Lidija Rangelovska
© 2002-6 Copyright Lidija Rangelovska.
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C O N T E N T S
I. On Disease
II. The Normal Personality
III. The Myth of Mental Illness
IV. The DSM Pros and Cons
V. The History of Personality Disorders
VI. The Metaphors of Mind – The Brain
VII. The Metaphors of Mind - Psychotherapy
VIII. In Defense of Psychoanalysis
IX. Metaphors of Mind – The Dialog of Dreams
X. Use and Abuse of Differential Diagnoses
XI. Althusser – The Third Text and Competing Interpellations XII. The Author
We are all terminally ill. It is a matter of time before we all die. Aging and death remain almost as mysterious as ever. We feel awed and uncomfortable when we contemplate these twin afflictions. Indeed, the very word denoting illness contains its own best definition: dis-ease. A mental component of lack of well being must exist SUBJECTIVELY. The person must FEEL bad, must experience discomfiture for his condition to qualify as a disease. To this extent, we are justified in classifying all diseases as "spiritual" or "mental".
Is there any other way of distinguishing health from sickness - a way that does NOT depend on the report that the patient provides regarding his subjective experience?
Some diseases are manifest and others are latent or immanent. Genetic diseases can exist - unmanifested - for generations. This raises the philosophical problem or whether a potential disease IS a disease? Are AIDS and Haemophilia carriers - sick? Should they be treated, ethically speaking? They experience no dis-ease, they report no symptoms, no signs are evident. On what moral grounds can we commit them to treatment? On the grounds of the "greater benefit" is the common response. Carriers threaten others and must be isolated or otherwise neutered. The threat inherent in them must be eradicated. This is a dangerous moral precedent. All kinds of people threaten our well-being: unsettling ideologists, the mentally handicapped, many politicians. Why should we single out our physical well-being as worthy of a privileged moral status? Why is our mental well being, for instance, of less import?
Moreover, the distinction between the psychic and the physical is hotly disputed, philosophically. The psychophysical problem is as intractable today as it ever was (if not more so). It is beyond doubt that the physical affects the mental and the other way around. This is what disciplines like psychiatry are all about. The ability to control "autonomous" bodily functions (such as heartbeat) and mental reactions to pathogens of the brain are proof of the artificialness of this distinction.
It is a result of the reductionist view of nature as divisible and summable. The sum of the parts, alas, is not always the whole and there is no such thing as an infinite set of the rules of nature, only an asymptotic approximation of it. The distinction between the patient and the outside world is superfluous and wrong. The patient AND his environment are ONE and the same. Disease is a perturbation in the operation and management of the complex ecosystem known as patient-world. Humans absorb their environment and feed it in equal measures. This on-going interaction IS the patient. We cannot exist without the intake of water, air, visual stimuli and food. Our environment is defined by our actions and output, physical and mental.
Thus, one must question the classical differentiation between "internal" and "external". Some illnesses are considered "endogenic" (=generated from the inside). Natural, "internal", causes - a heart defect, a biochemical imbalance, a genetic mutation, a metabolic process gone awry - cause disease. Aging and deformities also belong in this category.
In contrast, problems of nurturance and environment early childhood abuse, for instance, or malnutrition - are "external" and so are the "classical" pathogens (germs and viruses) and accidents.
But this, again, is a counter-productive approach. Exogenic and Endogenic pathogenesis is inseparable. Mental states increase or decrease the susceptibility to externally induced disease. Talk therapy or abuse (external events) alter the biochemical balance of the brain. The inside constantly interacts with the outside and is so intertwined with it that all distinctions between them are artificial and misleading. The best example is, of course, medication: it is an external agent, it influences internal processes and it has a very strong mental correlate (=its efficacy is influenced by mental factors as in the placebo effect).
The very nature of dysfunction and sickness is highly culture-dependent. Societal parameters dictate right and wrong in health (especially mental health). It is all a matter of statistics. Certain diseases are accepted in certain parts of the world as a fact of life or even a sign of distinction (e.g., the paranoid schizophrenic as chosen by the gods). If there is no dis-ease there is no disease. That the physical or mental state of a person CAN be different does not imply that it MUST be different or even that it is desirable that it should be different. In an over-populated world, sterility might be the desirable thing - or even the occasional epidemic. There is no such thing as
ABSOLUTE dysfunction. The body and the mind ALWAYS function. They adapt themselves to their environment and if the latter changes - they change. Personality disorders are the best possible responses to abuse. Cancer may be the best possible response to carcinogens. Aging and death are definitely the best possible response to over-population. Perhaps the point of view of the single patient is incommensurate with the point of view of his species - but this should not serve to obscure the issues and derail rational debate.
As a result, it is logical to introduce the notion of "positive aberration". Certain hyper- or hypo- functioning can yield positive results and prove to be adaptive. The difference between positive and negative aberrations can never be "objective". Nature is morally-neutral and embodies no "values" or "preferences". It simply exists. WE, humans, introduce our value systems, prejudices and priorities into our activities, science included. It is better to be healthy, we say, because we feel better when we are healthy. Circularity aside - this is the only criterion that we can reasonably employ. If the patient feels good - it is not a disease, even if we all think it is. If the patient feels bad, ego-dystonic, unable to function - it is a disease, even when we all think it isn't. Needless to say that I am referring to that mythical creature, the fully informed patient. If someone is sick and knows no better (has never been healthy) - then his decision should be respected only after he is given the chance to experience health.
All the attempts to introduce "objective" yardsticks of health are plagued and philosophically contaminated by the insertion of values, preferences and priorities into the formula - or by subjecting the formula to them altogether. One such attempt is to define health as "an increase in order or efficiency of processes" as contrasted with illness which is "a decrease in order (=increase of entropy) and in the efficiency of processes". While being factually disputable, this dyad also suffers from a series of implicit value-judgements. For instance, why should we prefer life over death? Order to entropy? Efficiency to inefficiency?
Health and sickness are different states of affairs. Whether one is preferable to the other is a matter of the specific culture and society in which the question is posed. Health (and its lack) is determined by employing three "filters" as it were:
1. Is the body affected?
2. Is the person affected? (dis-ease, the bridge between "physical" and "mental illnesses)
3. Is society affected?
In the case of mental health the third question is often formulated as "is it normal" (=is it statistically the norm of this particular society in this particular time)?
We must re-humanize disease. By imposing upon issues of health the pretensions of the accurate sciences, we objectified the patient and the healer alike and utterly neglected that which cannot be quantified or measured the human mind, the human spirit.
Back to Table of ContentsIn their opus magnum "Personality Disorders in Modern Life", Theodore Millon and Roger Davis define personality as:
"(A) complex pattern of deeply embedded psychological characteristics that are expressed automatically in almost every area of psychological functioning." (p. 2)
The Diagnostic and Statistical Manual (DSM)) IV-TR (2000), published by the American Psychiatric Association, defines personality traits as:
"(E)nduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts." (p. 686)
Laymen often confuse and confute "personality" with "character" and "temperament".Our temperament is the biological-genetic template that interacts with our environment.
Our temperament is a set of in-built dispositions we are born with. It is mostly unalterable (though recent studies demonstrate that the brain is far more plastic and elastic than we thought).
In other words, our temperament is our nature.
Our character is largely the outcome of the process of socialization, the acts and imprints of our environment and nurture on our psyche during the formative years (0-6 years and in adolescence).
Our character is the set of all acquired characteristics we posses, often judged in a cultural-social context.Sometimes the interplay of all these factors results in an abnormal personality.
Personality disorders are dysfunctions of our whole identity, tears in the fabric of who we are. They are allpervasive because our personality is ubiquitous and permeates each and every one of our mental cells. I just published the first article in this topic titled "What is Personality?". Read it to understand the subtle differences between "personality", "character", and "temperament".
In the background lurks the question: what constitutes normal behavior? Who is normal?There is the statistical response: the average and the common are normal. But it is unsatisfactory and incomplete. Conforming to social edicts and mores does not guarantee normalcy. Think about anomic societies and periods of history such as Hitler's Germany or Stalin's Russia. Model citizens in these hellish environments were the criminal and the sadist.
Rather than look to the outside for a clear definition, many mental health professionals ask: is the patient functioning and happy (ego-syntonic)? If he or she is both then all is well and normal. Abnormal traits, behaviors, and personalities are, therefore defined as those traits, behaviors, and personalities that are dysfunctional and cause subjective distress.
But, of course, this falls flat on its face at the slightest scrutiny. Many evidently mentally ill people are rather happy and reasonably functional.
Some scholars reject the concept of "normalcy" altogether. The anti-psychiatry movement object to the medicalization and pathologization of whole swathes of human conduct. Others prefer to study the disorders themselves rather to "go metaphysical" by trying to distinguish them from an imaginary and ideal state of being "mentally healthy".
I subscribe to the later approach. I much prefer to delve into the phenomenology of mental health disorders: their traits, characteristics, and impact on others.
Back to Table of Contents"You can know the name of a bird in all the languages of the world, but when you're finished, you'll know absolutely nothing whatever about the bird… So let's look at the bird and see what it's doing – that's what counts. I learned very early the difference between knowing the name of something and knowing something."
Richard Feynman, Physicist and 1965 Nobel Prize laureate (1918-1988)"You have all I dare say heard of the animal spirits and how they are transfused from father to son etcetera etcetera – well you may take my word that nine parts in ten of a man's sense or his nonsense, his successes and miscarriages in this world depend on their motions and activities, and the different tracks and trains you put them into, so that when they are once set a-going, whether right or wrong, away they go cluttering like heygo-mad."
Lawrence Sterne (1713-1758), "The Life and Opinions of Tristram Shandy, Gentleman" (1759)I. Overview
Someone is considered mentally "ill" if: 1. His conduct rigidly and consistently deviates from the typical, average behaviour of all other people in his culture and society that fit his profile (whether this conventional behaviour is moral or rational is immaterial), or
2. His judgment and grasp of objective, physical reality is impaired, and
3. His conduct is not a matter of choice but is innate and irresistible, and
4. His behavior causes him or others discomfort, and is
5. Dysfunctional, self-defeating, and self-destructive even by his own yardsticks.
Descriptive criteria aside, what is the essence of mental disorders? Are they merely physiological disorders of the brain, or, more precisely of its chemistry? If so, can they be cured by restoring the balance of substances and secretions in that mysterious organ? And, once equilibrium is reinstated – is the illness "gone" or is it still lurking there, "under wraps", waiting to erupt? Are psychiatric problems inherited, rooted in faulty genes (though amplified by environmental factors) – or brought on by abusive or wrong nurturance?
These questions are the domain of the "medical" school of mental health.Others cling to the spiritual view of the human psyche. They believe that mental ailments amount to the metaphysical discomposure of an unknown medium – the soul. Theirs is a holistic approach, taking in the patient in his or her entirety, as well as his milieu.
The members of the functional school regard mental health disorders as perturbations in the proper, statistically "normal", behaviours and manifestations of "healthy" individuals, or as dysfunctions. The "sick" individual – ill at ease with himself (ego-dystonic) or making others unhappy (deviant) – is "mended" when rendered functional again by the prevailing standards of his social and cultural frame of reference.
In a way, the three schools are akin to the trio of blind men who render disparate descriptions of the very same elephant. Still, they share not only their subject matter – but, to a counter intuitively large degree, a faulty methodology.
As the renowned anti-psychiatrist, Thomas Szasz, of the State University of New York, notes in his article "The Lying Truths of Psychiatry", mental health scholars, regardless of academic predilection, infer the etiology of mental disorders from the success or failure of treatment modalities.
This form of "reverse engineering" of scientific models is not unknown in other fields of science, nor is it unacceptable if the experiments meet the criteria of the scientific method. The theory must be all-inclusive (anamnetic), consistent, falsifiable, logically compatible, monovalent, and parsimonious. Psychological "theories" – even the "medical" ones (the role of serotonin and dopamine in mood disorders, for instance) – are usually none of these things.
The outcome is a bewildering array of ever-shifting mental health "diagnoses" expressly centred around Western civilisation and its standards (example: the ethical objection to suicide). Neurosis, a historically fundamental "condition" vanished after 1980.
Homosexuality, according to the American Psychiatric Association, was a pathology prior to 1973. Seven years later, narcissism was declared a "personality disorder", almost seven decades after it was first described by Freud.
Indeed, personality disorders are an excellent example of the kaleidoscopic landscape of "objective" psychiatry.
The classification of Axis II personality disorders – deeply ingrained, maladaptive, lifelong behavior patterns – in the Diagnostic and Statistical Manual, fourth edition, text revision [American Psychiatric Association. DSMIV-TR, Washington, 2000] – or the DSM-IV-TR for short – has come under sustained and serious criticism from its inception in 1952, in the first edition of the DSM.
The DSM IV-TR adopts a categorical approach, postulating that personality disorders are "qualitatively distinct clinical syndromes" (p. 689). This is widely doubted. Even the distinction made between "normal" and "disordered" personalities is increasingly being rejected. The "diagnostic thresholds" between normal and abnormal are either absent or weakly supported.
The polythetic form of the DSM's Diagnostic Criteria – only a subset of the criteria is adequate grounds for a diagnosis – generates unacceptable diagnostic heterogeneity. In other words, people diagnosed with the same personality disorder may share only one criterion or none.
The DSM fails to clarify the exact relationship between Axis II and Axis I disorders and the way chronic childhood and developmental problems interact with personality disorders.
The differential diagnoses are vague and the personality disorders are insufficiently demarcated. The result is excessive co-morbidity (multiple Axis II diagnoses).
The DSM contains little discussion of what
distinguishes normal character (personality), personality traits, or personality style (Millon) – from personality disorders.
A dearth of documented clinical experience regarding both the disorders themselves and the utility of various treatment modalities.
Numerous personality disorders are "not otherwise specified" – a catchall, basket "category".Cultural bias is evident in certain disorders (such as the Antisocial and the Schizotypal).
The emergence of dimensional alternatives to the categorical approach is acknowledged in the DSM-IV-TR itself:
“An alternative to the categorical approach is the dimensional perspective that Personality Disorders represent maladaptive variants of personality traits that merge imperceptibly into normality and into one another” (p.689)
The following issues – long neglected in the DSM – are likely to be tackled in future editions as well as in current research. But their omission from official discourse hitherto is both startling and telling:
• The longitudinal course of the disorder(s) and their temporal stability from early childhood onwards;
• The genetic and biological underpinnings of personality disorder(s);
• The development of personality psychopathology during childhood and its emergence in
adolescence;
• The interactions between physical health and disease and personality disorders;
• The effectiveness of various treatments – talk therapies as well as psychopharmacology.
Certain mental health afflictions are either correlated with a statistically abnormal biochemical activity in the brain – or are ameliorated with medication. Yet the two facts are not ineludibly facets of the same underlying phenomenon. In other words, that a given medicine reduces or abolishes certain symptoms does not necessarily mean they were caused by the processes or substances affected by the drug administered. Causation is only one of many possible connections and chains of events.
To designate a pattern of behaviour as a mental health disorder is a value judgment, or at best a statistical observation. Such designation is effected regardless of the facts of brain science. Moreover, correlation is not causation. Deviant brain or body biochemistry (once called "polluted animal spirits") do exist – but are they truly the roots of mental perversion? Nor is it clear which triggers what: do the aberrant neurochemistry or biochemistry cause mental illness – or the other way around?
That psychoactive medication alters behaviour and mood is indisputable. So do illicit and legal drugs, certain foods, and all interpersonal interactions. That the changes brought about by prescription are desirable – is debatable and involves tautological thinking. If a certain pattern of behaviour is described as (socially) "dysfunctional" or (psychologically) "sick" – clearly, every change would be welcomed as "healing" and every agent of transformation would be called a "cure".
The same applies to the alleged heredity of mental illness. Single genes or gene complexes are frequently "associated" with mental health diagnoses, personality traits, or behaviour patterns. But too little is known to establish irrefutable sequences of causes-and-effects. Even less is proven about the interaction of nature and nurture, genotype and phenotype, the plasticity of the brain and the psychological impact of trauma, abuse, upbringing, role models, peers, and other environmental elements.
Nor is the distinction between psychotropic substances and talk therapy that clear-cut. Words and the interaction with the therapist also affect the brain, its processes and chemistry - albeit more slowly and, perhaps, more profoundly and irreversibly. Medicines – as David Kaiser reminds us in "Against Biologic Psychiatry" (Psychiatric Times, Volume XIII, Issue 12, December 1996) – treat symptoms, not the underlying processes that yield them.
IV. The Variance of Mental DiseaseIf mental illnesses are bodily and empirical, they should be invariant both temporally and spatially, across cultures and societies. This, to some degree, is, indeed, the case. Psychological diseases are not context dependent – but the pathologizing of certain behaviours is. Suicide, substance abuse, narcissism, eating disorders, antisocial ways, schizotypal symptoms, depression, even psychosis are considered sick by some cultures – and utterly normative or advantageous in others.
This was to be expected. The human mind and its dysfunctions are alike around the world. But values differ from time to time and from one place to another. Hence, disagreements about the propriety and desirability of human actions and inaction are bound to arise in a symptom-based diagnostic system.
As long as the pseudo-medical definitions of mental health disorders continue to rely exclusively on signs and symptoms – i.e., mostly on observed or reported behaviours – they remain vulnerable to such discord and devoid of much-sought universality and rigor.
V. Mental Disorders and the Social OrderThe mentally sick receive the same treatment as carriers of AIDS or SARS or the Ebola virus or smallpox. They are sometimes quarantined against their will and coerced into involuntary treatment by medication, psychosurgery, or electroconvulsive therapy. This is done in the name of the greater good, largely as a preventive policy. Conspiracy theories notwithstanding, it is impossible to ignore the enormous interests vested in psychiatry and psychopharmacology. The multibillion dollar industries involving drug companies, hospitals, managed healthcare, private clinics, academic departments, and law enforcement agencies rely, for their continued and exponential growth, on the propagation of the concept of "mental illness" and its corollaries: treatment and research.
VI. Mental Ailment as a Useful MetaphorAbstract concepts form the core of all branches of human knowledge. No one has ever seen a quark, or untangled a chemical bond, or surfed an electromagnetic wave, or visited the unconscious. These are useful metaphors, theoretical entities with explanatory or descriptive power.
"Mental health disorders" are no different. They are shorthand for capturing the unsettling quiddity of "the Other". Useful as taxonomies, they are also tools of social coercion and conformity, as Michel Foucault and Louis Althusser observed. Relegating both the dangerous and the idiosyncratic to the collective fringes is a vital technique of social engineering.
The aim is progress through social cohesion and the regulation of innovation and creative destruction. Psychiatry, therefore, is reifies society's preference of evolution to revolution, or, worse still, to mayhem. As is often the case with human endeavour, it is a noble cause, unscrupulously and dogmatically pursued.
VII. The Insanity Defense "It is an ill thing to knock against a deaf-mute, an imbecile, or a minor. He that wounds them is culpable, but if they wound him they are not culpable." (Mishna, Babylonian Talmud)
If mental illness is culture-dependent and mostly serves as an organizing social principle - what should we make of the insanity defense (NGRI- Not Guilty by Reason of Insanity)?
A person is held not responsible for his criminal actions if s/he cannot tell right from wrong ("lacks substantial capacity either to appreciate the criminality
(wrongfulness) of his conduct" - diminished capacity), did not intend to act the way he did (absent "mens rea") and/or could not control his behavior ("irresistible impulse"). These handicaps are often associated with "mental disease or defect" or "mental retardation".
Mental health professionals prefer to talk about an impairment of a "person's perception or understanding of reality". They hold a "guilty but mentally ill" verdict to be contradiction in terms. All "mentally-ill" people operate within a (usually coherent) worldview, with consistent internal logic, and rules of right and wrong (ethics). Yet, these rarely conform to the way most people perceive the world. The mentally-ill, therefore, cannot be guilty because s/he has a tenuous grasp on reality.
Yet, experience teaches us that a criminal maybe mentally ill even as s/he maintains a perfect reality test and thus is held criminally responsible (Jeffrey Dahmer comes to mind). The "perception and understanding of reality", in other words, can and does co-exist even with the severest forms of mental illness.
This makes it even more difficult to comprehend what is meant by "mental disease". If some mentally ill maintain a grasp on reality, know right from wrong, can anticipate the outc