Monday, 6 August 2012

American madness

I will out myself before I write this review as someone very skeptical about a lot of aspects of psychiatry, especially those within the profession who claim to know all about the origins of mental distress and who fixate on diagnosis and the consequent pharmaceutical ‘treatment’. This is still very much the case in 21st century USA with the DSM wars, the hugely corrupt role that the pharmaceutical industry plays in the over medicalization of near normality, and the over diagnosis of children, young people, adults and the elderly inappropriately with various psychiatric disorders.

 The US psychiatric profession (or ‘alienists’ as they used to be called) has, in its short documented history,  thrown up probably more than its fair share of differing movements, terrible interventions, examples of neglect, ignorance, sidelining etc

This book, thicketty and academic, does bear persistence . It’s written in a not-exactly-jaunty style and does demand a large measure of commitment. The triumvirate at the heart of this odd piece of history are Adolf Meyer, Emil Kraepelin and Bleuler. 

Germany was feeding ideas through to the US at the turn of the 19th century. The whole idea of ‘disease’ was being challenged. For years illness was thought to be caused by a ‘disruption of natural balance’  - maybe a ‘miasma’  (fog, or filth), ‘imbalance of humors’, or heredity.  Occupation and personal habits were seen as causes of disease too (‘governess psychosis’, ‘milk fever’ etc). 

Then came the ‘specificity of disease’ theory – focusing on biological mechanisms. Neurologists reigned,  claiming professional jurisdiction over ‘functional ‘ nervous diseases such as ‘neurasthenia’ and ‘hysteria’ . Asylum doctors were the alienists. Asylums were overcrowded, apathy had descended and  the length of stay had drastically increased. Alcoholism, paresis (caused by syphilis) and depression and ‘dullness’ seemed to produce chronic patients. The popular thought then was heredity so psychotherapeutic efforts were limited. Medical students were untrained in psychiatry.

Heavy drugging with hypnotics and sedatives took place (plus sa change..) – bromides, chloroform. morphine, cannabis and hemlock among others.  Those in homeopathic hospitals had a much higher recovery rate and lower death rates.
The county asylums were filthy, cockroaches as well as infectious diseases such has typhoid and diphtheria were rife.

Fast forward:

This book tells the story of the sudden appearance of the diagnosis dementia praecox by 1912, when in 1895 there had been no cases. Then by 1927 it was fading away. Eventually it was replaced by schizophrenia. It is a dramatic story and Noll shows the codependency between a disease and the scientific status of the profession that treats it.  

Kraepelin named dementia praecox ‘corresponding with hebephrenia’. It marked a patient as incurable and transferred patients to asylums for the long haul. He equated each condition with ‘natural disease entities’. It also meant that psychiatry could reject ‘brain psychiatry’. He still believed in biological basis for mental diseases but he didn’t believe all causes were in the brain. Thus we weave through the many vicissitudes of diagnosis, conditions, explanations and conclusions. Meyer critiqued Kraepelin and so it went on. It pingpongs back and forth from a very ‘medical’ interpretation to a psychological one – nearer to  Freud and co who were airing ideas at the same time.

It’s a tough read but fascinating. Nothing really changes in the polarization of ‘cause’ and subsequent treatments. All through the 20c theories have swung from highly  medical to societal and stress-injured.  Time please for a swing towards the stress based model for origins.
Review: Polly Mortimer.

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