Psychiatry, DSM-V, and Japan

Hi all,

It’s been some time since I’ve updated.  I recently had to prepare for the conference, and I’ve been going through draft after draft of my personal statement for med school applications.  The work, I think, is paying off, but it has been a lot of work.  I submit my med school application within the next couple of weeks.

I would like to make a new post about something, something that has been important area of study for me for several years now.  I recently presented at a History of Medicine conference at Berkeley, and I put together the following paper for that.

I did not finish my presentation; my mouth ran dry within the first 15 seconds, and I had to run off to get water.  Also, unlike previous conferences, I went through the paper slowly and emphatically.  This means that I got through a lot less material than I normally would.  I prefer this, as I think it greatly improves the presentation quality.  But it has its drawbacks.

So, with minor modifications, I am attaching only the fragment that I completed in presenting.  The entire presentation, and the argument when put clearly, runs through so many twists and turns that it is impossible to fit it into such a small space of a 20 minute presentation.  I furthermore recognize how much I need to read the more modern, more theoretical historians of psychiatry, like Robert Castel, and others, like Deleuze and Guittari.

If you like what you see, check again every once in a while for the next year or so.  I will continue to post on this subject sporadically.


The use of DSM since DSM-III is ubiquitous in psychiatric research and practice: it is used for every research study submitted to the FDA to prove drug efficacy for registration; a diagnosis is applied to every patient in order to receive third party reimbursement through insurance, Medicare, or Medicaid; almost all patients come to understand themselves as having a DSM diagnosed disorder.

On the one hand, there is a corpus of research produced by the use of post-DSM-III nosology that is regarded as path-breaking and important–neuroscientific, epidemiological, molecular genetic. On the other, there is the ever-present caveat: are not the many persistent blind spots, perplexities, and limits in psychiatric research produced by the very categories that make it possible? This reflexivity is markedly present in the Research Agenda for DSM-V: “The limitations in the current diagnostic paradigm suggest that research exclusively focused on refining the DSM-defined syndromes may never be successful in uncovering their underlying etiologies. For that to happen, an as yet unknown paradigm shift may need to occur.” Nancy Andreasen–who was a core member of the initial 9-person DSM-III Task Force and Chair of the Schizophrenia Work Group for DSM-IV, wrote in 2007: “DSM diagnoses have given researchers a common nomenclature—but probably the wrong one. Although creating standardized diagnoses that would facilitate research was a major goal, DSM diagnoses are not useful for research because of their lack of validity.”  Andreasen received the National Medal of Science from Clinton in 2000.  She is not a crank.

I could go on for at least an hour with citations of the top guys in psychiatry who say these sorts of things.  The question is, then, how did DSM come about if it’s so poorly regarded by the top researchers in the field?

The immediate historical event that marks the background of practice at the psychiatric hospital as it exists today–and really, psychiatric services at large–is deinstitutionalization. Deinstitutionalization is generally defined as the movement of care for mentally ill from being confined in psychiatric hospitals, to outside of psychiatric hospitals, in outpatient care, prisons, nursing homes, marginal living conditions, the streets, etc. As you know, by the end of the around the time of the French revolution in the West (the years vary by country), the mentally ill had undergone a change in status during what Foucault called the great confinement. The rationale for this was that, by the patient’s being isolated from the community, in a specially created therapeutic environment, the patient could recover and be re-instated as a sane, rational member of the community. Therapeutic optimism was high; the practice was considered an apogee of civilized and humane practice, a capstone of Enlightenment.

In the 1950s and 1960s, this view was completely reversed. What was considered the hallmark of civilized society became the hallmark of its barbarity in a profound reversal.

What caused deinstitutionalization?

The view in psychiatry, among those not so familiar with the history or sociology of deinstitutionalization, the triumphalist view of the psychiatrists, is that the hospitals were emptied by the rise of the new psychopharmacology, the neuroleptics, the antidepressants, lithium, and so on, in the 1950s through the 1980s. This, according to the view, still found in much of the literature, including Edward Shorter’s widely read 1997 history, was the miracle of magic bullet medicine.  This was however refuted as early as 1964.  A list of reasons for refusing this interpretation include the following. First, it has been repeatedly shown that there was no statistical correlation between the introduction of Thorazine and the discharge rate in the hospitals. Second, the rate of deinstitutionalization has been extremely variegated worldwide, even as the introduction of neuroleptics has been relatively consistent—centered around 1955.  Third, Japan is a completely different—and opposite story—with almost as many patients per capita in hospitals as the United States at its peak; Japan probably uses psychotropics even more extensively in its hospitals than does the US—presumably, to make the custodial aspects of its hospitals even more efficient.  Fourth, in the spirit of the 1960s, all institutions were under fire and subject to reforms.  In conclusion, I claim that deinstitutionalization was caused by a broader progressive social trend affecting Western societies in a variety of other profound ways.  The psychopharmacological revolution was related to a third factor, a more fundamental change in psychiatry, which was in turn related to a restructuring of society’s social relations.

The fundamental change in psychiatry, about which discussion of deinstitutionalization is, I’d venture to claim, a mystification, is as follows.  Where psychiatry as a marginal medical specialty relegated exclusively to the administration of total institutions in 1900, with a fraction of a percent of the population in hospitals, to today, where 1 in 5 people are undergoing some sort of psychiatric treatment at any given time.  In a word, it is not so much that psychiatric patients have been mainstreamed, but that the mainstream has become psychiatric patients.  The notion of deinstitutionalization around which this contemporary discourse operates conceals its dialectical opposite in material reality.

What is it that changed fundamentally in society that caused the change in psychiatry, of which I claim that discourse on deinstitutionalization was a mystification?  To answer this question, let’s backtrack.

Japan, as I have said, is the only country of its level of development not to have pursued deinstitutionalization.  This is the exceptional case that will show the reason for the rule.

When other countries were criticizing the asylum, Japan was doing much the same.  Except in the case of Japan, what was criticized as inhumane was the practice of families locking up their mentally ill members in special rooms and cells at home. In Japan in 1950, legislation was passed to transfer patients from home care to the hospital setting.  Keeping mentally ill family members at home was outlawed.  In 1965, and several times thereafter, more legislation was passed to deinstitutionalize these asylums in turn, to no effect: while the legislation is on the books, the situation does not change. Today, there are over 350,000 hospital beds in Japan, often built up in remote mountain regions, secluded from society—13.5 times the number per capita as the US and 4.5 times the UK. This is almost as many as in the US, per capita, in 1955.

I claim that this configuration of the Japanese is not unrelated to other aspects of Japanese society that are unusual by Western standards.  The Japanese solution to the problem of the severely mentally ill is not unrelated to the mandatory confinement of lepers until 1996 on secluded island colonies, the notorious Japanese xenophobia, the almost neo-feudalist structure of society, the rigidity and polarity of gender roles, the strict conformism.

To have eccentric schizophrenics pursuing distinguished scholarly careers—as we know that Elyn Saks did in the past few decades (get her book, called The Center Won’t Hold; you can also see her TED talk)—while in the midst of intermittent psychosis would be unthinkable in Japan.  To have psychiatric services that attempt to re-shape subjectivities that diverge in wide variations to a basic cultural standard (as in the West) is unthinkable.  Such a wide range of subjectivities simply does not exist; social and moral authorities remain strict and immanent within Japanese society, not outsourced, as it were, to technical interventions in psychiatry.  When one’s desires do not match propriety, as they did for Confucius in old age, one represses oneself.

Not so in the West.  If the 1960s was the time in our history where universality was extended to an unprecedented multiplicity of groups, then it was also a time when no longer could we as a society comfortably define abnormality as merely a kind of moral and cultural “Other.”  Moral authority, the authority of the Father, was completely rejected at this time—we now live, as some call it, in a post-Oedipal age.  Recall Foucault’s indictment of Pinel, Pinel the Father, near the end of the History of Madness. With the abolition of Pinel, or the Father in general— (Foucault, in a move characteristic of his critique of psychiatry standing for a critique of society, conflates the two) — as the nodal points of morality, you also lose a unary notion of madness, you lose anything apart from the notion of a pragmatic, technical intervention into the problem behaviors of another.  This relativization, this critique of psychiatry was more than a critique of psychiatry, but a critique, as the 1960s radicals had it, of bourgeois morality as such.

Because of this collapse of the buttressing of psychiatry from the point of view of a uniform, homogeneous societal moral authority, Western psychiatry took a sharp turn; DSM-III is the outcome of that. As psychiatrist David Healy notes, the 1973 extirpation of homosexuality from consideration as a category in DSM-III was the crowning symbolic event of this change. The shift from DSM-II in 1968 to DSM-III in 1980 was a shift from a relatively unified psychoanalytic theoreticization of disorders numbering in the dozens, to the technical, atheoretical description of diverse aberrant behavioral domains numbering in the hundreds. (Although DSM-III was a manual produced in the 80s, it had its origins in 1967, with the Feighner criteria–which had all the main features of DSM-III categories.)  We are instead now encouraged to see a patient as mentally ill more primarily for the purposes of that context-specific intervention that suits them, not in the psychoanalytic framework of DSM-II, which, though less specific than DSM-III still implies a lot more that is claimed hard and fast about human nature.  If old moralities are still present (the moralities of the Father, that target of Foucault), each is today split and scattered about in dozens of pragmatic pieces.

The talk ended here, as I had a couple minutes left, and the following would have delved into deeper socioeconomic explanations.  I’m satisfied, well enough, as is.  With the next post that I make on the subject, I will discuss these socioeconomic explanations, flesh out the history of Japan in further detail (as it is relevant to my argument), and deploy a range of other evidence and examples.  I’m, however, in no hurry, and, in the meantime, will be posting on other things.


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