Among the first people I met was a young man who believed that he might be responsible for harm coming to his family if he didn't engage in time-consuming rituals, including arranging his shoes very particularly for up to half an hour. The logic motivating this man's behaviour was notably rather magical and unrealistic, appealing to notions of spirit possession and evil, which were culturally alien to his family. My supervisor, a sensitive and empathic clinician, who believed that most issues could be addressed by attentive listening and interpretation, tended to have a single diagnostic concern. The central question for him was whether the person was experiencing anxiety or manifesting the early symptoms of a psychosis. The latter ought to receive a more thorough assessment and more support than our clinic could offer.
Because of the magical quality to this person's reasoning, my supervisor decided that this might be an early sign of psychosis. He instructed me to refer the man to a new research clinic near my training site, which specialised in treating and researching the 'at risk' state for psychosis.
Of course, sensible and cautious though this seemed to me, it entailed telling this young man that he could not be seen by us for talking therapy. Instead, he should go to a clinic that specialised in something serious and frightening-sounding. When I broke the news, he was devastated. He left our clinic, and I later learned that he never followed up with the referral.
What I failed to appreciate at the time – and what some remedial reading later painfully revealed to me – was that, rather than being an early manifestation of psychosis, this man's presentation was more likely a case of obsessive compulsive disorder (OCD), a common condition in which people develop obsessive thoughts and feel compelled to engage in actions to prevent feared harms. If I'd had the diagnostic knowledge and confidence to assert this to my supervisor during the initial consultation, the man I met would likely have received help, rather than being referred to an inappropriate clinic that led to him falling through the cracks.
Yet, a popular and longstanding wave of thought in psychology and psychotherapy is that diagnosis is not relevant for practitioners in those fields, and should be left to psychiatrists, if at all. This is not a fringe view, it has been perennially present in clinical psychology since at least the 1960s, when the iconoclastic psychiatrists Thomas Szasz and R D Laing presented a dual challenge to their profession.
Szasz, a Hungarian émigré to the United States, argued that mental illness is a 'myth', rooted in a misuse of language. Neurological diseases are real, Szasz suggested, because they can be confirmed by a postmortem examination of the brain. In contrast, he argued that psychiatric 'illness' has no such neurological basis, and is just a medicalised way of talking about problems in life that could be solved by taking responsibility for yourself and your actions.
Meanwhile, Laing, a Scot who trained at the Tavistock Institute in London, argued in The Divided Self (1960) that psychosis is a psychic response to an increasingly alienated 'false self' obscuring the true emotional core of an individual. He held that so-called 'symptoms' (hearing voices, believing unusual things) were actually attempts at recovery in the face of this alienation.
These ideas resonated and had significant influence over psychiatric thinking throughout the 1960s. They contributed to diagnostic approaches to mental health – the idea that there are illnesses called schizophrenia, bipolar disorder and depression – becoming decidedly unfashionable. Indeed Szasz's and Laing's critiques became so popular that already by the early 1970s, the influential US clinical psychologist Paul Meehl grumbled in his 1973 paper 'Why I Do Not Attend Case Conferences' about an 'antinosological' (ie, antidiagnostic) bias taking hold in his profession.
Recently, the animus against psychiatric diagnosis has become more formal and scientifically argued. The British Psychological Society's Division of Clinical Psychology (DCP) – one of the official bodies representing the profession – published two documents in 2013 and 2015 articulating the difficulties with diagnosis, and promoting instead the value of individualised 'formulations'. While it is clear that the DCP's position on diagnosis is not universally held by practitioners in the UK, British psychologists are around half as likely to report regular use of a diagnostic classificatory system as their colleagues in some other countries (for example, fewer than 35 per cent of psychologists in the UK say that they use diagnosis regularly, compared with more than 70 per cent of psychologists in the US, Germany and South Africa). This likely reflects a UK professional culture steeped in suspicion of diagnostic thinking.
The suspicion is not unwarranted. One of the most interesting recent critiques of diagnosis has come from the Belgian psychoanalyst and clinical psychologist Stijn Vanheule. He invoked the philosophy of language to argue that diagnosis necessarily draws our attention to the shared meanings conjured by diagnostic language, rather than to the individual meanings inherent to people's experiences. Thus, for example, when I say 'schizophrenia', I focus attention on a generalised, clinical definition that exists in a book, rather than on the individual, personal significance of hearing voices or believing unusual things. For psychotherapists, Vanheule argued, the former is irrelevant, the latter vital.
These arguments are valuable, and they are correct in important ways. Their conclusions are a significant part of what inspired me to get into clinical psychology in the first place. Reading Laing as a teenager, I thrilled to the challenge he presented: to understand people as they endure the most extreme and bewildering psychic states; to try to find coherence even where it seems to be absent. This impulse is essential. Patience and careful listening can reveal that people are capable of engaging in communication more often than we tend to give them credit for. But my clinical training has shown me that, despite the importance of understanding people in an individualised way, having a knowledge of diagnostic categories is also essential.
To return to the example above, my supervisor and I were ignorant of valuable diagnostic information; we were ignorant of the ways that clinicians can distinguish magical obsessions from the early hints of delusion. We were ignorant of the fact that even quite magical ideas are well within the range of the former without shading into the latter. We were ignorant of how easy it would have been to provide effective help without raising the prospect of a terrifying psychosis down the pipeline. Our ignorance cost someone dearly.
Diagnosis is often vital for ensuring good care. Apart from the importance of ruling out organic causes for apparently straightforward instances of depression and anxiety (which can be symptomatic of a surprising range of endocrine, infectious and neurological diseases), linking psychological distress into a broader framework also helps clinicians make sense of the people they are trying to help. Certain forms of substance misuse could represent attempts at self-medication for highly treatable disorders of mood or attention, for instance. Correct identification of trauma symptoms can avert diagnosis of a psychotic illness. Proper diagnosis of depression in later life can frequently account for changes in memory and attention that might otherwise be mistaken for dementia, as unfortunately often happens. Diagnosis of bipolar mood disorder can prevent people being inappropriately treated for personality disorders.
Psychology's antinosological tendency encourages a belief that diagnostic thinking is somehow inherently unkind; that in thinking about categories you are always only 'labelling' people, and that this is an inhumane thing to do.
Conversely, it also encourages a belief that all you really need in mental healthcare is sympathy, rapport and interpretative heroics. This appeals to some of the questionable impulses of professionals: to our desire to see ourselves as people uniquely able to understand others, and to our ordinary human laziness. Who would want to engage in learning about taxonomy if to do so is both unkind and unnecessary?
Understanding people is a multifaceted enterprise. We all manifest a splendid idiosyncrasy, living out lives that could never be copied or repeated, so it makes sense to consider one another in the light of this uniqueness. But we also bear resemblances to one another. Important though it is to be seen in all your individuality, it is also helpful to know when your problems have precedent.
Psychiatric diagnoses are imperfect, sketchy theories about how people's minds can give them trouble. We know that they are largely less precise and valid than is popularly understood, but this does not render them totally uninformative. We have learned snippets of useful information by considering psychological problems in terms of categories: the effectiveness, or not, of treatments for particular groups of people; the elevated risk of suicide among others. Many symptoms can seem to 'make sense' in the context of a person's life, but we know that humans are sense-making machines, so we need to be vigilant against 'making sense' where it is only illusory. The great intellectual challenge of clinical psychology is to integrate knowledge about reasons and people with knowledge about causes and mechanisms. We should avoid relying solely on diagnostic information, but we shouldn't discard it altogether.
Huw Green
This article was originally published at Aeon and has been republished under Creative Commons. Read the original article.
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Excerpt from a 19th century map of the Paris Catacombs, showing the labyrinthine layout underground (in color) beneath the straight-lined structures on the surface (in grey).
Ancient mining areas below Paris for limestone (red) and gypsum (green).Credit: Émile Gérards (1859–1920) / Public domain
"If you're brave enough to try, you might be able to catch a train from UnLondon to Parisn't, or No York, or Helsunki, or Lost Angeles, or Sans Francisco, or Hong Gone, or Romeless."
China Miéville's fantasy novel Un Lun Dun is set in an eerie mirror version of London. In it, he hints that other cities have similar doubles. On the list that he offhandedly rattles off, Paris stands out. Because the City of Light really does have a twisted sister. Below Paris Overground is Paris Underground, the City of Darkness.
Most people will have heard of the Catacombs of Paris: subterranean charnel houses for the bones of around six million dead Parisians. They are one of the French capital's most famous tourist attractions – and undoubtedly its grisliest.
But they constitute only a small fragment of what the locals themselves call les carrières de Paris ("the mines of Paris"), a collection of tunnels and galleries up to 300 km (185 miles) long, most of which are off-limits to the public, yet eagerly explored by so-called cataphiles.
The Grand Réseau Sud ("Great Southern Network") takes up around 200 km beneath the 5th, 6th, 14th, and 15th arrondissements (administrative districts), all south of the river Seine. Smaller networks run beneath the 12th, 13th, and 16th arrondissements. How did they get there?
Paris stone and plaster of Paris
It all starts with geology. Sediments left behind by ancient seas created large deposits of limestone in the south of the city, mostly south of the Seine; and gypsum in the north, particularly in the hills of Montmartre and Ménilmontant. Highly sought after as building materials, both have been mined since Roman times.
The limestone is also known as Lutetian limestone (Lutetia is the Latin name for ancient Paris) or simply "Paris stone." It has been used for many famous Paris landmarks, including the Louvre and the grand buildings erected during Georges-Eugène Haussmann's large-scale remodelling of the city in the mid-19th century. The stone's warm, yellowish color provides visual unity and a bright elegance to the city.
The fine-powdered gypsum of northern Paris, used for making quick-setting plaster, was so famed for its quality that "plaster of Paris" is still used as a term of distinction. However, as gypsum is very soluble in water, the underground cavities left by its extraction were extremely vulnerable to collapse.
Like living on top of a rotting tooth: subsidence starts far below the surface, but it can destroy your house.Credit : Delavanne Avocats
In previous centuries, a road would occasionally open up to swallow a chariot, or even a whole house would disappear down a sinkhole. In 1778, a catastrophic subsidence in Ménilmontant killed seven. That's why the Montmartre gypsum quarries were dynamited rather than just left as they were. The remaining gypsum caves were to be filled up with concrete.
The official body governing Paris down below is the Inspection Générale des Carrières (IGC), founded in the late 1770s by King Louis XVI. The IGC was tasked with mapping and, where needed, propping up the current and ancient (and sometimes forgotten) mining corridors and galleries hiding beneath Paris.
A delightful hiding place
Also around that time, the dead of Paris were getting in the way of the living. At the end of the 18th century, their final destination consisted of about 200 small cemeteries, scattered throughout the city — all bursting at the seams, so to speak. There was no room to bury the newly dead, and the previously departed were fouling up both the water and air around their respective churchyards.
Something radical had to happen. And it did. From 1785 until 1814, the smaller cemeteries were emptied of their bones, which were transported with full funerary pomp to their final resting place in the ancient limestone quarries at Tombe-Issoire. Three large and modern cemeteries were opened to receive the remains of subsequent generations of Parisians: Montparnasse, Père-Lachaise, and Passy.
Who says stacking skulls and bones can't be fun?Credit: Rijin via Wikimedia and licensed under CC BY-SA 4.0
The six million dead Parisians in the Catacombs, from all corners of the capital and across many centuries, together form the world's largest necropolis — their now anonymized skulls and bones methodically stacked, occasionally into whimsical patterns. The Catacombs are fashioned into a memorial to the brevity of life. The message above the entrance reads: Arrête! C'est ici l'empire de la Mort. ("Halt! This is the empire of Death.")
That has not stopped the Catacombs, accessible via a side door to a classicist building on the Avenue du Colonel Henri Rol-Tanguy, making just about every Top 20 list of things to see in Paris.
An underground economy
However, while the Catacombs certainly are the most famous part of the centuries-old network beneath Paris, and in non-pandemic times draw thousands of tourists each day, they constitute just 1.7 km (1 mile) of the 300-km (185-mile) tunneling total.
Subterranean Paris wasn't just used for mining and storing dead people. In the 17th century, Carthusian monks converted the ancient quarries under their monastery into distilleries for the green or yellow liqueur that still carries their name, chartreuse.
Because the mines generally keep a constant cool temperature of around 15° C (60° F), they were also ideal for brewing beer, as happened on a large scale from the end of the 17th century until well into the 20th century. Several caves were dug especially for establishing breweries, and not just because of the ambient temperature: going underground allowed brewers to remain close to their customers without having to pay a premium for real estate up top.
Overview of the Paris Catacombs.Credit: Inspection Générale des Carrières, 1857 / Public domain.
At the end of the 19th century, the underground breweries of the 14th arrondissement alone produced more than a million hectoliters (22 million gallons) per year. One of the most famous of Paris' underground breweries, Dumesnil, stayed in operation until the late 1960s.
In that decade, the network of corridors and galleries south of the Seine, long since abandoned by miners, became the unofficial playground for the young people of Paris. They explored the fantastical world beneath their feet, in some cases via entry points located in their very schools. Fascinated, these cataphiles ("catacomb lovers") read up on old books, explored the subterranean labyrinth, and drew up schematics that were passed around among fellow initiates as reverently as treasure maps.
As Robert Macfarlane writes in Underland, Paris-beneath-their-feet became "a place where people might slip into different identities, assume new ways of being and relating, become fluid and wild in ways that are constrained on the surface."
Some larger caves turned into notorious party zones: a 7-meter-tall gallery below the Val-de-Grâce hospital is widely known as "Salle Z." Over the last few decades, various other locations in subterranean Paris have hosted jazz and rock concerts and rave parties — like no other city, Paris really has an "underground music scene."
Hokusai's Great Wave as the backdrop to the "beach" under Paris.Credit: Reddit
Cataphiles vs. cataphobes
With popularity came increased reports of nuisance and crime — the tunnels provided easy access to telephone cables, which were stolen for the resale value of their copper.
The general public's "discovery" of the underground network led the city of Paris to officially interdict all access by non-authorized persons. That decree dates back to 1955, but the "underground police" have an understanding with seasoned cataphiles. Their main targets are so-called tourists, who by their lack of knowledge expose themselves to risk of injuries or worse, and degrade their surroundings, often leaving loads of litter in their wake.
The understanding does not extend to the IGC. Unlike in the 19th century, when weak cavities were shored up by purpose-built pillars, the policy now is to inject concrete to fill up endangered spaces — thus progressively blocking off parts of the network. That procedure has also been used to separate the Catacombs to prevent "infiltration" of the site by cataphiles.
Many subterranean streets have their own names, signs and all. This is the Rue des Bourguignons (Street of the Burgundians) below the Champs des Capucins (Capuchin Field), neither of which exists on the surface.Credit: Jean-François Gornet via Wikimedia and licensed under
The cataphiles, however, are fighting back. In a game of cat and mouse with the authorities, they are reopening blocked passages and creating chatières ("cat flaps") through which they can squeeze into chambers no longer accessible via other underground corridors.
Catacomb climate control
Alone against the unstoppable tide of concrete, the amateurs of Underground Paris would be helpless. But the fight against climate change may turn the subterranean labyrinths from a liability into an asset — and the City of Paris into an ally.
The UN's 2015 Climate Plan — concluded in Paris, by the way — requires the world to reduce greenhouse gas emissions by 75 percent by 2050. And Paris itself wants to be Europe's greenest city by 2030. More sustainable climate control of our living spaces would be a great help toward both targets. A lot of energy is spent heating houses in winter and cooling them in summer.
This is where the constant temperature of the Parisian tunnels comes in. It's not just good for brewing beer; it's a source of geothermal energy, says Fieldwork, an architectural firm based in Paris. It can be used to temper temperatures, helping to cool houses in summer and warming them in winter.
One catch for the cataphiles: it also works when the underground cavities are filled up with concrete. So perhaps one day, Paris Underground, fully filled up with concrete, will completely fall off the map, reducing the city's formerly real doppelgänger into an air conditioning unit.
Cool in summer, warm in winter: Paris Underground could become Paris A/C.Credit: Fieldwork
Strange Maps #1083
Got a strange map? Let me know at strangemaps@gmail.com.
The prevalence of allergies arising in childhood has increased over the last 50 years, with 30 percent of the human population now having some kind of atopic disease such as eczema, food allergies, or asthma. The cause of this increase is still subject to debate, though it has been associated with a number of factors, including changes to the gut microbiomes of infants.
A new study by Canadian researchers published in Cell Reports Medicine may shed further light on how these allergies develop in children by examining the contents of their first diaper.
The things you do for science
The research team examined the first stool of 100 infants from the CHILD Cohort Study. The first stool of an infant is a thick, green, horrid-looking substance called meconium. It consists of various things that the infant ingests during the second half of gestation. Additionally, it provides not only a snapshot of what the infant was exposed to during that time, but it also reveals what the food sources will be for the initial gut bacteria that colonize the baby's digestive tract.
The content of the meconium was examined and found to contain such varied elements as amino acids, lipids, carbohydrates, and myriad other substances.
A graph of the comparative, summed abundance of different elements in a metabolic pathway after scaling to median abundance of each metabolite. The blue figures are those children without atopy, the yellow ones show the data for those with an atopic condition. Petersen et al.
The authors fed this information into an algorithm that used this data, along with the identities of the bacteria present as well as the baby's overall health, to predict which infants would go on to develop allergies within one year. The algorithm got it right 76 percent of the time.
A way to prevent childhood allergies?
Infants whose meconium had a less diverse metabolic niche the initial microbes to settle in the gut were at the highest risk of developing allergies a year later. Many of these elements were associated with the presence or absence of different bacterial groups in the digestive system of the child, which play an increasingly appreciated role in our overall health and development. The findings were summarized by senior co-author Dr. Brett Finlay:
"Our analysis revealed that newborns who developed allergic sensitization by one year of age had significantly less 'rich' meconium at birth, compared to those who didn't develop allergic sensitization."
The findings could be used to help understand how allergies form and even how to prevent them. Co-author Dr. Stuart Turvey commented on this possibility:
"We know that children with allergies are at the highest risk of also developing asthma. Now we have an opportunity to identify at-risk infants who could benefit from early interventions before they even begin to show signs and symptoms of allergies or asthma later in life."
A model for early childhood allergies
Petersen et al.
As shown above, the authors constructed a model of how they believe metabolites and bacterial diversity help prevent allergies. Increased diversity of metabolic products in the meconium encourage the development of "healthy" families of bacteria, like Peptostreptococcaceae, which in turn promote the development of a healthy and diverse gut microbiome. Ultimately, such diversity decreases the likelihood that a child will develop allergies.
