Dimensions of Madness
In my previous essay, I characterized mental disorders as descriptive types that can be placed on dimensions of dysfunction. I called the result a dimensional typology. Now, I’ll discuss what I mean by this.
The dimensions are the important things because they describe the broad categories of mental health problems that people can have and estimate just how seriously those problems impair an individual’s ability to function in life. In my view, mental disorder characterizations are merely linguistic placeholders on each dimension that describe observed patterns of dysfunction. They should reflect the relative severity of the dysfunction. Mental disorders are not discrete entities and have no definite boundaries. They are part of the continuum that make up the dimension.
There are no discontinuities in any of these dimensions. There are no lines separating normal from abnormal, well from sick or sane from insane. Dimensions simply range from extremely well-functioning to extremely impaired. We all function at some level on each of these dimensions.
DSM-5 appears to have come part way to this approach by describing some mental disorders as spectra. There is a schizophrenia spectrum and an autism spectrum and the DSM authors could have described a bipolar spectrum and others as well. But a spectrum is not a dimension because it still implies abnormality. People have to be diagnosed with a mental disorder in order to appear on the spectrum and everybody else is presumed to not be on it.
Where people fit on any dimension of dysfunction is not a static thing. All of us probably exhibit some degree of emotional, cognitive or behavioral dysfunction at some times in our lives. Most of us, though, lead lives on the more functional end of each dimension at least most of the time. Those of us who exhibit more extreme dysfunction on some dimension are the ones who get labeled schizophrenic, autistic, intellectually impaired or bipolar and the like. But they are only different from the rest of us in degree, not kind.
To better understand the dimensional model, I’ll offer the following imaginary illustration. Suppose we had an instrument, perhaps like an intelligence test, that could measure the attributes that characterize each dimension. The results of such an instrument would summarize the component dysfunctions and put them on a scale.
In my imaginary scale, each dimension would probably have a shape something like a normal or bell-shaped curve. Each would range from extremely good functioning to extremely poor with no breaks in these curves. We could, though, characterize different regions of each dimension, just as we do with IQ. The largest percentage of us would demonstrate adequate functioning with some people above average and some below. People in this average range might exhibit some degree of dysfunction or symptoms at least some of the time, but they can be expected to cope reasonably well.
A small percentage of people might be term super-functioners on a particular dimension and they would be unlikely to ever experience any of the deficits marking that sort of dysfunction. Below the average range, we could describe a smaller percentage of people who we might term borderline dysfunctional. These people display chronic deficits or significant vulnerabilities in the relevant dimension. As we get below borderline, the percentages get smaller and smaller as they describe people with a greater degree of impairment and perhaps times of severe disability. A very small percentage of people at the lowest end would exhibit a profound level of dysfunction.
There are dramatic cases of people on several of these dimensions who might be unable to function outside of institutions such as hospitals or prisons or otherwise be unable to perform everyday tasks or responsibilities. Among these are the people we typically call mentally ill.
Surveying the current descriptions of mental disorders and my own experience, I settled on nine primary dimensions of dysfunction. If other professionals accept a dimensional approach, they might conclude that there are more or less than nine dimensions and I might find that reasonable. We might also choose to define several sub-dimensions within each one. I would welcome a thorough discussion of these issues. Here, I will briefly describe each dimension as I see it and I will discuss each in detail in later essays.
Reality misperception: Schizophrenia is the poster-child for this dimension and is usually defined as a break with reality. The ability to distinguish external or consensual reality from internal imaginings and thoughts is central to good functioning. People with deficits in reality testing have a very difficult time dealing with the social world we must live in. Mental disorders like schizoaffective and delusional disorder fit on this dimension.
Depression and mood dysfunction: Mood dysregulation is a prime source of dysfunction. We are by nature moody in that our emotional states vary over time and circumstance. Most of us, though, are relatively stable and capable of going about our daily lives without significant emotional disruption. Those of us whose moods are extreme or protracted exhibit mood dysfunction. Terms like depression, mania and bipolar disorder describe the more dysfunctional end of this dimension.
Anxiety and its consequences: Anxiety is related to fear and fear is an essential survival mechanism. Some degree of anxiety is necessary for good social functioning. But when anxiety or its consequences becomes disproportionate, it is increasingly dysfunctional. Generalized anxiety, panic and phobias describe dysfunctional expressions of anxiety. Other disorders that are presumed to be anxiety -related, such as posttraumatic stress disorder, dissociative phenomena and obsessive-compulsive disorder fit on this dimension.
Cognitive competence: IQ is a term currently out of favor, but it is obviously true that intelligence highly correlates with good functioning in many areas of life. Intelligence has long been considered dimensional and is described by a normal curve, so it serves as a model for all my dimensions. Most people have adequate enough cognitive competence to live functional lives, but a small percentage do not. We now describe such people as having an intellectual disability or an intellectual developmental disorder. In company with intellectual disability, I include the form of cognitive deterioration called dementia, which we may acquire later in life.
Social competence: We are intensely social creatures and living independent and functional lives requires an adequate degree of social competence. Social competence requires an ability to read other people’s emotions, intentions and reactions. This ability goes by the term Theory of Mind. Social competence also entails control of our social behavior so that it is appropriately responsive to social settings. Both the autistic and attention deficit/hyperactivity disorders fit on this dimension.
Pain and bodily illness: Our sense of well-being and ability to cope with life is strongly influenced by our perception of somatic symptoms and our concerns about them. Paying attention to our bodies makes good survival sense. But in this age of modern medicine, many people develop dysfunctional beliefs and attitudes in response to perceived bodily ills. Chronic pain is a prime example when it overwhelms a person’s life. Other disorders that fit on this dimension are hypochondriasis, somatization and conversion disorders.
Substance misuse and dependence: We are told we have an epidemic of drug abuse and there certainly are many tragic stories associated with drugs. But this ‘crisis’ is 100-year war with no solutions insight. We must rethink what problematic drug use really means and how dysfunctional addiction really is. To do that we must stop making moral distinctions between good drugs that we see as medicines, evil drugs that we buy on the street and the ugly drugs we buy in retail stores. We must also define drug addiction, drug dependence and drug abuse in a new way. This dimension describes the dysfunctional use of all psychoactive drugs.
Controlling impulses and desires: Humans have needs, emotions, impulses and desires that we must appropriately express. Some expressions of what I’ll call drives and emotions are particularly destructive to social interactions and others are more directly harmful to the individual. The less able we are to appropriately regulate and direct our drives, the more dysfunctional we become. There are many motivations that can become dysfunctional, but I highlight sexuality, anger, hoarding, Internet addiction and greed.
Socialization dysfunction: A well-functioning society requires people who behave socially. This dimension is not about social competence because it is about how we treat others. Socialization deficits lie in caring for others, empathy and concerns about other people’s rights. At the low end of this dimension are society’s most destructive people we describe as psychopaths – people who lack conscience or concern for anyone outside themselves. Moving up the dimension toward the functional end, I describe abusers and bullies. Then in the less dysfunctional region are the types of people who take advantage of people who get close to them. I call these people tar-babies. People in the mild end of dysfunction are what I describe as unhappy loners who either lack the social skills for intimate relationships or who alienate others.
As a model for describing psychological dysfunction, I naturally direct my attention to deficits that significantly impact people’s lives. I can’t tell you what percentage of the population that dysfunction encompasses because “it depends”. What it depends on is appraising the factors that are going into creating dysfunction. I call the combination of causal factors that can contribute to dysfunction an ecological model consisting of biological, psychological and social factors.