Cultural confusion: the shifting line between sane and ‘unsane’

Where does sanity end and mental illness begin? It’s a shifting boundary, one based as much on culture as it is on our understanding of the brain and mental health.

The American public harbors deep collective anxieties about mental health that are continually being stirred up. Take Steven Soderbergh’s most recent film, “Unsane,” which tells the story of a woman who is committed against her will to a mental institution and becomes trapped, unable to convince anyone that she doesn’t belong there. Released in March, the trailer has garnered nearly 17 million views.

Or look at the public response to recent revelations by NBA star Kevin Love about his panic attacks, Mariah Carey about her bipolar disorder, and Chrissy Teigen about her struggle with postpartum depression. Along with a spate of new documentary and fictional films about mental illness, including “Unsane,” these reflect the cultural significance of mental illnesses.

This shouldn’t be surprising, given the unprecedented number of Americans being diagnosed with them. An estimated 44 million U.S. adults — that’s 20 percent of all adults — have a diagnosable mental, behavioral, or emotional disorder other than a developmental or substance use disorder. One in five youths experiences a mental disorder by the time they are 18.

Do these high numbers indicate a real growth in psychological distress among Americans, or do they signal a kind of creep in our definitions of mental illness? Has the range of what constitutes “normal” been radically truncated, and has minor distress — something that most of us experience — been redefined as an affliction?

The slippery boundary between the categories of sane and insane is central to my work as an anthropologist at Northwestern University studying cultural influences on the experience and understanding of mental illness.

And that boundary does shift. For years, the American Psychiatric Association considered homosexuality to be a disease. In 1973, it removed homosexuality from its Diagnostic and Statistical Manual, long considered the “bible” for identifying and categorizing mental disorders, essentially moving same-sex love and desire out of the realm of disease and into the realm of normal human behavior. This demonstrates how changing social norms can alter the mental health landscape, and vice versa.

The trend for anxiety, depression, and attention deficit hyperactivity disorder (ADHD) has been going in the opposite direction, with the number of people seeking treatment for symptoms associated with these disorders on the upswing in the last several decades. What were once seen as ordinary behaviors are increasingly being seen as signs of disorders.

In the U.S., academics and the public have begun expressing concern that diagnostic categories like depression and anxiety are more and more often being used to organize and label ordinary behaviors and characteristics that are deemed socially undesirable.

In their 2012 book, “The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder,” Allan Horwitz and Jerome Wakefield assert that not being happy all the time has become depression, and worrying or feeling stressed is quickly labeled anxiety. Renowned Harvard psychologist Jerome Kagan recently joined the debate on ADHD, a diagnosis shared by 6.4 million children in the U.S, questioning whether the disorder is even “real.”

Such discussions and debates suggest a growing suspicion that the trend of medicalizing normal behaviors is a result of what bioethicist Carl Elliott termed the “tyranny of happiness,” or the strong social norms and pressures in the U.S. for everyone to be high-achieving and “fulfilled.”

My research with families who have an adolescent in psychiatric care, along with research out of Harvard University, find that the parents of youths treated for depression or ADHD sometimes harbor doubts about the reality of their child’s diagnosis and the need for treatment. And yet these parents feel compelled to seek treatment when their children behave in ways that seem outside the norm and may threaten their capacity to achieve — performing poorly in school, not making friends, or breaking rules and defying authority.

Doubts about the legitimacy of psychological and emotional distress are far from new. In the U.S., mental illnesses have long been considered less real — they are “all in the head” — than physical ones.

What practitioners now understand as symptoms were in the past often seen as moral failings associated with a lack of will. Not surprisingly, such conditions have historically been associated with women, such as hysteria.

But both current medical explanations and past moralizing ones let us avoid acknowledging that the problems in question are actually social ones. The line between sane and insane, normal and pathological, has always been where society agrees to draw it.

In the past, the way this boundary moved has at times benefited particular individuals and groups within society and been harmful to others. While the exclusion of homosexuality as a mental illness in the 1970s was beneficial for gays and lesbians, the expansion of the diagnostic system to include post-traumatic stress disorder (PTSD) in the 1980s directly benefited veterans of the Vietnam War, who had returned home to find themselves socially excluded and morally condemned. A PTSD diagnosis helped to legitimize veterans’ suffering.

The currently expanding boundaries seem to be most beneficial to a narrow set of stakeholders: psychiatrists along with other mental health clinicians and researchers, and especially pharmaceutical companies.

There is evidence to support this contention, with the rise of illnesses like ADHD converging with the timing of the so-called pharmaceutical revolution in the 1970s and the inception of direct marketing to clinicians. The prevailing response to medicalizing is to medicate, and rates of long-term use of psychopharmaceuticals in the U.S. are startlingly high.

It’s ironic that as we cast the net for mental illness ever more widely, making eligible for diagnosis and drug treatment even those with seemingly mild levels of distress, our capacity to care for those in severe distress has become progressively worse. The undertreatment of individuals with severe mental illness is as worrisome as the over-treatment of those who are mildly distressed.

As the boundaries of mental health diagnosis and treatment shift and blur, it is essential that no one is lost between the lines.

Rebecca A. Seligman, Ph.D., is an associate professor of anthropology and global health at Northwestern University, a faculty fellow at the Institute for Policy Research, and a Public Voices Fellow.