You'd Have to Be Crazy

Mental illness is the new normal

According to a new government-sponsored survey, most Americans qualify for a psychiatric diagnosis at some point in their lives. Trying to explain how so many of us became mentally ill, The New York Times offered a history lesson that reminded me of an old Saturday Night Live sketch.

In the sketch Steve Martin plays Theodoric of York, a medieval barber with a patient whose condition has not improved despite a bloodletting, a sheep's-urine-and-staghorn poultice, and a night buried in the marsh up to her neck. "Medicine is not an exact science," Theodoric tells the girl's mother, "but we are learning all the time. Why, just fifty years ago, they thought a disease like your daughter's was caused by demonic possession or witchcraft. But nowadays we know that Isabelle is suffering from an imbalance of bodily humors, perhaps caused by a toad or a small dwarf living in her stomach."

To provide context for the government's mental health survey, the Times told a similarly inspiring story of science replacing superstition. In the old days, it explained, "gamblers and drinkers, the excessively impulsive or rebellious, [and] the sexually promiscuous…were considered sinners, deviants or possessed," while "those who denied themselves food or comfort, or who prayed or performed ritual cleansing repeatedly, often struck others as especially pious."

But "as science gradually displaced religion," the Times continued, "such behavior was increasingly seen in secular, diagnostic terms." Hence "excessive fasting became anorexia," and "ritualized behavior was understood as compulsive, or obsessive-compulsive."

This is the sort of progress that might impress Theodoric of York, but does it bring us any closer to the truth? If anything, the claim that mental illness causes someone's bad or odd behavior obfuscates the issue even more than the claim that the devil made him do it.

As the psychiatric iconoclast Thomas Szasz has been arguing for many years, mental illness is a literalized metaphor that conceals more than it reveals. Although their training and billing practices suggest that psychiatrists deal with medical problems, it seems unlikely that many of them truly believe all the myriad sins and foibles listed in their Diagnostic and Statistical Manual of Mental Disorders (DSM) are in fact brain diseases.

If they did, why would they cling to the deliberately ambiguous term mental disorder? Why would the diagnostic criteria for so many psychiatric conditions include ruling out, as opposed to confirming, an organic cause? And how could psychiatry be justified as a discipline distinct from neurology?

Judging from the way psychiatrists respond to Szasz's critique, most of them believe schizophrenia and perhaps a few other conditions described in the DSM are diseases of the brain in the same sense as Alzheimer's or multiple sclerosis, albeit with etiologies that are not yet clear. But when it comes to habits and traits such as smoking, gambling, gluttony, shyness, impulsiveness, inattentiveness, dishonesty, and nastiness—not to mention diagnoses that have fallen out of psychiatric fashion, such as homosexuality and multiple personality disorder—even psychiatrists recognize the arbitrariness of their taxonomy.

"The problem is that the diagnostic manual we are using in psychiatry is like a field guide, and it just keeps expanding and expanding," Johns Hopkins psychiatrist Paul McHugh told the Times. "Pretty soon, we'll have a syndrome for short, fat Irish guys with a Boston accent, and I'll be mentally ill."

Based on DSM criteria, the government's survey indicates that mental illnesses afflict one-quarter of us every year and more than half of us during our lives, with anxiety and mood disorders the most common problems, followed by impulse control and substance use disorders. Citing several limitations of the survey, the researchers argue that the true rates are even higher. Evidently mental illness is the new normal.

This pathologization of the human condition might be less troubling if psychiatric prescriptions were more effective than Theodoric of York's remedies. But by and large, it's not clear they are.

The survey's lead author says "we don't have a clue as to what will be effective" in treating all the "psychiatric hangnails" his study found. He and his colleagues note that mental illness rates have remained steady during the last decade despite the expansion of treatment; that "most treatment…falls below the minimal standards of quality"; and that there's "no evidence that pharmacotherapy significantly improves mild disorders."

Then they call for more treatment. Another bloodletting, Brungilda.