Sociology of Mental Disorder

William C. Cockerham

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781000215045
• Edition: 11
• Topic: Sozialwissenschaften
• Subtopic: Soziologie

The eleventh edition of Sociology of Mental Disorder presents the major issues and research findings on the influence of race, social class, gender, and age on the incidence and prevalence of mental disorder. The text also examines the institutions that help those with mental disorders, mental health law, and public policy.

Many important updates are new to this edition:

-DSM-5 is thoroughly covered along with the controversy surrounding it.

-Updated review of the relationship between mental health and gender.

- A revised and more in-depth discussion of mental health and race.

-Problems in public policy toward mental disorder are covered.

-International trends in community care are reviewed.

-Updates of research and citations throughout.

Chapter 1

Madness and Society

Photo 1.1

Mental disorder affects the lives and well-being of millions of people throughout the world. The exact number of persons who suffer from some form of it is not known, but the most recent estimate from the World Health Organization (2017) is that about one in every four persons in the world will have a mental disorder in their lifetime. On any particular day, the WHO finds that some 10 percent of all adults worldwide are experiencing a mental disorder. So while many people escape such problems, obviously, many others do not, which makes severe mental distress an important social concern.

For the United States, three major surveys—the Epidemiologic Catchment Area (ECA) study of the early 1980s, the National Comorbidity Survey (NCS) of the early 1990s (1990–1992), and its replication (NCS-R) a decade later (2001–2003)—suggest that anywhere from one-third to nearly one-half of the U.S. adult population between the ages of 18 and 54 years has a diagnosable mental disorder. In a reanalysis of the NCS-R study a few years later, Ronald Kessler and Philip Wang (2008; Kessler 2013) found that approximately half the U.S. population (46.4%) meet the criteria for one or more mental disorders in their lifetimes, and about one-fourth of the population meets the criteria in any given year. Most people experiencing a mental health problem were found to have their first onset in childhood or adolescence.

Although it might seem shocking that so many people have or will have a mental disorder in their lifetime, Kessler (2010) maintained that it is not really so remarkable. This is because classification categories are very broad and include many disorders that are either self-limiting or mild problems of a nonserious nature. “It should be no more surprising,” says Kessler (2010:59), “to find that half the population have met criteria for one or more of these disorders in their lifetime than to find that the vast majority of the population have had the flu or measles or some other common physical malady at some time in their life.”

Thus, it seems according to this all-encompassing definition that mental disorders are not unusual in society, as practically everyone becomes depressed, sad, or anxious sometime. Of course, the extent to which such moods and feelings actually constitute a clinical case of mental disorder is subject to debate. Some researchers believe these estimates are far too high (Wakefield and Schmitz 2017). One reexamination of the ECA and the first NCS studies, for example, produced a much lower but still substantial figure of 18.5 percent of all adults between 18 and 54 years of age with a mental disorder (SAMHSA 2013).

When it comes to serious mental disorders, the National Center for Health Statistics (2019a) estimated that in 2018 some 3.9 percent of the adult population age 18 or older, had experienced such an affliction in a past 30-day period. But the fact remains that the true prevalence or the extent of mental disorder is unknown. Most afflicted people do not come to the attention of reporting agencies, and community investigators face a multitude of problems in obtaining fully reliable data on the extent of mental disorders in non-institutionalized populations. Although the number of patients receiving treatment in mental hospitals and outpatient mental health facilities can be determined, others in the community with mental health problems not undergoing care often go undetected. Nevertheless, enough evidence is available to show that mental disorder is a major social problem throughout the world (World Health Organization 2017).

The extent of mental disorder and the high social and economic costs associated with it are considerable. But what is truly the most damaging aspect of mental illness is its shattering effect on its victims and their families. Suicide, divorce, alcoholism and drug abuse, unemployment, violence to self and others, child abuse, damaged social relationships, and wasted lives, not to mention the incalculable pain and mental anguish suffered by those involved, are among the consequences of mental illness. In these respects, mental disorder can be regarded as a terrible affliction for many people in the United States and elsewhere in the world.

With increasing numbers of studies uncovering a significant relationship between social factors and many psychiatric conditions, the study of mentally disturbed behavior has become an important area of research in sociology. A substantial body of evidence has accumulated over the past several decades, supporting the conclusion that the social environment has important consequences for mental health (Aneshensel, Phelan, and Bierman 2013; Scheid and Wright 2017). Unlike psychiatrists and clinical psychologists, who usually focus on individual cases of mental disorder, sociologists approach the subject of mental abnormality from the standpoint of its collective nature; that is, they typically analyze mental disorder in terms of group and larger societal processes and conditions that affect people and their mental state. What sociologists primarily do is investigate the consequences of social structures and relationships on mental health with the goal of identifying those aspects of society and social life that cause harm.

In a social context, mental disorder is seen as a significant deviation from standards of behavior generally regarded as normal by the majority of people in a society. The relevance of this perspective for our understanding of mental disorder is that even though a pathological mental condition is something that exists within the mind of an individual, the basis for determining whether a person is mentally ill often involves criteria that are also sociological. A psychiatric finding of generalized impairment in social functioning involves an understanding of such sociological concepts as norms, roles, and social status that establish and define appropriate behavior in particular social situations and settings. It is the disruption or disregard of the taken-for-granted understandings of how people should conduct themselves socially that causes a person’s state of mind to be questioned. Consequently, it is the overt expression of a person’s disordered thinking and activity as social behavior that ultimately determines the need for psychiatric treatment in most cases.

This situation has attracted sociologists to the study of mental disorder and has led to its development as a specialized area of sociological research. The sociology of mental disorder is generally viewed as a subfield of medical sociology. In fact, it was the funding and encouragement of the National Institute of Mental Health during the late 1940s that stimulated the development and rapid expansion of medical sociology in the United States. Therefore, from its most important beginnings, the sociology of mental disorder has been linked to medical sociology. Yet, despite its status as a subfield within medical sociology, the sociology of mental disorder has acquired an extensive literature containing significant theoretical concepts and applied knowledge of the human condition. In recognition of this development, the American Sociological Association sponsored a new research journal, Society and Mental Health, which first appeared in 2011 and focuses on the sociology of mental disorder. The purpose of this book, accordingly, is to provide an updated overview of the field for students, sociologists, health practitioners, and others interested in and concerned with the social aspects of mental disorder.

Defining Mental Disorder

Before proceeding, we should first define mental disorder. This is no easy task, as numerous definitions, many of them insufficient, have been offered over the years. In an effort to resolve this situation several years ago and formulate a precise concept for the American Psychiatric Association, Robert Spitzer and Paul Wilson (1975) began by asking (1) whether certain mental conditions should be regarded as undesirable; (2) how undesirable these mental conditions should be to warrant being classified as mental disorders; and (3) even if undesirable, whether the conditions in question should be treated within the domain of psychiatry or by some other discipline.

Some psychiatrists define mental disorder very broadly as practically any significant deviation from some ideal standard of positive mental health. This view, as pointed out long ago by Thomas Szasz (1974, 1987), a psychiatrist and long-standing critic of his profession, would regard any kind of human experience or behavior (e.g., divorce, bachelorhood, childlessness) as mental illness if mental suffering or malfunction could be detected. Other psychiatrists, in contrast, subscribe to a narrower definition of mental disorder, which views the condition as being only those behaviors that are clearly highly undesirable. Behaviors that are merely unpleasant would not be considered mental illness. This narrower definition would encompass those mental abnormalities such as schizophrenia, depressive or anxiety disorders, or an antisocial personality, which Spitzer and Wilson (1975:827) describe as “manifestations which no one wants to experience—either those persons with the conditions or those without them.” This latter approach appears more realistic.

The problem of defining mental disorder is further complicated by the fact that concepts of mental disorder change. For example, homosexuality was considered a mental disorder by American psychiatrists until the early 1970s, but is not considered such today after lobbying to have it removed (Whooley 2019). Terms such as melancholia (depression), amentia (mental retardation), hysteria (conversion disorder), and moral insanity (for people who were not truly insane but were thought to be amoral and perverted) are no longer used. Yet they were major classifications of mental disorders at one time or another during periods ranging from ancient Greece to the twentieth century. Another example is neurosis, which used to be a major behavioral disorder characterized by chronic anxiety, but now has its various subtypes classified under depressive, anxiety, somatic symptom, or dissociative disorders.

Surprisingly, neither standard textbooks in psychiatry nor the first and second editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) defined mental disorder. Spitzer, a research psychiatrist who headed the American Psychiatric Association’s Task Force on Nomenclature and Statistics charged with developing DSM-III, addressed this problem and subsequent editions have done likewise. According to Spitzer (Spitzer and Wilson 1975:829), mental disorder can be defined as follows: (1) it is a condition that is primarily psychological and alters behavior, including changes in physiological functioning if such changes can be explained by psychological concepts, such as personality, motivation, or conflict; (2) it is a condition that in its “full-blown” state is regularly and intrinsically associated with subjective stress, generalized impairment in social functioning, or behavior that one would like to stop voluntarily because it is associated with threats to physical health; and (3) it is a condition that is distinct from other conditions and that responds to treatment.

Of the three criteria just described, the first separates psychiatric conditions from nonpsychiatric conditions. The second specifies that the disorder may be recognizable only in a later stage of its development (full-blown) and that its identification depends upon consistent symptomatology regularly associated with the disorder. Spitzer also says that the disorder must arise from an inherent condition and that the impairment in functioning must not be limited to a single situation, but should include an inability to function in several social contexts (generalized impairment in social functioning). The second criterion also includes “behavior that one would like to stop voluntarily,” for instance, compulsive eating or smoking, or hearing imaginary voices in one’s head. The third criterion places the definition within a medical perspective by limiting it to distinct treatable conditions. This view continued to be followed through DSM-IV and the revised DSM-IV-TR (American Psychiatric Association 2000), but is simplified in DSM-5 (American Psychiatric Association 2013). The new and more generic definition in DSM-5 narrows the definition of mental disorder to that of a significant dysfunction in a person’s mental processes (Horwitz 2020; Wakefield and Schmitz 2017). The DSM-5 (2013:20) defines a mental disorder as follows:

A mental disorder is a syndrome characterized by a clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress and or disability in social, oc...