Subjectivity and ethics surrounding mental illness diagnoses

Question

I learnt the term 'anosognosia'; a 'lack of insight' into one's mental disorder. People who apparently 'suffer' from anosognosia are oblivious to the fact that they have a mental disorder, anosognosia is associated with 'egosyntonic' mental disorders; 'someone with anosognosia, or egosyntonic symptoms is in denial about their mental dysfunction'. What this means is that practitioners now diagnose and label patients mentally ill against their own will in the context of these egosyntonic mental disorders.

The extent to which the patient has mentally deteriorated to the point that their consent to being psychoanalzyed is insignificant should raise ethical issues surrounding the topic, but it is never mentioned in philosophical discussion.

I have seen mental illnesses that look very subjective, and are labeled as egosyntonic disorders as to diminish the patient's ability to object to being labeled mentally ill (as if the person is insane and doesnt know any better). Especially personality disorders in the DSM-V - which raises the subject of what extent someone's personality becomes so (subjectively) detrimental to themselves or others as to label them dysfunctional. What is the difference between a narcissist and a person with narcissistic personality disorder? Perhaps the difference is "severity" (to which the fate of the patient is at the hand of each individual practitioner's opinion of them; whether they think your ambitions and lifetime goals are "fantasies" and "signs of arrogance", whether they label your happiness and self-confidence as "a grandiose sense of self-importance" etc. - completely ridiculous, subjective criteria not fit for the supposed-to-be-objective nature of scientific/psychoanalytic research.), perhaps the difference is that the person with NPD was caught and the narcissist is still out there mistaken for a sane person, or perhaps there is no difference at all. Autism also has a few questionable symptom criteria. Restricted interests (lining up objects is a no-no apparently, the child is not allowed to do that), introversion, not showing enough emotion, strict adherence to routines etc. are indicative of a psychology that needs to be fixed, but what is the difference between an autistic child and a child with a personality exhibiting these characteristics - to what extent would it be morally right to declare that the autistic child go under psychological therapy to change their psyche and get it 'fixed' because the parents don't approve of the current one, how do they know the child is 'suffering'?

Where do we draw the line between a personality and a psychological dysfunction? When is it morally right to psychoanalzye someone, a child or an adult forced into therapy, with a mental disorder against their own will? Is mental illness subjective?

Answer 1

I think you run together a few issues

1. is psychiatry legitimate? Psychiatry is a form of overt, implied or covert social control. And the DSM, especially with respect to personality disorders, is notoriously expansionist.

2. are traits we associated with mental illnesses really illnesses? Szasz's argument - that all illness must involve physical lesions - is alert to social issues etc.. But the claim that that every illness has, independent of our concerns, that distinctive feature (see below), is natural kind essentialism, which seems unlikely outside at least chemistry. There are alternative definitions of illness ("a failure of ordinary doing in the absence of a preventing cause") with less radical concerns. The definition may also be too specific (excluding e.g. migraines).

3. do the traits we associate with mental illnesses really lead to personal suffering? That's an empirical question, and if you distrust psychiatry and self report you'll struggle to answer it.

4. as to what "insight" is, the Beck Insight Scale, which is usually for psychosis but is also used with BPD, operationalises it. There is no reference to whether or not the patient thinks they are ill, only whether their experiences can be explained by distress, if they are definitely right about their experiences, if they can listen to others, etc.. Believing you are ill could well change your insight as measured by the BIS, but it's not exactly the same thing.

• "Szasz need not suggest, as he seems to do, that the underlying state is a sufficient condition for the accurate ascription of the term 'disease'", but if we add another condition such as suffering, while the argument still goes through, it somehow seems less appealing.