Does Mental illness exist (2)

Following on from the first post titled “Does mental illness exist” after which Ted argued passionately, if unconvincingly, that coercive psychiatry was contrary to the principles of Natural law and was morally wrong. It occurred to me that if Psychiatry, coercive or otherwise, is to have any validity at all then it must be able to objectively describe and classify what is a mental illness. The Szaszian view of psychiatry is that mental illness is based on a fallacy or category mistake by ascribing abnormal behaviour patterns to physical disease categories. But even within Psychiatry there is an ongoing debate about how mental illnesses should be classified.

Currently we have two major systems of classifying mental illness the DSM IV and the ICD 10. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is an American handbook for Psychiatrists that lists different categories of mental disorders and the criteria for diagnosing them. The ICD 10 is a similar coding of diseases by the World Health Organization.

There are two aspects to any system of classifying illness, what conditions are classified as illness and how those conditions are grouped together. Controversial diagnostic categories in the past have included homosexuality and moral imbecility while categories such as psychopathy, personality disorder, and ADHD generate argument today. Even the unitary nature of Schizophrenia and Autism is coming under attack from some quarters. At the heart of classifying a condition as an illness as opposed to eccentric or unusual behavior is the distinction between normality and abnormality. When making the distinction between normal and abnormal behavior it is difficult to avoid making normative assumptions, assumptions about “how things should be” that presupposes the existence of a “normal” example of behavior. These assumptions are far from value neutral but it is hoped that any future classification of mental illness will be based on the causes of mental illness rather than on observed symptoms, as is the case in psychiatry today. At some point in the future it may be possible to identify neural dysfunctions associated with particular psychiatric symptoms and the professional distinction between neurologists and psychiatrists will evaporate. Psychiatric Diagnostic categories in the future may not need to find a clear philosophical difference between the mental and the physical.

But is it possible, given the normative assumptions made in differentiating between normal and abnormal behaviour for any classification of illness to be truly objective? This is a question that applies to all illnesses but the question has particular relevance to psychiatry because of the element of coercion that is occasionally brought to bear on patients diagnosed with a mental illness.

The main approach to the classification of mental illness in the West is based on the “medical model”. There is no one medical model as such but this general approach to classifying illness is based on the principle that it is possible to describe illness in a way that is both scientific and objective. It is debateable however if being “objective” and “unbiased” is necessarily one and the same thing. When deciding what is and what is not normal it is possible to be objective but still adopt a view that is far from value neutral. Most people would argue that in making a psychiatric diagnosis such assumptions about normality are unavoidable and the only thing we can do is to be as open and honest about them as possible.

Those that argue we can arrive at a definition of illness that is unbiased and objective argue that it is possible to do so by defining ill health in terms of dysfunction where dysfunction is defined in evolutionary terms. Boorse (1976) defines an individual as being psychologically healthy when the individual is not mentally ill; where illness is defined as an internal state which interferes with the performance of some natural function, or behaviour which is not in the true nature of that individual. Boorse uses evolutionary psychology to argue that mental illness is a psychological condition that interferes with the natural function of the individual, a function that would normally promote the continuation of the species as a whole. But this simply begs the question of what constitutes a natural function and what is the true nature for the individual. It is also problematic to base a concept of normalcy or naturalness on a state, mental or physical which promotes reproductive success for the species as suggested by evolutionary psychology. This would imply that homosexuality is an illness because it could be viewed as a “condition” which arguably inhibits the continuation of the species. Also psychiatry is concerned with what is normal for the individual rather than what is normal for society. If we base our ideas of what constitutes psychological ill health on evolutionary psychology we are likely to end up with a series of diagnostic categories which are normatively loaded in terms of what is good for society and far from value neutral in terms of the individual.

Jerome Wakefied (1992) developed the idea further by arguing that while evolutionary psychology can still help us decide which conditions are functional and which are dysfunctional, dysfunction as he defines it is a purely factual and scientific concept telling us nothing about what is considered normal by society. Hence conditions although judged dysfunctional in crude evolutionary terms might not count as an illness because they are not thought to be harmful to the individual. For instance homosexuality might be classed as dysfunctional in terms of evolutionary theory, (because in crude terms it hinders procreation), but it should not be classified as a disorder because it is not harmful to the individual. Sexual addiction on the other hand depending on if it is viewed as dysfunctional in terms of evolutionary psychology might be viewed as an illness because excessive promiscuity is generally viewed as harmful to the individual. However Wakefield does acknowledge that in basing our idea of illness on what is considered harmful to the individual as judged by the standards of the society in which the individual finds himself, we are still at risk of making normative assumptions that are far from value neutral.

Wakefield defines an illness in the following manner

“A condition is an illness if the condition causes some harm or deprivation of benefit to the person as judged by the standards of the person’s culture and if the condition results from the inability of an internal mechanism to perform its natural function.”

A natural function is defined by Wakefield in evolutionary terms as an attribute which confers a natural advantage on the individual or species. This definition is still open to criticism because it is far from clear what constitutes an advantage in evolutionary terms and it is open to debate if psychiatry should be basing its view of what is normal or natural on what is good for the species.

A different definition of illness comes from Culver and Gert (1983)

“A person has an illness if he has a condition that results in him suffering some evil such as death, pain, loss of freedom, opportunity or pleasure in the presence of a distinct sustaining internal cause”

Homosexuality would still not be seen as an illness under this definition because while being gay can make a person unhappy the sustaining cause is usually societal prejudice rather than the failure of some internal mechanism in the individual. Sexual addiction on the hand might be judged an illness if the cause of the dysfunctional behaviour is thought to be either psychodynamic or neuro chemical in origin. This definition allows for an objective view in determining if the individual is suffering what Culver describes as an evil and in determining what is causing that evil. There is still however an empirical issue surrounding if a person is suffering a disability, loss of opportunity or pleasure. Should a man with erectile dysfunction who is only able to have sex twice a week without taking medication count as having an illness or disability? It is difficult to answer this without questioning what is considered a “normal” level of sexual activity for the average male.

The subject of substance abuse is equally problematic in this regard. What level of freewill does an alcoholic or drug addict really have? If the answer is none then arguably they have lost their freedom and their condition properly qualifies as an illness. How we answer the question of free will depends on what normative assumptions are made regarding alcoholism and drug addiction, assumptions which are rarely value neutral. And should an artist who used to experience brief periods of intense creativity when manic, who now successfully treated but unable to paint be viewed as suffering from a loss of opportunity or freedom? The approach adopted by Culver and Gert does not rely on evolutionary psychology to define what is and what is not a dysfunction and so avoids some of the criticisms levelled at Boorse and Wakefield but the criteria for what counts as an evil depends on normative assumptions about the nature of normality which leaves Culver and Gert’s definition of illness based on a circular argument about what is and what is not normal behaviour.

References
1. Boorse, Christopher (1976) “What a theory of mental health should be” Journal of the Theory of social behaviour should be p 61 – 84
2. Wakefied, Jerome, (1992) “The concept of mental disorder: on the boundary between biological facts and social values” American Psychologist Vol 57 No 3 pp 373 – 388
3. Culver, Charles and gert, Bernard (1982) Philosophy in medicine, New York: Oxford |University Press