A cure to all mental illnesses?
Reading | Psychiatry | 2022-12-04
Mikaela Marinis, BS
Jhean Paul Varela Carrero, JD
In the mental health fields, there are two views towards psychiatric diagnostic categories: the realist and constructionist, which correspond somewhat to materialism and idealism. Arguing that the psychiatric diagnoses we create do not literally exist as discernible brain states, but are instead just helpful constructs, is critically aligned with idealism and offers a very different perspective to patients and their self-image.
When you are dealing with mental illness, you might defer to a psychologist or psychiatrist to help you figure out what precise illness you have. You may imagine that the mental illness represents a lack of a certain neurotransmitter, or even that you are about to finish a personality test, and find a new group of people just like you. Maybe you hope you don’t get ‘misdiagnosed’ and the psychologist or psychiatrist gives you the wrong treatment. But what if most of the diagnoses were pretty much, semi-secretly, the same?
Before the Enlightenment in Europe, judges lacked standardized procedures and legislation that would enable them to create uniform sentences. If two people committed the same crime in different geographical areas of the same State, judges would come up with completely different punishments, at a time when monarchies kept unlimited power.
Meanwhile, merciless tortures were an integral part of the judicial process. Foucault [1] described the hardships that some individuals went through, and made a special emphasis on the case of Damiens, a man punished for regicide in 1757:
The flesh will be torn from his breasts, arms, thighs and calves with red-hot pincers, his right hand, holding the knife with which he committed the said parricide, burnt with sulfur, and, on those places where the flesh will be torn away, poured molten lead, boiling oil, burning resin, wax and sulfur melted together and then his body drawn and quartered by four horses and his limbs and body consumed by fire, reduced to ashes and his ashes thrown to the winds.
Facing these severe conditions, one of the most influential thinkers of the Enlightenment, Cesare Beccaria, attempted to design a new judicial system. Among other objectives, the State would be prevented from abusing its powers and torture would be eliminated. This new system relied on standardized laws that were simply and clearly written in order to limit the interpretations of judges. According to Beccaria, syllogisms would make laws more precise and restrict possible abuses of power. An example of a legal syllogism could be, “Whoever murders goes to prison for 15 years. Patrick murdered. Thus, Patrick goes to prison for 15 years.”
These laws wouldn’t focus on the individual and his thoughts and feelings; the judges wouldn’t care about Patrick’s reasons behind committing the crime. They’d focus instead on the fact that a murder had taken place, and the laws were there to punish the prohibited behavior. This placed a lot of weight on the abstract constructions of the law, as opposed to an analysis of the psyche of the individual. There were two reasons for this approach according to Beccaria [2]:
- It’s impossible to know the vast amount of internal states behind why individuals commit crimes, as “this will depend on the actual impression of objects on the senses, and on the previous disposition of the mind; both of which will vary in different persons, and even in the same person at different times…”
- Even if it were possible to know the internal states, this would still require an immense amount of laws that simply couldn’t be dealt with, and the legal codes would be infinite; it would require “not only a particular code for every individual, but a new penal law for every crime.”
Beccaria published his seminal book An Essay on Crimes and Punishments in 1764, and justified his system through the concept of “moral responsibility.” Moral responsibility proposes that, since people have freewill, they’re all equally responsible for the decisions they make and the crimes they commit. Thus, all punishments should be dealt out the same to everyone. With the collapse of the authoritarian monarchies in Europe, many of the ideas that were proposed in Beccaria’s work were adopted worldwide, and continue to be used in contemporary times.
However, during the 19th century, a new school of thought would attempt to challenge these ideas. The Positive School of Italian Penal Law [3], inspired by the developments of science, argued that humans are completely subject to cause and effect and there is no freewill. The legal system, according to the proponents of this school, shouldn’t focus primarily on legal abstractions, but should concentrate on scrutinizing the criminal and his psyche. In that way, the root cause of the crime would be addressed.
The Positive School wanted to base its new ideas on recent developments from the fields of psychiatry and psychology, where ‘madness’ was no longer understood as a demonic possession or a decision by the crazy person themselves. Instead, it was seen as an illness. For the proponents of the Positive School, every criminal is different, so every crime is different. For this reason, there shouldn’t be standardized punishments for the same crime. Instead, this school proposed an individualized approach: a person would get out of prison once he was ‘cured,’ or ‘rehabilitated into society,’ based on scientific methodologies.
However, Beccaria was right that the Positive School’s ideas complicate our legal system. During the 20th century, the jurist Hans Kelsen [4] would go in favor of Beccaria’s system and argue that we shouldn’t focus on individual causes regarding criminal behavior:
Each concrete cause is simultaneously the effect of another cause and each effect the cause of another effect. There are, then, by definition, infinite chains of causes and effects, and each event is the point of intersection of an infinite number of causal chains.
Hans Kelsen, legal philosopher.
This debate escapes the confines of law and the arguments of both schools are, in contemporary times, more relevant than ever.
Where are psychiatry and psychology leaning towards nowadays? The options are: clean general categorization that doesn’t fit a causal model following the classical legal approach, or an insurmountable amount of causes that can’t be processed, and that resist categorization. If the scale was leaning towards an abstract model that has little to do with scientific causes and more to do with law, we’d expect the categories used to diagnose mental illnesses to collapse in the face of scientific scrutiny. And that is exactly what happens.
The DSM, or Diagnostic and Statistical Manual of Mental Disorders, is the modern bible for diagnosing different mental illnesses. But it’s a known secret that today’s academic psychologists acknowledge “the clinical reality that no clear divisions are empirically supported between most mental disorders and normality or, oftentimes, even between neighboring disorders,” [5] to the point where Dr. Steven Hyman, former director of the National Institute of Mental Health, called the DSM “an absolute scientific nightmare” [6].
For example, today, if someone goes to a psychiatrist to receive a mental illness diagnosis, chances are uncomfortably high the doctor next door would give them a different diagnosis. In trials for the DSM-5, 40% of mental illnesses did not meet “even a relaxed cutoff” for inter-rater [Editor’s note: between observers or, in this case, between psychiatrists] diagnostic reliability [7]. In one study in Canada, “misdiagnosis” of psychiatric labels was found to be 65.9% for major depressive disorder, 92.7% for bipolar disorder, 85.8% for panic disorder, 71.0% for generalized anxiety disorder, and 97.8% for social anxiety disorder [8].
In addition, mental illness categories have poor stability over time periods, with the diagnostic status of patients frequently changing over short intervals, and with vagrancies in symptom severity [9].
Aside from that, patients diagnosed with many mental illnesses are, more frequently than not, diagnosable for a second mental illness [10][11][12][13]. This is called comorbidity in the field of psychiatry. It is continuously found that different mental illness labels once perceived as unrelated are actually frequently comorbid with one another, or frequently can be diagnosed within the same individual [14][15].
Historically, scientists used to think of mental illnesses as discrete: either someone had schizophrenia, or they did not [16]. However, overtime, that view has been forced to change. Now the more accepted view is that mental illness is a spectrum across the human population [17]. Since scientists are yet to find even a single mental disorder that is a discrete categorical entity [18][19], it’s hard to be expected to provide concrete and objective diagnoses. However, even if a disorder is recognized as a spectrum across the human population, it still doesn’t tell us anything about the cause of that disorder within individuals.
If the lines between mental illnesses break down, it follows that the lines between treatment for mental illnesses would also break down. It has been hypothesized that psychiatric drugs work by correcting deficiencies in certain neurotransmitters. For example, an SSRI (Selective Serotonin Reuptake Inhibitor) drug supposedly fixes the lack of serotonin in the depressed brain, and treats it. But this has recently been disproven. Instead, the available evidence shows that psychiatric drugs are best conceptualized as enacting a particular psychological state that is not directly related to the diagnosis at hand, but instead could give anyone taking it similar results. Dr. Sami Timimi at Lincoln University argues: “As a psychoactive substance, SSRIs would appear to do ‘something’ to the mental state, but that something is not diagnosis-specific. Like alcohol, which will produce inebriation in a person with schizophrenia, obsessive compulsive disorder, depression or someone with no psychiatric diagnosis, SSRIs will also impact individuals in ways that are not specific to diagnosis” [20].
In fact, SSRIs are used for the treatment of Borderline Personality Disorder, Depression, Anxiety, OCD, anorexia nervosa, bulimia, panic disorder, social phobias, and more [20]. However, is there a general cure to all mental illnesses?
The NY Times journalists Pam Belluck and Benedict Carey lament that “the mechanisms of the field’s most commonly used drugs […] have revealed nothing about the causes of those disorders” [6]. But why would they? As Beccaria understood, the causes of behavioral and personality categories are unique to the individual, while categorization adopts an abstract form that is disconnected from causality. When people are diagnosed with mental illnesses, causality is largely thrown away, and they might as well be imputed using a legal code. Since each mental illness represents an unlimited number of possible causes, each mental illness must cover an overwhelming tent. Mathematicians have calculated that thousands of possible symptom combinations make up different mental illnesses, such as over 600,000 unique combinations qualifying a diagnosis for PTSD [21].
These diagnostic categories are actively creating generations of people who believe themselves to be mentally ill, from a scientific perspective. It’s undeniable that there are people in the world who are suffering from substantial impairments, or emotional distress. However, our explanatory models are, in many cases, insufficient. Often, the lines that divide legal codes and mental illness diagnostic codes are blurry. In the meantime, likely modeled after the Beccarian system itself, mental illness categories serve largely as legal heuristics.
Such heuristics end up granting prerogatives in front of the State, and deciding who deserves certain work, education, access to certain drugs, financial benefits or a shorter or longer punishment in the criminal system.
Scientists appear to be confused as to why its systems for studying mental illnesses aren’t working, and assume that aimlessly throwing data at the wall will eventually lead them to a cause for their models. But taking a step back to understand the immense social, philosophical, and political web that mental illness represents might shed some light on the problem.
Citations
[1] Foucault, M. (2019). Discipline and punish: The birth of the prison. Penguin Books Ltd.
[2] Beccaria, C. (1872). An Essay on Crimes and Punishments. Albany: W.C. Little & Co.
[3] Molina, C. M. (1999). Introducción a la Criminología. Bogotá: Leyer.
[4] Kelsen, H. (2009). Teoría Pura del Derecho. Buenos Aires: Eudeba.
[5] Ruggero CJ, Kotov R, Hopwood CJ, First M, Clark LA, Skodol AE, Mullins-Sweatt SN, Patrick CJ, Bach B, Cicero DC, Docherty A, Simms LJ, Bagby RM, Krueger RF, Callahan JL, Chmielewski M, Conway CC, De Clercq B, Dornbach-Bender A, Eaton NR, Forbes MK, Forbush KT, Haltigan JD, Miller JD, Morey LC, Patalay P, Regier DA, Reininghaus U, Shackman AJ, Waszczuk MA, Watson D, Wright AGC, Zimmermann J. Integrating the Hierarchical Taxonomy of Psychopathology (HiTOP) into clinical practice. J Consult Clin Psychol. 2019 Dec;87(12):1069-1084. doi: 10.1037/ccp0000452. PMID: 31724426; PMCID: PMC6859953.
[6] Belluck, P., & Carey, B. (2013, May 7). Psychiatry’s Guide is out of touch with science, experts say. The New York Times. Retrieved November 21, 2022, from https://www.nytimes.com/2013/05/07/health/psychiatrys-new-guide-falls-short-experts-say.html
[7] Waszczuk, M. and others (2020). Redefining Phenotypes to Advance Psychiatric Genetics: Implications from Hierarchical Taxonomy of Psychopathology. J Abnorm Psychol, 129(2), 143–161. https://doi.org/10.1037/abn0000486
[8] Vermani, M., Marcus, M., & Katzman, M. A. (2011). Rates of detection of mood and anxiety disorders in primary care. The Primary Care Companion For CNS Disorders. https://doi.org/10.4088/pcc.10m01013
[9]Baca-Garcia, E., Perez-Rodriguez, M. M., Basurte-Villamor, I., Fernandez Del Moral, A. L., Jimenez-Arriero, M. A., Gonzalez De Rivera, J. L., Saiz-Ruiz, J., & Oquendo, M. A. (2007). Diagnostic stability of psychiatric disorders in clinical practice. British Journal of Psychiatry, 190(3), 210–216. https://doi.org/10.1192/bjp.bp.106.024026
[10] Katzman, M. A., Bilkey, T. S., Chokka, P. R., Fallu, A., & Klassen, L. J. (2017). Adult ADHD and comorbid disorders: Clinical implications of a dimensional approach. BMC Psychiatry, 17(1). https://doi.org/10.1186/s12888-017-1463-3
[11] The Children’s Hospital of Philadelphia. (2017, June 14). Autism’s clinical companions: Frequent comorbidities with ASD. Children’s Hospital of Philadelphia. Retrieved November 21, 2022, from https://www.chop.edu/news/autism-s-clinical-companions-frequent-comorbidities-asd
[12] Munoli, R. N., Praharaj, S. K., & Sharma, P. S. V. N. (2014, July). Co-morbidity in bipolar disorder: A retrospective study. Indian journal of psychological medicine. Retrieved November 21, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4100412/
[13] Steffen, A., Nübel, J., Jacobi, F., Bätzing, J., & Holstiege, J. (2020). Mental and somatic comorbidity of depression: A comprehensive cross-sectional analysis of 202 diagnosis groups using German nationwide ambulatory claims data. BMC Psychiatry, 20(1). https://doi.org/10.1186/s12888-020-02546-8
[14] Plana-Ripoll O;Pedersen CB;Holtz Y;Benros ME;Dalsgaard S;de Jonge P;Fan CC;Degenhardt L;Ganna A;Greve AN;Gunn J;Iburg KM;Kessing LV;Lee BK;Lim CCW;Mors O;Nordentoft M;Prior A;Roest AM;Saha S;Schork A;Scott JG;Scott KM;Stedman T;Sørensen HJ;Werge T;Whitefo. (n.d.). Exploring comorbidity within mental disorders among a Danish national population. JAMA psychiatry. Retrieved November 21, 2022, from https://pubmed.ncbi.nlm.nih.gov/30649197/
[15] Caspi, A., Houts, R. M., Belsky, D. W., Goldman-Mellor, S. J., Harrington, H. L., Israel, S., Meier, M. H., Ramrakha, S., Shalev, I., Poulton, R., & Moffitt, T. E. (2014, March). The P factor: One general psychopathology factor in the structure of psychiatric disorders? Clinical psychological science : a journal of the Association for Psychological Science. Retrieved November 21, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4209412/
[16] Grinker, R. R. (2022). Nobody’s normal: How culture created the stigma of mental illness. W.W. Norton & Company.
[17] Kotov, R., Krueger, R. F., Watson, D., Achenbach, T. M., Althoff, R. R., Bagby, R. M.,…Zimmerman, M. (2017). The Hierarchical Taxonomy of Psychopathology (HiTOP): A dimensional alternative to traditional nosologies. Journal of Abnormal Psychology, 126(4), 454–477. http://dx.doi.org/10.1037/abn0000258
[18] Haslam, N., Holland, E., & Kuppens, P. (2011). Categories versus dimensions in personality and psychopathology: A quantitative review of taxometric research. Psychological Medicine, 42(5), 903–920. https://doi.org/10.1017/s0033291711001966
[19] Adam, D. (2013). Mental health: On the spectrum. Nature, 496(7446), 416–418. https://doi.org/10.1038/496416a
[20] Timimi, S. (2014). No more psychiatric labels: Why Formal Psychiatric Diagnostic Systems should be abolished. International Journal of Clinical and Health Psychology, 14(3), 208–215. https://doi.org/10.1016/j.ijchp.2014.03.004
[21] Galatzer-Levy IR, Bryant RA. 636,120 Ways to Have Posttraumatic Stress Disorder. Perspect Psychol Sci. 2013 Nov;8(6):651-62. doi: 10.1177/1745691613504115. PMID: 26173229.
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