Suckling Pigs, Stray Dogs, and Psychiatric Diagnoses

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IThe Order of Things, Michel Foucault, the great French philosopher cites a ‘certain Chinese encyclopedia’ that notes ‘animals are divided into: (a) belonging to the Emperor, (b) embalmed, (c) tame, (d) suckling pigs, (e) sirens, (f) fabulous, (g) stray dogs, (h) included in the present classification, (i) frenzied, (j) innumerable, (k) drawn with a very fine camelhair brush, (l) et cetera, (m) having just broken the water pitcher, (n) that from a long way off look like flies’.

The contemporary reader may look on at this classification of animals with amusement and bewilderment or contempt and derision. Yet, the same level of sophistication bedevils our classification of morbid mental life today, as catalogued in the Diagnostic and Statistical Manual of Mental Disorders, the official psychiatric bible. This cultural document, its current permutation a product of fin-de-siècle America, holds up emotions, behaviors, and beliefs deemed pathological as if they exist in external nature as timeless, universal ‘things’ and aims to define and classify them.

Attempting to avoid any reference to the causal basis of the disorders listed within, it also ignores the values, meanings, and assumptions imbued within the system of classification or the context in which these ‘disorders’ are experienced. About to enter its fifth revision, the DSM has been encircled in debates regarding which elements of mental life should be recognized as morbid, which disorders should bow their farewell, and where the disorders that are included should be classified. These debates miss the point. Without acknowledging the inherent meaning making in any system of classification, and the context in which mental life is defined as disorder and then categorized, the book is not only not valid, it is not useful.

A Brief History of Psychiatric Classification

Attempts at classifying elements of morbid mental life are not new. The first known system dates back to 1400 BCE India, and the Ayurveda, which regarded aberrant mental states as resulting from different forms of possession. In the West, Hippocrates, Arataeus of Cappadocia, and Galen also tried their hand at categorizing madness. Nor were they the only ones. Throughout the intervening years a number of physicians, philosophers and theologians delineated their own classifications of mental disorder. It was not until the 19th century, however, that classifications of mental disorder came from careful observation of the apparent causes, clinical course, and prognosis to differentiate different forms of madness.

Esquirol, more than anyone ushered in this era and noted five types of madness including lypemania (melancholy), mania, monomania, dementia, and idiocy. It was the German Psychiatrist Emil Kraepelin though that made the most detailed study of the classification of mental disorder, which was his life’s work and he refined his classification over eight editions of his famous Textbook of Clinical Psychiatry. The final classification included mostly medical problems including traumatic brain injury, epilepsy, syphilis, intoxication, infection, thyroid disease, and abnormal mental states in the context of brain disease.

His most enduring contribution to psychiatry was taking the “amorphous mass of madness” that existed before and separating it into manic-depressive insanity (which includes depression and bipolar states today), and dementia praecox (today’s schizophrenia). Dementia praecox was further divided into the hebephrenic, catatonic, and paranoid types. Amazingly, Kraepelin’s classification is the basis for our current psychiatric classification some 90 years later.

Why this long trend in classifying pathological mental states? By defining the unknown, and classifying psychopathology, we bring an element of knowability to that which we do not know. Further, we create the illusion and indulge in the deception of knowing more about that which we do not know than we do.

It is only natural that humans should try to reason with unreason, to order to disorder, to dispassionately delineate the boundaries between sanity and madness. It is ironic then, that this attempt at understanding and demystifying abnormal mental states, should have compounded the sense of otherness and alienation endured by those experiencing mental distress.

Is depression even a mood disorder?

The DSM attempts to catalog different aspects of mental life together that share some element of commonality. For example, depression and mania are classified as mood disorders, whilst generalized anxiety disorder, specific phobia, and social phobia are classified as anxiety disorders. It would seem to make intuitive sense to file major depressive disorder under the rubric of mood disorders, and generalized anxiety under the rubric of anxiety disorders. It’s in the names after all.

When we come to closer inspect the experience that is labeled as depression in the DSM, we discover that one does not even need to experience depressed mood to be diagnosed with depression. For many people, the experience is instead characterized by the inability to derive any joy from their existence, from persistent feelings of stress and worry, endlessly ruminating about the past, feelings of inadequacy, self-loathing and worthlessness.

It is almost as if the experience of ‘depression’ for these individuals is summed up by thinking too much. Indeed, the concept of depression does not exist for the Shona people of Zimbabwe. Instead, what would get labeled as depression in the West is called Kufungisisa in Zimbabwe, which means, “thinking too much”.

For others the experience of depression is not characterized by thinking too much or depressed mood. It is instead felt as a profoundly visceral sapping of the vital forces, of unending fatigue, heaviness, nausea, malaise, tinnitus, and unexplained aches and pains. The appetite has waned, sleep sparse and fitful. It is an extremely physical experience.

In China, the concept of depression does not exist, and despite attempts to make the diagnosis, it is not accepted. Instead, what would be understood as depression in the West is diagnosed as neurasthenia. Once regarded as an American disease, today it has been expunged from the American psychiatric classification as if it never existed. Even the selection of a particular aspect of mental experience as a hallmark as a whole category of disorders is a cultural act, laden with assumptions.

That generalized anxiety disorder should be grouped with other anxiety disorders and not depression is also more puzzling than might appear. For the Shona people of Zimbabwe, the idea of “thinking too much” might equally be diagnosed as generalized anxiety disorder or major depression in the West. It turns out there is so much overlap between the two experiences, that the idea of mixed-anxiety and depression is a common one in primary care. Intriguingly, this overlap was not always the case.

In the previous edition of the DSM, generalized anxiety disorder had different diagnostic criteria altogether. Instead of focusing on symptoms of worry, or constructing anxiety in cognitive terms, generalized anxiety disorder was a fear-based diagnosis, constructed in somatic terms. The experience was seen as characterized by persistent sweating, shakiness, tremulousness, being on edge, experiencing palpitations, breathlessness, a sinking sensation in the stomach, a sense of impending doom.

Just as neurasthenia (a physical experience and diagnosis) was supplanted by the more psychologically experienced depression, a somatically or fear-based anxiety disorder, has been supplanted by a more psychologically experienced anxiety disorder. As we become more psychologically minded, the way we experience distress is transformed from a somatic idiom to a psychic one.

The Problem with Psychiatric Classification

The process of psychiatric classification is weaved together with the assumption that with each new edition some new truth has been discovered, a new disorder unveiled, the boundaries between mental health and mental illness more firmly delineated, that the process is the result of scientific progress. But as Foucault demonstrated throughout his life, what appears as progress in seeing the world are merely different ways of seeing, they are not necessarily better.

In the pursuit of scientific progress, our system of psychiatric classification has attempted to uniformly describe the acceptable ways in which one can go mad, as if to lose one’s mind was a uniform, discrete experience discontinuous from the experiences of sadness, joy, fear, disgust, and terror we experience in our daily lives.

A psychiatric classification that ignores the wider sociocultural forces at work rather than taking these to the heart of the matter is woefully misguided. A psychiatric classification that attempts to homogenize madness, rather than accept the enormous variation in the experience of mental distress and the process of meaning making has missed the point. I will continue to dutifully document my multi-axial diagnoses in my notes. But like the DSM, my notes will be most salient not for what has been written, but for what has not been written.

 

 

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13 COMMENTS

  1. Dr. Datta,

    Good job on writing the historical review of the system of classifications.

    I’m reminded of what my mentor of long ago, Dr. George Saslow always said when I came to him for supervision:

    “Don’t tell me a diagnosis. Tell me about the patient.”

    It was clear to me that he believed sticking psychiatric labels over people kept you from understanding what was going on and how to help.

    I would like to hear what you think about the financial conflicts of interest that have gone into the making of the DSM. Is there any treatment purpose in sticking labels on a person?

    All the best.

    Keep reading, thinking and writing.

    Alice Keys MD

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    • I think that maxim has now changed to “don’t tell me about the patient. tell me the diagnosis”!

      I think the DSM-5 has received a lot of criticism (including from the hypocrites who are just sour they were excluded from the gravy train) re: conflicts of interest, being closed etc. The DSM-5 process has been the most open to scrutiny, with the tightest requirements for financial conflicts of any of the editions. I also think a lot of stock is put into how important the DSM is or isn’t in curtailing the medicalization of normal behavior. The reality is that clinicians don’t pay all that much attention to the DSM anyway, we all know how many patients who do not meet DSM criteria have somehow got a diagnosis of bipolar disorder etc.

      I do think diagnosis does have some importance of course. It is helpful to identify primary causes of psychopathology. It also has a social utility in allowing individuals protection under the ADA or to get access to benefits and special services. The over-emphasis of diagnosis-making came about in the 1970s when psychiatrists were losing ground to other mental health providers who could offer psychotherapy for less. As physicians, psychiatrists were able to carve out a new niche for themselves, not in psychoanalysis, but in making diagnoses, something only doctors could do. Now of course psychologists, PAs, NPs, even social workers can make diagnoses, the relevance of the act of diagnosis making as an inherently medical enterprise has been lost.

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  2. Vivek,

    Thanks very much for this helpful historical explanation, and for bringing Foucault into the discussion; he has a lot to say about these things, I think. Allow me to push that invocation a bit further, and perhaps provocatively, and I’d love to get your and others’ thoughts.

    I think there’s more of a problem than a new system of classification being not necessarily better than another (though your point is well taken there) and the current system missing the point. I’d suggest that in a very real sense the current system hits the point with great precision–it’s just the wrong point, if one is concerned with actual human beings, rather than an abstract system of control.

    Classification, as I think is implicit in your writing, is inevitable, simply one of the foundations of human thought. It can be more or less complex or “sophisticated” for a given realm. Perhaps even more important than the level of complexity are the uses to which a classification scheme are put. So, we’ve all heard probably how eskimos have dozens (hundreds?) of words to describe snow and ice. A very useful, good thing for them.

    What the DSM does, in my view, is provide classifications that perhaps at their best can be helpful pragmatically, just like the eskimos different types of snow; if you can name something, you can talk about it and begin to understand it. But the other thing it does is act as a symbolic tool of biopower (a la Foucault) that is crucial to the larger project of normalization of modern citizens and workers. It doesnt just give us terms of dubious value for personal well-being, it provides a framework for putting individuals in boxes and encouraging them or at times forcing them to tamp down their underlying and unruly (and I’d say often very healthily so) emotional states. The mind is a complex system verging on chaos at times; to clamp down on this sort of system, as is the norm these days, is very unhealthy. But the system is not after healthy minds so much as it is after productive subjects, in Foucault’s terms.

    It seems to me that antidepressants (which I spent the better part of ten years trying to get off of, finally successful last year) are essentially micro-capitalist tools for suppressing the symptoms of modern malaise and agony. In the process they both serve as explicit profit centers and as normalizing enforcement devices at the individual level. They help keep us nice complacent cogs in the big wheel. So I’d suggset, from a certain view, that this is precisely the point of the larger project, at a social and political-economic level.

    Where it gets really interesting for me is looking at the current resurgence of interest in psychedelics for treatment of a variety of psychic difficulties, but a one-time or occasional treatment that facilitates the self-healing of an active, organic psyche, as opposed to treating it as a passive vessel into which chemicals are to be poured. I don’t think it’s a coincidence or a surprise that the system clamps down on medicines that help expand the mind and the scope of human freedom (and are neither patentable nor addictive or dependence-causing) even as it promotes a variety of others that numb out, tamp down, and constrict the psyche–and of course have to be taken every day and result in considerable dependence, and sometimes in the need for still more drugs…and so on.

    As you can tell, my thinking is preliminary here, many more dots to connect. But it seems to me you are very much on the mark bringing in Foucault and I’d love to see if you have further thoughts and perhaps if you and maybe others with such interests would like to begin an exploratory dialogue on this. I am at dss1209 at gee mail.

    Many, many thanks!

    Daniel

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    • Thanks Daniel, you make a lot of interesting points. I don’t psychiatric drugs were designed to suppress individuals, but they have been used in that way. The same is true for psychoanalytic therapies, and CBT of course as I have written elsewhere. Psychiatric and psychological interventions are too often focused at the level of the individual rather than looking at the individual in the social world. It was with psychoanalytic ideas, not psychiatric diagnoses or drugs that American Psychiatry came to first to suppress discontent, the drugs revolution was the logical extension and allowed many more individuals with seditious murmuring to be dampened.

      I am also interested in the therapeutic potential of psychedelics. I do think it is misguided to see psychedelics as somehow apart from prescribed psychiatric drugs especially given that there is cross over in how they act on the brain. There is nothing inherently expanding about psychedelics, just as there is nothing inherently suppressing about neuroleptics. It is all about how these agents are used.

      vivek

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      • This is a very important point about HOW the drugs are used. I’m reminded of the psychotomimetic hypotheses vis. psychedelics and CIA and military attempts to use them in mind control (though not very successful, I believe; with enough stress they can, indeed, induce psychosis, but that’s hardly a controlled state!); and also the suggestion, I think borne out for some, that SSRIs can actually help make psychotherapy more effective–if things are a little less dark people can work more easily with emotional issues.

        I do find myself having to check a certain knee-jerk assumption about dichotomy between the two classes of drugs. (That tendency borne of bad experience with the one, good experience with the other.) Certainly, yes, they both affect neurotransmitters, but could you expand a bit on the similarities you see or why the contrast I suggest is off base?

        Do they not typically take people in quite different directions? My experience, I believe pretty much in line with the great majority of reports from others and from scientific research, has been that psychedelics, when used with care and appropriate preparation, are mind-expanding in the sense of opening up a perceptual window that allows for greater spiritual connection and awareness and for getting in touch with repressed emotions and memories; as well as often facilitating increased creativity. “Expanding” and “opening up” and “connecting” are, I would say, the most common terms people use to sum up the experience. My experience with SSRIs was in most respects quite the opposite–a tamping down, rather than opening up, of various emotional states–and I BELIEVE this is a common experience. Then there is the very transient nature of psychedelics vs. the need for continuous use of SSRIs and other mainstream drugs.

        That’s my take, from personal experience and quite a lot of reading, but I do have to admit that my understanding of the neurophysiology involved is rather poor. Any further thoughts?

        THANKS,

        DS

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        • p.s. There may also be something of a semantic issue here. I refer to SSRIs as tamping down or muting emotional states. But of course if one feels really rotten, muting that negative state can feel quite positive. At least in the short term; I’d say, in the long-term, it’s more of a band-aid that fails to do much about underlying causes. I expect you’d agree with that, but the paradox involved here seems worth pointing out.

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          • Well many people do experience some element of emotional blunting or inability to feel with antidepressants. But others report the ability to feel emotion for the first time in years, others still experience intensity of emotions with these drugs.Many people experience no discernible effect at all. Vivid dreams are commonly reported by those using SRIs. It’s quite variable.

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    • I appreciate your thinking here in this comment, Daniel! Biopsychiatry objectifies “consumers” by presuming a pill(s) could possibly satisfy the infinite longings of the human psyche, heart, and mind.

      Humans may naturally desire to categorize but only human folly could attempt to contain the nature of a human mind (and its unwritten human potential) in a label on behavioral “symptoms” while lacking genuine objective scientific markers. Psychiatry in the western world presently gets carte blanche to commit wide-scale societal guinea pig neuro-experimentation on people who are caught misbehaving/underperforming at the “wrong time, wrong place”. Glad to hear you escaped your AD addiction.

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  3. Great post!

    For me, two of the (many) big flaws about the DSM are:
    – using discrete categories,
    – trying to define a clear boundary between normal and ill.

    I think those two flaws were a significant factor in having most people believing the syndromes were valid diseases (making DSM extremely toxic). A multi-dimensional classification based on trying to define non-pathological personality traits (with the understanding that some extreme combinations are pathological but without defining any specific threeshold) might have been a better first step in trying to establish a common language among psychiatrists.

    On a related subject, what do you think about the NIMH RDoC (Research Domain Criteria) project?

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    • Well the categorical vs dimensional debate is an interesting one, but there are major problems with a wholly dimensional approach to classification as well. The dynamic approach to psychopathology that preceded our current approach was more fluid and the problem there was that because there was no clear boundary between mental health and illness, everyone could be viewed as mentally ill. The corrolary of discrete categories (at its extreme) was the unitary concept of madness, popularized by Karl Menninger which saw different aberrant mental states as varying only in degree and not in type.

      Some people are entirely anti-positivism and thus reject the notion of classification. I don’t. I think for purposes in research there can be utility in having a positivistic way of seeing. I also think it is important to acknowledge what is lost by doing so, and the inherent loss of essence that goes with it.

      The main problem with the DSM except for what I have already mentioned, is not really about its categorical nature. It is that the categories are not valid. They were never meant to be. DSM-III was wholly driven by the concept of reliability, and for the most common inclusions it was successful. The problem is the validity of these concepts was sacrificed and has never been addressed since. We also have the problem of reification.

      I don’t know much about the NIMH RDoC – I will look into it, thanks!

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  4. “Why this long trend in classifying pathological mental states? By defining the unknown, and classifying psychopathology, we bring an element of knowability to that which we do not know. Further, we create the illusion and indulge in the deception of knowing more about that which we do not know than we do.

    It is only natural that humans should try to reason with unreason, to order to disorder, to dispassionately delineate the boundaries between sanity and madness.”

    Is the “its only natural,” sense of which you write, more instinct than intellect? And do we give to much credence to the scientific notion of “objective” evidence and proof, leading us to study each other as “objects” rather than exquisitely sensitive, sensory creatures?

    In his book “The Psychotic Core” Michael Eigen suggests a long history of “objectification,” as we transit from hunter gatherer groups to present day urbanization, with ongoing diminution of our sensory nature, with an over-reliance on sight and sound, as the creators of our sense-of-being, with the development of languages about 6000 years ago, quickening this process?

    In her brilliant book “The Transmission of Affect” the late Teresa Brennan points out, that we are extremely reluctant to admit that our emotions are not entirely our own, even though we accept the social transmission of thought, while others point to our God fearing social consensus, as the mind suppressing social control, which limits an acceptance of our evolved nature. Yet of coarse, if one yells “fire” in a darkened room, the transmission of “affect,” and the primitive roots of our much vaunted intellectual mind, become apparent?

    Consider Ronnie Laing’s thoughts on the limits of language, when speaking about modes of experience beyond the norm;

    “I’m going to attempt what is literally impossible, to try to use words and syntax to speak about modes of experience where the distinctions enshrined by language haven’t yet been formed. Since language proceeds by the dilineation of contours, we can’t use it directly or in an unequivocal way to describe a state of affairs before contours have been formed. Yet at the same time, if I’m not going to whistle or dance it, Iv’e got to use language, in a sense, against itself to convey that its not conveying what it’s purporting to convey. And I’ve got to do this in such a way that isn’t what’s usually regarded as total schizophrenese.

    I’m trying to talk about what some people talk about more directly, and hence are regarded as psychotic for doing so. I might not succeed in this. I’m not without my anxieties on both sides, that if I say too directly what I’m trying to say, then you’ll regard me as mad but interesting; on the other hand, if I say what I’m trying to say too deviously, you will regard me as sane and dull. As long as you don’t think I’m being clever…” _R.D. Laing.

    Consider another view of the limits of our overly “objectified” languages and our mismatched narrative’s of Self-Interpretation;

    “The Limits of Language:

    At present we only have a rudimentary language for connecting sensations, affects, and words, for connecting bodily processes and a conceptual understanding of them. The further development of such language requires an attention to the pathways of sensation in the body. We need to formulate bodily knowledge more accurately and increase the rapidity of human understanding. Extending knowledge in this way is the reverse of gathering it by “objectification,” or studying bodily processes disconnected from living sensory attention. (p, 153.)

    Extending knowledge of sensation, following it further along its pathways, means extending consciousness into the body, infusing it with the conscious understanding from which it has been split, by a subject/object orientation. That split has hardened with the sealing of the heart as an organ of sensory reception and transmission, yet it has also come under examination in all the practices and knowledge’s that, taken together, presage the resurrection of the body.

    Some of these systems of knowledge already nestle in the arms of objective science, especially those focused on the complex systems of both body and brain, while others are found in more ancient, holistic health systems. What these systems of healing have in common with the study of the body and its complexity, is the notion of systems–of language and communication, insofar as a biochemical chain or a DNA sequence can be structured like a language in another medium. (p, 154.)

    The more conscious we become of what we repress in our subject/object orientation (remembering that primary repression is the repression of unprocessed sensory information) or ignore, the less we think in projected and judgmental terms. But such conscious consciousness is only possible when we invent or reinvent the words to say it with. The transliteration into language from the minutia of sensory knowledge and its sifting, may be processes entirely unknown to present day consciousness.

    Extending consciousness sensation, finding the words or images, means grasping the nuances of fleshy grammar and alphabets. It means describing and accounting for sensations, which entails translating them into the everyday currencies of speech and so extending the range of their visualization. What our subject/object ego orientation represses is not available to consciousness. This ego and its repressions, present themselves as disordered flesh, when in fact the ego and its repressions are the cause of such disorder. Disorder is not inherent in the body or the flesh, which loves natural regulation. The body thrives in health when its real needs are respected, as distinct from the ego’s imaginary anxieties. (p, 155.)”

    Excerpts from “The Transmission of Affect” by Teresa Brennan, PhD.

    THE MIND – THAT EMPEROR WITH NO CLOTHES?

    You start this post with the great French philosopher, Michel Foucault and possessions which belong to the Emperor? Which can perhaps be seen as metaphor, much like that which belonged to Rome, in Jesus answer to his charge of heresy?

    “In The Order of Things, Michel Foucault, the great French philosopher cites a ‘certain Chinese encyclopedia’ that notes ‘animals are divided into: (a) belonging to the Emperor, (b) embalmed, (c) tame, (d) suckling pigs, (e) sirens, (f) fabulous, (g) stray dogs, (h) included in the present classification, (i) frenzied, (j) innumerable, (k) drawn with a very fine camelhair brush, (l) et cetera, (m) having just broken the water pitcher, (n) that from a long way off look like flies’.”

    Consider the writing of Teresa Brennan again and her articulation of “affect” as judgment and ego as the will to power. In the great debate about conflicts of interest which now stalks psychiatry with a vengeance, can even the most liberal of psychiatrist’s come to terms with the “bottom-line” nature of survival, and the reality that his/her livelihood, is dependent on other people’s misery, just as civilization has always constructed its method of human classification?

    “Affect and Ego:
    Lacan dates the era of the ego from the late seventeenth century, while Foucault assigns an intensification of knowledge as the will to power, to the same period. Both are aware how the passion to control the other, causes a person to seek knowledge as a means to control, and that the exercise of such knowledge is aligned with discipline from without, or “objectification.” Taken to its objectifying extreme, this process leads to our present madness, which is the destruction of future life, even our own, for the sake of immediate gratification.

    Yet, to understand this, we need to see how the “negative affects,” cohere as an egoistic constellation, and why judging (diagnosing) or “projecting” affects onto others and the self is fundamental to why that egoistic constellation solidifies in the Western centuries progress. Unconscious affects bear on the ego by repressions and fixations as forms of judgment. Judgments based on images, memories, and fantasies about avoiding pain and increasing pleasure. (p, 106.)

    For Lacan, the interlocking of self and other, is an imaginary space, which is imaginary in that fantasies (assumptions) interlock within it. Yet by the power bodily affects, these interlocking fantasies are also physical, just as the force of the imagination is physical. In this respect, they can be something the self does to the self, energetically speaking, or something directed towards the self by another’s goal-seeking aggressive projections. (p, 109.)

    For the ego, comparison is effected by and mediated through images of others and fantasies concerning them. The history of an imaginary slight–in envy or wounded narcissism–can be built into a fantasy or psychical memory, and that history can be conjured in an instant together with its affective associations. This is why we can speak of these “affective” states as passionate judgments. The passionate judgment is what gives the other or the self a negative image, embodying the objectification of narcissism or the contempt of envy. These judgments are at odds with the soul, or actualization drive. (p, 110.)

    Excerpts from “The Transmission of Affect” by Teresa Brennan, PhD.

    As we compete for social status and rank here on MIA, can we be open enough to admit our own conflicts of interest in our sub-conscious, “passionate judgment is what gives the other or the self a negative image, embodying the objectification of narcissism or the contempt of envy” in this mind-less fight to sanctify the mind, that God dammed Emperor, with no clothes?

    Best wishes,

    David Bates.

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    • Thank you for your thoughtful post. The Transmission of Affect sounds like an interesting book. Certainly our attempts of classification take the positivisic view that emotions and mental states have their own existence in external reality, as tangible, measurable ‘things’. But as anyone who has experienced extreme emotional states realizes, “what is the reality of any feeling?” as Virgina Woolf noted.

      Vivek

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