Head Games

What are the rules for defining mental illness?

Pharmacracy: Medicine and Politics in America, by Thomas Szasz, Westport, Conn.: Praeger, 212 pages, $24.95

Creating Mental Illness, by Allan V. Horwitz, Chicago: University of Chicago Press, 289 pages, $32.50

I've never met Zacarias Moussaoui, but I have a feeling we would not get along. At a hearing in Alexandria, Virginia, last spring, the accused terrorist said he prayed for "the destruction of the United States of America" and "the destruction of the Jewish people and state." He also had harsh words for Russia. As an American Jew descended from Russian immigrants who has close relatives in Israel, I've got four strikes against me.

Moussaoui not only hates total strangers; he is not exactly gracious toward people who try to help him either. He denounced his court-appointed attorneys as a "blood-sucking death team" of "Jewish zealots." He accused U.S. Judge Leonie Brinkema, who patiently guided him as he struggled to represent himself, of "preparing me for the gas chamber." He refused to meet with an attorney hired by his mother, saying, "My mother has no means to find this lawyer. He has been found by someone else."

Naturally, the FBI was in on the conspiracy too. Moussaoui said the bureau had him under surveillance from the moment he entered the country in May 2001 and therefore knew he did not participate in the planning for September 11. He claimed the bureau bugged his motel room by hiding a microphone in a fan that was "mysteriously left on my car."

Based on such remarks, Moussaoui's original defense attorneys, who officially continued to serve as his advisers even though he refused to speak to them, argued that he had crossed the line between fanaticism and mental illness. They said he was therefore incompetent to represent himself, and perhaps even to stand trial. "Mr. Moussaoui's ideology appears to be interlaced with serious psychopathology, the nature of which is unclear," they told Judge Brinkema.

Two psychologists they hired speculated that "Mr. Moussaoui's decision to waive his right to counsel may be the product of a mental disease or defect rendering the decision involuntary." They cited "considerable evidence that Mr. Moussaoui's thinking is dominated by irrational and unrealistic persecutory beliefs." One of them claimed Moussaoui's behavior was "far more consistent with a paranoid psychosis than with being an extremist Muslim."

But the prosecutors had an expert of their own, a court-appointed psychiatrist who interviewed Moussaoui for two hours and concluded that he was capable of deciding for himself how to proceed with his defense. "His actions and attitudes are not the product of mental illness, but are based on his view of the world," the prosecutors said. "He is a fanatic, a jihadist, but he is not mentally incompetent to stand trial or waive his right to counsel."

Brinkema initially agreed, finding that Moussaoui was mentally competent to fire his lawyers. But later she indicated that she might reconsider that decision. She said she would allow the defense attorneys to continue looking for evidence to impugn their former client's sanity. In a handwritten motion filed after that ruling, Moussaoui tried to turn the tables on his examiners, saying Brinkema displayed "acute symptom of Islamophobia with complex gender inferiority." He recommended "immediate psychiatric hospitalization" in the "UBL Treatment Center," explaining that UBL -- the government's shorthand for "Usama Bin Laden" -- "of course…stand[s] for unique best location."

The dispute over Zacarias Moussaoui's mental health illustrates the two main dangers that Thomas Szasz has long emphasized in his criticism of psychiatry. Defining behavior as the symptom of a disease can excuse the guilty, something attorneys did in the case of John Hinckley, tried to do with Ted Kaczynski, and might have accomplished with Moussaoui if he had been more cooperative. It can also punish the innocent, since a psychiatric diagnosis may be imposed on someone against his will as a way of limiting his freedom. In Moussaoui's case, the court-appointed attorneys tried to take away his right to fire them. In other cases, someone who is not charged with a crime but who is deemed a threat to himself or others because of his mental illness may be locked up indefinitely and forcibly treated.

At the extreme, a psychiatric diagnosis may simply be a cover for suppressing dissent. An article in the Fall 1999 Journal of Asian Law describes a retired Chinese coal miner who was diagnosed with "paranoid psychosis" -- one of the labels floated in the Moussaoui case -- because of his political writings. A diehard Maoist, he criticized Deng Xiaoping's reforms and presented himself as "the leader who would guide the international communist movement during its third high tide." This case of "political lunacy" was presented in an official training manual for Chinese forensic psychiatrists published in 1994. "It was thus presumably seen as a typical illustrative case," the law journal article noted, "the concluding diagnosis being one fully appropriate for study and emulation by others in the legal-psychiatric profession today."

This does not mean that American psychiatrists routinely lock people up because they disagree with their politics. But any diagnostic system that leaves so much room for interpretation, with such serious implications for liberty, ought to be scrutinized carefully and skeptically. Even those who are convinced that some of the conditions treated by psychiatrists are genuine brain diseases should be concerned about a profession that seems bent on cataloging and curing every unpleasant or disapproved thought, emotion, and action.

Szasz, a reason contributing editor and a professor of psychiatry emeritus at the Upstate Medical University in Syracuse, has been warning us about the implications of this sweeping agenda for many years. In Pharmacracy: Medicine and Politics in America, he offers a concise summary of his views, along with observations about the government's broader involvement in health care.

"Disease reveals itself in the abnormal activity of the body, not of the person," Szasz writes. "When a lesion can be demonstrated, physicians speak of bodily illnesses. When none can be demonstrated, perhaps because none exists, but when physicians and others nevertheless want to treat the problem as a disease, they speak of mental illnesses. The term 'mental illness' is a semantic strategy for medicalizing economic, moral, personal, political, and social problems."

Rutgers sociologist Allan V. Horwitz is not nearly as strict with his terminology. He argues that "a valid mental disorder" can be a true illness even if it is not caused by a physical abnormality. But in Creating Mental Illness he nevertheless presents a devastating critique of the classification scheme embodied in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (or DSM), which he portrays as arbitrary, arrogant, and pseudoscientific. His history of how the current system came to be is illuminating and provocative. Unfortunately, the alternative he suggests has serious problems of its own, replacing faux precision with admitted vagueness and subjectivity.

Horwitz emphasizes that psychiatry originally focused on the extremes of mood and behavior that today are called psychoses. He cites substantial evidence from twin and adoption studies that a genetic predisposition plays a role in both schizophrenia and bipolar disorder (a.k.a. manic depression). At the same time, most people who receive these diagnoses do not have a family history of the condition. Furthermore, the identical twins of schizophrenics and manic-depressives do not necessarily turn out the same way. The concordance between identical twins is about 50 percent for schizophrenia and 60 percent for bipolar disorder. Clearly, genes are not the whole story.

Horwitz also notes that specific drugs -- phenothiazines and clozapine for schizophrenia, lithium for bipolar disorder -- can help control the symptoms of these particular conditions but are not effective for people with different diagnoses. He concludes that schizophrenia and bipolar disorder seem to represent discrete entities involving characteristic symptoms that can be alleviated with condition-specific treatments. But he does not draw any firm conclusions about what causes these conditions or whether they qualify as brain diseases.

Szasz cautions (and Horwitz acknowledges) that response to a drug is not a sound basis for diagnosis. The fact that you feel better after snorting cocaine does not mean your original state of mind was an illness. Szasz insists that psychoses should not be considered genuine diseases until there is a valid, reliable diagnostic test that indicates a biological defect. He argues that if a schizophrenic's brain could be distinguished from a healthy brain in the same way that the brain of a person with, say, Alzheimer's disease can be, schizophrenia would be treated by neurologists rather than psychiatrists.

"Physical reductionists [predict] that advances in molecular biology will show that many behavioral abnormalities -- now categorized as mental illnesses -- [are] bona fide diseases displaying characteristic lesions on a subcellular level," he writes. "I doubt it. But, supposing that that were to happen, the phenomena so identified would cease to be mental diseases and become instead infectious or neurological diseases -- much as paresis [syphilitic dementia] and epilepsy ceased to be mental diseases once their pathoanatomical and pathophysiological nature became established."

For Szasz, the fact that psychiatrists, politicians, bureaucrats, and activists are constantly insisting that mental illnesses are real diseases, just like cancer or diabetes, indicates that in fact they are fundamentally different. "There are no illnesses outside of the realm of the mental health field whose disease status requires defense by the White House," he slyly notes. "In the end, we come down to the meaning of the term 'mental illness': If we use it to mean brain disease, then psychiatry would be absorbed into neurology and disappear….However, pyromania is plainly not like multiple sclerosis, and treating a patient with schizophrenia without his consent is plainly not like treating a patient with anemia with his consent."

While Horwitz is more inclined than Szasz to believe that schizophrenia and manic depression have a biological basis, he shows that the case for viewing other mental disorders as inherited brain diseases is weak. At most, he suggests, people may be born with a general predisposition to psychological problems that can be manifested in a wide variety of ways, depending upon psychiatric fashion and the individual's sex, culture, and circumstances.

Using detailed examples, he argues that the malleability of mental disorders explains why symptoms of the same condition (depression, say) vary across cultures; why some disorders occur disproportionately among men (substance abuse) or women (bulimia), among people of a certain social class (neurasthenia), or in certain countries (attention deficit disorder); and why diagnoses and the behavior on which they are based suddenly proliferate (as hysteria, anorexia, and multiple personality disorder did) and later become rare or nonexistent.

From Horwitz's perspective, then, the 400 or so disorders listed in the latest edition of the DSM do not represent distinct underlying conditions. Accordingly, it's not surprising that so-called antidepressants such as Prozac and Paxil (known as selective serotonin reuptake inhibitors, or SSRIs) "work equally well for a broad range of disorders including panic, obsessive, and phobic conditions, as well as depressive and anxious states. They are also widely used for substance abuse and eating disorders and for general distress among both adults and children. Moreover, these medications are promoted as ways to enhance the personalities of normal people by improving self-esteem, self-confidence, interpersonal relationships, and achievement." This versatility makes even more sense in light of recent studies indicating that SSRIs may be little more than placebos.

As the range of applications for SSRIs suggests, there is not much (aside from actual diseases) that psychiatrists are not prepared to treat. Horwitz traces this broad purview to Sigmund Freud and his followers. "Neurotic behaviors were conceived as continuous with normal behaviors, the two blurring indistinctly into each other," he writes. "The joining of neurotic with normal behavior served at the same time to make pathological, nonpsychotic behavior ordinary and to pathologize everyday behavior." Hence "dynamic psychiatry transformed the jurisdiction of the mental health professions from people with serious mental illnesses to those with problems in their everyday lives….The potential domain of psychiatric classification was now all of human behavior."

By the 1970s, however, dynamic psychiatry was perceived as unscientific, with vague diagnoses, unfalsifiable etiological theories, and weak standards of effectiveness. Seeking to maintain their status as real physicians, and therefore their advantage over competing mental health professionals and their eligibility for coverage by third-party payers, psychiatrists adopted the precise-seeming approach reflected in the third and subsequent editions of the DSM. To be accepted by psychiatrists, the new DSM had to cover all the sorts of people they were already treating. In addition to distressed individuals seeking guidance and emotional support, these included people coerced into treatment because of their deviant behavior, such as alcoholics, illegal drug users, and juvenile delinquents. "Contrary to the common view that the DSM-III expanded the range of pathology the mental health professions treat," Horwitz writes, "in fact it simply recategorized as discrete diagnostic entities the wide range of problems that dynamic psychiatry had already pathologized."

The result was a bewildering array of diagnoses -- including such handy ones as "antisocial personality disorder," "generalized anxiety disorder," "social phobia," "hypoactive sexual desire disorder," "substance abuse," and "pathological gambling disorder" -- that could be applied to just about anyone a psychiatrist might encounter. "Defining symptom-based entities made these entities seem as if they were real," writes Horwitz, echoing a point Szasz emphasizes. "The focus on reliability," Horwitz continues, "provided the justification for psychiatry to claim it was scientific without having to demonstrate why any of the classified entities ought to be considered instances of mental disorder." Although the DSM is vague regarding the etiology of the conditions it lists, Horwitz notes, "a biomedical model presumes that psychiatric disorders are brain diseases similar to diseases of other bodily organs."

The DSM (now in its revised fourth edition, known as DSM-IV-TR) disparages its own definition of mental disorder, calling it an "anachronism of mind/body dualism," used only because "we have not found an adequate substitute." The implication seems to be that there is no real distinction between physical and mental illnesses because the mind is governed by the brain, which is part of the body. But as Szasz notes, if "everything that happens to or is done by human beings is biological, then saying so is a meaningless truism. Attributing mental illnesses, such as addiction and panic disorder, to biological alterations occurring at a 'subcellular level' is a parody of the denial of free will, choice, and responsibility."

The continued use of the term mental disorder suggests that psychiatrists do not have the courage of their reductionist convictions. Szasz observes that the term "is useful because it enables psychiatrists to waffle: 'It' may be a disease, or may not be; may render the patient incompetent, or may not; may annul intentionality, but not necessarily; may cause dangerousness to self and others, but not always; and be an excuse for crime, and may not be. It all depends on the psychiatrists' interpretation of their so-called clinical observations."

For Horwitz, by contrast, the main problem with the DSM's definition of mental disorder is that psychiatrists do not apply it fully and consistently. Borrowing from the sociologist Jerome Wakefield's condensation of the DSM standard, Horwitz defines mental disorder as "a harmful internal dysfunction" with "socially inappropriate" consequences. Too often, he says, psychiatrists ignore these criteria, improperly treating deviant behavior (such as illegal drug use) and normal, expected responses to stress (such as depression after divorce) as mental disorders.

The problem is even worse when the DSM's symptom lists are applied not to people seeking help from mental health professionals but to samples of the general population diagnosed by survey. Such studies, Horwitz argues, lead to absurdly exaggerated estimates of how many people suffer from particular disorders, or from mental illness in general, because they strip symptoms of their context, which is crucial in determining whether they arise from an "internal dysfunction."

Here is where Horwitz runs into trouble. As persuasive as he is in debunking psychiatry's pseudomedical pretensions, his own approach relies far too much on murky, tendentious definitions that cannot be applied objectively. "Psychological dysfunctions exist when some internal system of cognition, memory, linguistic ability, motivation, aggression, or perception is unable to perform properly," he explains. "A mental disorder indicates that something is wrong with the capacity of an internal mechanism to perform as it is designed to perform, not that an individual has made poor choices in how to behave. This incapacity renders a person unable to conform to social rules and so their impairment is involuntary….The distinction between mental disorders and deviant behavior is the distinction between people who can't conform and those who won't conform."

Horwitz concedes that telling the difference may be tricky. "The boundaries between 'appropriate' and 'inappropriate' functioning will often be very fuzzy," he says. "The value component of the appropriateness criterion in definitions of mental disorders insures that all disorders will have blurry rather than distinct boundaries." He cites pedophilia as an example. "Adults who sexually molest young children…are generally treated as having criminal responsibility for their behaviors because of the extreme social abhorrence of child molestation," he says. "The distinction between people who can't function appropriately and those who won't function appropriately is far more a moral value judgment than a judgment based on psychiatric knowledge."

It's hard to see how the odiousness of a crime can indicate that it was not the product of an "internal dysfunction." Indeed, people often make the opposite argument: that a crime was so heinous no sane person could have committed it. Horwitz appears to be dodging the implications of his claim that "internal dysfunctions" can make people do bad things. (As Szasz is fond of noting, Congress did something similar when it arbitrarily excluded pyromania and kleptomania from the conditions covered by the Americans with Disabilities Act.) It seems preferable simply to discard the concept of uncontrollable impulses, especially since Horwitz does not explain what causes them (saying only that "social as well as biological or psychological factors might be responsible") or how to distinguish them from ordinary urges.

Although Horwitz rejects the biomedical view of (most) mental disorders, he clings to its most troubling tenet: that people with mental disorders are not responsible for their actions. Whether mental illness is attributed to a hypothetical brain disease or to an "internal dysfunction" of indeterminate origin, the moral implications are the same. Which is why the world needs more skeptics like Szasz, who try to set limits when doctors charge past their proper domain.