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pink glassesThe Norwegian philosopher Peter Wessel Zapffe argued, essentially, that the human capacities for reason and self-awareness break with nature, giving us more than we, as a part of nature, can carry. So as not to go mad, ‘most people learn to save themselves by artificially limiting the content of consciousness.’

People not only limit the content of consciousness, but also fill it with less than the truth. In particular, most people think more highly of themselves than is warranted: they have an inflated sense of their qualities and abilities, an illusion of control over things that are mostly beyond them, and a misplaced optimism about their outcomes and prospects.

For example, most people claim to compare favourably to the average road user, citizen, parent… which is, of course, mathematically impossible, since not everyone can be above average. A couple on the verge of tying the knot is likely to overestimate the odds of having a carefree honeymoon or a gifted child, while underestimating the odds of having a miscarriage, falling ill, or getting divorced.

The concept of positive illusions first appeared in 1988, in a paper by Shelley Taylor and Jonathon Brown entitled, Illusion and well-being: A social psychological perspective on mental health. Still today, it is commonly believed that mental health corresponds to accurate perceptions of the self, the other, and the world, but in their paper Taylor and Brown argued that the evidence suggests otherwise, and that positive illusions are characteristic of normal human thought.

Positive illusions are helpful in so far as they enable us to take risks, invest in the future, and fend off despair and depression. After all, how many people would get married if they had any real sense of what awaited them? But in the longer term, the poor perspective and judgement that come from undue self-regard and false hope are likely to lead to disappointment and failure, to say nothing of the inhibitions and emotional disturbances (such as anger, anxiety, and so on) that can derive or descend from a defended position.

Positive illusions tend to be more common, and more marked, in the West. In East Asian cultures, for example, people are less vested in themselves and more vested in their community and society, and tend, if anything, to self-effacement rather than self-enhancement.

Positive illusions are also more prevalent in unskilled people, possibly because highly skilled people tend to assume, albeit falsely, that those around them enjoy similar levels of insight and competence. This Dunning-Kruger effect, as it has been called, is neatly encapsulated in a short fragment from the introduction to Darwin’s Descent of Man: ‘…ignorance more frequently begets confidence than does knowledge…’ And, of course, it may also be that, compared to highly skilled people, unskilled people are more reliant on positive illusions for their self-esteem and broader mental health.

Depressive realism

Just as it is commonly believed that mental health corresponds to accurate perceptions of the self, the other, and the world, so it is commonly believed that depression results in, or results from, distorted thinking.

‘Cognitive distortion’ is a concept from cognitive-behavioral therapy (CBT), developed by psychiatrist Aaron Beck in the 1960s and routinely used in the treatment of depression and other mental disorders. Cognitive distortion involves interpreting events and situations so that they conform to and reinforce our outlook or frame of mind, typically on the basis of very scant or partial evidence, or even no evidence at all.

Common cognitive distortions in depression include selective abstraction, personalization, and catastrophic thinking:

  • Selective abstraction is to focus on a single negative event or condition to the exclusion of other, more positive ones, for example, ‘My partner didn’t call me yesterday. He must hate me.’
  • Personalization is to relate independent events to oneself, for example, ‘The nurse is leaving her job because she’s fed up with me…’
  • Catastrophic thinking is to exaggerate the negative consequences of an event or situation, for example: ‘The pain in my knee is only going to get worse. When I’m reduced to a wheelchair, I won’t be able to go to work and pay the mortgage. So I’ll end up losing my house and dying in the street.’

However, the scientific literature suggests that, despite their propensity for such cognitive distortions, many people with depressed mood can also have more accurate judgement about the outcome of so-called contingent events (events that may or may not occur) and a more realistic perception of their role, abilities, and limitations—a phenomenon that is sometimes, and controversially, referred to as ‘depressive realism’.

The concept of depressive realism originated in 1979, in a paper entitled Judgment of contingency in depressed and nondepressed students: sadder but wiser? On the basis of their findings, the authors, Lauren Alloy and Lyn Abramson, argued that people with depression make more realistic inferences than ‘normal’ people, who are handicapped by their positive illusions. On the face of it, this suggests that people with depression are able to see the world more clearly for what it is, while normal people are only normal in so far as they are deceiving or deluding themselves.

This is a seductive proposition for someone like me, who has long been arguing that depression can be good for us—for example, in my book, The Meaning of Madness. But here’s the rub: people with depression are pessimistic even in situations in which pessimism is unwarranted, suggesting that, rather than being more realistic, their thinking is merely ‘differently biased’, and just as rigid and distorted as that of normal people with their positive illusions.

Wisdom, it seems, consists in being able to shed our positive illusions without also succumbing to depression, although, for many, depression may be a necessary step along the way.

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crown

The hallmark of narcissistic personality disorder is grandiosity. The narcissist harbors a strong sense of entitlement, self-aggrandizing fantasies, and a craving for admiration. In severe cases, she may be envious, lacking in empathy, and ready to exploit others in the pursuit of her lofty ambitions. Although she can be charismatic and charming, she more often seems self-absorbed, controlling, and insensitive. If she feels slighted or ridiculed, she might be provoked into a fit of destructive rage and revenge seeking. Such a paroxysmal reaction is sometimes called ‘narcissistic rage’ and can have disastrous consequences for all those involved, including the narcissist herself.

In the novel The Picture of Dorian Gray, both the characters of Lord Henry Wooton and Dorian Gray are strongly narcissistic. Lord Henry’s narcissism is insightful and often quite charming and no doubt similar to that of his creator and alter ego, Oscar Wilde.

I make a great difference between people. I choose my friends for their good looks, my acquaintances for their good characters, and my enemies for their good intellects. A man cannot be too careful in the choice of his enemies. I have not got one who is a fool. They are all men of some intellectual power, and consequently they all appreciate me.

On the other hand, Dorian Gray’s narcissism is cold and destructive, leading, among other things, to the suicide of actress Sibyl Vane. In Chapter 7, Sibyl tells Dorian that he brought her to “something [higher] of which all art is but a reflection” and made her understand the nature of true love. Instead of feeling flattered or humbled or otherwise moved, Dorian castigates Sibyl for her poor acting, claiming that it has killed off any love that he might ever have had for her.

‘Yes,’ he cried, ‘you have killed my love. You used to stir my imagination. Now you don’t even stir my curiosity. You simply produce no effect. I loved you because you were marvellous, because you had genius and intellect, because you realized the dreams of great poets and gave shape and substance to the shadows of art. You have thrown it all away. You are shallow and stupid. My God! How mad I was to love you! What a fool I have been! You are nothing to me now. I will never see you again. I will never think of you. I will never mention your name. You don’t know what you were to me, once. Why, once… Oh, I can’t bear to think of it! I wish I had never laid eyes upon you! You have spoiled the romance of my life…’

A study carried out by Board and Fritzon at the University of Surrey in England found that narcissistic personality disorder, histrionic personality disorder, and another personality disorder called anankastic personality disorder are actually more common in high-level executives than in mentally disordered criminal offenders at the high-security Broadmoor Hospital.

This suggests that people commonly benefit from strongly ingrained and potentially maladaptive personality traits. For example, people with narcissistic personality disorder may be highly ambitious, confident, driven, and able to exploit people and situations to maximum advantage. People with histrionic personality disorder may be adept at charming and manipulating others, and thus adept at building and exercising business relationships.

In their study, Board and Fritzon described the executives with a personality disorder as ‘successful psychopaths’ and the criminal offenders as ‘unsuccessful psychopaths,’ and it may be that highly successful people and disturbed psychopaths have more in common than first meets the eye. As the psychologist and philosopher William James put it more than a hundred years ago, ‘When a superior intellect and a psychopathic temperament coalesce… in the same individual, we have the best possible condition for the kind of effective genius that gets into the biographical dictionaries.’

Over in the United States, Mullins-Sweatt and her colleagues investigated how successful psychopaths might differ from unsuccessful ones. They asked several members of the psychology and law division of the American Psychological Association, professors of clinical psychology, and criminal attorneys to first identify and then to rate and describe one of their acquaintances (if any) who could be counted as successful and also conformed to psychologist Robert Hare’s definition of a psychopath:

…social predators who charm, manipulate and ruthlessly plow their way through life… Completely lacking in conscience and feeling for others, they selfishly take what they want and do as they please, violating social norms and expectations without the slightest sense of guilt or regret.

From the responses that they collated, the researchers found that successful psychopaths matched unsuccessful ones in all respects but one: conscientiousness. So, it seems that the key difference between unsuccessful and successful psychopaths is that the former behave impulsively and irresponsibly, whereas the latter are able to inhibit or at least restrain destructive tendencies and build on their achievements.

Narcissistic personality disorder is, of course, named for the Greek myth of Narcissus, of which there are several versions. In Ovid’s version, which is the most commonly related, the nymph Echo falls in love with Narcissus, a youth of extraordinary beauty. As a child, Narcissus was prophesized by Teiresias, the blind prophet of Thebes, to ‘live to a ripe old age, as long as he never knows himself’.

One day, Echo followed Narcissus through the woods as he hunted for stags. She longed to speak to him but dared not utter the first word. Overhearing her footsteps, the youth cried out, “Who’s there?” to which she responded, “Who’s there?” When at last she revealed herself, she rushed to embrace Narcissus, but he scorned her and pushed her away—just, in fact, as Dorian did Sibyl. Echo spent the rest of her life pining for Narcissus and slowly withered away until there was nothing left of her but her voice.

Some time after his encounter with Echo, Narcissus went to quench his thirst at a pool of water. Seeing his own image in the water, he fell in love with it. But each time he bent down to kiss it, it seemed to disappear. Narcissus grew ever more thirsty, but would not leave or disturb the pool of water for fear of losing sight of his reflection. In the end, he died of thirst, and there, on that very spot, appeared the narcissus flower, with its bright face and bowed neck.

What does this myth mean? On one level, it is an admonition to treat others as we would ourselves be treated, and in particular to be considerate in responding to the affections of others, which, as with Echo, are often so raw and visceral as to be existential. After being rejected by him, poor Echo had no self and no being outside of Narcissus, and ‘slowly withered away until there was nothing left of her but her voice’.

On another level, the myth is a warning against vanity and self-love. Sometimes we get so caught up in ourselves, in our own little egos, that we lose sight of the bigger picture and, as a result, pass over the beauty and bounty that is life. Paradoxically, by being too wrapped up in ourselves, we actually restrict our range of perception and action and, ultimately, our potential as human beings. And so, in some sense, we kill ourselves, like so many ambitious or self-centered people. Treating other people badly is a sure sign that we are still trapped in ourselves.

Teiresias prophesized that Narcissus would ‘live to a ripe old age, as long as he never knows himself’, because to truly know oneself is also to know that there is nothing to know. Our self, our ego, is nothing but an illusion, nothing more substantial than the ever-receding reflection that Narcissus was unable to grasp. Ultimately, Narcissus’s ego’s boundaries dissolved in death and he merged back into the world in the form of a flower. In Greek myth, the hero—Theseus, Hercules, Odysseus—has to die and travel through the underworld (the unconscious) before re-emerging as a hero. He has to conquer himself, to die to himself, to become more than merely human.

Echo had not enough ego, and Narcissus far too much. The key is to find the right and dynamic equilibrium, to be secure in oneself and yet to be able to dissociate from the envelope that we happen to have been born into.

References

  • Board BJ and Fritzon KF (2005): Disordered personalities at work. Psychology, Crime and Law 11:17-23.
  • James W (1902): The Varieties of Religious Experience, Lecture 1 ‘Religion and Neurology’, Footnote 6.
  • Mullins-Sweat S et al. (2010): The Search for the Successful Psychopath. Journal of Research in Personality 44:554-558.

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Is the medicalization of human suffering doing more harm than good?

‘Mental disorder’ is difficult to define.

Generally speaking, mental disorders are conditions that involve either loss of contact with reality or distress and impairment. These experiences lie on a continuum of normal human experience, and so it is impossible to define the precise point at which they become pathological.

What’s more, concepts such as borderline personality disorder, schizophrenia, and depression listed in classifications of mental disorders may not map onto any real or distinct disease entities. Even if they do, the symptoms and clinical manifestations that define them are open to subjective judgement and interpretation.

In an attempt to address these problems, classifications of mental disorders such as DSM-5 and ICD-10 adopt a ‘menu of symptoms’ approach, and rigidly define each symptom in technical terms that are often far removed from a person’s felt experience. This encourages mental health professionals to focus too narrowly on validating and treating an abstract diagnosis, and not enough on the person’s distress, its context, and its significance or meaning.

Despite using complex aetiological models, mental health professionals tend to overlook that a person’s felt experience often has a meaning in and of itself, even if it is broad, complex, or hard to fathom. By being helped to discover this meaning, the person may be able to identify and address the source of his distress, and so to make a faster, more complete, and more durable recovery. Beyond even this, he may gain important insights into himself, and a more refined and nuanced perspective over his life and life in general. These are rare and precious opportunities, and not to be squandered.

A more fundamental problem with labelling human distress and deviance as mental disorder is that it reduces a complex, important, and distinct part of human life to nothing more than a biological illness or defect, not to be processed or understood, or in some cases even embraced, but to be ‘treated’ and ‘cured’ by any means possible—often with drugs that may be doing much more harm than good. This biological reductiveness, along with the stigma that it attracts, shapes the person’s interpretation and experience of his distress or deviance, and, ultimately, his relation to himself, to others, and to the world.

Moreover, to call out every difference and deviance as mental disorder is also to circumscribe normality and define sanity, not as tranquillity or possibility, which are the products of the wisdom that is being denied, but as conformity, placidity, and a kind of mediocrity.

The evolution of the status of homosexuality in the classifications of mental disorders highlights that concepts of mental disorder can be little more than social constructs that change as society changes. PTSD, anorexia nervosa, bulimia nervosa, depression, and deliberate self-harm (non-suicidal self-injury) can all be understood as cultural syndromes. Yet, for being in the DSM and ICD, they are usually seen, and largely legitimized, as biological and therefore universal expressions of human distress.

Other pressing problems with the prevalent medical model is that it encourages false epidemics, most glaringly in depression, bipolar disorder, and ADHD. Data from the US National Health Interview Survey indicate that, in 2012, 13.5% (about 1 in 7) of boys aged 3-17 had been diagnosed with ADHD, up from 8.3% in 1997. It also encourages the wholesale exportation of Western mental disorders and Western accounts of mental disorder. Taken together, this is leading to a pandemic of Western disease categories and treatments, while undermining the variety and richness of the human experience.

For example, in her recent book, Depression in Japan, anthropologist Junko Kitanaka writes that, until relatively recently, depression (utsubyō) had remained largely unknown to the lay population of Japan. Between 1999 and 2008, the number of people diagnosed with depression more than doubled as psychiatrists and pharmaceutical companies urged people to re-interpret their distress in terms of depression. Depression, says Kitanaka, is now one of the most frequently cited reasons for taking sick leave, and has been ‘transformed from a rare disease to one of the most talked about illnesses in recent Japanese history’.

Many critics question the scientific evidence underpinning such a robust biological paradigm and call for a radical rethink of mental disorders, not as detached disease processes that can be cut up into diagnostic labels, but as subjective and meaningful experiences grounded in personal and larger sociocultural narratives.

Unlike ‘mere’ medical or physical disorders, mental disorders are not just problems. If successfully navigated, they can also present opportunities. Simply acknowledging this can empower people to heal themselves and, much more than that, to grow from their experiences.

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Generally speaking, culture-specific, or culture-bound, syndromes are mental disturbances that only find expression in certain cultures or ethnic groups, and that are not comfortably accommodated by Western psychiatric classifications such as the DSM and ICD. DSM-IV defined them as ‘recurrent, locality-specific patterns of aberrant behavior and troubling experience…’

One example of a culture-bound syndrome is dhat, which is seen in men from South Asia, and involves sudden anxiety about loss of semen in the urine, whitish discoloration of the urine, and sexual dysfunction, combined with feelings of weakness and exhaustion. The syndrome may originate in the Hindu belief that it takes forty drops of blood to create a drop of bone marrow, and forty drops of bone marrow to create a drop of semen, and thus that semen is a concentrated essence of life.

DSM-5, published in 2013, replaces the notion of culture-bound syndromes with three ‘cultural concepts of distress’: cultural syndromes, cultural idioms of distress, and cultural explanations for distress. Rather than merely listing specific cultural syndromes, DSM-5 adopts a broader approach to cultural issues, and acknowledges that all mental disorders, including DSM disorders, can be culturally shaped.

However, some DSM disorders are, it seems, much more culturally shaped than others. For instance, PTSD, anorexia nervosa, bulimia nervosa, depression, and deliberate self-harm (non-suicidal self-injury) can all be understood as cultural syndromes. Yet, for being in the DSM, they are usually seen, and largely legitimized, as biological and therefore universal expressions of human distress.

Thus, one criticism of classifications of mental disorders such as DSM and ICD is that, arm in arm with pharmaceutical companies, they encourage the wholesale exportation of Western mental disorders, and, more than that, the wholesale exportation of Western accounts of mental disorder, Western approaches to mental disorder, and, ultimately, Western values such as biologism, individualism, and the medicalization of distress and deviance.

In her recent book, Depression in Japan, anthropologist Junko Kitanaka writes that, until relatively recently, depression (utsubyō) had remained largely unknown to the lay population of Japan. Between 1999 and 2008, the number of people diagnosed with depression more than doubled as psychiatrists and pharmaceutical companies urged people to re-interpret their distress in terms of depression. Depression, says Kitanaka, is now one of the most frequently cited reasons for taking sick leave, and has been ‘transformed from a rare disease to one of the most talked about illnesses in recent Japanese history’.

In Crazy Like Us: The Globalization of the American Psyche, journalist Ethan Watters shows how psychiatric imperialism is leading to a pandemic of Western disease categories and treatments. Watters argues that changing a culture’s ideas about mental disorder actually changes that culture’s disorders, and depletes the store of local beliefs and customs which, in many cases, provided better answers to people’s problems than antidepressants and anti-psychotics. For Watters, the most devastating consequence of our impact on other cultures is not our golden arches, but the bulldozing of the human psyche itself.

He writes:

Looking at ourselves through the eyes of those living in places where human tragedy is still embedded in complex religious and cultural narratives, we get a glimpse of our modern selves as a deeply insecure and fearful people. We are investing our great wealth in researching and treating this disorder because we have rather suddenly lost other belief systems that once gave meaning and context to our suffering.

Distressed people are subconsciously driven to externalize their suffering, partly to make it more manageable, and partly so that it can be recognized and legitimized. According to medical historian Edward Shorter, our culture’s beliefs and narratives about illness provide us with a limited number of templates or models of illness by which to externalize our distress. If authorities such as psychiatrists and celebrities appear to endorse or condone a new template such as ADHD or deliberate self-harm, the template enters into our culture’s ‘symptom pool’ and the condition starts to spread. At the same time, tired templates seep out of the symptom pool, which may explain why conditions such as ‘hysteria’ and catatonic schizophrenia (schizophrenia dominated by extreme agitation or immobility and odd mannerisms and posturing) have become so rare.

The incidence of bulimia nervosa rose in 1992, the year in which journalist Andrew Morton exposed Princess Diana’s ‘secret disease’, and peaked in 1995, when she revealed her eating disorder to the public. It began to decline in 1997, the year of her tragic death. This synchronology suggests that Princess Diana’s status and glamour combined with intense press coverage of her bulimia and bulimia in general led to an increase in the incidence of the disorder.

An alternative explanation is that Princess Diana’s example encouraged people to come forward and admit to their eating disorder. By the same token, it could have been that the Japanese had always suffered from depression, but had been hiding it, or had not had a template by which to recognize or externalize it. The danger for us psychiatrists and health professionals when treating people with mental disorder is to treat the template without addressing or even acknowledging the very real distress that lies beneath.

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While personality disorders may lead to ‘severe impairment’, they may also lead to extraordinary achievement. A 2005 study by Board and Fritzon found that histrionic, narcissistic, and anankastic personality disorders are more common in high-level executives than in mentally disordered criminal offenders at the high security Broadmoor Hospital.

This suggests that people often benefit from non-normative and potentially maladaptive personality traits. For instance, people with histrionic personality disorder may be more adept at charming and cajoling others, and therefore at building and exercising professional relationships. People with narcissistic personality disorder may be highly ambitious, confident, and self-motivated, and able to employ people and situations to maximum advantage. And people with anankastic personality disorder may get quite far up their career ladder simply by being so devoted to work and productivity. Even people with borderline personality disorder may at times be bright, witty, and the life and soul of the party.

In their study, Board and Fritzon described the executives with a personality disorder as ‘successful psychopaths’ and the criminal offenders as ‘unsuccessful psychopaths’, and it may be that highly successful people and disturbed psychopaths have more in common than first meets the eye. As psychologist and philosopher William James put it, ‘When a superior intellect and a psychopathic temperament coalesce… in the same individual, we have the best possible condition for the kind of effective genius that gets into the biographical dictionaries.’

More recently, in 2010, Mullins-Sweatt and her colleagues carried out a study to uncover how successful psychopaths differ from unsuccessful ones. They asked a number of members of Division 41 (psychology and law) of the American Psychological Association, professors of clinical psychology, and criminal attorneys to first identify, and then to rate and describe, one of their acquaintances (if any) who could be counted as successful and who also conformed to psychologist Robert Hare’s definition of a psychopath:

…social predators who charm, manipulate and ruthlessly plow their way through life … Completely lacking in conscience and feeling for others, they selfishly take what they want and do as they please, violating social norms and expectations without the slightest sense of guilt or regret.

From the responses they collated, Mullins-Sweatt and her team found that successful psychopaths matched unsuccessful ones in all respects but one, namely, conscientiousness. So it seems that the key difference between unsuccessful and successful psychopaths is that the former behave impulsively and irresponsibly, whereas the latter are able to inhibit or restrain those destructive tendencies and build for the future.

Intelligence and conscientiousness are not enough to guarantee success, which also requires traits such as ambition, motivation, and people skills—traits that may be particularly pronounced when rooted in a personality disorder.

Personality disorders are generally thought to arise from a combination genetic factors and traumatic early life experiences such as parental loss and emotional, physical, and sexual abuse. People who have suffered childhood trauma may be left with intense feelings of despair, helplessness, and worthlessness. Later in life, they may seek out achievement and success to help compensate for these feelings. For instance, they may wish to be recognized by strangers because they were not recognized by their own parents, or they may wish to have control over others because they had none when they needed it most. The drive for achievement and success combined with the character traits and resilience that arise from loss and trauma may in later life propel them to the highest echelons of society.

This is borne out by a large study that looked at almost 700 eminent personalities, and found that 45 per cent had lost a parent before the age of 21. This ‘orphanhood effect’ seems particularly marked in creative people. One study looking specifically at a sample of authors found that 55 per cent had lost a parent before the age of 15. This suggests that disturbed psychopaths and creative visionaries do indeed share many features. While the former suffer from them, the latter are (also) able to put them to good use.

Broadly speaking, anyone’s personality can be said to lead to distress and impairment. For instance, a gregarious student is unable to isolate himself in the library and ends up failing his exams. A zealous company director loses his temper and regrets the damage that he has done to himself, others, and his company. An upstanding whistleblower ends up losing his job.

Everyone suffers for who he is, and, very often, our greatest strength is also the germ of our deepest suffering. While it is impossible to avoid such suffering, it is at least possible to value it for the personal growth that it can bring.

Like many blind figures in classical mythology, the prophet Teiresias could ‘see’ into himself. This self-knowledge enabled him not only to understand himself, but also to understand others and so to ‘see into the future’. Similarly, our suffering prompts us to look into ourselves. The self-knowledge this brings enables us not only to better regulate ourselves, but also to better appreciate others, the world, and our place within it. Thus, our suffering transforms our lives into a journey, a journey without an end, perhaps, but one that can also be seen as an end-in-itself. It is in this way that our suffering, or ‘impairment’, can bring deep meaning to our lives.

References:

  • Board BJ and Fritzon KF (2005): Disordered personalities at work. Psychology, Crime and Law 11:17-23.
  • James W (1902): The Varieties of Religious Experience, Lecture 1 ‘Religion and Neurology’, Footnote 6.
  • Mullins-Sweat S et al. (2010): The Search for the Successful Psychopath. Journal of Research in Personality 44:554-558.
  • Hare RD (1998): Without Conscience: The disturbing world of the psychopaths among us, opening lines. Guilford Press.