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by E. Fuller Torrey and Judy Miller
Rutgers University Press, 2002
Review by Duncan Double on Jul 8th 2002

The Invisible Plague

This book sets out to prove that an epidemic of insanity has taken place over recent centuries. It argues that a "plague of brain dysfunction" has occurred largely unnoticed. The implication is that the asylums should not have been emptied without ensuring adequate treatment to control the epidemic. Believing that insanity has always been with us in its present form is said to be a fundamental misunderstanding of its essence.

 Historical material is analysed to suggest that insanity was not a major problem in the seventeenth century. Records, including literary works, from England, Ireland, Canada and the United States are considered to demonstrate that the rising incidence of insanity started to be of concern at the end of the eighteenth century. The official view was that the disproportionate increase in the number of people confined in asylums compared to the population increase was only an "apparent" rather than a real increase in insanity. The book prefers instead the more straightforward, popular view that epidemic insanity is genuine.

"Anti-psychiatry" is blamed for neutralizing the issue of epidemic insanity by arguing that mental illness does not exist. Historians of psychiatry who point out that the availability of institutional facilities encouraged increasing confinement are dismissed. As far as the book is concerned, asylums were not built for social or economic reasons, but merely to respond to the epidemic. The prevalence of insanity since the middle of the twentieth century is said to be unclear, because dehospitalization and the move to community care have made accurate counts more difficult. In fact, the indications are said to point to a continuing increase, at least in Canada and the United States.

The book's thesis is that a concomitant factor of industrialisation and urbanisation must have caused the increase in insanity. Stress is excluded as a possible factor as there is said to be no evidence that stress causes insanity and, contrary to expectations, the World Wars and Great Depression did not produce an increase in severe psychiatric disorders. Further research is suggested to look for correlations with diet, improved obstetrical care, toxins and infectious agents, amongst other factors.

The book makes the assumption that schizophrenia and manic-depression are brain diseases. The rest of its thesis follows naturally. If insanity is entirely physical, uninfluenced by social factors, then the increase in numbers of people identified as insane must be real.

Such a proposition flies in the face of the facts. Psychiatric diagnosis may at least be unreliable and possibly at times invalid. Psychiatric practice is about social control, even if diagnoses are based on individual factors. Understanding the reasons for mental health problems is not helped by postulating brain pathology as their cause.

Although the book's perspective that social and cultural factors are totally irrelevant is extreme, research has consistently underestimated their importance. For example, it is commonly stated that the incidence of schizophrenia is the same the world over, ignoring variations in the presentation of symptomatology. Furthermore, outcome is variable across the world, at least influenced by treatment differences.

In Japan, the number of in-patients has increased from the 1950s, while that of England has decreased. Most Japanese in-patients are admitted compulsorily, whereas most are admitted informally in England. Does the Japanese data disprove the book's hypothesis, or is it evidence that the people in Japan have been exposed more recently to the same physical factors associated with industrialisation and urbanisation that caused insanity earlier in the developed world?

I enjoyed the literary references in the book. I did not take pleasure in much else and was annoyed by its speculations. I accept there are difficulties in deciding the legitimacy of biological causes of mental illness, but this book regards physical pathology as the proven basis for mental illness. Admittedly, much of psychiatric thinking agrees with this conjecture. In some ways, this book is more consistent in excluding a role for psychogenesis altogether, whereas mainstream psychiatry does recognise a stress‑diathesis.

I am sure that mental health problems have changed over the years and that mental illness is part of the human condition. Otherwise, I seem to be coming at the issues raised by the book from the polar opposite direction. I do not think the social role of psychiatry can be avoided. To argue that the rise of the asylum reflected a brain illness epidemic is trite and simplistic. In my view, the book is not a scholarly historical study. Don't read it, unless you are interested in its prejudices.

 

© 2002 Duncan Double

 

Duncan Double, Consultant Psychiatrist and Honorary Senior Lecturer, Norfolk Mental Health Care Trust and University of East Anglia, UK; Website Editor, Critical Psychiatry Network.


Reply to Duncan Double’s review, sent July 18, 2002:

Our book is, indeed, based on the assumption that schizophrenia and bipolar disorder are diseases of the brain, just as are Parkinson’s disease and Alzheimer’s disease.  The evidence for this is overwhelming, and it is unusual now to find a psychiatrist who questions this fact.  Social and cultural factors may influence the expression of psychotic symptoms and the relative availability of hospital beds, but they do not influence the incidence of schizophrenia any more than they influence the incidence of Parkinson’s disease.

E. Fuller Torrey, M.D.
Judy Miller



Duncan Double responds: July 18, 2002:

I am pleased the authors have confirmed that I have understood their book. I agree that it is unusual for psychiatrists to question the hypothesis that mental illness is caused by brain pathology. Such a view is almost heretical in the state of modern psychiatry, which I think should be of concern for society as a whole. The Critical Psychiatry Network does not believe that psychiatric practice needs to be justified by postulating brain pathology as the basis for mental illness.