Wednesday, 17 October 2018

Making Up Symptoms

I have a short article in Psychiatric Bulletin about the question of historical variation in psychiatric symptoms. It's brief and rather speculative, but I hope fun and interesting.

The essentially private nature of subjective experience means that its occasional misdescription by mental health professionals is virtually guaranteed. Given the centrality of subjective symptoms in assessing psychiatric disorder, such misdescription could have important ramifications.

Here are two anecdotes about language:

During the morning handover meetings in an inpatient unit I once worked on, the shift manager would read a thumbnail description of each resident’s behavior over the last twelve hours. The phrase “responding to internal stimuli” recurred over and again, far more frequently than seemed plausible if you knew the people on the unit at any given time and their propensity to attest to hallucinatory experiences. What was going on here, I suggest, is that in some percentage of these instances, staff were witnessing a set of objectively describable behaviors (speaking aloud to oneself, laughing, ignoring others) and attributing them to inner events that are unobservable from without. The use of the right sounding psychiatric language (“internal stimuli”) was reassuring to staff, who felt they had something professional to say. Unfortunately it also contributed to the elision of the messier and more complex reality. 

In another setting I noticed I heard the use of the Bleulerian notion of “blocking” more than I had ever heard it elsewhere. You could see, in some staff meetings with patients, how the word was applied. It seemed to me that whenever a patient paused, struggled to find the words, or remained silent for any socially awkward period of time, this was apt to be described later as blocking. Thought blocking is often defined with reference to behavior (see the Wikipedia article here), but it is something that can only be identified by reference to subjectivity. Feeling that your thoughts have been blocked is not the same as simply stopping speaking. Additionally, verbalizations such as “he’s blocking,” (blocking as a verb) imply something quite different from the passive concept (your thoughts being blocked) that Bleuler initially described. This shifting use of words changes our understanding of what people are experiencing.

It seems likely to me that this process of misdescription takes place frequently; it may be impossible to avoid. Mental health professionals receive, through their training and through clinical lore and fashion, a sort of rubric for how to make sense out of people who are behaving in ways that are hard to understand. Through such misdescription entire swathes of symptomatic experience may be getting essentially overwritten.

Image result for René Magritte

But this all still amounts to a fairly basic misapprehension, by one person, of the subjective experience of another. Such misapprehension is in principle rectifiable. But what if the confusion runs deeper? What if the interaction between experience and language through time has wrought a more pervasive form of overwriting? This is the subject of the Bulletin article. I suggest that changes in psychiatric terminology over time (namely the shift toward more homogenous descriptions of psychotic symptoms) have potentially had an impact on the very experiences that terminology tries to describe. This is a simple extension of an argument by Ian Hacking, who claims that new diagnostic categories actually bring new ways of being into existence (read this essay in the LRB for a brief overview of this idea, and to see from where I stole my title).

Unlike Hacking though, I think we need more conceptual resources to understand such change. I draw on the work of philosopher Eric Schwitzgebel (check out his excellent blog here), who has written interestingly about the indeterminacy of psychic experience. I am convinced by Schwitzgebel's argument that, far more than we habitually think, there is no fact of the matter about what many aspects of our experience are like. If that sounds extraordinary to you then I recommend you read his book Perplexities of Consciousness. If it doesn't, then you are some of the way to being persuaded by what I am suggesting. If consciousness is indeterminate to some degree then asking people questions like "do you hear the voice inside your head our outside it?" or "is it a male voice or a female voice" is likely, in some cases, to introduce more confusion than clarity to our understanding what an experience is like. Every time we do that, and every time we defer to official definitions of delusions as "beliefs" or hallucinations as "perception like experiences," we are potentially nudging people toward those definitions rather than nudging our definitions toward them.

No comments:

Post a Comment