Postings for class
Just posting here my postings for my class. You can read them if you want but they are here for longevity, since I can't access them after May and don't feel like saving them to my 'puter.
If you consider PTSD different from “shell shock” in the same way you consider Bipolar disorder different from “manic depressive disorder” (in the sense that the terms are not synonymous), Brown’s article does not discuss PTSD. It does, however, discuss a history that precedes the institution of PTSD as an official diagnosis. I consider the “take home” message of Brown to be that of historical consideration. Shell shock as a diagnosis of mental disorder has a complex history of politics, culture, law, science, and medicine. At heart the principle idea is that the concept of shell shock altered the view of human behavior in a moral vs. medical debate, and the result of which provides implications over the condition’s legitimacy.
The term ‘shell shock’ arose from American Civil War cases, but its prominence as a legitimate condition occurred during WWI. I think the history of PTSD coincides, at least according to this article, with hysteria. But even more broadly it causes one to consider the legitimacy of any categorization of mental disorder. Shell shock, as a condition pertaining exclusively to war-time, calls into question whether one can compare trauma across different wars. Current PTSD research, in regards to war, is heavily centered on Vietnam War veterans (with some research the Gulf War and currently the Iraqi War/ “War on Terror”). Research began with WWI, though. The history is one of developing categorizations, and a battle between functionality, anatomical etiology, and personality (Brown, 326). After 1880, PTSD-like neuroses were explored in “railway spine” syndrome and eventually ‘shell shock.’
In addition to arguments over the medical explanation of shell shock (somatoform manifestations due to neuroses vs. actual medical/biological explanations) was the added influence of the legal system. Whether these syndromes were considered one or the other had huge implications on the burden of responsibility. This manifested in railway companies as well as the British military. The increasing acceptance of the syndrome as a ‘functional disorder’ gave way to a functional interpretation of shell shock in WWI (328). By 1914 there was more acceptance of this interpretation, but was also at odds with a pathoanatomical model. These explanations would shift back and forth in their legitimacy during WWI, in response to political measures, particular the politics of War.
During wartime the issue of accepting shell shock as a bona fide neurotic response to trauma was called into question. Mainly this was due to considerations of morality, including military morale. At first, soldier populations were mainly of lower socio-economic statuses, including criminals, but as the war progressed, patriotism (and all the politics surrounding it) caused more middle-class people to join the military. This alone could have implications over how shell shock was treated. At the same time, the British army executed or otherwise disciplined many soldiers for desertion/cowardice (331). At the heart of this problem was a cultural acceptance. A man was expected to be manly - to be courageous in war. However the rates of desertion and incidences of shell shock were too high for this cultural ideal to be all-encompassing. Additionally, it became an issue to determine actual distressed reactions to war from malingering or cowardice. Medical explanations of shell shock may have confronted a moral issue but the cultural expectations were still an issue.
Brown points out some more issues that shaped the conceptualization of the legitimacy of shell shock. Diagnosis using similar symptoms varied from officers in the British military (who were often treated for shell shock and anxiety disorder) and lowly soldiers (who were diagnosed with “conversion hysteria” more often, and were also more likely to be tried for cowardice) (335-6). However there emerged a disconnect: if shell shock was actually a case of cowardice, it would mean officers were unable to handle dissent. This, and the relative success of analytical therapies led to a shift in who managed shell shock: military discipline to doctors and medicine. In came the issue of politics. If shell shock were now considered an actual disorder, how could political leaders in both governmental and military positions mediate the imperative to maintain morale during war? The military cannot execute all deserters (with or without shell shock), but cannot ignore the condition altogether. Thus a shift in mediation occurred: instead of moral values of discipline, courage, and cowardice, there was a mediation of shell shock through medicine and science. Brown notes that the process of war and its impact on traumatic neuroses “was only catalytic” (342).
The Young article is more analytic of the current state of PTSD. Diagnostics has experienced a shift from a monothetic system to a polythetic system. If Disorder X contains symptoms A, B, C, D, E, and F, and to be diagnosed with Disorder X only requires 3 criteria, this means one person can have symptoms A, B, and C, while another person has symptoms D, E, and F. In other words, these two people have dissimilar symptoms but both have Disorder X. From the DSM-III, especially the DSM-III-R on, we have “quasi-polythetic” or “quasi-monothetic” systems, including PTSD (119), as well as MDD and many others. For example in MDD, it is required to have diagnostic criterion 1 or 2, while having at least some of the remaining 6. Similarly for PTSD, it is required that the person is exposed to a traumatic event, while having varying symptoms.
This system of classification calls into memory the issue of classification itself. Classification is rarely (perhaps never) completely objective. Young spends plenty of time discussing the problematic nature of the DSM-III-R classification of PTSD-including attribution of symptoms. Once a traumatic event is established it becomes convenient to distinguish symptoms as a result of PTSD, instead of another disorder. While I could enumerate every part of Young’s appraisal of the wording in the DSM for PTSD, it is more useful to consider another idea he presents: the use of analogy in terms of diagnosis.
Because psychiatry and psychiatric diagnoses are often inexact sciences, we try our best to build reliable assessments. But as discussed in class before, these assessments are used to establish validity, much like considering a syndrome valid solely on the fact that a certain treatment works. In my opinion, analogy is essential, at least for our modern interpretations of mental disorders, since there are so many inexact disorders, or disorders with no specific etiology. The scientific method and evidenced-based research as accepted today, and the analogical interpretations of case studies and “exemplary models” are thus not mutually exclusive but are essential for interpreting mental disorders, particularly PTSD. As Young says, “In the absence of rules, analogy does a better job at proliferating meanings than conserving them…” (123).
Young dedicates several pages assessing what is “traumatic” in relation to PTSD. Potential flaws in understanding arise in what kind of events we consider traumatic in reference to cultural expectations. He also considers that some events considered traumatic are not necessarily distressing, and vice versa. Some patients downplay a traumatic event or ignore (or repress) them altogether. Thus a diagnostician must make the distinction in the absence of patient objectiveness. Consider Alex from In Treatment, who plays off a traumatic event as a duty. Patients’ emotional baggage complicates an objective assessment.
In reviewing several major studies of PTSD, Young points out several faults in PTSD categorization, but at the same time offers many explanations, the most profound of which include considerations of maintaining “between-groups variance.” Statistics will not be consistent of there is no consistent control for both between-groups and within-groups variance. Also problematic in comparing these studies is the concept that trauma is a different brand in differing circumstances. Trauma from war seems unique if we consider what many have written about war (refer to Kurt Vonnegut’s Slaughterhouse-Five and Tim O’Brien’s collective work The Things They Carried, as well as specific writings mentioned on both Brown’s and Young’s articles). At the same time, could we not consider the death of a close loved one traumatic? Trauma then becomes an event that we all must experience, and thus affects how we define it. Young succinctly summarizes these cross-study discrepancies as “differences in technologies rather than in population” (134). This could perhaps imply a firmer grounding of legitimacy for PTSD.
Finally Young explores many scientists’ categorizations of issues in PTSD , including McFarlane’s 7 types of trauma. Included in McFarlane’s explanation is room for a stress-diathesis explanation. Those who were “anxiety-prone” or had other premorbid factors were more likely to experience symptoms of PTSD (137). Young extrapolates 3 categories of PTSD events from McFarlane’s 7 types of trauma, and compares it to Horowitz’s and Janet’s 5 “response phases” (140), which do not seem too dissimilar to Kubler-Ross’ model of the five stages of grief. In fact if we consider the death of a loved one traumatic, we could expect the two categorizations of responses to be similar.
In Young’s article I interpret two categories: (1) anecdotal and analogous evidence and a monothetic system versus (2) scientific evidence through repetitive tests and a polythetic system. The latter seems like the more modern approach to mental disorders, but today we still rely on analogy to explain and categorize. Vietnam War veterans are frequently researched and have contributed to the definition and categorization of PTSD. This is in part due to the convenience of sampling, but also, as Young points out, to the politics of recognition.
Young says, “Patients are victims twice over: victims of the original perpetrators and…of an indifferent society…Vietnam War veterans are the first traumatic victims to demand collective recognition…” (142). With that consideration, it is difficult to view the development of PTSD as disconnected from any cultural influence. Indeed the cultural atmosphere today has greater emphasis on the politics of recognition than in almost any other time era. And being only one cultural consideration lends credence to this intrinsic link between culture and mental illness. Despite the myriad confounds in the definition of PTSD in the DSM-*, it still remains that there is a population of individuals experiencing a cluster of symptoms, and our best attempt at categorization is through our current “quasi-polythetic” organization.
Kushner and Sterk’s article explores the historical approaches to the analysis of suicide, in the context of social cohesion or social capital theory. Social disconnection was the focus of late 19th century and early 20th century inquiries of suicide. In particular, Durkheim explained that anomic suicide (resulting from disillusionment and disappointment, and therefore alienation), as well as egoistic suicide (resulting from deterioration of social bonds) were the important categories of suicide to explore.
However there has been mixed data in regards to what role social integration plays in the incidence of suicide. One claim that “increasing modernization and urbanization led to the breakdown of social cohesion” (1139) meant that social integration was important in the protection against modernizing forces. Social associations, networks, trust, and reciprocity, according to social capital theorists, led to more social cohesion and diminished suicidality. Durkheim’s data, on the other hand, showed higher suicide rates in areas of more social integration.
Durkheim had assumptions that were accepted for decades. Those assumptions included the assertions that modernity breeds alienation, that women were more socially integrated and thus more protected from suicide (and his data showed at the time that fewer women died of suicide than men), and that social integration is socially productive. However Durkheim ignored data on suicidal attempts, which showed that women attempted suicide 2.3 times more often than men. This would suggest women were unhappy with their social roles, but because of the interpretation of the suicide data, there was no need for a new social approach. Steinmetz found that women in socially integrated societies were more suicidal (e.g. rural Chinese women). However this data leaves open for interpretation the possibility that factores other than social integration are responsible for higher suicidality in women (such as a patriarchal societies, cultural norms and expectations).
As for military suicide, Durkheim points out that “passions [were] violently choked by oppressive discipline” (1142). This explanation exculpates Durkheim from a flaw in his theory that social cohesion reduces suicide. However as stated in the conclusion in the article, “[t]he lesson here is that we must remain skeptical about current claims that improved health outcomes and reduced mortality will result from increased submersion in community activity” (1142). ‘Social cohesion’ as a causation for the increase or decrease in suicide is too broad an explanation.
William Styron points out, from the perspective of severe depression, that suicide is a complex task. When speaking about his deep depression, he notes that his “dank joylessness” was not altered in the face of a prestigious award that should have “sparklingly restored [his] ego” (5). Depression makes you numb or inconsolable to any benefits of social cohesion. He points out several times in his memoir that “outsiders,” or those who have never experienced severe depression that pushes one to the brink of suicide, cannot understand the physical and mental feelings involved. This sentiment is echoed through phrases such as “So what?” and “You’ll pull out of it (38).”
Styron points out there is a taboo on suicide (obviously from a legal perspective as well). He points out his colleagues supposed suicide, and the outcry from his friends and family to have his death declared accidental instead of a suicide (31). The implication here is that there is much shame to suicide in the eyes of society. A socially-cohesive community will not be supportive of someone with suicidal ideations and it is therefore erroneous to assume social cohesion will confer lower suicidality (in fact it may worsen its incidence). The author also points out an American “faith in self-improvement” (53) which is not conducive to the acceptance of suicide.
Styron points out that “for me the real healers were seclusion and time” (69). This would suggest that social disconnection actually ameliorated his mental health and prevented suicidality. Of course this effect is indirect, but so is the supposed effect of lower suicide rates in response to social cohesion. I think Styron’s most poignant metaphor is as follows:
“A tough job, this; calling “Chin up!” from the safety of the shore to a drowning person is tantamount to insult, but it has been shown over and over again that if the encouragement is dogged enough-and the support equally committed and passionate-the endangered one can nearly always be saved” (76).
If we assume suicide is most often in response to clinical depression, then the metaphor of the depressed person struggling out at sea is appropriate. He is in essence alienated in his struggle, as society calls from the short that everything will be fine if he keep swimming. But the disconnect is that much of society underestimates the drowning man’s struggle, in my opinion, solely on their inability to completely empathize. In Styron’s anecdotal assertion, society did not necessarily worsen or make better his depression; his depression made him detached from society. Social cohesion is not as effective and straightforward as theorized-it has confounds pointed out by the Kushner & Sterk article, including negative influences from trust and reciprocity and the assumption that social cohesion is always benevolent. Had Styron not sought the solitude of his hospitalization he would have likely driven himself to suicide, and would have likely become another statistic. The reasoning behind his suicide (an act for which philosophy has very little reasonable explanations) would be argued, as most causes of suicide are argued today.
Mania as I understand it in diagnostic terms includes, among other variable symptoms, a state in which a person involuntarily has high amounts of energy resulting in euphoria but more often irritability. According to Ghaemi it always seems to include a level of impulsiveness and therefore a lack of control over one’s actions, which generally lead to unfavorable consequences both for self and society. Often Bipolar I Disorder is used interchangeably with “manic-depressive,” although technically a diagnosis of Bipolar I Disorder requires only a manic episode, and 10% of manic individuals do not experience depression (222). Finally I think that to those unfamiliar with mania in clinical practice associate it purely with euphoria, which contradicts the psychoanalysts’ claims that “depression was respectable, mania was not” (221). Perhaps my view is jaded but mania often seems glorified when considered as a ‘disorder’ of euphoria associated with creativity, productiveness, extroversion, and by inference, charisma-all considered positive traits.
I consider there to be a continuum of mood in relation to mania and depression which, on one end, includes deep, often involuntary sadness which we would call depression. Along the continuum is dysthymia, which is not considered as severely debilitating as depression, but a state of chronic sadness. Moving on is the range of normally-accepted emotions and expressions of happiness and joy or sadness and grief. Another move up the scale is labeled hyperthymia or hypomania, sometimes used interchangeably, sometimes differentiated. In this category is a range of often favorable behaviors which, according to Jamison, can be termed as ‘exuberance’ (96). Past this stage is mania, which in both its irritable and euphoric forms constitutes seemingly involuntary actions which demonstrate lack of control, impulsivity, and implied regret over actions taken while manic.
However the point of interest lies within this hypomanic/hyperthymic/’exuberant’ stage. I argue that the distinction between mania and normal happiness is crystal clear, as mania implies detrimental actions and an insult to functioning, including inconsistent moods, poor judgment and decision making, increased sexual energy leading to problems, and overall deviant and regrettable acts. I do not think that any of the three articles makes the case of mistaking mania for a positive or normal mood. Harris et al.’s satire of classifying happiness as a mental disorder is humorous but points out the logical flaws in the categorization of disorders (specifically stating that “psychiatric theory is so poor” (539)), rather than the vilification of happiness. By pointing out that sadness inhibits remembering happy events, by the same token happiness inhibits remembering sad events. The article points out the faulty assumption that “retrieving negative events” (540) is not an inherently bad thing, and happiness could equally qualify as impairment of memory just as sadness could. Reviewers of Harris point out that psychiatry produces an “over-classification” of behavior (540).
I found the first half of the Jamison article invested much attention in asserting the desirable characteristics of what we would consider, perhaps, the hypomanic, ‘exuberant’ personality who is high in activation and pleasantness. I propose that if we assume such a person to not act in a way that is detrimental to his or others’ health in a significant way, there is no ‘disorder’ to be classified. However the DSM-IV-TR does indeed include hypomania in its pages, which would inherently imply it to be a disorder. Particularly a hypomanic episode is especially distinguished by not being “severe enough to cause marked impairment in social or occupational functioning, or [necessitating] hospitalization, and [having] no psychotic features.” Additionally a hypomanic episode can also include irritability and other negative effects like psychomotor agitation. Interestingly in the diagnosis is the requirement that “[t]he episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.” This criterion in and of itself bears no malevolent implication, and can be hastily summarized to mean “the person is different than normal.”
I think, however, Jamison’s article exalts in its first half the “hyperthymic” exuberance; a “bubbling” personality, a positive emotionality (which constitutes and is inseparable from extraversion (105)). Additionally Jamison points out those who consider themselves consistently very happy were more extroverted than not, and in general draws the conclusion that the extraverted person is happier than the introvert. This exuberant personality, as argued, leads to many rewards from society and is a self-perpetuating condition: exuberants create rewarding environments where they create positive feedback from teachers, adults, parents, and peers (112). The exuberant also more motivated, creative, physically alert, and more likely to initiate tasks and take on new conditions with more optimism (120). Overall the tone of Jamison’s article suggests a huge advantage within society for the exuberant, sanguine, and energetic extrovert over the introvert.
It is important to note that there are millions of cases of mania, most of which include depressive episodes. In the vast majority of cases, whatever high energy, be it destructively irritable or euphoric, is countered by a depression. There are many who, without treatment for their manic symptoms, are likely to hurt themselves or others through their uncontrollable, debilitating, and oppressive runaway minds. I think there is no doubt the vast difference between a happy person and a manic person. In the cases where the manic person is purely euphoric and experiences little to no negative consequence from the manic episodes alone, he has a deep depression to look forward to and this is considered disabled by at least his inability to function in life. Mania does not confer happiness, it is often the opposite: the manic is full of scattered energy, starting and never completing project, thoughts and words racing, and conquered by impulse. I gather from the three articles that happiness really falls somewhere in the realm of the normal, expected range of emotions and perhaps breeches into the hyperthymic and many cases the hypomanic. I fail to see any real crossover between what society considers happiness and what is considered mania, lest that comparison be drawn from a misunderstanding of terminology. I believe that happiness is subject to subjectivity but remains completely distinguishable from manic behavior.
In answering the posed question, it is crucial to consider the history of the disorder, as described by both Hacking and Kenny. Kenny asserts quite strongly throughout his article that MPD “is a culturally specific metaphor…” (3). In particular, multiple personalities are reflected in the “time, place and culture,” a phrase he uses throughout his paper. Hacking’s approach is also a historical one, but he admittedly does “not want to emphasize the social epiphenomena” while admitting “it would be wrong to ignore them” (5). At the root of the disorder, as I see it, is a question of self, which exposes the philosophical influences in psychology. Additionally, much like the history of hysteria, depression, mania, PTSD, and many other termed mental illnesses, is an equally important perspective on history, culture, and politics. Like these, multiple personality disorder, dissociative identity disorder, double consciousness, split personality, cataleptic somnambulism and being possessed are all ways in which this syndrome is categorized throughout history.
Kenny has a specific answer to the posed question: “My view is…multiple personality is a socially created artifact, not the natural product of some deterministic psychological process. Once multiple personality became an object for psychological inquiry and entered into the literature as such, it attained the capacity to recycle back into reality” (14). In this regard MPD is self-perpetuating, manufacturing validity in its diagnosis through reliability. Specifically, Kenny seems to be saying the manifestation of MPD is a reflection of the zeitgeist. He also points out two types of stress that can be related to MPD manifestations: culturally specific sources of tension, and “unavoidable transitions in life” which almost exclusively include elements that are ritualized and/or culturally-defined (10). Thus inseparable from Kenny’s argument is the influence of culture on MPD. One might even read Kenny and gather that he implies MPD is a disease directly caused by cultural stressors and the struggle for identity. Through this and at the heart of split personalities, Kenny finds a dichotomous essence to MPD, as seen in past and present culture (Christian themes of self vs. God, Dr. Jekyll and Mr. Hyde, Id vs. Ego, Nature vs. Culture, science vs. religion, Christ-like resurrection and rebirth).
Kenny’s prominent example involves the stresses of Mary Reynolds coming to North America and the relevance of its time in terms of her analogous presentation of split consciousnesses. His argument is that Mary’s split personas were reactionary-a manifestation of her way of coping with dichotomous demands from societal roles. Her symptoms were also metaphors for the times. Her blindness, argues Kenny, a prototype of the Christian milieu. In a way, as George Herbert Mead noted, multiple personalities may be normal. Kenny notes that “every self is a composite of social roles, some of which may be mutually inconsistent” (22). In fact he also notes the marketable appeal of multiple personalities “because it speaks to contradictions that many experience in their own lives” (4). Behind this appeal is the appeal to make sense of the self (thus the popularity of therapy). He also notes a “quest for meaning” and the want for a “renegotiation of reality” by many in every time, place, and culture (15).
I think Mary’s case can be compared to most cases of similar symptoms. While hers were mediated by the conditions of the culture, her conversion was subversive. Mary, instead of being “reborn” in the Christlike, Augustinian since, did just the opposite. Hacking points out that in cases of MPD where there are two distinct personalities, the former tends to be more melancholic. The latter tends to be the inverse of the former, and this was true in Mary’s case. Her transformation seemed to me to confer Kenny’s and to some extent Hacking’s assertions of multiple personality characteristics: two opposite personalities. Mary’s case was almost precisely one of melancholia and introversion converting to extraversion and manic-like behavior-uninhibited. According to Kenny, this would make since in light of her social demands to be a submissive and passive caretaker, in addition to the rebellious act of moving to North America and the pressure of freedom (both positive and negative freedom-freedom to and freedom from).
MPD can manifest in more than 2 personalities. Both Kenny and Hacking cite cases of 100 “personalities.” Kenny acknowledges, in passing, the absurdity of this claim (I cannot find his exact wording). The effect of his comment is to show how unlikely it is one can have 100 ‘distinct’ personalities. Hacking notes in the history of multiple personality disorder as a formal diagnosis that incidence increased once the term was introduced into the DSM. While the careful scientist remembers that correlation is not causation, it is impossible to ignore the possibility that “a medical milieu…encourages this type of diagnosis” (5). He notes that there are therapies for reintegration, which in the context of our readings leads me to the inference that “dissociative identity disorder” is a term coined to replace “multiple personality disorder,” in part because of the apparent success of “reintegration therapy.”
Today’s American culture values liberation, especially gay liberation, or sexual liberation. As Hacking points out the past 35 years or so our culture has seen a surge in interest pertaining to sexual abuse in children, and sexuality in general. Kenny would argue that, at least in split cases of MPD, today’s diagnosed would present more often with gender dichotomies, and Hacking confirms this trend (8). Allow this talk of gender to be my weak transition into a discussion about the concept of personality.
Before the DSM-IV the symptoms were termed “multiple personality disorder,” a reasonable enough label to describe the symptoms. However in the creation of the DSM-IV the term was changed to “dissociative identity disorder.” Essentially, this change in label implies, at least to me, a change in understanding: before we understood the symptoms as a disorder of personality/personalities, and now we understand it as a disorder of identity/identities. Since ‘personality’ and ‘identity’ are not at all synonymous, and in many ways contradictory, I think this change has huge implications on the condition’s understanding.
Looking at the cultural context, one could argue that we see basically the same syndrome manifesting contingently-based on the values of the time. But cultural norms and values, for the most part, are analogous to Heisenberg’s uncertainty principle. In his principle, particles have an uncertain location at any point at time, and trying to measure their momentum increases this uncertainty (if I am understanding this theory correctly). Similarly, cultural values and norms are rarely a fixed entity, given a vast population with unique values and rituals. To say that any one personality perfectly conforms to all societal norms is absurd. We also think of personality as a more fixed idea, but identity is a more miscible and malleable. The implication here is that there comes a line between a single person with dissociated and amnesic selves, and a singular personality that is not completely grounded. A personality, and moreso an identity, can change, and often is in constant change.
Hacking mentions the possible criticism of the 100-personality individual, but is rather dismissive in saying that each comes out in therapy. Who’s to say this is not instead the result of one personality disintegrating, not into 100 distinct and autonomous personalities, but into a fragmentation. Kenny notes that MPD may persist in a “radically fragmented society paralleled by a fragmented psychology” (16). There is much to be understood about MPD, DID, or whatever you want to term it. I think the questions at heard are more philosophical than psychological or scientific. The therapeutic treatment, if considered to truly cure one of having multiple identities/personalities, is done in integrating the fractured psyches.
However I think one must question-why would such a thing happen in the first place, and is there value in reintegrating a self has disintegrated? If the disintegration is seen as adaptive, our therapy exists only self-indulgently. If we consider the disintegration maladaptive, the therapy is then justified. When Mary could no longer sustain the clashing conflicts of her surroundings, Kenny’s argument would have me believe her double consciousness was adaptive-and allowed Mary to live the two lives society demanded her to live. Perhaps the higher incidence of more than 2 personalities is a product of a fragmented society; a heterogeneous mix of American life, and our therapy is to reintegrate into a societal value-tolerance and acceptance, a purveyance of civil rights and liberation-a product of our Zeitgeist.
If you consider PTSD different from “shell shock” in the same way you consider Bipolar disorder different from “manic depressive disorder” (in the sense that the terms are not synonymous), Brown’s article does not discuss PTSD. It does, however, discuss a history that precedes the institution of PTSD as an official diagnosis. I consider the “take home” message of Brown to be that of historical consideration. Shell shock as a diagnosis of mental disorder has a complex history of politics, culture, law, science, and medicine. At heart the principle idea is that the concept of shell shock altered the view of human behavior in a moral vs. medical debate, and the result of which provides implications over the condition’s legitimacy.
The term ‘shell shock’ arose from American Civil War cases, but its prominence as a legitimate condition occurred during WWI. I think the history of PTSD coincides, at least according to this article, with hysteria. But even more broadly it causes one to consider the legitimacy of any categorization of mental disorder. Shell shock, as a condition pertaining exclusively to war-time, calls into question whether one can compare trauma across different wars. Current PTSD research, in regards to war, is heavily centered on Vietnam War veterans (with some research the Gulf War and currently the Iraqi War/ “War on Terror”). Research began with WWI, though. The history is one of developing categorizations, and a battle between functionality, anatomical etiology, and personality (Brown, 326). After 1880, PTSD-like neuroses were explored in “railway spine” syndrome and eventually ‘shell shock.’
In addition to arguments over the medical explanation of shell shock (somatoform manifestations due to neuroses vs. actual medical/biological explanations) was the added influence of the legal system. Whether these syndromes were considered one or the other had huge implications on the burden of responsibility. This manifested in railway companies as well as the British military. The increasing acceptance of the syndrome as a ‘functional disorder’ gave way to a functional interpretation of shell shock in WWI (328). By 1914 there was more acceptance of this interpretation, but was also at odds with a pathoanatomical model. These explanations would shift back and forth in their legitimacy during WWI, in response to political measures, particular the politics of War.
During wartime the issue of accepting shell shock as a bona fide neurotic response to trauma was called into question. Mainly this was due to considerations of morality, including military morale. At first, soldier populations were mainly of lower socio-economic statuses, including criminals, but as the war progressed, patriotism (and all the politics surrounding it) caused more middle-class people to join the military. This alone could have implications over how shell shock was treated. At the same time, the British army executed or otherwise disciplined many soldiers for desertion/cowardice (331). At the heart of this problem was a cultural acceptance. A man was expected to be manly - to be courageous in war. However the rates of desertion and incidences of shell shock were too high for this cultural ideal to be all-encompassing. Additionally, it became an issue to determine actual distressed reactions to war from malingering or cowardice. Medical explanations of shell shock may have confronted a moral issue but the cultural expectations were still an issue.
Brown points out some more issues that shaped the conceptualization of the legitimacy of shell shock. Diagnosis using similar symptoms varied from officers in the British military (who were often treated for shell shock and anxiety disorder) and lowly soldiers (who were diagnosed with “conversion hysteria” more often, and were also more likely to be tried for cowardice) (335-6). However there emerged a disconnect: if shell shock was actually a case of cowardice, it would mean officers were unable to handle dissent. This, and the relative success of analytical therapies led to a shift in who managed shell shock: military discipline to doctors and medicine. In came the issue of politics. If shell shock were now considered an actual disorder, how could political leaders in both governmental and military positions mediate the imperative to maintain morale during war? The military cannot execute all deserters (with or without shell shock), but cannot ignore the condition altogether. Thus a shift in mediation occurred: instead of moral values of discipline, courage, and cowardice, there was a mediation of shell shock through medicine and science. Brown notes that the process of war and its impact on traumatic neuroses “was only catalytic” (342).
The Young article is more analytic of the current state of PTSD. Diagnostics has experienced a shift from a monothetic system to a polythetic system. If Disorder X contains symptoms A, B, C, D, E, and F, and to be diagnosed with Disorder X only requires 3 criteria, this means one person can have symptoms A, B, and C, while another person has symptoms D, E, and F. In other words, these two people have dissimilar symptoms but both have Disorder X. From the DSM-III, especially the DSM-III-R on, we have “quasi-polythetic” or “quasi-monothetic” systems, including PTSD (119), as well as MDD and many others. For example in MDD, it is required to have diagnostic criterion 1 or 2, while having at least some of the remaining 6. Similarly for PTSD, it is required that the person is exposed to a traumatic event, while having varying symptoms.
This system of classification calls into memory the issue of classification itself. Classification is rarely (perhaps never) completely objective. Young spends plenty of time discussing the problematic nature of the DSM-III-R classification of PTSD-including attribution of symptoms. Once a traumatic event is established it becomes convenient to distinguish symptoms as a result of PTSD, instead of another disorder. While I could enumerate every part of Young’s appraisal of the wording in the DSM for PTSD, it is more useful to consider another idea he presents: the use of analogy in terms of diagnosis.
Because psychiatry and psychiatric diagnoses are often inexact sciences, we try our best to build reliable assessments. But as discussed in class before, these assessments are used to establish validity, much like considering a syndrome valid solely on the fact that a certain treatment works. In my opinion, analogy is essential, at least for our modern interpretations of mental disorders, since there are so many inexact disorders, or disorders with no specific etiology. The scientific method and evidenced-based research as accepted today, and the analogical interpretations of case studies and “exemplary models” are thus not mutually exclusive but are essential for interpreting mental disorders, particularly PTSD. As Young says, “In the absence of rules, analogy does a better job at proliferating meanings than conserving them…” (123).
Young dedicates several pages assessing what is “traumatic” in relation to PTSD. Potential flaws in understanding arise in what kind of events we consider traumatic in reference to cultural expectations. He also considers that some events considered traumatic are not necessarily distressing, and vice versa. Some patients downplay a traumatic event or ignore (or repress) them altogether. Thus a diagnostician must make the distinction in the absence of patient objectiveness. Consider Alex from In Treatment, who plays off a traumatic event as a duty. Patients’ emotional baggage complicates an objective assessment.
In reviewing several major studies of PTSD, Young points out several faults in PTSD categorization, but at the same time offers many explanations, the most profound of which include considerations of maintaining “between-groups variance.” Statistics will not be consistent of there is no consistent control for both between-groups and within-groups variance. Also problematic in comparing these studies is the concept that trauma is a different brand in differing circumstances. Trauma from war seems unique if we consider what many have written about war (refer to Kurt Vonnegut’s Slaughterhouse-Five and Tim O’Brien’s collective work The Things They Carried, as well as specific writings mentioned on both Brown’s and Young’s articles). At the same time, could we not consider the death of a close loved one traumatic? Trauma then becomes an event that we all must experience, and thus affects how we define it. Young succinctly summarizes these cross-study discrepancies as “differences in technologies rather than in population” (134). This could perhaps imply a firmer grounding of legitimacy for PTSD.
Finally Young explores many scientists’ categorizations of issues in PTSD , including McFarlane’s 7 types of trauma. Included in McFarlane’s explanation is room for a stress-diathesis explanation. Those who were “anxiety-prone” or had other premorbid factors were more likely to experience symptoms of PTSD (137). Young extrapolates 3 categories of PTSD events from McFarlane’s 7 types of trauma, and compares it to Horowitz’s and Janet’s 5 “response phases” (140), which do not seem too dissimilar to Kubler-Ross’ model of the five stages of grief. In fact if we consider the death of a loved one traumatic, we could expect the two categorizations of responses to be similar.
In Young’s article I interpret two categories: (1) anecdotal and analogous evidence and a monothetic system versus (2) scientific evidence through repetitive tests and a polythetic system. The latter seems like the more modern approach to mental disorders, but today we still rely on analogy to explain and categorize. Vietnam War veterans are frequently researched and have contributed to the definition and categorization of PTSD. This is in part due to the convenience of sampling, but also, as Young points out, to the politics of recognition.
Young says, “Patients are victims twice over: victims of the original perpetrators and…of an indifferent society…Vietnam War veterans are the first traumatic victims to demand collective recognition…” (142). With that consideration, it is difficult to view the development of PTSD as disconnected from any cultural influence. Indeed the cultural atmosphere today has greater emphasis on the politics of recognition than in almost any other time era. And being only one cultural consideration lends credence to this intrinsic link between culture and mental illness. Despite the myriad confounds in the definition of PTSD in the DSM-*, it still remains that there is a population of individuals experiencing a cluster of symptoms, and our best attempt at categorization is through our current “quasi-polythetic” organization.
Kushner and Sterk’s article explores the historical approaches to the analysis of suicide, in the context of social cohesion or social capital theory. Social disconnection was the focus of late 19th century and early 20th century inquiries of suicide. In particular, Durkheim explained that anomic suicide (resulting from disillusionment and disappointment, and therefore alienation), as well as egoistic suicide (resulting from deterioration of social bonds) were the important categories of suicide to explore.
However there has been mixed data in regards to what role social integration plays in the incidence of suicide. One claim that “increasing modernization and urbanization led to the breakdown of social cohesion” (1139) meant that social integration was important in the protection against modernizing forces. Social associations, networks, trust, and reciprocity, according to social capital theorists, led to more social cohesion and diminished suicidality. Durkheim’s data, on the other hand, showed higher suicide rates in areas of more social integration.
Durkheim had assumptions that were accepted for decades. Those assumptions included the assertions that modernity breeds alienation, that women were more socially integrated and thus more protected from suicide (and his data showed at the time that fewer women died of suicide than men), and that social integration is socially productive. However Durkheim ignored data on suicidal attempts, which showed that women attempted suicide 2.3 times more often than men. This would suggest women were unhappy with their social roles, but because of the interpretation of the suicide data, there was no need for a new social approach. Steinmetz found that women in socially integrated societies were more suicidal (e.g. rural Chinese women). However this data leaves open for interpretation the possibility that factores other than social integration are responsible for higher suicidality in women (such as a patriarchal societies, cultural norms and expectations).
As for military suicide, Durkheim points out that “passions [were] violently choked by oppressive discipline” (1142). This explanation exculpates Durkheim from a flaw in his theory that social cohesion reduces suicide. However as stated in the conclusion in the article, “[t]he lesson here is that we must remain skeptical about current claims that improved health outcomes and reduced mortality will result from increased submersion in community activity” (1142). ‘Social cohesion’ as a causation for the increase or decrease in suicide is too broad an explanation.
William Styron points out, from the perspective of severe depression, that suicide is a complex task. When speaking about his deep depression, he notes that his “dank joylessness” was not altered in the face of a prestigious award that should have “sparklingly restored [his] ego” (5). Depression makes you numb or inconsolable to any benefits of social cohesion. He points out several times in his memoir that “outsiders,” or those who have never experienced severe depression that pushes one to the brink of suicide, cannot understand the physical and mental feelings involved. This sentiment is echoed through phrases such as “So what?” and “You’ll pull out of it (38).”
Styron points out there is a taboo on suicide (obviously from a legal perspective as well). He points out his colleagues supposed suicide, and the outcry from his friends and family to have his death declared accidental instead of a suicide (31). The implication here is that there is much shame to suicide in the eyes of society. A socially-cohesive community will not be supportive of someone with suicidal ideations and it is therefore erroneous to assume social cohesion will confer lower suicidality (in fact it may worsen its incidence). The author also points out an American “faith in self-improvement” (53) which is not conducive to the acceptance of suicide.
Styron points out that “for me the real healers were seclusion and time” (69). This would suggest that social disconnection actually ameliorated his mental health and prevented suicidality. Of course this effect is indirect, but so is the supposed effect of lower suicide rates in response to social cohesion. I think Styron’s most poignant metaphor is as follows:
“A tough job, this; calling “Chin up!” from the safety of the shore to a drowning person is tantamount to insult, but it has been shown over and over again that if the encouragement is dogged enough-and the support equally committed and passionate-the endangered one can nearly always be saved” (76).
If we assume suicide is most often in response to clinical depression, then the metaphor of the depressed person struggling out at sea is appropriate. He is in essence alienated in his struggle, as society calls from the short that everything will be fine if he keep swimming. But the disconnect is that much of society underestimates the drowning man’s struggle, in my opinion, solely on their inability to completely empathize. In Styron’s anecdotal assertion, society did not necessarily worsen or make better his depression; his depression made him detached from society. Social cohesion is not as effective and straightforward as theorized-it has confounds pointed out by the Kushner & Sterk article, including negative influences from trust and reciprocity and the assumption that social cohesion is always benevolent. Had Styron not sought the solitude of his hospitalization he would have likely driven himself to suicide, and would have likely become another statistic. The reasoning behind his suicide (an act for which philosophy has very little reasonable explanations) would be argued, as most causes of suicide are argued today.
Mania as I understand it in diagnostic terms includes, among other variable symptoms, a state in which a person involuntarily has high amounts of energy resulting in euphoria but more often irritability. According to Ghaemi it always seems to include a level of impulsiveness and therefore a lack of control over one’s actions, which generally lead to unfavorable consequences both for self and society. Often Bipolar I Disorder is used interchangeably with “manic-depressive,” although technically a diagnosis of Bipolar I Disorder requires only a manic episode, and 10% of manic individuals do not experience depression (222). Finally I think that to those unfamiliar with mania in clinical practice associate it purely with euphoria, which contradicts the psychoanalysts’ claims that “depression was respectable, mania was not” (221). Perhaps my view is jaded but mania often seems glorified when considered as a ‘disorder’ of euphoria associated with creativity, productiveness, extroversion, and by inference, charisma-all considered positive traits.
I consider there to be a continuum of mood in relation to mania and depression which, on one end, includes deep, often involuntary sadness which we would call depression. Along the continuum is dysthymia, which is not considered as severely debilitating as depression, but a state of chronic sadness. Moving on is the range of normally-accepted emotions and expressions of happiness and joy or sadness and grief. Another move up the scale is labeled hyperthymia or hypomania, sometimes used interchangeably, sometimes differentiated. In this category is a range of often favorable behaviors which, according to Jamison, can be termed as ‘exuberance’ (96). Past this stage is mania, which in both its irritable and euphoric forms constitutes seemingly involuntary actions which demonstrate lack of control, impulsivity, and implied regret over actions taken while manic.
However the point of interest lies within this hypomanic/hyperthymic/’exuberant’ stage. I argue that the distinction between mania and normal happiness is crystal clear, as mania implies detrimental actions and an insult to functioning, including inconsistent moods, poor judgment and decision making, increased sexual energy leading to problems, and overall deviant and regrettable acts. I do not think that any of the three articles makes the case of mistaking mania for a positive or normal mood. Harris et al.’s satire of classifying happiness as a mental disorder is humorous but points out the logical flaws in the categorization of disorders (specifically stating that “psychiatric theory is so poor” (539)), rather than the vilification of happiness. By pointing out that sadness inhibits remembering happy events, by the same token happiness inhibits remembering sad events. The article points out the faulty assumption that “retrieving negative events” (540) is not an inherently bad thing, and happiness could equally qualify as impairment of memory just as sadness could. Reviewers of Harris point out that psychiatry produces an “over-classification” of behavior (540).
I found the first half of the Jamison article invested much attention in asserting the desirable characteristics of what we would consider, perhaps, the hypomanic, ‘exuberant’ personality who is high in activation and pleasantness. I propose that if we assume such a person to not act in a way that is detrimental to his or others’ health in a significant way, there is no ‘disorder’ to be classified. However the DSM-IV-TR does indeed include hypomania in its pages, which would inherently imply it to be a disorder. Particularly a hypomanic episode is especially distinguished by not being “severe enough to cause marked impairment in social or occupational functioning, or [necessitating] hospitalization, and [having] no psychotic features.” Additionally a hypomanic episode can also include irritability and other negative effects like psychomotor agitation. Interestingly in the diagnosis is the requirement that “[t]he episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.” This criterion in and of itself bears no malevolent implication, and can be hastily summarized to mean “the person is different than normal.”
I think, however, Jamison’s article exalts in its first half the “hyperthymic” exuberance; a “bubbling” personality, a positive emotionality (which constitutes and is inseparable from extraversion (105)). Additionally Jamison points out those who consider themselves consistently very happy were more extroverted than not, and in general draws the conclusion that the extraverted person is happier than the introvert. This exuberant personality, as argued, leads to many rewards from society and is a self-perpetuating condition: exuberants create rewarding environments where they create positive feedback from teachers, adults, parents, and peers (112). The exuberant also more motivated, creative, physically alert, and more likely to initiate tasks and take on new conditions with more optimism (120). Overall the tone of Jamison’s article suggests a huge advantage within society for the exuberant, sanguine, and energetic extrovert over the introvert.
It is important to note that there are millions of cases of mania, most of which include depressive episodes. In the vast majority of cases, whatever high energy, be it destructively irritable or euphoric, is countered by a depression. There are many who, without treatment for their manic symptoms, are likely to hurt themselves or others through their uncontrollable, debilitating, and oppressive runaway minds. I think there is no doubt the vast difference between a happy person and a manic person. In the cases where the manic person is purely euphoric and experiences little to no negative consequence from the manic episodes alone, he has a deep depression to look forward to and this is considered disabled by at least his inability to function in life. Mania does not confer happiness, it is often the opposite: the manic is full of scattered energy, starting and never completing project, thoughts and words racing, and conquered by impulse. I gather from the three articles that happiness really falls somewhere in the realm of the normal, expected range of emotions and perhaps breeches into the hyperthymic and many cases the hypomanic. I fail to see any real crossover between what society considers happiness and what is considered mania, lest that comparison be drawn from a misunderstanding of terminology. I believe that happiness is subject to subjectivity but remains completely distinguishable from manic behavior.
In answering the posed question, it is crucial to consider the history of the disorder, as described by both Hacking and Kenny. Kenny asserts quite strongly throughout his article that MPD “is a culturally specific metaphor…” (3). In particular, multiple personalities are reflected in the “time, place and culture,” a phrase he uses throughout his paper. Hacking’s approach is also a historical one, but he admittedly does “not want to emphasize the social epiphenomena” while admitting “it would be wrong to ignore them” (5). At the root of the disorder, as I see it, is a question of self, which exposes the philosophical influences in psychology. Additionally, much like the history of hysteria, depression, mania, PTSD, and many other termed mental illnesses, is an equally important perspective on history, culture, and politics. Like these, multiple personality disorder, dissociative identity disorder, double consciousness, split personality, cataleptic somnambulism and being possessed are all ways in which this syndrome is categorized throughout history.
Kenny has a specific answer to the posed question: “My view is…multiple personality is a socially created artifact, not the natural product of some deterministic psychological process. Once multiple personality became an object for psychological inquiry and entered into the literature as such, it attained the capacity to recycle back into reality” (14). In this regard MPD is self-perpetuating, manufacturing validity in its diagnosis through reliability. Specifically, Kenny seems to be saying the manifestation of MPD is a reflection of the zeitgeist. He also points out two types of stress that can be related to MPD manifestations: culturally specific sources of tension, and “unavoidable transitions in life” which almost exclusively include elements that are ritualized and/or culturally-defined (10). Thus inseparable from Kenny’s argument is the influence of culture on MPD. One might even read Kenny and gather that he implies MPD is a disease directly caused by cultural stressors and the struggle for identity. Through this and at the heart of split personalities, Kenny finds a dichotomous essence to MPD, as seen in past and present culture (Christian themes of self vs. God, Dr. Jekyll and Mr. Hyde, Id vs. Ego, Nature vs. Culture, science vs. religion, Christ-like resurrection and rebirth).
Kenny’s prominent example involves the stresses of Mary Reynolds coming to North America and the relevance of its time in terms of her analogous presentation of split consciousnesses. His argument is that Mary’s split personas were reactionary-a manifestation of her way of coping with dichotomous demands from societal roles. Her symptoms were also metaphors for the times. Her blindness, argues Kenny, a prototype of the Christian milieu. In a way, as George Herbert Mead noted, multiple personalities may be normal. Kenny notes that “every self is a composite of social roles, some of which may be mutually inconsistent” (22). In fact he also notes the marketable appeal of multiple personalities “because it speaks to contradictions that many experience in their own lives” (4). Behind this appeal is the appeal to make sense of the self (thus the popularity of therapy). He also notes a “quest for meaning” and the want for a “renegotiation of reality” by many in every time, place, and culture (15).
I think Mary’s case can be compared to most cases of similar symptoms. While hers were mediated by the conditions of the culture, her conversion was subversive. Mary, instead of being “reborn” in the Christlike, Augustinian since, did just the opposite. Hacking points out that in cases of MPD where there are two distinct personalities, the former tends to be more melancholic. The latter tends to be the inverse of the former, and this was true in Mary’s case. Her transformation seemed to me to confer Kenny’s and to some extent Hacking’s assertions of multiple personality characteristics: two opposite personalities. Mary’s case was almost precisely one of melancholia and introversion converting to extraversion and manic-like behavior-uninhibited. According to Kenny, this would make since in light of her social demands to be a submissive and passive caretaker, in addition to the rebellious act of moving to North America and the pressure of freedom (both positive and negative freedom-freedom to and freedom from).
MPD can manifest in more than 2 personalities. Both Kenny and Hacking cite cases of 100 “personalities.” Kenny acknowledges, in passing, the absurdity of this claim (I cannot find his exact wording). The effect of his comment is to show how unlikely it is one can have 100 ‘distinct’ personalities. Hacking notes in the history of multiple personality disorder as a formal diagnosis that incidence increased once the term was introduced into the DSM. While the careful scientist remembers that correlation is not causation, it is impossible to ignore the possibility that “a medical milieu…encourages this type of diagnosis” (5). He notes that there are therapies for reintegration, which in the context of our readings leads me to the inference that “dissociative identity disorder” is a term coined to replace “multiple personality disorder,” in part because of the apparent success of “reintegration therapy.”
Today’s American culture values liberation, especially gay liberation, or sexual liberation. As Hacking points out the past 35 years or so our culture has seen a surge in interest pertaining to sexual abuse in children, and sexuality in general. Kenny would argue that, at least in split cases of MPD, today’s diagnosed would present more often with gender dichotomies, and Hacking confirms this trend (8). Allow this talk of gender to be my weak transition into a discussion about the concept of personality.
Before the DSM-IV the symptoms were termed “multiple personality disorder,” a reasonable enough label to describe the symptoms. However in the creation of the DSM-IV the term was changed to “dissociative identity disorder.” Essentially, this change in label implies, at least to me, a change in understanding: before we understood the symptoms as a disorder of personality/personalities, and now we understand it as a disorder of identity/identities. Since ‘personality’ and ‘identity’ are not at all synonymous, and in many ways contradictory, I think this change has huge implications on the condition’s understanding.
Looking at the cultural context, one could argue that we see basically the same syndrome manifesting contingently-based on the values of the time. But cultural norms and values, for the most part, are analogous to Heisenberg’s uncertainty principle. In his principle, particles have an uncertain location at any point at time, and trying to measure their momentum increases this uncertainty (if I am understanding this theory correctly). Similarly, cultural values and norms are rarely a fixed entity, given a vast population with unique values and rituals. To say that any one personality perfectly conforms to all societal norms is absurd. We also think of personality as a more fixed idea, but identity is a more miscible and malleable. The implication here is that there comes a line between a single person with dissociated and amnesic selves, and a singular personality that is not completely grounded. A personality, and moreso an identity, can change, and often is in constant change.
Hacking mentions the possible criticism of the 100-personality individual, but is rather dismissive in saying that each comes out in therapy. Who’s to say this is not instead the result of one personality disintegrating, not into 100 distinct and autonomous personalities, but into a fragmentation. Kenny notes that MPD may persist in a “radically fragmented society paralleled by a fragmented psychology” (16). There is much to be understood about MPD, DID, or whatever you want to term it. I think the questions at heard are more philosophical than psychological or scientific. The therapeutic treatment, if considered to truly cure one of having multiple identities/personalities, is done in integrating the fractured psyches.
However I think one must question-why would such a thing happen in the first place, and is there value in reintegrating a self has disintegrated? If the disintegration is seen as adaptive, our therapy exists only self-indulgently. If we consider the disintegration maladaptive, the therapy is then justified. When Mary could no longer sustain the clashing conflicts of her surroundings, Kenny’s argument would have me believe her double consciousness was adaptive-and allowed Mary to live the two lives society demanded her to live. Perhaps the higher incidence of more than 2 personalities is a product of a fragmented society; a heterogeneous mix of American life, and our therapy is to reintegrate into a societal value-tolerance and acceptance, a purveyance of civil rights and liberation-a product of our Zeitgeist.