David Robertson // Like other fields of medicine, psychiatry depends upon “information infrastructures” in order to distinguish between different mental disorders. Such infrastructures include the personnel, tools, systems, and networks essential for the day-to-day collection of large quantities of data. Attending to the historical transformation of information infrastructures in psychiatry calls on the historian to think about how the production of psychiatric concepts and diagnoses emerges from the often mundane and bureaucratic structures of everyday practice and research. How might such demands have shaped the transformation of psychiatric classification across the twentieth century?
One example of such a history is Eric Engstrom’s excellent book Clinical Psychiatry in Imperial Germany (2003). Writing about the famous nineteenth and early twentieth century German psychiatrist, Emil Kraepelin, Engstrom traced the origins of Kraepelin’s lasting contributions to clinical psychiatry to the specificities of a late nineteenth-century Bavarian bureaucracy. Kraepelin, who is often posited as the founding father of “diagnostic psychiatry” – think of the modern DSM and the endless profusion of psychiatric diagnoses or “checklists” of symptoms it is often accused of promoting – made a lasting contribution to psychiatric classification in his distinction between manic-depressive psychosis (now termed bipolar disorder) and dementia praecox (now termed schizophrenia). For Kraepelin, the critical distinction between these two diagnoses related to their differing prognoses. Recognizing that patients with both disorders could exhibit identical symptoms, he distinguished between them according to their clinical outcomes. He observed that patients suffering from manic-depression tended to go through circular stages of remission and relapse, while those experiencing dementia praecox tended toward a terminal decline. This distinction between remission and terminal illness was imperative given the context of emerging state support for social insurance programs.
It is widely recognized that Kraepelin’s distinction was based on his novel methods of data collection known as Zählkarten. A catalogue of cards storing patient data, the Zählkarten enabled the researcher to make comparisons between patient symptoms and clinical outcomes. (An image of one such card accompanies this post.) Yet, as Engstrom wonderfully demonstrated, this was not an idea merely conjured up in the grey matter of Kraepelin’s undoubtedly prodigious brain, but rather, arose from the work practices of a Bavarian hospital bureaucracy. Employed by the Bavarian state in the late 1870s, Kraepelin had been required to file patient cards for census purposes. ‘In other words,’ wrote Engstrom, ‘long before he developed and employed his own Zählkarten for purposes of clinical research, Kraepelin had been busy filling out statistical Zählkarten for Bavarian government records.’ (Engstrom 141). The revolutionary research agenda this enabled Kraepelin to launch is an excellent example of the centrality of information infrastructures to transformations in psychiatric classification.
How might such an approach to tracing intellectual transformations inform an analysis of international psychiatry in the postwar era? The history of the World Health Organization’s pioneering psychiatric research beginning in the 1960s is one place we might begin to answer this question. In this period the organization began a sustained research agenda comprising multiple programs. Two of these programs are relevant here. “Programme A” was the sharpening and standardization of a classification of mental disorders for use internationally, while “Programme B” comprised epidemiological field studies in culturally-diverse settings.
The key outcome of Programme A was the amendment of the mental disorders section of the organization’s International Classification of Diseases (ICD). Programme B kick-started with the influential International Pilot Study of Schizophrenia which took place in nine urban hospitals around the world and tracked outcomes for 1202 patients. At the center of both programs was the effort to standardize the clinical interactions of psychiatrists and patients and, thereby, produce greater commensurability in the observation, labelling, and classification of mental disorders. Doing so required creating novel methods for gathering and arranging patient data. In other words, it required developing a new information infrastructure for use in international psychiatry.
Take the standardized clinical interview as one example. One of the earliest standardized interviews adopted by the organization was the Present State Examination (PSE). The PSE was originally designed by the British psychiatrist John Kenneth Wing in the late 1950s. It structured the clinical interview according to fourteen discrete items to be rated on a five-point scale. Wing’s intention was to standardize clinical descriptions by using down-to-earth terminology and to differentiate patients according to the severity of their symptoms. This was certainly part of an emergent effort to overcome diagnostic differences between clinicians, yet its structure clearly reflected the bureaucratic demands of overcrowded British mental hospitals, pressed as they were to make decisions about who was and was not ready to be released back into the community. Partly for this reason, the original PSE (1961) was designed for use by psychiatrists and nurses alike, thereby expanding the ranks of its potential workforce.
The WHO was soon using and updating Wing’s clinical interview to collect international data on mental disorders. Programme B’s International Pilot Study of Schizophrenia, for instance, used the PSE to collect just under two million pieces of patient data, a phenomenal achievement for this era and viable only because of new computer technologies for managing such unprecedented quantities of information. The computer program of choice – known as CATEGO – was programmed to cluster into “symptom profiles” huge sets of bite-sized data in ways that were previously unfathomable for researchers unaided by such technologies. Like Kraepelin’s Zählkarten, CATEGO and the PSE are examples of how transformations in a discipline’s information infrastructure shape the articulation of medical diagnoses. In this case, they enabled the relatively speedy collation of information from internationally-dispersed centers examining large numbers of patients to be turned into polished descriptions of “typical” symptom profiles of schizophrenia.
This new infrastructure altered the possible definitions of mental disorders available to the physician, including those offered in the WHO’s own classificatory manual, the ICD. Importantly, changes to methods of data collection and organization do not just “get at” the same clinical entities in slightly different ways, but rather, structure the evidence obtained and the conclusions that can be reached from it. I wrote above that Kraepelin’s categories of manic-depression and dementia praecox are today termed bipolar disorder and schizophrenia. But this is a simplification. “Manic-depression” and “bipolar disorder” are not just more recent terms for describing historically identical entities but reflect subtle shifts in how clinicians decide what to include and exclude in their picture of the patient’s experience. A crucial part of that decision-making process relates to the means by which information is collected and arranged.
The groundbreaking methods of data collection and arrangement unfolding within the WHO in the 1960s were not exclusive to the organization. Similar methods were being used by researchers in the United States working on radical revisions to the DSM soon to be released in the manual’s infamous third edition (1980). Like their counterparts in the WHO, these researchers were assisted by their own computer program – known as “DIAGNO” – for dealing with large quantities of patient data. Whether the original impulse to collect and classify data is driven by a late-nineteenth century Bavarian bureaucracy or a midcentury British hospital administration, the origins of research methods lay foundations for the ongoing evolution of clinical concepts. By thinking about the history of psychiatry as a history of shifting information infrastructures we are able to situate what can often seem like abstract diagnostic terms in the more pressing and down-to-earth contexts that enable and condition their emergence.
Engstrom, Eric J. Clinical Psychiatry in Imperial Germany: A History of Psychiatric Practice. Ithaca: Cornell University Press, 2003.