What is Mental Illness?

1. What is Mental Illness? Natalie Banner natalie.banner@kcl.ac.uk natalie_banner Pub Psychology, 13th November 2012

2. What I’ll cover & what I won’t • Relationship between mental and physical illnesses • Historical context of classification, the ‘medical model’ and the anti-psychiatry movement • Phenomenological approaches and subjective experience • Debate over conceptualisation of mental disorder in US classification (DSM) • Relevance of neuroscience to thinking about mental illness • Won’t cover: • Eastern or spiritualist traditions; sociological literature; psychodynamic theories; extensive critiques of Big Pharma

3. Increases in psychiatric diagnoses? • Year on year increase in antidepressant prescription rates of 9.1% 2010-2011 in England1 • Now form 6.5% of all prescriptions • Prevalence of ADHD very difficult to ascertain: adult rate approx. 8.2% (England)2 • Autism spectrum disorders: >250% increase in diagnoses in USA from 1997-20083 • Prevalence of psychoses largely unchanged over past 50 years, but higher among black Caribbean ethnic groups4

4. Public perceptions • Time to Change ‘1 in 4’ campaign • Celebrities and sportspeople ‘coming out’ about mental health problems • Psychiatric terminology becoming more common • ‘feeling depressed’ • ‘a bit OCD’ • ‘Aspy’/ ‘on the spectrum’ • Mental illness still heavily stigmatised From Daryl Cunningham’s Psychiatric Tales

5. Normality…to abnormality Collecting Hoarding Shyness Social phobia Dieting/binge eating Eating disorder Sadness/feeling low Depression Substance use Substance abuse Hearing voices Schizophrenia Extremism Psychosis (Anders Breivik?) Ruthless self-interest Psychopathy (Jon Ronson’s psychopathy test!)

6. What is illness? • We all experience illness, first hand or seeing it in others • Feeling that something is ‘wrong’ • May be associated with: • pain • distress (of self or others) • loss of ability/functioning • shortening of life expectancy • Easier to define with physical illness

7. What is illness? • Firstly, defining ‘illness’ • Presumed to be some dysfunction or deviation from a norm of functioning in the body • ‘Function’ conceptualised in evolutionary or statistical terms • Classified according to: • Aetiology (cancers, infectious diseases) • Organ/system affected (musculo-skeletal disorders, respiratory diseases) • Medical speciality treating (geriatrics, obstetrics)

8. Mental and physical illness • In Western medicine, division developed thanks to Cartesian influence in late 18th century • It is clear that in both aetiology and manifestation: • psychological and emotional factors are part of many physical disorders • Physical factors are part of many mental disorders Why do mental illnesses seem so different from physical conditions?

9. Historical background: the medical model • Emergence of psychopharmacology in 1950s/60s • Hormone treatments, insulin ‘shock’ therapies and development of chlorpromazine • Development of large-scale neurosurgery (esp. in USA) • ECT, lobotomy, esp. trans-orbital leucotomy • Mental illnesses increasingly viewed as brain disorders • Severe mental illness viewed as ‘un-understandable’ and therefore personal experiences not medically scrutinised

10. Historical background: antipsychiatry • Critical movement with intellectual roots in R.D. Laing, David Cooper, Thomas Szasz • Laing: “Insanity – a perfectly rational adjustment to an insane world” • Critical of psychiatric knowledge and pushing for reform its practices • Szasz called mental illnesses ‘problems in living’ • Heavily influenced by libertarian politics, advocated minimal role of state in individuals’ lives

11. The impact of classification: psychiatry as social control • Foucault drew attention to the power dynamic between medical professionals and patients • Diagnosis of mental disorder is extremely powerful • Psychiatry has a ‘survivor’ movement • Uses of ‘punitive psychiatry’ to suppress political dissidence in Soviet Russia • Declassification of homosexuality from DSM-II in 1973 • In response to civil rights protest, not medical evidence

12. What is going wrong? • In mental illness, the ‘disorder’ is picked out at the level of a person’s thoughts, feelings, values and behaviours • ‘Norms of functioning’ breached are not necessarily bodily: • Epistemic (irrational beliefs) • Affective (excessive or blunted emotions) • Evaluative (bizarre or obsessive values) • Behavioural (seen out as odd, worrying, unpredictable) • These norms are largely social and cultural

13. Phenomenology & subjective experience: depression • Important insights into nature of depression from first person narratives and literature • Loss of possibility • “It’s almost like I am there but I can’t touch anything or I can’t connect…I’m not really able to do anything…the act of doing that thing isn’t in my world at that time”5 • “The world holds no possibilities for me when I’m depressed. Every avenue I consider exploring seems shut off”6 • Not so much low mood as withdrawal from the world and its space for action/agency

14. The current definition of mental disorder in DSM-IV “…Each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disabilityor with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom…” Fundamentally evaluative, not objectively medical, judgements

15. Distress & impairment • Disruption of selfhood and sense of identity • Loss of control and agency over one’s life and actions • Impairment to autonomy? • Fear, anxiety, hopelessness, helplessness, loss of trust (in relationships and/or health services) • Connection with and embeddedness in the world is severed or disrupted • These are intrinsic to and often exacerbate illness

16. DSM-5: the future of classification? • Due to be published May 2013 • Dogged by controversy over methodology, scientific rigour, conceptualisation, theoretical underpinnings, pharmaceutical and insurance influence • Reliance on assumption of neuroscientificbasis for mental disorders (genetic, epigenetic, neurodevelopmental) • Role of ‘distress’ is minimised: • “…Some disorders may not be diagnosable until they have caused clinically significant distress or impairment of performance” (DSM-5 website)

17. Critiques of biological psychiatry • Risk of pathologising normal human variations of experience • Meaningfulness of experience is neglected by medicalisation and assumptions of neuropathology • Lack of attention paid to social and environmental context: locus of problem ‘in the individual’ • Biopsychosocial model is useful but also explanatorily problematic

18. Are mental illnesses brain disorders? Vast neuroscience literature Stress and trauma are heavily implicated in developmental and ongoing changes to the brain Neurotransmitter levels (e.g. tryptophan) have significant impacts on behaviour, decision-making etc But many life events change the brain… …do certain events make the brain disordered?

19. Are mental illnesses brain disorders? Be wary of neurobollocks! See neuroskeptic.blogspot.co.uk for excellent critical analysis of neuroscience research

20. A philosophical approach to mental illness • Critical tools for thinking about how we conceptualise mental health and illness • Framework for understanding historical and present controversies • Language and concepts are powerful in shaping how we think • Advances in neuroscience are fascinating and profound • But evidence of ‘illness’ need to be carefully scrutinised • Social, cultural and ethical values are intrinsic to illness concept

21. Thank you

22. References • Health and Social Care Information Centre (2012) ‘Prescriptions dispensed in the community: England, Statistics for 2001-2011’ available at: www.ic.nhs.uk • Jenkins, R. et al. (2009) British Mental Health Survey Programme, Social Psychiatry and Psychiatric Epidemiology, 44:899-904 • Boyle, C. et al (2009) Trends in the Prevalence of Developmental Disabilities in US children 1997-2008, Pediatrics, 127:1034-1042 • Kirkbride, J. et al. (2012) Incidence of Schizophrenia and Other Psychoses in England, 1950–2009: A Systematic Review and Meta-Analyses, PLoS One, 7:3, e31660 • Patient quoted in Horne & Cspike (2009) From Feeling too Little and too Much, to Feeling More and Less? A Non-Paradoxical Theory of the Functions of Self-Harm, Qualitative Health Research 19: 655-667, p.63 • Ratcliffe, M. Existential Feeling and Narrative in Psychiatric Illness, presentation at Institute of Philosophy, October 2012.

23. The current definition of mental disorder in DSM-IV (cont.) …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. Whatever its original cause, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual. 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.”

24. ICD-10 definition of mental disorder The ICD-10 states that mental disorder is "not an exact term", although is generally used "...to imply the existence of a clinically recognisable set of symptoms or behaviours associated in most cases with distress and with interference with personal functions." (WHO, 1992)