May is Mental Health Awareness month.
Although the term “mental health” is loaded with debatable philosophical suppositions, and though there may be a better term to substitute for this one, I find the term sufficiently suitable for the moment. Moreover, I am a firm believer in the need for attending to one’s psychological needs and desires.
But just because “mental health” is meaningful doesn’t mean, as many apparently think, that the terms “mental illness” and, synonymously, “mental disorder” necessarily are.
Ontology is the philosophy or study of being, of existence: What does it mean to be? To inquire into the ontological status of a thing is to inquire into what it means for it to exist, or how it exists.
The question before us here is, What is the ontological status of a mental disorder?
What kind of a thing is it? Every so many years, the American Psychiatric Association releases another version of its Diagnostic and Statistical Manual of Mental Disorders (DSM). With each new edition, its list of mental disorders grows. Presently, there are around 300 or so such disorders listed.
Now, pathology is the branch of medical science that focuses on the study and diagnosis of disease. This is from the Pathology Department at McGill University:
Clinical pathology involves the examination of surgically removed organs, tissues (biopsy samples), bodily fluids, and, in some cases, the whole body (autopsy). Aspects of a bodily specimen that may be considered include its gross anatomical make up, appearance of the cells using immunological markers and chemical signatures, as well as genetic studies and gene markers. Pathologists specialize in a wide range of diseases, including cancer, and the vast majority of cancer diagnoses are made by pathologists. The cellular pattern of tissue samples is observed under a microscope to help determine if a sample is cancerous or non-cancerous (benign).
Notice that pathologists practice both anatomical pathology (the examination of the structural alterations in tissues and organs) and clinical pathology (the use of laboratory tests in the identification of disease).
Pathologists determine the presence of diseases in their patients by signs — i.e., objective, demonstrable markers that they can directly observe. A fever, a rash, elevated blood pressure — these are all examples of signs. Signs are not the same thing as symptoms, which are just the subjective experiences that patients report. Fatigue, a headache, a pain in the abdomen — these are examples of symptoms.
As Jeffrey Schaler, who was once a member of the psychology department at Johns Hopkins University, reminds us, “it is a fact that there is no literal disease identified by pathologists as mental illness.”
There’s a good reason for this.
Mental illnesses are identified on the basis of symptoms alone. There are no signs — no saliva, urine, or blood tests, no laboratory tests of any sort — by which a mental illness can be diagnosed. And these symptoms are nothing more or less than the reported behaviors of the patient.
What this means, then, is that a mental disorder or illness is a cluster of types of behaviors to which the APA ascribes a label — the label of a “disorder” or “illness.” Furthermore, this determination its leadership makes on the basis of…a vote. The APA decides which behaviors constitute what it will classify as a disorder.
Since, then, a disorder is not a singular thing, but rather a manifold of those behaviors that the APA has chosen to label a disorder, it’s that much clearer why pathologists will not recognize so-called mental disorders: The behaviors that are supposed to constitute mental disorders are descriptive. They are not explanatory.
Pathologists, as we know, search for the underlying causes of disease. Psychiatrists, in glaring contrast, describe behaviors, symptoms, as their patients report them. Thus, for example, an “anxiety disorder” is not the cause of the heart palpitations, dry mouth, queasy stomach, perspiration, tightness of chest, etc. experienced by the person who has been so “diagnosed.” What the APA has decided to call an anxiety disorder is these symptoms. There is no disorder over and above these symptoms that is causing them.
The One and the Many is one of the metaphysical problems first identified at the inception of the Western philosophical tradition in ancient Greece. Characteristic of the Greek mind is the idea that behind “the Many,” the world of many, ever-changing things that we perceive with our senses, is a more ultimate reality, “the One,” a single, eternal, permanent thing upon which the former depends. From its earliest days to the present, philosophers have never stopped arguing with one another over how best to resolve this problem.
To put the ontological status of a mental disorder in the terms of the problem of the One and the Many, the verdict is clear: The Many don’t arise from the One. The Many are the One.
In other words, a person who says she has some or all of the symptoms associated with anxiety disorders but not at any specific time or toward any specific objects may think she is saying something informative when she attributes these symptoms to “Generalized Anxiety Disorder.” But since the latter is not a One — an entity underlying the symptoms and giving rise to them — but rather a short-hand way of referring to those very symptoms, what she is actually saying is only as meaningful as a tautology. Her “diagnosis” amounts to this:
I’m prone, for no particular reason and with respect to no particular object, to have heart palpitations, sweaty palms, and an upset stomach because I’m prone to have heart palpitations, sweaty palms, and an upset stomach for no particular reason and with respect to no particular object.
To be told, then, that a person has a mental disorder is only to be told that the challenging experiences with which one contends are those that a committee of psychiatrists has decided to label a “disorder.” Yet the label is the package of experiences. It adds nothing to one’s awareness other than the illusion of being offered a causal explanation for one’s specific life challenges.
We must conclude that, at best, the ontology of a mental disorder remains…elusive.
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