Monday, February 7, 2011

Mental Illness

As the subject of mental illness has come up several times in recent essays, I think it is time for me to clarify my position. I have several times made mention of the fact that I have some problems with current views and so I feel I should probably explain why. It also will make much easier when I finally write on my thoughts about the problem of involuntary commitment and other mental health issues.

My first problem is that there are no real objective diagnostic criteria. While some postulate a physical or genetic cause, the fact remains that, outside of a few dementias, we have found physical markers for none of our mental illnesses. Which means that diagnosis is based on arbitrary criteria. And more than that. Arbitrary criteria which cannot even be quantified.

And that is the real difference. You see, I am sure when I mentioned arbitrary criteria, some clever person would mention that a blood sugar of , say 60, is arbitrarily set as the cutoff for a "low" value. And it is true that what is the borderline for high and low is something of an arbitrary choice. But he difference is that there is still a blood sugar to measure, and numbers can be compared, values can be measured and so on. We can describe physical conditions at various numeric values.

Can we do that with sadness? What value of sadness is too sad? When does depression become an illness?

But it is not just the lack of quantification, it is also the fact that these supposed illnesses are just exaggerations of normal behavior, or even behaviors which could be normal in other contexts. If I am sad the day after my wife dies, most agree it is normal. If I am just as sad a week later, it is ok for most. A month, maybe. A year, and many think I have a problem.

And therein lies the problem. Some would and some wouldn't. Whether I am just sad or clinically depressed in the end comes down to judgment call on the part of the therapist, and is based more on what the cultural norms say about depression than any real diagnostic criteria. But, in my mind at least, cultural norms do not an illness create. Which means mental illness is more in the nature of behavior than an illness. When we say someone is mentally ill, more often than not we simply mean he has transgressed too far against our cultural norms.

And that isn't an illness. And it certainly doesn't sound like something biological in origin.

Now, usually by the time I reach this point, someone who has a friend or family member with a problem becomes offended and says "If you knew someone with [whatever] you wouldn't doubt it was a real disease!" Or maybe "it was biological!" But the truth is I have known many people with mental disorders, yet that does not change the facts. Mental illnesses are basically either an inability to meet certain social norms or the exaggeration of a specific trait or behavior. Why must that be a disease and not just a sign of normal human variability? We accept that there are virtuosos who excel in positive directions without calling it a disease. So if there are piano prodigies, why not fear prodigies, which we call paranoia? Why must the bad extreme of behavior be a disease while the good extreme is a virtue?

It seems to me that what we call mental illness is much more likely simply a problem of behavior or acculturation, sometimes simply an extreme of  temperament, and in some case, simple play acting by someone whose situation is improved by being thought "crazy".

Now, to blame much of it on aculturation and behavior is not to lay the blame on parents, as was common in the past. Likely some percentage of personality is innate, established form birth. And given that, an individual's reaction to stimulus can be rather unpredictable, even at a very early age. It also explains how two children from the same environment can grow into quite different adults. Parents play some role, but so does everything that goes into the environment surrounding a child. Which means that the behavioral and cognitive problems which we label mental illness could come from any number of sources, or even from the interaction of several.

Now having said that, I am sure some will come back with some very extreme example and argue that it "just couldn't be" due to behavioral or acculturation issues. But that ignores how little change it takes to result in completely bizarre behavior. For example, try this tomorrow. Whenever anyone uses a word beginning with the letter S take great offense. It is but one small change, a simple matter of a strange connotation no one expects or shares with you, but see how bizarre your behavior becomes. If that one small change can make you seem completely erratic, then imagine someone with a library of literally hundreds of idiosyncratic connotations, who has their own personal set of meanings attached to actions or words.

Now, I am not arguing here for a return to General Semantics, arguing that all of mental illness is a linguistic phenomenon. But I do think that added or missing connotations for words can explain much of the strange verbal and emotional behavior exhibited by some. Of course, that is not the only cause. A failure to understand rules of reasoning and association can be another. Psychiatrists even seem to recognize this, pointing out the superficial way schizophrenics associate ideas, yet they do not make the logical conclusion that schizophrenics simply don't know how to properly link ideas, and instead see it as a symptom. On top of this we can add extremes of personality, including an excess or lack of affect, as well as poor control of impulses, and maybe poor understanding of behavioral norms, and we can find an explanation for nearly everything that we are told is the result of  "mental illness".

It is less comforting to think that the crazy person is that way simply because he never learned what he needed to behave better. It makes us feel better to think he is sick. But just because something is comforting does not make it true.

POSTSCRIPT

Many will argue that I can't be right because psychological drugs "work".

I would argue that many work only in a very vague sense. For example potent sedatives do make some pliable and docile, but that does not mean they are cured, just drugged.

Others work, but not for the reason supposed. For example, many supposed anti-depressants (eg Paxil) are also sometimes abused for their euphoric effect. Is it any wonder that a euphoria producing drug will make people less depressed? That shows nothing about serotonin or dopamine. It just proves getting high makes people feel better for a time.Likewise, drugs which have a stimulant effect tend to be prescribed to those with lethargy, and not surprisingly have some beneficial effect. In the long run, a lot of psych drugs differ from self-medication with illegal drugs only in the view of the law.

But even those cases where a drug does not produce euphoric or stimulant effects and yet serves to elevate mood, that does nothing to prove problems are an "illness". The fact that inducing chemical change in the mind can effect mood proves nothing it all, except that mood, like all thought, is an electrochemical process. We know that. But it says nothing about the origin of depressions, autism, or any other disorder.

NOTE: As this is relevant for both of my blogs, it has been simultaneously posted on Random Notes and Examining the War on Drugs.

ADDENDUM

In some ways my thoughts mirror those of Thomas Szasz and Peter Breggin. I know that both are not held in high esteem by many in the medical community, but that does not mean they are wrong. While working in social services I had interaction with many supposedly suffering from mental illness and saw the supposedly minimal side effects of psychiatric medications. I also saw real organic brain damage while working with the retarded, so I have seen the difference between a real physical problem and the array of misbehavior and confusion we call mental illness.

Having said all that, I am open to the possibility that I am wrong, either in specific cases, or in general. Perhaps some mental illnesses do have an as yet unknown physical cause, but, as I said, excluding dementia of various types, I have not seen any persuasive evidence. And the ever changing genetic markers for schizophrenia have convinced me that media reports on the topic tend to insufficiently research before announcing breakthroughs.

Originally Posted on Random Notes and Examining the War on Drugs on 2008/06/17.

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