The nature of mental illness

The APA (American Psychiatric Association) has recently announced a new diagnostic manual (the DSM 5) which, among other things, introduces new "mental illnesses" for psychiatrists to diagnose. The choice of words in the last sentence, which may sound awkward, was intended to demonstrate the strange practices that the psychiatric association partakes in. Although I may be wrong, I am relatively confident in saying that the role played by the DSM in Psychiatry is significantly larger than the role of similar texts in other areas of medicine. While other doctors do find new conditions and illnesses, only in psychiatry is the issue of what constitutes an illness a major concern. This uncertainty is what makes the announcement of a new version of the DSM, and the "new illnesses" therein such a significant moment.

Many others have commented and criticized the new DSM for the inclusion of a number of new conditions. For example, the manual treats the depression that follows a loss, shyness in children, oppositional/defiant and apathetic behavior in children as new forms of mental illness. These have changed from being ordinary characteristics of life into abnormal "sick" states. Most of the criticism levelled against these new conditions claims that they're based on inappropriate influences from drug companies, or reflect an inappropriate desire to eliminate the ordinary diversity of the human condition.

Here I want to make a different sort of criticism. Many of the conditions identified by the DSM reflect issues in the social realm. Being oppositional or defiant is necessarily social, as is shyness. Furthermore, depression and apathy, while possible individual feelings, often occur for people within social contexts (though they could occur for “desert island” people too). Because these occur in a social context, it is only within this context that they can be understood. In other words, the processes involving “oppositional-defiance disorder” run through entire social contexts; they are not limited to individuals. Yet, psychiatry attempts to deal with these things as if they were individual problems. THe individual is separated from society, taken to the psychiatrist. There, in isolation, the psychiatrist attempts to understand the problem in terms of the individual. Treating mental phenomena that occur on the interpersonal realm by looking at individuals who are presumed to be at the center of these phenomena is like trying to understand the audience experience at a concert by studying the band alone. Such an approach cannot work. To understand the experience of a concert, one must study both the music/band, and the audience.

The psychological processes that reflect generalized versions of “oppositional defiance disorder” or shyness disorder are certainly distinct things--this can be granted. However, for something to be distinct it doesn’t follow that all of its elements must be distinct form the elements of all other things. For example, two songs for the piano may be distinct, even if they involve all of the same notes. The differences emerge at a higher level in terms of the vertical and horizontal arrangement of the notes. The same principle is true for other generative phenomena--language, DNA, etc. To bring this example to the realm of psychiatry, mental phenomena that exist as qualitatively distinct on the social level are not necessarily made up of distinct component processes. The component processes may simply be ordinary ones that have combined in a certain way to yield a certain result. Therefore, when a “mental illness” has been identified which manifests itself on the social level, there is no reason to expect that the optimal way to return to a healthy mental state is to change something on the level of the “afflicted” individual. The problem may not be with any of the component parts of the situation (the individuals involved) but with the results of their combination. A new view of psychological problems becomes available when we think of them as possibly deriving from unfortunate combinations of otherwise healthy, ordinary mental processes.