The Diagnosis Problem
In the early 19th century, French physician François Broussais published De l'irritation et de la folie, a medical treatise wherein he developed the concept of physiological “normalcy” - a framework with which we understand, identify, and classify aberrant health. It was a quintessentially Western idea involving categories, standardizations, ideals, and uniformity, that would eventually seed IQ, BMI, and other invasive metrics. The idea was that we define a health standard, like an inertial frame against which we see outliers drifting; by definition, outliers deviate from the norm, thus in this school of thought, they are unwell and ripe for pathologizing.
"Female Hysteria #2." La Médecine Illustrée, 1887. Courtesy of Science Photo Library.
I have given Broussais paternal ownership over the concept of normalcy here, but in reality, popular academic ideas are lent, snatched, borrowed, reframed, repackaged, reinterpreted, and transposed onto new disciplines until you can’t credit a sole individual. Let it be said that Broussais was borrowing some ideas from Philippe Pinel, and his contemporary Xavier Bichat was speaking from the same pulpit so to speak.
Normalcy is a fruitful idea but patently imperfect. It gives us the tools to notice that heart palpitations can be a concern, that stunted growth can be a sign of malnutrition, and that the South Sudanese ought not to be getting buried at age 52. However, it is repeatedly challenged by the diversity in and between populations. Had the fish-like Bajau or the astronaut-like Sherpas developed the concept of normalcy, the rest of us may be said to be suffering from a deficiency of the lungs. When a man lives on a diet of brandy, smokes, and butter-fried steak, and defiantly revels in life until his sudden arrhythmic sleep-death at age 95, does it serve any purpose to say that he was living unhealthily? According to normalcy, yes. I would suggest that this man belonged to a very small genetic population for whom consuming his kind of diet posed as much of a threat as eating celery does for the rest of us.
Applying a unified normal to a population capable of evolution is not a fatal flaw, but it is a persistent one. The way to ameliorate this “fitting problem” is to tailor special normals for subdivided populations. This was notably accomplished when East Asian countries turned their attention to the BMI metric in the early 2000s. They noticed that at a BMI of 23, they were at the relative same cardiovascular risks as a Westerner in the range of 25-27, in response they adjusted their normal.
As previously stated, the fitting problem is a niggle for physiology, but it is unfolding to be a disaster in psychology. As we continue, I will outline my reasons for believing that the psychological diagnostic literature is overdeveloped and could be slimmed without causing harm, with a supplementary explanation of how psychological diagnoses often impose unnecessary limitations on an individual’s personhood.
It was Ribot, a French psychologist in the 19th century, inspired by Broussais who thought to apply normalcy to human psychology. What ensued was over a century of crack-shot psychologists finding and investigating outlying mental states and pathologizing them in medical journals. It piques one’s attention that ADHD, Autism, Bipolar, panic disorders, bulimia, obesity, and practically every other psychological malady in the book has been on an upward trend for decades. As I see it, there are 3 explanations:
The socioeconomic conditions are such that we are being psychologically harmed more than ever before.
People with these disorders have always existed in the proportions they do today, and now with robust mental health institutions, broad public awareness of mental health, and strong health budgets, we are revealing the true, persistent scale of mental disorders.
By creating diagnoses, we are effectively creating a type of person who didn’t exist before and who may now exist in preponderance.
It is impossible to give a holistic explanation as to the rise of all disorders, each disorder has its own song to sing. Explanations 1 and 2 may be true for all or some, negligibly or significantly, but it’s explanation 3 that is most intriguing and for which the elucidation could be instructive in improving our approach to mental health.
I will reassert the claim: by creating a diagnosis, we are bringing behaviors and experiences into being in people who wouldn’t possess them otherwise. It’s an extraordinary claim expounded on by growing numbers of philosophers. If you asked Arnold Davidson if there were any “perverts” before the late 19th century, he might give you the following passage from his work: “No… Perversion was not a disease that lurked about in nature, waiting for a psychiatrist with especially acute powers of observation to discover it hiding everywhere. It was a disease created by a new (functional) understanding of disease.” Here, Davidson is not denying that behavior we call perverted did not exist, but that the pervert as a type of person did not exist (until normalism). If you asked Ian Hacking if there are more perverts now since the definition of the disease as a consequence of its being defined, he would claim that there absolutely is.
The primary idea is that people come to spontaneously fit their categories. When inspectors in England went to the mills, they found an informally arranged cohort of workers doing various undefined tasks. Observing this, the inspectors drew boundaries over the existing employment structure and created categories and job types based on what tasks were being done. Effectively, they formalized the informal structure. The reports were delivered to the mill owners who disseminated the information and the workers began to spontaneously embody the roles.
Initial state: Several workers are repairing the looms, shadowing subordinates working on them, and then grinding the mill. Inspector observation: “Loom managing” is a task being performed. Final state: Michael, becoming aware of this job, begins habitually shadowing people and ensuring the loom is well maintained. He becomes de facto loom manager.
In another case which is more aligned with my broad point about diagnostics, Split Personality Syndrome was formally defined around 1875. With so few possible cases having ever been recorded prior, it is hard to say why the delineation of this particular set of experiences was drawn in medical journals, but it was. Shortly, a flock of new “Splits” were diagnosed, primarily in France and the United States where it still predominates globally.
Is this disease real? I don’t doubt it. Is it invented? I believe so. Except for very few earlier examples, which were reinterpreted as SPS, there was no such identity or Syndrome for someone to adopt or display. The formalization of SPS supplied a frame or narrative by which certain disturbed persons could view their experiences, led by diagnosticians, psychologists, and psychiatrists who, knowing the literature, would ask targeted questions designed to lead towards a diagnosis. The patient would obligingly provide whatever memories can be reasonably interpreted as evidence to the present question. After going home with a new diagnosis, they take it on, internalize it, sew it into their identity, and believe it to be an immutable, irrepressible part of their make-up, leading to more pronounced symptoms.
When experts lead with the theory in this manner, it explains why since between the 1970s and 1980s the average number of “split personalities” in a single person rose from 2 or 3 to 18. Prior to 1970 did every psychiatrist fail to elicit the scale of the disorder, or did the disorder become more severe through the application of theory?
Prior to SPS, possession was a similar but unrelated case which seems to have become extinct in all but the most zealot communities. The innumerable accounts of possessions testify that people really did experience uncontrollable episodes of mania where they speak in gibberish, go into tangled postures, and vociferously denigrate God. Now that this narrative of possession has been excised from the medical literature, possession has disappeared. The identity of possession has gone, and so too has the experience of possession and the efficacy of exorcisms on suffering persons.
Fetishism and fetish identities have grown significantly in the age of the internet. The concentrations of increasingly niche fetishistic material call to anyone with even a slight interest to become immersed, and with but a single tinge of pleasure, one wonders if one has the fetish, leading to more investigation marked by suspenseful eroticism as one searches for new experiences of pleasure that we hope to find.
The final example I’d like to bring up is that of suicide, which I think illustrates the nominalism involved, which is to say the primacy of thoughts, ideas, feelings, and narratives over stenographic fact. As Elizabeth Anscome said: intentional human actions must be "actions under a description". We do not live on rails which unpack from our DNA, we perform roles. Descriptions are embedded in our practices and lives. What dogs do does not depend on description, but what we do does. A mountain will crumble according to nature but a person is delimited by description, their identity, and the narrative understanding of their place in the world.
Suicide did not exist to Europeans prior to the early 1800s when it was merely a branch of insanity. To experts, suicide was the final symptom in a series of manifestly insane (read: not sane) symptoms. But this is not mere lingualism; the fact that suicide with all its narrative power did not exist prevented self-murder—or perhaps it induced sanity—the point is that it affected people’s behavior.
This is generally called “dynamic nominalism”. It’s a twist on the nominalist position where adherents believe that perceived reality is not inherently categorized and that we impose categories on it, usually with unavoidable imprecision. A dynamic nominalist believes that the world is not inherently categorized but by creating categories we make them real. It’s a bridge between universalism and nominalism. As far as my knowledge goes, this only applies to identity/personhood, not chairs and tables.
The taking on of the identity is the first step of what Ian Hacking calls the Looping effect. The ones who identify go on to interact with the identity/diagnosis and change it. For a neat and benign example, take the eastern stairs of the Apadana, in Persepolis, what is now Iran. The frieze of those stairs illustrates a procession of peoples from the Medes to the Ethiopians presenting their most desired produce and art to the Achaemenid king. It wasn’t just ceremonial, it had stimulatory effects on the goods each people were stereotyped by. Every year, craftsmen would prepare and present articles that were finer than the year before. Moreover, the stereotypes did not remain consistent—in order for artisans to advance or stand out some would modify their wares, which eventually altered the stereotype. The stereotype was a moving target, and so too are diagnoses and all identities.
An identity/diagnosis slowly changes in character according to new and prevailing feelings and ideas among the people with it. A neat but less benign example of changing identities is that of homosexuality. Sexuality was binarized and both halves were labeled by psychiatric experts. The people categorized as homosexual initially resisted the label, but eventually, it was appropriated and redefined by them. New constellations of ideas, feelings, and experiences were attached to it. The people ran away with homosexuality as an idea and experts had to listen. This is bottom-up control of the identity.
Sometimes an identity becomes redefined from the top, that is to say by experts who do not themselves share the identities they study. Top-down control of identity expands the definition, whereas bottom-up control narrows it—in my experience. Expansion happens as greater numbers of people are classified and new streaks of commonality are recognized between the diagnosed. It is an effect which has no termination point.
The Diagnostic and Statistical Manual of Mental Disorders III (1980) recognized “infantile autism” and defined it as a “lack of responsiveness to other people, gross impairment in communicative skills, and bizarre responses to various aspects of the environment”. Contrasted against the 5th and latest version of the DSM published in 2022, the disorder has matured into “Autism Spectrum Disorder” and it is defined by multitudes of potential behaviors which are expounded on over 2 pages. This of course has coincided with a recent epidemic of autism in tens of millions of children worldwide.
Nearly one hundred million children are placed somewhere on the spectrum where social deficiency is a marked characteristic. When a diagnosis takes deficiencies into its narrative, it becomes self-limiting. When a girl is raised in a patriarchal environment where people (men) of an identity that she does not possess hold nearly all positions of ambition, it is understood that her perception acts as an opposing force against her.
In Being and Nothingness, Sartre nicely explains the oppression of identity: “Society demands that he limit himself to his function… There are indeed many precautions to imprison a man in what he is, as if we lived in perpetual fear that he might escape from it, that he might break away and suddenly elude his condition.” The precautions he writes about are the institutions, and even our friends, associates, and ourselves who conspire, sometimes with kind intention, to reaffirm the narratives belonging to our identities.
Take an autistic boy who is coming to understand that social deficiency is a constant part of his identity. His parents, teachers, and authority figures, if kind, and educated on autism, will not push him against his deficiencies, stunting his growth and development, the capacity of which cannot be assumed accurately by his diagnosis. It is lost potential.
Take the case of a woman, age 30, who, following the prescriptions of a psychiatrist, submits herself to an IQ test and learns that she has an IQ of 90. It can be easily sympathized that with this identity she will begin to give in to arguments more readily because she believes that she is likely wrong and just too stupid to understand. She won’t bother to read a challenging article, thinking she is too stupid to grasp the ideas. She will avoid buying unassembled furniture because putting piece A upside down on piece B is too painful a reminder of her deficiency. The self-limitation of identities/diagnoses is a cycle that cripples the area highlighted for deficiency by the medical expert.
As I have stated, each diagnosis has its own song to sing, and undoubtedly behind many instances of diseases, disorders, and syndromes there are issues worthy of our attention, but in our efforts to give them our attention we shape and sometimes worsen our experience of ourselves by taking on the identity of a well-described, narrativized diagnosis. Additionally, a deficiency can become self-fulfilling if it is believed to be part of the identity.
If you accept my early points about diagnoses creating people, and that the diagnoses tend to expand to encompass more people, it is a grave concern that so many men, women, and children are taking deficiencies into their identities, when for an unknown number of cases, it may be completely unnecessary.
