Friday, December 23, 2011

Mental Disorder and Monstrosity

The current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) defines “mental disorder” as “a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress...or disability...or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. In addition, this syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one...Neither deviant behavior (e.g. political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual, as described above” (xxxi, my emphases).

The American Psychiatric Association currently proposes to change this definition in DSM-V to a “behavioral or psychological syndrome or pattern that occurs in an individual, that is based in a decrement or problem in one or more aspects of mental functioning, including but not limited to global functioning (e.g., consciousness, orientation, intellect, or temperament) or specific functioning (e.g., attention, memory, emotion, psychomotor, perception, thought); that is not merely an expectable response to common stressors and losses (for example, the loss of a loved one) or a culturally sanctioned response to a particular event (for example, trance states in religious rituals); and that is not primarily a consequence of social deviance or conflict with society” (my emphases and semicolons). 

The APA explains that the proposed changes in the definition are meant mainly to shift the focus to the underlying cause and symptoms of a mental condition, leaving the condition’s consequences to the treatment-planning rather than to the diagnostic stage. But as I’ve emphasized, both definitions (1) use quasi-normative language of “disability,” “dysfunction,” “loss,” “decrement” (that is, loss from diminution or decrease), or “problem,” and (2) specifically rule out socially deviant behaviour as mentally disordered unless that behaviour is caused by a dysfunction. These two parts of the definitions conflict with each other.

The Incoherence of the DSM Definitions

As I’ve pointed out in other blog entries, there are no normative implications of strictly biological statements. (See, for example, Curse of Reason and Procreation for Ancestors.) Hence, no normative distinction between mental health and disorder follows, for example, from an evolutionary explanation of a trait’s origin. Any normative connotation, when speaking of a so-called biological or physiological “function,” is the result either of a useful shortcut for informal communication or of confusion from the lingering pre-Darwinian, theistic paradigm. For example, biologists can speak informally of the heart’s function of circulating blood, in which case a dysfunctional heart is one that “fails” to circulate blood. The more precise, formal way of speaking, however, eliminates any such trace of normativity. Thus, the biologist says that statistically normal, as opposed to in any way correct, hearts are those descending from certain naturally selected genes. In short, modern biology reduces the normative to the normal, and explains the appearance of design in prevalent biological patterns in terms of an environmental-genetic sorting process that naturally eliminates certain species and preserves others, depending on which have the adaptations necessary to survive under prevailing conditions. The biological notion of normality is entirely quantitative rather than qualitative, meaning that no normative evaluation follows from the biological theory itself, although people are free to interpret the theory according to their independent moral or aesthetic standards.

(Note that naturally selected effects may be abnormal or rare as long as they’re caused by genetically determined traits that characterize the members of a species. For example, a cheetah sprints but doesn’t always thereby catch its prey; still, catching prey may be the naturally selected result of a cheetah’s sprint, or the sprint’s so-called “function,” assuming that some ancestral catching of prey by that means helps explain the present cheetah’s capacity to sprint, in terms of natural selection. The underlying notion of normality is statistical rather than normative, because what’s relevant to biology is the causal relationship between environment, genes, and body types, and the behavioural effects that are selected for must be caused by traits possessed by most members of a species. This is because natural selection is a mechanism meant to explain how the differences between species originate, and a species is defined by what’s shared by its members.)

The relevance of this talk of biological function is just that the psychiatrist can’t cash her notion of mental disorder in biological terms (without falling back on a theological interpretation which is no part of scientific theory or practice). Why not? Because a mental disorder is the opposite of mental health, and these concepts are normative, the one being bad and the other good, whereas the biological notion of function is replaceable by a non-normative, statistical concept that has to do with the environment’s selection of genes that produce body types.

Now, there are only two other sources of the normative: an individual’s or a society’s subjective evaluation of something. The definition of “mental disorder” must inherit its normativity, then, from one of these sources. Suppose the difference between mental health and disorder were to depend on the individual’s evaluation. In this case, one person’s interpretation could differ from another’s, with the result that there would be as many standards of mental health as there are beholders of the good. For example, one person might regard empathy as healthy while someone else might admire the sociopath’s freedom from altruistic emotions. Assuming the goodness of mental health were to lie just in the values possessed by the individual who evaluates something, and the empathic and sociopathic individuals were to retain their opposing values, there would be absolutely nothing to resolve their conflict, no way to prove that one evaluation is more correct than the other. Such would be the effect of locating the subjective nature of normative evaluation in the mere individual.

Assuming that that chaos would be unpalatable to the psychiatrist, the source of the definition’s normativity must be the social convention that can overrule an individual’s evaluation as deviant or otherwise wrong. In this case, though, we run smack into the definition’s stipulation that behaviour caused by a mental disorder is precisely not the same as that which merely runs afoul of society (i.e. that’s culturally prohibited or deviant or that results from a conflict between an individual and society). The psychiatrist would seem, therefore, to face a dilemma: either give up all pretense of normativity in the (pseudo)scientific concepts of mental health and disorder or else identify mental disorder as an abnormal pattern that’s rejected by mere social convention.

Taking the dilemma’s first horn, there would be no reason to medically treat someone with a mental disorder, no standard of which the disordered person falls short. A retreat to pragmatism here would be fruitless since an appeal to what’s useful, such as protection of people from the dangers posed by a disorder, would have to presuppose the rightness of that goal; otherwise, there would be no prescription to motivate the medical treatment. At most, the psychiatrist could say, quite hypothetically, that if society wants to protect itself or the disordered individual, the individual should be turned over to psychiatrists for treatment. If society wants to accomplish that goal and so forces the individual to undergo treatment, we’d have here only a causal explanation of the treatment, not a justification of it. This is because there would as yet be no evaluation of the societal goal. Assuming the goal were conventionally rather than personally justified, the concept of a mental disorder would once again be normative and we’d find ourselves back in a conflict with the DSM distinction between mental disorder and social deviance. The pragmatic justification for treating a mental condition would still call upon a normative interpretation of that condition as bad in so far as the condition endangers certain people, and this interpretation would be sanctioned by society at large. Thus, a mental disorder would be a mental condition that works against a social objective, in which case the disorder would depend on a conflict between an individual and society, contrary to the DSM definitions.

Taking the dilemma’s second horn, according to which mental disorders are bad and the badness is solely a matter of a cultural standard, were a culture to regard, say, homosexuality as an unhealthy mental condition, the homosexual would need to be diagnosed as having a mental disorder. This is, of course, how psychiatry used to operate: the Western psychiatric condemnation of homosexuality used to follow from the religiously conservative cultures in Europe and the US, the pseudoscientific rationalizations offered by the psychiatrist for that enforcement of a social prejudice notwithstanding. As Western cultures became more secular and scientistic (democratic, capitalistic, politically correct), Western psychiatrists withdrew homosexuality from their list of mental disorders, contenting themselves in their DSM with an implicit labeling of homosexuality as socially deviant but not disordered. However, precisely that distinction must go if the psychiatrist means to affirm the normative aspect of mental disorders or at least presupposes a justification of medical treatment for certain mental conditions.

Mental Disorder as Monstrosity

As a matter of fact, people do generally believe that average mental states are healthy and good while abnormal ones are unhealthy and bad. Indeed, that’s an understatement. In Western societies, mental health is associated with the all-consuming goal of materialistic happiness (pun intended), and most mental illnesses are regarded not merely as bad but as horrible. The mentally ill are feared and shunned as freaks or monsters. The common reason for trying to eliminate mental illness, despite the mere cultural basis of the value judgment and thus the variation between cultural (as well as individual) standards of health, is that we loathe monsters, which causes us to demonize frightening or revolting abnormalities.

Regardless of which patterns are culturally sanctioned, what mental disorders have in common is their freakishness, and this is the politically incorrect reality that underlies the psychiatric enterprise. Instead of destroying monsters, we enlightened modern folk treat them as suffering from an illness, because we understand that their harmful behaviour has physiological causes that can be re-engineered with drugs or therapy. So-called healthy behaviours have physiological causes too, some of which are likewise engineered by drugs (culturally sanctioned stimulants like nicotine, alcohol, or caffeine) or by religious or commercial propaganda. Mental disorder is hardly just a matter of physiological causes that overwhelm the will; instead, those mental conditions are targeted for medical treatment which terrify or sicken a society, and that social condemnation is indispensable to psychiatry. Without the horror felt for certain psychological abnormalities, there would be no list of mental disorders and thus nothing for the psychiatrist to do; rather, there would be merely unusual mental conditions with no impetus to eliminate them.

Why are certain mental abnormalities terrifying or revolting? Superficially, the reason is just that they threaten people with harm and we naturally prefer to be safe. But some mental disorders are much less dangerous than others. What they all have in common is their relative strangeness, which threatens to upset the familiar world in which we’re most comfortable. Whether it’s a bizarre phobia, a split personality, or the lack of certain emotions, a mental disorder represents an encroachment on human nature by alien, inhumane forces. Our physiology sometimes breaks down or mutates because there’s no one at the helm of our evolution; our presence on the planet and our flourishing are accidental and subject to change. The natural forces that build us aren’t committed to maintaining us as we are in the most trustworthy way, by having feelings for us, since those forces are impersonal. What’s terrifying or repulsive about mental disorders, then, is the impersonality of their causes, which reminds us of what I call our grim existential situation. (See Happiness and Cosmicism.) The rarity of mental disorders surprises us and so wakens us from our stupor in a world of the familiar, and threatens to remind us of the fragility even of mental health and of the arbitrariness of our social standards.

In addition, there’s the ambiguity of strange abnormalities, since they can be interpreted as inferior or as superior to normal human attributes. A fictional monster can be subhuman or divine, a degraded human form or a superhuman god. This is why disgust for monsters should be distinguished from fear of them. Those movie monsters, for example, which disgust us, such as the fly monster shown above, are often insectile and so remind us of cognitively inferior creatures. Those monsters which terrify us, such as the Thing shown above, are often clearly superior to normal humans in some capacity, such as brute strength or intelligence. So mental abnormalities may cause revulsion or fear, depending on whether they’re interpreted as regressive or as more neutrally transgressive or even progressive.

Of course, the official psychiatric view is that all mental disorders are disabilities rather than superior abilities, but just because an abnormality endangers people or deviates from social standards, doesn’t mean the condition represents a teleological step backward. The most striking example of a potentially godlike mental abnormality is the psychopath’s lack of a conscience which often enables that “disordered” individual to rise to a position of great wealth and power, lording it over whole populations with his shameless expertise in manipulating people’s emotions. (See, for example, Babiak’s and Hare’s book, Snakes in Suits.) It’s not so farfetched to assume that a disproportionate number of powerful persons throughout history have been psychopaths or sociopaths of one type or another. From cult leaders to monarchs to politicians to corporate titans, these mentally “disabled” persons still manage to perform historically decisive, if amoral, feats. We fear the power of such emotionless predators, just as we’d fear a god or an extraterrestrial intelligence that lacks human sentiments. This ambiguity of monsters is another reason society condemns mental abnormalities: we worry about the mutability of our social norms, when natural forces contravene them by producing the abnormalities, but we also fear that our standards are inferior to those of a potentially higher form of life.

While their intentions are surely to cure their patients, to prevent them from harming themselves or others, and to make them happier, one effect of psychiatric treatment of abnormal people is to maintain the illusion that the mentally average masses are on friendly terms with natural forces. The mentally ill are segregated and hidden in asylums or treated with drugs that stupefy them, so that average people needn’t be alarmed by witnessing strange behaviour and so that the conventions of what it means to be a healthy person can appear unchallenged. Only when you’re familiar with the breadth of possible mental arrangements can you appreciate the groundlessness of psychological norms. Just as a mental abnormality can be ameliorated by therapy or drugs, so too can a mentally normal person become radicalized by those means.

Curiously, there are at least two trends that bring mental disorder to the fore, despite the psychiatrist’s efforts to hide the monsters and to whitewash the existential implications of mental strangeness with a pseudoscientific, cryptonormative understanding of it. First, as Adam Curtis shows in his BBC documentary, The Trap: Parts 1 and 2, the rise of materialistic individualism, by the power of commercial propaganda, had the unintended consequence that the psychiatrist came to defer to the patient’s concerns about her own mental health, instead of imposing a top-down ideal. Just as corporations sold products that no one needs, by tenuously associating them with unconscious cravings, Western psychiatrists replaced their authoritative criteria for mental illness, which were shown by David Rosenhan's experiments to be pseudoscientific, with objective, behaviouristic criteria that catered to the individual’s personal model of normality. Thus, the normative interpretations of mental capacities were relativized to the self-policing individual consumer, not just to society. This was a boon for the business of psychiatry since it greatly multiplied the cases of mental disorders which had to be treated.

Second, as medical science advances and pharmaceutical companies become more powerful, psychiatrists find themselves serving the supplier’s need to sell an ever-increasing store of drugs. Thus, medical conditions are invented to provide an incentive for purchasing the available treatments. Although the advertisements for these drugs are invariably sanitized, with no depiction of strange behaviour caused by mental abnormality, a barrage of such ads over the last two decades in wealthy countries nevertheless refers to physiological or mood disorders, such as attention deficit disorder or depression. Whether it’s an increase in demand for medical treatment or in the supply of that treatment, then, each development renders the standard of mental health more dubious.

In summary, the DSM definitions of “mental” disorder” are revealingly incoherent. They indicate that psychiatrists harbour quasi-normative assumptions about mental conditions which are incompatible with their scientific pretensions. Moreover, they inherit those assumptions not from evolutionary theory, despite that theory’s reference to biological functions, but from social values which are the main sources of normative judgments of goodness and badness. Again, admitting that the distinction between mental health and disorder derives from something as subjective and questionable as social convention would threaten psychiatry’s status as a science. After all, the cultural norms in question are propped up by horror from the existential impact of strange abnormalities on average people’s delusions of their security and superiority. Thus, psychiatrists stipulate that mental disorders aren’t due merely to a conflict between individual and society. But the psychiatrist can’t have it both ways.


  1. Love this eloquence, I feel a sense of familiarity with the problems I've felt existed with these definitions in the DSM (both current/proposed versions) yet would stumble over telling people in common phrase why I don't like them.

    It makes me happy to see writing like this when people take the time to dwell on it and find the words to explain the problems properly. Too often I think I'm mulling it over subconsciously so that I'm not thinking with language and can't explain why something feels wrong.

    1. Thanks. Of course, I could be wrong about the contradictions in the DSM definitions, but they seem pretty plain to me.