The brain reveals its secrets only slowly and in very small packages. Every exciting finding turns out to be a tease—providing no simple answers, rarely replicating fully in the next study, uncovering more heterogeneous complexity than it explains. To use a baseball analogy—there are no grand slams in this work and no walks, just plenty of strikeouts and at best the occasional single. And this will be a very slow and retail slog, not any one great leap forward. We will not have biological markers to set the boundary between normal and mental disorder until we understand the multitudinous mechanisms causing the different forms of psychopathology. And there won’t be a Newton or an Einstein or a Darwin to provide a grand unifying biological theory of normality and mental disorder—just patient scientists each working for decades to elucidate one very tiny piece of an enormous, trillion-piece jigsaw puzzle. Causes for mental disorder, as they are discovered, will (as with breast cancer) explain only a small percentage of the cases. The first real step in this advance will be laboratory tests for Alzheimer’s dementia, probably ready to come online sometime in the next few years.
The absence of biological tests is a huge disadvantage for psychiatry. It means that all of our diagnoses are now based on subjective judgments that are inherently fallible and prey to capricious change. It is like having to diagnose pneumonia without having any tests for the viruses or bacteria that cause the various types of lung infection.
Can Psychology Ride to the Rescue?
Sadly no. We can do psychological tests on people till they are bleary- eyed and blue in the face and still not be much further along in setting the boundary between who is normal and who is not. The limitation of almost all tests used by psychologists is that the distribution of their results follows our old friend—the bell-shaped normal curve. The test can tell us with remarkable precision just where a given person stands with respect to his comparison group, and knowing someone’s standard deviation position relative to the mean often has considerable predictive value. But the testing doesn’t tell us where to set the cutoffs for what is normal. That is determined by context, not by test score.
Take IQ testing. Two standard deviations below the mean of 100 put you at 70 and predicts the likelihood of school and life difficulties. Two standard deviations above normal put you at 130 and predicts academic and career success. But there isn’t any reason to think that having a IQ of 70 is really different from having one of 71 or even 75.9 There is a 5-point error of measurement in the test, many factors may have interfered with optimal test taking, and some people perform in life much better or worse than you might expect just from their IQ.
Selecting 70 as the unique cutoff for clearly disordered intellectual ability is purely an arbitrary convenience that has no particular significance other than that it selects for the lowest 2.5 percent of the population. These individuals are likely to qualify for special services and dispensations that are denied their near and almost identical neighbors. But there is nothing sacred about the two standard deviations below 100 cutoff at IQ 70—it doesn’t have a real world meaning. Slightly higher or slightly lower cutoffs would make equal or more sense, depending on the situation. If more resources are available, services should be offered to those with higher IQs than 70. In some environments, people with an IQ of 70 do just fine. And who says that two standard deviations should be the cutoff? Why not one or three or one and a half? The choice is always arbitrary and driven by context, not statistics.
This gets lost in translation. A recent galling example followed the Supreme Court ruling that it is unconstitutional to execute anyone who is suffering from mental retardation. Life versus death now depends on the silly, artificial nondistinction of having an IQ of 70, rather than 71.10
What would happen if we applied the two SD cutoff (2.5 percent) to psychiatry and suddenly required that people be that far removed from the golden mean of mental health before they could merit a diagnosis of mental disorder. Psychiatrists and other mental health workers would mostly be put out of business and have to collect unemployment insurance. One hundred years ago, psychiatry was limited to the very severely ill housed in hospitals, and very few people were employed caring for them. We have since worked our way up the bell curve much closer to the mean—so that 20 to 25 percent are currently considered mentally disordered, and we have more than half a million people caring for them. Using the psychological test paradigm, we can compare people very precisely to one another but have no way to decide whether to draw the line between normal and abnormal at 2.5 percent or 25 percent of the population.
Do Sociologists or Anthropologists Have the Answer?
Nope, again. Human customs around the world vary too dramatically across time, place, and cultures for there to be any ready answer to what is normal across all of them. Contrast the million or so people willing to starve to death during the siege of Leningrad (rather than break the norm against eating the readily available protein from human flesh) with a perfectly normal New Guinean who until fairly recently wouldn’t think twice about cooking up the body or eating the brains of his lately departed enemy. Two hundred years ago, the normal age of marriage everywhere in the world was around puberty (and it still is in some places), but this is now deemed criminal in our society. With longer life expectancies, it is normal now to marry at an age that only recently would be when we could reasonably expect to be dead.
Cultural universals are the exception, with just a few rock-solid cultural norms (e.g., no murder within tribe, incest restrictions, some sort of family structure). Cultures differ dramatically in their conception of normal because they face different survival challenges. Geographically isolated Inuit avoided inbreeding by finding it normal to offer up the wife as bedmate to passing strangers. In contrast, classical Greeks and modern Arabs have elaborated the strongest of strictures preventing any sort of female exposure to strange genes so that the inheritance of property would surely follow patriarchal bloodlines. Aboriginals desperately needing protein find ants to be a perfectly normal food source—whereas habitually eating them in Los Angeles might qualify one for the DSM mental disorder known as pica. And context can be all—murder is heroic and normal when committed against threatening outsiders; it is heinous and abnormal within the tribe.
Even within a given time and place there are conflicting norms. Durkheim11 fathered sociology more than a century ago with fascinating statistics documenting the predictable divergence between the morally normal and the statistically normal. Societies all prohibit crime, but crime abounds everywhere—perfectly normal from a statistical point of view, but perfectly abnormal from a legal one. Socie-ties also tend to prohibit suicide, but the suicide rate in each country is remarkably consistent year after year, even though suicide is the most personal of human decisions. Ruthlessness may be prized both among gangbangers and corporate leaders, but it will take very different forms and be rewarded and punished in very different ways.
Inbuilt hard wiring also makes for different tendencies in gender norms. Males are more adapted to fight for love and glory—consonant with their existential struggle for access to females, their prominent role in war with other tribes, and the needs of the hunt. Females are more likely to have inborn skills in nurturing and in food gathering. But there are huge individual and cross-cultural differences and there is far from any fixed normal when it comes to male or female behavior.
So at least for now (until Facebook succeeds in homogenizing the planet into one vast, dull social network), normal is a sociological will-o’-the-wisp. There is no norm for normal.
What About Freud?
Freud was a very smart guy who was overrated when he was alive and pays the price now of being greatly underrated. His insights on how the mind works were somewhat hit or miss, but he certainly hit a home run in his appreciation of the powerful role of inborn, unconscious instinct in guiding the most exalted and also the most mundane of everyday behaviors. Freud delighted in uncovering the underlying similarities in dreams, works of art, myt
hs, and in the neurotic and psychotic symptoms of psychiatric patients. He used dreams to uncover the meaning of symptoms, symptoms to uncover the meaning of myths, and his patients’ fantasies to interpret Hamlet and Oedipus. Literature and myth could be used to explain his patients, and his patients’ illnesses reciprocally helped him to explain literature and myth.
The psychoanalytic model tended to be all-inclusive, but there was one notable exception—there is no real place in it for normal. Freud emphasized the ways we are all in the same boat. He saw no great qualitative difference between the artist and the lunatic, and both resemble the rest of us every night when we dream. We all must repress forbidden impulses, which are always at the ready to pop out in dreams, symptoms, or works of art—we are different only in the balance of forces and their means of expression. No one is ever completely normal for Freud; everyone is neurotic and could use more insight. The most any successful treatment can ever hope to achieve is to turn neurotic misery into everyday human unhappiness. There is no normal, no cutoff marker saying treatment is necessary, or when it should end.12 The great unspoken paradox of the arduous process of psychoanalysis is that the best patients are the ones who never really needed it in the first place.
Abnormal Is Also Hard to Define
Proteus was the shape-shifting Greek sea god, a familiar of the Fates who knew the secrets of past, present, and future. But Proteus was wily and reluctant to share his knowledge—except if someone could grab him while he slept and hang on as he executed a succession of rapidly morphing, terrifying, and difficult-to-contain form changes. Not easy work holding a firm grip on a roaring lion that can suddenly transform itself into flowing water, or a charging bull, or anything else you can possibly imagine. Proteus is the personification of things that are liquid, elusive, indefinite, and mutable—things that defy clear definition.
“Mental disorder” and “normality” are both extremely protean concepts—each so amorphous, heterogeneous, and changeable in shape that we can never establish fixed boundaries between them. The definitions of mental disorder generally require the presence of distress, disability, dysfunction, dyscontrol, and/or disadvantage. This sounds better as alliteration than it works as operational guide. How much distress, disability, dysfunction, dyscontrol, and disadvantage must there be, and of what kind?13 I have reviewed dozens of definitions of mental disorder (and have written one myself in DSM-IV) and find none of them the slightest bit helpful either in determining which conditions should be considered mental disorders and which not, or in deciding who is sick and who is not.14–18
Not having a useful definition of mental disorder creates a gaping hole at the center of psychiatric classification, resulting in two unanswered conundrums: how to decide which disorders to include in the diagnostic manual and how to decide whether a given individual has a mental disorder. Binge eating was once considered a sin; should it now be a psychiatric disorder? Is the forgetting of old age an illness or just old age? Is having sex with a teenager just a crime or also a sign of craziness? And in evaluating any given person, we lack a general definition of mental disorder to help us decide whether he is normal or a patient, mad or bad.19, 20
The mental disorders included in DSM-5 have not gained their official status through any rational process of elimination. They made it into the system and have survived because of practical necessity, historical accident, gradual accretion, precedent, and inertia—not because they met some independent set of abstract and universal definitional criteria.21, 22 No surprise then that the DSM disorders are something of a hodgepodge, not internally consistent or mutually exclusive. Some mental disorders describe short-term states, others lifelong personality; some reflect inner misery, others bad behavior; some represent problems rarely or never seen in normals, others are just slight accentuations of the everyday; some reflect too little self-control, others too much; some are intrinsic to the person, others are culturally determined; some begin early in infancy, others emerge only late in life; some affect thought, others emotions, behaviors, interpersonal relations; some seem more biological, others more psychological or social; some are supported by thousands of research studies, others by a mere handful; some may clearly belong in DSM, others could have been left out and perhaps should be eliminated; some are clearly defined, others not; and there are complex permutations of all of these possible differences.
I sometimes joke that the only way to define mental disorder is “that which clinicians treat; researchers research; educators teach; and insurance companies pay for.” Unfortunately, this practical “definition” is elastic, tautological, and potentially self-serving—following practice habits rather than guiding them. The greater the number of mental health clinicians, the greater the number of life conditions that work their way into becoming disorders. Only six disorders were listed in the initial census of mental patients in the mid-nineteenth century; now there are close to two hundred. Society has a seemingly insatiable capacity (even hunger) to accept and endorse newly minted mental disorders that help to define and explain away its emerging concerns.
Are Mental Disorders Diseases, Myths, or Something Else?
Some radical critics of psychiatry have seized on its definitional ambiguities to argue that the profession should not exist at all. They take the difficulty in finding a clear definition of mental disorder as evidence that the concept has no useful meaning—if mental disorders are not anatomically defined medical diseases, they must be “myths,” and there is no real need to bother diagnosing them. This position is most appealing to libertarians concerned with preserving patient freedom of choice from what they perceive to be the enslaving snares of psychiatry. “Saving normal” is taken by them to its logical extreme—the extremely illogical position that everyone is normal.
This shibboleth can be believed only by armchair theorists with no real life experience in having, living with, or treating mental illness. However difficult to define, psychiatric disorder is an all-too-painful reality for those who suffer from it and for those who care about them.23 Saving normal, as I use the term, is not meant to deny the value of psychiatric diagnosis and treatment. Rather, it is an effort to keep psychiatry doing what it does well within its appropriate limits. It is equally dangerous at either extreme—to have either an expanding concept of mental disorder that eliminates normal or to have an expanding concept of normal that eliminates mental disorder.
The best way to understand the essence of mental disorder—what it is and what it is not—is to compare the balls and strikes calls of three different umpires. Most of epistemology boils down to their competing opinions on how well we can ever apprehend reality.
Umpire One: “There are balls and there are strikes and I call them as they are.”
Umpire Two: “There are balls and there are strikes and I call them as I see them.”
Umpire Three: “There are no balls and there are no strikes until I call them.”
Umpire One believes that mental disorders are real “diseases”; Umpire Three that they are fanciful “myths”; Umpire Two that they are something in between—useful constructs that provide no more (but no less) than a best current guess on how to sort psychiatric distress.
Umpire One has great faith in our ability to detect the true essence of things. For him, mental disorders will soon reveal their secrets through scientific study. This optimism was shared by most biological psychiatrists until about fifteen years ago but, except for a few diehards, is now rapidly fading away. Billions of research dollars have failed to produce convincing evidence that any mental disorder is a discrete disease entity with a unitary cause.24, 25, 26 Dozens of different candidate genes have been “found,” but in follow-up studies each turned out to be fool’s gold. Mental disorders are too heterogeneous in presentation and in causality to be considered simple diseases; instead each of our currently defined disorders will eventually turn out to be many different diseases. For now at least, Umpire One has been called out on strikes.27, 28, 29
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Umpire Three presents just the opposite view—the skeptical and solipsistic doubt that man can ever catch protean reality by the tail and know things as they truly are. He would argue that mental disorders are no more than arbitrary and sometimes noxious “myths” that unfairly restrict the freedom of choice of psychiatric patients. He worries about the slippery slope that eventually could be extended to other vulnerable groups.30 Indeed, there is reason for this concern—psychiatric diagnosis is now being abused for preventive detention of rapists in the United States and peasants complaining about corruption in China and previously was an excuse to hospitalize political dissidents in the Soviet Union.
It is of course imperative that we protect against the misuse of psychiatry in the service of legal or political masters—but Umpire Three far overstates his case. Mental disorders are not myths. Though not a discrete “disease entity” (like, say, a brain tumor or a stroke), schizophrenia produces profound and prolonged “dis-ease”—that is, distress and incapacity. The patterns of its presentation are clearly recognizable, can be reliably diagnosed, run in families, have brain imaging correlates, predict course, and respond to specific treatments. Schizophrenia is real enough and no psychiatric invention for those who suffer from it and for their loved ones.
Umpire Two has the firmest grasp on elusive reality, paradoxically because he understands and accepts that we can know it only partially. Of course, reality is “protean”—constantly changing shape and hard to hold. No doubt there is an enormous gap between things as they really are and things as we perceive them—and not just in psychiatry. Only 4 percent of our known universe can be directly detected by our senses—the rest of its energy and matter remaining “dark” to us. The quantum world is so weirdly discordant with our own that even the physicists who can mathematically predict its every characteristic cannot find an intuitive way to relate to it. And how can light manage to be a wave that suddenly turns into a particle just when we choose to look at it a certain way.
Saving Normal : An Insider's Revolt Against Out-of-control Psychiatric Diagnosis, Dsm-5, Big Pharma, and the Medicalization of Ordinary Life (9780062229274) Page 3