Insane, incompetent, immoral, just plain nuts, or you just don't like me?

In the sociology of medicine, we talk about diseases, which are physical traits, states or processes that meet certain criteria. Physicians structure their thinking, planning and action around these entities, conceived almost as embodied enemies. Military metaphors abound in medical discourse -- the armamentarium of therapeutic measures, viruses attacking cells, the war on cancer, etc.

Illness refers to the subjective experience of an individual who experiences physical limitations, pain or distress from some state, trait or process. Illness and disease may correspond very closely. The major distinction between influenza as a disease and as an illness is point of view. We largely define influenza by the symptoms. Although a laboratory test is available for infection by the influenza virus, it is seldom used. Doctors are usually content to tell us we have a flu-like illness, and who really cares, as long as we're back at work in a week or so? On the other hand, doctors may tell us we have the disease of hypertension, hypercholesterolemia, or even breast or prostate cancer when we had absolutely no symptoms and no illness. Once we are given that information, however, we acquire an illness because we now perceive ourselves differently, must take medication or undergo surgery, etc.

Notice I've talked about physical conditions. That was to keep things a little bit simple. What I really want to talk about here is the mental diseases. The vernacular is usually "mental illness" but I want to retain the sociological meaning of that term. Psychiatrists frequently diagnose people who think that they are perfectly alright, so the distinction is very important.

There is no escaping the cultural and moral element in psychiatric diagnosis, which is subtler in the other branches of medicine. Medical conditions which are diseases but not illnesses are classified as diseases because they are thought to put the individual at risk of some condition which will almost certainly be experienced as an illness in the future. My high LDL cholesterol doesn't bother me subjectively today, but a heart attack certainly would.

Most people who present to psychiatrists are in real subjective distress, and do perceive that something is wrong with them. But others don't. Some people who feel just fine and think they're just dandy can be diagnosed with a personality disorder or a psychosis. Other people may be quite unhappy but they don't attribute their unhappiness to facts about themselves, but rather to the way other people treat them. People with so-called Borderline Personality Disorder may be in this category. Some people are distressed only because others condemn them, or because they have been taught to be ashamed of themselves.

Homosexuality is the most famous example of the latter. It was officially a pschiatric disease until 1978; then the Gods of psychiatry eliminated homosexuality per seas a diagnosis, but added something called "ego dystonic homosexuality." Gay activists continued to protest even this diagnostic category, pointing out that it is not surprising that homosexuals are distressed about their nature given that lots of people hate them, but that doesn't mean it's the homosexuals who are sick. They finally prevailed when they proposed that if ego dystonic homosexuality is a disease, then logically, ego dystonic heterosexuality ought to be one as well. The Committee couldn't handle that idea, so homosexuality, dystonic or not, disappeared from the Diagnostic and Statistical Manual of Mental Disorders IV in 1987.

My friend Gary Greenberg wrote a scholarly article comparing the diagnosis of homosexuality to the diagnosis of borderline personality disorder, arguing that both hinge on culturally based judgements about how people ought to be or behave. People with BPD interpret their experience differently from the way their shrinks do - which makes them very frustrating to treat, by the way. I don't really agree with Dr. Greenberg about this particular question, for reasons which are too complicated to get into here. But it's a challenging argument.

So at last we come to the point, antisocial personality disorder, and psychopathy. People get these disease labels because they do bad things. In everday language, any serial murderer is insane. That sort of behavior is just abnormal. Healthy people don't do those things. (But of course they do, if they are soldiers.) In psychiatric language, all such people (who aren't soldiers) are eligible for a personality disorder label, or else they are psychotic, meaning that they act out of delusions. In legal terms, however, they may or may not be insane, although I believe that the legal concept of insanity is nonsensical. Ted Kazcynski was given a formal diagnosis of psychosis and also found legally insane. Friend Gary, who corresponded with him extensively, believes he is neither, and Kaczynski wholeheartedly agrees. I would basically label Ted Kaczynski as a real jerk, but I'm not a pro.