doi:10.

1093/brain/awq072 Brain 2010: 133; 1565–1568 | 1565

BRAIN
A JOURNAL OF NEUROLOGY

BOOK REVIEW
Hysteria, mania and the commercial–
political nature of psychiatric disease MANIA: A SHORT HISTORY
OF BIPOLAR DISORDER
Can diseases have biographies? What makes biography (the Volume 3 of the Johns
history of the lives of individual men; Oxford English Hopkins Biographies of
Dictionary) engrossing are the lessons learnt from how individuals

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Disease Series
chance under the influence of society and culture, and vice versa. By David Healy
Most diseases are unvarying pathophysiological entities not evol- Edited by Charles E. Rosenberg
ving personalities, and therefore one might conclude have little 2008.
potential for biography, but the two books under review prove Baltimore: The Johns Hopkins
the contrary. This is perhaps because psychiatric disease has had, University Press
for most of history, no known pathophysiology and is susceptible ISBN: 978-0-8018-8822-9
to sociocultural explanation. Indeed, antipsychiatrists maintain that Price: £16.50 (Hardback).
a disease without pathophysiology is not a disease at all; and that
‘psychiatric disease’ is nothing more than a social contrivance or
political façade. Even if one rejects this extreme position, it is very
clear that the conceptualization of disease in the field of psychiatry
is far from objective and very prone to political, commercial and
temporal influences. Both these two books illustrate how fruitful a
biographical approach can be in the context of psychiatric disease;
each showing how this category of disease is moulded by public HYSTERIA: THE BIOGRAPHY
opinion, commerce and politics. These biographies reveal as much Volume 4 of the Oxford
University Press of
about the post-lapsarian human condition as about disease and, as
Biographies of Diseases Series
such, are both well worth reading.
By Andrew Scull
With this preamble, it is intriguing to note that two distin-
Edited by William and Helen
guished university presses have both launched, roughly simulta-
Bynum 2009.
neously, ‘biography of disease’ series (although what would the
Oxford: Oxford University
Oxford English Dictionary section say about this linguistic con- Press
struction?), each in relatively small format books and both here ISBN: 978-0-1995-6096-7
addressing psychiatric conditions. The two series are edited by Price: £12.99 (Hardback).
distinguished medical historians, and both have chosen distin-
guished and accomplished authors—in the case of Hysteria, a
professor of sociology (Andrew Scull), and in the case of Mania,
a professor of psychiatry (David Healy). Each book has, as its
central theme, the profound and dramatic influence of politics
and commerce on the conceptualization and formulation of the books, that many intriguing questions are raised. Have these dis-
specified condition in different periods. eases actually changed or is it that explanatory models for each
Hysteria, of course, is a paradigmatic example, and this topic disease have changed? Have these disorders ‘come and gone’ or
has been well covered in a whole slue of previous books in recent have they always been present? More pointedly, to what extent
years; but mania (and bipolar disease) is a relatively new entrant are these psychiatric diseases simply trumped-up concepts, mere
into the arena. So large are the apparent changes in the symptoms medicalizations of behaviour which is not inherently pathological?
and frequency of hysteria and of mania at different times and in The latter point is a focus of Healy’s book particularly, in which
different cultures, and so convincing are the arguments in these he takes the argument further, pointing his finger at the

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1566 | Brain 2010: 133; 1565–1568 Book Review

pharmaceutical industry (and its surrogate, medical academia) for This is indeed an interesting question, and Scull has two expla-
actually inventing diseases to create the need for a market into nations. The first is that the disease was essentially exiled and
which to place its products. This is a startling accusation. written out of psychiatry by the interrelated phenomena of:
However, let us start with hysteria. Andrew Scull is, of course, a (i) the rise of psychopharmacology; (ii) the manipulation and injec-
distinguished commentator on historical aspects of psychiatry (and tion of money by the pharmaceutical corporations; and (iii) the fall
a contributor to Brain). His biography starts with an elegant dis- from grace of psychoanalysis [partly mediated through the third
course on the case of Mary Glover, a Londoner who in early May edition of the Diagnostic and Statistical Manual of Mental
1602 developed a severe hysterical illness: Disorders (DSM) published in 1980]. Both Scull and Healy detect
the global pharmaceutical industry at the centre of this transfor-
‘. . . she was turned rounde as a whoop, with her head back- mation, with American academic psychiatry falling over itself to
ward to her hippes; and in that position rolled and tumbled, avail itself of these funds.
with such violence and swiftness, as that their paynes in keeping This is a convincing explanation for the removal of hysteria from
her from receaving hurt against the bedsted, and postes, caused the medical gaze, but does not explain what has happened to the

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two or three women to sweat; she being all over colde and patient. Here is Scull’s second thesis, and this is that the symptoms
stiffe as a frozen thing. After she had ben thus tossed and have transmuted into chronic fatigue syndrome (analogous to the
tumbled in this circled roundes backward, her body was sud- 19th neuroasthenia). Hysteria has therefore not disappeared, but
denly turned round the contrary way, that is, her head forward has simply taken a different disguise. Why this has happened is
between her legs, and then also rowled and tumbled as before.’ the more interesting question, and here Scull is silent. It must
surely reflect social change, but how? This perhaps is for another
These contortions (a prototype for Blanche Wittman) resulted in book.
a case before the Court of Common Pleas, the conviction of Scull is interesting on the demise of psychoanalysis, which he
Mary’s adversary as a witch and a split in the medical establish- attributes partly to the third edition of the DSM. He notes that in
ment about causation and therapy. Mary’s physician wrote a 1970, with only a handful of exceptions, all the major departments
pamphlet calling the disease ‘the suffocation of the mother’ of psychiatry in North America were headed by a psychoanalyti-
(remarkably pre-Freudian), and the case then became a tussle cally trained psychiatrist. But within a decade and a half, this had
between Anglicans, Protestants and Papists. It is a fascinating, if entirely turned around. Scull considers that this sudden and spec-
alarming, tale and testament to the profound social and profes- tacular change in fortune was partly the result of ‘profound poli-
sional impact that hysteria can have. Scull follows this up with the tical miscalculation’. This was the failure of psychoanalysis to see
now more familiar descriptions of the humours of Galen; the where the DSM was leading. The lack of concern among psycho-
scientific revival of Willis and Sydenham; 19th century hysteria analysts about problems of descriptive psychopathology had led
(Mesmer and Charcot, again!); the medical obsession with muti- them to ignore the formation of the American Psychiatric
lating the female reproductive tract (clitorectomy and overotomy); Association’s Taskforce, charged with formulating the DSM
the shell shock of the first world war (Rivers and the appalling in 1974. The one analyst on the taskforce was scorned and
therapies of Yealland); Freud and the psychoanalytical theories of ignored, and he resigned in protest. The 1980 DSM was then
repression; and the more recent post-traumatic stress disorder (a produced, with scant mention of hysteria or other ‘neurosis’,
terrible term that Scull rightly ridicules as politically contrived). and was hailed as a ‘wholesale expurgation of psychodynamics
Throughout, the condition evoked sadistic tendencies among its from the psychiatric knowledge base’.
physicians, and hostility among both the public and medical pro- Hysteria, other ‘neuroses’ and psychoanalysis were, according to
fession towards women. This is a familiar tale, well told here and this thesis, the casualties of political machination, and the DSM
beautifully written, but hardly novel. The last chapter is the most proved indeed an effective weapon. The result was what Scull calls
interesting—entitled ‘L’hystérie morte?’ (Etienne Trillat’s phrase; the ‘re-biologization of psychiatry’ and the ‘exorcism of hysteria’.
but is the use of French subliminal conversion?). Scull writes: Bipolar disease on the other hand rose from the ashes like a
phoenix. It is worth spending a few moments considering the
‘Diseases disappear . . . More frequently, though, diseases vanish claim that a classification scheme such as the DSM is in effect
because medical fashions change . . . where are all the cases of the vehicle for translating socioeconomic–commercial forces into
hysteria that once thronged the waiting rooms of the nerve medical practice. This is surely exactly what classification does.
doctor – the paralysis and tics, the phobias and the phantasms, Critics of the DSM, cited by Scull, consider it ‘closely analogous
the amnesia and the somnambulism, the hemianaesthsia and to the extraordinary and baroque nosologies which were a feature
the histrionics, the inexplicable loss of voice and sight, the emo- of eighteenth-century medicine’. The number of psychiatric dis-
tional turmoil and the faints, and the dramatic muscular con- eases from which one can suffer rose from 180 in the third edition
tractions that used to culminate in the arc-en-cercle so familiar (1980) to 450 in the fourth—with no mention of the word hys-
from the beginning to the end of the nineteenth century?. teria—and provided the tools to ‘pathologize virtually any species
Where are the hysterical invalids, so many of them women, of human behaviour’ (compulsive shopping disorder, social phobia,
who were so visible then?’ etc.—conditions unknown before 1980). Both Scull and Healy are
Book Review Brain 2010: 133; 1565–1568 | 1567

also at one in detecting the financial might of the pharmaceutical diagnosis and classification for the purposes of selling drugs. This is
industry as being behind this transformation. As Scull wrote: powerful stuff.
Healy’s main point is that even if mental symptoms are ‘real’,
‘Since 1980, when the American Psychiatric Association promul- the abstraction of an entity from these symptoms can set up
gated the third edition of its Diagnostic and Statistical Manual ‘something of a fiction’. According to Healy, the machinations
(DSM111), American psychiatry has achieved worldwide hege- of the pharmaceutical industry have resulted in the creation of
mony, and in many ways pills have replaced talk as the domi- ‘disease’ to provide a target for treatment with their drugs.
nant response to disturbances of emotion, cognition, and Disease is in effect an illusion and a marketing ploy. This is not
behaviour. Pharmaceutical corporations have underwritten the to say that the symptoms do not exist, this is undeniable; but the
revolution, and have rushed to create and exploit a burgeoning central argument is that the conditions are manufactured. In both
market for an ever broader array of drugs aimed at treating books, the academic psychiatrist also comes out badly. The argu-
some of the hundreds of ‘‘diseases’’ psychiatrists claim to be ment goes that indistry recruits medical academics (who should be
able to identify. And patients and their families have learned a ‘counterweight to industry’) to this task, by providing grants,

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to attribute their travails to biochemical disturbances, to faulty sponsoring conferences and guidelines, paying honoraria to speak-
neurotransmitters, and to genetic defects, and to look to their ers and ghostwriting articles. The academics have become agents
doctors for the magic potions that will produce better living of what is essentially a marketing exercise—and as he notes, this
through chemistry.’ makes commercial sense, because ‘Professors of Psychiatry, even
from Harvard, at a few thousand dollars per lecture, are a cheaper
This applied not only to hysterical disorders but, according to resource than company detail men’. He notes that by 2000, 75%
Healy, also to bipolar disease. The accusations that it is the rede- of the randomized clinical trials appearing in major journals were
finition of terms via the DMS that racked up the numbers of sponsored by pharmaceutical companies ‘and it seems unlikely
‘bipolar’ patients, that this was a marketing initiative by the phar- that companies would have been prepared to leave the prepara-
maceutical industry through the agency of the American tion of any sizable proportion of these key marketing tools in
Psychiatric Association, consciously or not (psychoanalysts, stir in academic hands’. As part of this process, the marketing depart-
your graves), does rather seem to ring true. ments of the pharmaceutical companies set out, Healy writes, to
Scull’s book is scholarly, cool and of a phlegmatic humour. ‘segment’ the market so as to provide diseases to be treated with
Healy’s book is an interesting contrast. It is a fire cracker of a their drugs. We are entering Pharmageddon (Healy here quoting
text, full of choler and exuding yellow bile. The book is more Charles Medawar).
about bipolar disease than mania itself, and emphasis on the Healy heaps special odium on, and devotes a separate chapter
word Mania in the title is perhaps a playful reference more to to, the remarkable current fashion for diagnosing bipolar disease in
the behaviour of modern psychiatry in relation to psychopharma- young children (as young as 2 years old). Healy dates this vogue
cology. Only is the first chapter really focused on mania, and here to the publication of the book The Bipolar Child in 2000.
Healy makes a good case for dismissing the view that the disorder Organizations have since sprung up, such as the ‘Child and
was well-recognized in Greek times. The mania of Hippocrates Adolescent Bipolar Foundation’ and the ‘Juvenile Bipolar
was, he points out, really what would be known today as delirium Research Foundation’, sponsored by Big Pharma, which act as
or organic confusion. The next few chapters are a romp through lobby groups. It is now claimed that 4–5% of 10-year-olds have
history, and Healy digs out Galenic humouralism, the categoriza- bipolar disease. Support for parents is available in such books as
tions of Sydenham, the case reports of Wyman and Pritchard, the Brandon and the Bipolar Bear and My Bipolar, Roller Coaster,
famous row between Falret and Baillarger about precedence for Feelings Book. Conferences and guidelines published in the scien-
the description of folie circulaire and the descriptions of folie à tific press are sponsored by grants from a range of pharmaceutical
double phase, folie alterne and folie à double forme. He companies, as are the large satellite symposia of the American
discusses Kraepelin, who apparently did not cite any of his Psychiatric Association. Healy piles example on example of how
French predecessors when, in 1899, he defined manic-depressive Big Pharma, through medical academia, has set the agenda. Cited
psychosis for the first time. It was only at this moment that for instance are the meetings of the American Psychiatric
bipolar disease emerged from its long sleep and took on its Association in which there are up to 40 satellites, each sponsored
modern guise. by a pharmaceutical company for up to $250 000, and in which,
Remarkably, as Healy notes, 5% of the US population now end by 2003, 35% of the satellites were devoted to the topic of
up with a diagnosis of bipolar disease. Just when Scull’s hysteria bipolar disease to coincide with the launch of an entire raft of
seems to have disappeared, Healy’s bipolar disease appears to new drugs.
have arisen from nowhere; but why? Healy’s historical narrative Healy’s book, like Scull’s, opens with a case history—of Alex
is just a warm-up act for the main part of the book, occupying the who dropped dead at the age of 2 years while being treated
next six chapters and taking the form of a sustained assault on the with an antipsychotic for bipolar disease. This illustrates, according
pharmaceutical industry, its beneficiaries in medical academia, the to Healy, that the ‘Disease mongering, chicanery and deployment
American Psychiatric Association in their conspiracy to manipulate of the latest jargon to foster the interests of an establishment are
1568 | Brain 2010: 133; 1565–1568 Book Review

ever the same’, no doubt mirroring what went on in the past, but cortices; and so on, and so on. Who knows whether any of this
perhaps never before with the ‘same industrial efficiency’. is more or less valid than Freud’s concepts of repressed memories
Healy’s book is poorly edited, and it is difficult to follow all of of childhood seduction? What is clear, however, is that the ten-
his arguments that seem at times to lack coherence; a sharp red dency for the explanatory model to define the disease is surely
pencil would have been a great service. His book is partly polemic; back to front, and cannot be right.
but is it too far-fetched? I am not entirely certain; but it is stimu- Both these books finally demonstrate the sociocommercial–poli-
lating and presents argument and data of great importance. His tical nature of psychiatric diagnosis and classification, which over-
previous work has evoked very strong reactions, and if the phar- whelm the merely scientific. The problem of course is the fact that
maceutical corporations or American academia were in the habit without any robust pathological (or indeed any biological) marker,
of issuing ‘fatwa’, David Healy—no remote and ineffectual ‘don’ one can slice up disease categories anyway one likes. These are
with quavering or corroded pen—would certainly be in the line of salutary lesions for the naı̈ve view that science is the predominant
fire. influence. Neurological classification and categorization are more
The problem of psychiatric diagnosis is, of course, its inherent grounded in pathology or physiology, and as such are perhaps

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subjectivity—and this renders it vulnerable to many interpreta- more immune to social or commercial force; or is this neuro-com-
tions. The lack of biological markers is open season for would- placency? Certainly, one can think of new diseases created in
be nosologists and creative mechanists. Although Healy and recent years for which new therapies are made available.
Scull concentrate on the role of Big Pharma, it may be wrong to Neurology does not have its Healy and perhaps it should. Both
hold the industry entirely to blame for seeing the commercial books deserve a wide audience and each signifies that both bio-
opportunity presented by the rise of psychopharmacology. The graphy and history can provide explanatory models that tap
final responsibility surely resides in the academic community, hyp- sources wholly outside normal scientific discourse.
notized by the availability of research funds, for lack of rigour in
assessing their claims, and for not seeing the wood but only the Simon Shorvon
trees (albeit with gilded foliage). Other recent work heads in UCL Institute of Neurology, University College London,
different directions, for instance the suggestion that depression Queen Square, London, UK
may be a disorder of neural processing of reward, perhaps located
Advance Access publication April 12, 2010
within the medial caudate and ventromedial orbitofrontal