What is Mental Illness?
Relaunched: 9 May 2019
There are some very good reasons to try to define what mental illness is and, as a corollary, what good mental health is. For example, if a psychiatrist or clinical psychologist is to treat a patient, they must be able to identify the illness. For psychiatrists and clinical psychologists to be able to recognise illnesses reliably means having a classification system which lists the symptoms (indicators) of the various illnesses. Then, when the illness is correctly identified, the appropriate treatment can be administered. Good mental health is the recognised standard to be achieved via application of the treatment. Also, it is only by linking symptoms together to recognise the syndrome of the illness that is it then possible to search for causes of the illness (aetiology) and apply or develop a treatment for the illness. The example often used to justify this position is that of Richard von Krafft-Ebing. A medical student in the 19th Century, he linked together the symptoms of what we now call Syphilis – delusion, forgetfulness, mental deterioration, eventually paralysis and finally death – to form the syndrome of what he called ‘General Paresis’. From this he established (1886) that General Paresis was caused by infection of the syphilis bacterium, thus enabling an effective treatment to be developed.
Krafft-Ebbing’s approach to discovering aetiologies was developed by his contemporary Emil Kraepelin (1896) into the Medical Model. This is based on the assumption (meme) that all mental illnesses or psychiatric disorders have in their aetiology some key biological factor which, if discovered, should be treatable medically. Thus, Kraepelin emphasised the use of physical or behavioural symptoms – eg: insomnia, disorganised speech – rather than less precise symptoms such as poor social adjustment or misplaced drives. His ‘Psychiatrie: Ein Lehrbuch für Studirende und Aertze’ – revised periodically – was the first serious attempt to catalogue and categorise psychiatric disorders and, where known, their causes. Kraepelin also pushed the notion that, just like physiological illnesses, psychiatric disorders were characterised by clusters of symptoms – syndromes – which, by being clustered together, identify a condition. So, just as it is dangerous to diagnose a physical illness on the basis of a single symptom – eg: is sneezing a symptom of a cold, influenza or hayfever…? – so the same symptom can be an indicator of different mental health problems. Eg: anxiety is a major symptom of Generalised Anxiety Disorder, Obsessive-Compulsive Disorder and phobias. Thus, it is important to identify the syndrome – cluster of symptoms – of a disorder.
The drive to categorise also reflects the BLUE vMEME’s need to identify, order and standardise just what various psychiatric disorders are so that there is both accuracy and consistency in diagnosis.
The classification systems
Kraepelin’s idea of cataloguing and classifying psychiatric disorders was taken up by others and eventually led to the development of 2 major classification systems.
The Diagnostic & Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association (APA) and provides a common language and standard criteria for the classification of mental disorders. It is used in the United States – and in varying degrees around the world – by clinicians, researchers, psychiatric drug regulation agencies, health insurance companies, pharmaceutical companies and policy makers.
DSM evolved from systems for collecting census and psychiatric hospital statistics and from a manual developed by the US Army. It was dramatically revised in 1980 (DSM-III). Another major revision was the fourth edition (DSM-IV), published in 1994. The latest version, DSM-5, was published in May 2013.
The DSM has attracted controversy and criticism as well as praise. There have been 4 major revisions since it was first published in 1952, gradually including more mental disorders – though some have been removed and are no longer considered to be mental disorders. Minor revisions were published in 1984 and 2000.
The most fundamental scientific criticism of the DSM concerns the validity and reliability of its diagnoses – discussed below.
Some psychiatrists also argue that current diagnostic standards rely on an exaggerated interpretation of neurophysiological findings and so understate the scientific importance of social-psychological variables. It has also been alleged that the way the categories of the DSM are structured, as well as the substantial expansion of the number of categories, are representative of an increasing medicalisation of human nature, which may be attributed to ‘disease mongering’ by pharmaceutical companies and psychiatrists whose influence has dramatically grown in recent decades. Of the authors who selected and defined DSM-IV psychiatric disorders, roughly half had had financial relationships with the pharmaceutical industry at one time, raising the prospect of a direct conflict of interest. In 2005 then-APA president Steven Sharfstein released a statement in which he conceded that psychiatrists had “allowed the biopsychosocial model to become the bio-bio-bio model”. In 2009 Lisa Cosgrove et al revealed that over 70% of the team working on DSM-5 had financial connections with the pharmaceutical companies.
The interest of the big pharmaceutical companies in medicalising mental health issues can be meta-stated as the influence of the ORANGE vMEME in wanting to grow the industry to generate greater profits.
Advocating a more culturally-sensitive approach to Psychology, according to Shankar Vedantam (2005) critics such as Carl Bell and Marcello Maviglia contend that the cultural and ethnic diversity of individuals is often discounted by researchers and service providers. In addition, current diagnostic guidelines have been criticised as having a fundamentally Euro-American outlook. Although these guidelines have been widely implemented, opponents argue that, even when a diagnostic criteria set is accepted across different cultures, it does not necessarily indicate that the underlying constructs have any validity within those cultures; even reliable application can only demonstrate consistency, not legitimacy.
Criticisms around the cultural insensitivity of the DSM approach are, to some extent, answered via the International Statistical Classification of Diseases & Related Health Problems (ICD) which is published by the World Health Organization (WHO) and used worldwide for morbidity and mortality statistics, reimbursement systems and automated decision support in medicine. This system is designed to promote international comparability in the collection, processing, classification, and presentation of these statistics. The ICD is a core classification of the WHO Family of International Classifications. It is the most commonly-used alternative to DSM – though it covers far more than just mental illness. At the time of writing ICD-11 has been completed and is to be put to the membership of WHO for official adoption in late May 2019.
The ICD includes a section classifying mental and behavioural disorders. DSM is the primary diagnostic system for psychiatric and psychological disorders within the United States and some other countries; and it is used as an adjunct diagnostic system in other countries. Since the 1990s the APA and WHO have worked to bring the DSM and the relevant sections of ICD into concordance but significant differences remain.
One of the biggest discrepancies between DSM and ICD for years was homosexuality. In 1973 the APA asked all members attending its convention to vote on whether they believed homosexuality to be a mental disorder. 5,854 psychiatrists voted to remove homosexuality from the DSM, and 3,810 to retain it. In the next printing of the-then DSM-II homosexuality was removed as a mental disorder. However, WHO only removed homosexuality from ICD with the publication of ICD-10 in 1992. This discrepancy can be attributed to the DSM reflecting American values while the ICD has to represent values right around the globe.
Although it is almost totally ignored by Western psychiatrists and clinical psychologists, it should be noted that a third classification system exists: the Chinese Classification of Mental Disorders, published by the Chinese Society of Psychiatry. Currently on a third version, the CCMD-3 is written in Chinese and English. It is intentionally similar in structure and categorisation to ICD and DSM, though it includes some variations on their main diagnoses and around 40 culturally related diagnoses. It differs significantly from its Western counterparts in 2 key ways:-
- It makes no distinction between bodily and mental functioning which are seen as inter-relating and symbiotic
- More than the other systems, it recognises that mental disorders are culturally located and can vary considerably between cultures
- Difficulties in stimulus control of behaviour – ie: particular stimuli that produce inappropriate behaviour or do not produce different behaviours
- Deficient behavioural repertoires – ie: the client does not have the appropriate skills for day-to-day living – effectively failure to function adequately
- Aversive behavioural repertoires – eg: the individual behaves in ways that are unpleasant, irritating or harmful to others
- Difficulties with incentive systems – ie: the individual is receiving rewards for behaviours that are harmful – eg: restricting food intake
- Aversive self-reinforcing systems – are used by people who have unrealistic expectations and are overly critical of themselves
The Goldfried & Davison concept never really caught on outside of some Behaviourist circles. However, Alan Bellack & Michel Hersen (1980) claimed it had higher reliability and validity than DSM.
Problems in defining mental health and mental illness
There are real issues with trying to define mental health and mental illness. As David Rosenhan’s classic 1973 study On Being Sane in Insane Places only too clearly demonstrates, there may easily be a trade-off between reliability (consistency) and validity (accuracy) in diagnosis in trying to define and categorise mental illness. This raises questions as to whether disorders are actually real conditions in people in the real world – raising issues of ecological validity – that can be consistently/reliably identified by DSM/ICD-type diagnostic criteria. Such long-standing criticisms of the DSM were originally highlighted by Rosenhan’s study and continue being made despite some improved reliability since the introduction of more specific rule-based criteria for each condition.
David Barlow & Mark Durand (1995) emphasise that high reliability is only possible with very tight criteria for each disorder – effectively the BLUE vMEME running a Little Detail meta-programme. However, Barlow & Durand state such tight reliability risks sacrificing validity. Eg: Generalised Anxiety Disorder is characterised in DSM- IV-TR by “excessive anxiety and worry (apprehensive expectation) occurring more days than not for at least 6 months, about a number of events or activities”. Barlow & Durand point out that this is reasonably precise but rather arbitrary. Someone suffering from excessive worry for a week over 6 months is unlikely to be much different from someone suffering similarly for marginally under 6 months.
Reliability in diagnosis is itself often problematic. It is usually calculated using one of 2 measures:-
- Positive predictive value (PPV) is simply the proportion of people that keep the same diagnosis over time – usually expressed as a percentage. Eg: if Depression has a PPV of 80%, then that means that 80% of people with an initial diagnosis of Depression received a subsequent diagnosis of Depression when reassessed
- Cohen’s Kappa is the correlation between the results of 2 rounds of diagnosis in a group of patients. A kappa of +1 would mean there was complete agreement in 2 rounds of diagnosis in the same group of patients. A kappa of 0 would indicate no agreement and effectively zero reliability
A M Pontizovsky et al (2006) considered the degree of agreement in diagnosis between admission and release for 998 patients admitted to Israeli psychiatric hospitals during 2003, suffering from Depression and related mood disorders. They also looked at 1,013 patients with Schizophrenia and related psychotic disorders. They used ICD-10. The PPV for the mood disorders group was 94.2%, with a kappa of 0.68. The PPV for the psychotic patients was 83.8%, with a kappa of 0.62. Pontizovsky et al’s findings indicate good reliability.
Not so reliable was a study by Dasha Nicholls, Rachel Chater & Bryan Lask (2000). Investigating eating disorders amongst 81 patients aged 7-16 at London’s Great Ormond Street Hospital, they found only 64% reliability using DSM-IV, a disturbing 36% with ICD-10 but 88% with the hospital’s own system designed especially for children. Over 50% of the patients could not be diagnosed from the DSM criteria. This last finding also indicates a problem with criterion validity – ie the criteria used by DSM appear not to be valid.
In a test of criterion validity Almudena Sánchez-Villegas et al (2008) administered the current standard interview from DSM-IV-TR to 62 patients with a current diagnosis of Depression and 42 without a diagnosis. 42 of the of the 62 (68%) were correctly identified as depressed. 34 of the 42 (81%) were confirmed as not depressed. Sánchez-Villegas et al considered this to be “moderately good”.
For a mental illness to be classified and thus treatable, it must be distinct and separate from other illnesses – ie: very high in descriptive validity. If the syndrome of an ‘illness’ is not clearly distinct and separate from other illnesses, then its existence as a distinct illness can be called into doubt. However, comorbidity is a common feature of mental illness. Comorbidity – the presence of 2 or more disorders at the same time – can make achieving good descriptive validity all but impossible. Michael W Eysenck (1997) reported that up to 2/3 of patients with one anxiety disorder have also been diagnosed with one or more additional anxiety disorders.
Jordan Smoller’s Cross-Disorder Group of the Psychiatric Genomics Consortium 2013 findings call into question the usefulness of descriptive validity and also have implications for aetological validity. The Consortium found that people with disorders traditionally thought to be distinct – Autism, Attention-Deficit-Hyperactivity Disorder, Bipolar Disorder, Depression and Schizophrenia – were more likely to have suspect genetic variation at the same 4 chromosomal sites. These included risk versions of 2 genes that regulate the flow of calcium into cells. While the Consortium readily admit there is a long way to go before hard conclusions can be drawn from their work, clearly, if several illnesses are found to have the same aetiology – or a substantial identical aetiological element – then the idea that a discreet syndrome always has a specific, unique cause is seriously questioned. The sheer size of the Consortium’s sample – 33,332 patients with all 5 disorders and 27,888 controls – makes the results undeniably reliable. Doing this and finding the same 4 chromosomal sites implicated in the illness can be said to call into question some of the boundaries between these traditional diagnostic categories. It calls into question just how distinct and separate these illnesses really are.
Then there are those who actually dispute the ecological validity of the very concept of ‘mental illness – most notably the ‘Anti-Psychiatry Movement’. Coming to the fore in the 1960s, ‘Anti-Psychiatry” (a term first used by David Cooper in 1967) defined a movement that vocally challenged the fundamental claims and practices of mainstream Psychiatry. Thomas Szasz (1962) argues that ‘mental illness’ is an inherently incoherent combination of a medical and a psychological concept, saying:“Strictly speaking…disease or illness can affect only the body. Hence, there can be no such thing as mental illness.” He hypothesises that the concept is popular because it legitimises the use of psychiatric force to control and limit deviance from social norms.
R D Laing (1967) very much supports this view, seeing so-called ‘mental illness’ as ‘problems in living’ and blaming society at large and oftentimes parents for the problems.
Michel Foucault (1973-74/2006) states that the concepts of sanity and insanity are social constructs that do not reflect quantifiable patterns of human behaviour but which, rather, were indicative only of the power of the ‘sane’ over the ‘insane’. In this he is reflecting Labelling Theory and its identification of the powerful labelling the less-powerful to their disadvantage. Foucault notes that the novel One Flew Over the Cuckoo’s Nest became a bestseller, resonating with public concern about involuntary medication, lobotomy and electroshock procedures used to control patients.
The Anti-Psychiatry Movement can be seen as dominated by GREEN thinking in its opposition to labelling and the kinds of social control Psychiatry facilitates.
If there is such a thing as mental illness, then there are questions to be answered about how perceptions of what it is vary so much in time and place. As discussed above homosexuality was once a mental illness – and then in 1973 it wasn’t. Or as Lucy Johnstone (1989) put it: “The most spectacular cure achieved by modern psychiatry was when homosexuality was dropped as a category of mental illness from the DSM-III and millions of people thus ‘recovered’ overnight.” Or, at least homosexuality wasn’t an illness in countries where DSM held sway among psychiatrists and clinical psychologist; where ICD was more influential, it remained so until 1992. In some countries today homosexuality is still regarded as ‘wrong’. Thus, whether homosexuality was a mental illness was – and still is, to a degree – relative to the culture in which the person is located.
The concept of cultural relativism was developed by the noted anthropologist, Ruth Benedict (1934). A everyday example of cultural relativism that epitomises the issue comes from Otto Klineberg (1971) who reported that Lakota Indians consider it wrong to answer a question in front of those who don’t know the answer.
Rather more dramatic is the acceptance of auditory hallucinations – hearing voices – in many non-Western cultures. Usually taken in the West as the pre-eminent symptom of Schizophrenia, it is common in many African countries and is considered a blessing or sign of approval from the gods amongst Native American peoples. Melisssa Taitimu, John Read & Tracey McIntosh’s 2018 study of Māori voice-hearers is yet one more piece of research confirming the normality of hearing voices outside of Western society.
If cultural relativism muddies the waters as to how to define and categorise mental illness, culture-bound syndromes complicate the matter even further. DSM-IV defines a culture-bound syndrome as “locality-specific patterns of aberrant behaviour and troubling experience that may or may not be linked to a particular DSM-IV diagnostic category”. Examples include Amok and Koro in South-East Asia. A man suffering Amok will commit acts of extreme violence, then lie down and go to sleep; when he awakes he has no memory of the violence. However, Pow Meng Yap (1969) dismisses Amok as simply a “rage reaction”. Koro was first reported in the Western press in 1985 and attempts were made to label it ‘Genital Retraction Syndrome’ as it concerns men having extreme fear that their genitals will retract into their body. Arabinda Narayan Chowdhury (1998) prefers to see it as an example of Disordered Body Image Perception.
David Pilgrim & Anne Rogers (1999) contend that while, at different times and in different cultures, there may be variations in mental illness, it does actually exist as a real condition.
Biases in diagnosis
There are 3 major biases research has revealed in the diagnosis of psychiatric disorders:-
- Race bias
Approximately 5% of the UK’s population is black…yet blacks account for around 25% of hospitalised psychiatric patients. According to Raymond Cochrane & Sashi Sashidhara (1996), Afro-Carribeans are up to 7 times more likely than whites to be diagnosed with Schizophrenia. Roland Littlewood & Maurice Lipsedge (1997) also found that blacks were more likely to receive a diagnosis of mental disorder. Such findings might be meta-stated as indicating there may be a racial/genetic basis to these disorders, with blacks more vulnerable to developing them. However, Littlewood & Liversedge were not happy to ascribe this to race alone – noting that blacks were more likely to be seen by a junior doctor than a consultant. (Interestingly, the researchers had similar findings for Irish!)
Moreover, Raymond Cochrane (1983) cites an interesting study in which the incidence of diagnoses of Schizophrenia amongst white and black males in Birmingham was compared. The blacks were 6 times more likely to be diagnosed. However, when the whites were compared to an equivalent group of black males living in the Caribbean, no difference was found. This suggested that, rather than racial/genetic factors, it was cultural/environmental factors which shaped the difference between the 2 Birmingham groups.
- Gender Bias
There do seem to be indications that males are more likely to be diagnosed with some types of psychiatric disorders and females other types.
Lee Robins et al (1984) considered gender differences in the lifetime occurrences of various disorders across 3 American cities. They found-
– 90% eating disorders were female
– 27% men seriously abused alcohol compared to only 4% women
– 5% men had been convicted of anti-social behaviour compared to just 1% women
– 2% men suffered from Depression but 8% of women did
– 4% of men had a specific phobia but 9% of women suffered in this way
Maureen Ford & Thomas Widiger (1989) found gender differences in the correct diagnosis of Anti-social Personality Disorder (40% males; 20% female) and Histrionic Personality Disorder (80% females; 30% males).
George Brown, Tirril Harris & Catherine Hepworth (1995) argue that women are more at risk of mental illness due having more stress in their lives – eg: having to combine work with childcare and domestic chores. For single mothers, stressors can also include poverty, debt, unemployment and poor housing conditions.
- Social Class Bias
In 1991 Martha Bruce, David Takeuchi & Philip Leaf confirmed the view that the lower classes were far more vulnerable to severe mental disorders. They found that people on or below the poverty line were twice as likely as their middle class counterparts to abuse alcohol and/or suffer from Depression and/or Bipolar Disorder – and 80 times more likely to develop Schizophrenia!
Researchers – eg: Barlow & Durand – have long associated the lower classes with greater vulnerability to Schizophrenia. Social Causation theory hinges on the notion of the lower classes having more stressful lives, with greater stress creating greater vulnerability. Social Drift theory inverts this idea, focusing on how schizophrenics lose their jobs and thus drift into the lower classes. M J Turner & M O Wagonfield (1967), however, saw social drift and social causation as being inextricably connected, rather than competing concepts – ie: schizophrenics lose their jobs and end up in poverty (social drift) and their children then are much more likely to be vulnerable to developing Schizophrenia, in part at least due to their poverty (social causation).
From a literature review covering 40 years, Bruce Link & Jo Phelan (1995) concluded that there is a close relationship between material deprivation and poor levels of mental heath.
Social class bias seems to infect the way judgements are made in the assessment and treatment of mentally-ill patients. Johnstone makes the point that clinicians are more willing to diagnose Schizophrenia in working class patients than middle class ones – even when they have very similar symptoms. Sandra Unmbenhauer & Linda DeWitte (1978) found that professionals tended to offer less effective interventions to patients from the lower classes.
Of course, Intersectionality can make things that much worse. For example, Roy Luepnitz, Daniel Randolph & Kenneth Gutsch (1982) found working class African-Americans more likely to be ‘alcoholic’ than middle-class whites. Another example comes from Paul Crone et al (2008) who found women from British Pakistani and Indian households have Depression more than either men or women of white or Afro-Caribbean ethnicity.