Definition of mental illness

I have been thinking about the definition of mental illness by Dinesh Bhugra, Antonio Ventriglio and Kam Bhui which I quoted in my previous post. Dinesh and Antonio Ventriglio would be seen as representatives of social psychiatry (eg. see their article). Kam would be seen as a representative of cultural psychiatry, being a Professor of Cultural Psychiatry and Epidemiology. It concerns me that modern social and cultural psychiatry are apparently diluted versions of biomedical psychiatry.

Mental illness is not merely a "socially elaborated" state. Proper social and cultural psychiatrists would recognise the psychosocial origins of mental disorder.  They should not merely be talking about incorporating "sociocultural dimensions of individual experiences and distress as life story narratives" into diagnostic and management frameworks. Understanding these narratives can provide reasons for mental health problems. However helpful the perspective of McHugh & Slavney may be, there are problems with it (see previous post). Talking about getting "social psychiatry at the core of our clinical practice" (see article) won't happen if "neurophysiological or chemical alterations in body or brain functions" are seen as the cause of mental illness. I'm all for recognising the need to "reclaim professionalism and renew our contract with society", but we don't need genomics and epigenetics to tell us that psychiatric disorders are caused by psychosocial determinants. Transcultural psychiatry should not encourage a biomedical model of mental illness for all mental health systems worldwide (see previous post).

I've said before (eg. see previous post) that psychiatry needs to be more thoroughgoing in adopting a sociopsychobiological model of mental illness. In the last chapter of my Critical psychiatry book, I showed that Julian Leff, who represented social psychiatry for a previous generation, still upheld the biomedical model (see extract). It seems the present generation of social psychiatrists are no different. 

Problem with the term 'mental illness'?

As I have said before (eg. see previous post), I don't have a problem with the term 'mental illness'. In a recent comment in The Lancet Psychiatry, Dinesh Bhugra et al make a case for what they call reclaiming the term. They suggest that psychiatrists have given up using the concept. Part of their argument is that "A large number of psychiatric disorders ... are ... socially elaborated states of pathology or disease, with neurophysiological or chemical alterations in brain or body functions". But are they brain dysfunctions? No evidence is offered to support this conjecture and, as I keep saying in this blog, such a belief is mere conjecture.

Actually, perhaps I do have a problem with the term 'mental illness' if this is what it is supposed to imply, although I don't think it necessarily does. Better to stick to terms that Dinesh et al tend not to like, such as 'mental health problems', which don't have this ideological implication.

I think Dinesh et al are right that mental illness does imply a major or more serious rather than minor mental health problem. Before the 2007 revision, the Mental Health Act (MHA) used the term 'mental illness', although it was never defined. This has now been replaced by the more generic term 'mental disorder'. In principle, people should only be detained under the MHA for mental health problems of a nature or degree that warrant this intervention and psychiatrists would have generally understood the term mental illness to mean functional psychosis. And, as I've said several times before (eg. see previous post), there may be potential advantages in seeing mental health problems as illness as it integrates the medical perspective. Illness can be mental and not purely physical. The problem with Dinesh at al's view is that they may appear to regard mental illness as physical in origin.

Artificial kinds of mental disorder

Tsou (2016) makes a case for natural kinds of mental disorders. This seems to be dependent on his claim that there is "good evidence that the symptoms of schizophrenia are underwritten by stable neurobiological mechanisms". By this he means the dopamine theory of schizophrenia. Similarly he says "multiple lines of research indicate that the core signs of depression are underwritten by stable neurobiological mechanisms". Again, by this he means the monoamine hypothesis of depression. I guess if the dopamine and monoamine hypotheses are incorrect, his whole argument fails.

He does acknowledge the article by Kendler and Schaffner (2011) that I have mentioned before (eg. see previous post). This apparently doesn't undermine his faith in the dopamine hypothesis. The monoamine hypothesis is similarly not tenable (eg. see previous post). Even psychiatrists have described the 'chemical imbalance theory' as a kind of urban myth (see previous post and book review). Psychopharmacologists stopped believing in it a long time ago.

Tsou wishfully hopes that "mental disorders should be classified at a level of generality such that the characteristic signs of disorders are associated with stable biological mechanisms". His lack of clinical and scientific experience does not provide a sound basis for his philosophical theorising. Psychiatric diagnosis is inevitably purely descriptive. Considering the motivation for the revision of DSM-5 (see eg. previous post), information about the biological causes of mental disorders would have been incorporated if there is any, which there isn't.

Improving psychiatric training

Mary-Ellen Lynall in a BMJ blog says she'll be "deeply concerned" if new and better mental health treatments don't grow out of a deeper understanding of brain function. I haven't written a piece potentially undermining a trainee for a while (eg. see previous post) and I don't want to dull Lynall's enthusiasm, but I worry it's misdirected. I don't know what she means about "improved understanding of the neuroscience behind psychiatric disease ... recently".

I'm sure there'll be different medications introduced in coming years but whether they'll be any better than placebo is open to question. She worries that she won't be able to "explain the complex neurobiology of conditions such as depression, addiction, and psychosis to patients in an understandable way" and I agree this might not make sense. I hope she learns how to do the fundamentals of a history, mental state and formulation of people's problems (see previous post).

I don't understand why the Royal College of Psychiatrists is only reviewing its teaching of neuroscience and not its whole training. I guess it's easier to get funding just to look at neuroscience. Simon Wessely denies that this initiative reflects a biomedical bias but it would be nice to see a more balanced response from the College to improve training. I've said before we need to train open-minded psychiatrists (eg. see previous post). We need to return to modern psychiatry's educational roots in Adolf Meyer and Aubrey Lewis.

Mind-twist or brain-spot hypothesis of mental illness

I have always taken the view that modern psychiatry has been split between two conceptual understandings of mental illness. At the Triennial Medical Congress at Washington in 1910, Ernest Southard called these "two great groups of friendly opponents in the field of psychiatric theory" the 'mind twist men' and the 'brain spot men'.(1) He thought it was important to distinguish between those that looked for a psychogenic cause of mental illness and those that emphasised brain aetiology.

Southard was more of a brain-spot man himself. The main mind-twist man at the time in US psychiatry was Adolf Meyer. I have several times pointed out the link between the theory of Adolf Meyer and critical psychiatry (eg. see previous post).

I think modern psychiatry needs to make more of the differentiation that Southard described. The way was lost when psychiatry thought there was a "twisted molecule behind every twisted thought", which is clearly wrong.

(1) Southard, E.E. (1914) The Mind Twist and the Brain Spot Hypotheses in Psychopathology and Neuropathology, Psychological Bulletin 11: 117-130