Psychiatry After Postmodernism

If language is inherently unstable, then how can we hope to diagnose illness accurately?

Language separates humans from all the other animals on this planet. Birds may have their songs, bees may wobble their bottoms, but none of them can match us when it comes to describing the difference between a coffee cup, a runny nose and the theory of relativity. We have evolved language, a wonderfully complex system for manipulating, storing, retrieving and sharing meaningful symbols. Human language has given birth to human civilisation and all that we have achieved as a species, for better or for worse, over the past 50,000 years.  

Naming things, abstract or concrete, is a form of categorisation, but it is important to remember that our categories say more about the categoriser than the categorised. This need not be problematic if the difference is trivial. The philosopher Wittgenstein showed how words are fundamentally and necessarily imprecise; every effort to use a word to describe something and communicate it to another, is in some senses doomed to failure, because it can only be an approximation generated from that person’s individual experience of that word in his or her world.

Problems really begin, however, when the terms that we use to describe and classify our world go beyond the philosophical into the domain of suffering. Pain, illness, death and dying are hard to dismiss lightly. When it comes to talking about disease, we need to keep our misunderstandings to a minimum.

For the past 5,000 years, from the medical writings of the Hindu Ayurvedas, via the works of Hippocrates, Galen and the great Islamic physicians of the first millennium to Sydendham and Virchow, doctors have known the importance of recognising a disease and giving it a name. The word we use for this is diagnosis. The etymology of the word tells us that diagnosing something is much more than simply naming it. Dia implies an embracing of the entire of something, whereas gnosis roughly translates as the concept of knowing. Diagnosis, then, is what we do when we are moving deeper into the heart of something rather than simply naming it.

Diagnosis works best when we have some idea of what is going on. It allows us to make important distinctions between things, in the same way as we may use visual patterns to tell a giraffe from a zebra. In this respect, scientific medicine has come a long way, particularly in regard of illnesses where clear biological – or perhaps the better term mechanical – explanations underpin our ideas about the disease. In such cases, diagnostic precision can be remarkable. It allows us to, as Wordsworth put it, “cleave nature at the joins”. Because of this, diagnosis serves many functions beyond description; it can point to the cause and the course of the condition and, from this, it can guide what we do about it, in other words treat it. Or rather, treat the person who suffers with it.

Very few people are happy to be ill. Doctors know that patients come to them in a state of demoralised uncertainty. Communicating with someone perceived as expert at identifying your problem and doing something about it is one of the most important parts of the healing process.

Diagnosis, though, is a process, not a state. As science progresses, as it has done remarkably in so many aspects of our life, it continues to take us deeper into the heart of the matter. The application of advances in immunology and microbiology to the symptom pattern of Tuberculosis, for example, took us from a 19th to a 20th-century understanding of the disease and brought with it a remarkable improvement in the fortunes of the tubercular patient. The diagnostic art never stands still.

A more romantic way to put this is to say that diagnosis is really a journey. Diagnostic categories are mere way-stations on a journey towards the destination of perfect understanding, a place which we can never reach but only approach, in the same way that no number of perfectly drawn tangential lines will ever create the perfectly drawn circle.

This idea of a journey is useful when science continues to throw light onto a problem over time. But light shines more brightly into some areas of medicine than others and the shadowy complexities of the mind pose a special problem. We are beginning to understand that the mind is embedded not only in the brain but also the body, at an interface so unbelievably complicated that science may never be able to answer many of our questions about “the mind diseas’d”. The brain just isn’t like any other organ. In an Eskimo fisherman or a Frankfurt stockbroker, a pancreas is just a pancreas. But every human brain, with its exquisite structure that somehow carries a rendering of all that that person has ever been or done, is the home of that unique and indefinable sense of ‘self’ or ‘agent’. The brain is the only organ in the body that can vote.

This means that if we are to try and generate a meaningful account of the various ways in which the brain/mind/body complex can and does go wrong, our descriptions will have to take account of questions that do not admit of simple answers. Any useful account of mental disorder therefore will need to embrace both the general and the unique: easily measurable information about mood, speech and behaviour will need to be combined with more nuanced ideas of motivation, inspiration, imagination, hope and so on. And all of this in turn will need to take account of the vast amount of as yet undeciphered information pouring from our examinations of the living human brain. Try as hard as we might, we will never reach a consensus. Perhaps it wouldn’t be good if we did. As Baudelaire said “if by some mischance we suddenly understood one another, we’d never agree on anything”.

The philosopher Mary Douglas observed that we have a need to agree in times of uncertainty. It does not always matter if our agreements are wrong; our media are full of myths and fibs disguised as certainties. Given our uncertainty about the mind, our efforts to categorise its disorders will certainly generate myths for centuries to come. This is exactly as it should be, because frustration can drive our journey on into the heart of the matter. Unfortunately, our culture, with its increasing preference for certainty over wisdom, seems to be finding the journey towards useful explanations of mental illness rather exhausting and, as with any tiring journey, it is tempting to stop off for a rest. Unfortunately these rest-stops are becoming false destinations, for reasons that have little to do with the pursuit of understanding.

For many people – patients, therapists, politicians and businessmen, who have motives of their own – this may not really matter. Why bother to pursue truth if what we already have is reliable? As the great American psychiatrist Nancy Andreasen said when speaking of psychiatric diagnosis, “we appear to have sacrificed validity for reliability”. The question now is: reliable for what? And increasingly, the answer to this question is “for me!” Western civilisation alone enshrines the notion of the individual above other ideas of personhood which see the individual as merely one element in a much more complicated natural and social context. In such a self-absorbed setting, simple checklists of identifiable problems will prove especially useful. Who cares if our apparently valid checklists contain only half-baked explanations of “what’s wrong with me?” if it solves other more pressing needs?

This explains an increasingly common phenomenon in GP surgeries across the UK. A patient presents clutching a well-thumbed sheaf of printouts and says “I tick all the boxes” for this or that condition. Whether it be attention deficit hyperactivity disorder, generalised anxiety disorder, bipolar disorder, emotionally unstable personality disorder, gender dysphoria disorder, dissociative identity disorder or whatever (and the American Psychiatric Association offers us over 500 of them) this tempting array of categories says more about the categoriser than the categorised. It sustains the hope of a simple, quick, often chemical, answer to questions that have gone unanswered for thousands of years. Our categories will probably never give us the answers we really need.

There are many reasons for turning a diagnostic way-station into a final destination. Drug companies can and do profit from the creation of new conditions, or ‘syndromes’. Researchers need to feed their children just like everyone else; if I can get a paid for research into a category, why worry whether the category is valid or not? Similarly many people, worn down by life and finding themselves unable work for a living, can rely on apparently legitimate claims from benefit systems that are common in much of the Western world. For politicians, faced with the challenge of treating an ever-ageing population with decreasing public resources, they can become a convenient framework for the deferral of difficult ethical and political choices.

Such vested interests and motives are a far cry from the motives that drove Hippocrates, Sydenham, Virchow and their successors. The eras in which they lived were not so dominated by individualistic or instrumental concerns and more by the importance of detecting reliable patterns – constellations – of signs and symptoms that could tell us more about health and disease.

‘Constellation’ is a useful word. On looking into the sky on a cloudless night, the ancients saw the stars pretty much as we do today and fell back on their own cherished myths and stories to explain what they saw; The Hunter, the Great Bear, the Princess and so on. We know now that those blazing patterns of light in the night have no value or meaning in an astronomical sense. Those stars are in fact vanishingly distant balls of blazing hydrogen scattered through the galaxy and beyond that happen to fall in our line of sight. The patterns they throw on our eyes and our minds are nothing more than a reflection of our own point of view. Much the same can be said today about the way we categorise diseases of the mind. Unless our culture rediscovers the significance of the bigger world around all of us – our relationships, our air, our fibs, our myths, our habits, hopes and dreams – the journey towards diagnostic wisdom will remain stalled for some time to come.


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