Archive for February, 2012

New issue – History of Psychiatry

A new special issue of History of Psychiatry is now available online. It is entitled “Lunacy’s last rites: dying insane in Britain, c. 1629-1939” and includes the following articles:

Death and the dead-house in Victorian asylums: necroscopy versus mourning at the Royal Edinburgh Asylum, c. 1832–1901 (Jonathan Andrews)

This article examines the management and meaning of post-mortem examinations, and the spatial ordering of patients’ death, dissection and burial at the Victorian asylum, referencing a range of institutional contexts and exploiting a case study of the Royal Edinburgh Asylum. The routinizing of dissection and the development of the dead-house from a more marginal asylum sector to a lynchpin of laboratory medicine is stressed. External and internal pressure to modernize pathological research facilities is assessed alongside governmental, public and professional critiques of variable necroscopy practices. This is contextualized against wider issues and attitudes surrounding consent and funereal rituals. Onus is placed on tendencies in anatomizing insanity towards the conversion of deceased lunatics – pauper lunatics especially – into mere pathological specimens. On the other hand, significant but compromised resistance on the part of a minority of practitioners, relatives and the wider public is also identified.

‘Those, that die by reason of their madness’: dying insane in London, 1629–1830 (Jeremy Boulton and John Black)

Dying insane provoked ‘great fear, and apprehension’ in the minds of men and women. Death as a lunatic disrupted deathbed performance and rendered the victim incapable at law. This article examines lunacy as a cause of death in the metropolis between 1629 and 1830. It draws on new material from the admission registers of St Luke’s Hospital, existing data from Bethlem and the London Bills of Mortality and unique biographical data on pauper lunatics dying in the parish of St Martin in the Fields. The article argues that lunacy being ascribed as a cause of death had a distinctive chronology in this period. Those most vulnerable to the stigma of lunacy at death were those dying as parish paupers and those who inhabited metropolitan institutions.

Recording the many faces of death at the Denbigh Asylum, 1848–1938 (Pamela Michael and David Hirst)

The funeral was a symbolic event in Welsh society, and members of staff and relatives of patients at the Denbigh Asylum shared cultural assumptions about the importance of a final resting place for the body. Formal procedures following the death of a patient were governed by asylum rules and regulations. At Denbigh the asylum chaplain played an important role, both in terms of ministering to the dying and in performing the funeral ceremony. During the late nineteenth century the burial ground became a contested space as nonconformists and Roman Catholics fought against the ascendancy of the Anglican Church in Wales and demanded that patients be buried according to their religious affiliation. The lunatic asylum became a site for advancing the case for Welsh disestablishment. By the twentieth century, infectious diseases had become a serious concern, and the need to carry out screening and conduct post-mortem examinations resulted in the appointment of a pathologist, whose main role was to conduct biological and histological examinations to identify cases of tuberculosis, syphilis, dysentery, typhoid, influenza and other bodily diseases.

Explanations for death by suicide in northern Britain during the long eighteenth century (RA Houston)

This article uses coroners’ inquest findings, media such as newspapers, magazines, pamphlets and broadsides, and family correspondence (all drawn from Scotland and the north of England) as well as civil and criminal court records and medical and legal writings from both countries to explore perceptions of the link between state of mind and self-inflicted death. It asks how doctors, lawyers, families and ‘society’ at large conceptualized, responded to and coped with suicide, questioning the extent to which it became medicalized: i.e. consistently linked with mental pathology. The aim is to square the apparently clear-cut, but very different understandings of doctors and lawyers on the one hand and coroners’ inquests on the other with the more emotionally charged and morally complex ways those both close to and distant from attempted or successful suicides related to their situation.

‘Abnormalities and deformities’: the dissection and interment of the insane poor, 1832–1929 (Elizabeth T Hurren)

The body trade of anatomy schools in Victorian times that underpinned the expansion of medical education has been neglected. This article examines dissection records of insane paupers, sold to repay their welfare debt to society. Each cadaver was entered in an ‘Abnormalities and Deformities’ dissection book. Student doctors paid fees to anatomists to be taught the pathology of insanity under the Medical Act. Anatomists also dissected cadavers to do further brain and eye research on epilepsy and glaucoma in the insane. These bodies were often dissected to their extremities. Their fragmentary remains were then disposed of in a common grave. This secret body trade and its asylum supply-chain merit further work in disability studies and the history of psychiatry.

Under the shadow of maternity: birth, death and puerperal insanity in Victorian Britain (Hilary Marland)

Death and fear of death in cases of puerperal insanity can be linked to a much broader set of anxieties surrounding childbirth in Victorian Britain. Compared with other forms of mental affliction, puerperal insanity was known for its good prognosis, with many women recovering over the course of several months. Even so, a significant number of deaths were associated with the disorder, and a large proportion of sufferers struggled with urges to destroy their infants and themselves. The disorder evoked powerful delusions concerning death, with patients expressing intimations of mortality and longing for death.

Troubled proximities: asylums and cemeteries in nineteenth-century England (Chris Philo)

Asylums and cemeteries in nineteenth-century England were kindred spirits in the anxiety and exclusionary impulses that they engendered, leading them to be similarly exiled from nineteenth-century urban areas. They were uneasy ‘neighbours’, however, with contemporary authorities condemning the proximity of cemeteries to asylums on medical and moral grounds. The appearance at many asylums after mid-century of a burial-ground for deceased residents, usually located on an asylum’s own estate, was often criticized on grounds similar to those raised with respect to neighbouring parochial burial-grounds. Other objections arose to the ‘exclusivity’ of asylum-based burials, with off-site burial arrangements clearly being favoured. One consequence was that on-site asylum cemeteries ended up being treated as unwelcome occupants of asylum estates, hidden away as an embarrassment, creating a legacy of anonymity still generating concerns in the present.

‘Visitation by God’: rationalizing death in the Victorian asylum (Cathy Smith)

This article argues that death from insanity raised serious questions for the medical profession and for those who promoted the public asylum movement in the nineteenth century. While the medical emphasis on the somatic origins of insanity was increasingly accepted, limited observable signs of disease in the brain at post-mortem made it difficult to explain cause of death. This posed problems for a growing county asylum movement which was justified on the basis that insanity was a treatable disease and thus mortality rates would naturally decline. As asylum populations continued to grow and mortality rates remained little changed, statistics on lunacy ultimately became not the predicted measure of success but instead clear evidence of failure.

Welcome release: perspectives on death in the early county lunatic asylums, 1810–50 (Leonard Smith)

Deaths in the asylum could be interpreted as a sign of failure, particularly if they were related to the poor condition of those admitted, the spread of disease among patients, or the direct consequences of severe mental disorders. County asylum superintendents lamented the bad physical state in which many were sent to the asylum and the consequences for death rates. Due to limited consideration of environmental and sanitary matters before the 1830s, there was great risk of contracting fatal diseases in the asylum. Combined with the deteriorated physical condition of many patients, and the growing overcrowding, this had a notable influence on mortality. For some individual patients, death came about as a direct consequence of a profound mental disorder. Without effective treatments to confront manifestations of disordered thinking, mental symptoms might precipitate physical deterioration to the point of death, while severe distress led some to kill themselves in the asylum.

It also contains James Cowles Prichard’s classic text ‘Of the Termination of Insanity in Death’ (1835), with a commentary by Jonathan Andrews.

For more information, click here.

DSM-V and grief

Last week, an interesting discussion went on in the comments section of a post we published two years ago entitled DSM-V: Getting Closer to Pathologizing Everyone? In order to give this exchange more visibility, we decided to publish it as a separate contribution. First the remarks of Ronald Pies, columnist at Psychiatric Times, and then the response from Alan Horwitz, author of the initial post. We would like to thank both authors for taking the time to share their thoughts on h-madness.

First, the original comment:

It is technically not true that “…anyone who is sad, fails to derive pleasure from usual activities, finds it difficult to concentrate, and has sleep and appetite difficulties for a mere two weeks could be diagnosed with Major Depressive Disorder,” either using DSM-IV or the proposed DSM-5 draft criteria. Those features alone would not meet the full criteria set required for MDD. The person would also need to meet the “C” criterion [in DSM-IV] of “clinically significant distress or impairment in social, occupational or other important areas of functioning.” Moreover, simply being “sad” does not satisfy the criterion of having “depressed mood most of the day, nearly every day…” for 2 weeks.

Most recently bereaved individuals will not meet full DSM criteria for MDD; do not have a “disorder”; and do not need clinical treatment. Furthermore, there are profound phenomenological differences between ordinary grief and MDD that the experienced psychiatrist will recognize. For example, the ability to be consoled, as Kay Jamison has observed, is typically present in ordinary grief, but rarely in MDD.

That said, many of us believe that the 2-week minimum duration is too short, in most cases, to make a confident diagnosis after bereavement or any other major loss, such as divorce. However, this is irrelevant to the validity of the bereavement exclusion, (BE) and focusing on the 2-week minimum both misses the real point of the debate, and obfuscates the many underlying problems with the BE; e.g., there are no controlled, clinical studies (as contrasted with community survey data) of bereaved, MDD patients to support the BE.

The 2-week minimum is a separate problem that must be addressed separately, and in no way justifies continuing the BE. Leaving the BE in the DSM-5 will not fix the general problem of the 2-week interval. Indeed, elimination of the BE from DSM-5 would also rid us of the bogus, 2-month limit on the duration of “normal” bereavement, for which there is no scientific or clinical basis. Ordinary grief related to bereavement is quite distinct from MDD, and may go on for months or even years; it is not a disorder, nor does it require treatment, if the grieving person functions adequately in the social, vocational, and interpersonal spheres.

I hope that readers will take a look at my upcoming blog on the Psychcentral website, entitled, “Grief, Bereavement, and the DSM-5: How the Public is Being Misinformed.” Also, I have developed a preliminary screening instrument, called the PBPI, aimed at helping clinicians distinguish, phenomenologically, between ordinary grief and MDD. It may be found on the Psychiatric Times website, after a free registration step, under the title, “After Bereavement, Is It “Normal Grief” or Major Depression? The PBPI, A Potential Assessment Tool.”

Ronald Pies MD

For further reading:

Pies R. The two worlds of grief and depression. Accessed January 27, 2012.

Zisook S, Shear K: Grief and bereavement: what psychiatrists need to know. World Psychiatry. 2009;8:67-74.

Zisook S, Reynolds CF 3rd, Pies R, et al. Bereavement, complicated grief, and DSM, part 1: depression. J Clin Psychiatry. 2010;71:955-956.

Lamb K, Pies R, Zisook S. The Bereavement Exclusion for the diagnosis of major depression: to be or not to be? Psychiatry (Edgmont). 2010;7:19-25.

Jamison KR. Nothing Was the Same. New York: Vintage Books; 2011.

Then, the response from Alan Horwitz:

Before the DSM-5 Task Force began its deliberations, the idea that normal grief could be a psychiatric disorder would have seemed preposterous. Freud, for example, following thousands of years of psychiatric thought, noted that:
“Although grief involves grave departures from the normal attitude to life, it never occurs to us to regard it as a morbid condition and hand the mourner over to medical treatment. We rest assured that after a lapse of time it will be overcome, and we look upon any interference with it as inadvisable or even harmful.”
Indeed, the notion that grief is a natural reaction to the death of an intimate is so deeply commonsensical that the general definition of mental disorder in the DSM itself uses it as the sole example of a condition that should not be considered disordered: “(Mental disorder) must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one.”
There are also good empirical reasons for the bereavement exclusion. One of the causes for the original exclusion in the DSM-III was psychiatrist Paula Clayton’s findings that over 40 percent of individuals who had suffered the death of an intimate would meet the MDD criteria in the absence of the bereavement exclusion. Since Clayton used a one-month, rather than the existing two-week, duration that Pies’ suggestion would entail, a majority of the population could likely be diagnosed with major depression using the current diagnostic standards without the exclusion.
A recent study by Ramin Mojtabai uses prospective data from to test the validity of the bereavement exclusion by comparing the prognosis of bereaved and non-bereaved people who have had depressive episodes. Majtabai’s findings show that three years after the initial episode the rate of depression among the bereaved group (8.2%) was comparable to those who were never depressed (7.5%) but significantly lower than the depressed group that was not bereaved (14.7%). Bereaved people are no more likely than people who are not depressed to have subsequent depressive episodes; the prognosis of bereavement is benign compared to other depressed persons; and grieving people, as Freud predicted, are likely to self-heal without treatment. Providing further evidence for the wisdom of maintaining the bereavement exclusion, Majtabai also found that compared to those with other depressive episodes, respondents with bereavement-related episodes were less likely to have impaired role functioning, psychiatric treatment, or comorbid disorders. These findings are likely to understate the differences between the bereaved and others who met MDD criteria because the latter group included people who met these criteria because of other types of losses. Were this group excluded from the MDD group, the differences between the bereaved and non-bereaved group likely would have been even larger.
So, thousands of years of psychiatric history, common sense, and empirical findings all indicate that grief is a natural response to serious loss, not a mental disorder. Why then, does Pies suggest eliminating the current bereavement exclusion? Because the clinical significance criterion of the MDD diagnosis also requires: “clinically significant distress or impairment in social, occupational or other important areas of functioning.” Therefore, according to Pies, only distressed or impaired grieving people will be diagnosed as depressed in the absence of the exclusion. Pies’ rational is odd: obviously grief involves distress. It is part of our nature as humans to feel intense distress after the loss of a loved one. The clinical significance criterion will do nothing to stop the enormous pathologization of grief that abandoning the grief exclusion would entail.
Pies’ eccentric view flies in the face of empirical research, common sense, and thousands of years of psychiatric history, as well as the definition of mental illness in general and depressive disorder in particular, in every previous edition of the DSM. There is no better illustration of the intellectual bankruptcy of current mainstream psychiatric thought than the fact that the DSM-5 is likely to embrace this view. The general public will justifiably be astonished and scornful of the abandonment of the idea that grief is a natural part of life.

Talk and Exhibition: Shakespeare and the Four Humors (Bethesda, Maryland)

History of Medicine Division Lecture
Tuesday, February 28, 2012, 2:00 – 3:30 p.m.
Lister Hill Auditorium
NLM Building 38A
Bethesda, MD

Dear NLM Colleagues,

You are cordially invited to the next History of Medicine lecture, to be
held Tuesday, February 28, 2012, from 2:00 to 3:30 p.m., in Lister Hill

“Shrew Taming and Other Tales of the Four Humors”

Dr. Gail Kern Paster,
Folger Shakespeare Library

William Shakespeare is widely praised for creating the most recognizable
characters in all of literature, yet he understood human behavior in the
terms available to his age–the classical theory of the four humors of
blood, phlegm, choler, and melancholy. These humors accounted for the
health and actions of male and female, young and old, rich man and poor
man. It was the darker emotions of anger and melancholy that preoccupied
Shakespeare, especially as they appeared in the madness of Ophelia and the
shrewish resistance of Katharine Minola to her female destiny of wifely

This lecture is being held in conjunction with NLM’s newest exhibit, “‘And
there’s the humor of it’ – Shakespeare and the four humors,” a display,
online exhibition, and traveling banner exhibition featuring treasures
from NLM and the Folger Shakespeare Library

All are welcome.

Sign language interpretation is provided. Individuals with disabilities
who need reasonable accommodation to participate may contact Stephen
Greenberg at 301-435-4995, e-mail, or the Federal
Relay (1-800-877-8339).

Sponsored by
NLM’s History of Medicine Division
Jeffrey S. Reznick, PhD, Chief

Event contact:
Stephen J. Greenberg, MSLS, PhD
Coordinator of Public Services
History of Medicine Division
National Library of Medicine, NIH

Meet the historian: Sally Alexander

MEET THE HISTORIAN: Sally Alexander, 6pm, 22 Feb 2012, Room 104, South Block, Senate House, London WC1E 7HU
History Lab’s ‘Meet the Historian’ events are an opportunity to hear at first hand from noted historians how and why they became historians in the first place, their thoughts on research and the discipline generally, and about their latest work. There will be the chance to ask questions and enter into discussion, and to join the speaker for drinks after the talk.
Sally Alexander is Professor of Modern History at Goldsmiths, University of London. She has been an editor of History Workshop Journal since its foundation in 1976 and her research interests lie in the history of social movements, feminism in particular, London history, the history of psychoanalysis, oral history and subjectivity. Co-convenor of the Modern British History seminar and Psychoanalysis and History at the IHR, she is currently editing, with Professor Barbara Taylor, a volume on Psychoanalysis and History for Palgrave, 2012.

Grief Exclusion and DSM V

A recent report in the popular press cites Kenneth Kendler and Arthur Kleinman on the pathologization of grief.

CfP – Pain and Old Age


Public Conference: 27 October 2012

The Birkbeck Pain Project and the Birkbeck Institute for the Humanities

Birkbeck, University of London

Organised by Visiting Fellow to the Birkbeck Pain Project, Prof. Lynn Botelho (Department of History, Indiana University of Pennsylvania)

According to the British Pain Society, ‘pain is not a normal part of ageing’ (2008). Yet for generations of older people, pain was something that was intimately tied to the ageing process. For many, it was the body in pain that signalled their entry into old age. Furthermore, the elderly have not wanted to be a ‘burden’ to their families, friends, and support systems, and consequently they often endured pain with a quiet acceptance. When did this relationship between pain and old age undergo such a profound and fundamental shift? Or, did it? Were the elderly in the past always quietly accepting of the aches and pains of a physically declining body? Or did they fight against pain and the very real physical, emotional, and familial restrictions that chronic pain can impose?

This one-day conference explores the nature of pain in old age between the 18th and the 20th centuries. It explicitly does so through the lens of the humanities, rather than hard sciences. The conference strives to be wide-ranging in terms of disciplines, methodologies, and approaches. In doing so, it seeks to engage both panellists and audience in discussion, dialogue, and debate. Our aim is to facilitate new ways of thinking about both the nature of pain and what it meant to be old.

Possible paper topics might include, but are not limited to

  • Pain, old age and social relationships (partner, children, friends, neighbours)
  • Pain and sexual relations
  • The philosophy of pain
  • Pain and the ageing self
  • Pain as a marker of old age
  • Pain, piety, and religion
  • Representations of pain and old age in literature, art, and autobiography
  • Pain as a mechanism of self-fashioning
  • Pain clustering and the loci of pain, including physical, emotional, and spiritual pain
  • The elderly’s engagement with medicine and medical practitioners
  • The medical community’s response to pain in the old

Please send a 300-500 word abstract and a short C.V. by email to Lynn Botelho ( by 1 June 2012.

More information regarding the The Birkbeck Pain Project is available here.

Call for Papers: Second International Health Humanities Conference on Music, Health, and Humanity


Music, Health, and Humanity
The Colleges of the Arts and of the Humanities and Social Sciences at Montclair State University, New Jersey, USA, are hosting the Second International Health Humanities Conference from Thursday-Saturday, 9, 10, 11 August, 2012.


In accordance with the interdisciplinary nature of the Health Humanities, we invite the participation of colleagues from music, other arts disciplines, the humanities, and clinical health backgrounds who wish to participate in an exploration concerning the various relationships among music, health, and humanity. We encourage individual and group (colloquium) presentations addressing theory, practice, and/or research (in progress or
completed), addressing questions and issues pertinent to the conference theme. Example include (but are not limited to):
– How do the critical intersections of music and health manifest across other arts
modalities (visual art, dance, drama, etc.), and across the various humanities disciplines
(history, philosophy, literature, languages, law, etc.)? How do each of these
manifestations inform us about the role of music in expressing, communicating, and
promoting human health (physical, mental/emotional, social, etc.)?
– What is the role of music in the well being of communities, culture, and humanity?
– How do musical works and discourses about music raise and/or address issues
concerning gender, sexuality, ethnicity, age, economics, and power?
– In what ways does music represent “social capital,” and what are the implications for
one’s socioeconomic health?
– What are the manifestations and roles of music in fictional and non-fictional literature
conveying narratives relevant to health?
– What are some of the ways in which the field of music therapy can be understood from a
health humanities perspective? Is there social legitimacy and economic viability in such a perspective? How can this perspective be differentiated from, yet play a complementary role with, a health science perspective?
Please Note: We also invite proposals for at least one broad-based colloquium addressing
more general relationships among the arts, humanities, and health (not necessarily centered
upon music).
We foresee the publication of papers (expanded, revised and submitted to a peer-review
process) in one or more volumes post-conference, according to principles of intellectual and
theoretical coherence that will give such publications editorial consistency.


Deadline is 1st April 2012.

For more information, see

For the online application, see

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