Madness Studies

Obsession: A History, and: The Loss of Sadness: HowPsychiatry Transformed Normal Sorrow into Depressive Disorder,and: Shyness: How Normal Behavior Became a Sickness,and: Bipolar Expeditions: Mania and Depression in AmericanCulture (review)

Bradley Lewis

Literature and Medicine, Volume 28, Number 1, Spring 2009, pp. 152-171 (Review)

Published by The Johns Hopkins University PressDOI: 10.1353/lm.0.0035

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152 literature and medicine

Lennard Davis. Obsession: A History. chicago: university of chi-cago Press, 2009. cloth $27.50. 296 pp. Paperback, $17.00. e-Book, $5–$17.00.

Allan V. Horwitz and Jerome Wakefield. The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder. new York: Oxford university Press, 2007. 312 pp. clothbound, $31.95.

Christopher Lane. Shyness: How Normal Behavior Became a Sick-ness. new Haven, ct: Yale university Press, 2007. 272 pp. Paperback, $18.00.

Emily Martin. Bipolar Expeditions: Mania and Depression in American Culture. Princeton: Princeton university Press, 2007. 384 pp. Paperback or e-Book, $22.95.

madness Studies

in the last few years, several books from the humanities and social sciences have developed a new approach to psychiatric critique, among them: lennard davis’s Obsession: A History; allan V. Horwitz and Jerome Wakefield’s The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder; christopher lane’s Shyness: How Normal Behavior Became a Sickness; and emily martin’s Bipolar Expeditions: Mania and Depression in American Culture. together these books represent the maturation of new genre: “madness studies.” Previously, the most well-known form of psychiatric critique arose in the 1960s and was grouped under the term “anti-psychiatry.” Anti-psychiatry scholarship was short-lived and began to wane by the early eighties, but critique of psychiatry did not end with anti-psychiatry. at that time, “madness studies” also began to emerge—a form of critique that addresses the pharmaceutically supported turn toward science in psychiatry. the four texts reviewed here show that this genre is now poised to have a pivotal impact on the cultural understanding of psychiatry.

1980 is a useful date for understanding recent transitions in psychiatry and psychiatric critique. in 1980, the american Psychiatric association published the third edition of its Diagnostic and Statistical Manual (DSM-III). leading psychiatrists at the time hailed the DSM-III as a revolutionary book that would lead “to a massive reorganization

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and modernization of psychiatric diagnosis.”1 Historian edwin Shorter confirmed this theme years later when he argued that DSM-III signaled “a turning of the page on psychodynamics” and “a redirection of the discipline toward a scientific course.”2 this redirection brought a height-ened emphasis on biomedical models and pharmacological interventions. it shifted the psychiatric gaze, particularly in out-patient settings, from psychoanalytically-framed unconscious conflicts and childhood traumas to biomedically-framed broken brains and chemical imbalances.

1980 also heralded the decline of anti-psychiatry because the DSM-III crafted an effective counter-response to these critiques. anti-psychiatry writers, like thomas Szasz, david cooper, r. d. laing, thomas Scheff, and erving Goffman, were a diverse group, but one thing they had in common (or at least were interpreted as having in common) was a kind of ideological critique. anti-psychiatrists as a group argued that psychiatry was problematic because it represented a false conscious-ness (a socially constructed myth that distorted the truth of psychic life), and because it was an illegitimate form of social control and coercion. DSM-III pulled the sting out of both critiques by co-opting anti-psychiatry concerns and by providing a scientific solution. DSM-III developers agreed that the psychiatry of old was unreliable and could work as an illegitimate form of social control. thus, they offered the new DSM-III, which they claimed would fix these problems by devel-oping an operational, scientific classification system that assured both truth and legitimacy. through this tactic, DSM-III developers success-fully diverted anti-psychiatry arguments, and the energy of this wave of psychiatric critique began to dissipate.

the pharmaceutical industry played a pivotal role in this story, and 1980 marks a watershed moment for it, as well. marcia angell, former editor of the New England Journal of Medicine, points out that 1980 was the year the pharmaceutical industry transitioned from a good business to the colossus we know today. “From 1960 to 1980,” she writes, “prescription drug sales were fairly static . . . . but from 1980 to 2000, they tripled,” hitting over $200 billion by 2002.3 the primary strategy of pharmaceutical growth during these decades was aggres-sive promotion of “life-style” drugs for chronic conditions (arthritis, hypertension, cholesterol, diabetes, allergies, heartburn, and psychiatric conditions). The new scientific psychiatry fits perfectly into this business plan, and psychiatry’s shift toward a biomedical model was invaluable to Big Pharma’s fortunes. the pharmaceutical industry used a version of the DSM-III message to promote drug research and medical interven-tions into psychic life that effectively remade psychiatric training and


practice. Without a pharmaceutical push, it is unlikely DSM-III would have transformed the field as dramatically as it did.4

madness studies, which emerged after the DSM-III and after anti-psychiatry, uses two primary strategies for addressing the science question in psychiatry—critical empiricism and discourse critique—with most writers tending to use one strategy or the other (with some mix-ing along the way). The first strategy, critical empiricism, reveals how the new scientific psychiatry fails to live up to evidential scrutiny. these critiques are concerned about the quality of the new science in psychiatry, and they often find the scientific claims to be more about hype than evidence. critical empiricism, in short, examines instances when the new science in psychiatry is bad science.5 the second strategy, discourse critique, emerges out of the linguistic turn in the humani-ties and interpretive social sciences.6 these critiques do not directly challenge the science of psychiatry, but work from an understanding that all knowledge practices, including scientific ones, are only par-tially evocative of the real world. From this perspective, no discursive practice fully captures the rich complexity of the world or humans; each foregrounds some aspects of the real and downplays others. in addition, discourse critiques do not rely on a rigid binary between liberation and control because all discursive practices are seen as both enabling and constraining. aspects of social control and social liberation are present no matter which language of psychic life is used. despite this relative openness to different languages of psychiatry, discourse critique remains a critical approach that tends toward a democratic social critique. it focuses on the social relations and power dynam-ics of psychiatric knowledge production and application. Who gets to contribute to knowledge in psychiatry? And who gets to decide how it will be used?7

madness studies is a helpful label for this continuum of critical scholarship because the word “madness” is open-ended compared with the more sanitized and narrow terms “mental illness” or, worse, “brain disorders.” “Madness” evokes Foucault’s work in Madness and Civili-zation, which tracks historical shifts in the terms used to understand psychic differences and the divisions created by linguistic categories. For Foucault, “madness” speaks to the historical variability of what we now call psychiatric knowledge and practice and to the possibility that we might do things otherwise in the future. The term “madness” also facilitates a connection between academic critiques and the mad Pride movement of activists, artists, and intellectuals who have followed in the footsteps of Black Pride and Gay Pride to destabilize and reverse

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the binaries and hierarchies associated with mainstream psychiatry.8 mad Pride activists critique psychiatry’s heavy-handed pathologization and its use of forced treatment methods as forms of sanist oppression that too often ride on a logic similar to racism, sexism, and ableism. Finally, “madness” is often used by memoir writers to evoke aspects of psychic difference, suffering, and unusual states of consciousness that cannot be reached through a more scientific language.9

the four books reviewed here join a maturing body of academic work in madness studies that wrestles with, unpacks, and decodes the expert and scientific voices of today’s psychiatry. Each book establishes its own place on the continuum from critical empiricism to discourse critique.

Obsession

lennard davis’s Obsession: A History leans toward the discursive end of the spectrum. davis begins with a nimble discussion of the very idea of doing a history of disease as opposed to a more standard his-tory of medical discovery. He argues against a naïve realist perspective that takes DSM-III-style clinical categories as the truth about obsession, independent of cultural, historical, and social context. He emphasizes that the science of obsession, and clinical category-making in general, necessitates a linguistic practice, stating: “. . . the language we use to understand madness is itself a layered pentimento of concepts and terms that have arisen, been useful, become outmoded, and yet still persists [think “nervous breakdown”]. Since the words we use will predetermine the object of study, we have to be careful that when we speak of obsession, or madness, or other like terms, we understand that the objects so described through language may not correspond exactly to states of cognitive or emotional distress. although we are always looking at people, we describe what we see through words (24–5).

davis concludes that “thinking about obsession as simply a dis-ease is a mistake” (12). At the same time, however, and this point is equally important, davis’s discursive approach argues forcefully against an ideological perspective reminiscent of the earlier anti-psychiatry genre. With reference to Obsessive-compulsive disorder (Ocd), he states explicitly: “. . . i am not denying the existence of Ocd as a disease . . . . i have no doubt that Ocd is real to people suffering from it and real to doctors trying to help those people. i also have no doubt that the search for biological basis for Ocd is a real search


that aims to find specific brain functions, chemical interactions, and genetic locations that can help us understand how Ocd manifests it-self” (6–7). How can Davis keep this tension between the real and the constructed without collapsing his argument to one side of the binary or the other? He does it by recognizing that the social history of hu-man categories does not contradict the realness of those categories for lived experience and for cultural engagement with the material world. davis uses the example of money to make the point clearer. “money isn’t a naturally occurring thing. it’s a totally human-made invention, and yet it is real. its rules are socially constructed, and its effects can be radical. People without money suffer in a real way” (7).

davis goes further to situate this both/and perspective on obses-sion into a larger academic genre he calls “biocultures.” In a recent “Biocultures Manifesto,” he and co-author David B. Morris draw out similar arguments to make a larger point not just about psychiatry but also about biology and medicine more generally.10 From a biocultures perspective, whenever we attempt to understand and develop the dis-course of biology, we must always think about the cultural and the biological together. davis and morris group such academic work into the genre of “biocultures” to consolidate and validate the domain. Simi-lar to the recently emergent genre of “disability studies,” which Davis was also very much at the forefront of developing, once biocultures is seen as a larger academic movement, the individual work within this genre will have a larger impact. as davis and morris put it: “before disability studies became an accepted term, people working in a variety of allied fields and with a variety of impairments did not necessarily see any commonality in their various approaches. But with the advent of an umbrella term, a new and exciting synergy has come to pass. likewise with nanotechnology, feminist studies, or critical race theory. We are not necessarily nominalists, but we do believe in the power of a name to consolidate scattered research agendas and to generate change.”11 the same was true of anti-psychiatry, and it has the potential to be true for madness studies, which is a subset of biocultures. like biocultures, madness studies already has many individual practitioners and an increasingly rich history. the task at hand is to develop the domain and consolidate its key insights so that the individual works create a collective larger than the sum of their parts.

certainly a key insight present in all the books reviewed here involves the transience of mental illness categories. davis’s history of obsession is a good example as he shows how “. . . a number of symptoms and behaviors [that] come and go, [can] be attached and

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detached, to the constellation of obsessive behaviors” (211). Mental illness categories notoriously defy our attempts to pin them down to a single description or a single causal story. davis helps us see this by chart-ing transitions of mental categories going back to the renaissance and the notion that madness was caused by demonic possession. demonic definitions were gradually displaced by medical definitions through a series of complex cultural and conceptual transformations. For this to occur, demonology had to be disconnected from physical illness, mental states had to be distinguished from physical states, and the notion of a “nervous system” had to be developed over a previous humoral theory. Finally, “a notion of partial insanity had to be developed that would allow for one to be ‘crazy’ while at the same time being aware of being ‘crazy’” (32). This final step allowed a “democratization of madness,” which “extend[s] madness from a small number of people to a rather large number” (47). “In so doing,” says Davis, “the sever-ity of the disease is moderated, a trendy medical aspect is put in the mix, and a social and intellectual cachet is added” (47).

By the eighteenth and nineteenth centuries, these shifts create a contradictory european cultural space where obsessions and compul-sions can move to the foreground as prime examples of mental “ill-ness” and, at the same time, as core values for culture. The positive cultural value of obsession develops because this was the same period in which the sciences, the professions, and industry were emerging in europe—activities that put a premium on the values of attention, focus, precision, repetition, specialization, standardization, and mechanization (13, 79). Such preoccupation was desirable and, at the same time, dangerous, “both as a dreaded disease and as a noble and necessary endeavor” (3). While some expressions of obsession were celebrated, the dangers were gradually taken over by the emerging medical profes-sion. Still today, davis points out, “we live in a culture that wants its love affairs obsessive, its artists obsessed, its genius fixated, its music driven, its athletes devoted” (4).

davis’s historical analysis raises the question of agency. Who or what is the primary actor (or actors) in this transition? Is it the real? is it powerful elites? Or is it a heterogeneous struggle of many actors (in-cluding the real itself)? If we take the first option and see the primary actor as the real, we tend to look at science as a story of progress occasionally thwarted by wrong turns, mistakes, and irrational exu-berance (as in “bad science”). If we take the second option, we tend toward an ideological critique (as in anti-psychiatry). if we take the third option, we are in the land of a discursive critique where specific


actors are many, and it is hard to articulate with clarity which is the most influential. This latter choice fits best with Davis’s reading of his-tory. He charts the long transition from the renaissance to the present mostly in the passive voice. things change, history moves on, we look at the world and ourselves differently. “There was no necessity,” Davis writes, “that these features would coalesce into a culture of obsession, but there seems to be a trend, a river made up of converging streams, a zeitgeist within a culture” that is responsible for things working out as they did (79). the agent of change is not clearly stated. the reasons things change have to do with multiple competing influences that work themselves out in a particular way. it could have worked out otherwise, and for most of his history of cultural change, davis is not so much interested in charting which agents were most influential, but in describing the eventual result of their influence.

davis’s use of the passive voice starts to change, however, when he moves into contemporary times. the recent transformations in psy-chiatry toward biopsychiatry (with the concomitant increase in psychiatric diagnosis and treatment) have happened so fast compared with the long history davis charts up to then that they beg for a causal explanation. to get a sense of how fast and how dramatically things are changing in psychiatry, consider that in the 1970s, estimates of Ocd were from .05 percent to .005 percent of the u.S. population, and researchers considered OCD “one of the rarest forms of mental disorders” (209). Just a few decades later, Ocd moved from a rare condition to a quite common and routinely diagnosed disorder. researchers currently estimate that two to three percent of the population will have Ocd during their lifetimes, and recent attempts to describe an Ocd spectrum put its incidence as high as ten percent. this “ridiculously dramatic upsurge . . . anywhere from a forty-fold and a six-hundred-fold increase” calls out for an explanation that contains actors (217).

as davis goes through the most likely suspects, he quickly puts to rest the idea that the scientific discovery of a hidden epidemic of disease is the causal agent. davis does this through a close reading of the evidence for biological disease cited in the Ocd literature. in this section, he moves away from a discursive approach and adopts many of the tools of bad science critique. Davis finds the evidence for a hidden epidemic so full of holes that it “would not stand up to scrutiny in a freshman history class” (213). He then asks: If the scientific progress is not the agent of recent historical change, or at least not the only agent of change, what else could be driving it? Davis goes through several other possibilities, such as media exposure, diagnostic bracket creep,

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pharmaceutical marketing, and self help books. In the end, he finds all of these contributors relevant, and he does not privilege any particular causal agent. He argues that you can only understand a disease like Ocd with a “thoroughgoing knowledge of the social, cultural, histori-cal, anthropological, and political view of that entity” (235).

the next three examples of madness studies under review share davis’s concern about the dramatic upsurge of psychiatric diagnosing and medicating during the last thirty to forty years. unlike davis’s Obsession, two of these books, Allan Horwitz and Jerome Wakefield’s The Loss of Sadness and christopher lane’s Shyness, point at very spe-cific causal agents. Horwitz and Wakefield’s subtitle, How Psychiatry Transformed Normal Sorrow into Depressive Disorder, and lane’s subtitle, How Normal Behavior Became a Sickness, make it clear that these books will not only chart a cultural history, they will take a position on how and why cultural change occurred.

The Loss of Sadness

in The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder, Horowitz and Wakefield begin their discussion of contemporary psychiatric cultural change by comparing two very different interpretations of Willy loman, the lead character in arthur miller’s 1949 play, Death of a Salesman. loman suffers in the play from a deep sadness: he feels worthless, hopeless, and believes his life is a failure. By the end of the play, he kills himself in an automobile crash. How should we make sense of Loman’s sadness? The director of a recent revival of the play sought help by sending the script to two psychiatrists. Both psychiatrists “diagnosed loman as having a depressive disorder” (3). The psychiatrists argued that Loman’s prob-lems are symptomatic of his underlying depressive pathology. He has a medical illness caused by a brain disorder. arthur miller objected to this interpretation: “Willy loman is not a depressive . . . . He is weighed down by life. there are social reasons for why he is where he is” (4). He conceived of Loman as struggling with understandable sadness resulting from a difficult life situation. After all, “[he] never accomplishes very much. He has heavy debts, his health is failing, he is barely able to continue working at his job as a traveling salesmen, and his sons despise him. When he finally is fired from his job, he is forced to admit to himself that he is a failure” (3).

Horowitz and Wakefield show that these two perspectives represent a cultural shift. When the play first came out, Miller’s interpretation


was culturally dominant. audiences saw loman’s depression as com-ing from the sharp contrast between his beliefs and reality. He had entered his sixties still holding onto a fervent belief in the american dream that hard work would lead to success. even his suicide was understandable as a desperate attempt to get “his family some money from an insurance settlement” (3). The play struck a chord with so many people because loman’s troubles embodied “the everyman in american life who embraced the goal of achieving great wealth but found himself destroyed by it” (3). From this perspective, Loman’s difficulties are not pathological, but normal, even healthy, signals that something is wrong and needs attention. What needs attention is not loman’s broken brain, but his idealization of the american dream. taking away loman’s struggles without tending to their actual causes would be a mistake, and an important emotional signal would be lost, not unlike when an automobile driver fails to heed the low fuel light and ends up running out of gas.

Horowitz and Wakefield argue that: “[the] response of the psy-chiatrists is as exemplary of our time as loman was of his. What our culture once viewed as a reaction to failed hopes and aspirations it now regards as a psychiatric illness. the transformation of Willy lo-man from a social to a psychiatric casualty represents a fundamental change in the way we view the nature of sadness” (4). But Horowitz and Wakefield do not stop with charting this cultural shift or outlining some of the possible factors that contributed to it. they are willing to pass judgment about what has happened, to explain why it hap-pened, and to outline what should be done about it. to Horowitz and Wakefield, the approach represented by today’s psychiatrists is deeply problematic.

they use a bad science critique of contemporary psychiatry, arguing that it has seriously misread the data on depression. Psychiatric science is flawed because the DSM diagnostic criteria for major depression fail to distinguish adequately between two types of depression: “normal sadness” and “melancholia” (6).12 these diagnoses share similar symp-toms of “sadness, insomnia, social withdrawal, loss of appetite, lack of interest in usual activities, and so on” (6). However, for Horowitz and Wakefield, there is a clear distinction between them in that normal sadness has an environmental cause and depressive disorder does not. the authors argue that normal sadness is associated with environmental traumas of “loss or other painful circumstances that seemed to be the obvious causes of distress” (6). This kind of sadness is common, and it is not pathological. It is a normal reaction to difficult situations. People

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in such circumstances may need support and help with coping, but they are not ill. By contrast, melancholia, or “depressive disorder,” is depression without a cause. there appears to be no appropriate reason for the sadness, and the causes are thus considered to be internal to the individual. it is a rare medical disorder associated with individual dysfunction or defect that tends to be long-lasting and recurrent.

the failure to adequately separate normal sadness from depressive disorders has, according to Horowitz and Wakefield, led to an epidemic of depressive disorders. like the rapid increase in Ocd prevalence discussed by davis, the rise in depressive disorders is startling. Out-patient diagnosis of depression has grown by “300% between 1987 and 1997,” and increased diagnosis has led to an explosion of antidepres-sant treatments (4). they point out that, “antidepressant medications, such as Prozac, Paxil, Zoloft, and effexor, are now among the largest selling prescription drugs of any sort. their use among adults nearly tripled between 1988 and 2000” (4). All of this has so effectively slid into our daily life that Horowitz and Wakefield believe we now live in an “age of depressive psychiatric disorder” (3). Medication has become so pervasive that in any given month “10% of women and 4% of men now use these drugs” (4). In addition, “During the 1990s, spending for antidepressants increased by 600% in the united States, exceeding $7 billion annually by the year 2000” (4–5).

Horowitz and Wakefield argue that, because of the DSM’s faulty definitions, the bulk of the increased diagnosis of depression is misdi-agnosis. they take us into the technical details of the DSM to show how the diagnostic inflation occurred. In general, they find no real problem with the diagnostic criteria for major depression, but they see a glaring error with regard to DSM exclusion criteria. the DSM explains that even if people do fit the criteria for Major Depression the diagnosis should not be given if the symptoms can be “better ac-counted for by Bereavement, i.e., after the loss of a loved one” (8). Horowitz and Wakefield support the Bereavement exclusion but find it to be strangely narrow. the logic of the Bereavement exclusion shows how intense experiences of sadness can be normal and appropriate, but Bereavement only scratches the surface of negative life events that can make the symptoms of depression understandable and appropriate. the authors give additional examples of romantic betrayal, failure at work or school, life-threatening illness in oneself or in a loved one, endur-ing humiliation after disgraceful behavior, etc. “Such reactions,” they write, “even when quite intense due to the severity of the experience, are surely part of normal human nature” (9).


Horowitz and Wakefield explain how DSM-III framers fell into bad science because they were working in a time of crisis for psychiatry. The effectiveness of anti-psychiatry critiques, the field’s theoretical frag-mentation, and its diagnostic unreliability rendered “psychiatry’s claim to scientific status” at risk (100). Even worse, psychiatry’s “legitimacy as a medical field seemed in jeopardy” (100). DSM-III responded to the perceived crisis with a “largely decontextualized, symptom-based criteria . . . [designed] to develop a common language for psychiatrists . . . and to bolster the scientific credentials of the profession” (103). But the framers of the manual became so keen on resolving the predicament that they went too far. “In the urgent quest for reliability,” they “inad-vertently” misread the data on depression (103). In other words, through the irrational exuberance of the moment, DSM-III framers mistakenly failed to develop a diagnostic system that sufficiently recognized normal sadness or included appropriate contextual exclusions. Once this flawed diagnostic system spread to the community, psychiatry unintentionally initiated a “massive pathologization of normal sadness” (103).

the solution to this bad science mistake is to correct it with good science. the details and applications are complicated, but the basics of a good science of depression are clear for Horowitz and Wakefield. Over-diagnosis can be corrected by expanding the next DSM’s exclusion criteria beyond Bereavement to include a variety of contextual exclu-sions and expanding the DSM’s additional codes for “nondisordered but treatable” conditions. Such changes would allow much more “watchful waiting” in clinical settings, rather than the immediate prescription of medication (223).

When Horowitz and Wakefield discuss how hard it will be to change the science of depression in this direction, they move from a bad science critique to a discourse critique. in the last few pages of the book, Horowitz and Wakefield ask the question: “If the flaws in cur-rent diagnostic criteria are as compellingly clear as we argue that they are, then why haven’t they been changed, or why can’t they easily be changed?” (212). Their answer moves away from the earlier language of bad science to a language of social dynamics, particularly concerning “power relations within society and among its institutions” (213). The authors find that there are powerful constituencies for keeping a highly pathological approach to depression that minimizes the possibilities of normal sadness. these include psychiatrists, mental health workers, researchers, the World Health Organization, the national alliance of Mental Illness, pharmaceutical companies, and afflicted individuals who have internalized the pathological definitions. Horowitz and Wakefield

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only briefly review these groups, and they make no attempt to sort out their relative contribution to current discursive norms. they also make no attempt to consider strategies of social struggle that might be used in the face of these powerful constituencies. Horowitz and Wakefield seem fatalistic on this point because they see these constitu-encies as so entrenched that they will be difficult, if not impossible, to change. it appears to them that we may have to accept that the unfortunate outcome of the diagnostic entrenchment they describe is a lasting cultural “transformation of sadness into depressive disorder,” which has the lamentable effects of “shrinking the range of normal emotions” and “expanding pathology to ever-widening realms of hu-man experience” (217).

Shyness

christopher lane’s Shyness: How Normal Behavior Became a Sickness picks up the story at this very point and lasers in on the social power relations that Horowitz and Wakefield barely touch. Like so many others in madness studies, lane is concerned about the remarkable upsurge in psychiatric diagnosing and medicating over the last thirty years. His primary concern in this book is anxiety disorders, and he starts with a discussion of his mother, whom he describes as a pain-fully shy person. lane remembers that, throughout his mother’s life, some thought her to be awkward and unconventional, but she was never considered mentally ill. in just one generation, however, things have changed dramatically. “Shyness isn’t just shyness any more. it’s a disease” (1). Shyness has been recategorized with names like “Social Anxiety Disorder” and “Avoidant Personality Disorder” that are said to trouble millions of persons. One study put the “combined percent-age for any anxiety disorder at a staggering 28.8 [percent]” (213). the Harvard Review of Psychiatry dubbed social phobia the “third-most-common psychiatric disorder” (5), and a representative of the national institute of mental Health has called excessive shyness “one of the worst neglected disorders of our time” (6). In addition, since the 1990s, “the Food and drug administration agreed that powerful psychotropic drugs,” such as Paxil, Prozac, and Zoloft, are “suitable ways of treating these conditions,” with the result that millions are now being medically treated for shyness (1).

Like Horowitz and Wakefield, Lane argues that this rapid upsurge in diagnosis and treatment is the result of bad science, but the problem


for lane is less about scientists making mistakes or being irrationally exuberant, and more about a concerted effort from a variety of social actors to turn “shyness, self-consciousness, and even introspection into major psychiatric disorders” (10). Lane bases many of his conclusions on investigative research in the american Psychiatric association’s “vast archive of unpublished and hitherto unavailable letters, transcripts, and memoranda,” along with probing interviews with “the leading psychia-trists in question” (6). This investigative perspective brings Lane into a rarely seen world of psychiatric research where “deep-seated conflicts of interests, buried research data, professional ambition, and fierce mar-keting campaigns together have grossly exaggerated social phobia and avoidant personality disorder, turning behavior we recently accepted, and even welcomed, into pathologies needing medical treatment” (8).

lane’s investigation is particularly helpful in articulating the connection between the internal process of psychiatric science and the external influence of the pharmaceutical industry. Indeed, Lane uncovers a psychiatric science where what is “internal” and what is “external” become so intertwined that using separate terminology is misleading. He opens a world where it seems better to use a combined term like “corporate science” to describe this kind of knowledge making.13 the details of lane’s research support what others have argued about how robert Spitzer led the initial DSM-III committee. 14 lane shows how the committee obtained consensus for its categorical distinctions primarily through excluding those who disagreed. this exclusionary practice was less about bad science than bad politics. the DSM-III committee was unwilling to hear from most DSM-III stakeholders outside a biopsychiatric frame, but it was very willing to hear from its pharmaceutical supporters. For example, at a conference sponsored by upjohn during the lead up to DSM-III, upjohn’s chief executive unashamedly explained, “look, there are three reasons why upjohn is here taking an interest in these diagnoses. The first is money. The second is money. And the third is money” (74).

And what money was this executive talking about? It was the money associated with Xanax, a new “me-too” benzodiazapine that upjohn was trying to distinguish from the many benzodiazapines al-ready on the market. at the time, the data was very sketchy for the creation of panic disorders, and leading psychiatrists disagreed with the plan of “separating panic syndromes from anxiety syndromes” (74). But, as one participant in the debates put it, Spitzer cared less about the facts and more about responding to powerful constituencies. ac-cording to lane, Spitzer seemed to be saying “never mind about the

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pros and cons intellectually . . . . Don’t confuse me with the data” (74). although Spitzer denies vehemently that the committee was in-fluenced by the pharmaceutical companies, he concedes matter-of-factly that the outcome of the committee’s category decisions was partly “a function of ‘Do you have a treatment?’” (75). He continues: “If you have a treatment you are more interested in getting the category in . . . . if you have no treatment for it, there’s not as much pressure to put the thing in” (75).

lane’s research also supports former British Medical Journal editor richard Smith’s general conclusion that medical research has become an arm of pharmaceutical marketing.15 and it is certainly clear from lane’s investigation that the pharmaceutical industry has an overlapping two-part strategy that can be dubbed “disease mongering.”16 The first part of the strategy is getting the science to support your treatment, and the second is aggressively marketing the disease (which will simultaneously market your product). Often the treatment product involved in disease mongering is a “me-too” knock-off of a previous drug, since “me-too” drugs are cheaper to develop than genuinely new ones.

lane does an excellent job of working through how SmithKline used the technique of simultaneously developing a treatment, Paxil, and promoting the disease of shyness, now relabeled by DSM as “Social Anxiety Disorder.” SmithKline promoted Paxil, its “me-too” SSRI, over its competitors by hiring an advertising firm to plaster the nation with the slogan “Imagine Being Allergic to People” (122–3). As in similar campaigns, SmithKline not only used direct-to-consumer advertising, but it also used time-honored third-man public relations techniques to promote the disease through indirect strategies that make the pharmaceutical companies’ promotional interests harder to spot—news articles, news videos, celebrity endorsements, product placements, phony websites, pseudo-grassroots support groups, psychiatric thought lead-ers, review articles in scientific journals, and favorable ghost-managed scientific evidence (just to name a few). SmithKline’s marketing plan was so successful that it generated “1.1 billion media impressions” in the first year, and the advertising firm won an award from The Public relations Society of america (125–6).

Lane’s “unavoidable conclusion” from his research is that, despite pockets of resistance here and there, corporate science in psychiatry is creating a fundamental shift in culture (8). like Horowitz and Wake-field’s work on sadness, Lane sees the story of anxiety as part of a larger strategy to medicalize emotion. the result of this process for lane is that: “We’ve narrowed healthy behavior so dramatically that


our quirks and eccentricities—the normal emotional range of adolescence and adulthood—have become problems we fear and expect drugs to fix. We are no longer citizens justifiably concerned about our world, who sometimes need to be alone. Our afflictions are chronic anxiety, personality or mood disorders; our solitude is a marker for mild psy-chosis; our dissent, a symptom of Oppositional Defiant Disorder; our worries, chemical imbalances that drugs must cure” (8).

Bipolar Expeditions

emily martin’s Bipolar Expeditions: Mania and Depression in Ameri-can Culture takes the cultural transition charted by davis, lane, and Horowitz and Wakefield as her starting point. She provides a very brief history of manic depression that culminates with DSM-III renaming the condition “Bipolar Disorder.” Like the other authors, she charts the recent success of biopsychiatry to define “mood disorders” as brain disorders involving receptors and neurotransmitters that are amenable to pharmacological management. However, martin is less interested in this history or the causal forces that may be driving it than she is in the lived-experience of the current terminology. She does not take sides on what has happened or call the medicalization of moods “bad science.” Nor does she take sides on whether “social causes of mood disorders are more important than biological ones” (29). Instead, Mar-tin spends her time doing ethnographic work in psychiatric settings and self-help support groups where “the belief that the brain and its genetic determinants lie behind mental disorders like manic depression was simply assumed” (11). In these settings, cultural aspects of brain science and biopsychiatry are rarely questioned and “people usually greeted new evidence that bipolar disorder is a ‘brain disease’ as welcome news” (11). Martin’s key finding in her ethnographic explora-tions is that there are multiple contradictions and ambiguities in the way biopsychiatry operates in daily life. the uptake of biopsychiatry into culture is hardly linear or unidimensional. complications abound. accordingly, martin spends the bulk of the book charting the many ironies and paradoxes of Bipolar disorder and biopsychiatry as lived-experience and cultural practice.

One of the many ambiguities of biopsychiatric culture is that people given the label of Bipolar disorder are not simply irrational people (as the diagnosis might suggest). they are a complicated mix-ture of rational and irrational with considerable capacity to perform

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one or the other depending on the setting. individuals may accept the diagnosis and the disease model implications that they have a broken brain, or chemical imbalance, that is outside of their control, but the way they live the label is hardly as clear-cut as the model would suggest. Martin explains that “being manic does not fit easily at either end of opposites like conscious/unconscious; habitual/novel; compelled/chosen; or innate/learned” (83). In this way, “every mania has its own style” and this style escapes the narrow confines of pa-thology and medical diagnosis (84).

martin also discovers that the support groups that people living under the diagnosis form and join are not primarily about disease, dysfunction, or even conversations about extreme states of conscious-ness. instead, support groups are multifaceted human spaces that al-low people to create new social connections, solve practical problems, tolerate diversity of background and experience, and take care of each other in times of need. Furthermore, and perhaps most important, the experience of mania is far from a simple cultural negative. Similar to davis’s discussion of the contradictory readings of obsession as both a disease and a desired trait, mania, too, can be seen as a resource in multiple cultural spaces. it can be positively linked with sociability, creativity, vitality, business success, and even functioning markets. as martin explains, these positive cultural valuations of mania are not lost on those who have been labeled Bipolar: “So compellingly desirable are the depictions of mania in support groups and conventions that being manic depressive almost parts company with pathology” (207–8).

The value of mania is also not lost on “normal” people. In the current cultural climate, those who are not diagnosed (or at least not yet) are incited to monitor their moods because the market environment of relentless productivity and hyperactive consumption needs manic energy. indeed, manic intensity can become a neoliberal social expec-tation and the creative intensity of mania can veer from pathology to conformism. the result is that everyone is provoked into manic swings of emotion and it becomes “our individual responsibility” to monitor our moods in detail. in addition, it has increasingly become a norm to use psychopharmaceuticals to enhance socially required manic intensity. this leaves everyone, diagnosed or not, with a forever “watchful eye for the changing possibilities of pharmaceutical optimization” (277).

martin hopes that the many contradictions of lived-experience and cultural practice she uncovers will help rehabilitate the word “crazy,” just as the word “madness” is recognized as beneficial in madness studies. Martin explains the value of “crazy” this way:


looking optimistically to the future, i would like to make use of the word “crazy,” because its dictionary meanings include: insane, full of cracks or flaws (desirable in certain kinds of pottery glaze), being out of the ordinary, distracted with desire or excite-ment, and passionately preoccupied. The word “gay” went from a shameful whisper to a proud shout, as homosexual identity became less stigmatized. i would hope that, somewhat differently, the word “crazy” could come to mark the ways that everyone belongs in one way or another—even if only in their dreams—to the realm of the irrational. (xix)

As with the term “madness,” Martin is not saying in this passage that everyone is alike or denying that some of us are disabled by our craziness. But she is saying that there could be a much more “friendly recognition across the sometimes arbitrary line between rational and irrational acts and thoughts, not just in the corporate world but in all walks of life” (xix). In that spirit, Martin donates the proceeds of her book to the Live Crazy Network (www.livecrazy.org), a non-profit net-work for those interested in helping each other navigate the “swings” and arrows of life in a manic depressive time.

conclusion

martin’s optimistic hopes echo davis’s concluding remarks with regard to obsession and speak to the potential of madness studies as a genre. davis, too, argues that charting the many causal forces that have come together in a biocultural blend to produce ever-changing disease categories does not mean that suffering is not real. He argues just the opposite; disease history in madness studies helps us see how the very practice of categorizing and intervening in psychic difference can worsen suffering. the question becomes: How much do the oth-ering practices of current disease models contribute to suffering, and how much do they blind us to important variables of suffering? All too often, disease models can translate illness in a way that is too heavy-handed, too caught up in the forces of transnational capital, and too caught up in a sanist logic.

Davis argues that the binary between “illness” and “disease” begins to collapse through the process of detailed disease biography because the more fully we understand disease biographies, the more possible it will be to “bring together the patient’s experience with the clinician’s

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expertise” and “unpack the very nature of experience on both sides of the equation” (239). In the case of obsession, when we recognize that all of us in contemporary culture are constantly incited toward obsession and that OCD is a “subcategory of what we all do,” we can break down the isolation that so many people “with” the disease feel (243). these people, writes davis, “may have dipped into the stream a little too deeply, but we’re all wading through this difficult current” (243). davis extends this argument beyond the individual to society:

can we think of a changed society with a biocultural consciousness as one that has a new kind of control over disease? In this case, the disease isn’t controlled through cure and eradication, although these goals are always worthy ones, but through a systematic rethinking of the way disease is structured and positioned in our society. if knowledge is power, then knowledge of disease amounts to a kind of power over that disease. (239)

For davis, humanities scholarship, biocultural research, and disease biography can be therapeutic. not just for individuals, but for societ-ies as well.

these are invaluable ideas, especially for a society like ours, wracked by a health care crisis that will not resolve through a strategy of cure and eradication alone. these ideas and the books that explore them point to the importance of madness studies and biocultures, not just in the esoteric halls of humanities and social science departments, but in the real worlds of human difference and suffering. they point to an understanding of medical categorizing not simply as a medical practice but also as a cultural dividing practice. and they point to the complicated ways that such dividing practices are part of contemporary culture’s ongoing difficulties living justly with difference and find-ing limits to transnational corporate power. We should applaud this scholarship. moving on these topics is a major demand on thinking in our current era.

—Bradley lewisGallatin School of individualized Study

new York university


nOteS

1. andreason, The Broken Brain, 155. 2. Shorter, A History of Psychiatry, 302.3. angell, The Truth About Drug Companies, 3.4. For the role of the pharmaceutical industry see: rose, “neurochemical

Selves”; Healy, “Shaping the Intimate”; Sismondo, “Pharmaceutical Maneuvers”; and Matheson, “Corporate Science.” For a discussion of the insurance industry’s use of managed care and its role in biopsychiatry, see luhrmann, Of Two Minds, particularly her chapter, “The Crisis of Managed Care.”

5. examples include: Kirk and Kutchin’s The Selling of DSM; Peter Breggin’s Brain-Disabling Treatments in Psychiatry; and david Healy’s The Anti-Depressant Era.

6. lewis, Moving Beyond Prozac, DSM, and the New Psychiatry.7. examples include: Susan Bordo’s Unbearable Weight, Jonathan metzl’s Prozac

on the Couch, Jackie Orr’s Panic Diaries, and Joseph dumit’s Picturing Personhood.8. Lewis, “A Mad Fight.”9. See Perring, “‘Madness’ and ‘Brain Disorders,’” for a very helpful review

of the term “madness” and its use in memoir writing. 10. Davis and Morris, “Biocultures Manifesto.”11. ibid., 413.12. Horowitz and Wakefield use “DSM-III” when referring specifically to this

manual. they use “DSM” in a more generalized way to refer to DSM-III and the revisions that came after it. i follow their usage for the remainder of this essay.

13. Matheson, “Corporate Science.” 14. See lewis, Moving Beyond Prozac, 97–120.15. Smith, “Medical Journals.”16. Moynihan, Heath, and Henry, “Selling Sickness.”

BiBliOGraPHY

andreasen, nancy c. The Broken Brain: The Biological Revolution in Psychiatry. new York: Harper & row, 1984.

angell, marcia. The Truth About Drug Companies: How They Deceive Us and What to Do About It. new York: random House, 2005.

Bordo, Susan. Unbearable Weight: Feminism, Western Culture, and the Body. Berkeley: university of california Press, 1993.

Breggin, Peter r. Brain-Disabling Treatments in Psychiatry: Drugs, Electroshock, and the Psychopharmaceutical Complex, 2nd ed. new York: Springer, 2008.

Davis, Lennard J. and David B. Morris, “Biocultures Manifesto.” New Literary History 38, no. 3 (2007): 411–18.

dumit, Joseph. Picturing Personhood: Brain Scans and Biomedical Identity. Princeton: Princeton university Press, 2004.

Healy, David. “Shaping the Intimate: Influences on the Experience of Everyday Nerves.” Social Studies of Science 34, no. 2 (2004): 219–45.

———. The Anti-Depressant Era. cambridge, ma: Harvard university Press, 1997.Kirk, Stuart a. and Herb Kutchin. The Selling of DSM: The Rhetoric of Science in

Psychiatry. new York: aldine de Gruyter, 1992.lewis, Bradley e. Moving Beyond Prozac, DSM, and the New Psychiatry: Birth of

Postpsychiatry. ann arbor: michigan university Press, 2006.———. “A Mad Fight: Psychiatry and Disability Activism,” in The Disability Studies

Reader, 2nd ed. edited by lennard J. davis, 339–55. new York: routledge, 2006.

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luhrmann, t. m. Of Two Minds: An Anthropologist Looks at American Psychiatry. new York: Vintage Books, 2000.

Matheson, Alastair. “Corporate Science and the Husbandry of Scientific and Medical Knowledge by the Pharmaceutical Industry.” Biosocieties 3, no. 4 (december 2008): 355–82.

metzl, Jonathan. Prozac on the Couch: Prescribing Gender in the Era of Wonder Drugs. durham: duke university Press, 2003.

moynihan, ray, iona Heath, and david Henry. “Selling Sickness: the Pharmaceutical Industry and Disease Mongering.” British Medical Journal 324, no. 7342 (april 13, 2002): 886–91.

Perring, Christian. “‘Madness’ and ‘Brain Disorders’: Stigma and Language.” In Configuring Madness: Representation, Context and Meaning. edited by Kimberly White. in press.

Orr, Jackie. Panic Diaries: A Genealogy of Panic Disorders. durham, nc: duke uni-versity Press, 2006.

Rose, Nikolas. “Neurochemical Selves.” Society 41, no.1 (november 2003): 46–59.Shorter, edward. A History of Psychiatry: From the Era of the Asylum to the Age of

Prozac. new York: John Wiley and Sons, 1997. Sismondo, Sergio. “Pharmaceutical Maneuvers.” Social Studies of Science 34, no. 2

(2004): 149–59.Smith, richard. “medical Journals are an extension of the marketing arm of Phar-

maceutical Companies.” PLOS Medicine 2, no. 5 (2005): e138 http://www.plosmedicine.org/article/info%3adoi%2F10.1371%2Fjournal.pmed.0020138. (ac-cessed February 20, 2010).

Documents

Madness Studies