a mere catalogue?…

Posted on Wednesday 24 October 2012

The Classification of Insanity
by John Turner MB
British Journal of Psychiatry. 1912 58:9-25.

BEFORE attempting a classification, it is desirable to define what we exactly mean by insanity. It is not an easy matter. Who is to say where the dividing line is to be drawn between the sane and the insane ? The one state passes insensibly into the other, and a division, which may be valid in certain circumstances, may not be so in others.

Broadly speaking, every individual whose conduct is out of harmony with his environment is insane; the angry person incapable of listening to the voice of reason is so while his passion persists. But these transient states of insanity, whilst they concern the psychologist, are outside the sphere of the alienist. As medical men we must extend this definition so that it includes only prolonged or persistent want of harmony with the environment, and, for all practical purposes, the definition of insanity that it is a state in which conduct is persistently out of harmony with environment meets the case. But it does not follow that everyone who conforms to this definition is a proper person to be shut up in a lunatic asylum, or compelled by law to submit to medical treatment. An individual may be the subject of chronic insane delusions, but so long as he is not a source of danger to himself or to others, nor an annoyance to the community, the law has no right to control his liberty. Therefore to define such cases of insanity as are certifiable, we must still further expand the definition, so that it now appears as follows: A certifiable lunatic is one whose conduct (owing to disease) is persistently out of harmony with his environment, and who is, or may become, a source of harm to himself or a danger or annoyance to the community.

Every student of insanity, consciously or unconsciously, evolves a classification, for no subject can be studied without one. All knowledge resolves itself into classification, for all we can know of phenomena is comprised in comparing one phenomenon with another and noting likenesses or differences.

It may be a mere catalogue, in which the cases are bracketed together by superficial likenesses, and in which the sub-divisions have only an arbitrary relationship to each other, very much as if a librarian were to classify his volumes according to their size, bindings, and whether illustrated or not. It would make no difference where he placed any of his divisions. But a classification to be anything more than a mere catalogue must have some natural basis for its justification, where each class of cases and each variety has a definite position closely related to its adjoining classes and varieties, so that their position cannot be altered without upsetting the whole scheme. The problem of a natural classification is one, therefore, of the first importance, but unfortunately it is also one of the most difficult to solve, and the reasons are not far to seek…

 

Obviously, Eugene Beuler’s term, Schizophrenia, hadn’t yet crossed the English Channel [Dementia Praecox oder Gruppe der Schizophrenien, 1911] and they were still using Kraepelin’s Dementia Praecox. This paper on classification from 100 years ago can be downloaded here in case there are other history buffs:

Reading through Doctor Turner’s classification, one might conclude that we haven’t come very far in the intervening century. Anticonvulsants and antibiotics removed epilepsy and syphilis, but otherwise it’s familiar fare. But notice that it’s a classification of Insanity [grossly abnormal conduct], rather than Mental Illness [reported discomfort]. Around the time of this article, the psychoanalysts were beginning to treat Hysteria which started as observed conduct, but drifted quickly into reported experience – how people felt. The analysts were gradually joined by psychiatrists and psychologists alike. Rather than seeing only an "individual whose conduct is out of harmony with his environment," someone who was brought to be "certified," psychiatrists began to see people who came because of the how they felt and how they suffered. And that’s when our classification got complicated.
    Broadly speaking, every individual whose conduct is out of harmony with his environment is insane ; the angry person incapable of listening to the voice of reason is so while his passion persists. But these transient states of insanity, whilst they concern the psychologist, are outside the sphere of the alienist. As medical men we must extend this definition so that it includes only prolonged or persistent want of harmony with the environment, and, for all practical purposes, the definition of insanity that it is a state in which conduct is persistently out of harmony with environment meets the case.
While there were never that many psychoanalysts, particularly outside the metropolitan areas, their influence was widely felt as psychiatrists began using psychodynamic psychotherapy to treat patients in this new domain of of Mental Illness. In the first DSM [1952], the classification was based on Adolf Meyer’s idea that these non-Kraepelinian mental illnesses were rooted in the biography and life experience – something he called Reactions. So the Kraepelinian illnesses [Insanity] became the Psychoses, as distinguished from the Psychoneuroses. Dr. Turner’s distinction between the concerns of the psychologists and the sphere of the alienists and medical men evaporated and the DSM now included both Insanity and this expanded view of Mental Illnesses. The distinction between these categories had become a distinction within a unitary category.

The DSM-II [1968] came after the introduction of the first generation psychotropic drugs [the Neuroleptics, the Tricyclic & MAOI Antidepressants, the Anxiolytics, and Lithium] and maintained the split between the Psychoses and the Psychoneuroses, but used psychoanalytic concepts to explain the latter, roughly mirrored in biologic treatments for the former, and psychotherapies of various sorts for the rest. But the DSM-II was short-lived, replaced in 1980 by the DSM-III. Its author, Dr. Robert Spitzer, transcended the controversies that abounded at that point in our history. He escaped the murky area of etiology [biological, psychological, unknown] by etiological neutrality and thereby sidestepped the shoals of treatment choice and treating discipline. The distinction between Insanity and Mental Illnesses evaporated as everything became descriptive criteria for something new called Mental Disorders. All the eggs were in the neutral basket of Reliability. With the revisions, his classification has lasted for thirty years. But I can’t help but wonder what Dr. John Turner would’ve thought. Were Dr. Spitzer’s compromises successful because he created what Turner called a mere catalogue?

    It may be a mere catalogue, in which the cases are bracketed together by superficial likenesses, and in which the sub-divisions have only an arbitrary relationship to each other, very much as if a librarian were to classify his volumes according to their size, bindings, and whether illustrated or not… But for a classification to be anything more than a mere catalogue must have some natural basis for its justification
When the various psychotherapists began to treat people with Mental Illnesses rather than just Insanity, we abandoned Dr. Turner’s natural basis for our classification [persistent conduct out of harmony with the environment] and began to treat people based on how they felt [reported discomfort]. In traditional medical parlance, Dr. Turner and the alienists treated signs, but we began to treat symptoms. And when the neuropsychopharmacologists came along, they added the symptomatic illnesses to their focus on the behaviorally disturbed. Since then, we’ve lived in a netherworld where Spitzer’s Mental Disorders were increasingly treated as if they were Mental Diseases [comparable to Medical Diseases]. Proof of concept? Just around the corner we’re told. That’s what the DSM-5 Task Force was planning to do, finally provide a natural basis for the classification – a biological basis for Dr. Spitzer’s catalogue of Mental Illnesses [or at least get the ball rolling in that direction]. Not only did it not work out, but it also comes at a time when we read almost daily about the corrupt practices in the pharmaceutical industry, abetted by prominent psychiatrists. Hardly the Golden Age of anything, these days.

The course of psychiatry has not been smooth sailing in the century from the alienists of Dr. Turner’s day to the present – more akin to the series of storms that rolls off the coast of Africa in late summer headed for the Gulf, one following the other. But this most recent era has been different because of the massive intrusion of outside forces. We’ve been driven as much by industry as ideology this time – Managed Care, Hospital Corporations, Medicaid and Medicare reimbursement, the Pharmaceutical Industry, the Clinical Trials Industry, the Academic Industry. None of them are motivated to improve our diagnostic classification, yet each of them has had an impact on it in one way or another. And the fiscal implications of each diagnosis lurk in the background of its study. That hasn’t lead to a particularly good experience for patients or even most practicing psychiatrists. I found none of that kind of influence in Turner’s work. So if we were able to exhume Dr. Turner and the people he talked about in his article [Janet, Babinski, Freud, Kreapelin] for a consultation, we’d have a really hard time explaining to them how we got where we are without going into some detail about these industrial forces that have involved themselves in our directions. Without that perspective, our story over the latter third of the intervening century really wouldn’t make much sense.


An aside: There was something else in that old classification of insanity – defectiveness, certifiable defectiveness. At first, I thought the frequently used terms like idiot, imbecile, and lunatic had different meanings back then. But that wasn’t quite right. Turner’s seemed to be a classification of people who were constitutionally defective, rather than illness containing. So maybe we have made some progress after all…
  1.  
    Joel Hassman, MD
    October 24, 2012 | 10:25 PM
     

    I still like and apply Albert Einstein’s definition best: insanity is people doing the same thing over and over and expecting different results.

    Sort of, like, Big Pharma coming out with the next psychopharmacological breakthrough that will impact on depression, bipolar disorder, anxiety, schizophrenia, and whatever else is a disorder du jour. And then clinicians jumping to write for said meds and claiming this new drug is better and more efficacious than the last.

    Wow, what irony, the leaders of the profession are as insane as those they try to treat. Well, only if they believe their own press!

    Maybe the post here is insane! Sort of goes along with what is normal?

  2.  
    Carl
    October 28, 2012 | 7:48 AM
     

    Mickey,

    Your posts are uniformly informative and evocative both. This one has been especially useful to me and a current imperative for pondering how to help in a family matter.

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