Controversies and Dilemmas in Contemporary Psychiatry

Dusan Kecmanovic

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781351380089
• Edition: 1
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

The controversies and dilemmas in contemporary psychiatry are so numerous and serious that they, to a great extent, define psychiatry. Yet most psychiatrists pay little attention to the field's controversies, maintaining that talking about controversies tarnishes psychiatry's reputation and them along with it. Critics of psychiatry use these controversies and dilemmas, along with psychiatrists' unwillingness to discuss them, to undermine psychiatry. They question the existence of mental disorder and the purpose of psychiatric therapy. Kecmanovic undertakes a major effort of resolving with science, not ideology, such dilemmas.

Although psychiatrists give no thought to the mind-body relationship, their attitude towards this relationship determines their approach to the mentally ill, their understanding of the origin and nature of the mental disorder, and the therapy they think has priority. Sometimes psychiatrists implicitly or explicitly cite a specific school of philosophy in order to find conceptual support for their particular practice. As a result psychiatrists do not speak the same language about the same issues. Kecmanovic suggests that there can be no dialogue without common language; opposing views cannot converge without dialogue.

The behavior of the mentally ill is socially jarring. This is a major reason why the mentally ill are considered to be a menace. They threaten prevailing manners of communicating, expressing one's thoughts and feelings, and the existing meaning of symbols in a given environment. Deviance of a person with a mental disorder is specific; socially perceived as incomprehensible, irrational, and unpredictable. What is common to all reactions to the disruptive nature of a mental disorder is the desire to be protected from those with illness; in other words, to put them under control and supervision.

1 Towards a Definition of Mental Disorder

DOI: 10.4324/9781315146300-1

Physicians, including psychiatrists, give a lot of thoughts in their everyday work to answer the question of whether or not a particular patient has a disorder; they rarely give much thought to the broader issue of what constitutes a disorder.

Robert L. Spitzer, 1999

Attempts to define mental disorder are as old as the very concept of mental disorder.

If I say that there is no satisfactory definition of mental disorder even today, the reader will know how difficult it is to define. Otherwise, the many psychiatrists, psychologists, sociologists and anthropologists who have been trying for decades to find the real answer would have come at least close to the right answer to the question: what is mental disorder? And it seems they have not.¹ Assuming, of course, that there is a right answer.

Why is it Important to Define Mental Disorder?

The question of the nature and borders of mental disorder is not as academic as it might seem. The answer is particularly important for a person whose psychological state is evaluated as disordered or non-disordered. Being diagnosed as mentally ill has serious consequences for such a person and the members of their family, and to a somewhat lesser extent for the people from their work or their neighbors. In addition, it is important to public health in distinguishing mental disorder and non-disorder accurately. The incidence rate and prevalence of mental disorder in a specific community depends on the definition of mental disorder. The frequency of mental disorders in a specific community determines, or at least should determine, the amount of money that will be earmarked to treat and care for the mentally ill.

The definition of generic mental disorder is also essential when classifying mental disorders. In order to demonstrate the importance of the definition of mental disorder for diagnostics and classification, Allan V. Horwitz and Jerome C. Wakefield (2007: 8) used a figure. Imagine an inverted pyramid, a pyramid standing on its top. The construction of the pyramid is as strong as the top on which the pyramid is standing. The top of the pyramid is the definition of mental disorder and the different types of mental disorder constitute the rest of the pyramid.

Finally, defining mental disorder is also important for those who want to know more about a specific society. The definition of mental disorder has universal elements that apply to every mental disorder, in every society, in every historical era, and elements that refer to a specific sociocultural environment in which a specific behavior is diagnosed as a mental disorder. Anthropologists and sociologists are interested in that aspect of the definition of mental disorder that is linked to a specific sociocultural environment. They can use it to learn quite a bit about the prevailing value system in a given community, about its inhabitants’ likes and dislikes.

General Issues Linked to the Definition of Mental Disorder

Many issues have stood in the way to a generally accepted definition of mental disorder. The reader will learn about them in the text that follows; at least most of the relevant issues. Let me mention right away one of the general dilemmas about mental disorder. Some people consider that mental disorder exists and others maintain that mental disorder does not exist, that it is a mental construct with a certain explanatory value.

Those who represent the first viewpoint, the essentialists, stress that mental disorder is in the nature of the thing (in rerum natura). Essentialists believe that mental disorder exists as ens, as an entity, and there is something like an articulation or demarcation line in nature between mental disorder and non-disorder. It is scientists’ job to establish where this “articulation” or demarcation line exists. Representative of the other viewpoint, the nominalists, believe that concepts such as “mental disorder” are simply mental constructs that do not correspond to reality. According to nominalism, abstract concepts, general notions or universal ideas do not exist independently as doctrines, but only as names. There is nothing in reality that corresponds to the concept “mental disorder.” People have simply come up with the idea of “mental disorder” in order to explain certain phenomena (to themselves and other people).

Whoever takes up the thankless job of defining mental disorder will have to say what it is about mental disorder that distinguishes it from other phenomena, particularly phenomena that have some common characteristics with mental disorder, that are, in other words, similar to it in some respects. They will also have to say whether there is a difference between mental disorder and physical disease and if there is, in what respects.

Here are a few more general remarks regarding the definition of mental disorder.

Those who claim that mental disorder is a social construct actually deny the existence of mental disorder so their views of mental disorder—the argument goes—should not be taken into account when discussing the definition of mental disorder.

I do not agree with this opinion. I feel that those authors, primarily sociologists from the field of symbolic interactionism, who claim that mental disorder is a social construct define it in their own way. For them, mental disorder exists as a social construct. Such a definition of mental disorder should be accepted as legitimate.

A number of authors (for example, Kendell, 1975b, 1993, 2001; Wakefield, 1992, 1999a) who deal with the definition of mental disorder first define a so-called physical (organic, somatic) disease and then apply that definition to mental disorder, thereby tacitly or openly equating somatic disease and mental disorder. Other authors (for example, Klein, 1978; Henriques, 2002; Margolis, 1976), who also apply the definition of physical disease to mental disorder, are careful to point out certain specific features of mental disorder. A small amount of authors (for example, Sedgwick, 1982; Maslow and Mittlemann, 1951) define mental disorder without referring to the definition of physical disease.

Owing to the considerable differences between the nature of physical disease and mental disorder, which the reader will learn in the chapter “Physical Diseases and Mental Disorders: Should They Be Differentiated?” it is very difficult to include both types of pathological events in the same definition. This is why it is better to restrict the definition to only physical disease or only mental disorder. This text will deal solely with the definition of mental disorder. Where necessary, the definition of physical disease will also be considered.

It is difficult to look for the definition of mental disorder on only one of the following three levels: the cause(s) of mental disorder, its clinical picture, and its consequences. It is therefore no wonder that the authors of past definitions of mental disorder sought its specific features simultaneously on two or even all three of the above levels.

Attempts to establish what is distinctive to mental disorder on for example only the level of its etiology show how erroneous it is to keep to just one level of events when defining mental disorder. Every such attempt quickly leads to the realization that the task cannot be completed, since the cause of most mental disorders is unknown.

In addition, since different models or general concepts about mental disorder provide different explanations as to why it appears, when attempting to define mental disorder on the level of its etiology alone, we must opt for one of the concepts about the onset and nature of mental disorder. If we do this, our definition of mental disorder will be valid only within the definition of such a general concept or approach to mental disorder. All those with the ambition of defining mental disorder prefer to avoid such a restriction.

Also mental disorder is hard to define using only one of its characteristics. If they exist, monothetic definitions of mental disorder are lacking. Polythetic definitions provide a fuller definition of mental disorder and include several characteristics which, in the opinion of the authors of these definitions, are specific to mental disorder.

Further on in the text, I will present my own definition of mental disorder. My understanding is that psychiatrists use this definition of mental disorder when deciding whether a person is mentally disordered. As noted in the motto of this text, almost as a rule, psychiatrists neither try to define mental disorder nor think about which definition of mental disorder they use in their daily professional work. Yet, when one analyzes criteria most psychiatrists use in differentiating mental disorder and non-disorder it is not difficult to grasp what sorts of gauges they make use of.

As I present my own definition of mental disorder, which is in tune with how psychiatrists diagnose mental disorder, I will critically analyze the definitions of disorder, or disease, put forward by authors who have dealt with the matter of defining mental disorder.

After presenting my own definition of mental disorder, I will analyze two of the most important definitions of mental disorder that came out in the past thirty years: the definition set out in the third and fourth editions of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (here and henceforth DSM-III, 1980, and DSM-IV, 1994, are named DSMs) and the definition of mental disorder formed by Jerome C. Wakefield. Both of these definitions are attempts to create the clearest possible distinction between mental disorder and non-disorder.

I also feel it necessary to discuss attempts to blur the border between mental disorder and non-disorder. I have found such an attempt not in increasing indications of auditory hallucinations and delusions in non-psychiatric populations, but rather in the conclusions drawn on the basis of such findings.

Problems with the definition of mental disorder came up in psychiatric-epidemiological studies as well. I indicate that results of the psychiatric-epidemiological research of the rate of prevalence and incidence of mental disorders in the United States of America carried out in the past twenty years have revealed that the defects of this type of research has been caused mostly by an insufficiently clear distinction between mental disorder and non-disorder.

Several researchers (e.g., Rosenhan, Slater) using an unusual method (deceit), tried to show that psychiatrists do not know what mental disorder is and therefore cannot clearly distinguish the mentally ill from those who are not mentally ill. I have given a critical review of this research.

Also I have shown that sociological definitions of mental disorder do not provide a clear distinction between mental disorder and non-disorder.

Finally, the last section of this chapter presents the factors and circumstances that make it difficult to define mental disorder.

In the text that follows I will set out my definition of mental disorder, i. e., its defining characteristics.

Mental Disorder: Deviating from the Individual and Social Standard

The very word mental disorder suggests that there was order and it has been disturbed, resulting in disorder.

When it is said that order has been disturbed, resulting in disorder, this means that there has been a deviation, a departure from something that is considered standard or at least from some previous state that is not considered disturbed.

It is therefore no wonder that the concept of deviation is found in most definitions of mental disorder. Regardless of their differences and similarities, they all feature deviation as an important characteristic of mental disorder.

Thus, David P. Ausubel, an American psychologist, writes that “disease is generally regarded as including any marked deviations, physical, mental, or behavioral, from normally desirable standards of structural and functional integrity” (1961, my emphasis). Peter Sedgwick, Lecturer of Political Science and Psychiatry at the University of Leeds, notes in the same spirit that “all sickness is essentially deviancy” (1982: 32, emphasis in original) and adds that denoting some state as a disease is always preceded by calculating the size of the difference between the present behavior and some social norm. “If we could all function according to approved social requirements within any range of body temperature, thermometers would disappear from the household medical kit,” writes Sedgwick (1982: 34–5). Lester King, who was the editor of the reputable Journal of the American Medical Association (JAMA), in his essay “What is Disease” states that disease is “the aggregate of those conditions which, judged by the prevailing culture, are deemed painful, or disabling, and which, at the same time, deviate from either the statistical norm or from some idealized status” (King, 1954, my emphasis).

Ruth Macklin, author of numerous works on ethical questions in medicine, joins these views about deviation as an essential characteristic of mental disorder. She writes: “In actual practice psychiatrists use a composite approach. They diagnose behavior as clearly abnormal when it is seriously disabling, frustrating, and deviates from established cultural norms” (1972, emphasis in original). Henry Cohen, Professor at the School of Medicine in Liverpool, also maintains that “disease indicates deviations from the normal” (Cohen, 1955, my emphasis).

Emil Kraepelin, the father of clinical psychiatry, in his famous textbook, defined mental disorder as deviating from the normal or the average. Kraepelin writes that “the standard we use in recognizing the morbid features of a man’s mental life is the departure from the average in the direction of inefficiency” (1917: 295, my emphasis).

The mentally ill deviate from what is considered in a given community to be the normal, standard form of behaving, thinking and feeling, and relating to oneself and others. This happens when with no apparent reason someone says that a certain group of people is poisoning their food, when they cannot recognize their near and dear, when in an extremely heightened mood they squander property acquired with hard work, when they say that their internal organs are rotten and it is amazing that they are still alive, and when periodically, without any apparent reasons, they are seized by paralyzing fear accompanied by sweating, pounding of the heart and suffocation. I have given only some of the symptoms of different mental disorders to show that, regardless of the type of disorder, every mentally ill person deviates from the behavior and belief standard in a given community.

Highlighting decreased functional efficiency as a component part of the definition of disorder, Kraepelin indicated one more important characteristic of the mentally ill: they are less functional in one or several areas. They deviate in the functional sense as well: when disordered, they are less functionally capable in one or more areas than when they were mentally non-disordered.

Mental disorders appear in different periods of life. Very few are in evidence from the youngest age. When the disorder appears, the individual starts gradually or suddenly carrying out their social roles and tasks less successfully than they did before they were disordered, or cannot carry out new roles and tasks as successfully as most of their peers with the same physical condition and level of education.

There are two types of deviations: deviation from the individual and deviation from the social. From the individual since the person deviates from their (own) previous level of social functioning. Since their previous level of social functioning most often does not differentiate greatly from the level of social functioning of their peers with the same physical condition and education level, this is deviation from the social as well. When a person is less socially functional than their peers from an early age, this too is deviation from the social.

Five Groups that Contravene the Prevailing Behavior and Belief Pattern

Roughly speaking, those who contravene the established behavior and belief stand...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Preface, by Derrick Silove
• Introduction
• 1 Towards a Definition of Mental Disorder
• 2 From Normality to Mental Health
• 3 Physical Diseases and Mental Disorders: Should They Be Differentiated?
• 4 Conceptual Cacophony in Psychiatry
• 5 Ending and Beginning
• References
• Author Index
• Subject Index