Saving Normal : An Insider's Revolt Against Out-of-control Psychiatric Diagnosis, Dsm-5, Big Pharma, and the Medicalization of Ordinary Life (9780062229274)

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Saving Normal : An Insider's Revolt Against Out-of-control Psychiatric Diagnosis, Dsm-5, Big Pharma, and the Medicalization of Ordinary Life (9780062229274) Page 7

by Frances, Allen


  The Arabs Invent Modern Psychiatry (Circa AD 700 to AD 1500)

  Before entering its own dark age five centuries ago, the Arab world was the undisputed center of knowledge and progress. Islam had initially welcomed the wonders of scientific discovery as a way of perceiving Allah and his intentions. Current tribal readings of the Koran run directly counter to the intellectual freedom it had offered from the time of Mohammed until the clerics gained control as Arab political power waned in the sixteenth century. The Arabs were the first people in the world to introduce quantitative experimental science, taking advantage of their convenient number system (now ours), which greatly facilitated the computations that were so tedious using Roman numerals. They invented algebra, spherical geometry, and trigonometry. They preserved and integrated the best of Greek, Indian, and Persian science and expanded them all with native genius.

  Along the way, the Arabs invented psychiatry as a discipline and psychiatrists as a separate specialty and brought psychiatry to a level of sophistication in diagnosis, treatment, and theory not seen in Europe until the nineteenth century. Why the Arabs? The Koran has an enlightened view of mental illness, with none of the denigrating demonology of the Judeo-Christian and Greco-Roman traditions. No angry spirits, no jealous gods. Mental illness was a practical problem to be dealt with on human and humane terms, with no supernatural blinders.

  The Koran enjoins “feed and clothe the insane . . . and tell splendid words to him.” It sensibly advised against allowing the severely mentally ill to make property decisions, but it insisted that they be treated well and with respect. This led to a totally secular, enlightened, and clinical approach. The mentally ill were to receive custodial care in well-run hospitals whose mission was also to document and understand their problems. The first hospital specifically for the mentally ill opened in Baghdad in 705; Cairo followed in 800; and soon many other major cities. Muslim hospitals often employed Jewish and Christian doctors and included large outpatient clinics and pharmacies.

  The progression of psychiatric advance was astounding and anticipates exactly the same steps that occurred a millennium later when separate asylums for the mentally ill were finally established in Europe. The mental hospital was a wonderful cradle for scientific discovery. The psychiatric specialists had intimate access to a wide variety of patients and could compare their different courses over the passage of time. They made accurate clinical observations, sorted symptoms into syndromes, and developed effective treatment approaches. Arab psychiatry attained a level of detailed, practical learning never before known in the world and not to be achieved again until about 1900.

  A variety of psychiatric classifications were devised in the same excited way as occurred under similar circumstances in the West during the nineteenth century. The Arab world created a completely workable description of disorders equivalent to a modern DSM. Severity was divided into levels that were equivalent to later concepts of neurosis and psychosis. Depression was divided into endogenous, reactive, agitated, and involutional. There were good descriptions of mania, delirium, dementia, epilepsy, meningitis, and stroke. Delusions, hallucinations, strange behavior, and poor judgment were grouped into something like schizophrenia. Phobias, obsessions, compulsions, impotence, sleep disorder, hypochondriasis, and lovesickness were recognized. Clearly the basic psychiatric disorders are stable over time—even if fads come and go.

  Careful brain dissection disproved some of Galen’s assertions and revealed the distributions of the cerebral nerves and vasculature. Tracing the sensory tracts localized the different brain locations for sensory perception. It was known that the frontal lobe was needed for reasoning and common sense and that the ventricles expand in dementia.

  Arab psychiatry anticipated the holistic and respectful moral treatment that didn’t reach Europe for another thousand years. While patients were being scourged, tortured, and burned in the West, they received wise counseling, cognitive psychotherapy, dream interpretation, drugs, baths, music, and work therapy in the East. Mental and physical health were seen as closely intertwined; each could affect the other. The Arabs also accumulated a body of sophisticated knowledge on cognitive psychology, perception, psychotherapy, and neuroscience.9

  Sydenham Spots Syndromes

  Living at the dawn of the Enlightenment in seventeenth-century Cromwellian England, Thomas Sydenham retaught Europe the Hippocratic natural history method of medicine and psychiatry—no demons and no dogmas and no devilishly dangerous treatments. It is from patients that we learn disease, not theory or philosophy or religious doctrine. With his friend the philosopher John Locke, he developed an empirical, atheoretical approach to knowledge acquisition. Sydenham was the prince of practical, commonsense medicine. “You must go to the bedside. It is there alone you can learn disease.” The art of medicine could properly be learned only from its practice and its patients.

  Sydenham’s special role was to bring nosology, which is the classification of diseases, back to the center of medical attention. He was a master at describing syndromes and diseases. Observe, analyze, and compare. Identify regularly cooccurring clusters of symptoms and study their course and prognosis. Diseases were like plants or animals in the way they could be distinguished from one another—if only you know how to look and looked long and hard enough. Ultimately, understanding the pattern will help you uncover the cause and discover the treatment. “Nature, in the production of disease, is uniform and consistent, so much so, that for the same disease in different persons the symptoms are for the most part the same; and the selfsame phenomena that you would observe in the sickness of Socrates you would observe in the sickness of a simpleton.”

  Among the many diseases Sydenham studied and nailed were hysteria and hypochondriasis. Unlike the more gullible Charcot and Freud, working two hundred years later, Sydenham recognized that patients presenting with the physical symptoms of psychological distress could often be made worse by overtreatment. Stopping extreme treatments and substituting psychological techniques often helped patients recover. “Sometimes I have consulted my patients’ safety and my own reputation most effectually by doing nothing at all.”

  Seventeenth-century England, awash in plagues, was a wonderful laboratory for studying the spread of fevers. Sydenham was a pioneer in epidemiology, again following the model of Hippocrates, who had invented the field. Understanding the environmental causes of disease and contagions is the basis of a preventive public health approach that is much more effective than treating their consequences.

  Sydenham took the mystery out of chorea—contractions of the limbs and trunk that are outside the person’s control. He pointed out that chorea occurred after a strep throat, as did rheumatic fever—brain inflammation caused the movements, not demons. He also made three revolutionary and enduring contributions to the drug treatment of diseases: using the extract of a Peruvian bark that happened to contain quinine to treat malaria; promoting iron for anemia; and preparing a liquid form of opium, a medicine he much admired. But Sydenham was cautious in his prescription habits and suspicious of the heroically harmful treatment zealotry of many of his colleagues.10

  Linnaeus Shows That Classification Counts

  It would have been fun to have lived in the eighteenth century. This self-described period of “Enlightenment” was the one moment in history when it was most reasonable to hope that the steady advance of human knowledge would lead to our happiness. But the century ended badly and crushed illusions that have been impossible to resuscitate since. The French Revolution and Napoleonic wars burst the bubble of innocence. Subsequent experience revealed what previously unimaginable disasters can follow from human knowledge when it is unguided by wisdom and caution.

  But a smart person living in the 1700s (there were many) could still believe in the eventual perfectibility of man and the world. It was just a question of gathering data and finding the right way of ordering it. Astronomy provided a seductively simple model of science solving nature’s riddles. First
came the Copernican descriptive theory of a solar-centered universe. Then painstaking observations by Brahe and mathematical sorting of data points by Kepler. And finally, the great triumph of human understanding. Newton (with a big assist from Galileo) explains not only the grand motions of the stars and planets, but also what keeps our feet stuck on the ground and why a cannonball hits a target. Newton’s synthesis challenged science to seek basic truths in other intellectual pursuits. There was a feverish search for new knowledge and for better ways of sorting it. The enlightenment became the Age of Taxonomy, and the daddy of all classifiers was Carl Linnaeus.

  Among the many appealing geniuses of the Enlightenment, Linnaeus is my personal favorite. He was a practicing physician and a fervent botanist, then a necessary combination of roles. Since the days of the shaman, most useful medicines have come from plants, and every medical school was centered on its garden. Linnaeus never personally collected specimens beyond northern Europe, but he didn’t have to. The world came to him. His students were encouraged to become “apostles” pursuing adventure and specimens as ships’ doctor or naturalist. Nineteen of them set forth on collecting journeys covering North and South America, Africa, Japan, and the Asian tropics. The worldwide race of exploration was on. Certainly, the primary goals were to gain economic and military power, but knowledge of geology and biology was also a high priority. Navy vessels doubled as scientific labs, and the best collections and collectors were often afloat. Two apostles accompanied Cook on different round-the-world jaunts and several died in faraway places. But the enterprise resulted in an explosion of knowledge about life’s diversity. Linnaeus sat in the center of this worldwide web of discovery. His goal was to do for biology what Brahe and Kepler had done for astronomy. The raw data of life, in all its fecund complexity, needed to be sorted into manageable bins. If we could develop a crystallizing classification of all the world’s plants and animals, perhaps we could figure out God’s design. If gravity is a simple explanation for the seeming complexity of planetary motion, perhaps there is a simple explanation for the diversity of life.

  Linnaeus developed a compelling sorting scheme that has survived three hundred years and even manages to accommodate the revolution in modern genetics. He didn’t always get the details right, but this really doesn’t matter—it was his method that provided the powerful scientific tool. Based on similarities, 7,700 plants and 4,400 animals were sorted, within a six-step nested hierarchy into their appropriate kingdom, phylum, class, order, genus, and species. It worked. Linnaeus brought order to the seemingly chaotic biological universe. In a dramatic departure from previous religious exceptionalism, humans were included within the classification system, right next to apes and monkeys. Though a great blow to our dignity, it was a giant step forward toward the theory of evolution. Linnaeus’s careful sorting of descriptive complexity was the necessary precondition for Darwin’s simplifying explanation of how life had evolved into all its many niches.

  This was the second great demonstration of the three-stage process of observational science. What worked for astronomy also worked for biology. First, you need painstakingly careful descriptions of the natural world. Next, clever classification to reduce the seeming complexity into manageable patterns based on observed similarities. Then finally the payoff—an explanation so simple and obvious that everyone wonders why he or she didn’t think of it. It is impossible to come up with right answers until the questions get asked the right way. Any good classification shouts out the question “Why is nature like this?” And the hope is that someone will see causal meaning in the descriptive patterning.

  A century later, Mendeleyev got the same ball rolling in physics with his periodic table of the elements. Surprisingly soon, the questions raised by his sorting of the elements led to a deep and simplifying causal model of the different structures of their atomic nuclei. One of the great disappointments of modern medicine and psychiatry is that our classification systems have not succeeded in stimulating clear explanatory models. The body, and especially the brain, have a particularity and complexity that seem to forever deny any easy causal answers.11

  Philippe Pinel: The Father of Psychiatry

  The Renaissance and Enlightenment came late to psychiatry—not until the beginning of the nineteenth century. This is not because the people interested in human behavior were dumber. It is because the topic is so complicated. Planets are a lot simpler and more regular in their motions than brains are in their malfunctions. The general laws of astronomy and biology are much easier to discover than the precise mechanisms causing disease. Modern science wisely picked for initial discovery topics that lent themselves to grand abstractions. Gravity and evolution were remarkable intellectual feats, but they are fairly low-hanging fruit compared to understanding schizophrenia.

  Meanwhile the living conditions for the mentally ill had become increasingly dreadful. The Industrial Revolution, population growth, and urbanization had disrupted the old social patterns of management that had mostly been the responsibility of family, village, and priest. The new pressures on working-class families understandably reduced their tolerance and resources for supporting disturbed and disturbing family members. It was more convenient to ship them away to institutional settings often located in faraway places. Patients were confined along with other undesirables—paupers, criminals, orphans, and the intellectually infirm. The often for-profit poorhouses lacked any healing or scientific mission. Mixed in as they were, the mad were seen as bad, their symptoms the result of moral failings and not really of any medical interest. There was no profession of psychiatry and no clinical study that might lead to diagnosis and classification. The mad were considered less than fully human, more like wild animals needing taming, whipping, and chaining, and were subject to zoolike public demonstrations meant to raise revenue.

  Philippe Pinel saved the patients and created the profession of psychiatry in the Western world. Our field couldn’t possibly have a better father and role model. Both humanist and scientist, he taught us how to treat patients as people—with proper dignity as we study their problems. Pinel is most famous for stripping the chains from the mentally ill. You can still see the marks on the places where they were attached to the wall in an old building on the grounds of the still active psychiatric unit of the Salpêtrière Hospital in Paris. But Pinel gave them a bigger gift. He stripped away the medieval superstition that mental illness was demon possession and that its victims were to be dreaded, denigrated, neglected, perhaps even burned at the stake. He convinced (almost) everyone that mental illness comes from entirely natural causes equivalent to the causes of medical illness. And he developed a new model of “asylum” care devoted exclusively to the needs of the mentally ill, who he felt should be treated with respect in a pleasant and safe environment. Soon similar “asylum” hospitals sprang up all over Europe and the United States.

  Pinel liked his patients as people and treated them as if they were simply human. When given the choice of joining Napoléon as personal physician or staying with his patients, he turned down Napoléon. Pinel’s chief administrator, advisor, and teacher was a former inmate who had become a brilliant clinician and manager. Together they developed a “moral” (or “psychological”) treatment for mental illness that combined education, cognitive therapy, reality testing, work, exercise, therapeutic activities, support, and encouragement—all delivered with kindness, modesty, and a sense of humor. Pinel was deeply interested in each patient’s life story—the particular hopes, fears, motives, and circumstances that shape who we are. He wanted to learn how their troubles in life interacted with the illness.

  Pinel believed mental disease was caused by some combination of heredity, physiological damage to the brain, psychological and social stress, and the previous hideous treatment the patients had often received. He wanted to facilitate a natural healing, not a forced cure. No more bleeding, purging, blistering, or spin chairs. He was modest about what he could accomplish and trusted the resilience
and healing powers of his patients. Physical restraint with a straitjacket and chemical restraint with opium were reserved only for those who were most violent and responded to nothing else.

  Beyond being a wonderful person, Pinel was also a good scientist. He combined the syndrome approach of Sydenham and the classifying methods of Linnaeus to sort the symptoms of mental illness into convenient categories. The diagnostic labels used in psychiatry would be based on a natural science approach of minute observation. He spent a great deal of time with his patients, questioning in detail to determine the most frequent clustering of symptoms and the evolution of their course. His suggested categories were somewhat different from those used today, but our current methods of classification are the ones he introduced. As in everything, Pinel was modest. He presented his suggestions tentatively, “for the time being.”

  Pinel begins modern psychiatry and ends its dark ages. The growth of psychiatry in the nineteenth century made the classification of mental disorders an exciting endeavor on both humane and intellectual grounds. Beyond the obvious clinical purpose, there was the notion that clearly describing and demarcating the mental disorders might lead to better theories of what caused them. The classifiers were clinicians, but they were also observational scientists, doing for psychiatric diagnosis what Linnaeus had done for plants and animals. If they did a good enough job of describing, perhaps a psychiatric Darwin would come along and make sense of it all.12

  Following Pinel, there was an amazing flurry of creative classifying—a succession of different ways of sorting psychiatric disorders was suggested during the remaining years of the nineteenth century. The early systems were French, but then the center of scientific gravity gradually shifted to Germany, culminating in Emil Kraepelin’s crucial distinction between schizophrenia and bipolar disorder. It was a lucky coincidence that Kraepelin’s brother was a great naturalist—this sharpened his own considerable observational skills and also forced him to find ways to raise funds to support their frequent joint field trips to East Asia. Kraepelin’s moonlighting job changed the history of psychiatry. The table of contents of his remarkably popular and influential textbook became the DSM of its time and later formed the basis for our own DSMs. But Kraepelin had a big blind spot—he was a hospital-based doctor who never saw an outpatient. His conception of psychiatry was formed by, and restricted to, those who were ill enough to require long-term confinement, and his classification lacked appropriate niches for most of the people who are diagnosed today.

 

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