History of the Human Sciences (31) has published a special issue about “zones of uncertainty that defy psychopathology’s order of things.” The issue, Psychopathological Fringes: Knowledge making and boundary work in 20th century psychiatry, is edited by Nicolas Henckes, Volker Hess, and Marie Reinholdt. Enjoy!
Exploring the fringes of psychopathology: Boundary entities, category work and other borderline phenomena in the history of 20th century psychopathology
Nicolas Henckes, Volker Hess, and Marie Reinholdt
This special issue of History of the Humane Sciences intends to shed light on a series of psychopathological entities that do not target well defined conditions and experiences, but rather aim at delimiting zones of uncertainty that defy psychopathology’s order of things: mild diagnoses or subthreshold disorders, borderline conditions, culture bound syndromes, or ideas of dimensions and dimensionality. While these categories have come to play an increasingly central role in psychiatric and psychological thinking during the last 50 years, historians and social scientists have had remarkably little to say about how they have been created, what they have been used for, and what kind of realities they have helped to shape. In this introductory article we propose the concept of ‘psychopathological fringes’ to refer to these categories that are located somewhere at the border of psychopathological classifications and refer to zones of conceptual underdetermination. The notion of fringes serves to highlight both the conceptually and the socially marginal nature of the conditions, personal identities, and worlds delimited by these categories. The fringes of psychopathology are zones of vagueness, of epistemic uncertainty, and moral ambiguity. This introduction proposes a first incursion in these zones. It suggests some of the reason why they might have had attracted little interest in the past and why they may be more salient recently. It follows some analytical clues that might help chart a way through it and proposes a map through the collection of articles included in this issue.
Some limitations of ‘category work’ in the history of psychiatry are illustrated via the example of attempts within US alienism and psychiatry since 1889 to identify psychosis and its prodromes. A slowly evolving acceptance of the need for specifiable biological disease concepts, distinct diagnostic categories and defined boundaries of the ‘before and after’ of psychosis among some elite physicians challenged widespread vernacular methods of diagnosis expressed as intuition, feelings or scent as well as local practices of creating novel placeholder terms ‘as needed’ or using question marks to express liminality or confusion. When ‘error of diagnosis’ emerged as a concern circa 1909, the professional transformation of this ‘scientific self of subjectivity’ of the psychiatrist into a ‘scientific self of objectivity’ eventually resulted in the turn to numerical judgments based on rating scales for psychotic symptoms. However, rating scales do not ‘count’ anything at all and exist as instruments of liminality between subjective clinical opinion and the affection of objectivity that quantification symbolizes.
Existing accounts of the early history of Alzheimer’s disease have focused on Alois Alzheimer’s (1864–1915) publications of two ‘peculiar cases’ of middle-aged patients who showed symptoms associated with senile dementia, and Emil Kraepelin’s (1856–1926) discussion of these and a few other cases under the newly introduced name of ‘Alzheimer’s disease’ in his Textbook of Psychiatry. This article questions the underpinnings of these accounts that rely mainly on publications and describe ‘presenility’ as a defining characteristic of the disease. Drawing on archival research in the Munich psychiatric clinic, in which Alzheimer and Kraepelin practised, this article looks at the use of the category as a diagnostic label in practice. It argues that the first cases only got their exemplary status as key referents of Alzheimer’s disease in later readings of the original publications. In the 1900s, the published cases rather functioned as material to think about the limits of the category of senile dementia. The examination of paper technologies in the Munich psychiatric clinic reveals that the use of the clinical diagnosis of Alzheimer’s disease was not limited to patients of a certain age and did not exclude ‘senile’ cases. Moreover, the archival records reflect that many diagnoses of Alzheimer’s disease were noted in the medical records as suspicions rather than conclusions. Against this background, the article argues that in theory and practice, Alzheimer’s disease was not treated as a well-defined disease entity in the Munich clinic, but as an exploratory category for the clinical and histopathological investigation of varieties of organic brain diseases.
Performing doubt and negotiating uncertainty: Diagnosing schizophrenia at its onset in post-war German psychiatry
Nicolas Henckes and Lara Rzesnitzek
In the 20th century, the boundaries of psychosis emerged as an area in which psychiatric judgement faced numerous and profound uncertainties. Between obvious neuroses and personality and reactive disorders on the one hand, and unquestionable psychoses on the other, psychiatrists faced a world of suspected cases of schizophrenia, doubtful personality disorder diagnoses or probable cases of psychosis constituting a garden of equivocal clinical presentations in which both individual psychiatrists and the discipline as a whole were confronted with the limits of their knowledge. This article examines how psychiatrists from two German university clinics managed the multiple uncertainties involved in diagnosing cases of early psychosis between 1950 and 1980. Based on the analysis of a sample of records, we propose a pragmatic interpretation of the ways in which these uncertainties were recorded by psychiatrists. How were uncertainties and doubts expressed in the records and managed by clinicians? What means were used to dispel doubt? What were the consequences for patients of these diagnostic uncertainties? The article defines an uncertainty diagnosis as a diagnosis expressed with reservations by its author and recorded as such in a medical file. Depending on the nature of the uncertainty, the types of evidence used by the professionals and how this evidence was dealt with, we have identified three types of uncertainty diagnoses: suspicion, plausibility and probability diagnoses. The article then reflects on the role of the patients themselves in shaping these uncertain situations.
This article seeks to understand the origins of the Soviet concept of ‘sluggish schizophrenia’, a diagnostic category that was used to imprison political dissidents in the post-WWII era. It focuses on the 1920s and 1930s, a period when Soviet psychiatrists attempted to find ways to diagnose schizophrenia at its earliest stages. The new Soviet state supported these efforts, funding new institutions where clinicians encountered types of patients they had not previously studied. Conceptual disagreements arose about what symptoms could be used to diagnose schizophrenia, and how it could be differentiated from other ‘borderline’ mental disorders such as neurosis and psychopathy. Several research groups used their findings to propose new clinical concepts, including ‘mild schizophrenia’ and sluggish schizophrenia. By the early 1930s Soviet psychiatrists no longer shared a basic consensus about schizophrenia. At the same time, the priorities of the Soviet government under Joseph Stalin ceased to support preventative psychiatry. The result was a 1936 ‘discussion’ at which the concept of mild schizophrenia was criticized and sluggish schizophrenia was held up as a model for how the discipline should develop in the future.
This article explores the evolution of a major longitudinal ‘high risk for schizophrenia’ research programme, started over 50 years ago, which has been largely ignored in recent debates over ‘psychosis risk’ and early intervention. Studying mainly the offspring of individuals with schizophrenia, high-risk investigators aimed to identify a range of precursors of schizophrenia in the hope that the findings would eventually facilitate effective primary prevention. Specifically, the article examines the origins and impact of the pioneering Copenhagen High-Risk Project (1962–1989) and thus provides an important contribution to the sparse historical literature on schizophrenia research, including the study of milder conditions and at-risk states in the borderlands of psychosis.
On ‘moral injury’: Psychic fringes and war violence
This article is concerned with theories and therapeutic practices that interpret post-traumatic combat stress as a ‘moral injury’ produced by the shock of carrying out lethal violence in uncertain battlefield conditions. While moral injury is said to share many symptoms with post-traumatic stress disorder (PTSD), its proponents – military and Veterans Health Administration clinical psychologists, chaplains, and some psychiatrists – are concerned by PTSD’s inability to account for the meaning-based moral and ethical distress that counterinsurgency battlefields in Iraq and Afghanistan are allegedly especially prone to produce in US soldiers. Moral injury theorists seem to want to describe a phenomenon that is both more profound than PTSD but which, as clinical psychologists Shira Maguen and Brett Litz state, is not itself a mental disorder. In this article, I examine the links between moral injury theory’s fringe diagnostic status and the fringe status of the kinds of violence it understands as uniquely injurious to soldiers’ psyches. Moral injury valorizes war-fighting and military culture while casting war as a source of almost inevitable psychopathology. I argue that moral injury theory represents an effort to carve out a distinct domain of psychological expertise but also a negotiation of the tension between war violence’s ‘normal’ practice and its excessive or morally hazardous manifestations – both of which link mental illness directly to the politics of war violence and post-war care.