I was just thinking about this case on awakening this morning, after briefly discussing it with a friend who is not only a professor of criminology but who also has a master’s degree in psychology and who once worked in a psychiatric hospital. She knows my transgender daughter who lives with schizophrenia. The biggest thing that strikes me about our criminal justice system is how absurd its decisions can seem, and that is particularly the case when psychiatric illness is on trial. I think too many jurors are all too certain in their beliefs about evil. As Bertrand Russell once said or wrote, “the trouble is that in the modern world the stupid are cocksure while the intelligent are full of doubt.” (Note: Not long ago, I read an article by an author who advised using the word “cruelty” instead of “evil” to unload the metaphysical baggage.)
Bertrand Russell, like Robert Sapolsky today, was a believer in hard determinism which argues that we have no free will and are therefore not responsible for our own actions. Daniel Dennett, a compatibilist, believed in a softer determinism that leaves room for free will, as he defined it—an ability to learn society’s values and responsibilities so that we apply them as ethical agents, calling upon those learned behaviors stored in our adult brains. Dennett’s thinking about this appeals to me in an age of cold techno-libertarianism. And, I think Sadler’s challenge as described here is based on a belief that society is good and it can do better. It is an “ethics of knowledge” about human behavior that he seems to propose along the lines of what Jacques Monod wrote generally in a closing chapter of his classic book, Chance And Necessity, which was surely influenced by his friend Albert Camus. Now, I better go read Sadler’s book.
Not that the DSM is any paragon of compassion, but it would help if the next revision restored postpartum psychosis to its former status as a standalone diagnosis like schizophrenia and bipolar disorder so that our imperfect and retributive justice system might at least learn to take PP seriously.
When science had already existed, Aquinas wrote in the 1200s on the various degrees of passion clouding the intellect or the will. And without any special Abrahamic influence, in the Nichomachean Ethics Aristotle said the drives are uniquely "outside the governance of the intellect."
So I don't think Sadler is historically accurate that Abrahamic folk influence is the only source of retribution ideas, nor that retribution isn't compatible with science. The dichotomy is common sensical, (and Aristotelian/hylomorphic) and it is no different than the dichotomy of medical and psychosomatic illness.
The "folk metaphysics" of justice might be influenced by bloodlust, but I think it is also just irreducibly from giving basic respect to one another and to a criminal. We must give one another the right to be bad. But the "scientific worldview" may be used to oppress: “Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive... those who torment us for our own good will torment us without end for they do so with the approval of their own conscience... to be "cured" against one's will and cured of states which we may not regard as disease is to be put on a level of those who have not yet reached the age of reason or those who never will; to be classed with infants, imbeciles, and domestic animals.” -C.S. Lewis
Sadler isn’t claiming that Abrahamic folk influence is the only source of retribution ideas. He also doesn’t say that retribution in all forms or contexts is incompatible with science. In many everyday contexts, we rely on our reactive attitudes and will continue to. However, whether a legal system based on an accurate understanding of human behavior should prioritize retribution is a different sort of question. Recommend reading Sadler’s book or my Q&A with him for more details of his thinking.
Thanks, yeah, I figured i’m just guessing so I’m oversimplifying his views.
My first job was at the Hawaii State Hospital, and the schizophrenics were getting assaulted every week by the malingering criminals.
So I permanently separated them into two separate areas, and OSHA came after me. It was at heart a philosophical debate; they told me we are only a “hospital”, but I countered that many of the criminals were still awaiting an exam, and that my dichotomy of the two was an effort to protect my psychotic patients.
It so happens my first job was at a state hospital as well 😊 this dynamic is familiar indeed. And of course, any rational appraisal of the situation has to recognize the difference between psychosis and malingering, and why a different response is needed. One thing I’ll say is that my time at the state hospital gave me an appreciation of the humanity of criminal offenders, and I’ve become wary of how so many of us see violators of the law as sub-human. I believe that we cannot improve the care of people with mental illness in places like the state hospital and jails/prison unless we also approach individuals who violate law with some degree of grace. That of course doesn’t mean that we shouldn’t hold them accountable or don’t call out malingering etc but it means seeing and respecting their humanity, even when they have been convicted of violent crimes.
It seems that science (rather than metaphysics) says what is subhuman: Darwin said criminals are a throwback to other species, his cousin Galton said criminals had skull patterns of monkeys. They framed it as eugenicist compassion. Dont you think science and medicine are in just as much a danger as religion or folk ideas (perhaps more) of using pity as a cover for power?
There is certainly that danger but this sort of eugenicist compassion is exactly what I’m opposed to and see it as contradictory to recognizing the humanity of criminals.
Much was made of the question about whether she was within the postpartum period, which seems a moot point in my opinion. She was a mother of 3 young children who suffered against her brain’s inner workings. Why is that not sufficient reason to call her “insane”? As her attorney argued, how could a person who adored her children and then killed them be sane? Perhaps I am naive—there are certainly psychopaths who are capable of this, but there’s no evidence of psychopathy. I hope she is found NGRI. She has and will continue to suffer enough.
I agree that mad-vs-bad is absurd at its base, but personal responsibility is problematic in a far more pervasive way.
I referred to this recently in discussing commercial "brain hacking": the way junk food hacks our appetite system, social media hacks our attentional system, and AI chatbots hack our emotional attachment system. This trend increasingly calls into question what it means to make rational, independent decisions in the marketplace. Do buying decisions still reflect personal responsibility when companies exploit long-evolved deep brain structures that our cerebral cortices can't reliably overcome?
Our economic, democratic, and legal systems all assume rational actors. Yet we concede that in none of these domains are we fully rational. How we deal with this reality, as exemplified by the crude black-or-white insanity defense, reveals our awkward discomfort.
It seems apropos that (at least to my knowledge) one of the central purposes of the first judicial codices was the ending of blood feuds and cycles of revenge. „An eye for an eye“ was not meant to stoke bloodlust, but to limit the retribution taken to a proportionate amount. The fact that modern systems of justice are still retribution based, could therefore be seen as pragmatic. Not because retribution really offers any value to the afflicted, but to prevent people from taking justice in to their own hands.
So last week I believe there were TWO cases of "spree" infanticide (I am coining this term to describe a mother's killing more than one of her children at once) resolved in NEW YORK CITY ALONE. Neither received any publicity I appreciated beyond their respective articles in the NYTimes. Both mothers had a history of psychological troubles before the murders. Neither had any secondary gain. Both mothers concealed the killings,, in fact in one case the childrens' bodies were not discovered for hours after the murders. One mother from the Bronx was convicted of murder. The other from Brooklyn was acquitted. The articles did not explain the different outcomes, or how the prosecutors arrived at their respective management of the cases (in the acquittal case I believe the prosecutor collaborated to keep the case from trial). Also, an editorial in the NYTimes in the past week described HUNDREDS of women in California prisons for infanticide.
I describe the above just to point out that there is a stereotyped crime that the justice system is "handling" in a potentially random or unfair way, which isn't suprising given the way the criminal justice system handles mental illness generally. The Lindsay Clancy case upset me for a variety of reasons, probably the largest was the Reddington's defense strategy of mocking and criticizing the care Clancy received before the tragic infanticide. Nevertheless I see the basic unfairness and arbitrariness of how we approach these tragic crimes, and I am sympathetic to advocates for better support for struggling mothers.
I was also upset with the experts including poor Dr Tufts who was a particular target of Reddington's scorn, and Dr Mack, both of whom I felt did an exceptionally poor job of representing psychiatry to the jury, explaining its assumptions and contradictions, and its clinical challenges. I fantasized that had Reddington been bullying me on the witness stand I would not have let him off so easy, but then again, I have 25 years of experience versus Dr Tufts' one month. Dr Mack was an expert hired by the prosecution and since he wants more work, he presumably wanted to present their approach in the most favorable light, plus who knows what actual clinical experience he has treating psychotic disorders or even severe mental illness, in adults?
I deal with the contradictions the experts didn't explain to the jury, every day. What is the definition of "psychosis"? Did anyone notice that the experts kept using different definitions? One moment it was a severe psychiatric illness that deserved its own DSM code, another it was the symptom of hallucinations or delusions, and maybe thought disorder.
I'll tell you this, had Karl Jaspers himself been testifying he would not have been able to reconcile the facts with the law, which by the way Dr Mack seriously mischaracterized ("M'Naghten rule"). Of course no one cared because he was not a lawyer. But it deserved greater elaboration.
I am not critical of the jury or the hold-out juror. Juries are sequestered and supposed to be independent. The results are not assumed to be mechanistic or pre-determined. The idea that the juror "refused to follow the law" is absurd. In fact, "jury nullification" is a well known property of the jury system.
Sadler's attacking of “Abrahamic metaphysical assumptions" needs to be distinguished from Aristotle - which is the backbone of our civilization. Get rid of Aristotle, and you may as well throw away systems biology too. I will not endorse a book when it results in us being forced to pretend that the history of knowledge and wisdom began on the day of David Hume's graduation. That we're now also positing "folk psychology" in the debate, when Matt Ratcliffe has demonstrated "the folk do not speak folk psychology", that the word folk psychology was invented to solve an inconsequential debate about eliminitivism in the ivory tower, and was never employed by "the folk" in the first place, underscores how circular this "blame game" really is.
For thousands of years, irrespective of one's faith, we determined one's character by way of how a person in-forms the body and allocates and organizes various habits and virtues; these are freely-willed acts despite being constituted by the environment. It never began with the assumption of "failed mechanisms that caused themselves". Hence, the reason stigma exists about various preventable diseases and mental disorders is because we already know, a-priori, that "preventable" implies free-will and self-causation. A melancholic person is shunned in every known culture because melancholia is a freely-willed activity. There is not a thing called "melancholia" that a person "catches" like a common cold - it was the outcome of poor decisions and an infatuation with creativity (e.g. Radden).
I also find it problematic how tone-deaf the media is about how polypharmacy contributed to the cases outcomes.
Henry Maudsley wrote that “epileptic insanity” is the most dangerous and violent of all the forms (Maudsley, 1874, as cited in Shorter, 2015). It’s interesting to me that in Teicher et al. (1990) on fluoxetine and suicide one patient had temporal lobe epilepsy and two more had epileptiform discharges (Teicher et al., 1990, 1991). A coincidence perhaps, but while we lament the absence of postpartum psychosis from the DSM, we might also do well to ask what happened to Henry Maudsley's most dangerous psychosis? People will give easy answers to such things, but the emergence and disappearance of psychiatric diseases doesn't get much attention. What became of hebephrenia? (Shorter, 2015).
On postpartum psychosis, Brockington had a lot of other cases of brief insanity that he included as possible relatives, cortisone psychosis, it too fluctuates and can produce the most extraordinary acts of violence (Brockington, 2014, 2017).
Edward Shorter had the idea that when we describe our symptoms we reach for a socially accepted vocabulary (Shorter, 1992). Quite aside from whether or not it’s socially acceptable, it’s hard to describe symptoms we don’t have a word for. Command hallucinations might just be the socially acceptable word, also the legally acceptable one.
How does one explain planning though? Well, some of Teicher’s patients underwent personality changes that mimicked BPD (Teicher et al., 1993), and before anyone dismisses that too quickly, does anyone care to recall what Kramer said the effects of Prozac were? Striking personality changes (Kramer, 1993). Where else do we see striking personality changes? Well, Geschwind might say you might see such changes in the 3 patients with abnormal EEGs that Teicher and Cole described (Waxman & Geschwind, 1975; Teicher et al., 1991).
That’s one idea, I think it’s a lot better than psychosis. Brockington thinks postpartum psychosis is bipolar or that it’s the same physiological weakness, his theory is a third pole, that he calls the cycloid pole, certain precipitants, childbirth, fever, toxic substances push towards the cycloid pole (Brockington, 2014, 2017). It’s an interesting idea, but then why didn’t we notice this more in the heyday of imipramine, I could list a dozen big names but perhaps the most extraordinary example is Mogens Schou who wrote a paper suggesting imipramine might be a mood stabiliser in the 60s (Schou, 1963). So there is something we’re missing, Ross Baldessarini said in lecture that it’s the “mixed ones who switch”; in the same lecture he opined that he sometimes wondered if it’s even the same illness (see also Baldessarini et al., 2013). I asked Ross about this once and he said the clinical point is lithium still works in most cases. Lindsay was in a technical "mixed state" by definition but was it a "bipolar mixed state"?
So it’s not quite postpartum psychosis, not enough confusion, it’s not clear that it’s bipolar 1 because surely we would notice, it’s not epilepsy because where are the seizures. What is it?
The premenstrual tension cases are interesting, it might seem silly but since I found it, I just can’t get over Robert T. Frank giving a verbatim description of a symptom that I know some experts have called “virtually pathognomonic” of akathisia in a paper on premenstrual tension (Frank, 1931). You could say it’s a coincidence, which does seem more likely, but it’s the sort of sentence that haunts you.
Here is one of the cortisone cases:
"Mrs. L. H., a housewife aged 53, complained of arthritis of 25 years’ duration, beginning in the feet and gradually involving all other joints. The joints had become swollen and red in the early stages, but not recently. There had been marked difficulty in walking because of the pain. ...
Course in Hospital. The patient remained in the hospital from Aug. 25 to Sept. 23, 1950. She received during that time a total of 2.625 Gm. of cortisone. By September 3 there had been marked improvement. ... The patient had begun walking. On the date of her discharge, September 23, the patient’s sedimentation rate was 21 mm., she was walking about, happy, and was sent to her family physician with instructions that she receive 100 mg. of cortisone biweekly.
She was in excellent spirits when she returned home, although nervous, restless and sleeping poorly. Her husband and daughter, on returning from a fire down the street, found her “wild eyed, hysterical and screaming that ‘the devil was after her.’” The pastor was called, and he succeeded in quieting her. One of us saw her at 10:30 p.m., and sedation was prescribed. She said she needed a doctor for her soul, not a medical doctor. The family was advised never to leave her alone, but on the same day, while her daughter was dressing, the patient cut her throat with a straight-edged razor and died within five minutes."
Borman & Schmallenberg, 1951)
References
Baldessarini, R. J., Faedda, G. L., Offidani, E., Vázquez, G. H., Marangoni, C., Serra, G., & Tondo, L. (2013). Antidepressant-associated mood-switching and transition from unipolar major depression to bipolar disorder: A review. Journal of Affective Disorders, 148(1), 129-135. https://doi.org/10.1016/j.jad.2012.10.033
Kramer, P. D. (1993). Listening to Prozac: A psychiatrist explores antidepressant drugs and the remaking of the self. Viking.
Schou, M. (1963). Normothymotics, “mood-normalizers”: Are lithium and the imipramine drugs specific for affective disorders? British Journal of Psychiatry, 109, 803-809. https://doi.org/10.1192/bjp.109.463.803
Shorter, E. (1992). From paralysis to fatigue: A history of psychosomatic illness in the modern era. Free Press.
Shorter, E. (2015). What psychiatry left out of the DSM-5: Historical mental disorders today. Routledge.
Teicher, M. H., Glod, C. A., & Cole, J. O. (1990). Emergence of intense suicidal preoccupation during fluoxetine treatment. American Journal of Psychiatry, 147(2), 207-210. https://doi.org/10.1176/ajp.147.2.207
Teicher, M. H., Glod, C. A., & Cole, J. O. (1991). Dr. Teicher and associates reply. American Journal of Psychiatry, 148(8), 1091. https://doi.org/10.1176/ajp.148.8.1091
I was just thinking about this case on awakening this morning, after briefly discussing it with a friend who is not only a professor of criminology but who also has a master’s degree in psychology and who once worked in a psychiatric hospital. She knows my transgender daughter who lives with schizophrenia. The biggest thing that strikes me about our criminal justice system is how absurd its decisions can seem, and that is particularly the case when psychiatric illness is on trial. I think too many jurors are all too certain in their beliefs about evil. As Bertrand Russell once said or wrote, “the trouble is that in the modern world the stupid are cocksure while the intelligent are full of doubt.” (Note: Not long ago, I read an article by an author who advised using the word “cruelty” instead of “evil” to unload the metaphysical baggage.)
Bertrand Russell, like Robert Sapolsky today, was a believer in hard determinism which argues that we have no free will and are therefore not responsible for our own actions. Daniel Dennett, a compatibilist, believed in a softer determinism that leaves room for free will, as he defined it—an ability to learn society’s values and responsibilities so that we apply them as ethical agents, calling upon those learned behaviors stored in our adult brains. Dennett’s thinking about this appeals to me in an age of cold techno-libertarianism. And, I think Sadler’s challenge as described here is based on a belief that society is good and it can do better. It is an “ethics of knowledge” about human behavior that he seems to propose along the lines of what Jacques Monod wrote generally in a closing chapter of his classic book, Chance And Necessity, which was surely influenced by his friend Albert Camus. Now, I better go read Sadler’s book.
Not that the DSM is any paragon of compassion, but it would help if the next revision restored postpartum psychosis to its former status as a standalone diagnosis like schizophrenia and bipolar disorder so that our imperfect and retributive justice system might at least learn to take PP seriously.
I have a post coming on the issue of including PP in DSM!
I’ll be eager to read it!
When science had already existed, Aquinas wrote in the 1200s on the various degrees of passion clouding the intellect or the will. And without any special Abrahamic influence, in the Nichomachean Ethics Aristotle said the drives are uniquely "outside the governance of the intellect."
So I don't think Sadler is historically accurate that Abrahamic folk influence is the only source of retribution ideas, nor that retribution isn't compatible with science. The dichotomy is common sensical, (and Aristotelian/hylomorphic) and it is no different than the dichotomy of medical and psychosomatic illness.
The "folk metaphysics" of justice might be influenced by bloodlust, but I think it is also just irreducibly from giving basic respect to one another and to a criminal. We must give one another the right to be bad. But the "scientific worldview" may be used to oppress: “Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive... those who torment us for our own good will torment us without end for they do so with the approval of their own conscience... to be "cured" against one's will and cured of states which we may not regard as disease is to be put on a level of those who have not yet reached the age of reason or those who never will; to be classed with infants, imbeciles, and domestic animals.” -C.S. Lewis
Sadler isn’t claiming that Abrahamic folk influence is the only source of retribution ideas. He also doesn’t say that retribution in all forms or contexts is incompatible with science. In many everyday contexts, we rely on our reactive attitudes and will continue to. However, whether a legal system based on an accurate understanding of human behavior should prioritize retribution is a different sort of question. Recommend reading Sadler’s book or my Q&A with him for more details of his thinking.
Thanks, yeah, I figured i’m just guessing so I’m oversimplifying his views.
My first job was at the Hawaii State Hospital, and the schizophrenics were getting assaulted every week by the malingering criminals.
So I permanently separated them into two separate areas, and OSHA came after me. It was at heart a philosophical debate; they told me we are only a “hospital”, but I countered that many of the criminals were still awaiting an exam, and that my dichotomy of the two was an effort to protect my psychotic patients.
It so happens my first job was at a state hospital as well 😊 this dynamic is familiar indeed. And of course, any rational appraisal of the situation has to recognize the difference between psychosis and malingering, and why a different response is needed. One thing I’ll say is that my time at the state hospital gave me an appreciation of the humanity of criminal offenders, and I’ve become wary of how so many of us see violators of the law as sub-human. I believe that we cannot improve the care of people with mental illness in places like the state hospital and jails/prison unless we also approach individuals who violate law with some degree of grace. That of course doesn’t mean that we shouldn’t hold them accountable or don’t call out malingering etc but it means seeing and respecting their humanity, even when they have been convicted of violent crimes.
It seems that science (rather than metaphysics) says what is subhuman: Darwin said criminals are a throwback to other species, his cousin Galton said criminals had skull patterns of monkeys. They framed it as eugenicist compassion. Dont you think science and medicine are in just as much a danger as religion or folk ideas (perhaps more) of using pity as a cover for power?
There is certainly that danger but this sort of eugenicist compassion is exactly what I’m opposed to and see it as contradictory to recognizing the humanity of criminals.
Great chatting Awais
I look forward to reading some of your old articles, as I’m relatively new to Substack
Much was made of the question about whether she was within the postpartum period, which seems a moot point in my opinion. She was a mother of 3 young children who suffered against her brain’s inner workings. Why is that not sufficient reason to call her “insane”? As her attorney argued, how could a person who adored her children and then killed them be sane? Perhaps I am naive—there are certainly psychopaths who are capable of this, but there’s no evidence of psychopathy. I hope she is found NGRI. She has and will continue to suffer enough.
I agree that mad-vs-bad is absurd at its base, but personal responsibility is problematic in a far more pervasive way.
I referred to this recently in discussing commercial "brain hacking": the way junk food hacks our appetite system, social media hacks our attentional system, and AI chatbots hack our emotional attachment system. This trend increasingly calls into question what it means to make rational, independent decisions in the marketplace. Do buying decisions still reflect personal responsibility when companies exploit long-evolved deep brain structures that our cerebral cortices can't reliably overcome?
Our economic, democratic, and legal systems all assume rational actors. Yet we concede that in none of these domains are we fully rational. How we deal with this reality, as exemplified by the crude black-or-white insanity defense, reveals our awkward discomfort.
https://stevenreidbord.substack.com/p/brain-hacking-a-threat-to-capitalism?r=346o1x
Rock on, Dr. Aftab!
beautifully written, Awais.
It seems apropos that (at least to my knowledge) one of the central purposes of the first judicial codices was the ending of blood feuds and cycles of revenge. „An eye for an eye“ was not meant to stoke bloodlust, but to limit the retribution taken to a proportionate amount. The fact that modern systems of justice are still retribution based, could therefore be seen as pragmatic. Not because retribution really offers any value to the afflicted, but to prevent people from taking justice in to their own hands.
So last week I believe there were TWO cases of "spree" infanticide (I am coining this term to describe a mother's killing more than one of her children at once) resolved in NEW YORK CITY ALONE. Neither received any publicity I appreciated beyond their respective articles in the NYTimes. Both mothers had a history of psychological troubles before the murders. Neither had any secondary gain. Both mothers concealed the killings,, in fact in one case the childrens' bodies were not discovered for hours after the murders. One mother from the Bronx was convicted of murder. The other from Brooklyn was acquitted. The articles did not explain the different outcomes, or how the prosecutors arrived at their respective management of the cases (in the acquittal case I believe the prosecutor collaborated to keep the case from trial). Also, an editorial in the NYTimes in the past week described HUNDREDS of women in California prisons for infanticide.
I describe the above just to point out that there is a stereotyped crime that the justice system is "handling" in a potentially random or unfair way, which isn't suprising given the way the criminal justice system handles mental illness generally. The Lindsay Clancy case upset me for a variety of reasons, probably the largest was the Reddington's defense strategy of mocking and criticizing the care Clancy received before the tragic infanticide. Nevertheless I see the basic unfairness and arbitrariness of how we approach these tragic crimes, and I am sympathetic to advocates for better support for struggling mothers.
I was also upset with the experts including poor Dr Tufts who was a particular target of Reddington's scorn, and Dr Mack, both of whom I felt did an exceptionally poor job of representing psychiatry to the jury, explaining its assumptions and contradictions, and its clinical challenges. I fantasized that had Reddington been bullying me on the witness stand I would not have let him off so easy, but then again, I have 25 years of experience versus Dr Tufts' one month. Dr Mack was an expert hired by the prosecution and since he wants more work, he presumably wanted to present their approach in the most favorable light, plus who knows what actual clinical experience he has treating psychotic disorders or even severe mental illness, in adults?
I deal with the contradictions the experts didn't explain to the jury, every day. What is the definition of "psychosis"? Did anyone notice that the experts kept using different definitions? One moment it was a severe psychiatric illness that deserved its own DSM code, another it was the symptom of hallucinations or delusions, and maybe thought disorder.
I'll tell you this, had Karl Jaspers himself been testifying he would not have been able to reconcile the facts with the law, which by the way Dr Mack seriously mischaracterized ("M'Naghten rule"). Of course no one cared because he was not a lawyer. But it deserved greater elaboration.
I am not critical of the jury or the hold-out juror. Juries are sequestered and supposed to be independent. The results are not assumed to be mechanistic or pre-determined. The idea that the juror "refused to follow the law" is absurd. In fact, "jury nullification" is a well known property of the jury system.
Oh well. Just venting.
Sadler's attacking of “Abrahamic metaphysical assumptions" needs to be distinguished from Aristotle - which is the backbone of our civilization. Get rid of Aristotle, and you may as well throw away systems biology too. I will not endorse a book when it results in us being forced to pretend that the history of knowledge and wisdom began on the day of David Hume's graduation. That we're now also positing "folk psychology" in the debate, when Matt Ratcliffe has demonstrated "the folk do not speak folk psychology", that the word folk psychology was invented to solve an inconsequential debate about eliminitivism in the ivory tower, and was never employed by "the folk" in the first place, underscores how circular this "blame game" really is.
For thousands of years, irrespective of one's faith, we determined one's character by way of how a person in-forms the body and allocates and organizes various habits and virtues; these are freely-willed acts despite being constituted by the environment. It never began with the assumption of "failed mechanisms that caused themselves". Hence, the reason stigma exists about various preventable diseases and mental disorders is because we already know, a-priori, that "preventable" implies free-will and self-causation. A melancholic person is shunned in every known culture because melancholia is a freely-willed activity. There is not a thing called "melancholia" that a person "catches" like a common cold - it was the outcome of poor decisions and an infatuation with creativity (e.g. Radden).
I also find it problematic how tone-deaf the media is about how polypharmacy contributed to the cases outcomes.
Henry Maudsley wrote that “epileptic insanity” is the most dangerous and violent of all the forms (Maudsley, 1874, as cited in Shorter, 2015). It’s interesting to me that in Teicher et al. (1990) on fluoxetine and suicide one patient had temporal lobe epilepsy and two more had epileptiform discharges (Teicher et al., 1990, 1991). A coincidence perhaps, but while we lament the absence of postpartum psychosis from the DSM, we might also do well to ask what happened to Henry Maudsley's most dangerous psychosis? People will give easy answers to such things, but the emergence and disappearance of psychiatric diseases doesn't get much attention. What became of hebephrenia? (Shorter, 2015).
On postpartum psychosis, Brockington had a lot of other cases of brief insanity that he included as possible relatives, cortisone psychosis, it too fluctuates and can produce the most extraordinary acts of violence (Brockington, 2014, 2017).
Edward Shorter had the idea that when we describe our symptoms we reach for a socially accepted vocabulary (Shorter, 1992). Quite aside from whether or not it’s socially acceptable, it’s hard to describe symptoms we don’t have a word for. Command hallucinations might just be the socially acceptable word, also the legally acceptable one.
How does one explain planning though? Well, some of Teicher’s patients underwent personality changes that mimicked BPD (Teicher et al., 1993), and before anyone dismisses that too quickly, does anyone care to recall what Kramer said the effects of Prozac were? Striking personality changes (Kramer, 1993). Where else do we see striking personality changes? Well, Geschwind might say you might see such changes in the 3 patients with abnormal EEGs that Teicher and Cole described (Waxman & Geschwind, 1975; Teicher et al., 1991).
That’s one idea, I think it’s a lot better than psychosis. Brockington thinks postpartum psychosis is bipolar or that it’s the same physiological weakness, his theory is a third pole, that he calls the cycloid pole, certain precipitants, childbirth, fever, toxic substances push towards the cycloid pole (Brockington, 2014, 2017). It’s an interesting idea, but then why didn’t we notice this more in the heyday of imipramine, I could list a dozen big names but perhaps the most extraordinary example is Mogens Schou who wrote a paper suggesting imipramine might be a mood stabiliser in the 60s (Schou, 1963). So there is something we’re missing, Ross Baldessarini said in lecture that it’s the “mixed ones who switch”; in the same lecture he opined that he sometimes wondered if it’s even the same illness (see also Baldessarini et al., 2013). I asked Ross about this once and he said the clinical point is lithium still works in most cases. Lindsay was in a technical "mixed state" by definition but was it a "bipolar mixed state"?
So it’s not quite postpartum psychosis, not enough confusion, it’s not clear that it’s bipolar 1 because surely we would notice, it’s not epilepsy because where are the seizures. What is it?
The premenstrual tension cases are interesting, it might seem silly but since I found it, I just can’t get over Robert T. Frank giving a verbatim description of a symptom that I know some experts have called “virtually pathognomonic” of akathisia in a paper on premenstrual tension (Frank, 1931). You could say it’s a coincidence, which does seem more likely, but it’s the sort of sentence that haunts you.
Here is one of the cortisone cases:
"Mrs. L. H., a housewife aged 53, complained of arthritis of 25 years’ duration, beginning in the feet and gradually involving all other joints. The joints had become swollen and red in the early stages, but not recently. There had been marked difficulty in walking because of the pain. ...
Course in Hospital. The patient remained in the hospital from Aug. 25 to Sept. 23, 1950. She received during that time a total of 2.625 Gm. of cortisone. By September 3 there had been marked improvement. ... The patient had begun walking. On the date of her discharge, September 23, the patient’s sedimentation rate was 21 mm., she was walking about, happy, and was sent to her family physician with instructions that she receive 100 mg. of cortisone biweekly.
She was in excellent spirits when she returned home, although nervous, restless and sleeping poorly. Her husband and daughter, on returning from a fire down the street, found her “wild eyed, hysterical and screaming that ‘the devil was after her.’” The pastor was called, and he succeeded in quieting her. One of us saw her at 10:30 p.m., and sedation was prescribed. She said she needed a doctor for her soul, not a medical doctor. The family was advised never to leave her alone, but on the same day, while her daughter was dressing, the patient cut her throat with a straight-edged razor and died within five minutes."
Borman & Schmallenberg, 1951)
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