DSM V et dérives de la démocratie : quelques observations d’un clinicien inquiet

La mise en ligne des développements de la future cinquième version du célèbre manuel constitue un événement scientifique d’ampleur méritant que l’on s’y attarde parce qu’il est un observatoire heuristique d’une psychiatrisation de la vie sociale, comme la montré Lane (2009). Une brève visite du site construit par l’APA permet de se faire une idée de ce que seront les changements par rapport au DSM IV. Il m’est ici impossible de les examiner dans leur entièreté et avec la rigueur qui s’imposerait idéalement, c’est pourquoi je me centrerai sur lesdites « paraphilies » – soit littéralement les « manières d’aimer à côté » – que je connais mieux et qui me semblent paradigmatiques dans la mesure où la captation psychiatrique de la sexualité à travers le DSM pose une série de problèmes intéressants pour le chercheur en sciences humaines cliniques. Avant de m’intéresser aux paraphilies, je voudrais souligner que le terme « paraphilie » a remplacé celui de « perversion », ainsi que cela a été le cas d’autres termes comme celui de « névrose » en ce qu’ils émanaient du corpus psychanalytique. En changeant de terme, les concepteurs du manuel évacuent les débats d’école – pourtant riches et féconds – au nom du consensus politique auquel ils se sont promis d’aboutir coûte que coûte. On sait que ces mutations terminologiques traduisent l’élimination progressive des lexiques psychanalytiques, opération renvoyant à la recherche d’une légitimation d’une psychiatrie en mal de repères contre la psychanalyse (Blondiaux, 2009).

Avant d’examiner plus avant le sort réservé aux paraphilies, il me faut encore introduire une remarque substantielle sur la question de la démocratisation apparente et affichée de l’élaboration du manuel puisque tout un chacun est aujourd’hui invité à faire des commentaires sur le site web du DSM V, qu’il soit clinicien, chercheur, administrateur, malade ou parent de malade. Il est immédiatement possible d’interpréter cette offre comme relevant d’une vaste manœuvre de marketing qu’on ne pourrait manquer de relier à la rhétorique sous-jacente à l’élaboration du manuel (Kirk & Kutchins, 1998). Cette ouverture au public profane ou initié nourrit l’illusion d’une participation active à la conception d’un instrument qui les concerne : comment ne pas y voir une entrée de plus dans la psychiatrisation de la vie privée ? Les concepteurs vont-ils tenir compte des commentaires et, si oui, comment ? Se pose, selon moi, la question de la méthode et de son contrôle, à supposer bien sûr que la bonne foi accompagne l’élaboration du manuel. Et si les « feed-back » étaient effectivement considérés, seront-ils hiérarchisés ? Le commentaire d’un malade ou d’un parent a-t-il la même valeur que celui d’un chercheur ou d’un directeur d’institution psychiatrique ? Il me semble que ces questions témoignent d’une dérive de la démocratie, qu’on peut appeler le « démocratisme » (Lebrun, 2007), soit la propension de nos sociétés à développer un principe de symétrie dans le sens où tout se vaut, tout le monde a le droit au débat indépendamment de sa position dans le champ ; en quelque sorte chacun est « expert » et les différences interindividuelles ou intra-individuelles se voient lissées par une référence à l’égalitarisme juridique. De manière plus radicale, le problème de la rupture épistémologique entre sens commun et sens scientifique se pose ici avec une acuité singulière. Si la science n’est que la traduction savante du sens commun, alors elle ne mérite plus, à mes yeux, le statut de science au sens où elle devrait pouvoir développer un méta-langage susceptible d’éclairer autrement les phénomènes de sens commun.

Dans le registre des paraphilies, faisant partie des troubles sexuels et de l’identité de genre, les concepteurs de la nouvelle version réintroduisent le « trouble paraphilique coercitif » (Paraphilic Coercive Disorder) qui avait été proposé lors des précédentes révisions mais n’avait pas été adopté. Cette nouvelle entité a été proposée comme « syndrome distinct », séparé du trouble sadique sexuel (le diagnostic de trouble paraphilique coercitif exclut celui de sadisme). On parle de trouble paraphilique coercitif lorsque la personne est affligée ou détériorée par ses attirances ou a cherché la stimulation sexuelle en forçant la relation sexuelle sur trois personnes ou plus non consentantes dans des occasions séparées (je ne peux ici m’exprimer sur cette définition hautement problématique). Par le truchement de la référence au consentement, c’est le viol d’un point de vue légal qui paraît visé ainsi que semblent le confirmer les notes complémentaires faisant état de travaux menés sur des populations judiciarisées (en particulier des violeurs). On ne peut manquer de souligner l’infiltration des catégories juridiques dans le diagnostic psychiatrique aboutissant in fine à une classification hybride. De mon point de vue, la non-distinction comme l’absence d’autonomie entre les catégories juridiques et les catégories psychiatriques est non seulement une erreur épistémologique mais un véritable vecteur d’une pénalisation-psychiatrisation des populations, à grande échelle.

Cet ajout s’éclaire encore d’une autre lumière lorsqu’on le relie aux deux changements majeurs portant sur les paraphilies, lesquels affecteront le diagnostic. Il s’agit, d’une part, de l’introduction du terme « trouble paraphilique » et, d’autre part, de l’indication du nombre de victimes dont je ne traiterai pas ici. Le premier grand changement renvoie à la distinction posée entre constat d’une « paraphilie » et diagnostic d’un « trouble paraphilique ». En effet, les paraphilies ne sont pas ipso facto considérées comme des troubles psychiatriques. Une paraphilie ne réclame donc pas nécessairement une intervention psychiatrique. Est-ce l’aveu implicite que les constats pourront être posés par le quidam dans le sens d’une démocratisation des usages du DSM alors que le diagnostic ne le serait que par le clinicien ? Une définition du trouble paraphilique est donnée : ce qui cause une détresse ou une diminution de l’individu ou ce qui menace les autres. C’est donc au psychiatre de faire la part en ce qui sera un trouble et ce qui n’en sera pas un sur base d’une définition qui n’apporte que peu d’éléments. La frontière n’est donc pas claire pour décider du trouble ou non. La paraphilie est une condition nécessaire mais non suffisante pour devenir un trouble. Les concepteurs affirment que cette approche laisse intacte la distinction entre comportement sexuel normatif et non normatif pouvant intéresser les chercheurs mais ne menant pas automatiquement à considérer un comportement non normatif comme pathologique… Malgré cette nuance, pour officialiser cette position selon laquelle une paraphilie n’est pas en elle-même pathologique, les classes ont été revues : le sadisme sexuel est devenu le trouble sadique sexuel ; il en va de même des autres entités. Du reste, une paraphilie peut être considérée, dans la nouvelle version, comme « pré-pathologique » dans la mesure où les paraphilies se distinguent des « normophilies » ; au plus elles se ressemblent, au plus il faudrait de preuves pour déterminer qu’il s’agit d’une paraphilie. D’après moi, sous réserve de vérification, la « normophilie » est un nouveau néologisme exprimant qu’il est des « manières d’aimer normales » (à moins qu’il s’agisse de ceux qui aiment les normes…) et des « manières d’aimer à côté » (paraphilies) qui peuvent aussi être pathologiques (elles sont alors nommées troubles). Ce néologisme me semble faire l’aveu que les « paraphilies » sont bien du domaine psychiatrique, mordant toujours un peu plus sur le champ de la vie sociale et privée. Par conséquent, être paraphile, c’est ne pas être normal tout en n’étant pas malade… autant dire qu’il s’agit, de mon point de vue, de la définition même de ce qu’est un être humain en tension entre normalité et pathologie. Du reste, le diagnostic de paraphilie fait déjà mettre un pied dans la classification, et il y a fort à parier qu’il ne faudra que quelques efforts pour devenir malade. En fait, on peut facilement prédire que le désarroi du diagnosticien prudent ou, à l’inverse, la certitude de celui qui sait sera plus grand(e) encore qu’il ou elle ne l’était.

En conclusion, il semble bien que les « nouveaux désordres » (Disorders, traduit plus souvent par troubles) du DSM V en trahissent d’autres : épistémologiques, politiques, scientifiques… appelant à ce qu’un nouvel ordre s’établisse par la psychiatrisation et la pénalisation de la vie sociale et privée faisant de certaines de nos « manières d’aimer à côté », certes bizarres mais ni illégales ni pathologiques, de nouveaux objets de médicalisation et de judiciarisation. Ainsi, le juge et le psychiatre seront amenés à coucher dans notre lit ou à l’examiner de près. Il me semble que les dérives de la démocratie devraient pouvoir être considérées comme de nouveaux troubles, possiblement psychiatriques : la passion pour la démocratisation et le consensus devenant suspecte. Ainsi, vais-je plaider pour que le démocratisme fasse partie de la nouvelle version. Il en va de même de la coercition judiciaire ou psychiatrique forçant notre consentement à nous déterminer singulièrement, certes dans des limites qui ne sont jamais claires dès qu’il s’agit de sexualité.

Christophe Adam

BLONDIAUX Isabelle. 2009. Psychiatrie contre psychanalyse ? Débats et scandales autour de la psychothérapie ?, Paris, Le félin.

KIRK Stuart, KUTCHINS Herb. 1998. Aimez-vous le DSM ? Le triomphe de la psychiatrie américaine, Le Plessis-Robison, Synthélabo.

LANE Christophe. 2009. Comment la psychiatrie et l’industrie pharmaceutique ont médicalisé nos émotions, Traduit de l’anglais par François Boisivon, Paris, Flammarion.

LEBRUN Jean Pierre. 2007. La perversion ordinaire, vivre ensemble sans autrui, Paris, Denoël.

DSM-V: Getting Closer to Pathologizing Everyone?

For several years, the discussions about the deliberations of the various task forces involved in constructing the latest revision of the Diagnostic and Statistical Manual of the American Psychiatric Association, the DSM-V, have been shrouded in secrecy. The lack of transparency of the discussions generated highly publicized criticisms from such luminaries as Robert Spitzer, the major developer of the revolutionary DSM-III, and Allen Frances, chair of the DSM-IV task force. This situation radically changed in February with the release of the revisions of the changes proposed by the 13 work groups charged with revising the DSM.

Most of the public response to the proposed changes has centered on several alterations to particular diagnostic categories. The suggestions include using a new diagnosis of “temper dysregulation with dysphoria” for children instead of bipolar disorder, incorporating Asperger’s disorder, autistic disorder, and several other conditions into a single “autism spectrum disorders” category, and recognizing some new types of eating disorders. The focus on these specific changes, most of which are sensible, has deflected attention away from other suggestions that have much greater potential import.

Three changes, in particular, could lead to an enormous pathologization of non-disordered conditions. The first is the suggested revision of the criteria for Major Depressive Episode to remove the bereavement exclusion from this diagnosis. At present, the criteria for major depression require five or more out of nine symptoms including sadness or lack of interest or pleasure that least for at least two weeks. However, the criteria exclude people who experience these symptoms in response to bereavement: “The symptoms are not better accounted for by Bereavement” That is, people who develop enough symptoms to meet the criteria after the death of an intimate are nevertheless not defined as disordered but instead as suffering from a natural, nondisordered response to loss.

The reason for the bereavement exclusion is obvious. Voluminous evidence indicates that bereavement after the loss of an intimate is a natural reaction. The earliest literary portrayals of human experience such as Gilgamesh and The Iliad indicate that grief is a basic human emotion. Likewise, while different cultures have vastly different expressions of grief, sadness and accompanying psychological and somatic symptoms after the loss of a loved one is a universal experience. Even many primates show demonstrable signs of depression-like symptoms after the death of a close relation.  In the vast majority of cases, the universal symptoms of grief dissipate with the passage of time and only a minority of the bereaved remains highly symptomatic after several months pass.

If the suggested revision is implemented anyone who is sad, fails to derive pleasure from usual activities, finds it difficult to concentrate, and has sleep and appetite difficulties for a mere two weeks could be diagnosed with Major Depressive Disorder. Because virtually the entire population will be bereaved at some point in their lives and because such a high proportion of the bereaved would meet diagnostic criteria that require two week duration, this proposal could pathologize an enormous number of people.

A second proposal that has the promise of massively medicalizing natural emotions is to adapt dimensional assessments for the existing categorical diagnoses. On the surface, this proposal sounds sensible and desirable. Major Depression, for example, requires the presence of five symptoms but there is no natural cut-off point between four and five symptoms, or at any other particular point for this diagnosis. Depression, as well as the other major conditions in the DSM, seems to naturally be a continuous rather than a categorical condition.

The problem in dimensionalizing common conditions such as depression and anxiety is that a small number of “subthreshold” symptoms typically indicate a non-disordered condition, not a milder form of disorder. The only way to accurately use a dimensional system is to initially use criteria for disorder that separates natural from disordered conditions, regardless of how many symptoms are present. If adequate conceptions of disorder first distinguish contextually appropriate symptoms that are commonly transitory responses to stressors from mental disorders, then dimensional measurement could represent a distinct improvement in the DSM. As the discussion of bereavement indicates, however, the separation of disorders from non-disorders in the DSM-V seems to be getting worse rather than better. The current proposal to dimensionalize measures of frequently occurring disorders threatens to pathologize even mildly distressing conditions. While potentially valuable, it needs reconsideration and reformulation.

A final worrisome proposal lies in the creation of “at-risk” categories for mental disorder. At present, this possible category is limited to psychotic conditions; people who have just one symptom from among delusions, hallucinations, and disorganized speech who have never met the criteria for a psychotic disorder could receive the “at-risk” diagnosis. The diagnosis is well-intentioned and aimed at identifying people who might be at an early stage of a psychotic condition but who don’t yet meet the full criteria. Such people might benefit from early identification and treatment.

The problem with the “at-risk” category is its potential as a Trojan horse that would diagnose nearly a-symptomatic people as being in the early stages of a disorder. Yet, at present, there is no way of knowing which people with a single or a small number of symptoms will go on to meet the full diagnostic criteria and which will not. The latter group will typically outnumber the former group so that the potential for false positive diagnoses is enormous.

The current suggested revision only applies to psychotic conditions where it might not create too much damage. If it were applied to widely occurring conditions such as depression and anxiety, however, the result could be a massive amount of new pathology. For example, one of the best known studies of depression, the Dunedin Study, ties the presence of the small allele of the 5-HT gene to this condition. Yet, nearly 20% of people have two copies of the small allele and over half have one copy, so over two-thirds of the population could be viewed as “at-risk” for developing depression . Once a gene is identified as a risk factor for depression, anyone who has the gene may be a candidate for intervention, even if they don’t actually have a depressive condition. Genetic tests could identify “at risk” individuals, who could then be placed on long-term regimes of drug therapies. In the case of the 5-HT gene, a majority of people would be at risk for depression. While the DSM-V working groups have not (yet) proposed an atrisk category for depression or any other commonly occurring condition, this danger might be lurking in the future.

Overall, it appears that the original promise of the DSM-III in 1980 – the creation of a clear, precise, and reliable diagnostic system that would eventually lead to more accurate knowledge about the causes, prognoses, and treatments of mental disorders has not been fulfilled. Indeed, it is difficult to think of a single breakthrough that has resulted from psychiatry’s classificatory system. The major proposals in the DSM-V do not seem as if they will change this situation and could wind up making psychiatry’s central problem of distinguishing pathology from normality even more difficult to resolve.

Allan Horwitz

image©Vincent W. Hevern

Introducing new Resources page

H-Madness has added a new page on “Resources” (located in the toolbar at the top of the blog page). This page, which will be updated on a regular basis, includes links to syllabus archives, bibliographies,  key texts in the history of psychiatry, and case histories, as well as other materials or links of interest to teachers, students, and independent researchers. The editors welcome submissions or suggestions about new resources.

New exhibition at the Prinzhorn Museum (Heidelberg)

Recently, the Prinzhorn Collection was able to acquire with the help of the Brass foundation a unique picture series of 44 drawings. The artist, Wilhelm Werner (1898-1940), lived since 1919 in the Werneck asylum. He drew the images between 1934 and 1938, after his forced sterilisation. He transformed the experience of the degrading intervention into a series of impressively imaginative and original pictures. Two years later Werner became a victim of the Nazi “euthanasia” programme. His series of drawings is shown for the first time at the Prinzhorn Collection from the 17th of March.

New Issue of the International Review of Psychiatry

The latest issue of International Review of Psychiatry is dedicated to psychiatry in a colonial context.

Titles, authors and abstracts are listed below.

History of psychiatry in West Africa by F. Oyebode (Department of Psychiatry, University of Birmingham, Birmingham, UK). The abstract reads:

This paper explores the social context of the development of mental asylums in colonial Nigeria. The characteristics of the medical leadership is described, as is the environmental condition of the asylums. The colonial period produced conceptualizations of the African mind and of the pattern and distribution of mental illness in Africans. These conceptualizations are critically examined.

Psychiatry in the East African colonies: A background to confinement by Sloan Mahone (University of Oxford, Oxford, UK). The abstract reads:

This article is concerned with the discipline of psychiatry in colonial East Africa as it emerged out of the crime and disorder problem to become an intellectually significant ‘East African School’ of psychiatry. The process of lunacy certification, in particular, provides a snapshot of the medical and political tensions that existed among the medical establishment, the prison system and the colonial courts, all of whom sought to define collective African behaviour. This historical article utilises archaic terminology, such as ‘lunatic’ or ‘lunacy’, as these categories were in use at the time.

Modern psychiatry in India: The British role in establishing an Asian system, 1858-1947 by J. Mills (Centre for the Social History of Health and Healthcare Glasgow, Department of History, University of Strathclyde, Strathclyde, Glasgow, UK). The abstract reads:

Four broad phases can be traced in the development of modern psychiatry in India. After briefly considering the outline of each of these phases this article will focus its attention on the second and third. It will be argued through tracing the trends in patient admission, treatment regimes and the organisation of the asylum system in these years that the foundations of modern psychiatry were laid in India in the period 1858 to 1947 and that the modern psychiatric system in India as it is today, although it has evolved since Independence in 1947, continues in significant ways to be shaped by the colonial period.

Madmen and specialists: The clientele and the staff of the Lunatic Asylum, Bangalore by Sanjeer Jain and P. Murthy (Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India). The abstract reads:

The history of the asylum has proven to be an invaluable resource for exploring the interface between science, medicine, religion and social and political processes. The definitions of insanity have troubled humans for centuries, as have the methods for treatment. Diverse, and often conflicting, ideological positions are quite common. Documenting the specific histories of the staff and patients of an asylum can thus help us understand the evolution of the physical and the intellectual growth of psychiatry in India. In this endeavour, we have used the records of the Lunatic Asylum, Bangalore (later the All India Institute of Mental Health and subsequently the National Institute of Mental Health and Neurosciences [NIMHANS]) to explore the history of psychiatry in India. The only asylum maintained by a ‘Native Kingdom’, it exemplifies the dynamics of the growth of mental health services in the country. We trace the changes in administrative control of the Asylum, the changes in medical practice and some aspects of the social history of the region. This article traces the history of psychiatry at one institution, which, at the micro level, is a mirror to the understanding of the historical trends of psychiatric services in India.

A brief history of psychiatry in Singapore by B. -Y. Ng (Department of Psychiatry, Singapore General Hospital) and K. -T. Chee (Woodbridge Hospital and Institute of Mental Health, Singapore). The abstract reads:

The development of psychiatric services in Singapore during the last 150 years can be divided into four distinct, albeit overlapping, phases: (1) the origins of the Lunatic Asylum; (2) the interruption caused by the Japanese Occupation, and the post-war years; (3) the training of local psychiatrists and mental health professionals; and (4) the development of general hospital psychiatry and community mental health services. Early psychiatry in Singapore was essentially British psychiatry as an outpost but modified by local conditions. Modern psychiatry in Singapore has its roots in Singapore’s colonial past and is strongly influenced by Western psychiatry. It has come a long way since its humble beginnings when the first mental hospital was established in 1841.

The development of psychiatry in Indonesia: From colonial to modern times by H. Pols (Unit for History and Philosophy of Science, University of Sydney, Sydney, Australia). The abstract reads:

During the colonial period, mental health care policy in the Dutch East Indies was centred on the mental hospital, which provided custodial care. In 1949, independent Indonesia inherited four very large mental hospitals, about 10 acute-care clinics in the major cities, and an agricultural colony. During the 1950s, mental hospital care remained largely custodial. In 1966, the Directorate of Mental Health adopted the three-fold principles of prevention, treatment, and rehabilitation as the foundation of a comprehensive mental health care system. During the 1970s and 1980s, the number of mental hospitals in Indonesia doubled and a variety of treatment methods were introduced. Special attention was given to the care provided by dukuns, or indigenous healers.

Psychiatry and its institutions in Australia and New Zealand: An overview by Catharine Coleborne (Department of History, The University of Waikato, Hamilton, New Zealand) and Dolly MacKinnon (Department of History, University of Melbourne, Australia).

New Issue of History of Psychiatry

The first issue of the History of Psychiatry for 2010 has been released online. Included in this issue are seven articles, which address the madness of King George III, Philipp Pinel, Danish psychiatrist August Wimmer, Jean-Marc Gaspard Itard, William Saunders Hallaran and John Jackson.

Titles, authors and abstracts are listed below.

King George III and porphyria: a clinical re-examination of the historical evidence by Timothy J Peters (Institute of Archaeology and Antiquity, University of Birmingham) and D. Wilkinson (Institute of Education, University of London). The abstract reads:

« The diagnosis that George III suffered from acute porphyria has gained widespread acceptance, but re-examination of the evidence suggests it is unlikely that he had porphyria.The porphyria diagnosis was advanced by Ida Macalpine and Richard Hunter, whose clinical symptomatology and historical methodology were flawed. They highlighted selected symptoms, while ignoring, dismissing or suppressing counter-evidence. Their claims about peripheral neuropathy, cataracts, vocal hoarseness and abdominal pains are re- evaluated; and it is also demonstrated that evidence of discoloured urine is exceedingly weak. Macalpine and Hunter believed that mental illnesses were primarily caused by physical diseases, and their diagnosis of George III formed part of a wider agenda to promote controversial views about past, contemporary and future methods in psychiatry. »

The madness of King George III: a psychiatric re-assessment by Timothy J Peters (Institute of Archaeology and Antiquity, University of Birmingham) and Allan Beveridge (Queen Margaret Hospital, Dunfermline, UK). The abstract reads:

« This research, based on a study of King George III’s medical records and of contemporary diaries of his courtiers and equerries, further confirms the considerable doubt on the claim of Richard Hunter and Ida Macalpine that the King suffered from recurrent attacks of acute porphyria. The present study examines the above records from a psychiatric viewpoint, together with some additional reports, to re-assess the nature of the King’s maladies. It concludes that he suffered from recurrent mania (four episodes), with chronic mania and possibly a degree of fatuity during the last decade of his life. This is in agreement with previous reports that he suffered from manic-depressive psychosis. »

Science and morals in the affective psychopathology of Philippe Pinel by Louis C Charland (University of Western Ontario, Canada). The abstract reads:

« Building on what he believed was a new ‘medico-philosophical’ method, Philippe Pinel made a bold theoretical attempt to find a place for the passions and other affective posits in psychopathology. However, his courageous attempt to steer affectivity onto the high seas of medical science ran aground on two great reefs that still threaten the scientific status of affectivity today. Epistemologically, there is the elusive nature of the signs and symptoms of affectivity. Ethically, there is the stubborn manner in which fact and value are intermingled in affectivity. Both obstacles posed insuperable difficulties for Pinel, who never really managed to extricate his affective psychopathology from the confines of the Lockean intellectual paradigm. »

Wimmer’s concept of psychogenic psychosis revisited by Augusto C Castagnini (University of Cambridge). The abstract reads:

« In the early twentieth century the Danish psychiatrist August Wimmer (1872—1937) developed the concept of psychogenic psychosis (PP) as a category of mental disorders separate from schizophrenia and manic depression. It subsumed a variety of clinical conditions with affective, confusional and paranoid features typically triggered by a psychical trauma. Wimmer’s work has established itself as one of the classic texts in Scandinavian psychiatry but, for linguistic reasons, long remained almost unknown in other European countries. Translated into English in 2003, it is now available for historical and psychopathological analyses. This paper describes the original meaning of PP and sets it in context, then discusses the implications arising from the usage of the diagnostic categories introduced to replace PP in modern international classifications. »

J.-M. G. Itard’s 1825 study: movement and the science of the human mind by Sara Newman (Kent State University, USA). The abstract reads:

« Jean-Marc Gaspard Itard’s 1825 ‘Study of several involuntary functions of the apparatus of movement, gripping, and voice’ discusses 10 individuals with uncontrolled movements but no other significant impairments. Thus, otherwise normal people move in inappropriate ways against their better judgement. Although the study contains the first clinical description of Tourette Syndrome, it has received little attention beyond that notice. Examined in its entirety and in its cultural context, Itard’s study characterizes patients’ movements in terms of the will, propriety, animals and gender. Lacking control over their movements, the individuals are underdeveloped humans. Accordingly, sufferers’ facial expression, bodily movements and unplanned vocalizations render them more animal than human and more deviant than normal, although they are neither insane nor evil. »

Hallaran’s circulating swing by Caoimhghín S Breathnach (University College Dublin). The abstract reads:

« William Saunders Hallaran (c.1765—1825) was physician superintendent at the County and City of Cork Lunatic Asylum for 40 years, where he distinguished between mental insanity and organic (systemic) delirium. In treatment he used emetics and purgatives, digitalis and opium, the shower bath and exercise, and argued that patients should be saved from ‘unavoidable sloth’ by mental as well as manual occupation. However, it is as an exponent of the circulating swing, proposed by Erasmus Darwin and used by Joseph Cox, that he is remembered. His best results were achieved, as he recorded in An Enquiry in 1810, by inducing sleep in mania of recent onset, but perhaps his most enduring observation was that some of his patients enjoyed the rotatory experience, and he had enough sense to allow the use of the swing as a mode of amusement. »

The work of John Hughlings Jackson: Part 1 by JM López Piñero by GE Berrios (University of Cambridge). The abstract reads:

« After returning to Spain from a research period in London on a Wellcome Trust scholarship, José Maria López Piñero1 published in 1973 a short book entitled John Hughlings Jackson (1835—1911), Evolucionismo y Neurología (Madrid, Editorial Moneda). Written from the perspective of the classical German medical historiography that the author had imbibed from Werner Leibbrand and Annemarie Wettley, this work truly added to Jacksonian scholarship. Neither hagiographic nor nitpicking, it offered a sober assessment of the contribution of the great Yorkshireman and it was soon to become a minor classic among connoisseurs. Although important additions to Jacksonian scholarship have appeared since 1973, López Piñero’s book has retained its relevance. It will be published in History of Psychiatry in two parts. »

Review: Shutter Island

(Note: This review contains plot spoilers).

There are leaks in the ceiling. A storm is brewing. Inside, passageways are dark and twisted, and outside carefully groomed grounds are juxtaposed with ominous cliffs, crashing waves, and inaccessible caves (not to mention rats by the dozen). The setting of Martin Scorsese’s most recent film, Shutter Island, seems to be a hodge-podge of hastily drawn psychoanalytic symbols. Location? The mind of a madman.

Based on a Dennis Lehane novel of the same name, Shutter Island takes place in and around Ashecliffe  Hospital, an institution for the criminally insane located on a New England island. The film opens on a ferry transporting the protagonist, federal marshal Teddy Daniels (played by Leonardo DiCaprio), and his new partner Chuck Aule (Mark Ruffalo) to the island to investigate the mysterious disappearance of a patient who has somehow escaped from a locked cell. Once the missing patient anticlimactically reappears halfway through the film, however, the viewer becomes aware that she is a mere plot device, serving to bring Daniels to the island for the real investigation, which seems to involve secret, experimental surgeries forced on patients in an old lighthouse near Ashecliffe.

The thematic content of Shutter Island draws from a fraught period in the history of psychiatry, incorporating both the transorbital lobotomies made popular across the U.S. by neurologist Walter Freeman as well as the psychotropic drugs that were responsible for the surgery’s decline as the pharmaceutical treatments quickly gained popularity in the 1950s. The transorbital lobotomy (which involves an ice pick-like instrument inserted through the orbit of the eye and into the brain to sever nerve fibers) was performed, at times against a patient’s will (but sometimes with the consent of family), on thousands of people in the U.S., “treating” everything from depression, alcoholism, and unruly personalities to schizophrenia and other diagnosed mental illnesses. The movie depicts the complicated views on lobotomy in the 50s, when some practitioners were horrified at the zombielike patients the procedure produced. Ultimately, the pro-surgery doctors at Ashecliffe have the final say in the “treatment” of the protagonist. The film presents the procedure as a necessary evil in order to protect the staff and patients from Daniels, the asylum’s most violent criminal, whom neuroleptics have not sufficiently subdued.

In Dr. Cawley (Ben Kingsley), Ashecliffe’s primary physician, we are given a third type of psychiatric treatment in the form of psychotherapy. Self-described as a more humane practitioner, Cawley believes in the respect, dignity, and human rights of his patients. The inclusion of these dueling theories increases the stakes for Daniels’ actions as he runs through an elaborate investigation that is stymied by doctors and patients alike. He is eventually told that his partner, Chuck, has been his psychiatrist for the past two years and that everything he thinks is real on Shutter Island is actually an elaborate role-playing exercise constructed to bring him back to sanity and an awareness of his former crimes. The interpretation of his experiences ultimately becomes the focal point of the movie: is he mad or isn’t he? Is the plotline of the missing woman, investigation, and experimental procedures a paranoid delusion, or is he merely being made to believe he is insane to cover up the conspiracy? Although this hackneyed twist has drawn the derision of many reviewers, the film contains nuanced reflections on mental illness that go beyond the old “it was all a dream/it was me/it was a delusional fantasy” revelation. For example, we are confronted in several cases with the idea that once a person has been diagnosed with insanity (or even merely been assumed to be insane), it is nearly impossible for him or her to escape the associations and deprivation of political and personal power that come with such a conclusion. In the film, this of course leads us to further question how we can ever know whether Daniels (a supposedly crazy person who says he isn’t crazy) is or is not insane, but it also provokes consideration of similar diagnoses in contemporary culture—once mentally ill, always mentally ill? The right of interpretation–who determines what is or isn’t sane?–is questioned as well in the character of a woman who killed her husband after he abused her and no one would help. While considered insane by society, she found the action to be completely reasonable in the absence of other options.

Despite the inclusion of multiple forms of psychiatric intervention and constant emphasis of the subtleties of determining the boundaries of the normal, the film also contributes to harmful stereotypes that still circulate in today’s society, leading to the stigmatization and isolation of those with mental illness. The movie both plays on and contributes to the fear of insanity. Some will be quick to write off the portrayal of mental illness as merely an accurate representation of the asylums of a bygone era, but the force of such manifestations should not be discounted in a world where the stigma associated with mental illness is still going strong.  While, of course, some of the horrible experiences of patients in mental hospitals during the twentieth century are well documented, the almost exclusive portrayal of mental illness in movies as something to be feared or reviled propagates modern-day stereotypes that are painfully similar to the historical situations that may have initially inspired them. Although people with mental illness are, as a whole, no more or less violent than the rest of society, the constant portrayal of the insane patient who murders without cause still permeates popular assumptions about disorders of the mind and brain. Shutter Island presents us with anxieties over patients escaping, mauled faces, descriptions of murders the patients committed, and of course the most dangerous patient, our protagonist, a trained soldier who can only be controlled by the “brain death” of the lobotomy. Scorsese does not depart greatly from the pulpy source material, so one could blame Lehane for the cardstock representation of insanity, but Scorsese’s most obvious alteration is just as clichéd and harmful. At the end of the film, just before being carted away to be lobotomized, Daniels delivers this hardboiled line: « Is it better to live as a monster or die as a good man? » That Scorsese has even the patient himself validate the decision to lobotomize speaks to an anxious desire to settle the matter. Of course, the crazed escapee on a murdering rampage makes much better box office fodder than would a more humane representation of the spectrum of mental deviations and psychiatric care, but even so it would be nice to see more films centering on more accurate depictions of mental illness today.

Sarah Birge