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Still tilting at windmills: Commentary on … The myth of mental illness

  • Edward Shorter (a1)
Summary

Thomas Szasz's essay misses several key points about the undoubted changes that psychiatry has undergone since he wrote his original screed against the discipline in 1961. Szasz fails to recognise that the discipline today acknowledges a neurological basis for much psychiatric illness. Thus, his fulminations against psychiatry for treating ‘mental illness' is off-base. Szasz's original diatribe was heavily against psychoanalysis. Yet today Freud's doctrines can scarcely be said to play even a marginal role in psychiatry, and it is absurd to keep levelling the same old charges of 50 years ago. One has the feeling of looking at one of the last veterans of the Esperanto movement in confronting Szasz: lunacy at the time, bizarrely outdated today.

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This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
The Psychiatrist (pb@rcpsych.ac.uk)
Footnotes
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See special article, pp. 179–182, this issue.

Declaration of interest

None.

Footnotes
References
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1 Szasz, T. The myth of mental illness: 50 years later. Psychiatrist 2011; 35: 181184.
2 Shorter, E, Fink, M. Endocrine Psychiatry: Solving the Riddle of Melancholia. Oxford University Press, 2010.
3 Cobb, S, Cohen, M. Experimental production during rebreathing of sighing respiration and symptoms resembling those in anxiety attacks in patients with anxiety neurosis. Am Soc Clin Invest 1940; 19: 789.
4 Fricchione, GL, Cassem, NH, Hooberman, D, Hobson, D. Intravenous lorazepam in neuroleptic-induced catatonia. J Clin Invest 1983; 3: 338–42.
5 Shorter, E. Before Prozac: The Troubled History of Mood Disorders in Psychiatry. Oxford University Press, 2009.
6 Barone, P. Neurotransmission in Parkinson's disease: beyond dopamine. Eur J Neurology 2010; 17: 364–76.
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Still tilting at windmills: Commentary on … The myth of mental illness

  • Edward Shorter (a1)
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eLetters

Beyond Dualism and Defamation: Utility and Action

James Rodger, Specialty Registrar (ST6)
03 August 2011

A more interesting question than "where does the truth lie?" is to ask what are the implications for persons and society of Szasz and Shorter's respective positions. Even respected nosologists, explicitly acknowledged in the American Psychiatric Association's Research Agenda forDSM-V, have abandoned the quest of asserting nosological validity (based on the failure of even modified Feighner criteria) for most psychiatric 'disorders' but instead are asking questions about the utility of different diagnostic criteria (1)? Therefore if Szasz is right and mentalillness is a metaphor, the Shorter camp might productively ask "is it a useful metaphor?" instead of reverting to a wholly outdated mind-body dualism.

Functional brain imaging reflects lived mental states , and particular brain areas may 'light up' in response to a person's interaction with others and their environment, without necessarily implying neurological causality. Even structural brain changes can in fact imply interpersonal and environmental causality, as the neuroimaging exploring the impact of childhood maltreatment make clear (2). And 'difference' of course does not automatically imply 'disease', as the neurodiversity movement have so eloquently argued (3).

Individual mental phenomena can be simultaneously described at multiple theoretical levels - from neural networks and psychological descriptions through to narrative, meaning and conscious experience, with bidirectional influence between levels. How neuropsychological processes are recursively embedded within wider social processes is more complex still, although social looping theory represents a useful starting point here (4). The ability, however, to hold multiple levels of description in mind often breaks down when meaning is translated into action. The belief that the "voices in my head" are due to a progressive neurological diseaseas opposed to a disgruntled ancestor/spirit has almost irreconcilable consequences for action. The first signifying a need for medical treatment, presumably medication, the second perhaps a need for dialogue/appeasement with the ancestor/spirit (or within our contemporary psychologised cultural milieu, perhaps dialogue and integration with this voice / "split-off self part"). Members of the Hearing Voices Network would hold to whatever appears useful (5). New meanings may themselves influence psychological and associated neurological processes reinforced by social looping (4). Medication can only be reconciled with the ancestor/spirit metaphor as "something that might take the edge of my distress" while engaging with this process of restitution, although not all voice-hearers may find this acceptable or necessary (5). Szasz questioned the implications for individual agency and personal responsibility of attributing difficult or criminal behaviour to illness and even if we are not prepared to accept this position indiscriminately, for those already given a diagnosis we can be challenged to ask where is the boundary between illness and illness behaviour?

There is therefore a real scientific debate to be had. The Research Agenda for DSM-V proposes empirically testing the utility of different diagnostic criteria for the 'mental disorders' (1), and this evaluation process could be expanded beyond diagnosis to testing out the utility of wider non-diagnostic formulations (where used as an alternative rather than addition to diagnosis), and linked interventions, on short and longerterm outcomes (providing outcome measures reflect what is meaningful to sufferers, rather than being merely symptom based). Increasing numbers of practitioners are now challenging the value of diagnostic based systems (see http://www.causes.com/causes/615071-no-more-psychiatric-labels/about). Evaluating such different modes of practice lends itself toreal science rather than the moral defamation resorted to by Shorter in his assertion that critically minded practitioners are responsible for, and indifferent about, countless suicides. Where is the evidence that the massive worldwide increase in antidepressant prescribing has had a significant impact on suicide reductions?

References

1. Kupfer DJ, First MB, Regier DA eds. A research agenda for DSM-V. Washington, DC: American Psychiatric Association, 2002.

2. Teicher MH, Andersen SL, Polcari A, et al. The neurobiological consequences of early stress and childhood maltreatment. Neuroscience & Biobehavioral Reviews. 2003; 27(1-2): 33-44.

3. Fenton A, Krahn T. Autism, Neurodiversity and Equality Beyond the 'Normal'. Journal of Ethics in Mental Health. 2009;2(2):2. 4. Seligman R, Kirmayer LJ. Dissociative experience and cultural neuroscience: narrative, metaphor and mechanism. Culture, Medicine and Psychiatry. 2008; 32(1): 31-64.

5. Romme M, Escher S. Accepting voices. London: Mind Publications; 1993. James RodgerSpecialty Registrar (ST6) Sussex Partnership NHS Foundation Trust

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Ill-Mannered and Ill-Informed

Harold Bourne, Psychiatrist
24 June 2011

It is astonishing to read in “The Psychiatrist” the coarse, ignorant and abusive screed by Edward Shorter as a commentary on the 50th anniversary of Szasz’s scholarly book, “The Myth of Mental Illness.”

The book contains “bombast”, Shorter declares, and “cock-eyed belligerence.” Portentously, Shorter explains that: “..in the way of its fraudulent notions”, and those of the movie “One Flew Over The Cuckoo’s Nest,” along with the anti-psychiatrist writings of Foucault, Laing, Cooper (who actually were quite unconnected with Szasz, his book, and the film) people decided not to seek psychiatric help and “many died by suicide” instead – for which the “anti-psychiatry gurus” were therefore responsible.

Shorter cites no published evidence for this demonising of Szasz and the anti-psychiatrists and in fact there isn’t any to cite. If this were not enough, Shorter goes on to make pronouncements about psychoanalysis, which he declared is dead. Does he mean dead in Toronto where he lives, orworldwide? Either way his pronouncement is nonsence – I am personally acquainted with psychiatrists in academe in Toronto who are very much involved with and practise psychoanalysis. Also I live in Italy where psychoanalysis is alive and well as ever.

Harold Bourne FRCPsych
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Moving on from old frontiers......

Norbert JH Andersch, Consultant Psychiatrist
22 June 2011

Both contributions of Szasz & Shorter make for depressive reading. While Shorter never gets away from the dinosaur-concept of a mere‘brain disease’, Szasz indeed grasps a fraction of the argument that humanbehavior can only be understood and assessed in its cultural frame settings.

But their disintegration during mental illness does not turn them into a ‘myth’, as Szasz insists, nor is his disgust for society’s bigottery in any way helpful in disentangling the constantly changing and complex architecture of how pattern of biological circuits and those of social relations might be inter – or disconnected.

Mental stability is a functioning social construct indeed, as is a good marriage, a proper education or illuminating science. All of them areno ‘myth’ and very much real – yet not as a substance or an observable object but as a relational order.

The living architecture of those relations and their complex alteringgeometries should be at the heart of our understanding of mental health. Our different levels of consciousness are not simple representations of the outside world within our brain. Instead they are the product of a creative tension between stabilized categorical pattern of the subject (growing in its complexity - mainly left brain) and its social field or its sequences (continuously to be deconstructed - mainly right brain).

What is even more crucial: the short lived entities both Gestalt-creating correspondents are dealing with are not empirical sense data but symbols throughout. In general science no one doubts that human nature, our language, mathematics and our progressing tools of work-specification are based on and experienced as symbolic constructs, confirming the famousquote of philosopher Ernst Cassirer, that man is not the ‘animal rationale’ but the ‘animal symbolicum’.

This is more so highlighted in mental crisis, when in its course the symbolic matrix brakes down, our pattern-based construct of reality gets lost, our symbolic language is severely affected and early elements of magic self regulation and previous instinctive drives mix with the patient’s frantic efforts to calm these powerful forces with his diminished cultural tools.

All this in mind one would expect ‘symbolic formation’ and the loss of its complex matrix to play a major role in psychiatric diagnosis and therapy. But, strange as it is, the symbolic message has not hit home. The breakdown of ‘symbolic formation’ in our patients continues to be ignored.Its detectable transcultural codes of experience, its capacity as building-stones of mental equilibriums and its massive impact in the make-up of healing in group settings remain unused.

This is even more surprising as Neurologist Henry Head (1) had extensively researched symbol theories in England during the early 1920es already. So did Ernst Cassirer in Germany. He thought of extracting underlying patterns from cultural development in an attempt to find a 'universal system of symbolisation' underlying human consciousness (2)

He extended van Uexkuell’s biological circuit which finds animals adapted to a certain part of their environment, by adding an entirely new quality, which he calls the 'symbolic system'. While in animal physiology sense-perception is divided into more versus less variable components, differentiating basic type-specific patterns from those which are random or related to just a sole situation, the symbolic approach allows for the integration of meaning and for its anticipation in preplanned social encounter. This unique capacity however is not a biologically given but has to be drawn up in constant interaction by using a mental -symbolic- membrane, separating, selective, connective and protective at the same time, securing its architectural codes in a semantic link with external signs and objects.

Thus the multitude of human activities emerges from a limited number of ‘symbolic forms’ such as magic, myth, religion, law, science, the arts and a few others - while their underlying pattern can be used again and again – in endlessly changed settings.

Cassirer published his findings in a remarkable study on the ‘Psychopathology of symbolic Consciousness’ (1929) which took its strengthfrom intense clinical and theoretical discussions with neurologist Kurt Goldstein, psychologist Kurt Lewin and psychiatrists Ludwig Binswanger (3).

Translated into clinical terms, this approach leads to a different understanding of the multilayered architecture of mental health (which German Psychiatrist Blankenburg termed: ,natuerliche Selbstverstaendlichkeit’) integrating biological with social pattern. It allows for a sustainable point of reference in defining ‘mental illness’ and it might help us understand yet unexplained symptom changes during thecourse of treatment.

Seen from this ‘symbolic’ angle, mental health can be defined as the human ability to stabilize early pattern of personal experience, to successfully create, change and integrate ‚Symbolic Forms‘ of social interaction, while establishing an equilibrium between the demands and intentions of selfregulation and environment, adding its newly found results to human tradition(4).

Mental illness is the inability to (stabilize and/or) integrate own pattern of behaviour into a social framework, leading to a brakedown of (different & multiple) layers of ‘symbolic formation’, while the balance between cultural interaction and the emergence of inner preformed pattern is continuously (or constantly) changed towards the latter.

Clinical Psychiatry is entitled to move on from Szasz’ and Shorter’s outdated theories, yet is well advised to strengthen its focus on semioticand symbolic research. This may direct us towards a ‘science of meaning’ (salience), beyond mere biological function and to integrate this important sources of knowledge into the regular discourse of our discipline.

References:

(1) Head H 1921 Disorders of Symbolic Thinking and Expression.Brit J Psychol Vol XI (2) p 179-93

(2) Cassirer E 1929 "Etudes sur la pathologie de la conscience symbolique"Journal de la Psychologie 26 p 289-336

(3) Binswanger L 1924 Welche Aufgaben ergeben sich fuer die Psychiatrie aus denFortschritten der neueren Psychologie?Z f d g Neur u Psychiatr (Bd XCI/Heft 3/5)

(4) Andersch N 2007 Symbolic Form and Gestalt. Ernst Cassirer's Contribution to a 'Matrix of Mental Formation'. Gestalt Theory Vol 29 No 4 p 279-93

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Re: Whistling in the wind

Abraham L. Halpern, Psychiatrist
10 June 2011

Dr. Shorter's ad hominem attack on Professor Szasz provides no convincing argument against Szasz's well-known position concerning what he regards as

the spurious medicalization of mental illness. Nor will there be wide agreement with Shorter that neuroscientific studies suggesting a "neurological basisfor much psychiatric illness" negate Szasz's firmly held beliefs.

It is regrettable that Dr. Shorter missed the opportunity to remind our colleagues that the rampant misuse of psychiatry 50 years ago as describedby Szasz is applicable to the way institutional psychiatry is practiced todayin many parts of the United States, Canada and the U.K., and certainly in most of the other countries in the world. ... More

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Whistling in the wind

D B Double, Consultant Psychiatrist
23 May 2011

There are reasons to be critical of Thomas Szasz's views about mental illness. For example, few would want to go as far as him in recommending that society manage without a Mental Health Act. His definition of illness as physical lesion also unnecessarily excludes psychological dysfunction as illness.In his commentary (1), Edward Shorter focuses on criticising Szasz on an issue on which he is in fact correct, namely that no biological markers have been found for mental illness. Shorter seems to be using his skills as a historian to suggest that psychiatry has overlooked what he calls obvious evidence of organicity from past research in the role of panicogens in triggering panic disorder; the response of catatonia to barbiturates and benzodiazepines; and hypothalamic-pituitary-adrenal dysregulationin in melancholic depression (see my Critical Psychiatry blog entry). The general conclusion from this research, unlike Shorter, is that no biological cause of mental illness has been found. Even the American Psychiatric Association admit that "brain science has not advanced to the point where scientists or clinicians can point to readily discernible pathologic lesions or genetic abnormalities that in and of themselves serve as reliable or predictive biomarkers of a given mental disorder or mental disorders as a group" (2). Szasz has been dismissed as an anti-psychiatrist. Even 50 years later, the point of his Myth of mental illness has not been understood. Shorter's unscientific attack on Szasz does not promote the interests of psychiatry.

References

1. Shorter, E. Still tilting at windmills: Commentary on... The myth of mental illness. The Psychiatrist 2011; 35: 183-4.

2.American Psychiatric Association Statement on Diagnosis and Treatment of Mental Disorders. Release no 03-39, September 25, 2003
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