Mental illness as social construct

[solumanculver]

I’m sorry but that does not follow. Does a software malfunction entail a hardware malfunction?

Hi, I think that your analogy isn't apt for mental illness. If we accept that behavior supervenes on brain states, and we declare certain behavior to be pathological, we are, in effect, declaring the underlying brain states to be pathological. To use David Lewis' the paradigmatic example of supervenience: If we look at a dot matrix picture of a person, and notice a flaw in the picture such that it doesn't resemble that person in a critical way, we can say that the picture is wrong in some way. And since a dot matrix picture supervenes on the organization of the dots, meaning that the picture simply is nothing more than the dots, if the picture is wrong then necessarily there must be something wrong with the dots. Of course, on the level of the dots it might be difficult to see what's wrong, but once the problem has been identified by seeing it in its higher order representation, the picture, the only way to remedy that problem is on the level of the dot matrix.

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[toby jones]

The 'cognitive' level of explanation is fairly alien to pscyhiatry. This is probably because there isn't an analogous level in the rest of medicine. Within the sciences of the mind / brain the cognitive level of explanation is reputable enough, however. The whole notion behind 'cognitive neuropsychology' is that the computational level of functional mechanisms is analogous to software and the neurophysiological level of functional and structural mechanisms is analogous to hardware. If psychiatry wants to stipulate that mental disorder must be caused by mind / brain malfunction then cognitive neuropsychology is the relevant science for telling you what the mind / brain malfunctions are. Depending on what kind of notion of function you like, it might be that evolutionary cognitive neuropsychology is the relevant science for discovering mal/functions of the brain.

One could stipulate that only the neurological level is relevant but even if one does so it does not follow that the behaviours that lead someone to be diagnosed with a mental disorder entail that there is inner malfunction (of either the mental or neural variety). I'll elaborate on the neurology case.

Lets say that someone produces dopamine that is within normal range - but on the low end of the normal range. Then lets suppose that that person has a number of dopamine receptors that are within normal range - but on the low end of the normal range. Then lets suppose that the amount of something or other that neutralises the dopamine between synapses is within normal range - but towards the high end of normal range. It is possible that behaviour could be devient / harmful as a result of this arrangement but there are no malfunctioning inner mechanisms.

One might be temped to say that the dopamine system is malfunctioning. What are the grounds for regarding the dopamine system as malfunctioning, however? Is it because we have decided (on normative grounds) that the behaviour is malfunctioning (and hence we are seeking about for something inside the person to pathologise so we feel more scientific in making our normative judgement)? The individual mechanisms that make up the dopamine system aren't malfunctioning, remember.

The notion here is that function and malfunction doesn't necessarily transmit across levels. You can have biological malfunction but that doesn't mean that physicists need to posit a malfunction at the level of sub-atomic particles in order to explain it. Similarly we might judge there to be a behavioural malfunction but that doesn't mean neuroscientists need to posit a malfunction at the level of neurology in order to explain it. Of course the biological malfunction is realised by the sub-atomic particles. Of course the behaviour is caused by the neurology. But higher level (biological or behavioural malfunction) EVEN WHEN caused by (or realised by) lower level entities DOES NOT entail lower level malfunction.

> if the picture is wrong then necessarily there must be something wrong with the dots.

That doesn't follow either. Each dot can be a perfect dot that is related to each other dot in a perfectly acceptable way and yet the picture can still look wrong.

You are right that the only way to resolve the problem is by altering the arrangement of dots. But what is the best way to alter the arrangement of dots? Here I think the analogy breaks down.

What is the best way to alter neurology (in order to alter behaviour)? It could be that psychosurgery or medication are the best way to alter neurology or it could be that environmental / social interventions are the best way to alter neurology. That is an empirical matter. The WHO finding was interesting, however. Remember: two thirds of people in developing countries completely recovered from schizophrenia whereas one third of people in developed countries recovered from schizophrenia. This was found across three studies where participants were matched for severity. People in developing nations have less access to medications but are likely to have better access to social supports given the different family / social structure. This seems to support the notion that social / environmental interventions might well be more effective than medications. Of course there could be all sorts of counfounding factors, but the studies are suggestive.

Once again:

The problem with building 'inner malfunction' into the concept of mental disorder is that it is an empirical matter whether there is inner malfunction or not.

The sciences of the mind / brain could tell us that there is no inner malfunction (as in the dopamine case)

In that case we would have to conclude that the person was not mentally ill. (Very counter-intuitive).

Another way you could go would be to say 'there IS inner malfunction BY DEFINITION' in which case whatever scientists identify as the relevant causal mechanisms are malfunctioning BY DEFINITION. If a person with schizophrenia (say) had a dopamine system as I've described (lets pretend) and the scientists identified the dopamine system as the relevant causal mechanism then the dopamine system is malfunctioning BY DEFINITION.

Then my concern is the following:

What grounds do we have for concluding that the dopamine system is malfunctioning in the above case? Why, it is driven by our ALREADY HAVING DECIDED ON NORMATIVE GROUNDS THAT THE BEHAVIOUR IS ABNORMAL and then we are simply stipulating that the inner causal mechanisms are malfunctioning BY DEFINITIONS. In this latter case mental functions / malfunctions are SCIENTIFICALLY UNINTERESTING because they are determined by stipulation or by our a-priori conviction that inner malfunction is necessary.

Hence Murphy is led to conclude 'the debate around the analysis of the concept of mental disorder is an impediment to scientific research'.

Methinks it is worse than that, however, because it obscures the normative dimension which is primary (as some of the social constructivists have suggested).

Of course another way to go would be to try and make the notion of 'harm' objective rather than normative. Someone or other attempts this with the 'biostatistical theory of harm' but I haven't taken a look yet to see whether it is compelling. Otherwise... We are back to trying to figure out functions / malfunctions at the BEHAVIOURAL level (where we identify people as being mentally ill and indeed they are in fact mentally ill due to the harmful consequences of their malfunctioning behaviours).

 

[toby jones]

(I'm trying to write a paper on this stuff at the moment so I really hope that it is counter-intuitive and yet ultimately persuasive. Responses / criticisms most welcome)

 

[solumanculver]

Isn't the concept of disease inherently normative? In order to be a disease something must be "bad"... I don't think that it's a problem that mental illness is defined, at least on first reflection, based upon normative considerations... If we initially define schizophrenia as "early craziness", or something, and later find out that it is caused by Gene x, we can replace the original normative definition with a scientific definition. But why would we care about treating any biological condition if we didn't consider it "bad". That normative element is part and parcel to medicine, I think. I guess the concept of a malfunction is also inherently normative, since it's essentially "functioning in a bad way"... If a biological system is functioning differently than normal, and it causes bad results, it's called a malfunction, but if it causes good results maybe we'll call it evolution.

 

[Chewbacca Jung]

I think that a 'disease' example in medicine that fits TJ's concept of software vs hardware is SARS. Its highest mortality was in the young. The reason is because the worst pathology in the lungs occurred due to the hosts own 'normal' immune reaction to the corona virus. Once they started using steroids to treat SARS the mortality rate went down. Death from SARS was due to appropriately working hardware (the immune system) with faulty programming (the virus).

I agree that it is not necessary to have a dysfunction in the hard ware (brain) to have mental disease -- although I think in the case of schizophrenia I think that there is at least some amount of faulty hard ware. Other mental disorders may be another matter.

 

[solumanculver]

I agree that it is not necessary to have a dysfunction in the hard ware (brain) to have mental disease -- .

What definition of dysfunction are we using? If dopamine levels fall within a standard average range for all humans, and a person with high-end but normal dopamine starts acting psychotic, can we say that that person's brain is malfunctioning?

CJ and TJ seem to think not, but I don't see why not... After all we can't know what the optimal parameters are for any one person's body, all we can know is the average across a population. Comparing an individual to the average might lead one to make helpful inferences, but in and of itself it can really be dispositive evidence. If giving this "normal range dopamine" guy antipsychotics improves his functioning, it seems implicit that something in his dopamine system was malfunctioning before. I don't think that it matters how his dopamine levels compare to average levels in a population...

Another way you could go would be to say 'there IS inner malfunction BY DEFINITION' in which case whatever scientists identify as the relevant causal mechanisms are malfunctioning BY DEFINITION.

On the surface, at least, this seems to me to be necessary. I think that once we declare a behavior to be dysfunctional, and provided we accept behavior-brain supervenience, I think that we are already implicitly calling some certain brain states dysfunctional. If there isn't anything to behavior that is above and beyond the relevant causal structures in the brain then there is no room for us to call behaviors dysfunctional but not call the causal mechanisms in the brain dysfunctional.

As for the hardware/software analogy, why should we accept that anyway? Even if we did accept it, it still amounts to an argument that even though mental disorders are completely supervenient on biological processes, it is more useful to look at them in terms of a higher-order concept. After all, "software" is just a method of discussing very complex patterns of functioning in hardware, at the most fundemental level all we have are circuits with electrons flying through them...

 

[worriedwell]

If one eats enough cheeseburgers, they will get heart disease no matter what their genetic makeup or "hardware" predisposes them to (I don't have any evidence for this). However, for a handful of people, if they never eat a cheesburger in their life (they are vegetarian), they will develop heart disease. For everybody in between there is some balance between the hardware and software being "insulting" to when they develop heart disease.

If you get the faulty software of having an abusive dad, well if he abuses you enough, even with normal hardware you will probably manifest outward abnormal, "unhealthy" experience which includes significant morbidity and mortality. Some might say all the stress of the physical abuse is "bathing your brain in cortisol" which is highly toxic. The same way that if you drink enough alcohol and bathe your brain in that you'll get cerebellar degeneration and you can measure that by MRI after first judging it clinically by noticing the way someone walks and then define that as disease. The cortisol thing is a hypothesis, but you can measure ptsd changes in brain compared to normals. Its just that our imaging is not there yet to really make all this really routine (is what I believe) There is always an inherent interplay between hardware and software and if the manifestation of the interplay produces something where the PERSON is dysfunctional in some way in society, then that is DISEASE. In all of medicine, doctors are not concerned with treating inner mechanisms unless they can show empirically that the person as a whole (which may in fact be greater than the sum of his neurons) benefits from it by not ACTING dysfunctional outwardly (or by not dying, which is a form of acting dysfunctional).

I keep getting back to other medical examples because I feel like if one accepts that the logic the rest of medicine uses can be applied to the debate about mental illness, then one can accept mental illness being a "medical disease". This again presupposes that mind is derived from brain. If science rules, you probably believe that because if you remove all of someone's brain, any ability to observe a mind is impossible.

People keep coming back to the mind being greater than the sum of its parts argument, but I think it is important to understand that medicine works from the outside in, in that if a disease can be treated on the level of the biological, then in all cases, it must not JUST be a "socially constructed" disease (even though the initial decision to "mark" it as a disease is based on its "abnormalness" which includes distress outside of the norm, and behavior as in the case of epilepsy). Thus, if dopamine receptors can be used as a modality for treatment, then a syndrome than includes dopamine mediated hallucinations is a biological illness that falls in the realm of medicine and the science of progressing the MEDICAL discipline should go forth. This is how all of medicine has evolved throughout the history of time. It shouldn't be restricted to going forth only on the biological to determine treatment modalities, in the moment, but scientists are reductionists by definition. If you aren't thinking in a way that ultimately biology is the fundamental framework for health and disease as it pertains to everything contained within our skin, then you are calling the mind ethereal. Fine do that, but not when you are trying to treat patients the best you can through applied science. The reason you don't want to is due to deep seated ideals which amounts to one basic concept and that is RELIGION. If you remove all the intellectuallizing that goes on, then I think this is the conclusion you must come to. And so I come full circle back to the greatest movie of all time, the MATRIX. The fundamental flaw that will collapse the paradigm of science is CHOICE. This is where, to those who BELIEVE, science breaks down and the Whole can never be just the sum of its parts. But again, we practice medicine within the pardigm of the day and there is nothing inherently unique about the medicine of psychiatry except that it is the most fascinating and poorly understood discipline with tremendous things to unfold over the next century. It is a thrill to be in the middle of it, as a scientist, a physician, and even as a person in existential limbo.

 

[toby jones]

The concept of disease is thought to have a normative component, but it is also thought to have an objective component. The motivation for the objective component comes from people who want there to be a science of mental disorder (so psychiatry isn't just a matter of dealing with people who violate social norms). According to the two-stage view of mental disorder there are two individually necessary and jointly sufficient conditions for disease / disorder:

1) There is malfunction
2) The consequences of the malfunction are harmful.

It is typically thought that the first condition is objective (a scientific, or empirical matter) while the second condition is normative. I'm questioning the objectivity of the first condition, however. (It would also be possible to question the normativity of the second to see whether we can find objectivity there but I need to think about that some more).

Both of these conditions are thought to be necessary (and sufficient) for mental disorder. That means that malfunction alone is not sufficient. The reason the second condition is included is because (as you say) it is possible for a malfunction to have beneficial consequences and in those cases it seems counter-intuitive to regard the person as disordered.

But really... Who cares about our concept of mental disorder? I'm less interested in the concept of mental disorder (and whether the two-stage view is logically entailed by our common sense concept of mental disorder) and more interested in the NATURE of mental disorder. One could argue that the heavenly objects are all perfect spheres because they are 'heavenly' and because being spherical is the perfect shape BY DEFINITION but who cares? I would have hoped that philosophers (and scientists) would have learned from past philosophers mistakes...

You can of course decide that the term 'malfunction' refers to whatever the causal mechanisms are that are responsible for behaviours that we have decided are devient. You can stipulate that the term 'malfunction' should be used in this way. That way you could keep the above definition of mental disorder. The consequences of this are that malfunctions aren't a matter for science, however, as the scientists study causal mechanisms and we decide which of those causal mechanisms count as 'malfunctions' in the cases where we already regard the persons behaviour as devient. As such it seems that we proceed by firstly identifying people whos behaviour is devient. Secondly identifying the relevant causal mechanisms that produce their devient behaviour. Thirdly by labelling those causal mechanisms as malfunctions. Malfunctions are thus scientifically uninteresting and can't be used to justify our regarding the behaviour as devient.

> What definition of dysfunction are we using?

Well that is a million dollar question. Wakefield thinks it is evolutionary functions that are relevant but there are at least three different notions of function that are used in the life sciences and he offers us no argument why we should accept evolutionary functions over developmental functions or current functions. What we seem to do in practice is label 'malfunction' wherever it seems most intuitive. There doesn't seem to be a principled way of deciding what is relevant.

> If dopamine levels fall within a standard average range for all humans, and a person with high-end but normal dopamine starts acting psychotic, can we say that that person's brain is malfunctioning?

You can but I hope you can see that the process would be:
1) Judge that psychosis is devient / harmful (on normative grounds)
2) Attempt to find the causal mechanisms of the psychosis.
3) Attach the label 'malfunction' to the causal mechanisms.
You can do that if you want but if you do that then you can't cite 'malfunction' as an objective cause of devience (it is a label that is derived from our normative assessment it isn't objectively discovered by scientists).

> If giving this "normal range dopamine" guy antipsychotics improves his functioning, it seems implicit that something in his dopamine system was malfunctioning before.

Here the term 'functioning' seems to apply to behavioural functioning. I wonder if you can talk about the function of behaviours or the function of a person in a way that is non-normative. We would also like to avoid teleological accounts of function (which are problematic). When the DSM talks about 'occupational and social functioning' this notion seems to be normative about what it takes for a person to live a good life or somesuch. Whose values are relevant to determine the function of a person and the function of a persons behaviour? Hard questions... Who are we to say antipsychotics improve his functioning? We can say that these causal mechanisms resulted in this behaviour. We deemed the behaviour to be problematic. We intervened on his brain by introducing some substance. That had the causal consequence such that he no longer exhibited the problematic behaviour. That is what we did. You can attach the labels 'functioning better' and 'malfunctioning' if you like but that doesn't alter the process I've described. The way I've described it draws attention to the initial normative assessment that we made of his behaviour, however.

> I think that once we declare a behavior to be dysfunctional, and provided we accept behavior-brain supervenience, I think that we are already implicitly calling some certain brain states dysfunctional.

I've already showed how that does not follow.

> As for the hardware/software analogy, why should we accept that anyway?

Because it is an accepted framework within the cognitive neuro-sciences as the medical model is an accepted framework within psychiatry. That isn't to say that the frameworks are correct just because current research programs are using them. It is to lend some credibility to the metaphor, however.

> at the most fundemental level all we have are circuits with electrons flying through them...

No. At the most fundamental level all we have are sub atomic particles or whatever you want to call them. If you are going to be a reductionist (to the level of genetics or even to the level of neurobiology) why stop there? The point is that there are generalisations and predictions (and hence explanations) that are more robust at one level than there are generalisations, predictions, and explanations to be found at either higher or lower levels.

Just because something is ontologically fundamental or more basic does not at all mean that the best explanation or intervention is on the most ontologically basic level. That does not follow at all. (Try capturing Fisher's law in economics at the level of sub-atomic particles).

This is what I meant by cognitive neuro-psychology:

http://en.wikipedia.org/wiki/Cognitive_neuropsychiatry

(Don't even get me started on the Capgras and Cotard deluisons)

;-)

Also:

http://www.ncbi.nlm.nih.gov/entrez/...ve&db=PubMed&list_uids=16166028&dopt=Abstract

 

[Chewbacca Jung]

how about considering bereavement vs depression. Bereavement is considered normal behavior, and practically speaking often can not be differentiated from MDD, except for its proximity to an episode of extreme loss. After 2 months it magically transforms into MDD. So what is MDD? It seems that it could be the normal brain function, called bereavement, only it is turned on or prolonged for some reason-- could be psycho-social or biological. Some cultures handle bereavement much differently, and thus cultural must fit in here too.

if this is the case, perhaps the reason why SSRI's works is because the ratio of serotonin to some other unknown neuro-chemical (norepinepherine?) is responsible for turning on/prolonging bereavement.

Same thing applies to schzophrenia- maybe psychosis-ness is a normal thing-- developmentally children have imaginary friends and have imaginary play. As TJ points out creativity may hinge upon quasi psychosis (allusive thinking). A healthy dose of paranoia could keep people alive. DA may enable that normal state of psychosis-ness to be on more than it should, and inhibiting DA may restore normal frequency or levels of allusive thinking.

 

[Chewbacca Jung]

sorry to talk about something other than the match...

wait...

anyway, I happened upon a nice summary of Thomas Kuhn's "The Structure of Scientific Revolutions"-- so no need to read the whole book....

http://www.des.emory.edu/mfp/Kuhn.html

Its great for understanding the concepts of paradigms and "normal science"-- perfect for our discussion... Not to mention the blue prints that are laid out here for starting our own SDN spawned psychiatric revolution... ELOL (evil laugh out loud)

And if you can't already tell... I am completely addicted to using ellipses....

...

 

[Demosthenes]

WW- anorexia is a western phenomenon because of the "image" issues in western society especially for white girls like those images seen on the cover of vogue. if that same girl grew up in another culture (which we could possibly replicate with twin studies) like a 3rd world country, then my feeling is she would be strongly predisposed to having some illness which has control issues etc. However, even twin studies might fail because I consider the illness to be mediated by how, where, and with who that exact girl grew up.

The argument of anorexia being biologically derived requires the discovery (or creation) of an “illness which has control issues” to which both parties would be “strongly predisposed to having” to have merit.

Actually, no. A fellow from the Psychiatric Institute of The Hague (I think that's the right name) did a study in Curacao -- I'm hopeless at spelling, but worse at pronouncing -- which found that rates of Anorexia Nervosa were pretty consistent there, despite the lack of exposure to Western imagery, and despite their cultural standards of beauty favoring plump women.

I don't have the study linked, only have part of it in hard copy, so I can't/won't post any links to it. It was an interesting study, though. It shows that AN isn't entirely culturally mediated.

And, just for the sake of argument, the whole "anorexia is just about control" is facile at best. Personally, I look at it as having much more to do with anxiety, alexithymia, and obsessionality. An argument could be made that that's lack of control, but it's certainly not so simple as "she can control what she eats, but nothing else..."

 

[Chewbacca Jung]

Actually, no. A fellow from the Psychiatric Institute of The Hague (I think that's the right name) did a study in Curacao -- I'm hopeless at spelling, but worse at pronouncing -- which found that rates of Anorexia Nervosa were pretty consistent there, despite the lack of exposure to Western imagery, and despite their cultural standards of beauty favoring plump women.

I don't have the study linked, only have part of it in hard copy, so I can't/won't post any links to it. It was an interesting study, though. It shows that AN isn't entirely culturally mediated.

And, just for the sake of argument, the whole "anorexia is just about control" is facile at best. Personally, I look at it as having much more to do with anxiety, alexithymia, and obsessionality. An argument could be made that that's lack of control, but it's certainly not so simple as "she can control what she eats, but nothing else..."

Could you post the citation of that article, I'd be interested in it.

And you're right, anorexia, like the rest of life, is quite complex. It's not simply about control. But I think we were trying to get at what A.N. is. It would seem to me that anorexia nervosa could be

1. entirely culturally derived. In which case you would only see it in certain cultures which possessed the right dynamics to create the disease.

2. it is both biologically and culturally derived. In which case you would have some sort of control/anxiety/alexithymia/obsessionality predisposition (CAAOP), and culture would dictate/influence how those traits are manifest. In this case you may find a CAAOP disorder in all cultures at a similar rate (assuming hardy-wienberge equilibrium). Or,

3. It is entirely biologically derived. In this case you would see A.N. in equal proportions in all cultures if you looked hard enough (again assuming HW equilibrium).

I think it would need a lot of research to piece out which one it is. Other than the curacao piece, does anybody know of any sources?