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5. What exactly is 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 technological advances, the concept of disease has upplanted the concept of illness. Medicine is driven by a need for objective evidence and removal of subjective experience.

Although subjective data can help inform our understanding of diseases, by their very nature they are inherently unreliable. In contrast, objective, experimental approaches to various diseases and their treatments have led to major advances. With the cost of health care skyrocketing, making health care 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 are more likely to be defined and cured.

Humans, however, are more than just their diseases. To be human is to experience a disease in your own unique way, different from anyone else. 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 individual patient’s experience with the disease in the form of his or her illness.

Mental illness can be complicated to define, as it is generally based upon the subjective experience of those suffering from it. Fortunately, the field of psychiatry has experienced technological advances, and the number of effective psychiatric therapies available to treat mental illness has exploded in the past ten years.

Unfortunately, although scientific theories have continued to advance our understanding of possible underlying causes of mental illness, 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 why it remains so stigmatized by those who little understand it. Consider a patient who sees her internist for a variety of physical complaints and is told (after negative test results) that her complaints are “all in her head,” while a patient visiting the psychiatrist with the same array of complaints is provided with a medical explanation of her illness and feels reassured that it is “not all in her head.” Webster’s dictionary defines mental illness as a “disease of the mind,” illustrating the struggle to identify boundaries between disease and illness, mind and 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 such a label brings aid and comfort to those who suffer from it. There is certainly enough biological evidence to argue strongly for this definition even if no clinical testing existed.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revised (DSMIV-TR) does more than list a “menu” of symptoms for each disorder-it also requires the consideration of the impact those symptoms have on one’s life in terms of distress and disability. In addition, a medical illness cannot be the cause of the symptoms. It is the degree of symptom impact as well as the absence of a medical cause that defines the boundaries between normal variant, mentally ill, and physically ill. Defining the differences between the normal and pathological serve to avoid the subjectivity that can occur when defining illness of thought, emotions, or behavior.

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, 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 upon who defines them. These terms are routinely defined by:

• 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, popular culture and media often define mental llness by the idea that one is either “crazy” or not. Such terms 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 the term “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, this never stops the press 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. 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. Such definitions can lead people to avoid a psychiatrist’s office for fear of being labeled as “crazy” or “mentally ill.”

Second, political, legal, or economic definitions of mental illnesses are meant to protect people from arbitrary actions by virtue of their illness. Such terms include “biologically based,” “behavior disorder,” and “insanity.” 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 term “biologically based” was coined in order to force insurers to pay for treatment of such DSM-IV disorders as schizophrenia, major depressive disorder, and bipolar disorder.

Alternatively, “behavior disorders” are not considered to be “biologically based” from insurers’ perspective and thus are the responsibility of the individual and not subject to third-party payment. The term “insanity” carries 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 psychiatrists would say that he or she has a mental illness, and the popular press might call such a person “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 insofar as attempts are made to understand each individual, biological, psychological, and social element that goes into causing each disorder.

Psychiatry is not without its own arbitrary distinctions, however. Clinicians make distinctions between “major mental illnesses” and “personality disorders,” classified as Axis I and Axis II diagnoses in the DSM-IV.

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 it has allowed psychiatry to historically focus and set limits on what can be accurately defined and treated. In the past, psychiatrists considered personality disorders as not changeable and not treatable.

Science has advanced, however, showing that certain elements of personality do change with time and can be improved with treatment. Insurers and the courts, however, continue to distinguish between “biologically based” versus “behavior disorder” or mentally ill versus personality disordered.

Terms:

Mental illness - a medical condition defined by functional symptoms with as yet no specific  pathophysiology that impairs social, academic, and occupational function.

Personality disorder - maladaptive behavior patterns that persist throughout the life span that cause functional impairments

Bipolar disorder - a mental illness defined by episodes of mania or hypomania, classically alternating with episodes of depression. There are, however, various forms the condition can take, such as repeated episodes of mania only, or lack of alternating episodes.

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