Making Up Symptoms

The experiences that are associated with psychosis are extraordinarily varied and heterogeneous. Early descriptive psychiatry (e.g. Bleuler, 1912) placed emphasis on carefully explicating subjectivities that strike the reader... [ view full abstract ]

The experiences that are associated with psychosis are extraordinarily varied and heterogeneous. Early descriptive psychiatry (e.g. Bleuler, 1912) placed emphasis on carefully explicating subjectivities that strike the reader as remarkable and somewhat difficult to comprehend objectively. Yet modern descriptions of psychotic phenomena (e.g. the DSM criteria) have tended to focus on particular canonical types of “symptom” like “hearing voices” or holding “delusional beliefs”. Some recent scholarship (i.e. that of Louis Sass, 1994, 2014 and Nev Jones and colleagues, 2016) has re-introduced the striking diversity of phenomenological experiences that are reported in psychosis. How has this historical movement occurred, and why have we had to “re-discover” the heterogeneity of psychosis?
The philosopher Ian Hacking has a line of research which he has called “making up people”. Hacking has traced the history of several diagnostic categories (most notably autism and multiple personality disorder) and revealed how their codification has created new, but also quite rigid, ways of being distressed. A diagnostic class creates habits of thought and canonical forms of description, which limit the ways a person’s behaviour and subjectivity can be described and understood. It also creates “looping effects”, in which the “official” descriptions come to influence the first person experiences themselves.
In this paper I apply Hacking’s research to the description, classification and diagnosis of psychotic symptoms. By tracing the historical developments in how psychiatry has written about psychosis, it is possible to witness a tacit simplification and restriction in what psychosis is “supposed” to be. From a variety of auditory and non-auditory intrasubjective experiences of sound and voice (for example), we have moved to the simple formulation “hearing voices”, in a move I call “making up symptoms”. This canonical, official picture limits the experiences professionals are prepared to recognise in their patients.