The Volokh Conspiracy

The Center Cannot Hold:

That is the title of a new book by Elyn R. Saks, law professor at USC, and it seems now a psychology and psychiatry professor there as well.

I was very taken by the gripping narrative of this book. The subtitle is My Journey Through Madness. Here is one short review. Here is an excerpt.

Oliver Sacks liked it too. He called it "The most lucid and hopeful memoir of living with schizophrenia I have ever read."

Duncan Frissell (mail):
But what is this:
Though mental illness has become increasingly common in the population..., the stigma attached to it has not abated very much over the years. And this is even truer of thought disorders such as schizophrenia than of the so-called mood disorders such as depression and manic-depression. For a person of status like Elyn to write a memoir of schizophrenia is accordingly to take a risk


Why is it that maladaptive behavior has become more common. Is it perhaps because we have become more accepting of it? If misbehavior is discouraged by social approbation, you get less of it. Surprise, surprise.

If proprietary communities could throw the tattooed, the insane, the sloppy dressers into the 'outer dark' (consider the neo-victorian clan in 'The Diamond Age'), things would be much nicer all around.
9.8.2007 3:48pm
dearieme:
Or the classic remedy; send them to the colonies.
9.8.2007 5:59pm
Eliza:
If proprietary communities could throw the tattooed, the insane, the sloppy dressers into the 'outer dark' (consider the neo-victorian clan in 'The Diamond Age'), things would be much nicer all around.

Hmm. How about people with either a very wide nasty streak or an ugly, tasteless sense of humor?
9.8.2007 8:05pm
Greedy Clerk (mail):
Wow, Duncan, I hope you never have to deal with mental illness. What a disgusting comment.
9.9.2007 12:04am
American Psikhushka (mail) (www):
Duncan Frissel-

Why is it that maladaptive behavior has become more common. Is it perhaps because we have become more accepting of it? If misbehavior is discouraged by social approbation, you get less of it. Surprise, surprise.

Or how about this - the symptoms checklists are drafted so broadly that nearly everyone could be diagnosed with something if the mental health professional were creative or determined enough. Since these diagnoses are so easily manipulated they are useful for all kinds of agendas: Rent-seeking for the mental health professionals. Rent-seeking for the pharmaceutical industry. Rent-seeking for the self-help book industry. An easy way to discredit and marginalize agitators, eccentrics, dissidents, protesters, etc. and violate their rights. Etc, etc, etc...
9.9.2007 7:07am
Dr. Weevil (mail) (www):
Years ago I read somewhere that when a major disaster (enemy air raids, category-5 hurricane, 6.0+ earthquake) strikes, most mental patients, even those severely afflicted, will pull together and act like healthy humans to work together and save lives until the crisis is over, when they go back to their psychoses. That doesn't mean that they aren't really sick, but it does suggest that as life in general gets easier for most people -- less like a world war or the aftermath of an earthquake or hurricane --, there may be more mental illness, or more mental illness 'on display', as it were.
9.9.2007 11:16am
Dave Hardy (mail) (www):
The excerpt from the book illustrates the "loose association" of schizophrenia. Normally, we might reason A combined with B to cause C, for example.


But as her mind is functioning, it's statement about word A. But word B rhymes with A. And word B has other meanings, so turn to discussing them.

Dr Weevil: I read somewhere (forget just where) that London under the Blitz experienced its lowest recorded rates for insanity, committments for alcoholism, street crime, and suicide. People responded positively to an external threat. Suicides found life was worth living if someone was trying to kill you.

This is further proof of the perversity of mankind (grin). It pretty well trashed the prewar bombing theories, advanced by a Douhet, that a civilian populace, if sufficiently bombed, would suffer a sort of common nervous breakdown and be unable to resist.
9.9.2007 3:14pm
Dave Hardy (mail) (www):
Here's an interesting page on mental health trends and definitions. Basically, comparisons over time are hard to make because the definitions have been tightened up appreciably. But there doesn't appear much basis for saying that diagnoses as mentally ill are increasing, as the article suggests.

Basically, it suggests that about 20% of Americans would be "diagnosable," but only 9% of those would be thought to have a situation that impacts their life, 5% would have something that could be called severe, and about half of those really severe. Bear in mind that the above include depression, obsessive-compulsive (which I suspect most attorneys are; it's a field where if you don't have something of that streak you get into trouble). etc..

A friend once observed that most psychiatric texts say good things about obsessive-compulsive. Likely because you have to be something of an OC to go to the work of writing a psychiatric textbook, and authors are apt to see the good side of a trait that they have!
9.9.2007 3:26pm
Ben P (mail):

That doesn't mean that they aren't really sick, but it does suggest that as life in general gets easier for most people -- less like a world war or the aftermath of an earthquake or hurricane --, there may be more mental illness, or more mental illness 'on display', as it were.



I'm by no means qualified to make a statement like this, but it seems to me that if mental illness is a defect of the "rational mind" as it were, when people are put in stressful situations where the rational mind takes a lower position to more basic survival concerns, you would naturally see less mental illness appear.


Or, more probably the converse is true. The more time people with a mental illness are able to spend doing something other than surviving, the more likely it is the illness will manifest itself.
9.9.2007 8:54pm
Clayton E. Cramer (mail) (www):
As I point out here:


I'm reading E. Fuller Torrey and Judy Miller's The Invisible Plague: The Rise of Mental Illness from 1750 to the Present (New Brunswick, N.J.: Rutgers University Press, 2001), at the moment. The book presents a lot of what at first glance seems pretty persuasive statistical evidence that there was a quite dramatic rise in psychosis in England &Wales, Ireland, Canada's Atlantic provinces, and the United States from the 17th through the 20th centuries. There is pretty reliable statistical information from mental hospital admissions and government censuses from the start of the 19th century, and Torrey and Fuller make use of detailed records of doctors and hospitals from the beginning of the seventeenth century to corroborate other data from the 17th and 18th centuries that isn't quite as comprehensive.

What makes this so interesting is that Torrey is a big proponent of the biochemical/genetic origin of schizophrenia. All that I have read leads me to agree. Yet he admits that this dramatic rise in the rates raises interesting questions. I've previously mentioned that some studies show a strong correlation between growing up in an urban area, and developing schizophrenia. The Invisible Plague mentions a variety of studies that show the same, and psychiatrists were noticing the strong correlations between urbanization and psychosis as early as the 1920s. If urbanization explains the rise in psychosis over the last few centuries, then it would suggest that genetics could only be one factor--perhaps a predisposing factor. There would have to be some other specifically urban factor that actuates mental illness.

and:

Torrey and Miller's book has a discussion at 298-299 that does a nice job of summarizing the evidence for a dramatic increase in mental illness in the United States over a century. They point to the 1880 census of insane persons, and something called the Epidemilogic Catchment Area study "carried out from 1980 to 1985 in New Haven, Baltimore, Durham, St. Louis, and Los Angeles." The ECA study found that 2.2 per cent of adults were diagnosed with schizophrenia and bipolar disorder.

The 1880 census of the insane attempted to identify all mentally ill people--not just those in mental hospitals and workhouses (where a lot of the less dangerous mentally ill were kept in many states). The methodologies aren't quite equivalent, as Torrey and Miller point out.


The 1980s study included some individuals who would not have been counted as insane in 1880 (bipolar disorder II, depression with hypomania), and the 1880 study counted some individuals as insane who would not have been included in the ECA study (e.g., epilepsy with insanity).



Yet the 1880 census of the insane found 0.18 per cent of the total population was insane. Presumably after adjusting for the diagnostic category differences, Torrey and Miller assert that the ECA data shows almost a ninefold increase in insanity.

They also point to the data on those receiving SSI or SSDI payments for "mental disorders other than mental retardation." In 1997, that was 2.5 million people--or 0.94 per cent of the population--more than five times the results of the 1880 census of the insane. It is true that there are people collecting SSI and SSDI who are not insane or even disabled (I've known a few over the years), but I would expect that this is probably roughly balanced by the number of Americans who are so severely mentally ill that they aren't collecting SSI or SSDI.
9.9.2007 10:43pm
Dilan Esper (mail) (www):
Wow. I went to USC Law School, and never had a class with Professor Saks, but I knew a lot of people who did take her classes, and she had a fine reputation-- she was considered one of the smartest members of the faculty. I certainly heard her speak at various functions during my time there.

I never had any idea.
9.9.2007 10:43pm
Al Maviva (mail) (www):
Why is it that maladaptive behavior has become more common. Is it perhaps because we have become more accepting of it? If misbehavior is discouraged by social approbation, you get less of it.

Gee Duncan, it seems both you and Greedy Clerk are a bit remiss in your studies of Marcuse and Gramsci. The Frankfurt School neo-Marxists argued that revolution would be brought about not by some mythical uprising of the workers, but by the steady efforts to champion all transgressions of existing social norms, whether the norms were aesthetic, legal, or social-behavioral. The theory goes that if you could manage to infiltrate a fair number of revolutionaries into the institutions of the dominant social order, they could erode the existing order by privileging the prostitute over the priest, the crook over the cop, the madman over the physiatrist, and that this erosion would eventually overthrow the hegemony of the existing social order. The existing social order destroyed, utopia would shortly thereafter ensue.

This is part of the reason why there was a strange right/left handholding in the 1980's when the mentally ill in the United States were deinstitutionalized. Those on the right hated the idea of psychiatric confinement for individual liberty reasons, and seeing the 'psychiatric hospitalization' visited on anti-communist dissenters in the Soviet Union, not to mention the fiscal issues by maintaining state care for hundreds of thousands, perhaps at times millions of individuals. The notion of deeming political opponents mentally ill has bothered conservatives since the label has so frequently been applied to them by their own opponents. See the recent Berkeley studies for an example. Meanwhile, some of those on the left saw similar individual liberty issues, while others saw the revolutionary possibilities of making mental illness the new norm, or at least a competing norm. Obviously, not all on the left are followers of Gramsci or Marcuse and I would wager that fewer than 5 or 10 percent of people who would describe themselves as 'progressive' or leftists have ever read any significant amount of either philosopher's works, but their works are the animating spirit behind left-liberal/progressive politics in the same way that Hayek's work animates the small government conservatives' movement.

John Fonte wrote a useful summary of this phenomenon within the context of the culture wars for the Hoover Institute several years ago. Eric Raymond also wrote an interesting piece on undoing Gramscian Damage. Clerk, you in particular will probably think Fonte and Raymond are both morons, but you'd do yourself a favor to read some Gramsci, at least if you want to know what First Things underlay your progressive politics. I wouldn't bother with Marcuse unless you're having trouble sleeping.
9.10.2007 8:08am
Eliza:
Clayton, have you read Pete Early's book Crazy: A Father's Search Through America's Mental Health Madness? I read it a couple of weeks ago and remarked how similar his views on mental health law are to your own.
9.10.2007 8:25pm
nonny:
Weevil, (and Dave, in your response to the good doctor), your comments sound very similar to the writings of Walker Percy (whether you heard them from him or from one of the sources he studied, or something influenced by or totally unrelated to him, I have no idea), whom I increasingly have come to view as something of a modern prophet (or perhaps it is that I am young enough not to know and to be surprised that things were pretty much the same and have not much changed since the mid part of the century from which he drew :)).

as to the subject of the post, I read the excerpt, very interesting. May give it a look, thanks Tyler.
9.11.2007 12:24am

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