COMMENTS

http://dx.doi.org/10.5546/aap.2016.eng.503

An attempt to include happiness within the psychiatric disorders

PREFACE

The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V)¹ extends the range of new diagnostic criteria for adult and pediatric conditions. Since these criteria are so wide, there is a risk for a large portion of the general population to be included in one of the diseases described in the manual. On this basis, and in order to be consistent with the DSM-V, I thought it was appropriate to make a comment on an excellent article by Richard Bentall, from Liverpool University.² His article is longer than this comment, and includes a more extensive bibliography, but here I describe the complexity of definitions and the classification of "disease" as a nosologic category established as necessarily true.

Doctor Bentall's considerations are quoted in italics.

ARTICLE DESCRIPTION

Bentall introduces his article by stating "Happiness is a phenomenon that has received very little attention from psychopathologists; for this reason, research on the topic of happiness has been rather limited. Nonetheless, the guidelines described in the DSM-V provide sufficient case for classifying happiness as a psychiatric disorder. Although this proposal is likely to be resisted by the psychiatric community, the diagnostic criteria for happiness might be even more secure than those used to diagnose schizophrenia and other conditions".

Bentall based his work on Argyle M.'s research,³ which recognizes three components to happiness: affective, cognitive, and behavioral. "There are happy people across all cultures, which suggests that happiness may be biological in origin. Uncontrolled observations, such as those found in plays and novels, suggest that happy people are often carefree, have a high frequency of recreational interpersonal contacts, and display prosocial actions towards others identified as less happy. In the absence of physiological markers of happiness, it seems likely that the subjective mood state will continue to be the best diagnostic criterion (as occurs with pain). Argyle has remarked that 'if people say they are happy then they are happy'".

"The epidemiology of happiness is little-known, its incidence and prevalence depend on the diagnostic criteria used, as is the case of the diagnostic limitations posed by schizophrenia. Thus, although a survey conducted in the United Kingdom found that 25% of the sample said that they were 'very pleased with things yesterday',⁴ Andrews and Withey found that only 5.5% of adults felt 'satisfied with life'.⁵ In addition, if television soap operas in any way reflect real life, happiness is a very rare phenomenon indeed in places as far apart as Manchester, London and Australia. The prevalence of happiness also depends on the social classes: individuals in the higher socioeconomic groupings generally appear to feel they 'enjoy life more' than lower socio-economic classes".

"The etiology of happiness is unknown but some theories have implicated it is the result of positive life-events, while the advocates of genetic factors state that some people are generally happier than others, therefore reinforcing biological reasons related to self-esteem and social skills.^3,5 With respect to the environment, there seems little doubt that discrete episodes of happiness typically follow positive life-events. Moreover, several brain centers and biochemical systems have been observed to be related to this disorder; stimulation of various brain regions has been found to elicit the affective and behavioral components of happiness in animals, as has the administration of drugs such as amphetamine and alcohol".

"The question of whether or not happiness is a disease is yet to have a clear answer, but a sensible approach makes it worth referring to other psychiatric disorders, e.g. schizophrenia, bipolar syndrome, etc.⁶

As these conditions, happiness may be best thought of as a dimension of affect. However, the relationship between the dimension of happiness and other affective dimensions remains unclear. Thus, in a factor-analytic investigation it was observed that reports of happiness and reports of negatively valued affective states loaded on separate factors, suggesting that they are independent of each other".

"Interestingly, people who report high-intensities of happiness also report high intensities of other emotions, suggesting that happiness is related to a neurophysiological state of disinhibition; nonetheless, the frequencies with which people report happiness and the negatively valued affective states appear to be negatively correlated".

"Some confusion also exists about the relationship between happiness and mania. Although Argyle³ has noted that mania, in contrast to happiness, is mainly characterized by excitement, the diagnostic criteria for hypomanic episodes employed by the American Psychiatric Association seem to allow happiness to be regarded as a subtype of hypomania".

"Just as it is possible to elicit schizophrenic symptoms in some individuals by stimulating the parietal lobes, so too it is possible to produce happiness (by stimulation of subcortical centers). It has been suggested that positive (euphoric) and negative (depression) emotional states are regulated by a balance of both subcortical brain centers. Thus, abnormal affective states reflect a disturbance of this balance".

"There is a lack of clear data to state that happiness is statistically abnormal, but should it be associated with a biological disadvantage, it would be enough to consider it a disease. There is empirical evidence of an association between happiness, self-indulgence, obesity and alcoholic beverages. Given the link between both alcohol and obesity and life-threatening illnesses, it seems reasonable to assume that happiness leads to impulsive behavior and poses a moderate risk to life".

"Happiness may be considered a disease also from a philosophic perspective. According to Radden,⁷ the difference between a behavior that should not be the subject of psychiatric scrutiny and a psychiatric disorder is the irrationality of the latter. Irrationality would be a behavior that is bizarre, leads to no specific utility, fails to realize manifest goals, is contradictory, with no apparent sense and a lack of impartiality. Many of these characteristics are observed in happy states. Happy people overestimate their own achievements and share their unrealistic opinions about themselves when comparing to others. It is clearly evident that people suffering from happiness should be regarded as psychiatrically disordered".

"One possible objection to this proposal is that happiness is not normally a cause for treatment, but this may also be argued for other conditions such as anorexia nervosa and sickle-cell anemia, which became recognized as diseases that should be treated well into the 20^th century. Also, the fact that a condition is culturally accepted as positive is extremely dangerous; there is a risk of accepting as adequate the tradition of certain Hindu sects of burning widows alive so that they can join their recently deceased husband into the next world".

On this basis, Bentall proposes that happiness be included in the DSM-V under a more formal title and replacing "happiness" by "major affective disorder, pleasant type".

COMMENT

Bentall raises several fundamental questions:

First of all, it stands out that he managed to publish his article in a medical ethics journal. He probably believed that this was a transdisciplinary issue that involved medical practice in general, regardless of the discipline.

He sets out the debate on what disease means. Strangely, physicians rarely even consider such classification. As physicians, we believe that diseases are entities that existed before medicine, and that medicine only came to discover them, just like the laws of nature are once first described. But, as it turns out, there are no diseases in nature; the concept of disease is a social construct,⁸ and its criteria depend on culture.

To Egyptians, a malformation was a warning of their gods regarding the outstanding nature of the malformed subject that had to be respected; a seizure in the Middle Ages meant a demonic possession. In 1950 in Argentina, homosexuality was mostly considered a disease, and now equal marriage is legal.

As indicated by Bentall, another criterion that may be used to define disease would be statistics but with variations in the prevalence of happy people across countries, as occurs with hyperactivity disorder, which is extremely variable.⁶

The third criterion to define disease is the obvious "need for treatment" but once again, this criterion poses problems in relation to culture and even politics. In the 1950s in the Soviet Union, many political dissidents were considered "mentally ill" and were confined based on their disagreement with the regimen.

There are many examples of the definite influence of culture, history, and even politics on the creation of disease, so it may be easily deducted that these criteria may be influenced by financial factors. In this case, reasoning would be as follows: "If defining something as a disease is profitable, let us recognize it as such".

In my opinion, it would also be necessary to solve the problem of extreme deviations from normality, e.g., height that is less than the 3^rd percentile (by definition, short stature), or children who are either very quiet, very active, or even very rebellious (let us remember there is a condition called "oppositional defiant disorder"⁹), as many other deviations from human behavior which are considered discrete.

These are social constructs of our culture, categorizing them as "disease" may lead "affected" individuals to become a cause for therapeutic concern, resulting in their exclusion from the normal population.

Horacio A. Lejarraga, M.D.

REFERENCES

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5^th ed. Washington: APA; 2013.         [ Links ]

2. Bentall RP. A proposal to classify happiness as a psychiatric disorder. J Med Ethics 1992;18(2):94-8.         [ Links ]

3. Argyle M. The psychology of happiness. London: Methuen; 1987.         [ Links ]

4. Warr P. Payne R. Experiences of strain and pleasure among British adults. Soc Sci Med 1982;16(19):1691-7.         [ Links ]

5. Campbell A. The sense of well-being in America. New York: McGraw-Hill; 1981.         [ Links ]

6. Lejarraga H. La venta de enfermedades. Una tendencia contemporánea a transformar a las personas en pacientes Med Infant 2013;XX(1):62-9.         [ Links ]

7. Radden J. Madness and reason. London: George Allen & Unwin; 1985.         [ Links ]

8. Lejarraga A. La construcción social de la enfermedad. Arch Argent Pediatr 2004;102(4):271-6.         [ Links ]

9. Pardini DA, Frick PJ, Moffitt TE. Building an evidence base for DSM-5 conceptualizations of oppositional defiant disorder and conduct disorder: introduction to the special section. J Abnorm Psychol 2010;119(4): 683-8.         [ Links ]