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  • Eoghan McCauley

UNDERSTANDING HOW MENTAL ILLNESS IS STRUCTURED: A CALL FOR SOCIETAL UPHEAVAL?

Eoghan McCauley explores the limitations of diagnostic criteria behind mental illnesses - because they are defined by subjective societal expectations of what makes a person 'functional'.


Whilst much is now written on mental health and mental disorder, not much has been written in the mainstream about the structure of such disorders – usually it is taken at face value that mental health simply lies on a continuum with physical health. In this article, I will argue the opposite case: mental health is structurally differentiated from physical health – specifically, mental health is structured pragmatically. I will argue further that understanding this structure is necessary both for an understanding of the disorders themselves, as well as for a proper orientation towards their prevention and treatment.


This pragmatic structure becomes evident as soon as you begin looking at diagnostic criteria; to illustrate this I will use the DSM-V {1} (Diagnostic and statistical manual of mental disorders)entry for Major Depressive Disorder. The manual lists 9 symptoms, 5 or more of which must be present for depression, with the added caveats that one of the two main symptoms (depressed mood or loss of pleasure) must be present and that “the symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning” for a diagnosis to be given. A number of interesting things fall out of this categorisation of depression, as well as this mode of characterising mental illnesses in general.


The first is that these criteria imply that two extremely different people, with varying problems and experiences, can be simultaneously diagnosed with the same disorder. To illustrate, I will provide two symptomatologies that would both fall under major depressive disorder:


Case 1:

· Depressed mood most of the day, nearly every day, as indicated by either subjec­tive report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)

· Feelings of worthlessness or excessive or inappropriate guilt (which may be delu­sional) nearly every day (not merely self-reproach or guilt about being sick)

· Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation with­out a specific plan, or a suicide attempt or a specific plan for committing suicide.

· Significant weight loss when not dieting or weight gain (e.g., a change of more than5% of body weight in a month) or decrease or increase in appetite nearly every day.(Note: In children, consider failure to make expected weight gain.)

· Diminished ability to think or concentrate, or indecisiveness, nearly every day (ei­ther by subjective account or as observed by others).


Case 2:

· Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).

· Significant weight loss when not dieting or weight gain (e.g., a change of more than5% of body weight in a month) or decrease or increase in appetite nearly every day.(Note: In children, consider failure to make expected weight gain.)

· Insomnia or hypersomnia nearly every day.

· Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).

· Fatigue or loss of energy nearly every day


It is somewhat transparent that these are very different cases, with different problems – one case appears to be dominated by a sense of misery, whilst the other is one primarily defined by a dysfunctionality and an inability to engage with life. And yet, it remains the case that the DSM-V has no issue placing both of these symptomatologies under the same disorder. It is here that the first apparent distinction between the structure of mental and physical health emerges – whilst traditional physical health uses symptoms as indicators for a larger condition which can then be independently checked for and confirmed, there is no confirmation structure in mental disorder – the only things confirmable are the instances of the symptoms themselves, with the disorder being an applied structure over and above the symptoms shown. Mental disorders are therefore pragmatically structured; they allow us to categorise mental disorder without any distinct objective criteria for verifying the disorders themselves. This explains the disparate nature of the two diagnoses – unlike physical disorders and conditions (for example, a broken leg), where the disorder can be predicted by the symptoms and then later confirmed or denied by some independent measure (an x-ray), mental health diagnoses do not need to pick out some kind of ontologically objective condition – conditions are rather connected to each other under the category of one disorder in a manner much closer to what Wittgenstein{2} referred to as a “family resemblance” relation rather than any kind of objective, necessary criteria.


Further insight is found in the requirement that symptoms must cause 'clinically significant' distress. Here another key pragmatic cornerstone of mental disorder becomes clear: what matters most is that your mental affliction affects your ability to function within society, not the 'content' of the affliction as such, which is only relevant with regard to the type of disorder you are diagnosed with. What makes a disorder adisorder is this additional criterion. Just how pragmatic a distinction this is can be made clear by describing a study done by Peters et al., 1999{3}, comparing the scores on delusion metrics between religious and psychotic populations. They found that members of new religious movements scored higher than controls on all measures of delusion aside from distress – as well as this they found that they could not differentiate between members of these religious groups and a group of people diagnosed with schizophrenic-type disorders, finding similar levels of convictions in unsubstantiated beliefs, if again not the same level of distress. My interest here is not to call those who are religious delusional. My point, rather, is to make clear that what differentiates 'delusional' beliefs from beliefs that are not delusional is the degree to which they fit into the functional structure of society – it remains the case, for example, that significant amounts of government funding is allocated to religious institutions in the UK {4}. Mental disorders are therefore fundamentally characterised not by 'delusion' or any other measure in the objective sense, but rather by a complex relation between the mode of being of the subject and the expectations and structure of social reality.


What emerges as 'disordered' functioning and 'delusional' thinking depends critically on the societal background against which they become dysfunctional and delusional. In some sense, societal structures can be seen to play a key role in generation of disorders themselves. For example, it is not until you expect young children to sit still for 7 hours a day and study that being unable to focus for that long or being excitable become problematic or dysfunctional traits.


Presenting the structure of mental health like this makes apparent the fact that it is fundamentally political – what is determined to be a disorder and what is not as well as any 'treatment' suggested are at bottom issues relating to what is acceptable and not acceptable within a society. Discourse that suggests a continuum between physical and mental health obscures this fact. Mental disorders are not 'inside' the way that physical disorders are – treating them this way privatises mental disorder and occludes the possibility of viewing disorders as something which can be changed through large societal upheaval if they are deemed unjust. For example, is the correct response to ADHD medicating a large percentage of the population, or is restructuring society and societal expectations such that those who prefer to lead a less structured and stratified existence are not widely alienated a better solution? What should we care about when making these decisions?


Citations:

{1} American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub, 2013. (Placeholder1)

{2} Wittgenstein, Ludwig. Philosophical investigations. John Wiley & Sons, 2010.

{3} Peters, E., Day, S., McKenna, J., & Orbach, G. (1999). Delusional ideation in religious and psychotic populations. British journal of clinical psychology, 38(1), 83-96.

{4} Memorandum of understanding between the catholic church and the department of education, Department of Education, 2016

{5} American Psychiatric Association. (1968). Diagnostic and statistical manual of mental disorders (2nded.).

{6} World Health Organization. (‎1990)‎. ICD-10 : international statistical classification of diseases and related health problems : tenth revision, World Health Organization.

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