What makes “a new mental illness”?: The cases of solastalgia and hubris syndrome. Cosmos and History, 2009. Part 2

The concept of mental illness: psychiatrists and philosophers

Defining what psychiatry is and what mental illnesses are can often seem a circular process. One indisputable fact is that psychiatry, as it is currently constituted, is a branch of medicine. While contemporary psychiatrists tend to aspire to practice using a “biopsychosocial approach” (Clare, 1999, p. 109), their training and the structure of the vast majority of psychiatric practice fits a medical model. People present with symptoms and exhibit signs which are examined. If these symptoms and signs are deemed to provide evidence of pathology, they lead to a diagnosis of an illness. Investigations and treatments are ordered. Medications and other interventions are prescribed to treat the illness. The cessation of the symptoms and signs marks recovery from the illness. This is, on the surface, similar to how an ophthalmologist would approach cataract, or a respiratory physician chronic obstructive pulmonary disease. Dictionary definitions of psychiatry describe it as the medical specialty concerned with mental illness (Oxford English Dictionary, 2007) Psychiatry textbooks too generally gloss over the actual meaning of mental illness but assume it has a readily understood and commonly accepted meaning.

A key paper from within the psychiatric establishment on the definition of mental illness is Robins and Guze (1970) on the establishment of diagnostic validity in psychiatric illness, with regard to schizophrenia. This paper’s approach has had a strong influence on the development of DSM-IV, the American Psychiatric Associations classification of mental illnesses which is used in clinical practice (although it was developed primarily to enable researchers to communicate with each other rather than as a clinical tool) for diagnostic purposes.Robins and Guze describe a five step method for achieving diagnostic validity in psychiatric illness is described, consisting of five phases: clinical description, laboratory study, exclusion of other disorders, follow-up study, and family study. The method was applied in this paper to patients with the diagnosis of schizophrenia, and it was shown by follow-up and family studies that poor prognosis cases can be validly separated clinically from good prognosis cases. The authors conclude that good prognosis “schizophrenia” is not mild schizophrenia, but a different illness.

“Diagnostic validity” means that a diagnosis of schizophrenia is in fact a case of schizophrenia. It differs from a related concept, reliability, which describes how well diagnoses match each other—a reliable diagnosis of schizophrenia means that other clinicians would come up with a diagnosis of schizophrenia given the same case. It is possible for a diagnostic process to be reliable but not valid, although validity implies reliability.It does not, however, address the question of what schizophrenia is.

Validity implies that one is describing an entity whose existence and nature is not disputed. It does not address fundamental questions of what this entity actually is. Solastalgia may well fit the Robins and Guze framework very well. Clinical description has already been carried out. “Laboratory investigation” is mirrored in the development of the Environmental Distress Scale. Exclusion of other disorders could, arguably, involve showing that the distress experienced by the person is due to environmental change and no other factor.

Hubris syndrome also fits this framework very well. Already clinical description and exclusion criteria are provided by Owen. Owen suggests possible avenues for laboratory study, referring to neurotransmitters. Although the rarity of hubris syndrome may make this study and follow-up studies challenging, it may be that analogues to hubris syndrome in less eminent persons will be developed. Family studies would be more problematic, although cases such as the two Bush Presidents and the Nehru-Gandhi dynasty in India would suggest that this could be overcome. Follow-up and family studies, in any case, refer to activities psychiatric researchers undertake, and implicitly assumes that the diagnosis is an entity in itself.

And this points to the essential circularity of mainstream psychiatry’s definitions of mental illness. Robins and Guze’s formulation of mental illness is made up of five steps that refer entirely to medical and psychiatric activity itself. Psychiatry is the medical specialty concerned with mental illness, and mental illnesses are conditions which are the concern of psychiatry.

As outlined in the statement of the Focus & Scope of this journal, a tension between “cosmology, conceiving the cosmos as an immutable, timeless order, and history, concerned with actions, intentions, conflicts and the rise and fall of individuals and communities, has been at the core of virtually all intellectual and political oppositions throughout the history of European civilization.” This tension is particularly germane to psychiatry. Psychiatrists spend much of their time trying to improve the image of psychiatry within medicine by insisting it is a scientific enterprise, characterised by the assumptions of expertise, specialist knowledge and greater objectivity that (it is assumed) are possessed in full by other medical specialties. However psychiatry, as shall be seen, is also intimately concerned with values and the concerns of the humanities. The tension between the worldviews of ethical and political philosophy on the one hand and the traditional scientific view on the other is particularly acute in psychiatry.

Any attempt at any overarching, definitive definition of what philosophy is will be even more contested than that of psychiatry. Just as with medicine and medical practice, there are very many disciplines subsumed within philosophy, and while the medical model described above is generally accepted within most medical specialties, there is no such consensus within philosophy as to what philosophers do, what “the business of philosophy” should be, or how philosophers should approach the problems that come under the heading of “philosophy.” Of the many things that philosophy is, it is perhaps safest to say that philosophy questions assumptions and encourages critical thinking about things taken for granted.

The concept of “mental illness”, which as we can see from the above can be considered an assumption in common usage within the psychiatric profession (and, perhaps, in wider society), has been subjected to a thoroughgoing critique from philosophers, psychiatrists, psychologists, social workers, political scientists, feminists and many other figures. This critique has taken five main approaches:

  • a psychological model, as exemplified by the British psychologist Hans Eysenck, arguing that mental disorders are in fact learned abnormalities of behaviour (Eysenck 1968)

  • a labelling model, as exemplified by the American sociologist Thomas Scheff, who argued that the features of mental disorder are in fact a response to the labelling of an individual as “deviant” (Scheff 1974)

  • a “hidden meaning” model, postulating that the apparently irrational, harmful or meaningless behaviour associated with mental disorder is in fact meaningful. The Scottish psychiatrist R.D. Laing, for instance, argued that “madness” was a sane response to an insane society. (Laing, 1960)

  • an “unconscious mind” model, influenced by psychoanalysis, which postulates that, again, the apparently irrational can be comprehended, this time with reference to the unconscious mind

  • political control models—this critique of psychiatry sees it as a legitimising the social status quo and allowing those who dissent from it to be labelled mentally ill. The practice of psychiatry in the former Soviet Union exemplifies this. Another example is the feminist critiques of post-natal depression, which feminists would argue reflects society’s treatment of mothers rather than being a disease per se. Thus legitimate distress at the unfair structure of society is pejoratively labelled an illness. Similarly, the Franco-Algerian psychiatrist Frantz Fanon argued that psychiatry was a tool of colonial control and part of the hegemonic order of industrial capitalism.

This questioning, much of which has been posed by psychiatrists, has forced psychiatry to scrutinise its own concept of what constitutes mental illness. Many of it is more about the role of various psychological, social and political factors in the development of mental illness, rather than being an attack on the basic concept of mental illness. Other critiques have not so much been of psychiatry as a discipline or practice, but on the cultural significance of a therapeutic ethos, for instance that of Philip Rieff in “The Triumph of the Therapeutic.” (1965) For Rieff, the rise of psychotherapy and the “psychological man”—marked a turning point in human culture, being the death-knell of a Western culture whose ideals had lost their power to deeply pervade the characters of its members. In a therapeutic ethos, truths are contingent and negotiable, and commitments or faiths only survive as therapeutic devices easily discarded in the interests of therapy. For Rieff, this is a symptom of Western cultural decadence and decline.

Much of the “antipsychiatry” critique has been absorbed into mainstream psychiatric thinking and practice. Psychiatry is generally practiced in the community in a multidisciplinary, biopsychosocial fashion, and psychiatrists themselves lobby for extra resources to achieve this. Government policies enshrine the concept of patient-centred care that meets holistic needs and aim for “recovery” that goes beyond the simple alleviation of symptoms (Expert Group on Mental Health, 2006.) Compulsory treatment of those diagnosed as mentally ill is surrounded by tight regulatory control in Western societies.

However, for the most thoroughgoing anti-psychiatrists, this is not enough. They favour not tighter controls on compulsory admission, but the complete abolition of the phenomenon.One of the most influential critiques is that of Szasz (Szasz, 1960). Szasz disclaims the label “antipsychiatrist” and also insists he is not a philosopher, however his work could be seen both as the quintessence of “antipsychiatry” and as having a strong influence on philosophical approaches to mental illness. Throughout his career he has stated emphatically that illness requires the presence of a physical lesion which causes disease. With mental illnesses, there is no identifiable physical lesion. Therefore “mental illness” is a myth. This is not to say that the phenomena described as mental illnesses are not actually happening, but that they are not illness. “Mental illness” involves a value judgement, whereas the diagnosis of bodily illness does not. What has formerly been termed mental illnesses are in fact “problems of living.” This leads Szasz to a radical and continuing critique of psychiatry as a discipline (Schaeler, ed, 2004.) Other critics of psychiatry (for instance Eysenck, 1968) have argued that many, if not most, patients presenting with mental illness are in fact experiencing problems of living, but have generally conceded that some at least are experiencing a biologically based mental illness. Szasz, however, has consistently maintained what could be called a “hard” position denying the validity of mental illness and, from this position, attacking both psychiatric coercion (involuntary admission and treatment) and “psychiatric excuses” (the insanity plea) Szasz has not argued for the abolition of psychiatric practice, but that psychiatric practice should only be between two consenting adults (what he calls “contractual” psychiatry), that psychiatrists should have no powers to compel treatment or admission, and that courts deliver verdicts of either guilty or not guilty with no acceptance that insanity can be a mitigating circumstance. Over the course of his career he has compared “institutional” psychiatry (contrasted to “contractual” psychiatry) to the Inquisition, the slave trade and the Holocaust. (Szasz 2002)

Szasz has never stated that the phenomena described as mental illnesses do not exist—that people who are diagnosed with depression are not suffering from distress, or that people who are diagnosed with paranoid schizophrenia are not reporting persecution without a basis in real events. Szasz simply states that these presentations are not illnesses, and their treatment as such is not simply an intellectual error but has lead to massive violations of human rights on a worldwide scale.

There have been many “pro-psychiatry” counterparts to the work of the antipsychiatrists. Kendell (1975) described the ‘biological disadvantage’ criterion of illness, based on the work of Scadding (1967), a chest physician who described a disease as ‘the sum of the abnormal phenomena displayed by a group of living organisms in association with a specified common characteristic or set of characteristics by which they differ from the norm for the species in such a way as to place them at a biological disadvantage.” Kendell used this criterion of “biological disadvantage” to argue that, in fact, a value-free concept of illness was possible, and also that it applied to mental illness, as it shortened life expectancy and reduced reproductive advantage.Later, Kendell changed his position and came to believe that value judgements were inescapable with regard to any illness (Kendell 2002). Kendell’s original argument was directly intended as a response to Szasz and the other antipsychiatrists. So, where Szasz defined bodily illness as cellular dysfunction, Kendell defined it as a process leading to “biological disadvantage.”

Kendell and Szasz share, however, a view that defining bodily illness is uncomplicated compared to mental illness. Their debate is framed in terms of comparing mental illness to bodily illness, and arguing that mental illness is illness in so far as it is more or less like bodily illness. Many critics of Szasz since have taken the same basic approach—for instance, that there are in fact biological pathologies associated with mental illness, or that as medical science progresses we will identify these pathologies. To which Szasz replies that, if this indeed turns out to be the case, these conditions will become bodily illnesses to be treated by bodily physicians, as Alzheimer’s Disease and General Paralysis of the Insane (tertiary syphilis) did in the late nineteenth century.

Many later respondents to Szasz have argued that his concept of illness is narrow, and that bodily or purely physical illness or disease is not to be defined as simply as he suggests. Szasz himself has continued to hold to his original position, writing that “I use the terms disease and illness interchangeably” (Szasz, 2000, p. 3.) Szasz has continued to insist that bodily illness is an uncomplicated concept and mental illness an unjustifiable extension of that concept. One of his supporting references is the introductory material for pathology textbooks, which (in a way analogous to the simple definitions of mental illness that are used in psychiatry text books) generally simply state that disease is due to cellular damage. Whether the authors of these textbooks, any more than those of psychiatric textbooks, have taken a philosophical approach to the underpinnings of their specialty could perhaps be questioned.

Boorse (1976) has also described the distinction between illness and disease, with disease referring to dysfunction (which, Boorse argues, can be used to describe cognitive and perceptual as well as purely physical domains) and illness referring to the social consequences of disease. “Disease” is a value-free, objective entity—“illness” is a value-laden, socially determined process or consequence of disease. Boorse argues that a disease becomes an illness when it becomes incapacitating for the person experiencing it. In social terms, it must be undesirable for its bearer, “a title to special treatment” and “a valid excuse for normally criticisable behaviour” Boorse argued that the fact that mental illness is value-laden relative to physical illness was not because physical illness was value free—for the whole concept of illness is value-laden. Mental illness is seemingly more value-laden because the sciences that underlie mental illness are not as well developed as those underlying other medical specialties, but this is simply a historical factor which will be rectified over time.

Boorse’s disease/illness distinction—an attempt to retain value-free evaluation of pathology while accepting the value-laden nature of diagnosis, treatment and the sick role—brings us to one of the pivotal work of the French epistemiologist and physician Georges Canguilhem. Canguilhem, author of one of the key texts in the philosophy of medicine, The Normal and the Pathological (Canguilhem, 1989), challenged the dominant “scientific” paradigm of pathology based on statistical norms of supposed immutability, which defined boundaries on a continuum between normal and abnormal. For Canguilhem, health and disease were properties of a total organism, with health being the capacity to withstand change and to establish new norms—the ability to fall sick and recover,  or normativity—and disease the lack of this capacity. Anomalyper se was not abnormality, and a list of symptoms and signs or deviations from a statistical norm did not define disease.

Canguilhem’s work was rooted in an approach to the history of medicine that looked at the evolution of conceptual rather than factual knowledge (Horton, 1995). For Canguilhem, as for many other philosophers of science as the twentieth century progressed, the positivist view of science as based on observations made in language entirely independent of theory was untenable.The dominant positivist view of medicine reflected the influence of  physiologists such as Claude Bernard, who championed an approach to understanding disease based on laboratory experimentation separated from clinical conditions. Against this, Canguilhem argues that a purely “scientific”, lab-based understanding of illness divorced from clinical experience or understanding the conditions of disease is impossible—“it is first and foremost because men feel sick that a medicine exists. It is only secondarily that men know, because medicine exists, in what way they are sick.” (Canguilhem, 1989, p. 229)

A futher key of Canguilhem’s approach was that the history of medicine had shown a gradual movement from concepts of health and disease as qualitatively different entities, to one in which there is only a quantitative difference. For Canguilhem, the pathological state is qualitatively different from health because of its implications for the organism’s survival and ability to flourish. It is this factor that  purely positivist accounts of sickness cannot account for, but cannot ignore. The implications of Canguilhem’s writing for mental illness have been discussed by Magree. (Magree, 2002)

Arguments continue about definitions of mental illness. As outlined above, Szasz has kept very strongly to his original position over the years, in the face of all critics. However the debate has moved on to other terms. Christopher Megone, for instance, describes illness both bodily and mental as incapacitating failure of bodily or mental capacities to fulfil their functions (Megone, 2000). He traces this concept of functional impairment back to Aristotle.Fulford, meanwhile, focuses on the actual experience of illness as a basis for thinking about illness (Fulford, 1993). This is influenced by the work of the philosopher J L Austin and the sociologist David Locker (Austin, 1961 and Locker, 1981). Austin was a philosopher associated with the Linguistic Analytic move in philosophy, which emphasised examining how a concept is used in ordinary usage as a way of finding out its is meaning. One of the approaches to “doing philosophy” which was seen traditionally as leading to clear thinking was to “define your terms.” In other writings Fulford has discussed how the assumption that “defining your terms” is a necessary condition for clinical utility has become so prevalent within medicine has lead to the belief that concepts are only clinically useful if they can be so clearly defined (Fulford, 2001). Austin suggested that “philosophical fieldwork”—exploration the use of concepts in everyday language and usage—may be a better means of approaching the meaning of concepts, rather than concentrating on definitions per se.

Austin also described the complexity of actions. Philosophers had previously tended to focus on particular aspects of action—intention, voluntariness and so on—and to unpick them by defining them. Austin focused on “the machinery of action” which involves a wide range of processes and activities—“we have to pay (some) attention to what we are doing and to take (some) care to guard against (likely) dangers; we may need to use judgement or tact; we must exercise sufficient control over our bodily parts; and so on.” (Austin, 1961)Fulford utilises this as a way of approaching the medical concept of illness, as “action-failure.” “The machinery of action” has a wide range of elements, and this breadth gives Fulford a wide range of approaches to understanding illness experiences, both physical and mental.

The work of  Locker on those features of experiences that people identify as marking out these experiences as illnesses helped suggest this approach.Four relevant features were identified—the experience is negatively evaluated,  has a certain intensity and duration,  is not “done to or happens to” the person undergoing it, and  is not “done by the person” themselves.

Fulford has built on Austin and Locker’s work to describe the importance of “action failure” in defining illness. At first sight, “action failure” does not seem too different from the “dysfunction” of Boorse’s thought. Action and function are closely related, but are also more distinctthan one might think. Individual people (as agents) perform actions; particular physiological systems or body parts function. Fulford uses this distinction to draw a parallel with the distinction between the patient’s experience of illness and a doctor’s knowledge of illness. Fulford has described a “full field” model of mental illness. Going beyond purely medical models, focusing on disease and failure of function, it combines the social, value-based concept of illness with corresponding failure of action.

To the objection that unpleasant experiences such as pain or psychological distress are often involved in illness experiences (and that these do not immediately obviously fit into the concept of action failure, Fulford replies that pain is integral to “the machinery of action”, as is psychological distress, and therefore action-failure analysis can be applied.