Defining Abnormality- Illness, Disorder, or the Crystallization of culture?

Chapter II*- A Genealogy of Abnormality: Framing Subjectivities
Section D

Defining Abnormality: Illness, Disorder, or the Crystallization of culture

“To characterize a process as a disease is to weave it into a complex web of social meaning that comprises both norms of evaluation and technologies of remediation. Natural events become instances of health or illness only after human beings intervene with their systems of classification” (Woolfolk, 1998; The Cure of Souls p.38)

As previously mentioned, mental illness is difficult to define. When looking at the variety of modern-day interpretations for what is regarded as mental illness/a disorder, a clear discrepancy is brought to our attention: one that has been present through out documented history, and continues to be an issue for those attempting to systematically define and classify mental illness/disorder. This discrepancy is also present in the many ways we refer to, and label, those who experience mental suffering. Throughout history, individuals characterized as mentally ill have been, and continue to be, placed within the confines of un-encompassing, very stigmatizing, labels that define their subjective realities. Madness (the mad), insanity (the insane), mental disease (mentally diseased), mental illness (mentally ill) and mental disorder (mentally disordered) are among the many labels that define both their subjective realities, and the socially understood notions that becomes their reality.

The incongruity existing amongst all of these labels is based within a subtle difference in the many archetypal meanings present in the language used to describe their mental experiences. Essentially, all of these labels are describing the same thing while Providing a structurally different understanding of what constitutes suffering in a mental fashion. With all of this in mind, take a moment to consider the following definitions of “mental disorder” or “mental illness” as described by the DSM- V and The National Alliance on Mental Health:

A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily be tween the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above (DSM-V, p.20)

Mental illness is a medical condition that disrupts a person’s thinking, feeling, mood, ability to relate to others and daily functioning. Just as diabetes is a disorder of the pancreas, mental illnesses are medical conditions that often result in a diminished capacity for coping with the ordinary demands of life. Serious mental illnesses include major depression, schizophrenia, bipolar disorder, obsessive-compulsive disorder (OCD), panic disorder, post-traumatic stress disorder (PTSD) and borderline personality disorder. The good news about mental illness is that recovery is possible. Mental illnesses can affect persons of any age, race, religion or income. Mental illnesses are not the result of personal weakness, lack of character or poor upbringing. Mental illnesses are treatable. Most people diagnosed with a serious mental illness can experience relief from their symptoms by actively participating in an individual treatment plan (National Alliance on Mental Illness)

Clearly, in the eyes of professional practitioners, illness and disorder are not synonymous. This kind of ambiguity is problematic. This conflect between what is meant by mental illness and mental disorder pre-dates even the idea of a mental disorder. Before there was mental illness, there was madness. To be mentally ill was to be mad, or sometimes mentally diseased. Champlin provides a detailed account on the major differences between mental disease and mental illness in which he emphasized mental diseases’ use as a metaphor for mental illness. In addition, he refutes that mental illness, as a concept, does not exists in response to philosophers who had previously made this outlandish claim.

He bases his argument, that mental disease is a metaphor used to describe mental illness by describing the difference between the two, conceptually.

The language of psychiatry is full of medical terms, such as ‘treatment, cure, patient, doctor, hospital, symptom, and syndrome’. But then, politicians who are trying to cure the disease of inflation no doubt hold regular surgeries and have been known to nurse their constituencies; yet calling inflation a disease remains a piece of rhetoric and economics is not thereby reduced to a branch of medical science (Champlin, 470).

As he describes above, the use of the term disease to describe any phenomenon does not correlate directly with it being a medical issue. Although the language of psychiatry does place mental illness within the realm of medicine, it does not base mental illness’ conceptual descriptions on the same grounds as that of physical illness. The use of disease to describe both inflation and mental illness is metaphorical in that both mental illness and inflation are not physical entities on which disease can manifest.

The use of the term disease to describe mental illness pre-dated the term mental illness. Before mental illness, as previously stated, the concept was placed under many labels which hold varying meanings. Philosophers, of course, took it upon themselves to grapple with the interchangeable use of the two terms once mental illness gained prominence over all over definitive labels. As Champlin describes, mental disease has the weight of history behind it, where as mental illness is of relatively recent origin. The contrasting meanings of illness or disease give rise to the issues surrounding mental illness’ conceptualization in relation to the term used to describe it. If one were to describe as physical disease as disease, why not then describe depression and hypomania as disease?

The existence of tin disease does nothing to show that it is a real disease like syphilis, brucellosis, or Dutch elm disease. Disease is logically parasitic on organic growth. A branch of a tree can become diseased, but not the once sound leg of a table. Similarly, the existence is mental, social, spiritual and economic diseases does not, contrary to the claims of several philosophers, ‘extend the concept of disease’; we do no more than speak in metaphors, as when we say ‘Politicians are blind to our real needs’ (Champlin, 1981)

Since there is nothing traditionally physical about mental illness, labeling it as mental disease should be taken literally. Illness and disease are not interchangeable terms describing the same essential condition.

Diseases, such as conjunctivitis, acne, and athletes foot are not illnesses. Yes, both diseases and illnesses have symptoms, there is a significant difference in the ways those symptoms are manifested (Champlin, 1981). For example, symptoms of disease are manifested as morbidity, putrefaction, degeneration, and decay; symptoms of illness, on the other hand, do not physical abnormalities and deterioration (Champlin, 1981).

… [D]isease is a physical substance lodged in the body in a way that illness is not. This view is reinforced by thoughts such as the following. We remember all those royal ladies who have carried the disease haemophilia and transmitted it to their male offspring without themselves actually having the disease. Disease-ridden corpses have been known to be tossed into besieged fortresses in order to spread the disease to the defenders. The disease anthrax can survive in the soil for several years. But neither carrying a disease nor having a disease is the same as having the substance inside you which causes the disease (Champlin, 1981)

He then continues on to explain, “disease is like damage;” one can examine and try to minimize both damage and disease, but when it comes to dealing with, for example, a damaged clay pot, one cannot sort the broken pieces onto one side and the damage onto the other. A person with a diseased leg to described to have the disease: it is the person who is diseased, not his leg. Yes, disease and illness are similar in some sense; for example, it is impossible for a corpse to be diseased, and it is impossible for it to be ill (Champlin, pp. 474-475 1981).

Interestingly, when running a Google search for the term “mental disease,” almost all the search results are definitions of mental illness. The only exceptions being two dictionary definitions of the term itself, one of which describes mental disease as “any disease of the mind; the psychological state of someone who has emotional or behavioral problems serious enough to require psychiatric intervention.” Why should a metaphor require psychiatric intervention? The answer is as simple as: because mental disease is a metaphor for mental illness. As Champlin explicated, there are key differences between having an illness and being ill that is generally lacking in disease. In addition, there is a difference between having an illness and being ill on the physical side of the fence, which creates this division between the physical, and the mental, forms of illness. (Champlin, 1981). One can feel ill from eating too much cake, but one does not thereby have an illness–one is merely feeling the consequential effect that eating too much cake has on the digestive system.

I think, no ‘mental’ counterpart to the illness without ill health of the boy who ate too many green apples. The failure to find such a counterpart is not a sign of the nonexistence of mental illness but of the fact that all mental illness is a mental health problem, i.e. mental illness necessarily involves impairment of one’s mental health, just as all suffering from physical illness necessarily impairs one’s physical health. Mental and physical health are, I appreciate, just as problematic at this stage as mental and physical illness; my point is that mental illness should be compared to physical illness involving impairment of health, and should be contrasted with being ill when one does not have an illness (Champlin, 1981).

Taking on the view of dominant psychological discourse, Champlin explains the difference between physical and mental disease, as being specific to the impairment of one’s mental health, as being physically ill is an impairment of one’s physical health; he later goes on to explain that to be mentally ill differentiates itself from insanity is by identifying the difference between, for example obsession and insane obsession, is that of being insanely obsessed. One can be obsessed, but not insanely obsessed, as one can be insane but not mentally ill. Thus, to be mentally ill is to exhibit explicitly insane behavior; Mental illness is the impairment of sanity, of mental health, rather than of physical health; with the metaphor of disease to represent it, but not describe it.

Disregarding Champlin’s clear adherence to dominant discourses in psychology, the key difference between mental disease, and mental illness, is characterized by the manner in which it manifests– disease exists parasitically, placing itself non-consensually onto the body, where as illness is physically present with our without disease. The discrepancy between the two extends further by touching upon the most modern conceptualization of mental “abnormality.”

The differences between disorder and illness may contrast even more than that of illness and disease. The table below breaks down the two definitions of mental illness/disorder as described by both the DSM-V and the National Alliance on Mental Illness in an attempt visually describes the magnitude to the existing dichotomy:

Mental Disorder Mental Illness
  1. A syndrome
  2. Characterized by: clinically significant disturbance cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.
  3. Associated with significant distress or disability in social, occupational, or other important activities.
  4. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder.
  5. Socially deviant behavior
  6. Conflicts primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the îindividual, as described above (DSM-V, p.20)
  1.  Medical condition
  2. Disrupts a person’s thinking, feeling, mood, ability to relate to others and daily functioning.
  3. Just as diabetes is a disorder of the pancreas, mental illnesses are medical conditions that often result in a diminished capacity for coping with the ordinary demands of life.
  4. Serious mental illnesses: major depression, schizophrenia, bipolar disorder, obsessive-compulsive disorder (OCD), panic disorder, post-traumatic stress disorder (PTSD) and borderline personality disorder.
  5. The good news: recovery is possible.Mental illnesses can affect persons of any age, race, religion or income.
  6. Mental illnesses are not the result of personal weakness, lack of character or poor upbringing.
  7. Mental illnesses are treatable

What is even more striking is that the DSM pioneer Al Frances has previously denied that there can be a definition or concept of mental illness:

Every so often Al Frances says something that seems to surprise even him. Just now, for instance, in the predawn darkness of his comfortable, rambling home in Carmel, California, he has broken off his exercise routine to declare that “there is no definition of a mental disorder. It’s bullshit. I mean, you just can’t define it.” Then an odd, reflective look crosses his face, as if he’s taking in the strangeness of this scene: Allen Frances, lead editor of the fourth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (universally known as the DSM-IV), the guy who wrote the book on mental illness, confessing that “these concepts are virtually impossible to define precisely with bright lines at the boundaries.” For the first time in two days, the conversation comes to an awkward halt . . .

He is not alone in this line of thinking. In fact, some mental health researchers believe that the DSM is at the brink of facing a revolution, of not rendered completely obsolete. As Neurobiological approaches make their way into dominant psychological discourse, such questions about the DSM’s future are inevitable. In the United States, the National Institute of Health’s mental health branch (National Institute of Mental Health) is the leading pioneer for neurobiological research in psychology in addition to the major source of funding for mental health research. In fact, just two weeks before the DSM-5 was scheduled for release, the NIMH withdrew it’s support for the manual, causing a lot of controversy.

According to Insel, too much of that problem remains. As he cautioned of a manual whose precision and reliability has been overstated for decades, ‘While DSM has been described as a ‘Bible’ for the field, it is, at best, a dictionary, creating a set of labels and defining each.’ And not even a particularly good dictionary, apparently. Of the decision to steer research in mental health away from the manual and its parameters, Insel states: ‘Patients with mental disorders deserve better.’ Yet what the NIMH is offering as a solution the DSM’s fumbles and errors is not without major problems of its own, including because of the agency’s single-minded focus on biological psychiatry as the represented solution to all such ambiguities and confusions. Among the consequences of that emphasis, interest in symptoms will be radically curtailed: ‘symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.

In essence, the NIMH’s perspective on “disordered” behavior is that all of the answers are located in the brain, and only through brain research will we be able to find and cure individuals who are disordered– the deviant members of society.

In recent years, the National Institute of Mental Health has launched an effort to transform psychiatry into what its director, Thomas Insel, calls clinical neuroscience. This project will focus on observable ways that brain circuitry affects the functional aspects of mental illness—symptoms, such as anger or anxiety or disordered thinking, that figure in our current diagnoses. The institute says it’s “agnostic” on the subject of whether, or how, this process would create new definitions of illnesses, but it seems poised to abandon the reigning DSM approach. ‘Our resources are more likely to be invested in a program to transform diagnosis by 2020,” Insel says, “rather than modifying the current paradigm.’

The NIMH, being a federal agency, has very specific goals in mind– goals that represent the overarching political ideology of the United States. In fact, it has established a set of four goals:

  1. Promote discovery in the brain and behavioral sciences to fuel research on the causes of mental disorders
  2. Chart mental illness trajectories to determine when, where, and how to intervene
  3. Develop new and better interventions that incorporate the diverse needs and circumstances of people with mental illnesses
  4. Strengthen the public health impact of NIMH-supported research.

These goals, which were constructed out of their mission…

… to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery, and cure. For the Institute to continue fulfilling this vital public health mission, it must foster innovative thinking and ensure that a full array of novel scientific perspectives are used to further discovery in the evolving science of brain, behavior, and experience. In this way, breakthroughs in science can become breakthroughs for all people with mental illnesses.

The Agency’s primary motive is to fulfill the goals it has established for itself, and does so by designing and promoting a very particular kind of research training and opportunity. As Dazinger pointed out, once a mission statement is defined, one’s intellectual interests (as reference in footnote 11 above) which is the basis on which all work, and knowledge, are based and produced.

Lets turn our attention back to the Google search. Although not one of the exceptions, the tenth result on the webpage is noteworthy– Page Ranked as the least important given it’s position on the webpage; “Mental Illness– Center for Disease Control and Prevention,” was the anchor text linking to a United States government agency that operates under the Department of Health and Human Services– The Center for Disease Control and Prevention– once clicked on, one is redirected to a page on which the agency’s definition of mental illness can be found.

Mental illnesses refer to disorders generally characterized by dysregulation of mood, thought, and/or behavior, as recognized by the Diagnostic and Statistical Manual, 4th edition, of the American Psychiatric Association (DSM-IV). Mood disorders are among the most pervasive of all mental disorders and include major depression, in which the individual commonly reports feeling, for a time period of two weeks or more, sad or blue, uninterested in things previously of interest, psychomotor retardation or agitation, and increased or decreased appetite since the depressive episode ensued.

Clearly, the terms illness and disease are interchangeable in the eyes of some, or are –at the very least – believed to be mutually inclusive. If disease is nothing more than a metaphor for mental illness, why is it being considered by the Center for Disease Control and Prevention?

First and foremost, consider Turner’s postulate on the relationship between the body and society:

  1. Disease is a language
  2. The body is a representation
  3. Medicine as a political practice

The term disease, in this context, is interchangeable with illness, disorder, or any word one can think to use as a descriptor for any physical or mental malady. Language constitutes disease, and the body takes on the heavy task of adaptation: the physical manifestation of disease/illness/disorder/etc. is a performance of language in the same way that a film adaptation of a book is a performance of language. The words describing the subjective experience define the way the experience is both represented and interpreted.

The language of biomedicine is never alone in the field of empowering meaning, and its power does not flow from a consensus about symbols and actions in the face of suffering (Haraway, p. 203, 1991).

Disease as language and the body as a representation can also be described contextually as an, ‘epidemic of signification’ (Treichler, 1987) for the broad “social text of sickness” (Haraway, 203, 1991).

The power of biomedical language – with it’s stunning artifacts, images, architectures, social forms, and technologies – for shaping the unequal experience of sickness and death for millions is a social fact deriving from ongoing heterogeneous social processes… The power of biomedicine and biotechnology is constantly re-produced, or it would cease. This power is not a thing fixed and permanent, embedded in plastic and ready to section for microscopic observation by the historian or critic. The cultural and material authority of biomedicine’s productions of bodies and selves is more vulnerable, more dynamic, more elusive, and more powerful than that (Haraway, 204, 1991)

The body as a representative model for the social text of sickness is brought into socio-political awareness through the language of disease, which is constructed and regulated by the political practice of medicine.

… inside the room a word was echoing still, the word “plague.” A word that conjured up in the doctor’s mind not only what science chose to put into it, but a whole series of fantastic possibilities utterly out of keeping with that gray and yellow town under his eyes, from which were rising the sounds of mild activity characteristic of the hour; a drone rather than a bustling, the noises of a happy town, in short, if it’s possible to be at once so dull and happy (Camus, 38, 1947)

Camus impeccably represents Turner’s notion of medicine as political practice. Plague is just another term for disease or illness; and the doctor acts as the political utility of science– the discourse of knowledge that has conceptually identified and defined the physical make up and manifestation of plague, and placed it in the doctor’s mind as an indisputable truth.

Taking this perspective points to the notion highlighted many of Foucault’s texts– the medicalization of mental illness, which is, to put it simply, the process through which madness became a medical issue. Centering mental illness within the structural paradigms of medicine allowed for the categorization and institutionalization of the mentally ill. The medical discourse invented the concept of a mentally ill individual through creating a structurally defined concept on which one is expected to understand their subjective experience objectively. Disease as language provides a basis on which to understand mental illness/disease/disorder within paradigms of highly politicized medical discourse that generates the language by which knowledge about disease is produced. The Center for Disease control and Prevention takes a mental illness as an issue worthy of it’s concern due to our understanding of mental illness as something which can be controlled, and prevented through treatment and research– just like any other medical condition.


*Excerpt from section D, chapter II (Div III -undergraduate thesis-) P. 31-49


Defining Abnormality: Illness, Disorder, or the Crystallization of culture

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