[Paleopsych] NYT: Who's Mentally Ill? Deciding Is Often All in the Mind

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Who's Mentally Ill? Deciding Is Often All in the Mind
http://www.nytimes.com/2005/06/12/weekinreview/12carey.html

    By [3]BENEDICT CAREY

    THE release last week of a government-sponsored survey, the most
    comprehensive to date, suggests that more than half of Americans will
    develop a mental disorder in their lives.

    The study was the third, beginning in 1984, to suggest a significant
    increase in mental illness since the middle of the 20th century, when
    estimates of lifetime prevalence ranged closer 20 or 30 percent.

    But what does it mean when more than half of a society may suffer
    "mental illness"? Is it an indictment of modern life or a sign of
    greater willingness to deal openly with a once-taboo subject? Or is it
    another example of the American mania to give every problem a name, a
    set of symptoms and a treatment - a trend, medical historians say,
    accentuated by drug marketing to doctors and patients?

    Changes in societies over time, and differences across cultures, make
    it extremely difficult to compare prevalence levels of mental illness,
    even today. Levels of depression in China were thought to be very low,
    for example, until the Harvard anthropologist Dr. Arthur Kleinman
    found in the 1980's that many Chinese did not think or talk about mood
    disorders the way Westerners do. They came to doctors or healers with
    physical complaints - dizziness, headaches and other pains that were
    treated as such, though in many cases they could be diagnosed as
    depression. A World Health Organization survey published in 2004 found
    that 2.5 percent of Chinese reported a mood disorder in the last year,
    compared with a rate of 9.6 percent in the United States.

    In Japan, too, reported levels of depression tend to be low - just
    over 3 percent reported a mood disorder in the last year, in the
    W.H.O. survey - in part because of a culture of stoicism, said Dr.
    Laurence Kirmayer, director of social and transcultural psychiatry at
    McGill University in Montreal. Depression, after all, is not one
    symptom but many, and in Japan there is strong cultural taboo against
    repeated, vague complaints.

    In addition, said Dr. Margaret Lock, a professor of social studies in
    medicine at McGill, Japanese doctors tend to be attentive to men's
    complaints of mood problems, and dismissive of women's. The result:
    depression rates are higher in men than in women, the reverse of the
    United States and much of Europe.

    But more than anything, historians and medical anthropologists said,
    the rise in the incidence of mental illness in America over recent
    decades reflects cultural and political shifts. "People have not
    changed biologically in the past 100 years," Dr. Kirmayer said, "but
    the culture, our understanding of mental illness" has changed.

    That evolving understanding can have implications for diagnoses. For
    example, in 1973, the American Psychiatric Association dropped
    homosexuality from its manual of mental disorders, amid a growing
    realization that no evidence linked homosexuality to any mental
    impairment. Overnight, an estimated four to five million "sick" people
    became well.

    More common, however, is for psychiatrists to add conditions and
    syndromes: The association's first diagnostic manual, published in
    1952, included some 60 disorders, while the current edition now has
    about 300, including everything from sexual arousal disorders to
    kleptomania to hyposomnia (oversleeping) and several shades of bipolar
    disorder.

    "The idea has been not to expand the number of people with mental
    conditions but to develop a more fine-grained understanding of those
    who do," said Dr. Ronald Kessler, a professor of health care policy at
    Harvard Medical School and lead author of the latest mental health
    survey.

    But if contemporary trends, whether scientific or commercial, can
    serve to expand the franchise of mental illness, the mores, biases and
    scientific ignorance of previous centuries did much to hide it.

    In the 18th and 19th centuries, doctors had far fewer words for mental
    impairment - madness, hysteria, melancholia - and estimated its
    incidence at somewhere around 5 percent to 10 percent, as far as
    historians can determine.

    In some communities, the mentally ill were tolerated as holy fools or
    village idiots. The city of Geel, in Belgium, was particularly
    enlightened. There, in the 18th and 19th centuries, lunatics "could
    walk the streets, engage in commerce, they would deliver food, carry
    milk, they were incorporated into the society and respected," said Dr.
    Theodore Millon, director of the Institute for Advanced Studies in
    Personology and Psychopathology in Coral Gables, Fla., and author of a
    recent history of psychiatry and psychology, "Masters of the Mind."

    But Geel was exceptional. More typical, Dr. Millon said, was for
    people considered mad or uncontrollable to be confined, sometimes in
    homemade chambers called lock boxes. They were captive, uncounted,
    beyond any hope of treatment, their stories lost to history.

    The behavior of millions of others who were merely troubled,
    rebellious or moody was often understood - and veiled - in religious
    terms, said Dr. Nancy Tomes, a professor of medical history at the
    State University of New York in Stony Brook.

    Gamblers and drinkers, the excessively impulsive or rebellious, the
    sexually promiscuous (especially women) were considered sinners,
    deviants or possessed. Conversely, those who denied themselves food or
    comfort, or who prayed or performed ritual cleansing repeatedly, often
    struck others as especially pious, Dr. Tomes said.

    As science gradually displaced religion in the industrializing
    countries through the 19th century, such behavior was increasingly
    seen in secular, diagnostic terms, historians said. Excessive fasting
    became anorexia; ritualized behavior was understood as compulsive, or
    obsessive-compulsive.

    "In some ways this is the story of the past century, the
    medicalization of many behaviors that once were seen in an entirely
    religious context," Dr. Tomes said.

    Beyond that, some experts are convinced that modern life in the West -
    especially urban life - is more stressful than in earlier periods, and
    that the increased numbers of illnesses in the psychiatric
    association's diagnostic manual is a reflection of that fact.

    Dr. Millon, who has served on panels to write and revise the manual,
    tells the story of borderline personality disorder. In the late
    1970's, he was among a small group of psychiatrists and psychoanalysts
    who settled on the term "borderline" to mean people who fell somewhere
    between neurotic and psychotic.

    Some doctors in the room hated the term; others liked it; several said
    it was meaningless. But after hours of debate, reversals of opinion
    and bruised egos, the diagnosis was born: borderline personality
    disorder, to describe a needy, scattered, uncertain self, or
    personality.

    Borderline is now one of the most popular diagnoses in psychiatry, an
    umbrella term that covers a multitude of symptoms that all seem to
    point to a similar problem.

    "This is seems to me a kind of diagnosis for our age, this complex,
    changing, fluid society in which young people are not allowed to
    internalize a coherent picture of who they are," Dr. Millon said.
    "There are too many options, too many choices, and there's a sense of,
    'I don't know who I am - am I angry, am I contrite, happy, sad?' It's
    the scattered confusion of modern society."