Map of life expectancy at birth from Global Education Project.

Monday, May 22, 2006

More on the Sociology of Mental Illness

I know, I know, there's a federal law that if you have a blog, you can't take a break. Sorry about that, anyhow I'm back. As promised, I want to spend some time on this whole question of the social construction of mental illness and the ontological status of the DSM labeling system, etc. There are some other matters I need to deal with, so as usual these posts will be interspered with others, but I'm going to try to make it add up to a coherent discussion.

So, here is some historical background.

Psychiatry has always occupied a somewhat uncomfortable place within the medical institution. Indeed, psychiatry's origins are substantially separate from those of the other medical specialties. But we are talking about the post-Englightenment era: the dichotomy between healers of the body and "soul" (the literal meaning of psychiatry is "soul healing") is a product of modern philosophical and social developments.

The ancients viewed the mind and body as a single entity. Hippocrates was thus able to write with equal authority about diseases we would today classify as physical and mental. "Hysteria", for example, was caused by movement of the uterus, and depression by an imbalance of the humours. In extant traditional cultures, we find a similar holism. In Haiti, for example, diseases such as mouvais sange, in which the blood rises in the body producing all sorts of physical symptoms, may be caused by emotional shock or stress; while a variety of syndromes with both physical and behavioral manifestations may be caused by sorcery, or by improprieties of diet or bathing, sexual abstinence, etc.

Modern positivist philosophy, often traced to Descartes, has forced a splitting apart of mind and body. From Descartes' time until very recently (if at all) the inner workings of the mind have not been readily susceptible to empirical investigation by the standards of positivist science. Hence investigation of the mind was relegated to the province of philosophy rather than science.

Perhaps Cartesian dualism contributed to the separate development of the institutions that cared for the mentally ill in the Western world from the rest of the medical institution. Whatever the reasons, during the 18th and 19th Centuries this is clearly what happened. In England, the profession of psychiatry was founded when physicians took over the operation of madhouses. Asylums run by physicians became popular in the United States in the 19th Century.

According to Paul Starr, as the asylum became the preferred setting for treatment of the mentally ill, the general hospital remained the least desirable setting for those with other forms of illness. Says Starr, "Although by the 1840s, most superintendents [of mental asylums] were doctors, they kept aloof from other physicians. And, increasingly, as mental hospitals shifted from therapeutic to custodial functions, psychiatry became primarily an administrative rather than a medical specialty."

At that time, the remainder of physicians, who delivered their services in patients' homes and, increasingly, in their own offices, could do no better than psychiatrists at curing the diseases which came their way. However, that all changed with the development of the germ theory of disease. For the first time, this gave physicians an empirically supported theory of disease processes. This understanding allowed them to undertake surgical procedures with a somewhat lower chance of killing the patient. Ultimately, it led to effective antibiotic therapies which gave physicians real power over many of the most feared diseases.

Psychiatry, however, did not benefit from the empirical advances of the early 20th Century, even though one important condition which had been within the domain of psychiatry, general paresis, was explained and conquered at this time. Paresis, formerly nearly indistinguishable from schizophrenia, was found to be the terminal stage of syphilis. However, psychiatry gained no lasting prestige from this discovery because the consequence of effective chemotherapy for syphilis was that paresis would not occur in the first place. Hence the disease passed from the psychiatric domain to that of general or internal medicine.

Furthermore, even when individuals do present with paresis or other syndromes of brain disease or trauma such as epilepsy, stroke, or tumor, as soon as the organic disease process is identified, the claim of psychiatry on the case is largely undermined and it passes instead to neurology or another specialty. The domain of psychiatry has continued to be defined by mind/body dualism. Only for so long as a pathology of mind could not be explained by a phenomenon of the body could psychiatry retain its claim.

Sigmund Freud was, of course, the most influential individual in shaping modern psychiatry. Although the empirical support for his theories was limited to anecdote, he provided psychiatry with a generally accepted toolkit for treating the mind. Furthermore, by discovering the conversion disorders, he forged a link between psychiatry and what I will for now call "physical" medicine which psychiatrists could exploit to try to enhance their prestige within the medical community. At last psychiatrists had something to offer other physicians in the diagnosis and treatment of "real" diseases. Finally, Freud's work got psychiatry out of the ghetto of the lunatic asylum and gave psychiatrists the opportunity to set up private practices and treat paying patients, like other doctors.

Nevertheless, Freud's work, if anything, contributed to the influence of dualism in shaping psychiatric practice and its relationship with the remainder of medicine. While the theory of "functional" disorders did forge a link between mind and body, nevertheless the etiology of such disorders lay in psychodynamic processes, the still insubstantial stuff of mind. A psychiatric diagnosis will be used to rule out "organic" causes of illness and lead to a patient's being transferred to a psychiatric ward; hence the disorder is no longer seen as a "medical" problem.

Next: The era of psychosomatic medicine.

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