“What is Mental Illness?” Psychiatry in a State of Flux

UPDATE: Skeptically Speaking interviews Richard McNally (6/12/11)

An untidy stack of new books on psychiatry has sprouted in my office since our last conference on cultural and biological contexts of psychiatric disorder in January 2010. At the top is a slim volume by Harvard clinical psychologist, experimental psychopathologist, and DSM-IV (PTSD and specific phobia) committee member Richard McNally entitled What is Mental Illness? (Belknap Press, 2011) that promises to cut through “both professional jargon and polemical hot air, to describe the intense political and intellectual struggles over what counts as a ‘real’ disorder, and what goes into the DSM.” (McNally is also advisor to the DSM-V Anxiety Disorders Sub-Workgroup.) The book, which was written for an academic/trade audience and can be read through in a single evening, is an impressive synthesis of research and scholarship interwoven with insights.

Like Arthur Kleinman’s Rethinking Psychiatry: From Cultural Category to Personal Experience (save for another evening),  the titles of McNally’s chapters are phrased in the form of questions: “An Epidemic of Mental Illness?”; “Are We Pathologizing Everyday Life?”; “Can Evolutionary Psychology Make Sense of Mental Disorder?”; “Psychopathology as Adaptation?”; “Does Society Create (Some) Mental Disorders?”; Is It in Our Genes?”; “Do Mental Disorders Differ by Kind or Degree?”; “So What is Mental Illness Anyway?” The “gift” of this book is McNally’s ability to  survey and evaluate a broad swath of psychiatric, evolutionary, philosophical, anthropological, historical, and neuroscientific literature, with the biological, classificatory, pharmacological, social, and narrative aspects of mental illness given equal play.

Although nearly half of all Americans suffer from some form of mental illness according to a recent study, McNally argues that we shouldn’t be surprised at the high rates. Just as “physical illness runs from the common cold to cancer,” he writes, so mental illnesses can range from mild phobias to severe psychoses. The real problem according to McNally, one that his book attempts to address, is in distinguishing the concept of “mental disorder,” and all that that classification entails, from the differing degrees of “mental distress” in response to the emotional tangles, ruptures, or situational predicaments of everyday life.

McNally believes that some forms of psychopathology “are likely natural kinds discovered by observant clinicians across cultures and throughout history.” These include mania, melancholia, panic disorder, obsessive-compulsive disorder, and alcoholism.  (Although McNally describes schizophrenia as a biological disorder of recent vintage, he doesn’t consider it a “natural kind” because there are likely distinct phenotypes.) He recognizes other illness, like multiple personality disorder, as instantiations of one of Ian Hacking’s (1999) “interactive kinds” whereby psychiatric classification has a feedback effect on the behavior of the people being classified, as well as beliefs, institutions, and practices. [1]  Still other illnesses may reflect what he considers an encroachment of psychiatry on “normal suffering” as a result of life’s “inevitable disappointments and limitations,” e.g., sexual dysfunction, social anxiety disorder, eating disorders,  and PTSD – disorders that are tied to particular contexts, motives, and practices. (McNally, who is the author of a previous, terrific book, Remembering Trauma, is particularly critical of our capacity for “conceptual bracket creep in the definition of trauma.” )

He concludes that mental illnesses can never be defined on the basis of any single approach (or explanatory level)  “because the questions asked by the stakeholders may require different kinds of answers.” The various definitions are based on the contexts in which disorders occur.

New books challenging our assumptions about psychopathology by McNally, Ethan Watters (Crazy Like Us), Irving Kirsch (The Emperor’s New Drugs), Jonathan Metzl (The Protest Psychosis), Daniel Carlat (Unhinged), Robert Whitaker (Anatomy of an Epidemic) and Gary Greenberg (Manufacturing Depression) are kicking up dust clouds all over biological psychiatry (see NYRB for a recent, 2-part essay review  on the Kirsch, Whitaker, and Carlat books). Public debate matters because there are multiple stakeholders, a slew of treatments (some dubious), overmedicalization, unmet need, and an ethical decision to be made on whether or how to intervene in the face of psychological suffering. Psychiatrists, researchers, and the nearly fifty percent of us whom anthropologist Emily Martin refers to as living under the description of a psychiatric disorder will find McNally’s even-handed approach to the DSM’s validity issue of immense value.

[1] Although McNally refers specifically to “interactive kinds,” Hacking (2007) has since dispensed with the term: “Interactions among classifications, people, institutions, knowledge and experts are essential to the explanation of the looping effect and making up people, but there is no well-defined type of classification of people worth calling interactive or human kinds. Interaction, yes, but interactive kinds as a distinct class, no” (2007, p. 293, fn. 21).

References

Angell, M. (2011, June 23). The epidemic of mental illness: Why? The New York Review of Books, 58(11). Retrieved from http://www.nybooks.com/issues/2011/jun/23/

Carlat, D.  (2010). Unhinged: The trouble with psychiatry – a doctor’s revelations about a profession in crisis. New York: Free Press.

Greenberg, G. (2010). Manufacturing depression: The secret history of a modern disease. New York: Simon & Schuster.

Hacking, I. (1999). The social construction of what? Cambridge, MA: Harvard University Press.

Hacking, I. (2007). Kinds of people: Moving targets. Proceedings of the British Academy, 151, 285–318.

Kirsch, I. (2010).  The emperor’s new drugs: Exploding the antidepressent myth. New York: Basic Books.

McNally, R. (2003). Remembering trauma. Cambridge, MA: Belknap Press.

McNally, R. (2010). What is mental illness? Cambridge, MA: Belknap Press.

Metzl, J. (2010). The protest psychosis: How schizophrenia became a black disease. Boston: Beacon Press.

Watters, E. (2010). Crazy like us: The globalization of the American psyche. New York: Free Press.

Whitaker, R. (2010). Anatomy of an epidemic: Magic bullets, psychiatric drugs, and the astonishing rise of mental illness in America. New York: Crown.

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This entry was posted in bipolar disorder, cultural & biological contexts of psychiatric disorder, Defining mental illness by Constance A. Cummings. Bookmark the permalink.

About Constance A. Cummings

Constance A. Cummings, PhD, is Project Director of the non-profit Foundation for Psychocultural Research, which supports and advances interdisciplinary research and scholarship at the intersection of brain, mind, culture, and mental health and illness. She is co-editor (with Carol Worthman, Paul Plotsky, and Dan Schechter) of Formative Experiences: The Interaction of Caregiving, Culture, and Developmental Psychobiology (Cambridge University Press, 2010) and (with Laurence Kirmayer and Rob Lemelson) the forthcoming Re-Visioning Psychiatry: Cultural Phenomenology, Critical Neuroscience, and Global Mental Health (Cambridge, 2015). She received her doctorate in theoretical linguistics from New York University.

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