St. Louis, Missouri, United States (Winter 2018)
|“The Madhouse (Casa de locos). Francisco de Goya.|
In The Birth of the Clinic, Michel Foucault traces the history of our present-day understanding of disease. One of the most significant and more recent problems this understanding had to confront was the pre-nineteenth century outlook that “neuroses and essential fevers were fairly generally regarded as diseases without organic lesion.”1 In his book’s penultimate chapter, Foucault addresses medicine’s “crisis in fevers.”2 However, he remains conspicuously silent on any corresponding crisis in neuroses, perhaps because that crisis is still upon us today.
Prior to the crisis in fevers, “pathological anatomy” was the dominant clinical method among prominent European physicians.3 Working off the premise that all diseases could be tied back to an original tissue-based defect, this method paved the way for diseases to be analyzed beyond the life of the patient through autopsy. “Hence the appearance that pathological anatomy assumed at the outset: that of an objective, real, and at last unquestionable foundation for the description of diseases.”4 From here emerged a new philosophy of medicine called medical positivism, or the idea that all clinical knowledge should be scientifically verifiable, and its future corollary that all clinical interventions should be evidence-based. Unfortunately, the existence of non-lesional diseases such as fevers of unknown origin (FUO) did not fit neatly into this otherwise compelling schema. Since FUO could be proved to be so only negatively, by disproving other causes, such a diagnosis failed to meet the scientific criterion of reproducibility. Until more scientific explanations could be provided, medical positivism could only be incomplete.
According to Foucault, clinicians found a satisfactory answer to the question, “What is a fever?” when they reframed their understanding of disease to encompass “no more than a certain complex movement of tissues in reaction to an irritating cause.”5 Under this new program, the problem of FUO disappeared, since all fevers could now be understood as merely part of an inflammatory response. The extent to which this revised framework might help us understand neuroses is debatable, however. While the irritating agent in the case of fevers is most often consistent with current conceptions of a pathogen, the same cannot be said of the irritating agent in the case of neuroses. Perhaps neuroses such as depression could be a reaction to psychic stress, but the very idea of stress is subjective and resistant to models of pathogenesis. This inherent difficulty prompted the editors of the Diagnostic and Statistical Manual of Mental Disorders (DSM) to eliminate the category of “neurosis” in 1980, which “represented the shift of the essential focus of psychiatric knowledge from the clinically based biopsychosocial model to a research-based medical model.”6
Rather than attempting to describe hidden mechanisms of mental disorders, psychiatry narrowed its clinical gaze on detectable, maladaptive behaviors. This is in stark contrast to the pathophysiological approach adopted by the rest of medicine, which seeks to identify and treat not only the effects of disease, but primarily its causes. For the simple reason that psychological mechanisms are just not as empirically testable as, say, germ theory, psychiatry is inherently less scientific than the rest of medicine. To illustrate this point, the medical anthropologist Arthur Kleinman highlights the fluid and culture-bound nature of mental disorders throughout his work. In one of his most influential publications about somatization in China, he comments that “it is most clinically useful to regard [neurasthenia] as bioculturally patterned illness experience (a special form of somatization) related to either depression and other diseases or to culturally sanctioned idioms of distress and psychosocial coping.”7 In other words, the very diagnosis of depression may carry added stigma in certain cultures, and so symptoms are occasionally displaced into more “culturally sanctioned” diagnoses, such as neurasthenia.
Although the most recent version of the DSM contains specific diagnostic criteria for ailments such as major depressive disorder and generalized anxiety disorder, the extent to which such diagnoses are distinct or overlapping is unanswerable in a psychiatric paradigm without clear mechanisms. Furthermore, the specific criteria themselves may bend or break against varying cultural forces, as Kleinman theorizes. Confronting malleable definitions and manifestations of mental disorders, clinicians are perhaps in the midst of an epistemological crisis. If a patient’s mental well-being is just as much a product of environment as physiology, and each environment is experienced differently, how broadly applicable can systematized medicine really claim to be when it comes to mental health?
After the crisis in fevers, “the medicine of diseases has come to an end; there now begins a medicine of pathological reactions,”8 in which the physiology of morbid phenomena supersedes pathological anatomy. Likewise, “disease breaks away from the metaphysic of evil, to which it had been related for centuries; and it finds in the visibility of death the full form in which its content appears in positive terms.”9 Medical positivism evolved out of this revised understanding that although disease no longer represents an essential opposition to life, death can nevertheless provide a useful endpoint for pathophysiological processes that return organisms back to inorganic material. However, mental illness might not be completely describable in physiological terms, nor does it always have to be oriented towards death. Rather than death serving as the upper limit of pathology, the “normal” often fulfills this role in defining mental disorders. For example, although autism spectrum disorder (ASD) is associated with a lower life expectancy, it is primarily characterized in terms of deficient social skills. The fact that ASD patients on average do not live longer may be due to comorbidities and the added stress of living with a disability.10 However, it is not death that illuminates ASD for clinicians, but rather social norms and functioning.
One troubling casualty of categorizing pathological behaviors based on normality is the tendency to medicalize social deviance into disorders. What counts for normal now may shift in the future, as were the cases when homosexuality and gender identity disorder were removed from the DSM in 1973 and 2013, respectively. Furthermore, cultural relativism may neutralize mental disorder diagnoses in different social contexts. For example, devout spiritual beliefs may meet the criteria for delusional disorder depending on the assessor. If religion is ingrained into a community, such beliefs may be considered normal by those in the community, while pathological by those outside of it. Rather than representing disease without organic lesion, mental disorders might now embody disease merely resistant to strict categorization.
Confronted with this possibility, medical positivism has largely conceded its limitations by focusing on diseases more amenable to pathophysiological models of understanding. Eradication or near-eradication of diseases such as smallpox and polio attest to the efficacy of this approach, in at least certain situations. At the same time, however, mental illness often requires a softer touch. Just as clinicians bridged the gap between pathology and physiology during the crisis in fevers, perhaps culturally competent caretakers may begin bridging the divide between clinical definitions of disease and individual patient narratives of illness. In any case, philosophers of medicine are now faced with the daunting task of reconciling the structure of psychiatric knowledge with medical positivism or separating the field of psychiatry further away from the rest of medicine altogether.
- Michel Foucault, The birth of the clinic: An archaeology of medical perception, trans. A. M. Sheridan Smith (New York: Vintage Books, 1975), 178.
- Ibid, 174
- Ibid, 124
- Ibid, 129
- Ibid, 189
- Wilson, M. (1993). DSM-III and the transformation of American psychiatry: A history. The American Journal of Psychiatry, 150(3), 399-410.
- Kleinman, Arthur. “Neurasthenia and depression: a study of somatization and culture in China.” Culture, medicine and psychiatry 6, no. 2 (1982): 117-190.
- Michel Foucault, The birth of the clinic: An archaeology of medical perception, trans. A. M. Sheridan Smith (New York: Vintage Books, 1975), 191.
- Ibid, 196
- Hirvikoski, T. et al. “Premature mortality in autism spectrum disorder.” The British Journal of Psychiatry Mar 2016, 208 (3) 232-238
TAYLOR TSO, BS, graduated in 2013 from Washington University in St. Louis with a degree in Biomedical Engineering and a minor in Chinese Language and Culture. He currently works for a medical device company in St. Louis as a Clinical Research Associate.