The Problem of Mental Illness

The simple title of this section belies the extraordinary scope, complexity, and controversial state of contemporary psychiatric thought. Some have argued that if the myriad types of disorders bedeviling humankind were ranked by the net misery and incapacitation they caused, we would discover that psychiatry captures a larger share of human morbidity than does any other medical specialty. It seems ironic - if not tragic - that a clinical field of such magnitude is at the same time distinguished among its peers by a conspicuous lack of therapeutic and philosophical consensus. That the discipline lacks a set of internal standards by which to differentiate unequivocally the correct theory from the false, or the efficacious therapy from the useless, is an open secret. In a sense, if the disputing psychiatric camps are all equally able to claim truth, then none is entitled to it. Consequently, there exists not one psychiatry, but many psychiatries, a simple fact that alone has had enormous ramifications for the field's comparatively low medical status and conceptual disarray. Everywhere recognized and yet nowhere fully understood, insanity continues to challenge us as a problem that demands attention and yet defies control.

Situated so uneasily within the medical domain, the subject of mental illness poses a challenge of singular difficulty for the geographer and historian of human disease. One typically locates disease in place and time by first asking an array of standard questions: What are its immediate and predisposing causes? How does it normally progress? Upon whom is it most likely to befall? For example, in this volume any of a number of essays on infectious diseases (cholera, smallpox, plague) may begin with a tightly drawn narrative of how the disease unfolds in an untreated victim, knowable to the patient or casual observer by conspicuous signs and symptoms and to the medical investigator by the additional involvement of organ or systemic changes. We learn about the life course of the offending infectious agent and about the mechanisms by which it wreaks physiological havoc.

Once a clinical portrait and a chain of causation have been well established, it is possible to position a disease on the social as well as geographic landscape; its prevalence by age, sex, social class, and nation may be determined with some justification. At the same time, the work of the medical historian comes into focus. Paradoxically, as the present becomes clearer, so does the past. Using our clinicobio-logical model as a guide, we can search the historical record for answers to additional questions: When did the disease first appear and how did it migrate? Over the centuries, how wide has been its trail of morbidity? We can also reconstruct the story of when and how medicine, in fits and starts, first isolated the entity as a specific disease and then unraveled its pathogenic mechanisms. Indeed, endeavors such as this volume are indicative of the high confidence we have that our current nosology (fashioned by such triumphs as bacteriology and molecular biology) does, in fact, mirror the contours of biological reality. We are certain that typhus and cancer are not the same disease, and thus tell their stories separately.

Contemporary psychiatry, however, provides us with no map of comparable stability or clarity. When the standard array of aforementioned questions are applied to a mental disorder, satisfactory answers fail to emerge. Indeed, for a given mental illness psychiatrists would be hard-pressed to point to any unambiguous anatomic markers, to describe its pathophysiological process, or to explain its cause with a model that is intuitive, testable, and conforms to prevailing biological wisdom. Lacking in these familiar desiderata of scientific medicine, a mental disorder such as paranoia simply is not granted the same level of ontological certainty that is ascribed to an "organic" disease like leukemia. Until such time as we solve the age-old conundrum of the relations between mind and body, discovering a formula that converts states of consciousness to properties of matter (or vice versa), it is likely that such barriers will persist.

Visibly unmoored to fixed biological truths, classifications of mental disease thus seem capable of infinite drift. In consequence, the task of writing a history or geography of any given psychiatric illness might be regarded as a pointless, premature exercise. What exactly are we trying to map? If we follow the development of the word neurosis, we find that in one century it refers to exclusively nonorganic conditions, and in a century earlier, it includes organic disorders. If we disregard this problem as one of mere wordplay and try to identify the actual conditions that were labeled to such mischievous effect, another quandary develops. It is difficult enough to establish whether a given mental disease appears in another country, let alone in a distant time. That different eras produce variant mental diseases is more than plausible. Unfortunately, there exists no assay of human experience that can bridge the past. Though the bones of a mummy may reveal to X-rays whether a pharaoh suffered from arthritis, they remain silent as to his having suffered a major depression. Finally, each of the many psychiatries has its own guide to understanding mental disease; which filter, then, do we apply to the past? Do we look for anxiety disorders as interpreted by the behaviorist, neuropharmacologist, or psychoanalyst?

Current philosophical critics of psychiatry, such as Thomas Szasz, advise us to abandon the effort. Szasz contends that, strictly speaking, mental illnesses are not valid medical entities and thus their stories have no place in any compendium on human disease. Madness exists, to be sure, but it is a quality of personhood, not of body or disease. Problems of living are manifold and serious, but without positive evidence that an individual's condition is due to a physiological cause, the physician has no business intervening. Unless psychiatrists can meet the best standards of scientific medicine, they should be thought of as modern quacks, laughable if not for their countless victims. According to Szasz, labeling someone a schizophrenic in the late twentieth century is no different from calling someone a witch in 1680 or a communist in 1950. It means that you disapprove of them, wish them ill, and have conspired with the community to punish them.

Any critique that brings to light real and potential abuses of psychiatry is laudable. As a general historical framework, however, Szasz's approach is limited, in that it conflates a philosophical ideal of what medicine should be with what the historical record shows it in fact is. A significant portion of current -and virtually all of past - medicine fails to meet similar tests of scientific purity. Are there only a few "real" physicians? It is easy to forget that the criteria of what constitutes "good" medical science are not fixed, but evolve. For example, controlled clinical trials became the ideal only after World War II. We may be chagrined to learn, just a few decades from now, that our remaining "real" physicians were quacks, too.

A better approach is to revisit categories of mental disorder in their original historical context, to see how they fit within prevailing conceptions of disease - not to define an illness according to an abstract standard, but to derive its meaning from the actual interpretations of patients and physicians. Otherwise, we are left with the absurdity that only those doctors who employ correct therapeutics, and conceptualize in terms of true disease categories (as judged by today's knowledge), have the right to be called physicians. Rather, we might follow the lead of Donald Goodwin and Samuel Guze and simply consider as diseases those conditions linked to suffering, disability, and death, which the lay and medical community regard as the responsibility of medicine. As much recent writing in the history of medicine argues, the "existence" of a disease can be as much a matter of social convention as a question of its biological reality.

This alternative approach to the history of mental disease will also sidestep the pitfalls associated with following the story of any particular psychiatric disorder through the centuries. The goal of this essay is to reconstruct the stages and processes by which insanity came to be seen first as a medical problem and then as a matter for specialized expertise. Particular attention will be given to the interactions between lay and medical conceptions of mental illness, in which physicians become drawn to issues of social concern and, in turn, their theories are incorporated into social thought; to the fit between the specific professional agenda of physicians and the medical conceptions they espoused; and to the challenges as well as opportunities that advances in general medicine posed for psychiatric practitioners. In so doing, we might arrive at a better appreciation of what is embedded within our current categories of mental illness and a clearer perception of what is the social function of psychiatry as a medical discipline.

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