Ethan Watters writes: Imagine for a moment that the American Psychiatric Association was about to compile a new edition of its Diagnostic and Statistical Manual of Mental Disorders. But instead of 2013, imagine, just for fun, that the year is 1880.
Transported to the world of the late 19th century, the psychiatric body would have virtually no choice but to include hysteria in the pages of its new volume. Women by the tens of thousands, after all, displayed the distinctive signs: convulsive fits, facial tics, spinal irritation, sensitivity to touch, and leg paralysis. Not a doctor in the Western world at the time would have failed to recognize the presentation. “The illness of our age is hysteria,” a French journalist wrote. “Everywhere one rubs elbows with it.”
Hysteria would have had to be included in our hypothetical 1880 DSM for the exact same reasons that attention deficit hyperactivity disorder is included in the just-released DSM-5. The disorder clearly existed in a population and could be reliably distinguished, by experts and clinicians, from other constellations of symptoms. There were no reliable medical tests to distinguish hysteria from other illnesses then; the same is true of the disorders listed in the DSM-5 today. Practically speaking, the criteria by which something is declared a mental illness are virtually the same now as they were over a hundred years ago.
The DSM determines which mental disorders are worthy of insurance reimbursement, legal standing, and serious discussion in American life. That its diagnoses are not more scientific is, according to several prominent critics, a scandal. In a major blow to the APA’s dominance over mental-health diagnoses, Thomas R. Insel, director of the National Institute of Mental Health, recently declared that his organization would no longer rely on the DSM as a guide to funding research. “The weakness is its lack of validity,” he wrote. “Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever.” As an alternative, Insel called for the creation of a new, rival classification system based on genetics, brain imaging, and cognitive science.
This idea — that we might be able to strip away all subjectivity from the diagnosis of mental illness and render psychiatry truly scientific — is intuitively appealing. But there are a couple of problems with it. The first is that the science simply isn’t there yet. A functional neuroscientific understanding of mental suffering is years, perhaps generations, away from our grasp. What are clinicians and patients to do until then? But the second, more telling problem with Insel’s approach lies in its assumption that it is even possible to strip culture from the study of mental illness. Indeed, from where I sit, the trouble with the DSM — both this one and previous editions — is not so much that it is insufficiently grounded in biology, but that it ignores the inescapable relationship between social cues and the shifting manifestations of mental illness. [Continue reading…]
An even more profound problem with the reductionism of neuroscience is that it fails to question the physicalism that has become the bedrock of the scientific outlook. In other words, the belief that if something is real then it must be observable through standardized instruments which enable different observers to agree on the characteristics of the same thing.
In reality, human experience and the human world is primarily constructed from non-physical entities: ideas.
Take for instance the idea of a road — something that at first glance might seem indisputably physical. Imagine a six-lane freeway, filled with fast moving traffic. What could be more physical than that mass of steel and concrete carved emphatically through the landscape?
In fact, a road is a highly abstract concept that only exists inside a human mind and what allows us to drive on roads is the fact that generally speaking we share the same idea about what a road is — that it is a place which allows for the passage of wheel vehicles and is not suitable for picnics or sunbathing; that in the absence of symbolic warnings its boundaries will remain parallel and its continuation will not terminate without warning; that the road’s users will conform to a code of behavior that makes individual actions generally predictable by, for instance, avoiding contact with adjacent vehicles, driving on the same side, and at similar speeds. To drive at night, when sensory input is reduced to a minimum — from road markings whose location we mentally compute; from the narrow field of vision provided by headlights; from the lights of other vehicles whose standardized positions and locations allow us to unconsciously compute their proximity — is to place full faith in the idea of the road.
Neuroscience has advanced to the point where it’s now possible to map in some detail the neural foundations of thought, but a thought can no more be reduced to the firing of neurons than can a word be reduced to the illumination of a configuration of pixels. Ideas do not have an atomic structure and are not bound by time or space. The cartography of the mind cannot be charted by any kind of imaging technology. Not only is such technology ineffective; it is also redundant, since mind is by its very nature (along with a certain amount of discipline and practice) open to self scrutiny.
