In Medieval days people who had mental illnesses were thought to be possessed by the Devil or by demons. Nowadays we have developed three systems of classifying mental illnesses, according to a recent study, and each views them in a different way. But are today’s systems really better?
“The phenomenon of mental illness or psychopathology is much more complex, much more multi-determined, much less categorical than any of us ever thought going into it,” one of the authors of the study, Lee Ann Clark notes.
Clark and her co-authors, all from the University of Notre Dame, point out that the systems used to classify mental illnesses, The Diagnostic and Statistical Manual (DSM) used In the United States, the International Classification of Diseases (ICD), used internationally, and the newly created Research Domain Criteria, or R-DoC used by the National Institute of Mental Health, are all too narrow in their focus, causing them to make misleading assumptions. These misleading assumptions then affect how mental health clinicians diagnose and treat various mental disorders.
“For many years people had the idea that mental disorders had single, simple causes like streptococcus causes strep throat, that sort of thing,” Clark said. “But as we learn more and more about mental disorders, that’s just absolutely not the truth. They’re caused by multiple factors. They have genetic and other biological causes, plus environmental influences, both personal and cultural. It’s very complex.”
Clark and her co-authors consider four problems that affect how we understand and classifying mental disorders: These issues are: (1) what combinations of factors cause them? (2) Since they are not actually distinct categories, how can they best be diagnosed? (3) What are the thresholds for diagnosis? (4) How do clinicians deal with the fact that most people with mental illnesses meet the diagnosis for multiple mental disorders.
The bottom line is that the three systems of classification that are currently used by clinicians all over the world are flawed—perhaps even fatally flawed. Perhaps mental illness is just one phenomenon. Perhaps it is like a tree with different branches.
Most experts today agree on the symptoms of the various mental illnesses, but they disagree about the causes. Psychiatrists emphasize genetics while clinical psychologists put more stress on environmental factors. The diathesis-stress model is therefore the theory that finds the most agreement among professionals: it states that mental disorders are caused by a combination of genetics and traumas in the early environment.
The DSM was first published in 1952. Before that The DSM evolved from systems for collecting census and psychiatric hospital statistics, as well as from a United States Army manual. The originators of the first DSM wanted to categorize mental illnesses the same way medical illnesses were, detailing the symptoms of each illness the same way doctors have codified the symptoms of, say, sclerosis of the liver. But, as Clark, et al. point out, mental diseases are not analogous with psychological disorders, because it is actually rare for a person to have just one of the psychological disorders without having features of others.
Major Depressive Disorder is classified as a different disorder than Dysthymia Disorder in the DSM, but they could just as well be classified as the same disease, ranging from mild (dysthymia) to severe (major depression). One also finds depression in posttraumatic stress disorder, adjustment disorder, bulimia , substance abuse disorder, and a host of others. And anxiety is present in many disorders as well, including depression.
As a clinician I don’t find it helpful to give a client a diagnosis. In the past, when I did give them a diagnosis, they would look it up online and get all wrapped up with the notion of having that kind of personality disorder. Sometimes they would argue with me about it, citing facts and figures they had found online. Sometimes they would attempt to treat themselves based on information they found online. Often this was like a kind of branding that affected their identity.
Maybe there is no such thing as a mental illness. Maybe there are people who have problems coping with life, conflicts of varying severity. Maybe these problems can have many features involving depression, anxiety, suicidal thoughts, substance abuse, eating and sleeping issues. But maybe they are all caused by the same underlying imbalance: an imbalance of homeostasis. Maybe this cause is linked with genetics, with congenital factors, or with environmental traumas and stress; but in either case they create an imbalance of varying degrees of severity from a mild phobia to major depression and schizophrenia.
A whole industry has been established around the notion of mental illnesses. We have psychiatrists prescribing medication for these illnesses; drug companies coming up with newer and better medicines for these illnesses, and hordes of mental health workers for various kinds of these illnesses. But what if mental illnesses were seen as mild or severe problems of living? Clark and her coworkers suggest that the three systems of classification need to be changed and I agree. In fact, I might even go further.
Maybe they should not be classified as “diseases,” but instead viewed as variations of emotional imbalances that create varying degrees of depression, anxiety, eating problems, sleep problems and various other symptoms. Treatment would locate the amount of depression, anxiety, delusions, and other features involved in each problem.
Instead of pathologizing life problems, we would understand them as life conundrums that all of us share, depending on the combination of good, mid-range or bad nature and nurture affecting our lives.