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[Andrea Weinstein] Good evening. I'm Andrea Weinstein, I'm the senior director of academic
development for the University of Rochester River Campus Libraries, and I'm welcoming
you here this evening on behalf of the libraries and on behalf of the Neilly's and the Neilly
Series. The Neilly Series is supported by an endowment from the former president of
John Wiley & Sons and it has been an extraordinary experience for us. We are in our 11th or 12th
year at this point. People often ask me how we choose speakers. We get recommendations
from all kinds of sources, but I often am able to have somebody whose studies I've used
myself, and in both my undergraduate degree and my graduate degree I used a lot of Andrew
Scull's, so this is a particularly exciting experience for me. Tonight we're going to
have Stephanie Brown Clark, who is head of the department of Medical Humanities in the
Medical School who'll do the formal introduction, and then we'll have Dr. Scull speak. Thank
you very much. [Dr. Stephanie Clark] Well welcome everyone and thank you very much for
coming to tonight's lecture. I will tell you that one of the true pleasures and the real
perks of teaching at a University like this one, is the abundance of lectures and presentations
on diverse and really fascinating subjects by all sorts of scholars and researchers from
all sorts of disciplines, some home-grown from the University of Rochester, and others
from institutions across the country and around the globe, and the Neilly Series is a favorite
for many of us, I think, that are here tonight, and certainly for me. So I would like to acknowledge
the libraries and also Janet and Andy Neilly for the endowment that makes this possible.
And I would like to thank Andrea Weinstein and her colleagues for making these lectures
happen. Tonight it is a privilege and a pleasure to introduce this evening's speaker, Professor
Andrew Scull. He received his B.A. from Oxford University and his PhD from Princeton. He
taught at the University of Pennsylvania and at Princeton, prior to coming to the University
of California at San Diego. His books include: Museums of Madness, Mad Houses, Mad Doctors,
and Madmen, Social Control and the State which he wrote with Stanley Cohen, Social Order,
Mental Disorder, Masters of Bedlam, and most recently Hysteria the Biography. His articles
have appeared in leading journals in a variety of disciplines, European Journal of Sociology,
Medical History, British Journal of Psychiatry, and he has held a number of fellowships, from
the Guggenheim Foundation and the American Council of Learned Societies, and I could
go on, but I will stop, and I will say to you that one of the oddities of working at
a University is that academics often first meet each other, not in person, but in publications,
and I confess that I have always been a huge fan of Andrew Scull's books on madness for
the last two decades. It's always a thrilling moment, I will tell you, when you actually
meet the person who wrote the book that you admired, and that of course as an academic,
you've lavishly quoted and cited repeatedly in your own stuff. I think, in fact, it is
no exaggeration to say that anyone who works in the history of medicine or the history
of psychiatry has probably read some of Andrew Scull's works. What he does not know is that
20 years ago, when I was, I had finished medical school and was doing my PhD in the history
of psychiatry and romantic literature. At the very first conference of the European
Association for the History of Psychiatry, in London in 1993, he was there. He had made
a very considerable impression that year with what many historians of medicine consider
to be one the best books on the history of the asylum, and that book is called The Most
Solitary of Afflictions: Madness and Society in Britain, 1700-1900, and for those of us
there at that conference, those of us who were trying to understand something about
the marginalized social group which we now call the mentally ill, but in the 18th century
and before were simply called "the mad", we wondered what exactly madness meant, and who
was considered mad? And by whom? And why? And how those mad were managed and treated
and how asylums came into existence and why? And how asylums grew in numbers and the numbers
of inmates confined within them grew too, and why? And all these questions have, as
Professor Scull clearly and provocatively articulated in that book and in other of his
books, is, what we say, very complicated, very disturbing, sometimes paradoxical, and
always conflicted, at least up to the point where he ends his story in his history books,
around 1900. But historians, good ones, like Professor Scull, look backwards and forwards
and in a recent article in The Lancet in April, 2010, Scull focuses on what happened to asylums
after 1900 in the United States and what that has meant for the mentally ill in 2011. In
the middle of the 20th century, the US had a burst of new institutions that were built
to house, and then essentially warehouse, a bulging number of individuals diagnosed
as mentally ill. And then, something happened. Asylums decreased in number and the number
of patients admitted there, decreased. In Rochester, we have the remains of one such
facility, the Terrence Tower on Elmwood Avenue. It's that, very tall, 1950's building that's
beside the Rochester Psychiatric Center. It was built around 1959 and it was closed around
1995 and it remains, as you see it. A number of developers have looked at it, but it stands
there, empty. So one has to wonder, where did those patients go? And what caused the
change? In the last 50-some years, the asylums as institutions for the mentally ill, have
in essence, been transformed once again, and so has the scientific paradigm for defining,
and treating, or controlling mental diseases. The reasons are social, cultural, economic,
and pharmaceutical. But that is not my story to tell, I'm going to leave that to Dr. Scull.
I will conclude by saying that Andrew has confessed that although he never intended
it, and I quote, "He remains as fascinated as ever with trying to understand the elaborate
social institutions we have devised to grapple with, manage, and dispose of the mad, and
with the intellectual puzzle that mental illness itself, represents." Andrew Scull never intended
that his "early infatuation with disorders of the mind should turn into a lifelong obsession",
that's his quote. He makes it sound almost like an academic sickness. And if that is
the case, than those of us interested in the history of mental illness, the puzzle of mind
vs. brain, and health and illness, and your provocative and insightful analysis of the
social and cultural complexities that inform and vex medicine on these subjects, all I
can say is, here's to your continued ill-health. Please welcome Dr. Scull [Andrew Scull] Alright.
So that you don't hear me in stereo, I'm going to turn that mic off and assume this one works,
but if you need me to turn up the volume I can do that. Is everybody able to hear me?
That's good because I don't like to lecture standing still, as you'll discover, and that
frees me from having to be within arms reach of that microphone. So it's very kind to introduce
me in those glowing terms, I'm not sure I entirely recognize myself, but it's a great
pleasure to be here in Rochester. I have actually relatively long ties to this city, of a rather
tenuous sort, because my sister-in-law who is here tonight, has lived here since the
late 60's, and so periodically I've visited and always enjoyed being here, but this is
actually the first time that I've talked at the University so it's interesting to do.
The Lancet piece that was referred to in the introduction is something I was asked to write
a couple of years ago, and it provoked a bit of autobiographical reflection on my part
about the fact that, as I realized with some shock, it had been, really about 40 years
that I've been working in this field, and I thought, my goodness, this is really quite
extraordinary because I didn't plan on that, at the beginning. Although I did find the
field very fascinating, obviously, since I made it the subject of my PhD thesis. And
in those days, what was then a beginning field, the history of psychiatry, tended to focus
very much on what I call, "museums of madness", on those large Victorian buildings that once
upon a time, for actually a very long time, dominated the delivery of care to the seriously
mentally ill, both here in the United States and all across Europe and elsewhere, come
to that. So my initial intellectual puzzle was to think about those institutions, and
in the course of that, I spent an inordinate amount of time, not just in the archives of
mental hospitals, but actually in them. And they were really very striking pieces of architecture,
I mean you've got a very late example, 1959 is extraordinarily late to be building a tower
to house 1000 people, by then the mental hospital populations were just beginning to turn down,
but before that, the notion that "moral architecture", if I can call it that, that the very buildings
and physical space the mentally ill were confined in, would be, somehow therapeutic, had grabbed
hold of people all across the Western world, and initially, when you use the word asylum
these days, it conjures up visions of madhouse and confinement and bars and all those sorts
of things, but that wasn't what the people who built the first generation of asylums,
thought they were doing at all. The word "asylum" of course, has another meaning, a respite
from the world, and that really was the meaning attached to it early on, and there was a great
deal of utopian optimism about what these asylums would accomplish. In North America
in particular, in the 1830's and 40's it was a real "cult of curability", as it came to
be known afterwards. Psychiatrists were, well they weren't called psychiatrists back then,
they would call themselves asylum superintendents, competed with each other to assert that 60%,
70%, 80%, even 90% of the mentally ill could be cured if only they came into these therapeutic
institutions early enough. Now, it goes without saying that those utopian hopes and promises
weren't fulfilled. And in the second half of the 19th century the reputation of the
asylum plummeted, the numbers of people confined there, paradoxically, shot up. The average
size of a mental hospital grew enormously, and Rochester's example, the psych center,
was typical. It was, as one of your number was telling me just before I was going to
speak, it housed between 4 and 5 thousand patients, at its peak. And that was not at
all unusual; there were hospitals in New York State down on Long Island that housed as many
as 10 or even 15 thousand patients, so these were more like towns than individual buildings.
That whole era is now largely gone. I well remember going into those places, and there
was, always at the edge of my subconscious, a kind of slightly anxious feeling, going
in, and it wasn't anxiety about the patients, who by then, were largely long-stay patients.
Most of the others had been discharged, many of them were heavily medicated, they weren't
in any sense a threat to someone like me, but I think it was a psychological little
thing that was playing in the back of my brain, I hope I get out tonight. And I always did,
I could always come back to the so-called real world, and that was fortunate, but you
don't go away from those places without remembering how run-down, how stark, how smelly they'd
become. The odor of a mental hospital was very characteristic. So that was really where
I began. You might have thought that any sensible person confronting this rather dismal set
of piles would have run a thousand miles away and done something else for a living, and
somehow I didn't. I ended up becoming fascinated by the whole subject and moving both forward
and backward in time, writing extensively on the 18th century, and then writing on the
early 20th century, really on a period when mental patients had very few rights, if any.
When the modern norms about informed consent before experimentation took place, didn't
happen. When a desperate set of asylum doctors experimented with a whole range of treatments
that in retrospect, tend to arouse horror in us. The one I wrote about in Madhouse which
involved eviscerating people, pulling all of their teeth out, pulling tonsils out, removing
colons, bits of stomachs, and all kinds of nastiness in the pursuit of a theory that
was totally misguided, but widely thought of plausible at the time. Giving people comas
by injecting them with insulin, some of you may have heard of Sylvia Nasar talking and
John Nash was given insulin treatment at one point in his schizophrenia. Electrocompulsive
therapy, which is still in use. It's the only one of those treatments that is still in use
and that appears, by some patients' testimony and some doctors' testimony to have some use.
And of course, lobotomy, an episode in treating mental disorder by physically damaging people's
brains, which won the Nobel prize for its inventor some 14 years after he introduced
it. For a while, world medicine thought this was a great breakthrough. Now we tend to look
at it through the lens of watching One Flew Over the Cuckoo's Nest, and similar things.
I worked in this field for a very long time, and more recently I traveled as far back in
time as the ancient Greek's, when I was talking about hysteria. When the Lancet asked me to
talk about contemporary psychiatry, I thought well, here I am, I've been doing this for
40 years, what's been going on in psychiatry during that 40 year period when I've mostly
been immersed in the past, although not completely, mostly? And the answer is that it's transformed
itself, very dramatically, over that same 40 year period. And I want to talk about a
bit about that transformation, what some of its central elements, it seems to me, amount
to, and then I want to bring the story all the way up to 2013. We're not quite there
yet, but we'll talk about 2013 which will be an important date in American psychiatry,
and indirectly, in world psychiatry, for reasons I'll try to illustrate. When I started out
in the field in about 1970, American psychiatry was dominated by psychoanalysis, by Sigmund
Freud, and by psychoanalytic doctrines. When I say it was dominated by it, I mean virtually
every major department in an American medical school was headed by either a psychoanalyst
or a fellow traveler, somebody who was thought as sympathetic to analysis. All the best people
coming into the field tended to migrate into that direction. The field, the profession
itself had already broadened so that although there were still roughly a half-million people
in America's mental hospitals on any given day, the bulk of the psychiatric profession,
85 or 90 percent of it, didn't work at mental hospitals anymore, they worked out in outpatient
settings. And very much of that work was of a psychotherapeutic sort. And when we look
now, or even 10, 15 years on, from that period, something very dramatic happened. Psychoanalysis
imploded. I don't mean it completely went away, it was a bit like the Cheshire Cat,
it sort of faded away, you know the Cheshire Cat fades away and leaves behind a grin? Psychoanalysis
faded away and left behind a bunch of squabbling sectarians. Different variants of psychoanalysis
who spent just as much time fighting one another as anything else. It remained culturally important,
it tended to retreat to departments of literature and anthropology and philosophy, and it remained
important to Hollywood, Hollywood continued to churn out films that explained mental illness
in terms of trauma and in terms of the family dynamics. you can think of anything from Suddenly
Last Summer, all the way down to Robert Redford's Ordinary People, there have been a whole string
of movies that exemplify the continued hold that psychoanalysis has on the public imagination,
and just the sheer volume of books that publishers bring forth on Freud and the Freudian enterprise
every year is astonishing to me, because in many ways Freud's an intellectual corpse.
Within modern psychiatry, that's not something most psychiatrists spend a lot of time learning.
They've moved in a radically different direction, and that revolution really can be dated fairly
precisely. Not many things in history can you say, well there's this date, you can say
1776, and the French revolution in 1789, but within psychiatry 1980, in some ways, is a
key date, and it's a key date because it marks a shift back to biology, and to accounts of
mental illness pitched in terms of brain disease. It marks as well a radical shift in the way
American psychiatrists approach the problem of deciding who is mentally ill and who is
not, and if they're mentally ill, what kind of mental illness they have. The reason that
date is so important is the production of a book that changed history. Perhaps an anti-intellectual
book, in some ways, if that's not a contradiction in terms, called The Diagnostic and Statistical
Manual of the American Psychiatric Association 3rd Edition. So there had been more than one,
and we'll come back to that later on in my talk tonight if I have time. I'm conscious
I don't want to stick with you, stick you with too much of my thing. Where did that
version of The Diagnostic and Statistical Manual (DSM) come from, and why was it so
important, why did it play such a pivotal role in shifting the focus of American psychiatry?
Well of course, like many revolutions, it had much longer roots than that period, but
it emerged from an odd sort of place when you look back at where it was predominantly
produced. It didn't come from Harvard or Yale. Not from the elite East Coast knowledge factories.
It came from a renegade psychiatrist at Columbia, by the name of Robert Spitzer, and from collaborators
of his, who, at one of the few departments of psychiatry that hadn't succumbed to Freudianism,
Washington University in St. Louis, Missouri. Not the obvious place where you'd expect a
transformative event like this, as I will suggest it was, to have occurred. But that
is indeed what happened. I'll talk somewhat later, I'm going to shift away from DSM for
a bit because I'll come back to it. There's presently an endeavor that's been under way
for a number of years now, to construct yet another edition of this tome, something that
I call the yellow pages on steroids, because it keeps growing, like the blob in the science
fiction movie that just can't be contained. Let's leave that aside, but let's talk about
another facet of this revolution. And this is where my remark a few moments ago about
revolutions having longer histories than just a particular day would imply, comes into the
picture. Because the other facet in the revolution of the way psychiatrists practiced and the
experience of being a mental patient that is decisive to this shift is the so-called
psychopharmacological revolution. The introduction of drugs, and drugs becoming the first line
of attack on mental illness, for most people. That of course, didn't begin in 1980. The
first generation of antipsychotic drugs had actually materialized, not that drugs hadn't
been tried back in the 19th century and before that, but if we're talking about things that
supposedly had a specific antipsychotic action, the first of those to hit the American marketplace
was Thorazine and it emerged in the mid-1950's. So it had been around for about a quarter-century
by the time 1980 rolls around. It was, drugs were sort of at odds with psychoanalysis.
Psychoanalysis insisted that what we saw, the surface symptomatology of their thing,
was the least of your problems. You didn't solve symptoms, you got to the deeper underlying
problems that lay behind the symptoms. Spitzer's manual, and the drugs, specifically aimed
at the symptoms, that was their modus operandi. So it was a different kind of logic, control
the symptoms and you control the madness, rather than find out what the source of the
symptoms is and then you relieve the madness. So the drugs had been around. They were used
extensively on the people who were in the mental hospitals and then on the sorts of
people who once would have been in the mental hospitals, or were being discharged from the
mental hospitals. Less so for the other patients, but to the extent that psychoanalysts had
adapted to the presence of these new drugs in this new era. What they tended to say was
that the drugs were all very well, what they did was, and this is accurate, damp down the
florid symptomatology of the patient, make them less disturbed, overtly, and thus make
them accessible to the psychotherapy that was going to do the real work. What changed
after 1980, I would argue, once there's this see changes in American psychiatry, is that
that notion of psychotherapy, psychotherapy being central to psychiatry, disappeared.
It took a while to die, but it's largely died, that's not what. To the extent that psychotherapy
survives, and it still does, it has migrated elsewhere. To the hands of clinical psychologists,
psychiatric social workers, rather than expensive M.D.'s who don't get adequately reimbursed
for spending a whole hour with an individual patient. We can be very cynical about this,
but I think these things do drive some of what goes on. Thorazine and the other phenothiazines,
the first generation of antipsychotics that emerged in the 50's were initially, majorly
oversold. They were sold as though they were going to be a penicillin for psychosis. They
were no such thing. They were in fact drugs which had differing effects on different subclasses
of patients. It was hard to predict what their effects would be. For some patients, I think,
it was very clear. And I don't want this to come across as toxic psychiatry kind of lecture
by from someone from scientology, that drugs have no place. I'm not that kind of person,
if that's your belief, that's not mine, but nonetheless, the drugs were a distinctly mixed
blessing. For many patients they were a curse. And arguably, in a broader sense, they were
also very mixed in their effects. There were many many patients who didn't respond to the
drugs at all. There were another group of patients who responded to the drugs, but suffered
severe, life-long side effects from what the drugs did. And then there were a group of
patients for whom the drugs worked relatively well. For those people, unambiguously, that
was a real positive step forward. But they are, the drugs as I say, were not a peniceer.
They also, contrary to what many psychiatrists believe and what many ordinary people believe,
weren't the real first mover behind the collapse of mental hospital populations. That process,
which has been called deinstitutionalization or decarceration, which is a really ugly word
which I used at the title of one of my books, I didn't invent the term, the opposite of
incarceration it was supposed to be, that movement was driven much more by politics,
by policy changes, by the opportunity to transfer costs between levels of government, to move
people off the State budget and onto the Federal budget initially, and now onto nobody's budget,
sort of. So the drugs helped persuade psychiatrists this was possible, but there's all kinds of
evidence that their direct role in bringing this about is far less than people assume,
not least because of the problem of patient compliance. All of you lot, I venture to say,
take prescription medicines. All of you, I venture to say, don't take them properly.
You don't comply, absolutely. Your doctor lectures you and she says "Make sure you take
these even after you start feeling better", but you disobey, which is another kind of
problem for the rest of us. Imagine now that you're mad, you're mentally disordered, and
these pills have unpleasant side effects as well as welcome effects. Will you be motivated
to take them every day? Maybe not. So for all sorts of reasons, I would argue and I'm
not, obviously going to get into those at length tonight, the drugs of ease have been
oversold. It was the second phase of the drugs revolution that came along in the late 80's
early 90's with the rise of Prozac, a new generation of antidepressant pills. The pharmaceutical
industry had found drugs directed at mental illness to be among the most lucrative things
in what is the most lucrative business on the planet. If you look at the top 5 categories
of drugs prescribed worldwide, antipsychotics and antidepressants routinely are in the top
5, often among the top 2 or 3. They're a huge source of profits. They transformed Swift
Glen and French, which then was, from tiny company, into a huge one, and no question
that the sum of what we've seen in psychiatry and in society at large, has been driven by
that drive for profit, on the part of the drug companies. It's distorted, I think, the
care of the mentally ill, it's led us in unfortunate directions, it's corrupted psychiatry, I regret
to say, but I think so, and it's made for a very simple view of mental illness that
I think is misguided. We've kind of lurched away from attributing everything to "refrigerator
mothers" to a surplus of serotonin, or a deficiency of dopamine, there are various hypotheses
that have been put forward as to why these drugs work. Hypotheses that we usually invented
after the fact, and for which the evidence, turns out, to be not very good. But there
they are, the drugs, as I say, have been enormously important, and they've led, in 1991, George
Bush the 1st got up and announced, he'd been fed the text, as Presidents always are, by
their underlings, that the 1990's were going to be the decade of the brain. This was a
line he'd been fed by NIMH [National Institute of Mental Health] who were going to pursue
this and the notion was that the new neuroscience and the new psychopharmacology was going to
finally unlock the problem of mental illness. Well, like the war on cancer and the war on
poverty, that hasn't gone so well. Not to say we haven't advanced our understanding
of the brain, we clearly have, but not, we know that much, of that much, in my view.
We have a huge amount still to learn and we often, including the scientists who are at
the center of this thing are far more overconfident about what they've discovered than the actual
science would justify. It's not uncommon to do, we all overestimate our importance at
one time or another. That led to the public as well, being taught to view depression,
and schizophrenia through the biological lens. We were all taught that when you were depressed
it was because the neurotransmission, the neurotransmitters in your brain were out of
whack, and we needed a pill that would chemically readjust things, so then we'd feel happy.
It's not so simple. It's not so simple. The drugs, clearly have been very, very important.
Psychiatry used to be at the margins of medicine, and certainly all that Freudian talk about
sex and parents fiddling around with their children didn't help matters much. The idea
that illness could be cured by talking about it seemed positively bizarre to most mainstream
doctors, although it was one of the things that attracted, I think, many bright people
into psychiatry, the fact that they actually had extended human contact with their patients,
and I think that's largely gone now. When you see people to adjust their meds, 3 to
5 minutes on the manage-cure cycle, you're not going to get very deeply into the source
of their emotional and cognitive difficulties. So there we are. So we see then that impact
on the profession, the vast amounts of money that it generates. If you ever go, as I did
a few years ago, when the American Psychiatric Association held its conference in San Diego.
It is mind-blowing, forgive the pun, because you walk in and you see drug money everywhere.
You read the psychiatry journals and page after page of ads. The profession has been
seduced by this and medical school Deans have been seduced by it, because of course one
of the great phenomena of the post-World War Two world, is the rise of knowledge factories
like this one, who become increasingly dependent on, as my institution is, federal funding
and attracting all these research grants. So psychiatrists, once they allied with the
pharmaceutical houses and there was all this research, piled into this, and in fact, it's
been very distorting in terms of its effects in all kinds of ways. The very categories
in which we think about mental illness have been manipulated to make sense of things in
this fashion. So that when we discover that drug "D" has a particular effect on some sublimation,
we define them as having a new disease. The drug brings about the disease, rather than
the disease bringing about the drug. Bringing new drugs to market is a very complex process.
It involves now multi, usually trials that extend over multiple sites with many, many
patients enrolled, and the people who control all the data, control what sees the light
of day, and the people that control the data are, by and large, big pharma. So when data
is not very convenient, it tends never see the light of day. So what we think is evidence
based medicine may not be evidence based medicine, it's selective evidence based medicine. And
that violates the whole notion behind these trials. So there's a lot of that going on.
It even extends, as has been exposed by the Anglo-Irish psychologist James Healy, to a
practice of extensive ghost-writing of articles which appear, even in journals like JAMA,
New England Journal of Medicine, The Lancet, tip-top journals in the field, have been deceived
in this way. And very often the people putting their names on those papers, in return for
grant money, have not actually done the research and have had nothing to do with writing it,
and often they're being written, it turns out, by public relations journalists employed
by the pharmaceutical house to massage things. So it's a very tricky world that we've moved
into, and one that is in many ways, is disturbing. Not least because the first generation of
antipsychotics, the Thorazine's of this world and their like, turned out alongside their
effects in controlling psychiatric symptomatology to produce a wave of iartogenic illness, of
physician caused illness. And often some of the worst of these side-effects only became
visible when you came off the drugs. And the only way to mitigate them was to come back
on the drugs, so you're caught into this, the worst of them is probably called Tardive
dyskinesia which causes uncontrolled movements of the extremities and things. Very stigmatized
and often seen by laypeople as a sign that somebody's mad, which is a horrible bit of
irony because they're actually a side effect of the drug. So we've shifted, the profession
has shifted more recently to what are called atypical antipsychotics, which actually had
been discovered a couple of decades earlier, but had just kind of lain around, partly because
they had some side effects of their own. They're now being re-prescribed. Many of them produce
heart disease, diabetes, massive weight gain, 50, 60, 70 pounds, they're life-threatening,
they shorten people's lives. The gravely mentally ill are among the few groups in society whose
life expectancy has decreased in the last 20 years, I think that tells us something
rather profound about what's been going on. Definitely, the psychopharmacological revolution
has been like the Russian god, ah Russian god, forgive me, Freudian slip there, the
Roman god, was what I meant to say, Janus, who has a face at the front and a face at
the back. Clearly they're being beneficial for some, for others they're sort of a wash,
and for others they've been actively harmful, and for the profession they really have done
some bad things. Now, let me turn back quickly, we'll leave some time for questions, but let
me turn back to this Diagnostic and Statistical Manual that I said was such an important event.
Let's talk a little bit about that and about its contemporary manifestations because just
as I think there's been a growing set of scandals about this medical, this drug company involvement
and even major psychiatrists, people like, places like Emory and Harvard have been caught
up in this, as if you've read the newspapers you might have seen. Let's look at the issue
of DSM. Now obviously, the whole question of how we decide who's mad and who's sane,
and if you're mad what kind of madness you've got, has long been something that's preoccupied
people. And in the 19th century when I began working in this field it seemed almost every
asylum superintendent came up with his own set of labels, and it was only "him" in those
days. There were any number of different versions of mental disorders that one could suffer
from, and none of them really were very important. In part because they weren't very practical.
One of the big problems with the diagnostic system is if it remains at the level of theory,
and you can't, in practice, apply it very easily; it's not very useful to you. And when
we see DSM-3, meaning the third edition, that reminds us there had been two earlier ones,
and there had been, a DSM-1 and a DSM-2. They were very tiny, the first one was about 100
pages, the second about 130 pages, there were about 100 different diagnoses you could be
given, most of them with some kind of psychoanalytic gesture towards where they came from. DSM,
very few psychiatrists used these things or had any regard for them. Psychoanalysis didn't
have much time for broad categories, it was interested in the specifics of the psychodynamics
of the individual case. So DSM-2 cost $3.50 and most psychiatrists thought it wasn't worth
that much. DSM-3 is a whole different animal. When it was brooded, the psychoanalysts couldn't
really care. And they made a fatal mistake in my view. When the task force was set up
with Spitzer as its director, they thought it was a nonevent. They had one person on
the task force who drew no respect from his colleagues and soon stopped attending. Meanwhile,
the guys who were getting together called themselves "DOPs", Data Oriented Persons,
unlike the analysts who just kind of sat in their armchairs and invented. When in fact,
there wasn't a whole lot of data that lay behind DSM-3. It was a whole lot of politics,
and a lot of attempt to deal with a problem that had been haunting American psychiatry
and world psychiatry increasingly, as the 1960's and 70's wore on. The problem had many
manifestations, I'll just quickly allude to two of them. One of them was as psychiatrists
themselves began to study the question of how reliable their diagnosis were, that is,
if you as a patient went to this psychiatrist here or this one over here, would you get
the same diagnosis? The answer was no, to an extraordinary extent. Their own literature
suggested that this was not happening. There was a particularly famous study that was done
comparing schizophrenia and manic depressive illnesses, they were then described, in the
United Kingdom and the United States. And it turned out in the United Kingdom there
was a lot of manic depressive illness and not much schizophrenia, and in the United
States there was a lot of schizophrenia, not much manic depression. And when you actually
looked at it, you gave psychoanalysts on each side of the Atlantic the same clinical records,
the Americans called them schizophrenic and the British called them manic depressive.
And this was not inconsequential, because schizophrenia was a very nasty label to get,
and it even affected what kinds of treatment you got. So the lawyers got hold of this,
and this was the period when lawyers were starting to intrude on all kinds of civil
rights issues, the rights of the mentally ill became one of them and so the inability
of psychiatrists to agree was regularly brought forth in the courtroom. There was another
kind of problem as well. As drug companies wanted to develop new drugs and to test them,
they needed homogenous populations who were the same in Rochester as in San Diego as in
London. And yet none of the ways of diagnosing patients, which primarily depended on clinical
intuition, produced that sort of reliability. That's what Spitzer and his team did. They
constructed a device, basically a tick-the-boxes approach to diagnosis. If you've got 6 of
these 10 symptoms, you're a schizophrenic. Well the problem is, very often people had
more than one mental illness according to that, well they developed the concept of comorbidity,
one of these weird things where you can have 2 or 3 or 4 of these diseases simultaneously,
all slightly different, or very different. Notice a couple of things about that process.
It's anti-intellectualism, it's not concerned with the origins of the disease, it's not
concerned with what we might call the validity of the diagnosis, that is are we really cutting
nature at the joints, are we distinguishing between pneumonia and tuberculosis, or are
we inventing categories of our own that don't really correspond to what's out there in nature.
That issue was pushed aside in favor of the advantages and the increased legitimacy for
the profession of the fact that the shrinks in my town and the shrinks in your town would
diagnose the same case identically, that was seen as a step forward, not necessarily. So
once we've launched ourselves on that pathway, what happens is that that manual is repeatedly
revised in an effort of cope with anomalies and to cope with new cases and to bring new
things into being, and what's happened over time is the number of mental disorders has
expanded exponentially. The criteria by which you're diagnosed as this or that have shifted,
very often in ways that broaden the rules surrounding this. And so now there's another
attempt to fix that issue because you have a legitimacy problem if you diagnose too inconsistently.
You have another kind of legitimacy problem if it turns out everybody's mentally ill or
the categories just simply explode. And I'm going to actually go back to my notes here
because I don't carry these stats in my head and I do want to cite a few examples of what
I mean by this. So just if you'll bear with me for a moment. So we got, in these later
editions, social anxiety disorder, oppositional defiant disorder, school phobia, I suffered
from that as a young man, narcissistic and borderline personality, some people would
say I suffer from that one too. But now apparently in DSM-5 if the leaks are to be believed,
these are going to be joined by these new kinds of mental illness like pathological
gambling, binge eating disorder, hypersexuality disorder, a get out of jail free for those
who commit *** offences, I guess, temper dysregulation disorder, mixed anxiety depressive
disorder, minor neurocognitive disorder, attenuated psychotic symptom syndrome, any number of
these things. So physically, the book is now, my DSM-4 text revision, it was nearly 1000
pages, 994 pages, so you can see, and this next edition is going to be bigger. It becomes
utterly unwieldy, it becomes itself, sort of a nasty joke. And yet, because we don't
have anything better to put in its place, we're kind of trapped, or the profession is
trapped, in this world. It would be nice if we could differentiate mental disorders according
to their ideology, according to their cause, but since we don't know the cause of schizophrenia,
or bipolar disorder, or any number of other things like school phobia, it's kind of hard
to do things that way. So the profession is kind of trapped. And this has huge effects.
Again I'm trying to find these data in my, in what I prepared, and I'm not finding them,
but if you look at the epidemic of autism, for example, which has occurred and you're
all aware of, or the epidemic of ADHD. Autism was in the news a lot recently because it
was leaked that the new definition coming in DSM-5, and by the way, these DSM's used
to use roman numerals, like the Superbowl, but DSM-5 is going to be back to arabic numerals,
the pretension has been dropped. If you look at those, the incidence of those has doubled
and tripled and everybody's going, oh my god, we've got an epidemic, is it vaccines, is
it this, is it that? Alan Frances who was the editor of DSM4 has said publicly that
the epidemic was caused because he changed, he and his task force changed the definition
to soften the edges of it, and inadvertently brought in all these new cases. But when it
was leaked that the diagnosis might narrow, who was it that screamed the loudest? It wasn't
the psychiatrists, it was families, because we've all become dependent as a society. Access
to scarce resources like additional help for your children, is dependent on you giving
this child this awful diagnosis. Not to say that the problems aren't real, that the behavioral
difficulties of the child may not be there, but autism was once a very rare disorder.
Even as late as the 1990's it was 1 child in 400. Now it's many times that, and the
same with ADHD, and the same with many other mental disorders. When you define things by
committee, and you define them by symptoms, which is the way American psychiatry operates,
it's rather like 18th century medicine with the rest of the body, when you could suffer
from something called a fever. For us, a fever is a sign or a symptom, it's not the disease,
in the 18th century it was a disease. For psychiatry, symptoms are now the disease,
and the proliferation, it's easier to get new categories out of the bottle than to stuff
them back in. Once you've created an audience, once you've created a whole industry that
depends on these labels, it's very hard to shift them. So I think that originally, DSM-5
was supposed to be published in 2011. Robert Spitzer who edited DSM-3, and Alan Frances
who edited DSM-4, screamed bloody *** that it was being done in a hurry, that it was
utterly unscientific, that it was going to create epidemics of psychiatric disorder.
There was even something called pre-psychotic syndrome that they were going to identify
in schoolchildren and treat them so they didn't become psychotic in adulthood. Now imagine
your child comes home from school diagnosed as pre-psychotic, and now you better have
this medication to help ward off something that might happen in the future. It's a nightmare.
So I think the profession is facing the same sort of crisis that occurred in the 70's all
over again. Quite where it's going to turn out, since I'm as lousy at foreseeing the
future as everybody else, I don't know. But that's where it seems to me we are now, at
the end of the revolution of the last 50 years, back in a time of serious turmoil within the
profession and great worry about where it'll go. And at that point I think I should shut
up. Thank you.