1 Boring Old Man

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:}

^{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.}

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…}

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.