"You can know the name of a bird in all the languages of the world, but when you're finished, you'll know absolutely nothing whatever about the bird… So let's look at the bird and see what it's doing – that's what counts. I learned very early the difference between knowing the name of something and knowing something."
Richard Feynman, Physicist and 1965 Nobel Prize laureate (1918-1988)
"You have all I dare say heard of the animal spirits and how they are transfused from father to son etcetera etcetera – well you may take my word that nine parts in ten of a man's sense or his nonsense, his successes and miscarriages in this world depend on their motions and activities, and the different tracks and trains you put them into, so that when they are once set a-going, whether right or wrong, away they go cluttering like hey-go-mad."
Lawrence Sterne (1713-1758), "The Life and Opinions of Tristram Shandy, Gentleman" (1759)
I. Overview
Someone is considered mentally "ill" if:
His conduct rigidly and consistently deviates from the typical, average behaviour of all other people in his culture and society that fit his profile (whether this conventional behaviour is moral or rational is immaterial), or
His judgment and grasp of objective, physical reality is impaired, and
His conduct is not a matter of choice but is innate and irresistible, and
His behavior causes him or others discomfort, and is
Dysfunctional, self-defeating, and self-destructive even by his own yardsticks.
Descriptive criteria aside, what is the essence of mental disorders? Are they merely physiological disorders of the brain, or, more precisely of its chemistry? If so, can they be cured by restoring the balance of substances and secretions in that mysterious organ? And, once equilibrium is reinstated – is the illness "gone" or is it still lurking there, "under wraps", waiting to erupt? Are psychiatric problems inherited, rooted in faulty genes (though amplified by environmental factors) – or brought on by abusive or wrong nurturance?
These questions are the domain of the "medical" school of mental health.
Others cling to the spiritual view of the human psyche. They believe that mental ailments amount to the metaphysical discomposure of an unknown medium – the soul. Theirs is a holistic approach, taking in the patient in his or her entirety, as well as his milieu.
The members of the functional school regard mental health disorders as perturbations in the proper, statistically "normal", behaviours and manifestations of "healthy" individuals, or as dysfunctions. The "sick" individual – ill at ease with himself (ego-dystonic) or making others unhappy (deviant) – is "mended" when rendered functional again by the prevailing standards of his social and cultural frame of reference.
In a way, the three schools are akin to the trio of blind men who render disparate descriptions of the very same elephant. Still, they share not only their subject matter – but, to a counter intuitively large degree, a faulty methodology.
As the renowned anti-psychiatrist, Thomas Szasz, of the State University of New York, notes in his article "The Lying Truths of Psychiatry", mental health scholars, regardless of academic predilection, infer the etiology of mental disorders from the success or failure of treatment modalities.
This form of "reverse engineering" of scientific models is not unknown in other fields of science, nor is it unacceptable if the experiments meet the criteria of the scientific method. The theory must be all-inclusive (anamnetic), consistent, falsifiable, logically compatible, monovalent, and parsimonious. Psychological "theories" – even the "medical" ones (the role of serotonin and dopamine in mood disorders, for instance) – are usually none of these things.
The outcome is a bewildering array of ever-shifting mental health "diagnoses" expressly centred around Western civilisation and its standards (example: the ethical objection to suicide). Neurosis, a historically fundamental "condition" vanished after 1980. Homosexuality, according to the American Psychiatric Association, was a pathology prior to 1973. Seven years later, narcissism was declared a "personality disorder", almost seven decades after it was first described by Freud.
II. Personality Disorders
Indeed, personality disorders are an excellent example of the kaleidoscopic landscape of "objective" psychiatry.
The classification of Axis II personality disorders – deeply ingrained, maladaptive, lifelong behavior patterns – in the Diagnostic and Statistical Manual, fourth edition, text revision [American Psychiatric Association. DSM-IV-TR, Washington, 2000] – or the DSM-IV-TR for short – has come under sustained and serious criticism from its inception in 1952, in the first edition of the DSM.
The DSM IV-TR adopts a categorical approach, postulating that personality disorders are "qualitatively distinct clinical syndromes" (p. 689). This is widely doubted. Even the distinction made between "normal" and "disordered" personalities is increasingly being rejected. The "diagnostic thresholds" between normal and abnormal are either absent or weakly supported.
The polythetic form of the DSM's Diagnostic Criteria – only a subset of the criteria is adequate grounds for a diagnosis – generates unacceptable diagnostic heterogeneity. In other words, people diagnosed with the same personality disorder may share only one criterion or none.
The DSM fails to clarify the exact relationship between Axis II and Axis I disorders and the way chronic childhood and developmental problems interact with personality disorders.
The differential diagnoses are vague and the personality disorders are insufficiently demarcated. The result is excessive co-morbidity (multiple Axis II diagnoses).
The DSM contains little discussion of what distinguishes normal character (personality), personality traits, or personality style (Millon) – from personality disorders.
A dearth of documented clinical experience regarding both the disorders themselves and the utility of various treatment modalities.
Numerous personality disorders are "not otherwise specified" – a catchall, basket "category".
Cultural bias is evident in certain disorders (such as the Antisocial and the Schizotypal).
The emergence of dimensional alternatives to the categorical approach is acknowledged in the DSM-IV-TR itself:
“An alternative to the categorical approach is the dimensional perspective that Personality Disorders represent maladaptive variants of personality traits that merge imperceptibly into normality and into one another” (p.689)
The following issues – long neglected in the DSM – are likely to be tackled in future editions as well as in current research. But their omission from official discourse hitherto is both startling and telling:
The longitudinal course of the disorder(s) and their temporal stability from early childhood onwards;
The genetic and biological underpinnings of personality disorder(s);
The development of personality psychopathology during childhood and its emergence in adolescence;
The interactions between physical health and disease and personality disorders;
The effectiveness of various treatments – talk therapies as well as psychopharmacology.
III. The Biochemistry and Genetics of Mental Health
Certain mental health afflictions are either correlated with a statistically abnormal biochemical activity in the brain – or are ameliorated with medication. Yet the two facts are not ineludibly facets of the same underlying phenomenon. In other words, that a given medicine reduces or abolishes certain symptoms does not necessarily mean they were caused by the processes or substances affected by the drug administered. Causation is only one of many possible connections and chains of events.
To designate a pattern of behaviour as a mental health disorder is a value judgment, or at best a statistical observation. Such designation is effected regardless of the facts of brain science. Moreover, correlation is not causation. Deviant brain or body biochemistry (once called "polluted animal spirits") do exist – but are they truly the roots of mental perversion? Nor is it clear which triggers what: do the aberrant neurochemistry or biochemistry cause mental illness – or the other way around?
That psychoactive medication alters behaviour and mood is indisputable. So do illicit and legal drugs, certain foods, and all interpersonal interactions. That the changes brought about by prescription are desirable – is debatable and involves tautological thinking. If a certain pattern of behaviour is described as (socially) "dysfunctional" or (psychologically) "sick" – clearly, every change would be welcomed as "healing" and every agent of transformation would be called a "cure".
The same applies to the alleged heredity of mental illness. Single genes or gene complexes are frequently "associated" with mental health diagnoses, personality traits, or behaviour patterns. But too little is known to establish irrefutable sequences of causes-and-effects. Even less is proven about the interaction of nature and nurture, genotype and phenotype, the plasticity of the brain and the psychological impact of trauma, abuse, upbringing, role models, peers, and other environmental elements.
Nor is the distinction between psychotropic substances and talk therapy that clear-cut. Words and the interaction with the therapist also affect the brain, its processes and chemistry - albeit more slowly and, perhaps, more profoundly and irreversibly. Medicines – as David Kaiser reminds us in "Against Biologic Psychiatry" (Psychiatric Times, Volume XIII, Issue 12, December 1996) – treat symptoms, not the underlying processes that yield them.
IV. The Variance of Mental Disease
If mental illnesses are bodily and empirical, they should be invariant both temporally and spatially, across cultures and societies. This, to some degree, is, indeed, the case. Psychological diseases are not context dependent – but the pathologizing of certain behaviours is. Suicide, substance abuse, narcissism, eating disorders, antisocial ways, schizotypal symptoms, depression, even psychosis are considered sick by some cultures – and utterly normative or advantageous in others.
This was to be expected. The human mind and its dysfunctions are alike around the world. But values differ from time to time and from one place to another. Hence, disagreements about the propriety and desirability of human actions and inaction are bound to arise in a symptom-based diagnostic system.
As long as the pseudo-medical definitions of mental health disorders continue to rely exclusively on signs and symptoms – i.e., mostly on observed or reported behaviours – they remain vulnerable to such discord and devoid of much-sought universality and rigor.
V. Mental Disorders and the Social Order
The mentally sick receive the same treatment as carriers of AIDS or SARS or the Ebola virus or smallpox. They are sometimes quarantined against their will and coerced into involuntary treatment by medication, psychosurgery, or electroconvulsive therapy. This is done in the name of the greater good, largely as a preventive policy.
Conspiracy theories notwithstanding, it is impossible to ignore the enormous interests vested in psychiatry and psychopharmacology. The multibillion dollar industries involving drug companies, hospitals, managed healthcare, private clinics, academic departments, and law enforcement agencies rely, for their continued and exponential growth, on the propagation of the concept of "mental illness" and its corollaries: treatment and research.
VI. Mental Ailment as a Useful Metaphor
Abstract concepts form the core of all branches of human knowledge. No one has ever seen a quark, or untangled a chemical bond, or surfed an electromagnetic wave, or visited the unconscious. These are useful metaphors, theoretical entities with explanatory or descriptive power.
"Mental health disorders" are no different. They are shorthand for capturing the unsettling quiddity of "the Other". Useful as taxonomies, they are also tools of social coercion and conformity, as Michel Foucault and Louis Althusser observed. Relegating both the dangerous and the idiosyncratic to the collective fringes is a vital technique of social engineering.
The aim is progress through social cohesion and the regulation of innovation and creative destruction. Psychiatry, therefore, is reifies society's preference of evolution to revolution, or, worse still, to mayhem. As is often the case with human endeavour, it is a noble cause, unscrupulously and dogmatically pursued.
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