Читать книгу Schizophrenia - Orna Ophir - Страница 10

Schizophrenia, also known as the paradigmatic form of madness,³ the “sacred symbol,”⁴ or “heartland”⁵ of psychiatry, was first used as a medical classification by the Swiss psychiatrist Paul Eugen Bleuler in 1908.⁶ It was coined as a diagnosis exactly a century after the name “psychiatry” (from psykhe, meaning soul, and iatreia, connoting medical treatment) was first used by the German physician Johann Christian Reil. In his seminal 1808 paper, “On the Term of Medicine and its Ramifications, Particularly with Regard to the Revision of the Topic in Psychiatry,” Reil called for the establishment of a specific subdivision of medicine to treat mental illnesses.⁷ Ever since, psychiatrists in Europe and around the world have been engaged in an ongoing collective effort to classify – that is, to identify and name, describe, and treat – such psychological ailments.

Nevertheless, attempts to classify specific mental disturbances and the ways in which they affect the behavior of those suffering from them have a much longer history. One of the first attempts to classify different types of mania – the Greek term for madness – can be found in Plato’s dialogue Phaedrus (c.370 BC). In the text, Socrates defines eros or Love as a form of madness, and thus as a disturbance of our conventions and conducts.⁸ Socrates then distinguishes between madness that is caused by human ailments, and madness that is sent by the gods:⁹

SOCRATES: … we said did we not that love is a kind of madness, didn’t we?

PHAEDRUS: Yes.

SOCRATES: And that there are two kinds of madness, one caused by human illnesses, the other from a divine release from the norms of conventional behavior.

PHAEDRUS: Quite so.

SOCRATES: And we divided the divine kind of madness into four parts, each with its own deity. We attributed prophetic inspiration to Apollo, mystical inspiration to Dionysus, poetic inspiration to the Muses, and the fourth kind to Aphrodite and to Eros.¹⁰

In Phaedrus, Plato derives his definitions of mania from contemporary Greek medical writings, which began with the generic concept of madness, before proceeding to differentiating its species. Just as he distinguishes between two methods of reasoning, Plato defines the method of collecting diverse elements under a single generic term as one method, and that of dividing this genus into further species as the other. However, this second method of division should not be applied crudely, like an unskilled butcher indistinctly carving up an animal. Rather, Socrates claims, when we make divisions or classifications, we should carve nature at its joints. Even when we think we are looking at a single physical body, on closer scrutiny, we see that it contains pairs of organs. And even though these separate organs may share the same name, they are still distinct, in the same way that a left hand is distinct from a right hand. The same holds true for madness, as Socrates argues. Although we have a single name for it (a generic form), we can carefully divide it into further parts, “carving its nature at the joints.”

During the Enlightenment, attempts to order elements in the natural world expanded significantly. These efforts were undertaken in different disciplines, from chemistry to mathematics, and applied to various objects of study, from minerals and animals, to human diseases. The first psychiatric classifications of mental diseases followed the early medical nosology (from the Greek nosos, “disease”), which was inspired not by anatomy but by botany. Indeed, they drew on the model of plant taxonomy, or classification.¹¹ Despite these systematic ambitions, however, it was soon realized that when it comes to mental illnesses, constructing a valid “family, genus, species” along the lines of classification in the natural world was a difficult task. The combination of body and soul (with all its variations, distortions, and pathologies) does not always follow the same patterns as the rest of the natural world. Most importantly, mental phenomena rarely fit into the predictable models of natural laws and probabilities that regulate causes and effects in the material world. While metaphysicians have long employed the idea of carving nature at its joints in relation to the phenomenon of madness, when it comes to rapidly changing psychiatric diagnoses like schizophrenia, it is far from obvious that there even is a natural essence – with presumably decisive, descriptive, and classificatory categories – to be carved out.

In his criticism of the American psychiatric classification system, the Diagnostic and Statistical Manual of Mental Disorders (DSM), the philosopher Ian Hacking shows how psychiatry encountered insurmountable problems in its early modern endeavor to emulate botany. As Hacking notes, these difficulties occur not so much on the level of assessing different “trees” (the various diagnoses found in the DSM), but rather, of encountering the “wood itself” (that is, the classificatory enterprise as such).¹² For him, there is a flawed logic at the heart of an enterprise that tries to think about mental illnesses in terms of natural categories. First of all, unlike other medical fields, in psychiatry – or, for that matter, in psychology, psychotherapy, and psychoanalysis – the object one tries to observe, classify, and heal, is not always easily identifiable or recognizable. It might not even be a unitary object at all. Furthermore, while in animals and plants the various aspects which are classified arise naturally by evolutionary descent, the abnormal behaviors that psychiatry sets out to classify and heal have no such shared genealogy or pathogenesis. As a consequence, “paranoid schizophrenia” cannot be traced back to “schizophrenia,” just as schizophrenia does not derive from a “schizophrenic spectrum.” On the other hand, an “American elm” can be traced back to the genus of “ulmus/elm” and to the family of “ulmaceae/elms,” in the same way that “sugar pine” can be traced back to the genus of “pinus/pine” and to the family or differentiated species of “pinaceae/pines.”

In retrospect, as Hacking shows, the reason for psychiatry’s failure in properly identifying – and thus, treating – mental illnesses was as simple as it was compelling. This endeavor was fundamentally flawed in its attempt to use the botanical, naturalist model as a foundation for its method of classification. Rather than referring to a single and permanent object, our concepts of madness, mental deviance, and, a fortiori, schizophrenia, refer to an unstable state or episode, whose symptoms can change, both throughout history and in an individual’s lifetime. Schizophrenia is not a stable object, Hacking concludes, but “a moving target.”¹³

In their alternative reading of the botanical metaphor of mental illnesses, the psychiatrists Daniel Mason and Honor Hsin refer to yet a different way in which their field used this model in its effort to classify mental illnesses. They demonstrate how the American neurologist George Beard (1881), in his American Nervousness: Its Causes and Consequences, offered a radical conceptual departure from the botanical metaphors used by eighteenth-century taxonomists, with his “evolutionary tree” of nervousness. According to Beard, all mental illnesses are branches on the same tree. They share the same trunk, the same roots, the same soil, indeed the same ecosystem, in which psychiatric illnesses can thrive.¹⁴ Ecosystems, or more precisely “ecological niches,” in which mental illnesses flourish, were the better metaphors offered by Hacking to describe the many elements that make a new type of diagnosis possible, and in the absence of which the diagnosis cannot survive.¹⁵