Monday, 21 October 2013

No the DSM is not like Astrology

I am genuinely ambivalent about the broad line of arguments we can call "the case against the DSM". I don't mean ambivalent in the modern sense ("a bit confused and unsure what to think"), I mean ambivalent in the classic psychoanalytic sense; harbouring strong feelings in both directions. On the one hand there is the interesting and essential level of critique which brings to our attention the experience of feeling labelled and the unsettling bureaucratisation of medical terminology. This line of argument I feel very positive about and engaged with. On the other there is the ever resounding echo chamber of over-confident assertions about the malign intentions of the APA and the total unusability of the DSM for research or clinical purposes. One recurring theme in the latter category is the quip that the DSM is no better than astrology. It appears in this (otherwise excellent) piece by Edward Shorter, in this interview with Richard Bentall, and in many other places besides.

DSM diagnoses would be just like the signs of the zodiac 
if  it weren't for the fact they're very different in many ways.

In the Bentall profile, the New Scientist interviewer opens by asking if comparing the DSM with astrology isn't "a bit strong". "No" says Bentall. I happen to agree with him, but not with the reasons he gives. Comparing the DSM with astrology isn't "a bit strong" (criticism of something you dislike should be strong) it's wildly off the mark. Why? Well although you can derive some superficial comparison between the categories of the DSM and the signs of the zodiac (both describe classes of people; both aspire to some degree of reliable prediction) there are also clear differences.

The most obvious and important difference is the way the way the categories are derived and assigned. The signs of the zodiac are assigned to people on the basis of their date of birth and based upon the idea that these dates are linked to personality characteristics in a meaningful way. Meanwhile DSM diagnoses are applied on the basis of set of criteria describing patterns of behaviour. Someone designated as having, say, OCD, can be expected to resemble a particular broad set of clearly defined features. However a Libra is not just someone who is "on an even keel" (which may way not be an unreasonable classification in itself) but someone who was born between the 22nd September and 23rd October and is regarded as "on an even keel" in virtue of this fact. In short, astrology makes a needless jump--the linking of birth dates and personality traits--that the DSM doesn't.

Why does this matter? It's not as though it puts the DSM above criticism after all. My answer is that the debate about mental health and diagnosis is very important, but if we want a serious discussion about DSM's flaws we need to accord some respect to considerations of plausibility. You can hate the very guts of the manual and its creators and still martial the strongest possible case against it. If you spin off into crowd-pleasing claims and ignore reality people will stop listening.

Monday, 14 October 2013

Aberrant Salience and a New Meaning of "Lynchian"

Fans of the director David Lynch have a clear sense of what it means for something to be "Lynchian", but if we are pushed to put into words what this adjective captures we confront an extremely difficult task. Urban Dictionary gives us this: "having the same balance between the macabre and the mundane found in the works of filmmaker David Lynch." but that definition seems almost circular. Lynch isn't the only person to balance the macabre and the mundane (see also the ubiquitous slasher films of the late 70s and 80s) and we are left with a sense that the word just means "Lynch-like". David Foster Wallace had a go at a definition in the essay here, but was still forced to admit that it is "ultimately definable only ostensively – i.e., we know it when we see it."

There is something that unites all Lynch films for me, and that is the sense that one is being invited to take as significant and sinister various encounters in the plot which turn out to have no ultimate explanation or meaning. I have been struck how this reminds me of the Aberrant Salience account of psychosis. The aberrant salience theory arose out of a brilliant review by Shitij Kapur positing that the mesolimbic dopamine system regulates the salience of elements of our environment, and that it is this process which becomes dysregulated in psychosis and gives rise to phenomena like delusions. When faced with a feeling that something is inexplicably salient or significant humans, story telling creatures that we are, cook up a story to account for the feeling. Part of the beauty of the theory is the way it offers a means for thinking about the interaction between the biological and the psychological. Kapur's language also makes the idea wonderfully intuitive:

By Kapur's account, a dysregulated dopamine system is "the wind of the psychotic fire" and helps us to understand how people can get wrapped up in terrifying implausible stories, but what does any of this have to do with David Lynch? 

Lynch's films, by my account, do a similar thing with our tendency to tell ourselves explanatory stories. Lynch can't dysregulate your dopamine system for you (that's a bit too "This is Your Brain on Cinema" for me), but what he can do is obey nearly all of the conventions of straightforward story telling while artfully ignoring others. Thus we have a series of wonderfully opaque and seemingly significant moments throughout Lynch's oeuvre. Each one seems to add something highly meaningful to the plot, but we can't be sure what. Who is the Cowboy who appears to Adam Kesher (Justin Theroux) in Mulholland Drive to tell him how to cast his film? We don't know, but the exchange has all the hallmarks of a plot-changing moment and we wait eagerly to find out what sinister forces lie behind this sinister man's authority: 

Mulholland Drive's Cowboy: A Vagueness we Are Forced to Explain

What we are doing here, filling in a story in the absence of being let in on its details, bears a striking similarity to what Kapur describes in the formation of a delusion. Something salient has happened and our minds go into overdrive to impose meaning on it. Something similar takes place when Betty and Rita visit Club Silencio and are moved to uncontrollable sobbing as they watch the singer's rendition of Llorando:

Club Silencio

The sense of significance is reinforced by the appearance in Betty's hands of a locked blue box, which appears to be a key clue for understanding the entire film. Unfortunately, no clear resolution exists, and we are left with a plurality of efforts to untangle the multi-layered plot. Film critics have tried but can't agree, and the Internet is home to an endless quantity of logorrheic accounts cooked up by obsessive fans. 

Mulholland Drive is just one example of the way an entire Lynch plot can feel like it hangs on a meaningless symbol. Apparent clues abound in nearly everything Lynch makes. In Twin Peaks, agent Dale Cooper solves the mystery of the death of Laura Palmer after a dream in which he is told "that gum you like is going to come back in style":

The Red Room

Has he solved the crime, or is he just subject to the feeling that something highly significant has happened? What about the severed ear on the lawn which opens Blue Velvet? To the viewer here is a moment that seems so macabre that it must explain something. Whose ear is it? Why was it cut off and by whom? The human tendency to paranoia goes into overdrive and is never resolved.

Blue Velvet's Ear on a lawn: The Macabre and the Banal in spades

Lynch's last film, Inland Empire, consisted almost entirely of such floating signifiers; bedside lamps and bizarre unconnected characters; extended sequences with rabbits talking gibberish. As Laura Dern navigates this confusing world she finds herself outside Room 47, which seems (from the horrified look on her face and the lingering camera work) like it must be a scene of some highly significant event. 

Inland Empire: One Long Paranoid Detour

But like the rest of the film, there is little in the way straightforward resolution to this encounter. Something profoundly creepy happens right afterwards (I'll let you find the clip on YouTube if you're curious) but with no explanation as to why. In many ways Inland Empire was the logical end point of Lynchian cinema. Over the last few films he had eroded the coherence of his plots and emphasised the apparent meaningfulness of moments, symbols and exchanges. The two most recent films especially look like an exercise in discovering how much you can ask the viewer to fill in for themselves. Because of the reliable beauty of Lynch's imagery, and his mastery with creating salient episodes, we go along with him. The resulting experience is an exquisite paranoia, more chilling and rich than almost any other thriller. 

Monday, 7 October 2013

Useful Guides Which Limit our Thinking

This quote is a follow on from this previous post. I came across it while reading Heinz Kohut and Ernest Wolf on Self Psychology. Like the earlier Freud quote, it has relevance to the modern debate on psychiatric diagnosis:
"The best efforts of the past [...] are no exception to the rule that the simplified correlation of specific patterns of manifest behaviour with universally present psychological conditions which of necessity forms part of any such typology will, in the long run, impede scientific progress. Why then, do we persist in the attempt to devise characterologies? The answer is that such classifications, even though we must be aware of the fact that they may eventually limit our thinking and stand in our way, can for a while be valuable guides in psychological territory in which we feel not yet at home."
 Kohut, H., Wolf, E.S. (1978). The Disorders of the Self and their Treatment: An Outline. Int. J. Psycho-Anal., 59:413-425.