What is mental illness? What is a major
mental illness?
Before mental
illness can be defined, the concept of illness needs to be understood
more completely. As medicine has become increasingly driven by
technologic advances, the concept of disease has supplanted the concept
of illness. Medicine is driven by a need for objective evidence and
removal of subjective experience. Subjective data, although they can help
inform our understanding of diseases, are by their very nature
experienced only by the one subject, rather than witnessed by a
community, and thus, they are inherently unreliable. In contrast, major
advances have come from objective, experimental approaches to various
diseases and their treatments. With the cost of healthcare skyrocketing,
making healthcare dollars less and less available to treat any given
disease, simple economic necessity dictates that we spend money on things
that yield results. With a finite number of dollars, money is therefore
spent on diseases that can be defined and cured.
Humans, however, are more than just their diseases. To be human is to
experience the disease in a unique way that other humans cannot
experience. To be human with a disease is to suffer from an illness.
Having an illness is a subjective experience that may be easily dismissed
as less important than the objective facts of the disease. In treating
individual patients, doctors address both disease and illness; one piece
of that treatment is the elimination or control of the disease. Healing,
on the other hand, requires more than just the elimination of disease; it
requires an understanding of the person's experience with the disease in
the form of their illness and the elimination of that as well.
Mental illness can be complicated to define, as it is generally based on
the subjective experience of those suffering from it. Fortunately, the
field of psychiatry has experienced technologic advances, and the numbers
of effective psychiatric therapies available to treat mental illness have
exploded in the past 10 years. Unfortunately, although the scientific
theories have continued to advance our understanding of possible
underlying causes, little to no clinically useful objective evidence
remains to validate the disease concept. This is why mental illness is so
devastating to individuals suffering from it and remains so stigmatized
by those who little understand it. Consider the different feelings
experienced by a patient who sees his or her internist for a variety of
physical complaints for which all of the testing is negative and he or
she is left languishing in the helpless idea that his or her complaints
are "all in his or her head," whereas a patient visiting the psychiatrist
with the same array of complaints is provided with a medical explanation
of his or her illness and feels reassured that it is "not all in his or
her head." Webster's dictionary defines mental illness as a "disease of
the mind," illustrating the struggle to identify boundaries between
disease versus illness and mind versus body. Such a distinction has its
utility but leads to the shame and stigmatization that exists for those
suffering from mental illness.
Mental illness is better thought of in the less pejorative sense of being
a disease, if merely for the fact that it brings aid and comfort to those
who suffer from it. Certainly enough biological evidence exists to argue
strongly for this definition even if no clinical testing exists. What
defines the "menu" of symptoms listed in the
Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, Text-Revised (DSM-IV-TR) is
not just having the list of symptoms outlined in each disorder, but
rather showing the impact that those symptoms have on one's life in terms
of distress and disability. It is that universal inclusion criteria
(along with the universal exclusion criteria of "not due to a medical
condition or toxic reaction") that define the boundaries between normal
variant, mentally ill, and physically ill. Defining the differences
between the normal and pathologic serves to avoid the subjectivity that
can occur when defining illness of thought, emotions, or behavior. Any
condition defined in the DSM-IV-TR is considered a mental illness or
disorder.
Many terms are thrown about today in popular culture that are used to
distinguish between types of mental illnesses, most of which stem from
the previous discussion regarding the stigmatization and shame that
accompany the diagnosis. Such terms include, but are not limited to,
behavior disorder, brain disorder, minimal brain dysfunction, nervous
breakdown, neurosis, psychosis, panic disorder, depression,
schizophrenia, personality disorder, character disorder, major mental
illness, minor mental illness, and "biologically based condition". Most
of these terms have more than one meaning depending on who defines them.
These terms may be defined by the following:
-
Media and
popular culture
-
Politics that
ultimately influence an insurance company's financial responsibility to
pay for the treatment
-
The legal
system to aid the criminal courts' decision to find someone not guilty by
reason of insanity
-
The
psychiatric and psychological communities
First, in
popular culture and media, mental illness is defined by the idea that one
is either "crazy" or not. Terms such as insane, deranged, "demented,"
mentally ill," "psychotic," and "schizophrenic" are most often associated
with some appalling violent or criminal act that seems to lack any
understandable motive that can be discovered by either the police or the
press. In this situation, "crazy" substitutes for the lack of apparent
motive. No matter how many times the argument is made that the mentally
ill are no more violent than society at large, the press never stops from
pointing out when someone is mentally ill after being arrested for a
heinous criminal act. Some of these terms, such as schizophrenia, do have
specific psychiatric definitions that are part of the DSM-IV-TR. Some
include legal terms (such as insanity) that only the courts can
determine. The media and popular culture, however, define all in
pejorative terms that carry clear moral connotations. It is such
definitions that lead patients to avoid a psychiatrist's office for fear
of being labeled crazy or mentally ill.
Second, political, legal, or economic definitions of mental illness are
meant to protect people from arbitrary actions by virtue of their
illness. This is where the terms biologically based, behavior disorder,
and insanity derive. Because of the broad reach of behavior making up the
definitions of mental illness where no validated biological tests exist,
the potential for abuse in our social system is rife. As a result, legal
and political definitions were instituted to protect individuals and
organizations from that potential abuse. To protect individuals, the
definition of biologically based was established in order to force
insurers to pay for their treatment. These include such DSM-IV-TR
disorders as schizophrenia, major depressive disorder, and bipolar
disorder. Alternatively, behavior disorders are not considered
biologically based from the insurers' perspective and thus are the
responsibility of the individual and are not subject to third-party
payment. Insanity is a strictly legal definition that only the courts can
determine. It may be informed by the fact that an individual is suffering
from a mental illness, but that is only part of the equation. One may
suffer from schizophrenia but rob a grocery store for purely financial
reasons. He or she is not judged insane; although from the point of view
of psychiatry, he or she has a mental illness, and from the point of view
of the popular press, that person can be called "crazy."
Definitions that interest scientists and clinicians the most are of the
third type, specific operational criteria attempting to codify mental and
behavioral phenomena in a pattern that has a specific etiology (cause),
diagnostic symptom list (pattern), and prognosis (result). The history of
attempting to classify and understand mental illness is as long as the
history of medicine itself. Distinctions between biologically based,
psychologically based, and socially based are relevant only in so far as
attempts are made to understand each individual, biological,
psychological, and social element that goes into causing each disorder.
This does not mean that psychiatry is without its own arbitrary
distinctions. A distinction can be made between major mental illnesses
and personality disorders, classified as Axis I and Axis II diagnoses in
the DSM-IV-TR. The two axes distinguish between major mental illnesses or
states that can wax and wane with time and treatment and personality
disorders, or traits, that are generally considered to be enduring and
unresponsive to biological therapies. States change. Traits endure. This
distinction is one of the "useful fictions" that inform our understanding
of behavior in general and mental illness more specifically. The line
between state and trait is very gray but has allowed psychiatry to focus
historically and to set limits on what can be accurately defined and
treated. In the past, personality disorders were considered not
changeable and not treatable. As science has advanced, however, there has
been a discovery that certain elements of personality do change with time
and are improved with treatment. Insurers and the courts, however,
continue to make such distinctions, as this is what is generally meant by
the difference between biologically based versus behavior disorder or
mentally ill versus personality disordered.
