A historical and social science perspective on psychiatry at the fringes of psychopathology
This two-day workshop was held on 13–14 February 2015 at the Institute for the History of Medicine and Ethics in Medicine (IGM) of the Charité – Universitätsmedizin Berlin.
Originating in the German–French research program ‘Psychiatric Fringes: A Historical and Sociological Investigation of Early Psychosis in Post-war French and German Societies’, the workshop presented an opportunity to share and discuss the results of this research project with historians and social scientists of psychiatry from Germany, France, Denmark, Sweden, Italy, the United Kingdom, Australia, the United States, and Canada.
The workshop investigated the multifaceted practices developed by clinicians, epidemiologists, biologists, administrators, and patients to negotiate and objectify the boundaries of diagnostic categories. In contrast to constructionist perspectives, our goal was not to show the less-than-solid nature of core psychiatric categories, but rather to explore the already internally contested and marginal categories devised to target conditions situated at the borders of psychopathology.
Thirteen papers were presented and discussed, covering the period from 1840 to the present, and focusing on a wide array of conditions – from dementia praecox and the concept of psychopathy to culture-bound syndromes like koro, to emerging conditions like ‘moral injury’. The papers were organised in four sessions: ‘The Fringes of Psychosis’, ‘Psychopathy as a Liminal Concept’, ‘Emergent Categories’, and ‘Cultural Fringes’. Some of the recurrent themes in our discussion were what one might call the ‘functional uncertainty’ of diagnostic categories, the role of ‘gut feeling’ vs. the use of explicit criteria in psychiatric diagnosis, and how psychiatric concepts travel from clinics to other settings and vice versa.
Opening the conference, Edward Shorter (University of Toronto) explored the rise and fall of what he called a ‘stage theory’ in psychiatric thinking at the end of nineteenth century. Stage theory refers to the observation that many patients experienced diverse symptoms during their illness. These fell into patterns of stages, through which a patient moved over time. Accordingly, psychiatric disorders could be characterised by their course, like distinguishable ‘trains leaving a station’.
Richard Noll (DeSales University, Pennsylvania) argued that there was a disjunction between theories developed ‘at the bench’ and their bedside application in US psychiatry during the first half of the twentieth century. While the psychiatric profession made strategic use of the category of dementia praecox to establish itself as a profession, it remained nevertheless rather unconcerned with elite and scientific discourses on this disorder.
Moving back to Europe, Marie Reinholdt (CERMES3 – Research Centre for Medicine, Science, Health, Mental Health, and Society, Paris) traced the history of the Danish study of schizophrenia from the 1960s onwards. The study aimed at researching the risk factors involved in the development of schizophrenia. Although it produced few robust findings on the aetiology of schizophrenia, it stimulated the creation of a wider high-risk research movement in the US, which in some respects can be seen as one of the forerunners to the currently influential early psychosis intervention movement and clinical high-risk research paradigm.
In his commentary, Volker Hess (IGM, Berlin) drew attention to the paper-based technologies underpinning the research described in the presentations by Shorter, Noll, and Reinholdt – individual files, indexing cards, registers – arguing that it would be worth thinking about the materiality of psychiatric research, and the interrelation between recording and indexing activities and the idea of psychopathological fringes.
The two first papers of the afternoon session examined the status of psychopathy in Northern European countries. Annika Berg (University of Stockholm) discussed the negotiations around psychopathy and querulous behaviour in 1930s Sweden. Bolette Frydendahl Larsen (Lund University) looked at psychopathy as a traveling concept between Danish schools for difficult children and psychiatric institutions, demonstrating the difficulties these institutions had in developing a unified vision of the social treatment of a group of young girls presenting antisocial behaviours.
Nicolas Henckes and Lara Resnitzek (CERMES3, Paris and IGM, Berlin) then showed how uncertainty was an integral element of differential diagnosis of early psychosis in two postwar German university psychiatric clinics. They proposed a typology of what they call ‘uncertainty diagnoses’ and showed how these diagnostic uncertainties were related to diverse ways of conceiving the fringes of psychosis.
Finally, Ken MacLeish (Vanderbilt University, Tennessee) explored the emergence of a new concept of ‘moral injury’ (MI), which derives from the established concept of post-traumatic stress disorder (PTSD) in contemporary US military behavioural health. MI is seen as an injury to an individual’s moral conscience resulting from an act of moral transgression that produces profound emotional shame. The paper demonstrated that this concept derived from changing expectations of soldiers’ ability to function in the face of violence.
To investigate its ambiguous status between pathology and morality, Steeves Demazeux (University of Bordeaux Montaigne) suggested analysing MI in light of Jerome Wakefield’s (1992) idea of a ‘harmful dysfunction’, proposing to call it ‘PTSD without D(isorder)’. The discussion also suggested that MI might be performing a double-displacement process of dysfunction. As one discussant noted, MI displaces the dysfunction outside the body and into the moral realm. It thus re-erects the body–mind separation. Since it occurs primarily in soldiers returning from Afghanistan and Iraq, it also might displace the origin away from home, and re-produce the ‘imaginary fracture’ (Corm 2005) between Orient and Occident.
The second day of the workshop began with three presentations that explored a series of fringe, liminal, or ambiguous categories in contemporary psychiatric classifications. Building on the case of minor neurocognitive disorder, Lara Keuck (Max Planck Institute for the History of Science, Berlin) elaborated on the different linguistic or literary possibilities to convey diagnostic information through poetry, prose, and artificial language. She made a strong argument to look at the impact of the use of language to promote communication across fields or express more complex and contextual meanings.
In an ethnographic account of the use of the category ‘pervasive developmental disorder not otherwise specified’ (PDD NOS) in a French diagnostic centre for autism, Céline Borelle (University of Picardie, Cachan) demonstrated that this liminal and rather nonspecific diagnostic category served divergent objectives for clinicians: to gain parental acceptance for diagnostic and treatment plans, and to do clinical research. While the category’s vagueness served the first objective, it hampered the second.
In the last paper of the session, Vincent Pidoux (University of Brussels) traced the move of the concept of ‘executive functions’ from the periphery to the centre of diagnostic practices around schizophrenia and attention deficit hyperactivity disorder (ADHD). He proposed that this move inverted the relation between psychosis and cognitive symptoms, as psychosis is now increasingly seen as the result of a disorder in thought processes rather than the inverse.
The last session addressed the impact of social and cultural representations on psychiatric category work. Ivan Crozier (University of Sydney) explored koro – penis-shrinking anxiety. Egidio Priani (Leicester University, UK) discussed the diagnostic practices around pellagra – a vitamin deficiency leading to skin changes and psychic symptoms – in Venetian asylums between 1840 and 1920. Both demonstrated that psychiatric entities defy the grasp of taxonomy. In the case of pellagra, it was the failure to ‘sort things out’ (Bowker and Star 1999) between soma and psyche that led to the establishment of new working categories. Koro performed a looping effect, initially helping establish the concept of culture-bound syndrome in earlier editions of the Diagnostic and Statistical Manual (DSM), but currently acting as an example that challenges the concept of culture-bound syndrome.
Finally, Benjamin Zajicek (Towson University, Maryland) traced how Soviet psychiatrists used communist ideology in order to carve out a place for themselves inside the discipline, while at the same time moving the boundaries between what is considered normal and pathological. In his discussion, Stefan Ecks (University of Edinburgh) pointed out the changing status of culture itself in the DSM-5, suggesting the need for an analysis of ‘the culture of the DSM’. Ecks showed that while there has been an effort to include culture in all parts of the manual, there has been a change in the definition of culture, and argued: ‘the new definitions of culture ultimately jeopardize the entire logic of describing and ordering symptoms of the manual’.
The conference marked the end of the collaborative project funded by the Deutsche Forschungsgemeinschaft (DFG) and the Agence Nationale de la Recherche (ANR) for the period 2012–2014, but the work leading to this conference is continuing. On the German side, research will focus on the analysis of the material from the Bonn longitudinal study of schizophrenia, which played a key role in the development of the German approach to early detection in psychiatry. The French team will continue working on a comparison of practices in the field of early detection in France and German-speaking countries. In addition to publishing a selection of the conference papers, we hope to be able to report more about the history of, and current practices at, the fringes of psychopathology in a future meeting.
Report prepared by Stefan Reinsch on behalf of the organising committee: Volker Hess, Lara Resnitzek, and Emanuel Delille (IGM – Germany) and Nicolas Henckes, Marie Reinholdt, and Stefan Reinsch (CERMES3 – France)
Bowker, Geoffrey C., and Susan Leigh Star. 1999. Sorting Things Out:Classification and Its Consequences. Cambridge: MIT Press.
Corm, Georges. 2005. Orient – Occident: La fracture imaginaire. Paris: La Découverte.
Wakefield, Jerome C. 1992. ‘Disorder as Harmful Dysfunction: A Conceptual Critique of DSM-III-R’s Definition of Mental Disorder’. Psychological Review 99, no.2: 232–47.