[Paleopsych] NYT: Who's Mentally Ill? Deciding Is Often All in the Mind
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Sun Jun 12 19:00:58 UTC 2005
Who's Mentally Ill? Deciding Is Often All in the Mind
By 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
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
"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
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
"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
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."
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