Social Construction of Mental Illness: Social and Cultural Aspects of Physical Illness

Obviously, as a practicing neuropsychologist, I believe that genetics as well as brain structure and function have a tremendous influence on behavior. But, is errant behavior always a result of biology gone awry?

According to Allan Horwitz, a sociologist of mental health at Rutgers College, cultures and subcultures “provide publically available and shared meanings that facilitate certain kinds of symptoms interpretations while discouraging others.”

Are many normal behaviors pathologized because they are the brain’s normal accommodations to the stresses of daily living? Psychosocial stress can have profound effects on the central nervous system and on the body.

For example, attention deficit disorders in children and adolescents are uncommon, if non-existent, in other cultures such as East Asian societies. Why is there such a rash of these disorders in often high-functioning individuals across the US? Why is there such seemingly high rates of diagnosed anxiety and depression in Western cultures?

One problem, noted by many, is the diagnostic system. Symptom-based measures tend to pathologize normal behavior leading to a gross overestimation of the occurrence of actual mental disorders. Inflated statistics of prevalence rates of mental disorders (prevalence refers to the actual percentage in the population) are repeatedly cited in the mass media and are misleading. A better estimate of actual prevalence rates is probably something like 50% of individuals who receive mental health treatment have no diagnosable mental health conditions. What’s going on? Why are narcissistic personality disorders and bipolar disorders (cycles of mania and depression) largely found only in cities? Why is the diagnosis of multiple personality disorder more likely to be diagnosed in a clinician that is already invested in the diagnosis?

Sociocultural Factors

One’s social network (family, friends, co-workers, and acquaintances), forms of social support (community and religious groups), quality of work and family life, as well as one’s financial condition can greatly alleviate or increase distress and human mental suffering. Often individuals who lack these forms of social, physical, and financial support unknowingly attribute mental distress to internal causes alone — psychiatric disorders and disease — often to family members or friends.

As it turns out there are gender differences, too. Women tend to refract stress as anxiety and depression, anorexia, and various forms of panic disorder given their underlying biology, whereas as men refract stress as impulse control disorders, obsessive-compulsive behaviors (addictive disorders: substance abuse, sex, and gambling), and attentional issues given their underlying biology. All of these behaviors are significantly affected by sociocultural factors.

As regards treatment, psychoactive/psychotrophic drugs can be helpful but often have mixed or illusory effects. Typically, about a third of individuals, even on combinations of psychoactive medications, show no response at all. Moreover, about a third of individuals respond positively to placebos, substances without therapeutic benefit, to make matters even more confusing. Of course, given the intimate and inextricable relationship between mind and body, this is not surprising. The underlying biological mechanisms, unfortunately, are not well understood as are the effects of psychosocial stress and the environment on individuals. In addition, psychotherapy can be effective but it also has mixed results. As Dr. Horwitz argues: “Psychotherapy is an undefined technique applied to unspecified problems with unpredictable outcome. For this technique we recommend rigorous training.” Like psychoactive medications and placebo effects, psychotherapy (both the cognitive-behavioral and interpersonal varieties) can be effective with some individuals but less so with others, but the efficacy of psychotherapy is often considerably enhanced when combined with medication and stress-reduction techniques. The reasons for these heterogenous outcomes, however, are unclear.

Take-Home Point

Mental distress is rooted in social experiences and social connections. These are significantly affect by the culture and the environment. Psychosocial stress has profound effects on the central nervous system. As does genetics and biology. Unfortunately, normal behavior as a reaction to stressful environments, is often pathologized in otherwise mentally healthy individuals. What many distressed individuals need is care and concern and social support from others rather than the reflexive attribution of their behavior to solely internal causes resulting in labels of mental illness.

Some suggesting reading:

(1) American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, D.C.: American Psychiatric Association.

(2) Horwitz, A. (2002). Creating mental illness. Chicago: University of Chicago Press.

(3) PDM Task Force. (2006). Psychodynamic diagnostic manual. Silver Spring, MD: Alliance of Psychoanalytic Organizations.

(4) Stahl, S. M. (2000). Essential psychopharmacology: Neuroscientific basis and practical applications (2nd. ed.). Cambridge: University of Cambridge Press.

(5) World Health Organization (2004). International classification of diseases (10th rev.). Geneva: World Health Organization.