The Disordered Mind

George Graham

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781000172515
• Edition: 3
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

The Disordered Mind, Third Edition, is a wide-ranging introduction to the philosophy of mental disorder or illness. It examines and explains, from a philosophical standpoint, what mental disorder is: Its reality, causes, consequences, compassionate treatment, and more.

Revised and updated throughout, the third edition includes enhanced discussions of the distinction between mental health and illness, selfhood and delusions about the self, impairments of basic psychological capacities in mental disorder, and the distinct roles that mental causation and neural mechanisms play in mental illness.

The book is organized around four questions:

• What is a mental disorder or illness?

• What makes mental disorder something bad?

• What are various mental disorders and what do they tell us about the mind?

• What is mental health and how may it be restored?

Numerous disorders are discussed, including addiction, agoraphobia, delusion, depression, dissociative identity disorder, obsession-compulsion, schizophrenia, and religious scrupulosity, among others. Several neurological disorders are examined. Various problems associated with DSM-5 and with psychiatric diagnosis are explored. Including chapter summaries and suggestions for further reading, The Disordered Mind is an ideal text for courses in philosophy and should appeal to not just philosophers, but to readers in cognitive science, psychology, psychiatry, and related mental health professions.

1 Introduction

The problem of mental instability

Alice trusted Howard, her husband. She had reason for doing so. He was devoted to her. Or so she thought.

When Howard died unexpectedly, Alice, in preparing for his memorial service, opened his computer files only to discover that Howard had recently been leading a secret and complex second life. He had married another woman in another city, fathered a child with her, and periodically lived with both second wife and child, as he described things to Alice, while “out of town doing regular business in Kansas City.”

Alice’s grief over Howard’s death, which was profound, was mixed with anger and pain, which were deep. A positive interpretation of her husband’s character (such as “Howard was a good man. He loved me and our children, and I will miss him terribly”) would have led to a much better emotional and behavioral adjustment to the loss than her bitter negative evaluation (“He lied to me and to the children; I did not really know him”).

Alice fell into a protracted despondent mood. She was diagnosed with a major depressive disorder.

Ian believes that he is the victim of a government plot. He is convinced that he is the object of a conspiracy conducted by the Federal Bureau of Investigation (FBI). “The FBI believes that I am running a terrorist cell.” Ian refuses to leave his home for fear that he will be arrested. The business he owns, a men’s clothing store, is faltering in his absence. When asked to describe evidence of his being persecuted, Ian replies that he cannot discuss the matter lest federal agents overhear the conversation. “The shirts in my closets are bugged with voice detectors. The cuffs on my trousers contain electronic devices that signal my physical position to the FBI.” He is diagnosed with a paranoid delusional disorder.

What to do with the Alices and Ians of this world? How should they be understood? Treated? Sigmund Freud (1856–1939), the Austrian psychologist and founder of psychoanalysis, famously fretted over them. He tried to fathom the mind’s emotional and behavioral fault lines: The creaks, cracks, and crevices of persons mentally divided or disordered within themselves. Freud recognized that mentally disturbed human beings may, and sometimes do, reclaim mental health and well-being. People recover from a mental illness. (I use “mental disorder” and “mental illness” interchangeably throughout the book.) For Freud, however, there is a prudent precondition for taking wise and measured aim at reclamation or construction of mental health. This is not to set the bar for emotional and psychological well-being too high.

The philosopher Owen Flanagan eloquently writes of the “wish to flourish, to be blessed with happiness, to achieve Eudaimonia – to be a ‘happy spirit’” (Flanagan 2007: 1). If Flanagan is right, that’s a wish we all share. Truly to be happy. Wisely to be blessed. Freud, though, promoted a more modest aspiration. When asked by a despondent patient how he hoped to assist her in regaining mental well-being, he had this to say: “No doubt fate will find it easier than I do to relieve you of your illness. But you will be able to convince yourself that much will be gained if we succeed in transforming your hysterical misery into common unhappiness” (Breuer and Freud 2000: 305).

Common unhappiness? Was Freud being ironic? In part, yes. Mainly, however, he was trying to be pragmatic or realistic. The conditions or circumstances of human existence, Freud believed, are such that an absolutely healthy, unified, orderly, stable, trouble-free mental life is much too optimistic for a person to expect, whether recovering from a disorder or not. Why so? Why not absolute mental health, behavioral and emotional well-being? Why not total and pure flourishing? Because, he said, “our body is doomed to decay and dissolution, the external world [rages] against us,” and suffering comes from our relations with other people. “The suffering which comes from this … source is perhaps more painful to us than any other” (Freud 1989/1930: 26). We are psychologically vulnerable and unstable creatures, whom the vicissitudes and tragedies of life may inevitably wear down or pull apart. As persons we must therefore try to live dignified, productive lives, all the while remaining susceptible to periods, perhaps pronounced or protracted periods, of distress, discord, and mental instability.

In order to elicit an intuitive sense of our vulnerability to instability or distress, consider a brief thought experiment. The experiment is counter-factually presumptuous to be sure. Contrary-to-fact presumption, however, is no impediment to human imagination.

Suppose you are none other than Mother Nature, although endowed with powers of deliberation, foresight, and decision making of which she herself in her actual or factual form is not a party. Imagine that humankind has yet to appear on the earthen landscape. You wish to build the sort of human mind that will help us as persons to engage with life on the planet and with each other. You are not going to rely on Father Time to do this. (He takes forever.) No supernatural or divine agent is behind your efforts. You are, as you conceive of the task, utterly on your own.

Suppose you think of two possible kinds of minds. Think of these as a stable and an unstable mind. You picture each as follows.

The stable mind. A human mind that is inherently stable and orderly. It possesses purity of heart and soundness of reason. It does things because it believes them to be desirable and is willing to face down the often and unanticipated aversive consequences of its actions. It assesses itself with equanimity, free of regret and self-doubt. It never loses control of itself. When entering into interpersonal relationships, it aims to insure that these are harmonious, coordinated, and cooperative. When it confronts the vicissitudes of life, chronic pain, physical illness, and death, it does so with courage and fortitude. It loves with magnanimity, dreams contentedly, and is anchored in a firm sense of personal dignity and self-respect. Its life, far from being an anarchic master, is the object of single-minded dedication and intelligent direction.

The unstable mind. A human mind that is inherently unstable and disorderly. It possesses conflicting motives, impulses, and inhibitions as well as biases of thought and impediments to reason. It does things because it believes them to be desirable, but often is unwilling to accept the negative consequences of its actions and frequently is conflicted or befuddled about just what is reasonable or desirable. It is prone to regret and self-doubt. It frequently loses its grip on itself. When it enters into social relationships, its agency is prone to be disharmonious, discordant, and uncooperative. When it confronts the vicissitudes and heartaches of life, it seeks refuge or escape. It loves with rapturous passion but also with breath-taking infelicity and self-destructive inconstancy. Its self-criticisms are harsh and unforgiving. The demands of life drive it into disarray and dissolution.

Which sort of mind would you make if you were the imagined Mother Nature? “An absolute no-brainer,” you say. “The answer is utterly obvious. Stability, most certainly.” True, stability lacks high drama. Its theatricality is thin. Instability, however, is riddled with dissonance and burdened with discomfort and unhappiness. It is also, of course, grossly incompatible with the desired ends of your creation. An utterly unstable mind could never do philosophy or do so sagaciously. Discover cures? Found universities? What sort of academic institutions would these be like? (If you answer, “Like those that exist today,” then you must be a professional academic.)

What has the real (not hypothetical) Mother Nature actually done – not intentionally of course, for the actual forces of Mother Nature are mindless? Here’s what, to the naked anthropological eye, she has designed for us. She has composed a type of mind that is both stable and unstable. She has mixed each form of mentality in us. She has made us orderly and disorderly, content and discontent, courageously facing life’s vicissitudes but also at times seeking cowardly refuge. True, some folks are more temperamentally secure than others. True, some people are much less able to undergo various trials and tribulations than others. But beneath our individual differences, however, is a fusion of both. Each of us is endowed with a stable/unstable mind. No person has all of the one but none of the other. Even the most unstable or discordant individual is not without some slice or sliver of stability. Even the most stable is not without a shadow or sway of instability.

Periodically, of course, instability holds total or near-total dominance. When it does so, we become anxious about small things, develop imprudent patterns of thought, and slip or slide into emotional conflicts. Small influences may unhinge a person. Then, in more sadly serious cases, dissonance, distress, and disturbance may seize truly powerful and persistent dominion. A person’s mind may break down or become disordered or mentally ill in a psychiatric or clinical sense. One or more mental capacities or psychological faculties may dissemble into harmful or hurtful incapacity, dysfunction, or impairment. Thoughts may become obsessive, preferences addictive, perceptions hallucinatory, beliefs delusional, and post-traumatic amnesia may impose ignorance on significant parts of one’s past. Paralyzed by phobic anxiety, a person may avoid any and all public places. Numbed by major depression, an individual may listlessly disengage from people and projects once held near and dear.

Mental disorder, depending on its pulse and purport, may require professional mental health treatment or clinical address. One hopes that assistance is sound and sensible, but treatment and attention are unhelpful and even dangerous when resting on false or improper assumptions about mind and illness. The history of medical treatment for mental disorder is a chequered affair. It is benevolent, informed, and sensitive on occasion, given the state of medical knowledge at a time or in a culture. But other chapters in that history are characterized by superstition, ignorance, intolerance, and inhumanity.

The history of theory and treatment for mental illness is recounted in numerous texts. This is no place to repeat the history here. To help us to begin the present book, I do, however, want briefly to sketch more recent phases. This short historical sketch helps to show why it’s important to have a sound and sensible philosophy of mental disorder. We will then examine the ways in which the subject of philosophy may contribute to human understanding of mental disorder.

Recent psychiatry

In the late nineteenth and early twentieth century in Western Europe the category of mental illness or disorder was applied only to the most serious problems and pathologies of mentality, viz., those identified, in effect, with psychoses, severe manias, and depressions. Emil Kraepelin (1856–1926), arguably the leading psychiatric taxonomist of the period, attended primarily to three main types of disorder. Kraepelin spoke of dementia praecox (roughly, schizophrenia), depressive illness, and paranoia, a term he used broadly to refer to delusional disorders (one form of which is persecutory). For him mental illnesses fell into a small set of discoverable types, identified by symptoms and family history. Hospitals and asylums purported to treat (even if all that they sometimes succeeded in doing was to house patients in a custodial manner) persons with such illnesses. Most people who wished help for less severe or disabling disturbances, which went by names such as “nerves,” “neurasthenia,” or “hysteria,” did so with general medical practitioners. These were doctors who did not identify themselves as specialists in mental health. Rest and diet were popularly recommended cures for less severe cases. For the wealthy but worried well, occasional respites at health spas aimed to regenerate their spirits. For all battered souls, the clergy were available for counseling.

Then, later into the early twentieth century, mental illness diagnosis and treatment underwent a dramatic transformation. Freud was a major force for change. He and his disciples helped to turn clinical insight and therapeutic resource into a distinct medical specialty. This field is now known, of course, as psychiatry.

Freud published his first major work, The Interpretation of Dreams, in 1900 (1958 [1900]). He died in 1939. By the time of his death, in the words of Rutgers University’s Allan Horwitz, “the most basic ways of thinking about mental disorder had changed” (2002: 40). Psychiatry had become a distinct specialty within medicine. Its range or breadth of application had expanded to consider less severe disturbances than psychosis or incapacitating depression. The mental malaises or psychological infirmities that formed the focus of Freud’s psychological theory, such as anxiety, obsession, and sexual frigidity, were described as manifestations of unconscious conflicts festering within the lives of all human beings: The severely ill, the worried well (or non-severely ill), and even the well. The primary function of therapy or treatment was to uncover those hidden conflicts and the manners in which people effectively adjust, or fail to adjust, to social and cultural demands. Some attention was given to diagnosis and to identifying categories of disorder, but one and the same set of symptoms or patient complaints was thought, in theory, to stem from just about any form of disorder. So, taxonomic labels failed to carry uniform and reliable conditions of application. Chronic fatigue, headaches, and weight loss may signify obsession in one individual, phobia in a second person, or sexual frigidity in a third. Horwitz aptly sums up Freudian diagnostic practice: “only deep, extensive, and intensive exploration of the individual personality could indicate the true meaning of any symptomatic presentation” (2002: 45).

Freudian thought was widely endorsed and medically institutionalized. It dominated thinking about mental disorder until the 1960s, when it fell into quite rapid decline. The organizational, economic, and social situation of psychiatric medicine, once again, underwent a transformation. Weaknesses in the Freudian framework became apparent. To be sure, Freudian psychology was not well suited for understanding the nature of, and best treatment for, truly severe psychoses (Beam 2001; Hobson and Leonard 2001). A desire for detailed and reliable clinical diagnosis became widespread (Horwitz 2002; Bentall 2004). Psychiatry grew biomedical. Not without dissenters. (In Britain, R. D. Laing was one of the more prominent opponents of the biomedicalization of psychiatry.) But overall the field became convinced that patient distress and complaint were symptoms of specific and tractable illness types or disease categories, much like somatic or bodily illnesses, though housed in the brain. A proliferating range of ailments of consciousness and behavior were thought to merit classification as distinct and distinguishable disorders.

Drugs emerged as critical for the understanding and treatment of mental disorder. In many cases they were regarded as the first line of treatment. The aim was to restore biochemical functionality or normality to a neural base of mental disorder and to reduce symptoms. Chlorpromazine was introduced in the 1950s for the treatment of severe psychoses like schizophrenia. Monoamine oxidase inhibitors and tricyclics were widely deployed for the treatment of major depression. Presuppositions of drug therapy – foremost, the assumption that specific illnesses require specific drugs – imply that it makes a difference for care and treatment whether a set of symptoms is diagnosed as, say, clinical depression or schizophrenia. Depression should be targeted with one drug. Schizophrenia addressed with another. No longer was one Freudian style of therapy sufficient for all disorders.

References to Freudian phenomena such as “repression,” “sublimation,” and “oedipal dilemma,” as well as to the Freudian unconscious, were charged with being unscientific and clinically unsound (Grunbaum 1984; Horwitz 2002). Freudians, as they do today, continued to function in the profession, although Freudian-style psychiatry and its conceptual brethren moved to the perimeter of psychiatric medicine. Freud was often cast as a scapegoat for problems or false starts in the profession. Psychiatry as a profession did not blame Freud for contributing to its social and cultural prominence. Few professions lament prominence. Freud, however, was criticized for burdening the specialty with opaque concepts and elusive forms of clinical treatment. No doubt, certain effective counter-criticisms of the anti-Freudian momentum in psychiatry were willfully ignored (Lear 1998: 23). But non-Freudian biomedical trends became secure. Fine-grained diagnostics and illness-specific medication became the prescribed aspiration of the medical specialty.

The twentieth century has ended, of course, and the twenty-first has more than begun. Understanding and treatment of mental illness are in post-Freudian biomedical full bore. Psychiatry has moved from the language of mind and mentality to that of brain science, or to mixes of languages of mind and brain science, in fields such as cognitive neuroscience and cognitive neuropsychiatry, but in which brain science more or less is the aspirational canonical tongue. Preference for reference to the neural is close to holding the day. The methods and manner of neuroscience, it is widely presumed, offer the best ultimate understanding of and treatment for a mental disorder. It is only a matter of time, some say, before psychiatry will become a sub-discipline of neurology (Ramachandran 2003).

Indeed, sub-disciplinary status for psychiatry just is what one prominent observer says has already taken place. In the words of M. A. Taylor: “Psychiatry and neurology [is] one specialty” (Taylor 1999: viii). Taylor adds: “Mental illness is not ‘mental’ at all, but the behavioural disturbance associated with brain dysfunction and disease” (Taylor 1999: viii).

To be sure, interest in the brain is not new to psychiatry. When Wilhelm Griesinger (1817–1868), a professor of psychiatry at the University of Berlin, authored the first editorial of the Archives for Psychiatry and Nervous Disease, a journal he founded in 1867, he wrote: “Patients with so-called ‘mental illnesses’ are really individuals with illnesses of the nerves and brain” (see B...