Excerpt from Psychologys Ghost: The Crisis in the Profession and the Way Back by Jerome Kagan, Yale

University Press, 2012. Who Is Mentally Ill? The number of adults diagnosed with a mental illness has been growing steadily over the past fifty years and absorbing a larger share of the health budgets of many nations. The physicians in some countries have invented what seem like new illness categories. Swedish psychiatrists decided that burnout was a mental disorder.1 Actually, this category is not novel but the return of a popular nineteenth-century belief that the increased pace of modern life, which required long hours of work, excessive pressures for meeting deadlines, and mastering unfamiliar technologies, was causing a serious loss of bodily energy. This loss led to the symptoms of fatigue and insomnia called neurasthenia. Experts estimate that about one-fourth of Americans older than age eighteen (close to sixty million) had at least one bout of mental illness during the previous year. It is important to note, however, that only 10 percent of this group (about six million) had symptoms so disabling they required professional help. Most of the sixty million were coping with their responsibilities in a satisfactory way.2 The current psychiatric handbook, the Diagnostic and Statistical Manual of Mental Disorders, abbreviated as DSMIV, describes more than three hundred mental illnesses, which is more than three times the number found in the first handbook, published in 1952. This increase would not be a problem if the larger number was the result of reliable research revealing that each illness had a distinctive biology and/or life history. Unfortunately, the list of illnesses is based on the majority opinion of experienced psychiatrists and psychologists who debate the validity of each diagnosis while sitting around large tables. More important, most of the illnesses are defined primarily by the patients verbal descriptions of symptoms that cause intense personal distress or interfere with the ability to meet the days responsibilities. Psychiatrists rarely include behaviors observed in the patients life settings or biological measures as essential elements in the diagnosis. A few personality profiles are called illnesses simply because a majority of Americans regard the traits as violating their ethical notion of what is appropriate. Psychiatrists invented the category narcissistic personality disorder to describe adults who are interested only in their pleasures, are unusually arrogant, and need reassurance from others affirming their superiority. I know several successful men who fit this description. But none regard themselves as unhappy, all cope adequately with

their responsibilities, and they would be insulted if told that they were mentally ill. Most physical diseases are defined by the biological processes that produced the symptoms rather than by the complaints patients report to their physician with the limited vocabulary characteristic of daily conversation. Although the official definition of a mental illness is supposed to be indifferent to its frequency, it is usually the case that a minority satisfy the criteria for a disorder. 3 This is not true for physical diseases. If 60 percent of the adults in a particular region of a country had the HIV virus and the early symptoms of AIDS all would be classified as ill, independent of their feelings or daily functioning. If 60 percent of Americans reported in 2011 that they felt anxious over the current economic recession, warming of the oceans, and the threat of another terrorist attack, most clinicians would regard them as responding appropriately and would not classify them as mentally ill. When social conditions create a sharp increase in despondency or worry among many members of a society, which occurred in America during the depression of the 1930s and the threat of nuclear destruction during the cold war, most commentators regard the society as sick. This was the theme of Philippe de Brocas popular 1966 film King of Hearts, which portrayed the lighthearted mood of a group of mental patients housed in an asylum in a small French town who were simultaneously shocked and saddened by witnessing the mutual destruction of platoons of French and German soldiers during the First World War. Whenever historical events disrupt social arrangements that have existed for many generations, uncertainty penetrates the moods of the populace, and many look for a scapegoat to blame. The persecution of witches from the twelfth to fourteenth centuries is a classic example. During this period the church had become corrupt and full of dissension, the feudal estates were being replaced with nation-states, and urban groups were challenging the power of the rural gentry. Satan was charged as the culprit. Those who were different from the majority were accused of being possessed by Satan and plotting malevolent actions against innocents. Today, increasing economic inequality, religious and ethnic diversity, radical Islamic groups threatening random bombings, and always the danger of a nuclear explosion have raised the level of distress among citizens in many developed nations, but genes and early experience, rather than social conditions, are nominated as the villainous causes of these moods.

Worry, sadness, guilt, shame, frustration, and anger are frequent experiences among humans in all societies. Fear assumed special prominence during the medieval era, when anxiety over Gods wrath was a preoccupation. Augustine regarded anxiety as adaptive, for it motivated greater civility. A thousand years later, John Bunyan affi rmed that a fear of God was a blessing because it facilitated a love of the Deity. Contemporary experts are certain that chronic fear is an abnormal state that restricts the ability to love. These facts invite a closer examination of the meaning of an abnormal psychological state. A majority of psychiatrists contend that the brain states, emotions, and actions that define a mental illness are abnormal, meaning that they reflect processes nature did not intend to be a general human characteristic. A mental illness is assumed to be analogous to malaria. If, however, most humans experience at least one serious, although temporary, bout of depression or anxiety during their lifetime, it is not obvious that these states refl ect abnormal brain profiles produced by deviant genes. Gregory Miller, a respected scientist working in this area agrees, We must be vigilant against indefensible but popular . . . claims that most illness is simply a brain disorder, a chemical imbalance, or a genetic problem. Samuel Beckett had one of the characters in his play Endgame remark, Youre on earth, theres no cure for that.4 Adults who become depressed, irritable, and insomniac because the person they loved rejected them are not experiencing abnormal emotions that are unusual in our species. Michelangelo Antonionis 1957 fi lm The Outcry portrays a mechanic, Aldo, who is deeply in love and living with a woman whose husband had deserted her. When news of the husbands death arrives, Aldo anticipates the joy of marrying the woman and becoming the legitimate father of a preadolescent girl their union had conceived. The womans unexpected rejection of Aldo precipitates a year of wandering the countryside marked by deep despondency, irritability, and insomnia. At the end of the fi lm Aldo returns to the village where the woman lives hoping for a reconciliation, sees through a window that she has a new infant, goes back to the refi nery where he used to work, and climbs to the top of one of its tall towers. The woman had caught a glimpse of Aldo when he peeked in the window and follows him to the refinery. She yells to him as he stands on the top rung of the tower, he waves to her, begins to sway back and forth as if he has lost his balance, and falls to his death. Aldo meets all the psychiatric criteria for a diagnosis of serious depression. The question is whether his symptoms are abnormal products of a biology that is unusual

among members of our species. If most humans are capable of becoming as despondent as Aldo after losing a cherished goal they had idealized, whether a love relationship, child, prize, or position of high responsibility, and I suspect this is the case, it is necessary to separate the concept of depression from the concept of illness or disease. Psychiatrists are treating these two ideas as synonyms. Almost all humans develop one or more painful dental cavities during their lives. Neither dentists nor patients regard tooth decay as an illness that requires an abnormal biological vulnerability that only a few individuals possess. It is probably true that, during their lifetime, 25 percent of Americans have suffered at least one serious bout of depression or form of anxiety that interfered with their functioning. Scholars who study the semantics of language can debate whether this means that 25 percent of Americans had a mental illness! Eighteenth- and nineteenth-century social scientists expended extraordinary energy gathering national statistics on birth, death, and marriage rates. Today, experts add documentation of the rates of mental illness. Both groups assumed that the numbers reflected important laws governing human nature. Intense personal distress is the criterion psychiatrist use most often to define most mental illnesses. A woman who cleaned her home daily, washed her hands frequently, checked all doors twice before leaving the house, and saved every elastic band might not be diagnosed as mentally ill if these habits were not bothersome and she was effective in her marital, parental, and occupational roles. A woman with exactly the same traits who was distressed by her persistent urge to implement these rituals would be diagnosed with a mental disorder. The same is true for the many wives who do not have a frequent desire for sex with their husbands. The only women who would be regarded as mentally ill are those who were upset because they believed their weak libido was abnormal. Many contemporary Americans, especially older adolescents and adults under age fifty, find it hard to inhibit an urge to check their cell phone, Blackberry, or laptop computer for an incoming message or to send one. This behavior meets the criterion for a compulsive ritual. But few who engage in this behavior are bothered by this practice; indeed, most enjoy it. Hence, this habit is not yet regarded as a sign of an obsessive-compulsive disorder. The authors of DSM-IV confessed that their definitions of most mental illnesses were not clear enough to allow experts to discriminate perfectly between those who were ill and those were not. They were aware of individuals like Aldo and wanted to exclude intense emotional

reactions that were appropriate or typical reactions to a situation. Treating prolonged bereavement following loss of a beloved spouse as an illness is tantamount to reducing the dignity of a broken heart to a biological abnormality requiring medicine.5 This decision, however, opens a Pandoras box containing a host of ambiguous cases. A youth encouraged by his peers to murder a member of a rival gang acted in accord with the mores of his social setting. Psychiatrists wriggle out of this dilemma by arguing that the symptom has to reflect a dysfunction in the persons biology. Unfortunately, the meaning of biological dysfunction is ambiguous, leaving the boundary between mental illness and normality fuzzy. Richard McNallys elegant summary of the research on mental illness arrives at the same conclusion. The current list of mental disorders composed by a committee of psychiatrists and a few psychologists sitting in hotel rooms arguing about the criteria for each illness might resemble the list composed by a committee of gods on Mount Olympus who, having watched humanity for eons, arrived at a consensus on the discontents that plague this species.6 The problem with a heavy reliance on the opinions of experts is evident in the judgments of twenty-five eminent American sociologists who, in 1916, ranked the major ethnic and national groups on a variety of psychological traits. Not surprisingly, white Americans who emigrated from Germany or England were classified as possessing the highest intelligence and the best ability to control impulses. The experts ranked Slavs, southern Italians, and Negroes the lowest on these qualities.7