Guest Post: What puts the ‘mental’ in mental illness?

Written by Anke Snoek

Macquarie University

I have a 3 year old who doesn’t eat. He seems not to be interested in food in general. We were offered many explanations for why he doesn’t eat and most specialists suspect a psychological source for his lack of appetite. But recently a friend suggested that maybe there is something wrong with the muscles in his mouth that makes it hard to swallow. I wondered: why didn’t I get offered more of these physical explanations as opposed to psychological ones? What makes ‘not eating’ almost by definition a mental disorder for most people? What other behaviour are we inclined to label as a mental disorder rather than staying open for other explanations?

What makes mental disorders ‘mental’? Does the cause need to be mental (for example in the brain), or are just the symptoms mental (for example erratic behaviour)? Nowadays many people understand mental disorders, such as depression and schizophrenia, as chemical imbalances in the brain. However, there can be very many different causes for so called ‘mental illnesses’.

Some ‘mental’ disorders have a strong biological cause. Thyroid problems, for example, can lead to symptoms that can be easily mistaken for mental illness. People with an overactive thyroid may show symptoms of depression and anxiety – even schizophrenia in extreme cases. To treat them with antipsychotic medication is of course ineffective. When Robin William committed suicide, the logical explanation, most people thought, was that it was due to his depressions. But the autopsy revealed that he also suffered from a range of physical diseases: Parkinson and Lewy body dementia. These conditions are often accompanied with symptoms of depression.

Another possible cause of mental illness is being incompatible with our environment,  either the physical environment or the moral values surrounding us.

There is also a strong normative component to mental illness. Which behaviours do we, as a society, find deviant? Around 100 years ago women who didn’t conform to the social roles of mothers and wives were diagnosed with hysteria. Clare of Assisi starved herself in a monastery to honour God in ascetic devotion and spent the last 27 years of her life in bed in ill health. In the modern era she might have been treated for anorexia nervosa, whereas back then her life was considered exemplary. One era’s shaman is another’s schizophrenic. What is our mental illness du jour? Dutch scientist Trudy DeHue describes a “depression epidemic”. She argues many cultures today fail to allow for the possibility people might not be constantly happy. Happiness is required to avoid being pathologised – “thou shalt be happy”. This arbitrary normativity used to define mental disorders gave rise to an anti-psychiatry movement in the sixties, which claimed that all mental illnesses are socially fabricated.

If mental illness can have such diverse causes and if these causes really matter for treatment, does it still make sense to call them ‘mental’ illnesses? Should these new scientific insights on the diverse causes of mental illness lead us to conclude that the concept of mental illness has outlived its usefulness? In an interesting article in AEON, Herbert gives the following example on how scientific insights lead to reclassifications of diseases: “It’s interesting that Alzheimer’s disease has moved from the province of psychiatry to neurology. Why has it been reclassified? Because we now know something about the pathological changes in the brain that underlie it. Medical scientists can see what’s going wrong in an Alzheimer’s brain. The disorder itself has not changed, but our understanding of it has.” Herbert claims that such a breakthrough has not yet happened with mental illnesses. We still don’t understand the brain well enough.

It might be too early to reclassify mental illness, but maybe in the meantime we should think about another word for the concept of mental illness since it is unclear what exactly is ‘mental’ about mental illness. Should we distinguish between types of depression as a result of chemical imbalance, childhood abuse, and those caused by physical problems like inflammation or thyroid problems? Should we use the label mental illness primarily for suffering caused by neuro-chemical imbalance? Or will that create new stigma?

We are inclined to think mono-causally: smoking causes cancer, the economic crisis in Germany caused the rise of Hitler, etcetera. Most phenomena however, are multi-causal rather than mono-causal. A famous Dutch writer, Joost Zwagerman, recently committed suicide. His father had been severely depressed as well. Did Zwagerman inherit the disease of his father? He also recently got divorced, and he had Bechterew’s Disease, a very painful, rheumatic condition. Was his depression a side-effect of Bechterew’s Disease? In most cases, it is not easy to determine one cause of mental illness. As George Slavich, a prominent researcher on depression, puts it: “I don’t even talk about it as a psychiatric condition any more. It does involve psychology, but it also involves equal parts of biology and physical health.”

Maybe we should re-evaluate which discipline is most equipped to define, diagnose and treat symptoms of mental illness. Is it psychiatry? Neuroscience? Medicine? Psychology? Or perhaps sociology? Or, as Foucault suggested: philosophy? Probably all these disciplines need to work together on a non-hierarchical basis to understand the concept of mental disorder and to reclassify what we now call mental illness.