What Is Mental Illness?
'When I use a word.' Humpty Dumpty said, in a rather scornful tone, 'it means just what I choose it to mean - neither more nor less.'
'The question is,' said Alice, 'whether you can make words mean so many different things.'
'The question is,' said Humpty Dumpty, 'which is to be master - that's all.'
(Lewis Carroll Through the Looking Glass)
The cost of mental illness in the UK has been variously estimated at between £3.75 and £7 billion.1 These figures are based mainly on the cost of lost production, sickness payments and National Health Service facilities, but not on the cost of individual suffering. It is reckoned that at least one in five of us will succumb to mental illness at some time during our lives, some of us more than once. Whichever way you look at it, it is a serious problem.
What exactly do we mean by the term 'mental illness'? Is it the same as a 'nervous breakdown'? Is it imagined, 'all in the mind', a reluctance to 'pull oneself together', an unconscious kind of malingering? Or is it a condition that requires medical treatment?
If you have yet to look up 'illness' in a dictionary, you may be in for a surprise. Both it and 'mental' are abstractions; and abstractions are by their nature difficult to define accurately. Sometimes they seem to have as many different meanings as the number of people who employ them.
'Illness' is therefore ...well, illness; and the dividing line between 'ill' and 'not ill' is largely a matter of opinion. In industrialised societies, judgement is often delegated to medical practitioners. The word 'mental', on the other hand, comes from the Latin for 'mind', the collective term we use to describe such activities as thinking, wondering, remembering, calculating, judging, planning, learning, knowing, understanding, feeling, wanting, imagining. It tends to be used exclusively in connection with the 'cognitive' activities: 'mental arithmetic', for example. Perhaps that is one of the reasons why Daniel Goleman's term 'emotional intelligence' has become fashionable.
Because so much mental activity depends on brain circuitry, many people do not distinguish between 'mind' and 'brain'. In fact, however, the brain is the physical organ that facilitates mental activity. Although the distinction may seem merely pedantic, in my view it is central to an understanding of mental illness.
For practical reasons. perhaps influenced by the thoughts of René Descartes in the seventeenth century, most modern societies now distinguish between the mainly physical and the mainly mental illnesses. In cases of physical illness, the presence or absence of objectively measurable physical symptoms makes it relatively simple to establish an acceptable boundary between 'ill and 'not ill'. But in mental illness few symptoms can be measured with the same degree of objectivity.
In an attempt to distinguish the mental from the physical illnesses, many health workers prefer to describe the mental kind as 'disorders'. Some of these disorders are caused by brain impairment: the dementias that result from Alzheimer's, Pick's, Creutzfeldt-Jakob's, Huntingdon's, Parkinson's and human immunodeficiency virus (HIV) diseases, for example, as well as from dependence on mood-altering substances. These are usually called 'organic' because they are a consequence of brain impairment.
But organic mental disorders are relatively few. The great majority of mental disorders are 'dis-eases' of the mind, emotional disturbances so prolonged and acute as to produce thought disorder. These are often called 'functional' because they relate to mental malfunctioning that is not caused by brain impairment. Confusion often arises because many people believe that psychiatry is the most appropriate treatment for all kinds of mental disorder. Another confusing factor is that there is sometimes a reciprocal relationship between the functional mental disorders (FMDs) and physical illness, so that it is difficult to distinguish cause from effect.
Although the FMDs are by definition not caused by detectable brain impairment, does that mean that there really is no impairment - or simply that none has so far been detected? Absence of evidence is not evidence of absence. The diagnosis of schizophrenia is an example. Is there a genetic factor, as some studies have suggested? Are the brain abnormalities that have been detected in some of the people described as schizophrenic the cause or the effect? Perhaps the truth is that there are a number of different disorders that produce symptoms of what we call schizophrenia, some of them organic and some functional!
When we fall in - or out - of love, for instance, or become frightened or exhilarated, there are undoubtedly changes in our brain chemistry. Can there, in fact, be any thought or feeling that does not involve such changes? Is post-natal depression, to take another example, caused by a hormonal imbalance? If so, what causes the hormones to be in balance of those women who give birth without becoming depressed?.
Perhaps the most important difference between FMDs and the mainly physical illnesses is that the categories psychiatrists and other medical practitioners use to diagnose FMDs are of a very different kind from those used to diagnose physical illnesses. In the case of physical illness, the diagnosis is often clearly related to the probable cause. A diagnosis of influenza, for instance, suggests the multiplication of a virus taking advantage of a weakened immune system. Byssinosis suggests that the person has been employed in a cotton factory. Malaria suggests exposure to a certain kind of mosquito; and so on. A FMD diagnosis, on the other hand, consists only of a group of symptoms, some of which may be physical and some mental. We can only guess at the causes. 'Stress', the term most often cited as a cause, tells us little, if anything.
The FMD categories used in medicine are in essentially conjectural: aggregates, or 'clusters', of symptoms that seem - to the person making the diagnosis - to be connected. Such categories both enable the practitioners to select particular forms of treatment and to help reassure their patients that their condition is a medically recognised one. The conjectural nature of the categories is typified by the fact that, until the most recent edition of the World Health Organisation's list, homosexuality was included as a mental disorder. Apparently, the Italian Court of Cassation (Supreme Court) and the Vatican's Sacra Rosa still regard it as such.2
When the causes of FMDs are carefully analysed by the sufferer, perhaps with the help of someone who specialises in such work, they are invariably found to consist of difficulty coping with the demands of living: for example, the experience of puberty, marital breakdown, isolation, unsatisfactory relationships, parenthood and perhaps the eventual 'empty nest', bereavement, loss of financial or social status, unemployment, adverse working conditions, involvement in a serious accident, heavy or prolonged bombardment, neighbourhood crime, violence, intrusive noise, a sense of being completely isolated or abandoned.
Mostly, we react to such events in ways that enable us to cope without becoming 'ill'. Such reactions as headaches, depression, anxiety, listlessness, shortness of temper and nightmares may be warnings that we need to detach ourselves from the situation in order to determine what is really troubling us and the best way of dealing with it. But, if too many adverse events occur within a limited period or if we are ill-prepared for them, they tend to create an 'information overload' that swamps our mental capacity. Our minds become 'unbalanced'. We are unable to 'see the wood for the trees'. Thoughts may become so jumbled or disordered that we tend to behave irrationally and even bizarrely.
Many people assume that the suffering involved in mental illness is not as real, and therefore not as intense, as the suffering that accompanies physical illness. But there is no objective means of measuring the intensity of suffering. The suffering experienced in mental illness is all too real to the patient and it may be equally, if not more than, distressing to what is experienced during physical illness. At the very least, it is usually accompanied by extreme anxiety, or nervousness. Hence, I suppose, the term 'nervous breakdown'.
The difficulty of deciding whether someone is ill or simply responding to events in ways that would otherwise be regarded as healthy, provides us with opportunities to profit from the situation by exaggerating our symptoms. Some of us do it wilfully, but we are all capable of over-estimating, as well as under-estimating, the severity of our symptoms without realising that we are. Hence the difficulty of distinguishing between malingerers and those who are truly sick. How, for instance, ought we to categorise the litigant who, when asked how far he can, raises his arm only to shoulder level - and then raises it well above his head when asked how far he could before the accident? Perhaps children who suffer from the FMD related to hyperactivity are occasionally tempted to believe that they misbehave because they are ill. There are even a number of instances on record of people in responsible positions avoiding criminal charges by persuading a psychiatrist (and themselves?) that they are too ill to plead. Some patients have also been known to exaggerate their symptoms in order to obtain cosmetic surgery. The surgeon's dilemma is compounded both by the absence of lesions and the conjectural nature of the psychiatric diagnosis.
Does this suggest any connection with 'psychopathic' behaviour? Pyromania, kleptomania, paedophilia and sadomasochism, for example, are 'personality disorders' for which there is no recognised medical treatment., but there is little agreement whether or not. they are FMDs. We sometimes describe such behaviour as 'sick'. Might it be 'a cry for help'? In the USSR, a number of political dissidents were compelled to accept psychiatric treatment because it was clear from their activities that. their minds were unbalanced. Were the men in the Kremlin being duplicitous or just unknowingly misled by genuine belief?
Perhaps some of the difficulty understanding and resolving the problem of mental illness would be overcome if we were less disposed to regard undesired and/or undesirable behaviour as a mainly medical matter, and listened more to Humpty Dumpty …
Thomas Szasz The Manufacture of Madness. Harper & Row, New York 1970
David Smail. Illusion and Reality J.M. Dent & Sons, London 1984
Herb Kutchins & Stuart A. Kirk Making Us Crazy. The Free Press, New York 1997
A Report by the British Psychological Society Division of Clinical Psychology.Recent Advances in Understanding Mental Illness and Psychotic Experiences June 2000
[This is a modified version of a page from the author's website http://www.baxter03.fsnet.co.uk/]