psychological disorders The time is the late nineteenth century, the place a physician's clinic. A female patient complains of dramatic mood swings, paralysis on one side of her body, hallucinations, convulsive seizures, and religious delusions. Is she suffering from hysteria, a nervous condition the Viennese neurologist Sigmund Freud believed to be treatable through an analytic discussion of the patient's dreams and memories of childhood? Or is she suffering from what German psychiatrist Emil Kraepelin called dementia praecox, the antecedent of today's schizophrenia? Or is she a victim of syphilis, once dubbed ‘the great imitator’ because of the mental disorder that it produces? Since her symptoms could fall into any of these three disease categories, what kind of disorder does she have? Is it psychological, that is, purely ‘mental’, or is it neurological, that is, caused by distinctly organic factors?

These questions all illustrate the complexity involved in defining the term ‘psychological disorders’. It begins with the words ‘psychological’ and ‘disorder’. A disorder can be described as a pathological condition of the organism, mental or physical. When the term is applied to psychology — the study of the mind and behaviour — a disorder becomes a functional deviation from normal mental or behavioural conditions. As such, there is little to distinguish it from many psychiatric diseases, at least from a diagnostic point of view. Indeed, among psychiatrists the word ‘disorder’ is preferred to ‘disease’, as a glance at the American Psychiatric Association's Diagnostic and Statistical Manual-IV (DSM-IV) proves. In these terms, then, mental and psychological disorders are synonymous.

Captive to language

Nonetheless, psychiatrists remain dissatisfied with the use of the phrase ‘psychological disorder’ or its virtual equivalent, ‘mental disorder’. To psychiatrists, both terms hark back to the French philosopher René Descartes (1596–1650), who argued that mind and body were utterly dissimilar. As the authors of the DSM-IV state: ‘mental disorder unfortunately implies a distinction between “mental” disorders and “physical” disorders that is a reductionistic anachronism of [Cartesian] mind/body dualism. A compelling literature documents that there is much “physical” in “mental” disorders and much “mental” in “physical” disorders.’ Probably because of their medical training as physicians, psychiatrists are loath to accept the notion that psychological disorders are purely mental. Hence, the DSM-IV concludes that there is no ‘fundamental distinction between mental disorders and general medical conditions.’ Mental disorders are in fact tied to ‘physical and biological factors and processes’, even if scientists are unable determine precisely what these processes are. Conversely, general medical conditions are often influenced by ‘psychosocial factors or processes.’

In the eyes of modern psychiatrists, then, psychological disorders are biological phenomena just as much as certifiably medical diseases are. But in explaining how they arise, researchers must still use Cartesian terms of reference. To this point no new terminology to describe the natural reality of psychological disorders has been widely accepted, terminology that could transcend the ages-old concepts of mind and body. Psychiatry, so to speak, is captive to language that has not kept pace with the march of biomedical knowledge.

Challenges to classification

Psychiatrists and psychologists usually divide psychological disorders into three main classes: mental handicap, personality disorders, and mental illness. Mental handicap, also called mental retardation, is evident in the early years of individual development and is accompanied by abnormally low intelligence, though other psychological features might be affected. Severely mentally-handicapped people frequently have physical handicaps, such as difficulty in walking or controlling the bladder, but with help most can live fairly normal lives.

Personality disorders typically develop in teenage years, affecting all aspects of personality but not intelligence. One kind of personality disorder is the psychopathic personality disorder. Individuals with this disorder often combine superficial charm with serious inability to love, trust, respect, and care for other persons. Another is the paranoid type of personality disorder, featuring suspiciousness, secretiveness, insensitivity, and deception as salient personality traits.

Mental illnesses are divided into neuroses and psychoses. Psychoses are characterized by serious impairment of self-insight, inability to meet some ordinary demands of life, and loss of contact with reality. Although the terminology is still controversial (see psychosis), three principal groups of psychoses are generally recognized: schizophrenia; the affective disorders (primarily mood disturbances); and the organic psychoses, which can be caused by things like brain tumours or toxic products in the bloodstream, and which sometimes culminate in dementia, or the severe loss of intellectual abilities. Schizophrenia and the affective disorders are usually called ‘functional’ psychoses, to denote the absence of a verifiable organic pathology.

The neuroses, or neurotic disorders, leave patients distressed, but there is no grave impairment of functioning or loss of self-insight, and contact with reality is maintained. Typical symptoms of the neuroses include obsessions and acute anxiety. Hysteria, often accompanied by symptoms of physical illness without physical causes, was once defined as a neurosis but is no longer recognized as a mental disorder by the American Psychiatric Association.

There is considerable mind–body interaction in psychological disorders. Delusions, phobias, hallucinations, anxiety, and other mental dysfunctions can be caused by physical substances, particularly alcohol, amphetamines, caffeine, nicotine, sedatives, and cocaine. The prolonged use of neuroleptic drugs (major tranquillizers) can produce movement disorders, including tremors, tics, and smacking of the lips. Dementia can also be caused by HIV infection, head injuries, or the onset of Alzheimer's disease.

Then there is the class of disorders named somatoform or psychosomatic. This class generally refers to the condition labelled ‘neurasthenic’ by earlier generations of physicians. Today some of the best known of these conditions are total allergy syndrome, chronic fatigue syndrome (the ‘Yuppie Flu’), and anorexia nervosa and bulimia. Symptoms vary from patient to patient, but nausea, lethargy, phobias, dyspepsia, malaise, and weight loss are often present, some at the same time. Until recently a widespread belief was that these disorders were due to a patient's unresolved mental conflict, possibly dating back to an earlier traumatic event, the awareness of which signalled a step towards cure. Other physicians prescribed rest and a medically-monitored regimen. However, with the rise of immunology since the 1960s numerous doctors and patients now believe that many of these symptoms can be traced to a viral origin.

The relationship between the body and another class of psychological disorders, the psychotic disorders like schizophrenia and the mood disorders like depression, is less evident. While an illness like postpartum depression patently corresponds to physical conditions, it is not clear what connections exist between the body and delusional disorders. The optimism surrounding the announcement, in the early 1990s, of the discovery of genes for schizophrenia and manic-depressive illness has subsided, though family histories still point to a hereditary dimension to these disorders. Recent research into brain biochemistry linking neurotransmitters to abnormal mood and thought functions has also sustained hope that more progress will gradually erode the ontological distinction between the mind and the central nervous system.

One of the most troublesome obstacles to a proper classification of psychological disorders is the fact that patients can often suffer from more than one disorder; for example, personality disorder and mental illness. This and other problems have hamstrung psychiatrists' efforts throughout history to agree on a truly natural classification of mental disorders. Certain national communities of psychiatrists, like the French, have developed idiosyncratic classifications, based as much on chauvinism as clinical reality. Many have also argued that the entire classification enterprise is hopelessly relativistic, that mental disorders are wholly determined by cultural and socio-political environments. But much progress has been made in developing a valuable taxonomy, starting with the impressive efforts of Emil Kraepelin around the turn of the twentieth century. With the growing hegemony of the DSM there are hopes that a common vocabulary for recording mental symptoms is emerging in the early twenty-first century.

Therapeutic hopes

If diagnostic progress is a realistic expectation, optimism about therapeutic progress may even be more glowing. For much of its history psychiatry has swung back and forth between mainly psychological and physical approaches to treating mental disorders.

In the early nineteenth century, when numerous recognizably modern mental hospitals (or ‘asylums’) were built throughout the Western world, psychiatrists tended to emphasize what would later be called ‘milieu therapy’ — that is, treatment based on the belief that an institutional environment exerted a huge influence on a patient's psychological state. But drug therapy never vanished from asylum medicine and in fact grew in popularity as the century wore on. With the emergence of Freudian psychoanalysis and similar theories of mental illness in the early twentieth century, there were renewed efforts to treat even severely psychotic patients with methods stressing non-physical therapies. At the same time psychiatrists and neurologists explored new and radical somatic treatments for long-term institutionalized patients, including electroshock, metrazol convulsion, malarial fever, insulin coma, and psychosurgical therapies. Many of these somatic treatments, however, died out when a series of new antipsychotic drugs were introduced, beginning with chlorpromazine in 1954. Despite studies that showed physical side effects of prolonged drug use, the pharmaceutical revolution of late-twentieth-century psychiatry shows few signs of being over. The controversy over the antidepressant Prozac, introduced in the early 1990s, underscores the fact that feelings run high on both sides of the debate.

Insanity and the arts

Psychological disorders have fascinated countless poets, novelists, painters, musicians, and playwrights throughout the ages, to say nothing of the public at large. Madness appears prominently in Shakespeare's plays, such as Hamlet and King Lear. James Boswell documented Samuel Johnson's melancholy. The madness of King George III attracted considerable attention and led to calls for more humane forms of treatment. The cultural profile of psychological disorders grew dramatically as the nineteenth century wore on. The Romantics in particular were deeply interested in madness, especially the mysterious boundaries between insanity and sanity and the curious combination of genius and madness in certain individuals. The writer Emile Zola took a more naturalist approach when he vividly described abnormal mental states in his Rougons-Macquart series of novels. The Shakespearean character Ophelia was a favourite topic for Victorian artists and writers interested in the impact of madness on women. Indeed, the whole issue of women and their mental and nervous illnesses — especially hysteria — produced a literary avalanche in the late nineteenth century, centering on the well-publicized studies by the neurologist Jean Martin Charcot and the clinical theories of his former student Sigmund Freud.

In the twentieth century the romanticization of psychological disorders continued. The rise of psychoanalysis did much to validate the contents of mental symptoms, including delusions. To a lesser extent, the philosophy of phenomenology triggered subjective attempts by psychiatrists to study human behaviour and thought. Later in the 1960s the Scottish psychiatrist R. D. Laing argued that the mentally ill were actually saner than the apparently normal. Others like Michel Foucault and Thomas Szasz, though they never went as far as Laing, attributed malicious motives to the mental health care professions past and present, thereby running the risk of depicting the mentally ill as unwarranted victims of abuse and undermining their status as patients with bona fide diseases. Hollywood films like Frances and One Flew Over the Cuckoo's Nest reinforced this trend. But since the 1970s this view has gradually declined in the face of the theory that psychological disorders are indeed illnesses.

Ian Dowbiggin