Mental Disorders Are Real, Diagnosis Or Not

The need for diagnosis before compassion shames us

If headlines are to be believed, we are facing a crisis in mental health of epidemic proportions. In the UK and the US, lifetime prevalence rates are estimated to be roughly 1 in 6 and rising. What explains these rates and what ought we to do about them?  An important, preliminary point is that the distribution across the population is not even. A disproportionate burden falls on women and those who suffer socio-economic disadvantage and other forms of adversity and hardship. Equally, the increase is not uniformly distributed across kinds of disorder. Rates of autism, schizophrenia, and bipolar disorder are relatively stable, with lifetime prevalence estimated to be roughly 1 in 100. The increase lies predominantly with anxiety disorders, depression, and addictions.

There are three possible and related explanations for these rates. The first is that the social stigma surrounding these mental disorders is decreasing. Today’s patients are more able to be open about their problems and seek treatment, and clinicians are on the whole better equipped to recognize and diagnose these disorders. There are therefore fewer cases of undiagnosed disorder, less discrimination, and better access to and quality of care. If this is the explanation, we should not be alarmed by the rates. We should simply keep up the good work.

The second explanation is that the number of people who have these disorders is increasing. This is indeed alarming. If it is true, the question is why. What is it about contemporary society that is causing soaring rates of mental disorder? Here, the uneven distribution across the population, coupled with the fact that the increase lies with predominantly with anxiety disorders, depression, and addictions, should immediately give us pause. People who are poor and marginalized, with severely limited employment and education opportunities, and who may be victims of gender, racial, and other forms of discrimination, have reason to be stressed, anxious, and despairing. Arguably, there is more inequality and social isolation and loneliness in our world than ever before. For young people, there are in addition the perils of social media, including bullying and low self-esteem. And, of course, people who are less socio-economically or otherwise disadvantaged and marginalized will nonetheless face life events that are intensely painful, and undergo periods of real hardship. Life can be miserable and brutal for all of us at times. Anxiety is a natural, normal response to stress and uncertainty about future wellbeing, just as sadness, grief, and despair, are natural, normal responses to loss, trauma, and humiliation. Relatedly, people who feel these ways and live in such circumstances have reason to use drugs and other modes of escapism, namely, as relief from the pain and miseries of life. Rates of anxiety disorder, depression, and addictions may therefore be increasing because the problems people face in contemporary society are multiple, severe, and appear irresolvable. In other words, there is more than adequate cause.


"The fact that we require people to be labeled with a disorder to be worthy of care is an indictment of our collective moral community"


Perhaps there is room for doubt that our world really is getting worse. Nonetheless, we do seem to be diagnosing some disorders more. The third explanation of increasing rates is that the criteria for diagnosing have loosened over time, so that people who would not have been diagnosed with a mental disorder in the past currently are. As the sociologists Allan Horwitz and Jerome Wakefield have argued in relation to depression, one indication of this shift is that less attention is now paid to context.

The criteria for diagnosis of anxiety disorders, depression, and addictions consist in lists of specific psychological and behavioural symptoms, which patients experience and clinicians observe.  Good clinical practice always seeks to understand the individual circumstances of a patient and requires the exercise of clinical judgement. Nonetheless, diagnosis now proceeds by establishing that a sufficient number of symptoms on the list are both present and the cause of significant distress and impairment in one or more areas important to wellbeing, such as employment, education, or relationships. If the distress and impairment is indeed significant, a diagnosis can be given, whether or not the context renders the symptoms explicable and intelligible – a natural, normal response to the person’s circumstances. In the past, context was more reliably used to distinguish normal from pathological conditions, especially in relation to mental disorders involving negative emotions and moods. This change in diagnostic practice has both costs and benefits in the current climate.

The benefits are plain and of paramount importance. People who are suffering and struggling to cope are much more likely to get help in our society if they are diagnosed with a disorder. As the philosopher Nomy Arpaly has argued, our willingness to show compassion is often predicated on a diagnosis, as if the label makes a person’s suffering and struggle real and legitimate in a way it would otherwise not be. The fact that we require people to be labeled with a disorder to be worthy of care is an indictment of our collective moral community. Strong, negative emotions and moods are natural, normal responses in many circumstances. So too is being desperate to alleviate them – so much so that a person may take any means available. This does not make them any less painful or overwhelming. We ought to help people in need simply because they are in need – apart from any label they may or may not have. But, given the fact that our willingness to help is often restricted in this way, loosening the criteria for diagnosis is a good thing, for it makes it easier for more people who need help actually to get it.

But there are also costs to a more liberal approach to diagnosis. The idea of mental disorder implies that something is wrong – with a person’s mind, and, in today’s world, we are prone also to assume with their brain. The hope of biological psychiatry is that we will ultimately discover an underlying brain pathology that is the common cause of the psychological and behavioural symptoms diagnostic of each type of mental disorder, just as we have discovered specific physical pathologies that underlie the surface symptoms of many physical diseases. But despite great advances in the cognitive and neurobiological sciences and much research dedicated to this hope, at most twice in the history of psychiatry has this model proven apt. Around the turn of the 20th C, scientists discovered that, in some patients, the collection of symptoms of paranoia, grandiosity, and confusion, was caused by tertiary syphilis, which can be treated with antibiotics. More than one hundred years later, preliminary studies conducted over the last few years have suggested that other cases of first-time psychosis may be caused by specific antibodies in the blood, which respond to immunotherapy. These are great advances, especially for those patients whose symptoms are indeed caused by these physical conditions. And we should not give up hope that similar such discoveries may be forthcoming in future. But their rarity is nonetheless striking. In the meantime, the cost of assuming that mental disorders are always caused by underlying brain pathologies is significant. For it pathologizes a person and their mind by treating their symptoms – which include their emotions, moods, and actions – as mere effects, caused by a brain disease, rather than reflective of anything significant about the person’s subjective experience and life circumstances.


"Treating mental disorders as resulting from an underlying brain pathology obscures the way people may need to find a path towards recovery which draws on their own agency for change and sense of personal responsibility"


This has three important costs. The first is directly to the person. Treating a person’s emotions, moods, and actions as mere effects of an underlying brain pathology strips them of meaning they would otherwise have. The fact that they may be explicable and intelligible responses to a person’s circumstances is lost from view. Subjective experience and ways of acting become something only to be managed, not to be understood or made sense of. This can be an impoverishment, in life and in relationships with others.

The second cost is that it becomes all too easy to lose sight of the socio-economic and wider environmental causes of mental disorder, namely, the inequalities, injustices, and destructive cultural trends of contemporary society. Our focus all too easily turns to what is wrong with the person, and in particular, with their brain – as opposed to what is wrong with our world. To improve mental health, often what is needed – alongside help, support, and a period of respite from the demands of life – is poverty relief, employment and education opportunities, as well as the chance to belong to a community, have a sense of purpose, and forge meaningful relationships. Rather than address these wrongs, or show simple compassion in the face of human suffering and struggle, the pathologization implicit in the idea of mental disorder can mean that a diagnosis results in us putting it all down to a person’s brain.

The third and final cost is that the person is disempowered in their recovery. Emotions and moods are involuntary in the sense that they are not under the direct control of the will. But people do have some control over what they do with their emotions and moods – as well, of course, over their actions more generally. There are a range of different attitudes and actions we can take in light of our emotions and moods, some of which are more and some less self-caring and self-compassionate, or constitutive of a step, however small, towards a different future. Treating mental disorders as resulting from an underlying brain pathology obscures the way people may need to find a path towards recovery which draws on their own agency for change and sense of personal responsibility, as opposed to waiting for a medical fix. This is in no way to deny that medication can be helpful. But it is very rarely the whole solution.

As well as being a philosopher, I have also spent the last decade working clinically with people with personality disorders, many of whom struggle with anxiety, depression, and addictions. Through this experience, I have come to believe that effective clinical treatment and personal recovery often involve what I call a Responsibility without Blame stance. It is easy for all of us – people with mental disorders, clinicians who work with them, and society at large – to get stuck between two equally unhelpful mindsets. Sometimes we “rescue” a person by pathologizing them. We see their emotions, moods, and actions as caused by an underlying brain pathology. In which case, we think they can’t help it and they’re not to blame. This mindset is part of why diagnosis with a mental disorder not only inclines us to see a person’s suffering as real and their impairment as legitimate, but also to see them as worthy of care. For, without the diagnosis and the implicit pathologization, we may fall into a “blame” mindset, where we stigmatize and judge those with mental disorder. In this mindset, we may be prone to think people with mental health problems should just “pull themselves together” and don’t genuinely deserve care and support.

Both mindsets lack the kind of nuance we need to understand and address mental disorder in today’s world. On the one hand, if our willingness to offer compassion and help depends on pathologization, then it is less effective than it might otherwise be because it disempowers and disables. Recovery often requires people to develop their own agency for change and sense of personal responsibility. But this is no easy task in the face of suffering, impairment, limited opportunities and hard circumstances. It requires genuine care and support from others to be possible. On the other hand, if pathologization is our only protection from a blaming and stigmatizing mindset, then we have no other humane option. To find a middle way between these mindsets, we need to combine recognition and support for a person’s sense of agency and responsibility, with compassion as opposed to blame. This requires acknowledging the reality of their suffering and legitimacy of their impairment without disempowering through labeling and pathologization. To stop the rising rates of mental disorders, don’t just ask what’s wrong with people who have one. Ask what’s wrong with our world and what we need to change about ourselves.

Hanna Pickard is a Professor in Philosophy of Psychology at the University of Birmingham and a Visiting Research Scholar in the Program in Cognitive Science at Princeton University 2017-19. She has created The Responsibility without Blame Project which offers an open access, accessible e-learning for anyone interested in thinking about our ideas of responsibility and blame, and finding ways to work and relate more effectively with people with personality and related mental disorders.

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Allan Olley 19 April 2018

"There are therefore fewer cases of undiagnosed disorder, less discrimination, and better access to and quality of care. If this is the explanation, we should not be alarmed by the rates. We should simply keep up the good work."

This just seems fallacious. There could be a reducing rate of mental disorder and we still might be neglecting the social and political actions we could take that would be reducing the suffering associated with those disorders mentioned later in the article. So the opening seems to be posing a false trichotomy. Although it seems like it is unintentional since it it opens saying "There are three possible and related explanations for these rates."

In terms of the main point of the article it seems to me that the author misses two points about how we medicalize things.

First we medicalize in terms of what care/treatment is appropriate. So we should give antibiotics to people with tertiary syphilis suffering paranoia, but not to those with paranoia but no bacterial infections. So part of categorization are just about what form of care is appropriate. So part of saying X is a mental disorder could just be saying X should be cared for (partially or fully) by a method that denies responsibility and blame (like antibiotics or psychoanalysis or cognitive behavioural therapy or whatever). And we naturally just deal (or think we should deal) with quotidian mental anguish with methods of emotional support like those mentioned in terms of responsibility without blame or in terms of socio-political stuff mentioned (we can make people's life better by reducing economic inequality etc.).

So in terms of this it is not clear that the problems suggested are not that we are just failing to care enough for quotidian mental anguish and failing to recognize how non-medical interventions (responsibility without blame, reducing wealth inequality etc.) would help those we categorized as suffering from a mental disorder. So we just need to rebalance our existing ethics of care rather than overcoming some reductive oversimplification.

Second there is the fact that part of how we medicalize is in terms of acuteness of condition. So mental anguish that fails to debiltate or disable is just not called a disease/disorder for that very reason. Similarly brain tumors are more disease than the occassional mild tension headache, just because brain tumours may kill, or severly disable, but otherwise both cause suffering and both have a physical basis. Further it seems like we have a threshold for action such that if the suffering, danger etc. is not acute enough we are less liable to act. So even if minor headaches being common cause masses of suffering we may not act to care proportionate to that because, each individual case is below our threshold whereas every brain tumour is well above our threshold so we are sensitive to that and are more willing to care. So our lack of care for quotidian mental anguish may be about that sort of threshold issue rather than our failing to categorize it as morally relevant suffering.