The Lumber Room: Mental Illness in the House of Medicine
In 1995, Nicholson Baker wrote a masterful disquisition on the literary history of the word lumber, which in England today means something like rubbish or odds and ends.(1) The term lumber room refers to the dark, cluttered, cobwebby room in an English house used for storing those miscellaneous, disused items that don’t belong anywhere else and that one is unwilling to discard. The goal of the present essay is to look into the term mental illness, which began to supplant madness early in the twentieth century.
Baker used concordances, databases and an enormous well of knowledge of English literature to pursue lumber. My resources are more modest. I focus here on the border line between physical illness and mental illness.
What does it mean when the doctor says you have a mental illness, not a physical illness? The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the American Psychiatric Association’s hefty encyclopedia of mental-illness diagnoses, is not scheduled for publication until 2011, so let’s look at the older versions to see how the idea of mental illness has evolved. The earliest editions of the DSM, published in 1952 and 1968, are slight volumes, less than 150 pages each, that would easily slip into the pocket of a doctor’s white coat. The first edition superseded the American Psychiatric Association’s 1942 Statistical Manual for the Use of Hospitals for Mental Diseases, a 71-page pamphlet on hospital record-keeping: use white cards for first admissions, it advised, blue cards for deaths, tan cards for transfers, black ink for male patients, red ink for female patients. Standard designations for diagnoses are listed in the manual, as are standard designations for occupations and race, to facilitate a national census of the patient population.(2) Nevertheless, diagnostic nomenclature proliferated, with institutions, agencies and the armed services modifying standard nomenclature for their own purposes. So along came the 1952 Mental Disorders: Diagnostic and Statistical Manual, DSM-i,expressly to establish naming standards for diagnoses. Statistics took a back seat, demoted to one quarter of the total pages. By the 1968 second edition, statistics is reduced to eleven pages.
Nomenclature-wise, DSM-I and DSM-II reflect the psychoanalytical orientation of their times. For example, in DSM-I, schizophrenia and manic-depressive psychosis are psychogenic, that is, due to mental or emotional conflicts. Psychosis is a pathological reaction to stress: “the personality, in its struggle for adjustment to internal and external stresses, utilizes severe affective disturbance, profound autism and withdrawal from reality and/or formation of delusions and hallucinations.”(3) The crafty personality is the culprit, and the symptoms are coping strategies. Hence, the schizophrenogenic mother and the refrigerator mother: their healthy children developed schizophrenia and autism in reaction to catastrophic parenting.
In 1980, DSM-III was published: larger in all dimensions than its predecessors and nearly 500 pages long, it seems destined to sit on the shelf between consultations. Though the topic of statistics has vanished entirely, the reference remains in the title, a souvenir of the book’s heritage, as the word melancholy commemorates the ancient humoral theory of disease that ascribed depression to a surfeit of black bile (melan + chole in Greek). Dsm-iii emphasizes observation and description over theory:
For most of the DSM-III disorders . . . the etiology is unknown. A variety of theories have been advanced, buttressed by evidence—not always convincing—to explain how these disorders came about. The approach taken in DSM-III is atheoretical with regard to etiology or pathophysiological process except for those disorders for which this is well established.(4)
Goodbye, psychoanalysis; hello, a measure of humility: no more schizophrenogenic mothers. Those few DSM disorders whose etiologies are well established are mostly dementias due to brain disease, like Alzheimer’s. Decades after DSM-III, psychoanalysis as therapy for mental disorders is now thoroughly discredited. There never was any evidence that poor parenting caused schizophrenia or unexpressed anger caused depression or repressed sexual urges caused tic disorders. There were just difficult-to-manage patients with schizophrenia, depression and tic disorders. Advance to the publication of DSM-IV in 1994, and mental disorders are distinguished by their causes. There are now mental disorders due to a general medical condition (e.g., depressed mood associated with Cushing’s syndrome), substance-induced mental disorders and primary mental disorders, defined as “those that have no specified etiology.”(5) This last batch includes all the afflictions we think of as mental illnesses: schizophrenia, bipolar disorder, depression and so forth. The authors of DSM-IV write:
[T]he term mental disorder unfortunately implies a distinction between “mental” disorders and “physical” disorders that is a reductionist anachronism of mind/body dualism. A compelling literature documents that there is much “physical” in “mental” disorders and much “mental” in “physical” disorders. The problem raised by the term “mental” disorders has been much clearer than its solution, and, unfortunately, the term persists in the title of DSM-IV because we have not found an appropriate substitute. (p. xxi)
Let a student of English step up and solve this book-title issue. We started in 1952 with the American Psychiatric Association’s Mental Disorders: Diagnostic and Statistical Manual. The statistics disappeared in 1980 and come 1994 mental disorders is suspect, yet the latest edition is still called Diagnostic and Statistical Manual of Mental Disorders. Maybe the best remedy is to call the next edition the American Psychiatric Association’s Diagnostic Manual. This leaves unanswered the question of what is a psychiatric disorder, but at least it doesn’t flaunt in the title a term, mental disorder, that leaders in the field consider unfortunate.
So, what is meant by the term mental disorder or, more commonly, mental illness? In the DSM-IV’s modest formula (excluding cases of substance abuse), mental disorders are known to be due to medical conditions or their causes are unknown. Knowing the medical cause of a mental disorder holds out the hope of effective treatment,(6) but even in the absence of effective treatment, knowing that there is a medical cause disburdens the patient of blame for the aberrant behavior due to the disease. I’m Not Crazy is the title of one patient’s memoir of her stay in a psychiatric hospital with a schizophrenia diagnosis: turns out she had a brain tumor.(7) The discovery of a brain tumor doesn’t retroactively de-crazify the odd behavior that landed her in the bin; it’s still as crazy as it ever was, but she gets to shake the crazy label when she can point to a lesion on a CT scan. The cause of her mental disorder was known . . . eventually. If the cause of a mental disorder remains unknown, then people—not the DSM, but writers, advocates, therapists, insurance companies, regular folks—call the disorder mental illness. In the absence of evidence, scientists refrain from identifying the cause of such an illness, but others are not so hindered. In the absence of evidence, we use what evidence we have and fabricate the rest.
Mental symptoms fit poorly into our understanding of illness; otherwise, doctors wouldn’t use words like mimic, mask and masquerade to explain the association of mental symptoms with afflictions of known etiology, for example, hypothyroidism “masquerading” as depression. Whatever the symptoms, the lucky patient whose psychiatric diagnosis is supplanted by a medical diagnosis leaves a realm of mystery and struggle and incapacity for the bright lights and established protocols of rock-solid science. As the authors of DSM-IV declare, mental disorders have known etiologies, in which case they are medical disorders, or they do not, in which case they are primary mental disorders. The difference between a medical diagnosis and a psychiatric diagnosis thus has less to do with the patient’s symptoms and more to do with how much the doctor understands the illness. Every so-called “physical” symptom imaginable has at one time or another been termed psychogenic by eager theorizers, and when the physiological basis of a patient’s mental symptom is revealed, like the secret compartment in a magician’s cabinet, the flamboyant madness evaporates, leaving behind a leaden residue of organ damage and biochemistry.
This is not a condemnation of psychiatry. Research in psychiatry is illuminating this least understood realm of afflictions. Treatment saves lives. Good psychiatrists are heroes, taking on the most reviled, most difficult population of patients in all of medicine, the people everyone else gives up on, and persevering at the frontier of the unknown. If the history of medicine is any guide, however, that frontier will recede.
2. American Psychiatric Association, Statistical Manual for the Use of Hospitals for Mental Diseases. Utica, NY: State Hospitals Press, 1942. Tenth edition. Race had a somewhat different meaning then, with English, Armenian and Italian among the many options, and advice was offered that seems odd today: “Care must be taken not to include Negroes and Spanish-Americans among ‘Cubans.’ . . . No difficulty will be experienced in identifying Hebrews and they should be so classified without regard to the country from which they come.” (p. 53)
6. Of course, the history of medicine shows that, more often than not, practitioners have discovered effective treatments without knowing why they worked, e.g., lemons for scurvy, foxglove for dropsy, quinine for malaria.
Published: February 25, 2007