The delusional status of mental illness classifications

Last week, I talked about how being human is a pretty difficult process. As a part of this, I touched on the notion that most so-called “mental illnesses” are actually normal human reactions to difficult situations. I’ve been thinking a lot about this idea lately and wanted to expand on it this week.

Like most psychologists who studied clinical psychology, I learnt to classify mental illness using the Diagnostic and Statistical Manual (the DSM). It’s been through various incarnations (currently in 4th edition – text revision) with a 5th edition due out soon. It’s a literal compendium of all the things that can go wrong mentally with human beings and includes (as the title suggests) detailed classification and diagnostic criteria for making an appropriate diagnosis. Chances are, if you’ve heard of it (or haven’t) it’s in there. In fact, there’s increasing pressure to add more and more classifications to recognise the (apparently) increasing spectrum of psychological disorders. It’s no stranger to controversy either; not too long ago, the DSM (version 2) classified homosexuality as a mental illness.

My problem with the DSM, and the thinking that it espouses, is that it presupposes that all of these “conditions” are actually a real thing (i.e., an illness or disease, as per a medical condition), rather than end points or symptom clusters of a normal human reaction to an abnormal situation. Let me explain…

When a physical illness or disease is classified and diagnostic criteria developed, we’re talking about a definable, measurable phenomenon, often one that can be detected through physical signs (e.g., the presence of viruses or bacteria, cancerous cells, low white blood cell count, etc.). Using objective testing such as blood work or scans, physicians can figure out what’s going on and, potentially, treat the root cause. Because psychiatry evolved as a branch of medicine, it was only natural that it would emulate the existing diagnostic and classification procedures of other branches of medicine. The problem is that the so-called mental illnesses rarely have tangible signs, only symptoms (the subjective result of the condition). For example, anxiety usually manifests as an unpleasant feeling (either specific or generalised), with resultant avoidance strategies. It might be accompanied by raised pulse rate or blood pressure, but these are outcomes, not causes. Further, objectively, anxiety is the result of excessive activation of the sympathetic nervous system, often the consequence of excessive limbic system activity (particularly in the amygdala), but this activation can’t always be linked to a causal event. In other words, we’re talking about a symptom cluster that has been labelled as an illness, without an obvious root cause, or any measurable signs (activation of the amygdala doesn’t count here as it’s far too general and can’t be used to make a specific diagnosis).

OK, don’t get me wrong – I’m not suggesting that anxiety and other DSM Axis 1 classifications (such as depression) aren’t the cause of substantial distress to a lot of people. What I’m suggesting is that (except in instances where there is a distinct biological explanation, such as in schizophrenia) the entire notion of mental illness classification is flawed. That the entire strata of mental illnesses, from anxiety to autism, actually represent common symptom clusters rather than actual diseases.

You might well be thinking: so what? Surely, classifying mental illness is a useful mechanism, even if the reasoning is flawed? It must help with the treatment of these terrible illnesses, right? Nope… The problem is that, by classifying a person with an illness, a variety of things occur. First, we start to treat the symptoms (with medication or therapy). In this case we’re literally treating only the symptoms instead of the actual cause. If fact, often, because we’ve made a diagnosis, we’ll stick rigidly within its guidelines. Second, we label the person suffering from this “disease”. In doing so, given the giant stigma associated with mental illness, we also label them as flawed, broken or abnormal. This labelling does little to help the individual, and a lot to alienate and blame them.

This second distinction is especially important because, in many cases, when people are diagnosed with a mental illness, they honestly believe that something is wrong with them. Many people blame themselves, or feel that they’re weak, or useless – largely because of the stereotypes surrounding mental illnesses. Let’s straighten this up for the record. I believe that most “mental illnesses” are nothing of the sort. They are normal human reactions to difficult or abnormal situations. The reason that one in three adults will experience anxiety, and one in four depression, is because these mental states are completely normal human experiences!

Again, let’s not take this out of context. Despite being normal* human experiences, they are not pleasant – in fact, they’re shit. Anxiety and depression (I’m focusing on these two because they’re so common) are more than unpleasant, they can be crippling. But they are not diseases, they are the result of people doing the best they can with shoddy neural architecture and programming (see my other blog posts) to deal with difficult or overwhelming situations.

Let me illustrate what I’m talking about with what I call the continuum of human experience. We’ll use anxiety, because it’s such a common experience for humans. Humans evolved into their current state because they developed a large number of systems for surviving. Our midbrain is basically a system for approach (pleasure) and avoidance (fear) (see here for a lot more on this). The fear system acts on false positives. This means that it’s much better for survival to react to the slightest indication of danger (like a noise behind you) even if there’s no danger (what if it’s a tiger?). So, we have evolved a structure that exists for keeping us out of danger by reacting to anything that might be dangerous. In the modern world, this system can be easily overwhelmed, because so many of the situations we find ourselves in are ambiguous. It’s very possible for this system to become over active resulting in the highly unpleasant feeling that we call anxiety, and its potentially debilitating consequences (like the inability to leave the house).

So far so good. For most people, this system is activated regularly, resulting in feelings of anxiety on a reasonably regular basis. Even though the feelings are unpleasant they aren’t usually overwhelming. For some people, however, these feelings do become overwhelming – often as a result of some sort of trauma. Again this makes a lot of sense – the system exists to keep us safe. If we experience an event that is perceived as highly dangerous, the system will do its utmost to keep us away from other situations in which we might experience danger. This avoidance is reinforced by very strong feelings of anxiety, either specific to a behaviour, activity, situation or person, or generalised. So what we, in fact, have here is a continuum of normal human experience, from mild to extreme avoidance behaviour. What’s important to note is that any one of us could shift from the mild to the extreme simply through exposure to trauma. It’s what we’re built to do. And similar processes occur in depression and in many other DSM Axis 1 disorders.

So is this a disease? Is the activation of a system that evolved to keep us alive an illness? I don’t think so. And telling people that they’re ill (and, because of the stigma associated with mental illness, by default that they are broken or defective) doesn’t help.

So what should we be doing instead? For a start, viewing human experiences as diseases isn’t helping. Explaining to people that they are experiencing a normal human reaction to a difficult situation, and providing them with a variety of tools to respond to the demands of that situation is better. Even better is working to teach people to understand the human condition and what its vulnerabilities are. From here, we can help people understand how they can act in a way that provides meaning (see here), help them to separate from the thoughts, images, sensations and feelings that they find debilitating, and to be mindful of the present world.

I’m planning a post that summarises a lot of the ways that we can be more functional. In the meantime, I’d love to know what you think of today’s post.

* Just to explain the statistical notion of the word normal. Normal represents the case for a majority and is often expressed as one standard deviation either side of the mean on a normal curve (representing around 68% of a sample or population).