Monday, March 29, 2010


Things that caught my eye:

1. David Elkind in the Times describes the quickly vanishing traditional culture of childhood, although he doesn't mention the major implications for parenting.

2. In an interview physicist (and priest) John Polkinghorne contrasts the impersonal knowledge of science with the deeply personal knowledge of faith, which he attributes to irreducible and untestable individual experience. However, the argument from personal experience, while it has given me empathy with believers, never gets me myself beyond agnosticism. For my personal experience has always been of a transcendently ineffable mystery at the heart of reality, which only folly tries to collapse into the simplistic myths of the Bible or Koran. The devil is in the details, indeed. The religious impulse is profound, but it has no rightly specific implications. Even a disposition such as compassion, supposedly so basic to religiosity, does not necessarily follow from the possibility of a deity.

3. In a review of a biography of philosopher R. G. Collingwood, Simon Blackburn gives this wonderful summary of the function of art:

Collingwood carefully separates art proper from art as craft, where there is a predetermined, independent aim to be achieved; and from art as amusement, where the function is to arouse an emotion so that an audience can indulge it; and from art as magic, where the aim is to facilitate some practice or stance toward the world, by the arousal of an emotion that aids it. Art proper is none of these. It is the expression of the way in which the artist feels and thinks about the subject, and in great art it is the imaginativeness, the truthfulness, and the rarity of those feelings and thoughts that overcome us. Collingwood's description of what is involved in communication, expression, imagination, and truthfulness has never been bettered. Even stripped of its context, his final sentence bears remembrance: "Art is the community's medicine for the worst disease of the mind, corruption of consciousness."

Wednesday, March 17, 2010

Muddling Through

A few posts ago a commenter questioned why the perpetual furor over psychiatric diagnosis is so strident and acrimonious. I think the matter, dealing as it does with questions of human nature, identity, and responsibility, hits close to home, and often in a visceral way. Psychiatry presumes to comment upon the selves that we are and the selves we ought to be--as such it is as ambitious and as rightly contentious as politics or religion.

This came to mind yesterday when I read Stanley Fish's typically fine primer on pragmatism as a philosophy of life. Pragmatism is the difficult third option once despotic absolutism and cynical nihilism have been spurned. His piece demands to be read in full, but I particularly liked this:

It is a story, says Margolis (following Kuhn) driven from behind and not by a teleological end awaiting us in the form either of a union with a deity or an ascent to the realm of pure Reason. It is, Margolis tells us, "an extraordinary form of bootstrapping."

Pragmatism, when done well, achieves rigor and clarity without oversimplification and preserves freedom and ambiguity without slack complacency. It is the inherently messy, political, and incremental process by which humanity--comparing and trying out alternatives--somehow muddles through, although often not without appalling errors. I particularly like the idea of the universe as propelled by contingency and not drawn forward by the will-o'-the-wisp of a static perfection.

Psychiatry will never be perfected any more than politics will be perfected. However, we readily recognize some politics as preferable to others--it is not a matter of "anything goes"--and so with psychiatry. There is, in theory, no end to the possible number of DSM editions any more than there could be an absolute end to interpreting the constitution. After all, human nature and culture are moving targets.

Tuesday, March 16, 2010

Why Psychiatry Is Not Neurology

I need to work on briefer posts, so that I can be more consistent here. The blogger as aphorist. Nothing so pithy today, but on Arts & Letters Daily today I found a book review by Sally Satel that pretty much summarizes what psychiatry is about. Read the article yourself--isn't that what makes web links so wonderful, that they obviate the need for dull summaries?

Mental disorders are disorders of agency and intentionality, which is not to say that they are simply chosen or merely willed. That is why psychiatry cannot and should not merge with neurology, which deals primarily with the nervous system as machine. As Satel notes, the crucial difference is the response of mental disorders to contingencies, which gives them a social and semantic distinction from purely physical disease states.

This is not to say that there is a clear and absolute dividing line between mental and non-mental disorders, but the distinction is there nonetheless. Inasmuch as they pertain to ailments of identity and free will, mental disorders are disorders of the self, which may sound grim and slanderous until one remembers that "ailments" range from the blemishes that we all have to, well, the cancers of the soul (which is the brain--how complicated!).

Friday, March 12, 2010

Sometimes a Fantasy

She didn't read books so she didn't know that she was the world and the heavens boiled down to a drop. Man attempting to climb to painless heights from his dung hill.
Then one day she sat and watched the shadow of herself going about tending store and prostrating itself before Jody, while all the time she herself sat under a shady tree with the wind blowing through her hair and her clothes. Somebody near about making summertime out of lonesomeness.
This was the first time it happened, but after a while it got so common she ceased to be surprised. It was like a drug. In a way it was good because it reconciled her to things. She got so she received all things with the stolidness of the earth which soaks up urine and perfume with the same indifference.


Most humans didn't love one another nohow, and this mislove was so strong that even common blood couldn't overcome it all the time. She had found a jewel down inside herself and she had wanted to walk where people could see her and gleam it around. But she had been set in the market-place to sell. Been set for stillbait. When God had made The Man, he made him out of stuff that sung all the time and glittered all over. Then after that some angels got jealous and chopped him into millions of pieces, but still he glittered and hummed. So they beat him down to nothing but sparks but each little spark had a shine and a song. So they covered each one over with mud. And the lonesomeness in the sparks made them hunt for one another, but the mud is deaf and dumb. Like all the other tumbling mud-balls, Janie had tried to show her shine.

Zora Neale Hurston, Their Eyes Were Watching God

Those two excerpts, it seems to me, contain the debate over the nature of art: morbid escapism ("It was like a drug") or ultimate bid for redemption? Going against the traditional grain of literary opinion, Rob Nixon makes the case for non-fiction as the genre that, more often than not, captures reality better than fiction. The issue, of course, is that reality is a mansion of many rooms. There is sociological reality and there is emotional reality.

In my own case I would say that as I've grown older my need for non-fiction has increased, while my patience with fiction has decreased, and given the choice between a mediocre example of either, I will go with non-fiction. The problem with fiction, as with film, is that so much of it is mediocre, and as one ages, the pressure of reality increases, making it harder to justify the expenditure of time in the pursuit of mediocrity.

However, fiction (in which I include poetry and drama) at its best surpasses anything that non-fiction can offer, and given a medium-sized suitcase for a sojourn on the proverbial desert island, I can think of very few non-fiction works that I would pack (Walden is the only obvious one that comes to mind). This is because, as I and many others have written, fiction offers an extra dimension of meaning. Indeed, non-fiction could be likened to tradition 2-D film: solid, reliable. Fiction, like 3-D, offers a far more intense experience, but it also carries the risk of being merely goofy.

A long time ago I came across a remark by Tolkien, whether in his letters or in an essay I don't recall, in which he protested the common dismissal of escapism as a literary motivation. He argued that if the reality in which one finds oneself seems to be a prison, what is wrong with trying to escape from it? There are all kinds of problems with this, including the Platonic and Christian assumption that if one escapes from the cave, one will find oneself anywhere else but in a larger cave. But I think he has a point that the artist seeks not merely to reconcile himself and others to the world as it is--the work of art adds to the world as it is, and in so doing it aspires to redeem it. Art is not a housecleaning--it is a remodeling, even an annex, while non-fiction is a diagnosis. Each has its place.

Oh, and what is the genre that seeks to combine the reality of diagnosis with the supreme emotional truth of art? Wouldn't that be religion? But can that circle be squared?

Friday, March 5, 2010

Crooked Timber

What causes schizophrenia? The short answer may be "nothing" or more precisely "no one thing." In most cases, schizophrenia is an end result of a complex interaction between thousands of genes and multiple environmental risk factors--none of which on their own causes schizophrenia. Daniel Weinberger, in his classic paper on brain development and schizophrenia, entertained the "unlikely" possibility that schizophrenia is "not the result of a discrete event or illness process at all, but rather one end of the developmental spectrum that for genetic and/or other reasons 0.5% of the population will fall into." Over 20 years later, this unlikely scenario is looking more realistic. Schizophrenia is increasingly considered a subtle neurodevelopmental disorder of brain connectivity, of how the functional circuits in our brains are wired. Schizophrenia may in fact be the tail end of a distribution of how the estimated 20 billion neurons and their trillions of synaptic connections in our brains are generated, eleminated, and maintained. Schizophrenia may be the uniquely human price we pay as a species for the complexity of our brain; in the end, more or less by genetic and environmental chance, some of us get wired for psychosis.

This eloquent passage by John H. Gilmore, M.D., from a recent editorial in the American Journal of Psychiatry, struck me as emblematic of the field now. In one sense, his statement seems obvious--we nod knowingly, muttering the mantra that the mind is complicated, etc. But in another sense, it seems to dash our hopes. For what if not only schizophrenia, but most or all mental disorders, are no more easily accounted for than are other complex psychological features, such as intelligence, personality, or the nature of consciousness itself?

Even if we never expected to find THE CAUSE of most mental disorders, the smoking guns, nonetheless we have nourished hopes that one or two of the myriad causes might be found to predominate and to offer chances to nip in the bud "the thousand natural shocks that flesh is heir to." This lust for explanation certainly isn't unique to psychiatrists--patients themselves continually cast about for a simple and compelling narrative, whether it be the abusive parent, the head injury at age 12, or whatever.

Potentially the most embarrassing question psychiatrists are asked is "What caused this?" We still cannot legitimately answer beyond vague references to genes, synapes, and life experience, all of which offers little more clarity than the notorious "chemical imbalance." It may be that we are not only in practice (that is, currently with all our technical limitations), but crucially in theory (that is, forever and by nature of the inquiry) no better able to explain why Johnny is depressed than we can explain why his IQ is 112, or why he prefers baseball to football, or why he likes going to church. The contingency goes all the way down.

Gilmore's editorial also implies that mental disorders may not be contingent afflictions, but may be closely bound up with the very nature of the human animal. It is easy to imagine a world without AIDS (oh right, most of history), and even cancer seems no more integral to human identity than smallpox long must have seemed. But a world in which suicide, madness, and addiction don't happen, period, seems no easier to envision than a world wholly without war or poverty. That isn't to say that it can't or won't happen, but it would involve a radical alteration in human experience.

The murkiness of etiology continues to frustrate the project of neatly carving out mental disorders from the (hopefully) broader region known as normality. All we see wherever we look are continua and shades of gray, and the distinction between treatment and enhancement grows fuzzier. If we had a pill that would increase IQ by ten points, then why would an increase from 50 to 60 be "treatment" (of mental retardation) and an increase from 100 to 110 would be "enhancement" if mental retardation is merely part of the natural (normal?) distribution of intelligence? These distinctions threaten to be made primarily based on pragmatic and political bases (e.g. how many IQ-raising pills can we afford to make, how will be distribute them, etc.).

I've always been struck by the example of Alzheimer's disease, the prevalence of which climbs above 50% in individuals over 85. In this case dementia becomes normative, and statistically an example of "normal" aging. Arguably it is no more a "disorder" than death itself is a disorder. So if we had effective treatments for Alzheimer's "disease," then they could be viewed as an example of "enhancement," as an alleviation of potentially normal aging. What we label "disease" is merely what we would choose not to live with.

In philosophy of mind the "hard problem of consciousness" is the vexed question of how a physical brain produces the experience of subjectivity. As a bad pun I can think of a second "hard" problem of consciousness, that is, the existential reality that consciousness is hard to tolerate at times--it can be raw nerve held up to the universe. But there could be a third kind, a sense in which the brain is evolutionarily hard to produce, the most complex object in the universe that we know of. Mistakes were made. To paraphrase Samuel Johnson's infamously misogynistic (and anti-clerical) comparison of women preachers to dogs walking on their hind legs, one marvels not that it isn't always done well, but that it is done at all.

Monday, March 1, 2010

The Argument

"Well then, my fine friend," said Mr. C..., "you now have all the knowledge you need to grasp my meaning. We see that in the organic world, to the same degree that reflection gets darker and weaker, grace grows ever more radiant and dominant. But just as two lines interesect on one side of a point, and after passing through infinity, suddenly come together again on the other side; or the image in a concave mirror suddenly reappears before us after drawing away into the infinite distance, so too, does grace return once perception, as it were, has traversed the infinite -- such that it simultaneously appears the purest in human bodily structures that are either devoid of consciousness or which possess an infinite consciousness, such as in the jointed manikin or the god."

"In which case," I observed, a bit befuddled, "would we then have to eat of the fruit of the tree of knowledge again to fall back into the state of innocence?"

"Undoubtedly," he replied; "which will be the last chapter of the history of the world."

"On the Theater of Marionettes," Heinrich von Kleist

On this remarkable account, humanity is an awkward absurdity as compared to the infinite grace of an unself-conscious plant. And yet humanity is redeemed by the possibility that it is in fact a point of transit on the way to something else, something infinitely better.

After a promisingly ingenious career, Kleist committed suicide in 1811 at the age of 34; what a disjunction between the life and the work. And yet the fact that any thumbnail sketch of him mentions the nature of his demise speaks volumes about the unique place of psychiatry. Whether a genius dies of leukemia, congestive heart failure, or tuberculosis we really couldn't care less. But suicide bespeaks far more than mere failure of the flesh, it suggests a moral claim, and a moral act with profound social implications. Just as social withdrawal implies a rejection of others, so suicide implies...a murdering of the human race. Killing oneself makes the rest of the human world disappear from consciousness too. That is why we view the suicide not only with pity, but also with consternation.

(It has been a fine day actually; this post just happened to strike me).