"Thought-provoking and important. . .Drawing on and consolidating the ideas of a range of authors, Horwitz challenges the existing use of the term mental illness and the psychiatric ideas and practices on which this usage is based. . . . Horwitz enters this controversial territory with confidence, conviction, and clarity."—Joan Busfield, American Journal of Sociology
"Horwitz properly identifies the financial incentives that urge therapists and drug companies to proliferate psychiatric diagnostic categories. He correctly identifies the stranglehold that psychiatric diagnosis has on research funding in mental health. Above all, he provides a sorely needed counterpoint to the most strident advocates of disease-model psychiatry."—Mark Sullivan, Journal of the American Medical Association
"Horwitz makes at least two major contributions to our understanding of mental disorders. First, he eloquently draws on evidence from the biological and social sciences to create a balanced, integrative approach to the study of mental disorders. Second, in accomplishing the first contribution, he provides a fascinating history of the study and treatment of mental disorders. . . from early asylum work to the rise of modern biological psychiatry."—Debra Umberson, Quarterly Review of Biology
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CREATING MENTAL ILLNESS
By Allan V. Horwitz
THE UNIVERSITY OF CHICAGO PRESS
Copyright © 2002 The University of Chicago
All right reserved.
A CONCEPT OF MENTAL DISORDER
Any adequate definition of mental disorder must be valid. A valid definition provides an answer to the question "what is a mental disorder?" It includes conditions that may productively be considered types of mental disorders and excludes those that may not, and so defines the boundaries of mental disorder. In particular, it distinguishes mental disorders from normality and from deviant behavior. Although a valid definition of mental disorder defines the appropriate subject matter for the field of mental health and illness, few studies focus on issues of validity. Instead, there have been two contrasting approaches toward definitions of mental disorder.
Most sociologists and anthropologists reject the possibility of developing a general concept of mental disorder that would be valid across social groups. They view mental disorders as culturally specific phenomena; mental illness is whatever a particular group defines as such. For example, Benedict (1934) claims that the Siberians assign people who hallucinate valued religious roles, presumably showing the culturally relative nature of schizophrenia. Foucault, as well, states that madness is a culturally specific category that developed only after the leprosariums closed at the end of the Middle Ages in Europe (Foucault 1965). In this relativist view, the great diversity of social definitions of mental illness precludes the possibility of a concept that transcends particular social contexts.
In contrast to the relativist view, research psychiatrists, epidemiologists, and clinicians simply accept as mental disorders whatever conditions the DSM lists. They do not ask how these conditions came to be regarded as mental disorders. Instead, researchers strive to develop reliable measures of particular diagnostic entities without questioning whether the conditions they measure are valid disorders or not. Likewise, mental health professionals often obsess over the question of what particular disorders their patients have but take for granted that these entities are mental disorders (Spitzer 1999). Yet, in the absence of a well-defined and conceptually adequate definition of mental disorder, there is no reason to accept that any particular group of symptoms represents a valid form of mental disorder.
Despite the mental health community's relative inattention to issues of validity, it is more fundamental to attain validity than reliability (Kleinman 1988; Wakefield a; Kirk and Kutchins 1992). Conditions that are reliably measured are not mental disorders unless they meet criteria of validity. Because diagnostic psychiatry has little concern for validity, it indiscriminately combines conditions that have defensible claims to be mental disorders with conditions that reflect the expectable consequences of stressful social circumstances and with norm-breaking, but not disordered, behaviors. Current conceptions of mental illness include far more behaviors than a valid definition of disorder warrants. The consequences of this are that rates of presumed mental illness are elevated to artificially high levels, non-disordered people are treated as if they are disordered, social behaviors are defined as individual pathologies, and the mental health system overemphasizes the treatment of problems of living at the expense of serious mental disorders.
No concept, especially one as controversial as mental disorder, is universally true or false. Rather, any particular concept of mental disorder is more or less useful for various purposes (Brodbeck 1968). One central sociological task is to distinguish between mental disorders and normal reactions to social stressors. There is nothing wrong with people who respond to stressful environments, situations, and relationships with depression, anxiety, and other signs of distress. Their reactions are normal, not abnormal, responses to their environments. Another essential distinction is between mental disorders and social deviance. Deviations from social norms arise not only because of internal pathologies but also because of many other reasons including conflicting cultural norms, conformity to the standards of subcultures, or a lack of adequate social control (see, for example, Merton 1938; Sellin 1938; Hirschi 1969). An adequate concept will only label deviance that arises from internal dysfunctions as mental disorder. This chapter develops a definition that limits mental disorder to symptoms that result from psychological pathologies, thus distinguishing mental disorder from expectable responses to stressful environments and from social deviance. A good place to begin the consideration of validity is with the definition of mental disorder found in the official diagnostic manual of the American Psychiatric Association, the Diagnostic and Statistical Manual, Version IV (DSM-IV). This definition is nearly hidden in three paragraphs of the prefatory material to a 900-page manual. It is framed with an apology that states it is "a reductionistic anachronism of mind/body dualism," that it persists "because we have not found an appropriate substitute," and that it is included "because it is as useful as any other available definition" (APA 1994, xxi). Hardly a ringing endorsement, this passage perhaps reveals why there is no further discussion or application of the concept to the nearly disorders that follow in the manual. Indeed, many of the actual definitions of particular conditions in the DSM do not meet the criteria delineated in the concept of mental disorder. The major problem with the DSM concept of mental disorder is the failure of the manual to apply it to the many particular conditions it defines.
The DSM defines mental disorder as follows:
In DSM-IV, each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e. impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. In addition, this syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one. Whatever its original cause, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual. Neither deviant behavior (e.g. political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual, as described above. (APA 1994, xxi-xxii)
This definition has three critical aspects: mental disorders are internal dysfunctions, mental disorders are not expectable responses to particular events, and mental disorders must be distinguished from deviant behavior.
The philosopher Jerome Wakefield has developed the most useful elaboration and critique of the DSM definition of mental disorder. Wakefield argues that when the conceptual redundancy, inconsistency, and confusion of the DSM definition is eliminated, it can be reformulated more simply as stating that mental disorders are harmful internal dysfunctions. In Wakefield's reformulation, there are two essential components of valid mental disorders: they are internal dysfunctions, and they have harmful consequences for individuals as defined by sociocultural standards. A mental "disorder exists when the failure of a person's internal mechanisms to perform their functions as designed by nature impinges harmfully on the person's well-being as defined by social values and meanings" (Wakefield 1992a: 373). I use Wakefield's definition, although I believe that "socially inappropriate" more adequately captures the social aspects of mental disorder than the notion of "harm."
Wakefield's concept addresses the central problem a valid definition of mental disorder must overcome: how to reconcile cultural particularism with biological universalism (Fabrega 1992). A valid definition has two components, which take into account the universal and the cultural aspects of mental disorder, respectively. Internal dysfunctions, which are universal, are necessary components of mental disorders. The universal component of mental disorders implies that similar failures of functioning in internal mechanisms would be mental dysfunctions regardless of the particular social context in which they occur. This aspect of mental disorder produces natural constraints around which culturally specific definitions vary. Although internal dysfunctions are necessary components of mental disorders, they are never sufficient components. Only internal dysfunctions that are also defined as socially inappropriate are mental disorders.
The Universal Component of Mental Disorders Mental disorders are dysfunctions of some internal psychological mechanism. A mental disorder exists when psychological systems of cognition, thinking, perception, motivation, emotion, memory, or language are unable to function appropriately. These functions are very general and universal properties of the human species: perceptual apparatuses are designed to convey accurate information about the environment, fear responses allow people to avoid danger, language allows for communication, and so on. In this sense, they are components of human nature shared in all times and places. The essential aspect of an internal dysfunction is that some psychological system is unable to work as it has been designed to work by the processes of natural selection (Wakefield 1999a). Internal dysfunctions are necessary components of mental disorders-if nothing is wrong with people's internal functioning, they are not mentally disordered.
An internal dysfunction exists only when an internal mechanism is unable to perform its natural function, not when it simply doesn't perform this function (Wakefield 1992b, Klein 1999). For example, unlike the self-starvation of modern anorexics, the fasting of holy women in medieval Italy was not a mental disorder because there was nothing wrong with their psychological functioning. Their failure to eat reflects an individual choice, not a dysfunctional internal mechanism. Likewise, people who have internal dysfunctions that preclude them from having sexual orgasms are distinct from those who are not orgasmic because they choose to be celibate, have bad interpersonal relationships, or engage in sex for monetary compensation. It is not the failure to have orgasms but the inability of sexually dysfunctional people to be orgasmic that distinguishes them from monks, people in troubled relationships, or sex workers. Similarly, all nondisordered people have the capacity to use language appropriately: the difficulties in communication that are products of autism are mental disorders, while the intentional silence of members of some religious orders is not.
Using the criterion of dysfunction to define mental disorders implies that the presence of symptoms alone is never sufficient to indicate a mental disorder: only symptoms that stem from internal dysfunctions reflect disorders. The same symptoms that might result from internal dysfunctions in other contexts might be normal reactions to stressful environments. This is why bereaved people do not suffer from the mental disorder of depression. People are naturally depressed after the death of an intimate; there is nothing wrong with their affective mechanisms. Likewise, fear mechanisms are designed to enable people to detect danger. Intense symptoms of anxiety that arise among soldiers who are about to enter combat are not products of an internal dysfunction but are rational responses to external circumstances. The identical symptoms may indicate an anxiety disorder when they do not reflect a proportionate response to environmental dangers. Mental disorders must be distinguished from deviant behavior as well as from expectable responses to stressful environments. Heavy drinking need not indicate alcoholism, nor is career criminality equivalent to antisocial personality disorder. These would only be mental disorders if it were clear that they stemmed from internal dysfunctions that render alcoholics or sociopaths unable to control their conduct.
That all mental disorders involve internal dysfunctions does not imply that all mental disorders must have internal causes. The DSM appropriately states that the causes of an internal dysfunction need not themselves be internal: "Whatever its original cause, (this syndrome or pattern) must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual" (APA 1994, xxi-xxii). Psychological dysfunctions exist when some internal system of cognition, memory, linguistic ability, motivation, aggression, or perception is unable to perform properly. Social as well as biological or psychological factors might be responsible for causing these dysfunctions. The presence of dysfunctional internal mechanisms, not particular kinds of causes of the dysfunctions, determines whether a mental disorder exists or not.
The dysfunctional aspect of mental disorders parallels the dysfunctions of bodily mechanisms that define physical disorders; in principle, the determination of adequate mental functioning is very similar to that of adequate physical functioning (see Lewis 1953; Klein 1978). In practice, however, there is generally consensus on the appropriate functions of physical systems: the eyes should accurately convey visual information, the ears should hear only sounds that are present in the environment, the heart should circulate blood, the digestive system should absorb nutrients and discard wastes, and so on. There is far less consensus on, and far less knowledge about, what constitutes appropriately functioning systems of cognition, emotion, reasoning, motivation, and the like. This lack of consensus insures that the boundaries between "appropriate" and "inappropriate" functioning will often be very fuzzy (Lilienfeld and Marino 1995).
The Culturally Relative Component of Mental Disorders The dysfunction criterion used to define mental disorders is analogous to definitions of physical diseases that are dysfunctions of bodily organs. The second criterion, however, distinguishes definitions of mental illnesses from definitions of physical illnesses: cultural values and meanings are necessary components of any valid definition of mental disorder. While all mental disorders involve failures of internal functions, only internal dysfunctions that are also socially defined as inappropriate qualify as mental disorders (Wakefield 1992a, 384). In contrast to the notion of internal dysfunction, which refers to universal properties of human organisms, the notion of inappropriateness arises from social definitions applied in particular contexts. Cultural standards of normality are integral parts of a valid definition of mental disorder.
All definitions of mental disorder must contain culturally specific components. The DSM, for example, uses terms such as "inappropriate," "bizarre," "unexpectable," and "maladaptive" when defining the disorders of major depression, schizophrenia, panic disorder, and alcohol intoxication, respectively (APA 1994, 237, 275, 402, 197). Such terms have no universal referents but are only meaningful within given social and cultural contexts. For example, cultural definitions are necessary aspects of decisions about whether or not hallucinations are signs of dysfunctional perceptual processes. Bereaved Native Americans often hallucinate visions of their dead spouses and talk to them (Kleinman 1987). Such hallucinations are not mental disorders in this context because they are culturally appropriate ways of reacting to grief. Likewise, cultural values always enter into judgments over whether reactions to stressors are proportionate or disproportionate. The DSM, for example, considers a diagnosis of major depression after bereavement appropriate when symptoms persist for longer than two months. In Mediterranean societies, however, widows traditionally have been expected to grieve for periods of time that would be considered excessive by American standards (Kramer 1993). Grief of comparable intensity and duration might be a mental disorder in the United States but not in Greece. Comparably, a fear of snakes might be appropriate where snakes are plentiful but indicative of a phobia in an urban area; and fear of crime in a city might be adaptive while the same fear in a secure vacation resort area might be inappropriate (Simpson 1996).
Excerpted from CREATING MENTAL ILLNESS by Allan V. Horwitz Copyright © 2002 by The University of Chicago. Excerpted by permission.
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Table of ContentsPreface
Introduction—The Proliferation of Mental Illnesses
1. A Concept of Mental Disorder
2. The Expansion of Mental Disorder in Dynamic Psychiatry
3. The Emergence of Diagnostic Psychiatry
4. The Extension of Mental Illnesses into the Community
5. The Structuring of Mental Disorders
6. The Biological Foundations of Diagnostic Psychiatry
7. Social Causes of Distress
8. Diagnostic Psychiatry and Therapy
Mental Illnesses as Social Constructions