Abstract
This book deals with the historical examination of psychiatric symptoms from 1800 to 1950. The author posits that the contemporary challenges faced by psychiatry, including epistemological, theoretical and nosological crises, may stem from the difficulty in precisely defining what a psychiatric symptom is. Demazeux explores this issue through the perspective of successive generations of clinicians, who have embraced three distinct conceptions of psychiatric symptoms: as subjects open to interpretation, as clues (or evidence) of an underlying pathology, or as quantifiable elements. These varying conceptions played a pivotal role in shaping what Demazeux refers to as an ‘appareil sémiologique’ (Chapter V), contributing to the establishment of an ideal of objectivity within the field of psychiatry.
This is a skilfully crafted book that straddles the realms of clinical science, philosophy of science, and conceptual history. It provides a succinct and readily comprehensible presentation enriched with interesting metaphors. Although, at times, these metaphors can lean towards rhetorical persuasion, they draw a compelling parallel between clinicians and detectives, both engaged in the pursuit of critical clues, as well as between clinicians and photographers, both striving to capture the evolving objectivity of their respective realities.
The book seems to uphold rigorous scientific standards by maintaining historical accuracy regarding the emergence of an eclectic approach to psychiatry in the early nineteenth century, which harmoniously blends influences from phenomenology, psychoanalysis and Kraepelinian medicine. Based on these intertwined influences, the book predominantly delves into the evolving institutional role of psychiatric clinicians, who act as intermediaries between patients (expressing symptoms) and the realm of symptomatology (used for deciphering these symptoms). Within the underlying narrative of this historical account, three primary theses emerge.
The first of these pertains to three successive conceptions of what a symptom represented in the history of clinical psychiatry. Initially, the symptom was ‘literalized’, meaning it was perceived as an element to be interpreted, carrying inherent meaning. Subsequently, it was described as a ‘clue’ to an underlying pathology, a conception that found expression through the study of language, semiotics and linguistics within an indiciary paradigm. Finally, the symptom became something to be quantified, akin to the probabilities used in detective novels to solve a mystery. These three positions on the symptom may have contributed to the creation of an ‘appareil sémiologique’, which is the second discussed in the book. An appareil sémiologique refers to a method of observation composed of a set of symptoms, based on a specific practice, a distinct technical vocabulary, a particular descriptive style, and a shared set of values. The formation of any appareil sémiologique would be made necessary by the ideal of objectivity supported by psychiatry. Faced with imprecisions, subjectivity, ambivalence, contingencies, and inherent fluctuations in psychiatric clinical practice, conceiving such a structured appareil allowed clinicians to dispel the belief that a purely objective gaze can be cast on clinical questions.
This belief in a ‘purely clinical’ perspective leads to the third main thesis identified in the book. The ideal of objectivity in psychiatry has been analysed by clinical psychiatrists through the lens of the ‘three crises of clinical objectification’ that the symptom has undergone. The first crisis is the crisis of the scenography of psychiatry, which turns psychiatry into a ‘spectacle’, embodied by master clinicians such as Charcot. The second crisis is about the clinicians’ dialogue, which traditionally should eliminate the subjective experience embedded in their language. The third crisis is the crisis of simulation, requiring a rethinking of the conditions for guaranteeing valid clinical observation. It is through these three crises that a conception of clinical practice is said to have led to the ‘eclipse of the symptom by quantity’ as we know it today.
The significance of this book lies in its deconstruction of two myths circulating in psychiatric epistemology, which have been unearthed through this historical attempt to postulate the three theses and to define what is a symptom – ultimately conceived as a clue guiding us from observed effects to hidden causes, much like the ‘holes in the snow’ that hunters follow. The first myth refers to the autonomy of clinical practice, which implies that symptom collection can exist independently of any aetiological considerations or nosological frameworks. The second myth, referring to ‘disease-as-text’, suggests that symptoms appear as isolated letters in a decipherable text. The meaning of a symptom is, in fact, determined by its place within a theoretical system.
Certainly, these epistemological arguments resonate with several challenges and issues raised by contemporary clinicians, such as the notion of quantifiability, classification coding, and the integration of psychiatry into the realm of science. However, they also provide a rather sombre historical perspective on the position of clinicians and symptoms within the discipline. Amid these epistemological, theoretical and nosological crises, clinicians seem to overlook certain aspects that have propelled – or at the very least sustained – psychiatry: their collective commitment to a unified community centred around the concept of symptoms, e.g. conceived as a boundary object (Star and Griesemer, 1989), or the multitude of promises they embraced to maintain faith in their practice. Furthermore, the book approaches symptoms through the clinician’s perspective. However, various historical studies (e.g. Jan Goldstein’s work) have shown that institutional, political and judicial forces wielded significant influence over clinical practice (Goldstein, 2002). Therefore, engaging in discussions about such strong theses on psychiatric practice would require the incorporation of these broader issues. This, in turn, would necessitate a complementary examination encompassing other countries and archives.