social insurance responsible for the post-World War II boom in psychotherapeutic professionals and services?  What role have pharmaceutical companies played in health insurance systems affecting mental health across the globe?  What effects did health insurance schemes have on the process widely known as deinstitutionalization?  Please post any responses on the blog.

GE

New Issue of Psychiatrie, sciences humaines, neurosciences

Date 23 mars 2010 |

The latest issue of Psychiatrie, sciences humaines, neurosciences is dedicated to psychiatry in a colonial context. One article is specifically dedicated to the history of the notion of obsession in Germany.

Psychiatrie au-delà du Rhin: obsessions et compulsions dans la psychiatrie de langue allemande by M. Géraud (Centre hospitalier Charles-Perrens, Bordeaux). The abstract reads:

The notion of obsession was built late in France. The same is true in German-speaking countries (first occurring in 1867). But obsessional disorders have kept a more autonomous nosographic position in these latter countries than in France, where obsession has long been connected with the idea of degeneration, which is not given emphasis in Germany. Mentioned for the first time by Krafft-Ebing in 1867 and by Griesinger in 1868, obsession (Zwangsvorstellung) has been the subject of an exemplary clinical description by Westphal, in 1877, who defined it as an autonomous pathology radically different to “paranoia” (Verrücktheit) and melancholia; according to him, obsessions never change into delusions. This field has varied considerably in its symptomatic area: some authors going so far as to introduce the idea of obsession, sensations, feelings, impulses, and actions; obsession, according to Löwenfeld, encompass the intellectual, emotional, and motor functional spheres. Other authors, notably Bumke, keep to a more strictly defined area, within the direction defined by Westphal. Fundamental emotional disorders are either rejected or identified with anxiety. Connections with other illnesses have given rise to a number of concepts. Considered autonomous by Westphal and Bumke, obsessional symptomatology has been thought of, by other authors as primary or secondary to other pathologies, originating in melancholia or changing into it. The nosographic position varies. Either obsession is considered an autonomous illness or it is connected to other pathologies (neurasthenia, degeneration, Verrücktheit). Connections with other illnesses are dominated by relationships to melancholia; connections to paranoia are much more problematic; those with hysteria are seldom mentioned. After setting up frameworks for manic-depressive psychosis and schizophrenia (Kraepelin, Bleuler) and for hysteric neurosis (Freud), the nosographic position of obsessions, which have become “obsessional neurosis”, varies according to these pathologies and becomes complex. Kraepelin has it as an anxiety disorder connected to phobias but links some obsessions with “manic-depressive insanity”. The followers of Kraepelin insist on the connection with manic-depressive illness. Bleuler connects the obsessions to schizophrenia-schizothymia. These relations between obsession and schizophrenia give rise to abundant literature. Their links are located at a psychopathological level (“Spaltung,” the defense, slowing down, repairing and recovery from schizophrenia), at a symptomatological level (pedantry-mannerism, schizophrenic autism-closed aspect of the obsessed, their motor disorders-catatonia), or at a clinical level (obsession-schizophrenia association). Obsessions are considered by other authors as personality disorders. Notably by Kretschmer (sensitive reaction) or by Schneider as a psychopathic personality: anancastics, second subgroup of the self uncertain psychopaths. As for the anthropological-existential point of view, it tackles the patient with obsessive disorders in his or her totality and analyses the transcendental constitution of his or her world.

DSM-V: Continuing the Confusion about Aging, Alzheimer’s and Dementia

Date 19 mars 2010 |

Since the early twentieth century, when Alois Alzheimer and Emil Kraepelin constructed it as a unified clinical-pathological entity, Alzheimer’s disease has been both one of the most stable and one of the most problematic neuropsychiatric entities.

Alzheimer’s (listed as Dementia of the Alzheimer’s Type in DSM-IV) remains one of the very few instances in which psychiatry has managed to associate a well-defined clinical syndrome – global deterioration of cognitive ability – with clear-cut brain pathology – the senile plaques and neurofibrillary tangles that continue to be regarded as the essential biomarkers of the disease.

And yet it has been one the most problematic of disease entities because – despite the relative clarity around its clinical symptoms and pathological correlates – a clear boundary has not been established between Alzheimer’s and aging. The cognitive deterioration that defines Alzheimer’s and other forms of dementia is experienced by everyone as they age, though to a much lesser degree in people not diagnosed. Similarly, decades of accumulated autopsy evidence has demonstrated that the plaques, tangles and all other putative biomarkers for Alzheimer’s and other major forms of dementia are found to varying degrees in all aging brains.

Thus on evidentiary grounds, at least as good a case can be made for viewing Alzheimer’s as an endpoint on a spectrum of cognitive changes associated with normal aging as for viewing it as a disease. But for political reasons, since the 1970s psychiatrists, neurologists, and Alzheimer’s advocates in the United States and Europe, have overwhelmingly asserted that it should be regarded as a disease. These political reasons can be summed up succinctly: government funds research for dread disease, not for discovering the fountain of youth. And as a political construct, Alzheimer’s as dread disease has been wonderfully successful at winning federal funding for research.

But critics – most notably neuroscientist Peter Whitehouse and anthropologist Daniel George in the their book The Myth of Alzheimer’s, have argued that the Alzheimer’s disease construct represents the medicalization of brain aging and profoundly exacerbates the stigmatization of age-associated cognitive decline.

To no one’s surprise, the draft of DSM-V does not back off of the commitment to viewing Alzheimer’s and similar conditions as disease entities distinct from aging. But it does propose two significant changes that, while well-intentioned, may greatly extend the medicalization of aging and worsen the stigma of age-associated cognitive decline.

Perhaps the most dramatic change related to these conditions in the draft DSM-V is the proposal to drop the term “Dementia” and replace it with the term “Major Neurocognitive Disorder.” The stated rationale for the proposed change mostly focuses on nosological considerations that seem on the whole sensible to address. But interestingly, the rationale also notes that the term dementia has “acquired a pejorative or stigmatizing connotation.” For just this reason, even critics of the Alzheimer’s disease construct seem to be welcoming this proposed change (for example, see the comments to the Myth of Alzheimer’s blog post on DSM-V changes.)

I am less optimistic that the ostensibly more neutral language of neurocognitive disorder will significantly lessen the stigma associated with Alzheimer’s disease or the milder cognitive impairments associated with aging. To be sure, the label dementia is deeply stigmatizing. But its stigmatizing power comes not from the word itself but from a deeper cultural impulse of marginalization. As long as we judge the worth of human beings by normative standards of productivity and competence, any label used to denote an impairment that prevents an individual from meeting those standards will soon enough come to be stigmatizing. Absent any meaningful attempt to change the normative standards that drive the stigmatization of aging and cognitive impairment, changes in terminology will not be de-stigmatizing but merely euphemistic. To the degree that the deployment of euphemism allows us to ignore unpleasant realities and shirk difficult social and cultural work, it will do more harm than good.

The other major change related to age-associated cognitive deterioration in the draft DSM-V is the proposal to add the category “Minor Neurocognitive Disorder” to recognize “the substantial clinical needs of individuals who have mild cognitive deficits in one or more of the same domains but can function independently… often through increased effort or compensatory strategies.”

The creation of the “Minor Neurocognitive Disorder” is an especially worrisome example of what, in a post to h-madness a couple of days back, Allan Horwitz characterized as a “Trojan horse that would diagnose nearly a-symptomatic people as being in the early stages of a disorder.” While such early diagnosis and treatment might be a well-intentioned effort to make help available early on, or to enhance investigation of the causes of a disorder, it has clear potential for abuse by a pharmaceutical industry eager to expand the market for their goods. This potential can be seen in the stated rationale for the proposal, which notes that early recognition of

“Mild Cognitive Impairment may be particularly critical, as it may be a focus of early intervention. Early intervention efforts may enable the use of treatments that are not effective at more severe levels of impairment and/or neuronal damage, and, in the case of neurodegenerative disease, may enable a clinical trial to prevent or slow progression.”

This is a fairly transparent statement of the hope that the drugs found to be of dubious value to patients diagnosed with Alzheimer’s disease might be found to offer greater benefit to patients in prodromal stages – or at least to generate more profits for drug companies.

The proposed diagnostic criteria for Alzheimer Subtype of Major or Minor Neurocognitive Disorders in the draft DSM-V stops just short of endorsing Mild Cognitive Impairment (MCI) as a prodrome of Alzheimer’s disease. The stated rationale for the proposal notes that research is ambiguous. Patients with MCI in memory disorder clinics have been shown to progress to Alzheimer’s at a rate of 12-15% per year, but population-based studies show a much lower rate of progression, with some individuals actually improving. Thus, the predictive value of MCI (or what under DSM-V will be called Minor Neurocognitive Disorder with Memory Impairment) does not warrant an automatic diagnosis as prodromal Alzheimer’s disease. The diagnostic criteria require not only evidence of mild memory impairment, but “clear supporting evidence for the Alzheimer etiology (e.g., a positive test for a known mutation in an Alzheimer’s disease associated gene), or with evolving research, documentation based on biomarkers or imaging.”

A positive test for one of the Alzheimer’s genes is a high diagnostic hurdle that would function to prevent dramatic inflation of this diagnostic category, but given the value to many powerful interests of very early Alzheimer’s diagnosis, who can doubt that progress in biomarkers and imaging will be quickly forthcoming? Smart money should be investing in pharmaceutical companies that stand to tremendously enlarge the market for drugs that have proven to be of dubious value for people diagnosed with Alzheimer’s.

And once every senior moment is diagnosable, we really will have reached the point – as Horwitz right worries – of pathologizing everyone.

Jesse Ballenger

This post can also be find on Alt(z)heimer

Du « facteur de risque » au « risque de psychose » : focus sur la schizophrénie dans l’esquisse du DSM-V

Date 18 mars 2010 |

Le comité de rédaction du manuel de psychiatrie américain (Diagnostic and Statistical Manual of Mental Disorders) a réussi à créer le buzz sur Internet en dévoilant le mois dernier l’avant-projet de la cinquième édition, annoncée pour 2013. Ce manuel est l’objet d’une attention particulière parce qu’il sert de référence aux compagnies d’assurance américaines, mais aussi aux publications scientifiques internationales. À ce titre, il s’est imposé à tous, non pas en créant le consensus, mais en offrant des données standardisées, qui construisent la condition de possibilité d’une mise en commun de données hétérogènes, même si personne ne s’accorde sur l’interprétation psychopathologique à leur donner. Quelle est la grande nouveauté du DSM-V ? Une approche dimensionnelle des troubles mentaux, selon les méthodes de la psychologie cognitive. En clair, il s’agit d’abandonner les catégories discontinues, pour passer à une conception définie à partir d’échelles qui mesurent le comportement et qui peuvent faire l’objet de calculs de corrélation. Le but visé est d’établir des variations par rapport à la norme et des liens transversaux entre les troubles mentaux.

L’approche dimensionnelle du DSM-V doit réduire la comorbidité excessive que l’on trouve dans les diagnostics actuels, nous dit-on dans l’argument. Mais d’autres modifications sont attendues, notamment en ce qui concerne la schizophrénie. Il faut rappeler que la schizophrénie est une représentation de la maladie mentale propre au XXe siècle : ce n’est pas une entité clinique typique, c’est un regroupement nosologique de formes cliniques disparates, mis en ordre naguère sous le terme de démence précoce par Kraepelin, puis par Bleuler (Dementia praecox oder die Gruppe des Schizophrenien, 1911), à partir des mécanismes freudiens. Plusieurs types de psychose schizophrénique sont classiquement décrits : la schizophrénie simple, l’hébéphrénie, la catatonie et la démence paranoïde. La première forme a connu une fortune considérable : reformulée par Kretschmer comme une forme latente et non évoluée (schizoïdie), elle permet de considérer tout un continuum d’états bizarres ou franchement pathologiques, en regroupant des formes discrètes de folie. Une fois réunis dans une même entité, ces troubles de gravité variable se prêtent plus facilement aux analyses psychologiques dynamiques, et globalement la schizophrénie s’est imposée au siècle dernier comme l’expression d’une modernité dans le champ de la psychiatrie. À titre de comparaison, on peut dire qu’elle a pris la forme d’un phénomène socio-culturel aussi important que l’hystérie à la fin du XIXe siècle, mais sur un plan international, et qu’elle est une représentation bien connue du grand public, notamment grâce à la littérature et au cinéma américains. Après-guerre, la schizophrénie a concentré les essais thérapeutiques, encouragés par la découverte du premier neuroleptique (chlorpromazine, 1952), mais aussi par la diffusion des psychothérapies. Depuis les années 1980 (DSM-III) le manuel américain a abandonné la référence à la psychanalyse et se contente de répertorier cinq formes de schizophrénie, sans interprétation psychopathologique : type désorganisé, type catatonique, type paranoïde, type indifférencié et type résiduel. Désormais le DSM-V rompt avec ce modèle catégoriel : les frontières entre les sous-catégories sont abolies au profit des dimensions, et deux syndromes reconfigurent la schizophrénie, en renforçant le pôle de la schizophrénie simple, débutante ou non évoluée : la catatonie est séparée de la schizophrénie et un nouveau syndrome de risque de psychose est avancé.

Premier point : la catatonie est une ancienne catégorie qui désigne une inertie motrice et un repli sur soi (tant comportemental que psychique), décrite par Kahlbaum en 1874. Néanmoins ce trouble est devenu plus rare sous sa forme déficitaire grave, il peut se rencontrer au cours d’autres troubles comme la mélancolie et il répond favorablement à certains médicaments anxiolytiques. En résumé, séparer la catatonie de la schizophrénie est un geste de rupture fort par rapport à l’héritage de la psychiatrie classique depuis plus d’un siècle – mais cela n’aura pas une grande incidence sur la pratique psychiatrique quotidienne, d’autant plus que le DSM-V permettra toujours de diagnostiquer une schizophrénie avec une forte dimension catatonique.

L’autre point passe pour une innovation : l’avant-projet du DSM-V a créé un effet d’annonce en dévoilant une nouvelle entité, le syndrome de risque de psychose (Psychosis Risk Syndrome) et en incitant le public à s’exprimer sur sa validité, en l’état actuel des connaissances et des pratiques de prévention de la schizophrénie débutante, qui laissent les spécialistes partagés (les traitements étant lourds, invalidants et stigmatisants). D’autres modifications du diagnostic de schizophrénie sont à l’étude, comme la recommandation d’abandonner la catégorie de trouble schizo-affectif. Là encore, les nouvelles évaluations dimensionnelles permettront d’établir un lien sous la forme d’une schizophrénie avec une forte dimension de l’humeur.

Que penser de cette reconfiguration de la schizophrénie ? Au premier abord, elle abrase son image déficitaire, la schizophrénie étant séparée de la catatonie et renforcée au niveau de son spectre de variation à la norme, par une évalution de la schizophrénie débutante en tant que facteur de risque de psychose. D’un point de vue historique, l’évolution du DSM est-elle révolutionnaire ? Certes non sur le plan méthodologique, l’approche dimensionnelle de la personnalité est un programme de recherche bien établi de la psychologie cognitive depuis plus de vingt ans. Je propose ici une autre piste de réflexion : l’évolution de la psychiatrie vers une gestion des risques, telle que le sociologue Robert Castel (La Gestion des risques. De l’anti-psychiatrie à l’après-psychanalyse, 1981) l’avait analysée, connaît peut-être ici une nouvelle étape, en subordonnant la schizophrénie débutante aux catégories usuelles de l’épidémiologie. En effet, le syndrome de risque de psychose ressemble à s’y méprendre à l’application directe des facteurs de risques épidémiologiques dans un manuel clinique.

Emmanuel Delille


"The game of death"

Date 17 mars 2010 |

This evening, France 2, a French public national television channel, will broadcast a documentary inspired by the Milgram experiments in the 1960s. "Le jeu de la mort", signed by Christophe Nick, transposed to the television the experiment at Yale University by Stanley Milgram in the 1960s to probe the mechanisms of the submission of the Nazi Germans. For this experiment, 80 volunteers who had never attended a game show were recruited. They were told that they participate at a new entertainment-show called "Xtreme Zone". The goal: to submit a candidate - in fact a comedian - to a series of questions. The punishment? An electric shock ranging from 80 to ... 460 volts. With each wrong answer, the public also recruited, cries "punishment". . 80% of questioners go to the end of the game as it becomes a torture session. Only 16 candidates have abandoned the game resisting the authority of television. The documentary has raised a major debate in France on reality shows and the power of television.

You find the webpage of the documentary here.

DSM-5 – or what are you and were they thinking?

Date 17 mars 2010 |

The original DSM series was motivated by an attempt to correlate several conflicting classification schemata (such as still persist in the ICD).  However, since the American Psychiatric Association was taken over by a set of narrow specialists in neurobiology in the 1940s (Kirk and Hutchins) it has become an ever more inflexible instrument.  In general – with a few notable exceptions such as the grudging acceptance of homosexuality as normal behavior (the topic of a brilliant episode of This American Life) – each edition has been worse than the last.  The new edition promises to continue this proud trend.

Before going into some particular changes for this edition, let me rehearse two problems with the entire set.   A significant logical flaw is that it is entirely self-fulfilling: psychiatrists, psychologists and patients can only get re-imbursements for sessions attached to a specific DSM diagnosis.  There can be no disagreement with the code, even if the whole is largely flawed.  In my own experience and that of my friends, this generally means that we sit down with our psychiatrist during a session and choose a code which will do relatively little professional damage if it gets out, and will provide the drugs that she and I prefer.  I know a large number of psychologists and some psychiatrists (the non-pill-pushing variety) who find this a tad abhorrent.  Further, and again I’ll speak for myself as patient, I find the current set of available conditions massively restricting. When going through what your average Australian would call a 'rough spot' several years back, I was offered variously diagnoses of depression, hypermania, hypomania, manic depression, ADHD, anxiety, hyperthyroidism and anhedonism – I deeply prefer the nineteenth century offerings of melancholic, bustling, a delicate sort: each with their own social acceptance and romantic overtones. Bateson's definition of information (a difference which makes a difference) does not obtain here, since most ascriptions of these classifications lead to the prescription of a very small set of drugs.

I am feeling ever more constrained to always keep my behavior within acceptable limits.   In the nineteenth century I could, in my Sherlock Holmes persona – but maybe I’d better not talk about that one -  fall into a black depression, shoot up some cocaine and play the violin then come out of my funk and rid the world of Moriarity.  Today, that archcriminal would quickly get me hospitalized.  In short, the medicalization of deviance – a term first deployed in the 1970s – is in its heyday.   Where the United States still manages to see itself as a haven for liberty,  I wonder how one can maintain that rosy façade in the face of the medicalization of the minds of most of our population and the largest incarceration and execution rate (the only really competing paradigm in the United States to DSM is mortal sinners vs nice people) in the developed world.

Enough of a rant perhaps.  Let’s take as given a tradition of not recognizing social, communal and family dimensions of difficult internal lives of citizens. I find it hard to be truly beatific in a world bent on ecological self-destruction and living in a society bent on unjust wars and providing no safety net for its poorest citizens so that many die unnecessarily, but I guess that’s my fault. It’s sad, but fortunately I have some happy pills.

I actually rather like the potential dissolution of Asperger’s syndrome into Autism Spectrum Disorder - despite the shocked reaction of parents of some computer geeks, who are often characterized by some forms of behavior associated with Asperger’s (just visit the Google campus for a day to verify this).  These are clearly part of a package of behaviors which run the full gamut from what should be considered normal to that which is definitely problematic.  If I had a general theory of what is called mental illness I would take this principle as a baseline: it’s spectrums all the way down.  That’s what multidimensionality is all about.  I do find some fault with Susan Swebo’s report though – what exactly does it mean to cleave to a principle that collapses without disambiguating:

"How to address Pervasive Developmental Disorders – Not Otherwise Specified (PDD-NOS). The individuals currently diagnosed with PDD-NOS may still be described in DSM-V, but the work group will discuss whether they can redefine ASD in such a way that the PDD-NOS diagnosis isn’t necessary, as this diagnosis currently captures a very heterogeneous group of individuals."

If I understand the logic of this (though I’m getting depressed as I write so please don’t pay any attention to me), this means that a heterogeneous group of individuals  will become homogeneous (which basically means treated by the same drugs) if we wiggle the definition of ASD.  And this is seen as a breakthrough rather than sweeping interesting problem cases under an available carpet?

I am not totally negative about this revision.  Indeed,   I close on a somewhat hopeful note.  There are revisions being suggested to the definition of just what a mental disorder is, which include:

"C    Must not be merely an expectable response to common stressors and losses (for example, the loss of a loved one) or a culturally sanctioned response to a particular event (for example, trance states in religious rituals)

D. That reflects an underlying psychobiological dysfunction

E. That is not primarily a result of social deviance or conflicts with society"

If in practice we really honored C and E and defined D in some useful way (which would have to go way beyond psychobiological) then we might work towards a socially useful and culturally rich treatment of mental disorders.   First, though, the psychiatric community needs to come up with rich treatments of C and E, since currently childhood deviance or conflict is not seen in this way (even though it’s of the nature of adolescence) and the set of ‘common stressors’ and ‘culturally sanctioned’ do not include living in an overcrowded world (which we know, through rigorous study,  causes problems for rats).

Geoffrey C. Bowker


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