- The DSM-5 in Perspective: Philosophical Reflections on the Psychiatric Babel (edited volume, with Steeves Demazeux. Under contract with Springer)
How can psychiatrists objectively identify mental disorders without projecting their own values and prejudices? In the 1970’s, the removal of homosexuality from the Diagnostic and Statistical Manual of Mental Disorders (DSM) marked a turning point in the history of this question. Under pressure from gay activists, psychiatrists voted to remove homosexuality from the manual. While the outcome of this democratic decision is today accepted almost universally among psychiatrists, it nevertheless laid bare the value-ladenness of psychiatric nosology and challenged the validity of the classification. Through the successive editions of the DSM psychiatrists have tried to respond to this challenge. In a superficial sense, this effort has paid off. Since the DSM-III this manual has acquired a hegemonic role in the health care professions, to the point of acquiring the nickname “The Psychiatric Bible.” The DSM has also had a broad impact on the lay public, which has been quick to appropriate new diagnoses or conversely to impose new diagnoses on the DSM.
Yet none of the editions of the DSM has been able to establish convincingly the validity of psychiatric nosology, which has continuously been under attack, whether for pragmatic and political reasons or for scientific and philosophical ones. The sheer number of mental disorders has kept growing, along with the number of unresolved problems: the still weak reliability of the classification, and its lack of validity; the several cultural, gender and sexist biases that are apparent in the criteria; the comorbidity issue; the categorical vs. dimensional debate, etc.
The DSM-5, slated for publication in May 2013 and to which our project is devoted, will be the next important step in the history of the DSM. Since the DSM-III a new edition of the DSM has been published quite regularly every 6-7 years: DSM-III (1980), DSM-III-R (1987), DSM-IV (1994), and DSM-IV-TR (2000). We can speculate whether the uncharacteristic 13-year hiatus between the DSM-IV-TR and the DSM-5 indicates that the DSM is being revised to an unprecedented degree, or whether it is the consequence of the accumulated difficulties that psychiatric nosology has been facing for years. What is certain is that even before its publication the DSM-5 has created much debate. Multiple articles have been written in scientific and popular journals, blogs have ensured that the flames of controversy are constantly and immediately fanned, petitions have been signed, and ad hominem attacks have been made.
The DSM-5 in Perspective will be the first book-long assessment of the DSM-5. It will only include original essays, written by some of the most established and well-known scholars in the field as well as by younger scholars who are experts in the DSM and the philosophy of psychiatry.
Contributors:
Derek Bolton
Rachel Cooper
Steeves Demazeux
Luc Faucher
Michael First
Allen Frances
Andrew Hinderliter
Stuart Kirk
Dominic Murphy
Jeffrey Poland
John Z. Sadler
Patrick Singy
Jacqueline Sullivan
Şerife Tekin
Jonathan Tsou
Jerome Wakefield
- Sadism at the Limits: Sex, Violence, and the Historical
Boundaries of Sexuality (monograph)
Homosexuality, sadism, masochism, fetishism, frotteurism, telephone scatologia, acrotomophilia, and so many others: the colorful list of perversions coined by psychiatrists since the nineteenth century appears to be endless. Yet only homosexuality has benefited from the sustained attention and intellectual commitment of scholars – LGBT programs are spread all over the academic world, but no university has ever built a CSS (Center for Sadist Studies). While there were and remain very legitimate political reasons for such an exclusive focus on homosexuality, Sadism at the Limits: Sex, Violence, and the Historical Boundaries of Sexuality argues that sadism has played in fact a much more decisive role in the history of sexuality. The ambition of this study is therefore not simply to rectify a historiographical balance, but to offer a new reading of the history of sexuality as a whole by focusing on what has been historically its paradigmatic perversion.
Why
sadism? Sadism at the Limits argues that the discourse of sexuality emerged within the context of the
rise of forensic psychiatry. Starting in early nineteenth-century France, psychiatrists
began to claim an expertise in criminal matters. One of their concerns was to
decide the criminal responsibility of individuals who had committed atrocious
sexual deeds without motives. Some of those individuals were deemed legally
irresponsible: they were perverts whose uncontrollable instinct had forced them
to commit violent and cruel acts. Sexual violence toward others, which in 1890
was coined “sadism” by Richard von Krafft-Ebing, played therefore a fundamental
role in the emergence of sexuality. Sadism at the Limits further argues that after a long period when it
receded into the background in favor of homosexuality, sadism has become once
again the perversion par excellence.
- Abus de soi et "usage des femmes" au dix-huitième siècle. Les pratiques sexuelles des correspondants de Samuel Auguste Tissot (edition of selected letters to Tissot, with extensive introduction. Under contract with Editions BHMS, Lausanne)
Ce livre est divisé en deux parties. La première, proprement historique et historiographique, fait d’abord le point sur les travaux historiques sur la sexualité au dix-huitième siècle, et montre ensuite en quoi la nouvelle perspective rendue possible par l’étude des lettres à Tissot doit modifier profondément notre compréhension de l’histoire de la sexualité. Dans la deuxième partie sont rassemblées les lettres les plus intéressantes sur le sujet de la sexualité. Ainsi le lecteur pourra avoir accès lui-même à cette source historique exceptionnelle.
- Embodied: Space, Time, and the Emergence of Modern Medicine (monograph)
Traditionally, scholars have argued that the emergence of clinical medicine in late eighteenth-century France was the outcome of the rise of physical examination, which itself was possible when physicians overcame cultural taboos against touching bodies. Questioning this interpretation empirically as well as methodologically, I historicize both the patient’s diseased body and the physician’s experience of perception. My project shows how the shift in medical practice that took place between 1750 and 1850 was not located in the physicians’ putative acknowledgment of the body, but in a new conceptualization of disease and a new way of looking at, touching and listening to the body. While my general approach is reminiscent of Foucault's in Birth of the Clinic, the specific historical conclusions I reach are significantly different.
Embodied concentrates on four medical practices, chosen both for their historical importance and for strategic reasons: consultation by letter, the taking of the pulse, percussion of the chest and pathological anatomy. Current scholarship takes consultation by letter as a symbol of Ancient Regime medicine because of the absence of any direct physical contact between patient and doctor; it assumes that the taking of the pulse has not undergone any dramatic change between 1750 and 1850; and it sees in both percussion of the chest and pathological anatomy the first steps in the emergence of modern medicine. By giving a new interpretation of the history of each of these practices, Embodied offers an original understanding of the emergence of modern medicine as a whole.
- “Medicine and the Senses” (book chapter, to be included in vol. 4 ("The Enlightenment") of A Cultural History of the Senses. Edited by Anne Vila)
- “Introduction: What Do We Want Epistemological History to
Be?” (short introduction, co-authored with Matthew L. Jones)
In this introduction to our edited volume, Beyond Cause and
Meaning: Essays on Epistemological History (see below), Matt Jones and I will
describe the main characteristics of a historiographical tradition that
has its roots in the work of Gaston Bachelard, Georges Canguilhem, and Michel Foucault, and that
has been developed more recently by scholars such as Lorraine Daston, Arnold
Davidson, and Ian Hacking.
- “Writing History With a Saw” (book chapter)
In this polemical essay I defend the use of discontinuity as
a historiographical tool. I distinguish between "chronological
discontinuity," which necessarily raises the thorny issue of
periodization, and "epistemological discontinuity," which is only
secondarily related to the temporal dimension of history. I argue that
most of the attacks that have been launched against the idea of discontinuity
stem from a confusion between these two types of discontinuity. I then describe
some of the specific narrative and philosophical characteristics of histories organized by the concept of
discontinuity.
This essay will be published in the volume I am co-editing with Matt Jones, Beyond Cause and Meaning: Essays on Epistemological History (see below).
- Beyond Cause and Meaning: Essays on Epistemological History (edited volume, with Matthew L. Jones)
For several decades social and cultural historians of science have been working to debunk the old myths of Whiggish history. Without a doubt, they have been successful. Whether considering Robert Boyle’s air-pump or today’s laboratories, numerous case studies have shown that science cannot be reduced to a universally valid method or practical norms. The most assiduous observers, like the most recluse theorists, are sometimes driven by less-than-rational interests, and science as a whole is a culture like any other, with its own procedures, etiquettes, and polities.
For all its innovations, the social and cultural study of science has created or reinforced a series of assumptions that have often solidified into historiographical habits:
1) The assumption that causality governs history, and the concomitant disciplinary rule that historians must always subordinate the task of description to the task of causal explanation.
2) The assumption that the true reality of any scientific activity lies in the details of local practice, and the methodological correlate that historical understanding improves in proportion to the narrowness of the historian’s gaze.
3) The assumption that history is necessarily continuous, and the hope that the devout frequentation of archives will smooth the asperities of time and seamlessly connect the chains of precursors.
4) The assumption, rooted in a vague form of humanism, that human beings are always, ultimately, the explanans of history (and sometimes its explanandum as well), with the clear implication that historians must first and foremost pay attention to flesh-and-blood scientists, lest they produce studies that are flawed, uninteresting, or overly abstract.
The essays collected in Beyond Cause and Meaning describe, debate about, and embody an approach to the history of science that is primarily descriptive, voluntarily global, profoundly discontinuous, and unapologetically antihumanist -- an approach sometimes called historical epistemology or historical meta-epistemology. What can such an approach reveal that traditional social and cultural history leaves aside? What are the stakes – historiographical and philosophical – of this approach? Can such an approach overcome the limitations of local history of science without reifying some universal rationality? How does this approach evade the problems inherent to alternate approaches in the history of science and traditional intellectual history?
This book will include historiographical essays by Lorraine Daston, Arnold Davidson, Claude-Olivier Doron, Peter Galison, Philippe Huneman, Matthew L. Jones, Kevin Lamb, Paolo Savoia, and myself.
- “Forensic Psychiatry and the Misuse of the DSM” (book chapter, to be included in Contemporary Essays in the Philosophy of Medicine. Edited by P.Huneman, G. Lambert, and M. Silberstein. Springer, forthcoming 2012)
In this paper I criticize how the DSM is used in forensic settings. Lawyers routinely ask forensic experts whether a defendant suffers from a mental disorder, especially when they try to establish legal responsibility or the necessity for civil commitment. Forensic psychiatrists rely heavily on the DSM to pronounce their expertise.
In the first part of my paper I argue that the relation between the DSM and forensic psychiatry is in fact based on a misunderstanding, which consists in regularly confounding the concept of “incapacity” with the concept of “mental disorder.” Lawyers are concerned with incapacities, such as lack of self-control, while the DSM is concerned with mental disorders, such as the paraphilias. This conceptual distinction is crucial since the DSM itself warns explicitly that there is no perfect overlap between incapacities and mental disorders. For instance, a paraphiliac might, or might not, be able to control himself; a diagnosis of paraphilia does not determine the issue of self-control—and yet it is precisely this issue that matters legally. The use of the DSM in the courtroom can therefore only be misleading, since it answers with “disease” a question about “incapacity.” For this reason, the DSM should no longer be invoked in legal decisions, and should become a purely clinical tool.
In the second section of my paper I look at the consequences, for both parties, of the divorce between forensic psychiatry and the DSM.
For forensic psychiatry, the divorce would force this discipline to focus on the right question: not, Does a defendant have a disorder or not? But, Does a defendant have an incapacity or not? I then focus more specifically on the issue of lack of self-control, and argue that since forensic psychiatry is a deterministic science, it will never be able to answer scientifically a question that is ultimately about free will.
For the DSM, its divorce with forensic psychiatry implies that all the diagnoses that serve a forensic function should be removed from the DSM. By way of a short historical detour, I show in particular how the paraphilias have always had a forensic function. I conclude that they should be removed from the DSM.
- “Thinking Straight About Perversion” (book chapter, to be included in The Psychiatric Babel: Assessing the DSM-5, edited by Steeves Demazeux and Patrick Singy)
Since the removal of homosexuality from the Diagnostic and Statistical Manual of Mental Disorders (DSM) in the 1970’s, psychiatrists have grudgingly tried to explain why the other paraphilias (fetishism, exhibitionism, sadism, etc.) need to remain in the DSM. Their arguments have typically been theoretically weak, to say the least. For instance, Robert Spitzer, the architect of the DSM-III, has flatly admitted that a paraphilia like fetishism has remained in the DSM because fetishists have never protested as forcefully as homosexuals did in the 1970’s, while Allen Frances, a key player in the construction of the DSM-IV, has invoked the weight of a tradition that cannot be changed without terrible yet unforeseeable consequences. In contrast to this theoretically conservative approach, the Sexual and Gender Identity Disorders Work Group of the future DSM-5 (forthcoming in May 2013) has opted for a much more aggressive strategy. Instead of trying to maintain the status quo, the Work Group wants to loosen the criteria for paraphilias, which will result in the expansion of the territory covered by each paraphilia. In addition, it has even more radically advocated for the inclusion of new paraphilias in the DSM. Among those, one of the most controversial ones is “hebephilia” (sexual attraction to adolescents). The proposal to add hebephilia in the DSM-5 has been met with strong opposition, including from the theoretically conservative psychiatrists who have had their share of responsibility for the current paraphilia section in the DSM.
In this paper I look at arguments for and against the inclusion of hebephilia in the DSM. In the first and more historical part of my paper, I put hebephilia in the context of the history of sexual perversions, and argue that the category of hebephilia signals a return to the early nineteenth century, when perversions were defined legally rather than biologically. A peculiarity of hebephilia is that it seems impossible to justify its validity by invoking a biological dysfunction, since it is natural (in an evolutionary sense) to be attracted to young people of reproductive age. Like in the early nineteenth century, with hebephilia the criterion that separates the normal from the pathological is a purely legal one (the legal age of consent).
In the second and more philosophical part of my paper, I am concerned with the consequences for the DSM of either including or rejecting hebephilia. I show first that if hebephilia is rejected, then all the current DSM paraphilias should logically be erased from the DSM. Contrary to what theoretically conservative psychiatrists imply, one cannot maintain the status quo about paraphilia while at the same time rejecting hebephilia.
Next, I show that if hebephilia is on the other hand included in the DSM, then the overt use of legal criteria in a psychiatric manual will encourage psychiatrists to create a diagnostic category for every crime, and more generally to blur the line between psychiatry and the law. The burglar, the forger, the prostitute, the perjurer or the tax evader, for instance, could soon no longer be only types of criminals, but also types of mentally ill people (in a manner reminiscent of nineteenth-century monomaniacs). I conclude that because of the close conceptual connection between mental illness and legal irresponsibility, such diagnostic innovations will have dangerous juridical consequences. By making transparent the value-ladenness of some of the most controversial diagnostic labels, they will also be devastating for the scientific legitimacy of psychiatry.