Before mental illness can be defined, the concept of illness needs to be understood more completely. As medicine has become increasingly driven by techno-logic 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 experience may help guide the clinician to focus on a particular area of concern, but when there is no objective evidence underlying the subject’s report, the validity of the report is called into question. It is an objective finding, something that can be independently seen in some manner, that constitutes disease. 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 dis-missed as less important than the objective facts of the disease. But doctors ultimately treat people and cannot ignore the experience of illness. Part of that treatment means targeting the disease. But another part of that means targeting the person’s illness, or eliminating the distressing symptoms, that may not necessarily disappear simply with the elimination of the disease. The challenge often is targeting the elimination of an illness, that is, the distressing symptoms, when no clear under-lying disease exists. This occurs with many conditions such as migraine headaches, chronic pain syndromes, and fibromyalgia. Mental illness poses an additional challenge in that the symptoms point to no particular part of the body but instead focus on the gray area between the brain and the mind.
Mental illness can be complicated to define, because it is based largely on the subjective experience of those suffering from it. Fortunately, the field of psychiatry has experienced technologic advances, and sophisticated brain scans and genetic studies have begun to tease out the underlying pathologic processes that lead to the development of mental illness. Concomitantly, the numbers of effective psychiatric therapies available to treat mental illness has expanded in the past 10 years. Unfortunately, although 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.
By way of example, consider the alternative feelings experienced by a patient who sees his or her internist for a variety of physical complaints for which all testing is negative and he or she is left languishing in the helpless idea that his or her complaints are “all in the head,” whereas a patient visiting the psychiatrist with the same array of com-plaints 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 biologic 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 dis-order 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 thrown about today in popular culture 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, insanity, 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, which 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,” “men-tally 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 from 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 biologic 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 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, biologic, 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 biologic 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.