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
The End of a Diagnosis?
While in the late 1960s Tony Wilson could be diagnosed with paranoid schizophrenia, coded 295.3 by the 1968 version of the American Psychiatric Association’s DSM-II,16 this diagnosis is no longer permitted by the newest version of the manual (the 2013 DSM-5). Is this to say that there are no longer any “paranoid schizophrenics” among us? Have these individuals changed their nature? Or rather, has psychiatry changed its way of classifying and ordering disturbances in human psychological behavior?
Given the fundamental uncertainty that now surrounds the idea of carving nature at its joints when it comes to mental illnesses, most psychiatrists tend to reach their clinical diagnoses and proposed therapies by cutting to the chase, as Dr. Brewster did with Tony. After all, as The History of Nosography aptly noted in 1923, most physicians “cannot live, cannot speak or act without the concept of morbid categories.”17 They have no choice but to chop up the organic whole of mental illness into ill-defined parts, at times like clumsy butchers. Whether in the research lab or clinic, to make a diagnosis, psychiatrists are driven by their own pragmatic and bureaucratic needs, in addition to the urgency of their patients’ suffering. Furthermore, patients and their families – like Tony’s – are often just as eager as psychiatrists, in wanting a clearly defined, definitive, medical category. A diagnosis gives one something to hold onto, to replace the perplexing and, at times, terrifying experience of mental illness.
In his 2007 book, Our Present Complaint: American Medicine Then and Now, historian of medicine Charles Rosenberg argues that “the act of diagnosis links the individual to the social system.”18 Not only does a diagnosis serve a bureaucratic need (keeping records, setting up reimbursements, coordinating between professionals and institutions), it also serves an emotional necessity, offering patients and their families the security of a narrative. It gives a sense of solid ground to stand on, where previously uncertainty and anxiety prevailed. Patients want to know what they are suffering from: “What is wrong with me?,” as Anisha asked Amy June Sousa, who conducted her fieldwork in Lucknow, India, “Do you know if my illness has a name?,”19 she persisted. Or just as another patient diagnosed with schizophrenia who otherwise was not entirely comfortable with the diagnosis of the disease wrote: “The label has helped me, though, to feel less guilt about my inability to ‘conquer’ my problems, and to learn to make some allowances for my difficulties in handling situations.”20
In his book, Rosenberg describes diagnoses as passwords that grant access to the institutional software managing contemporary medicine. In this way, a diagnosis connects the individual to the collective, and vice versa. The problem, however, is that diagnoses then become “part of reality as much as our clogged arteries or dysfunctional kidneys.”21 In other words, for all its shaky grounds, not only does the clinical classification become “real,” but from there on, it wields a tyrannical power over our minds. This is fatefully illustrated by the astonishing willingness of physicians and psychiatrists to keep using categories of so-called “nosologies,” despite the wealth of clinical and therapeutic reasons to doubt their fundamental validity.
Dr. Brewster and other clinicians who still use the DSM understand this end of a diagnosis. Significantly, the DSM itself – also known as the Bible, the Rosetta Stone,22 and even the Chinese Menu23 of psychiatry – changes every few years, introducing new categories and putting an end to earlier diagnoses. Indeed, diagnoses are removed from the DSM when they fail to stand the test of time, that is, when the accumulated critical experience of doctors, patients, and families calls for a fresh look and a revision of previously established criteria. Collective disappointment thus produces a renewed effort to identify and classify madness or mental deviance – including schizophrenia – which then allows for completely new ways of diagnosing them. Together with disorganized schizophrenia, catatonic schizophrenia, undifferentiated schizophrenia, and residual schizophrenia, the diagnosis of paranoid schizophrenia became obsolete in the DSM-5. Formally speaking, there are no longer any “paranoid schizophrenics” among us. Since 2013, the kind or type of people (genus and species) that Dr. Brewster had labeled Tony with is nowhere to be found.
According to Hacking, the human sciences (including psychology, psychiatry, the social sciences, and clinical medicine) are driven by nine engines of discovery, and involved in a process of “making up people.”24 By counting people (say, 1 per 100 people in America suffers from schizophrenia); by quantifying them (age of onset before 45, duration of psychotic symptoms longer than a month), by creating norms; by correlating data about them (schizophrenics are 10% more likely to die of suicide); by medicalizing, biologizing, and geneticizing these subjects while trying to normalize deviance, by bureaucratizing
