Free associations

Free associations

Six psychiatric concepts that have mutated: for better or worse

Like spilled drinks, psychiatry’s concepts are sticky and have a tendency to spread. Over the past century several of the field’s ideas have undergone large changes in meaning and adhered to new phenomena. Sometimes these changes have originated within the profession. Other times, new meanings emerged when psychiatric ideas entered everyday language.

Let’s consider six psychiatric concepts whose meanings have shifted. Each is widely used in ways that deviate from its original medical sense.

Addiction

Addiction was once a physical dependency on an ingested psychoactive substance. Addicts developed physiological tolerance for their preferred drug, requiring increasing quantities to achieve the desired result. They also experienced strong withdrawal symptoms when deprived of it.

More recently the concept of addiction has broadened to include “behavioural addictions”. In these cases no substance enters the body but the person may feel a sense of compulsion and powerlessness. Addictions to sex, gambling and the internet are often proposed, as well as to exercise, work, tanning and, of course, love.

Encouraged by this loosening of definitions within the mental health field, the concept of addiction among the general public has expanded. It now includes almost any compulsive behaviour, however mild. The line between a pathological dependency and a bad habit has been smudged and then crossed.

Hysteria

To the ancient Greeks, hysteria was caused when the uterus became dislodged from its usual resting place and roamed the body. The diverse physical symptoms hysterical women suffered were due to its wandering mischief.

Although the “wicked womb” theory of hysteria had long been abandoned, the term survived in psychiatry well into the 20th century. By the 1980s it was no longer used in respectable professional circles. The diagnosis itself had fractured into several distinct conditions involving medically unexplained physical symptoms and absences and other dissociative states.

Meanwhile “hysterical” took on a new meaning, coming to refer to apparently uncontrolled emotional reactions such as laughter. By association, very funny jokes became hysterical as well. The word “hysteria” is now dead within psychiatry, but it lives on riotously in everyday speech.

Phobia

Phobias are intense fears that interfere with everyday life. People are often troubled by excessive and pathological fears of animals, heights and public speaking, for example. However in the last few decades the concept of phobia has been extended in questionable ways.

In particular, antipathies to social groups are now often referred to as phobias. Homophobia, transphobia, Islamophobia and the like apply a clinical language of fear to social attitudes. Words such as these discredit undesirable attitudes by likening them to pathologies, arguably using one stigma to battle another.

The attitudes in question are troubling, but there is little or no evidence they are in any meaningful sense phobias. They are generally rooted in simple aversion, not fear, and do not impair their holder’s daily functioning. To call them phobias is to stretch the concept close to breaking point.

Psychopathy

Some psychiatric concepts have stretched, but psychopathy is an example of one that has shrunk. The term originated in 19th century German psychiatry, where some writers used it as a synonym for mental disorder. Others used it to refer to a wide assortment of pathological personality styles, including paranoid, obsessive and depressive varieties.

More recently psychopathy has contracted back to the callous and unempathic personality that attracts so much attention today. So much that the public is once again expanding the concept’s reach beyond killers and career criminals to include office tyrants and ex-spouses.

Schizophrenia

“Schizophrenia” was coined a little over 100 years ago by Swiss psychiatrist Eugen Bleuler. The word’s derivation refers to a split in the mind, by which Bleuler meant a lack of integration of mental functions such as perception and memory.

Regrettably the idea of schizophrenia as split mind soon became conflated with Jekyll-and-Hyde split personality. This misunderstanding confuses schizophrenia with a different condition that is now called “dissociative identity disorder”. As a result of it, “schizophrenic” is commonly used metaphorically to refer to any apparent contradiction or ambivalence.

This inaccurate usage has been tenacious. A recent study found 74% of references to “schizophrenia” in the Italian print media invoked this error, although an Australian study found a more encouraging 13%. However, this use of “schizophrenic” remains common in everyday speech, arguably contributing to the perception that people with the condition are dangerous.

Trauma

In early 20th century psychiatry “trauma” only appears in the sense of a physical insult to the brain. The first edition of the famous Diagnostic and Statistical Manual of Mental Disorders, published in 1952, used the term only in relation to brain trauma caused by gross force and electricity. “Trauma” enlarged its meaning to include psychological injuries inflicted by life events only in 1980.

Since then, what counts as a traumatic experience has progressively broadened. Mental health professionals have increasingly identified less severe and more indirect or vicarious experiences as traumatic. The general public has taken its cue from this expansion, using the word “trauma” to describe experiences as innocuous as a bad hair day.

Our six concepts have all shifted their meanings over time. How mental health professionals understand them has evolved. In some cases the public has picked them up and taken them further.

We should not expect concepts to stand still or object mindlessly when they move. Instead we should be mindful of these changes in meaning and recognise that some may be problematic.

Sometimes, as with “trauma”, they dilute or trivialise something that should not be trivialised. Sometimes, as with “schizophrenic”, they spread misconceptions. And sometimes, as with “addictions” and attitudinal “phobias”, they erase distinctions that may be worth preserving.