Portal de Periódicos da CAPES

Retrospective diagnosis of mental illness: past and present

2019; Elsevier BV; Volume: 7; Issue: 1 Linguagem: Inglês

10.1016/s2215-0366(19)30287-1

2215-0374

Mathias Schmidt, Saskia Wilhelmy, Dominik Groß,

Mental Health and Psychiatry

Each year, new publications are issued by doctors, (medical) historians, or publicists on suspected mental illnesses of deceased historical persons. Many of these expert opinions attract great public attention, especially when they concern the infamous and notorious, such as Adolf Hitler. What is the purpose of such retrospective diagnoses, why do they attract readers, what do they reveal about their authors, society, and medicine, and how should they be approached? The task of historians is to reconstruct past events to the highest degree of accuracy, and thus make use of traditional sources (ie, letters and personnel files) and contemporary illustrations. Medical historians are often limited in their efforts, especially in historiography of ill persons and reconstruction of their diseases.1Leven K-H "At times these ancient facts seem to lie before me like a patient on a hospital bed"—retrospective diagnosis and ancient medical history.in: Horstmanshoff HFJ Stol M Van Tilburg CR Magic and rationality in Ancient Near Eastern and Graeco-Roman medicine. Brill, Leiden and Boston, MA2004: 369-386Crossref Scopus (39) Google Scholar This limitation applies especially to mental illnesses, as some disorders cannot be objectified using laboratory parameters. In many cases of mental illness, little was known about their ontogenesis. General paresis of the insane offers a prototypical example: this neuropsychiatric disorder was originally considered to be a form of mental illness due to so-called dissolute character. For a long time, everyone—including the medical profession—was unaware that this disorder was a late form of syphilis. This absence of knowledge makes retrospective diagnoses difficult and susceptible to speculation, rumours, and conspiracy theories. In the case of mental illnesses, internationally uniform diagnostic criteria were only established with the introduction of ICD-6 (1948). However, these classifications are subject to continuous changes and thus these diagnostic criteria are not suitable for retrospective use. Diagnoses do not only depend on zeitgeist, but also on the social context in which they are made. Customs, environment, working conditions, nutrition, medical attitudes and practices, social interaction, and other factors, have, and have had, an influence on attribution of diseases.2Kohut TA Psychohistory as history.Am Hist Rev. 1986; 91: 336-354Crossref PubMed Scopus (19) Google Scholar Mental illnesses should be seen as social constructions.3Kleinman A Rethinking psychiatry. From cultural category to personal experience. The Free Press, New York, NY1988Google Scholar For example, what was considered as a psychiatric disorder in the past (eg, homosexuality) is nowadays considered a norm variant, and some disorders have no equivalent past disorder.4Richards G Of what is history of psychology a history?.Br J Hist Sci. 1987; 20: 201-211Crossref PubMed Scopus (51) Google Scholar In other words, medical knowledge is socially and culturally transformed. Thus, projection of disease categories and definitions into the past is an inadmissible simplification and an anachronism.1Leven K-H "At times these ancient facts seem to lie before me like a patient on a hospital bed"—retrospective diagnosis and ancient medical history.in: Horstmanshoff HFJ Stol M Van Tilburg CR Magic and rationality in Ancient Near Eastern and Graeco-Roman medicine. Brill, Leiden and Boston, MA2004: 369-386Crossref Scopus (39) Google Scholar, 5Karenberg A Retrospective diagnosis: use and abuse in medical historiography.Prague Med Rep. 2009; 110: 140-145PubMed Google Scholar For example, post-traumatic stress disorder cannot be projected into the past when terms such as shell shock, thousand-yard stare, combat fatigue, or combat stress reaction were used in connection with war trauma.6Jones E Fear NT Wessely S Shell shock and mild traumatic brain injury: a historical review.Am J Psychiatry. 2007; 164: 1641-1645Crossref PubMed Scopus (164) Google Scholar At best, we can draw parallels without equating; otherwise the past would be changed retroactively. An example in this context are soldiers who deserted in the First World War and are diagnosed with post-traumatic stress disorder retroactively. This approach is not possible because the concept of post-traumatic stress disorder is based on existing clinical and research developments.7Hacking I Indeterminacy in the past: on the recent discussion of chapter 17 of "Rewriting the soul".Hist Human Sci. 2003; 16: 117-124Crossref Scopus (13) Google Scholar, 8Young A The harmony of illusions: inventing post-traumatic stress disorder. Princeton University Press, Princeton, NJ1995Google Scholar Finally, written texts cannot be regarded as objective sources, but should be considered in terms of their subjectivity (pronounced in so-called ego documents, such as letters and autobiographies). Most historical documents were compiled for reasons other than those that interest modern researchers, in humanities and sciences alike. Standards of proof were also subtly different, especially when diagnosing and treating mental disorders. Undoubtedly, it is the task of historians to analyse and interpret past events and processes as well as the constitution of individual historical protagonists. But this means that historical research is not a matter of attributing retrospective diagnosis to a person, but of clarifying how contemporaries thought about the person's condition, how they came to their assessment, and how they dealt with the situation. Medical information in historical sources should not be simplified or instrumentalised. Modern-day medical pronouncements on the state of mind of historical persons are mostly characterised by three general characteristics. First, medical statements are often unscientific because they suggest historical accuracy that does not exist. Diagnoses are constructed and sometimes based on sources of authors who deliberately wanted to convey a specific image of a person. Therefore, doctors and historians should self-critically scrutinise retrospective diagnoses.1Leven K-H "At times these ancient facts seem to lie before me like a patient on a hospital bed"—retrospective diagnosis and ancient medical history.in: Horstmanshoff HFJ Stol M Van Tilburg CR Magic and rationality in Ancient Near Eastern and Graeco-Roman medicine. Brill, Leiden and Boston, MA2004: 369-386Crossref Scopus (39) Google Scholar, 5Karenberg A Retrospective diagnosis: use and abuse in medical historiography.Prague Med Rep. 2009; 110: 140-145PubMed Google Scholar No physician should make a diagnosis without examining the person concerned, especially if no medical records or medical data are available. The American Psychiatric Association explicitly requires this approach in The Goldwater Rule (1973): "it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorisation for such a statement".9American Psychiatric AssociationThe principles of medical ethics with annotations especially applicable to psychiatry.2013 edn. American Psychiatric Association, Arlington, VA2013Google Scholar, 10Kroll J Pouncey C The ethics of APA's Goldwater rule.J Am Acad Psychiatry Law. 2016; 44: 226-235PubMed Google Scholar Similarly, every historian is required not to rely uncritically on memory reports and memoirs from contemporary witnesses. No physician or historian should fall short of these professional standards. Second, statements might be one-dimensional because they try to explain multicausal historical developments in a monocausal way, reducing complex social interdependencies. Third, medical statements can also be morally questionable and irresponsible, especially if they provide simple explanations for far-reaching political events. For example, the highly quoted assumption that Hitler was mentally ill during his leadership reduces responsibility of the German people. The historian, Hannes Heer, summarised this premise in the title of his book Hitler war's. Die Befreiung der Deutschen von Ihrer Vergangenheit (It Was Hitler. The Exemption of the Germans from their Past).11Heer H Hitler war's. Die Befreiung der Deutschen von Ihrer Vergangenheit. Aufbau Verlag, Berlin2005Google Scholar Furthermore, this practice of exculpation regularly leads to questioning and uncertainty: what if Hitler had not caused the Second World War in his supposed delusional state? Such questions—known as "virtual history" or "counterfactual history"—do not contribute to investigation of historical events.12Evans RJ Altered pasts. Counterfactuals in history (The Menahem Stern Jerusalem lectures). Brandeis University Press, Waltham, MA2014Google Scholar Psychiatry and history work best in diagnosis when they apply rigorously the optimal methods of both disciplines, and physicians and historians should be aware of their responsibilities. This online publication has been corrected. The corrected version first appeared at thelancet.com/psychiatry on April 27, 2020 This online publication has been corrected. The corrected version first appeared at thelancet.com/psychiatry on April 27, 2020 We declare no competing interests. Correction to Lancet Psychiatry 2020; 7: 14–16Schmidt M, Wilhelmy S, Gross D. Retrospective diagnosis of mental illness: past and present. Lancet Psychiatry 2020; 7: 14–16—In this Comment, Mathias Schmidt and Saskia Wilhelmy contributed equally. This correction has been made to the online version as of April 27, 2020. Full-Text PDF