Book Review: Dancing Around Obsession

The problem with writing a book about a subject that sits on the interface between science and the humanities is that you will likely either not satisfy either side, or you will satisfy one side and not the other. So it is with Obsession: A History, by Lennard J. Davis, University of Chicago Press, 2008.

In modern clinical psychiatry, the essential features of obsessive-compulsive disorder (OCD) are recurrent obsessions or compulsions sufficiently severe to cause marked distress to the individual.

Examine the detail: "...sufficiently severe to cause marked distress..."

Clearly, if your obsession (the novel you're writing or your current research project or your ballet practice) gives you pleasure directly or indirectly (by providing you with an income) you are of no interest to clinical psychiatry.

There is no useful point in blurring the distinction between obsession as a clinical diagnostic entity in psychiatry and obsession as a description for certain kinds of behaviors that can be extremely productive. The clinical entity, OCD, involves serious dysfunction, and in fact nearly 70 percent of OCD patients sooner or later suffer major depression and become even more dysfunctional.

Professor Davis, who teaches at the University of Illinois at Chicago and whose major specialty is apparently English Literature, navigates an intellectual minefield is his attempt to conflate clinical psychiatry and the humanities. He's unhappy with how clinicians and neuroscientists deal with obsessive-compulsive disorder. He wants more attention paid to history and literary allusions to obsessive behavior and obsessive characters. He wants less reductionism in attempts to understand OCD. In other words, he wants more humanities in science. That sounds lovely, but for the clinician and scientist, the problem is that scientists and clinicians hardly ever find the humanities a useful backdrop in their daily sweat to understand how the brain works when it's healthy and not healthy. As for medicine, it's true that psychiatric categories are merely labels for clusters of symptoms, but it's also true that psychiatric categories of some kind are absolutely necessary in the clinic as a guide for what sort of behavior to expect from a patient. A psychiatric label is simply a practical device to assist in treatment. Unfortunately, these labels are too often misunderstood, misused, and bandied about in public as buzz-words -- but usually not by clinicians and scientists.

Any book on this subject is a difficult project, and each reader will have a positive or negative response depending on their own intellectual context. This book is a literate look at a humanities-science interface -- but maybe from only one side of the fence between the two cultures. Yes, the fence is still there, and after all these years it may even be more formidable.

Comments

[Josepj Tabbi]

(Sorry, I mistakenly posted this as a 'reply' to a specific comment when I had meant it to be an overall response to the review.)

I have ordered Obsession and so I navigated to Dan Agin's review, hoping to get a sense of what I will find in Professor Davis's book, as well as a scientist's viewpoint. But there is not so much as one citation or even a summary of Davis's argument or approach. Agin says the 'distinction' between creative and clinical obsession is 'blurred' by Davis. But then Again doesn't give a very clear definition of his own and in any case why should it matter to science, whether obsession reveals itself in creativity, in human pain and anxiety, or in some combination of these? I appreciate that there may be more funding to be had, by scientists seeking to cure illness than for studies offering insights into the creative imagination. But this is an economic and political issue, not in itself a justification for science to focus on one or another form of obsessive behavior.

[DHarrold]

As a senior medical student about to specialize in psychiatry, I’m very aware of the emphasis of neurobiology in the discipline, and thankful for the advances it has given us. However, I also know that mental illness is defined and diagnosed by so much more than neurotransmitters and genetics.

Isn’t it useful then, to expand our view of obsession beyond that of what we are typically exposed to as clinicians, to place it in a larger context that might shed some light on it?

I think Davis's blurring the distinction between obsession as a clinical diagnostic entity in psychiatry and obsession as a description for “certain kinds of behaviors that can be very productive” is a very useful way to think about where we draw the line between mentally healthy and mentally ill, and moves us to ask why.

I agree that psychiatric labels are practical devices used to assist in treatment, but they are imperfect and deserve ongoing examination; I think this area is ripe for input from the humanists. I disagree that clinicians and scientists usually aren’t the ones to misunderstand or misuse psychiatric labels. I’d argue that since the labels are so imperfect, they are always misused; not a small detail when one is treating patients.

The refusal to acknowledge the contributions the humanities can offer science in terms of thinking about what informs the definition, construction, and treatment of mental illness is an issue in psychiatry. Divorcing socio-cultural implications from science is bad medicine.

[Dan Agin - Huffpost Blogger]

Thanks for your comments. We just had eight years of a destructive "contribution" of the humanities to science: the banning of stem-cell research because of an argued violation of ethics. We had thousands of years of a destructive "contribution" of the humanities to medical education: the banning of cadaver autopsies because of various superstitious views about the human body. We had agonies in the 20th century involving destructive "contributions" of the humanities to science: the attempts of political movements on both Right and Left (Nazis and Soviet Communists) to control science, attempts that derived from one of the grand old men of the humanities, Political Philosophy. The list of destructive "contributions" of the humanities to science is endless. As I have written elsewhere, the two cultures articulated by C.P. Snow many years ago are still with us, more separate than ever, and the divide affects the education of every college student in America. The differences are so stark, the possibility of intellectual alliance seems hopeless. I think the most fundamental difference concerns where people look: science looks to the future, to new knowledge, to new possibilities, while the humanities look to the past, to tradition, to literary and artistic golden ages, to aesthetic ideals of past centuries. Throughout history, attempts by the humanities to shape and control science have led to too much human misery. So, as the saying goes, be careful about what you wish for. I truly want the humanities to flourish -- but science needs freedom.

[Lendavis]

Dan is speaking at a somewhat frustrating level of generality. If those caveats are well-known among OCD researchers, why do they not appear in any of their published work? I spent a good five years researching the subject and no professional article or book on OCD has mentioned such caveats. I would much appreciate any specific citations that Dan might have to back up rigorously his assertions. Anything short of that is, in my opinion, unscientific at best and mere assertion at worst. By the way, I don't think a good fallback position is to say that any of the people working in the intersection of science and the humanities believe that scientists are idiots. Critique does not involve any such demotion of character or intelligence but is offered in the spirit of the free exchange of ideas..

[Dan Agin - Huffpost Blogger]

This is getting off-base about old stuff, but read the first chapter of Turner and Hersen (1997): Adult Psychopathology and Diagnosis. The chapter title is: "Mental Disorders as Discrete Clinical Conditions: Dimensional versus Categorical Classification". With about 80 references. In general, it's a mistake to underestimate the capacity of scientists to doubt themselves, since doubt is probably the most important characteristic of research in science. The literature in modern psychiatric research and psychiatry in general is filled with doubt; see especially books by Thomas Szasz and E. Fuller Torrey. As for brain research, there's a frenzy of doubt going back to Descartes. It might be a good thing if more people in some branches of the humanities doubted their "truths" as often as scientists do. Thanks for all your comments.

[Dan Agin - Huffpost Blogger]

Concerning OCD, here's a typical qualification in a recent published study:

"The vast heterogeneity of the disorder and the limitations of some studies, which do not control the influence of variables such as comorbidity and medication, do not allow more definitive conclusions."

Martínez-González AE, Piqueras-Rodríguez JA. Neuropsychological update on obsessive-­compulsive disorder. Rev Neurol. 2008 May 16-31;46(1­0):618-25. (in Spanish)

You will find such qualification throughout the literature, not in every paper because it's trivial and understood.

Here's another statement from a recent review of OCD:

"the nature of the obsessions and compulsions can vary greatly between individuals with similar ratings of disease severity, and this has led some researchers to question the value of treating OCD as a single nosological entity."

S.R. Chamberlaina, A.D. Blackwella, N.A. Finebergb, T.W. Robbinsc and B.J. Sahakiana. (2005). The neuropsychology of obsessive compulsive disorder: the importance of failures in cognitive and behavioural inhibition as candidate endophenotypic markers. Neuroscience & Biobehavioral Reviews. 29:399-419.

[Lendavis]

Sorry, I made a very long comment and had to break it up into three sections. You should beging with the "Dan" comment and then read the "relevant points" comments, and finally the "so given" one.
LJD

[Lendavis]

So given all those caveats, mediated by cultural concerns and also simply logical concerns--why would you believe that OCD is a discreet and monolithic disease which exists over all times and all cultures and that you can find in the brain as such? If you can't make that claim, then how can you assume there will be discreet neurological data that will apply exclusive to the entity you are now calling OCD? The job of the humanist here is to provide the cultural queries and ask some of the hard conceptual questions that your training may not necessarily have caused you to ask. And if your training has caused you to ask it, then you've stepped over into cultural studies, and I'd say "Welcome!"
By the way, we have at UIC a monthly meeting of scientists and humanists--perhaps you'd like to attend or even better present your position and we could continue this discussion in a more collegial way.

[Dan Agin - Huffpost Blogger]

Hello, Lennard. I assure you that all your caveats are already well known to anyone who does research on the brain and its dysfunctions. The verbal classifications of psychiatric symptoms are of little current importance in neuroscience, since everyone, basic neuroscientists and research psychiatrists alike, understands that the classifications are more a matter of clinical expediency, indications of probable patient behavior as case reports are passed from one mental health worker to the next, and satisfaction of requirements for patient applications for health insurance. Psychiatric diagnostic categories are devices only. I assure you that no research neuroscientist works with a copy of DSM-IV on his or her desk. You accuse me of assuming an isolated neurological substrate for OCD, but I make no such assumption at all. Every neuroscientist understands that our mundane verbal categorizations of behavior, our labels, may have little to do with the actual working of the brain. Finally, as for humanists in general who focus on the sciences, it would be helpful to everyone if there were some understanding that people who work as scientists are not idiots; they are fully aware of the limitations of what they do, and that's particularly true of brain research. Your caveats are all already in the scientific and clinical literature on OCD, schizophrenia, autism, and so on, and it's unfortunate if the general public is given a wrong impresssion about that. Anyway, thanks for your comments.

[JayClayton]

Lennard Davis's three-part reply to Dan Agin outlines a powerful way in which the humanities can be of use to ongoing scientific inquiry. Dan Agin's reply that "all [Davis's] caveats are already well known to anyone who does research on the brain and its dysfunctions" seems true to me, as well. Unfortunately, those caveats are not well known to regulators, insurance companies, educators, journalists, consumers, patients, and many practicing physicians. Perhaps the audience for humanities scholarship on science should not be scientists themselves--or even the medical community--but the policy makers who shape funding priorities and develop regulatory structures. I suspect Davis does not agree with this last point, but until humanities scholars find ways to address this other audience, they will continue to be accused of thinking scientists are "idiots."

[Lendavis]

The relevant points I make, which perhaps you didn't focus on the first time around, are that 1) OCD isn't a simple disease--it is one that is made by committee (the folks at the DSM IV TR and now the DSM V), it is an arbitrary though perhaps useful conglomerate of symptoms that can and is organized differently under different cultures and circumstances, 2) its meteoric rise (600 per cent ) from a completely rare disease to the fourth most common mental disorder is inexplicable from the point of view of brain chemistry or function--it seems to be a highly culturally influenced increase, 3) the issue of pain and suffering caused by the disorder seems to have a large cultural and moral component--you won't mind washing your hands and muttering phrases if your are, say, and orthodox jew, you won't mind checking behavior if you are in a dangerous war zone or polluted area, religious people have higher rates of OCD, if your partner now "knows" through a checklist provided in a magazine that you have the required symtoms, they may suggest treatment, etc. 4) so far the evidence indicates a widely varying data set for brain location, genetic location, and neurochemistry so that no explanation or even valid partial explanation has emerged in any consensus way.

[Lendavis]

Dan, if I may, as a neuroscientist, your job is to find a neurological basis for the disease OCD. You've got a fairly simple and straight forward task as you see it. Why in the world would you want a humanist to come into your lab? And from your point of view the humanist would be of no help. You see the humanist as equipped with novels and poetry, theories about cultural studies, and some interesting if relatively meaningless philosophy for you to contemplate as your do your bench work. That is precisely not the model that most of us humanists currently interested in the sciences are operating under. I'm wondering if there is perhaps a generation gap at work here, and that we new biocultual humanists need to do a better job of explaining what exactly our contribution might be. I think I try to do that in my book Obsession: A History.

[JayClayton]

Dan Agin may be right when he asserts that “scientists and clinicians hardly ever find the humanities a useful backdrop in their daily sweat to understand how the brain works when it's healthy and not healthy.” Although many scientists have an abiding interest in literature, history, philosophy, and art, it is rarely an interest that guides their clinical investigations. No surprise. Disciplinary specialization is a necessary component of advanced research in virtually every area of the humanities as well as the sciences.
That is why transdisciplinary approaches to difficult problems such as OCD are so important. “Straddling disciplinary boundaries” may not be the answer, as Agin says in his reply to Tess Jones, but neither is ruling out alternative approaches tout court. The practical problem of OCD is best tackled from multiple disciplinary perspectives at once. When national policy committees formulate guidelines for further research in this area, they will want to take Lennard Davis’s interesting book into account, alongside studies by neurscientists, psychiatrists, legal theorists, patients, and many others. They may well want Lenny Davis himself on those committees.

[Dan Agin - Huffpost Blogger]

Thanks for your comment. We will see what national policy committees do or don't do. Brain research is not the same as public policy about psychiatric disorders, and most scientists reject the idea that any injection of humanities into their work would necessarily be helpful. A recent review of the Davis book in the journal Nature (15 January 2009 457:266) concluded: "By presenting science as excessively reductionist and as responsible for the mis- or over-diagnosis of obsession, his arguments for reclassifying the disease remain incomplete and lack scientific rigour."

[WildlyParenthetical]

I haven't read Davis' book, but I do work in a similar area. The question for me is, in the diagnostic category of 'causing marked distress', what, precisely, causes the distress? Some would say OCD, and yet even Agin observes that if your obsession earns you money, it's unlikely to be a psychiatric symptom. Thus what makes something a symptom is not given by the symptom itself, nor by the brain, but by how particular behaviours are situated within a given culture. What defines something as a symptom is not, in the end, a psychiatric matter. Which means that psychiatrists really need to be able to engage with the context within which that symptom occurs; what makes a particular behaviour problematic? Yes, severe distress, but what produces that distress? A mismatch between the expectations of the context within which the person works, and that person's behaviours.

You might say that none of this matters, but as has already been pointed out, the use of psychiatric drugs is already re-setting the bar for what counts as 'normal' within our cultural context. As a result, more people are falling outside 'normal behaviour' and this, then, causes the distress which is apparently key to rendering something a psychiatric symptom. Thus ipsychiatrists need to begin to engage with understandings of the world which do not treat the brain as if it occurs in a vacuum, because to do otherwise is to reproduce and expand the very problem they are supposedly seeking to address.

[TessJones]

Most of the scholars and educators in the multi- and interdisciplinary fields of medical humanities and cultural studies of medicine might be somewhat chagrined but not surprised to learn that there are still educated and thoughtful individuals such as Mr. Agin who still view their work as "lovely." Humanities faculty have now been theorizing, publishing, conducting research, teaching and contributing to the culture of heath care education and delivery alongside their colleagues in the basic and clinical sciences for over thirty years. Our professional organization, the American Society of Bioethics and Humanities, has past its tenth anniversary, and three major American scholarly journals have been published in the field of medical humanities for approximately fifteen years (In the interest of full disclosure, I am the editor of the JOURNAL OF MEDICAL HUMANITIES which is published by Springer). While those of us whose home disciplines might include literature, philosophy, women's studies, cultural studies, and visual arts are still on occasion considered as "window dressing" or "eye candy" in medical education, most of us have earned the respect and garnered the admiration of our colleagues but most importantly, our students who are far more comfortable with challenging and transcending that artificial boundary between science and art--the legacy of Enlightment philosophy whose boundaries divide and oppose everything from mind/body, reason/emotion, objective/­subjective­, male/female, and technologi­c/aestheti­c. Oh...and serious/lovely.

[Dan Agin - Huffpost Blogger]

Thanks for your comment. If the issue is the substantive intellectual connection between the humanities and the practice of medicine, I have no disagreement with you, none at all. But if the issue is the source of present and future contributions to biological psychiatry that will explain the etiology of OCD and provide rationales for treatment, then I don't think such contributions are coming from the humanities or from journals devoted to the interface between the humanities and the practice of medicine. OCD remains a research problem in medical and neuroscience. Turn the cart around and imagine what your reaction would be to neuroscientists advising you how to do research in literature, philosophy, cultural studies, and so on. Straddling disciplinary boundaries as an academic exercise is fine and can lead to useful philosophical and cultural insights, but the immediate practical problem is the neurobiological cause of OCD and how to treat it. Where do we put our energies for this problem? In literature, philosophy, and culture studies? I do think the energies belong in science, and it's hard for me to believe that you disagree with that. But I don't know, maybe you do, and if you do, the wall seems insurmountable.

[Warren Goldstein - Huffpost Blogger]

I'm with Davis, here, who clearly shows the ability to read science AND language. Agin, on the other hand, seems to think that this phrase-- "...sufficiently severe to cause marked distress..­."--offers real clarity to the clinical psychiatric profession. No wonder my college students are overmedicated and overdiagnosed when they get to college, filled with claptrap about their long list of learning disabilities (reading comprehension, aural comprehension). At least three words in that allegedly "clinical" category cry out for interpretation: "sufficiently," "marked," and "distress." Even so-called scientists need to rely on language, the province by and large of the humanities, to make sense of their own work to themselves and to others. Trying to build a conceptual fence between their discipline and the rest of us, doesn't necessarily help them understand our symptoms, distress, or disorders. This is finally a small-minded review, only meant to reinforce disciplinary doctrine; fortunately, like most such efforts, it fails.

[Lendavis]

I am the author of Obsession: A History. I appreciate some of the comments of Dag Agin, but his too quick and easy dismissal of a project that questions the dividing line between the sciences and the humanities is worth noting. He thinks I want psychiatrists to read more literary works...I don't. I want them to start thinking more like scientists and to take a long hard look at their own claims to being scientific. Rather than respond to the substantial information I develop about the problems with diagnosis, the issues around trying to use fMRI's and PET scans to localize the "place" in the brain where OCD resides (an impossible task since OCD may well not be an "entity" but rather might be a convenient cubby hole in which to put a list of symptom) You can see the profound confusion in Agin's own sentences: diagnoses are "merely labels" but also "absolutely necessary" and at the same time a diagnosis is "simply a practical device." What kind of logic or lack of logic is involved in that formulation? If diagnoses are practical devices, then what exactly is being treated-- just some amorphous conceptual category? My point throughout is that the DSR and psychiatry in general needs a more rigorous, not more literary, approach to its own concepts. It is not a surprise that psychiatry is considered one of the least rigorous medical specialties and one that is based on poor, confusing, and unsystematically thought out principles.

[Dan Agin - Huffpost Blogger]

Thanks for your comment. I think in your post here you're not accounting for the reality that since science does not yet know how the brain works, diagnostics and treatment must be constrained by pragmatism, by what seems to work. For this, labeling and categories of symptoms in the clinic are essential. Diagnostics and treatment according to etiology are not yet possible because brain science is not advanced enough. Certainly the answer is not to close the clinics, but to do more brain science, which requires enormous government support. Your complaint that "psychiatry is considered one of the least rigorous medical specialties and one that is based on poor, confusing, and unsystematically thought out principles" suggests you believe that at the present time there's a better way to do clinical psychiatry. It may happen as biological psychiatry advances, but we're not there yet. Meanwhile, people who are distressed by psychiatric symptoms do want and need treatment. Psychiatrists are not to be blamed as individuals for the complexity of the human brain. If anyone is to be blamed, it's legislators who think aircraft carriers are more important than scientific and medical research laboratories.

[Pierogi]

Thank you for your review. As someone who suffers from OCD, I found the book's treament of the disorder to be obtuse. There is a reason why OCD is classified as an anxiety disorder. The obsessions that sufferers experience are unwanted, intrusive, extremely distressing, and often shameful and embarrassing. Those who suffer from OCD turn to psychiatry for some relief from their torment, not for aesthetic perspective. The literary approach to psychiatry (Freudianism) has proved to be a disastrous failure. There is no need to repeat such mistakes.

[Josepj Tabbi]

I have ordered Obsession and so I navigated to Dan Agin's review, hoping to get a sense of what I will find in Professor Davis's book, as well as a scientist's viewpoint. But there is not so much as one citation or even a summary of Davis's argument or approach. Agin says the 'distinction' between creative and clinical obsession is 'blurred' by Davis. But then Again doesn't give a very clear definition of his own and in any case why should it matter to science, whether obsession reveals itself in creativity, in human pain and anxiety, or in some combination of these? I appreciate that there may be more funding to be had, by scientists seeking to cure illness than for studies offering insights into the creative imagination. But this is an economic and political issue, not in itself a justification for science to focus on one or another form of obsessive behavior.