This is a question that has broad implications.   In fact, this is one of the questions of the ages.   Modern diagnosis is in conflict and controversy.   Yet there is much agreement in ”recognizing” the disability of mental illness.   When psychiatrists work with a mental health team they generally seek a broader consensus.  In teamwork settings diagnostic formulations are usually the result of an interaction between different disciplines.   Never the less, the concept of “Mental Illness” is far from clear and there is both professional and public dissension of this critical issue that effects most of us.

There is a lot of literature lately discussing the validity of psychiatric diagnosis as the DSM V is being developed and prepared.   Most of the nomenclature has only vaguely descriptive names that are, as yet, lacking objectivity.   The best the DSM can do is group symptoms and signs to form a diagnosis.   This system tells us nothing about the actual etiology or cause of the disorder.    In medical disorders the disease is named in accordance with it’s pathophysiology and, when known, its etiology. For example “Chronic Obstructive Pulmonary disease” describes something about the pathophysiologic mechanism of the pulmonary disorder.  It is the increasing difficulty exchanging oxygen and carbon dioxide due to ongoing obstruction of the airways through the loss of elasticity of thoracic structures.   True, in this case there can be numerous reasons it develops but the nature of the disease is universally understood and diagnostic concordance is very high.

Mental illnesses are usually too complex and vary too much from one patient to another to arrive at a clear understanding of what defines the illness.  There is usually an evolution of mental illnesses that can be quite dramatic.   The presentation of the illness in the beginning stages can be different from the more chronic stages.  Meanwhile beyond the confusion about the boundaries of mental health the process of diagnosis and treatment is going on and psychiatry has had mostly partial success in treatment outcome.   Today’s psychoactive medications have a tremendous overlap in therapeutic usage so , for example, the antidepressant Prozac, a selective serotonin re-uptake inhibitor is used to treat depression, anxiety, obsessive compulsive disorder, bipolar disorder, Post-traumatic Stress Disorder plus used as an adjunct to the treatment of schizophrenia, substance dependence and Personality Disorders.

Regarding etiology we are also mostly in the dark.   For most psychiatric disorders there are theoretical causes ranging from genetic, early childhood trauma, other environmental influences, bacterial or viral exposure to parental neglect or substance or chemical use.   Any particular patient diagnosed with schizophrenia could have very different causal factors to another with the same disorder.   The manifestations of the disease can have only limited overlap of symptoms while personality differences can bring about a significant variety of presentations for the same diagnosis.

The designation of ‘mentally ill” has a broad range of effects in a particular persons life.   So deemed mentally ill can make one eligible for government subsidies,  or remove the ability to assume certain employment positions.  It can affect the findings and course of judicial proceedings.   Social standing can be significantly affected if certain diagnoses are made public.   One’s position in the family can be altered once diagnosed with a mental illness or disorder.   It can affect one’s chances of finding a suitable partner or spouse and may stigmatize the individual’s entire family.  Once deemed mentally ill, it may be very difficult to remove even in the event a cure takes place.  Being deemed mentally ill affects those and can bring about a myriad of effects, often quite negative.

As mentioned in other past articles, attitudes toward mental illness vary widely according to groups, cultures, families or individuals.   In the modern utilitarian nations one’s position in the society is greatly effected by economic issues. This varies greatly with more rural or developing cultures.   There is tolerance to more eccentric behaviors and the mentally ill tend to become dealt with in the family.    Likewise local cultural or tribal units may take little notice of people/patients within their group who would be considered mentally ill in the greater society.

The fundamental aspects of mental illness include thought, speech, emotion, and behavior.   How they manifest in a person’s life determines a lot about how the brain is functioning.   This has a lot to do with the difficulty understanding mental health since the bio-molecular processes occurring on a microscopic level are the operational units.  Our understanding of these processes, and how they coincide with behavior is extremely limited.   Even our grasp of the workings of the human mind itself, although much greater than 20 or 50 years ago, remains fairly rudimentary.   I believe an apt metaphor of medical sciences understanding of the brain is a huge dark auditorium filled with thousands of people.   In walks medical science holding up a small candle.   This light gives a slight illumination so a few shadows are highlighted but otherwise the rest of the observers can only see the candle and get a sense of the size of the theater.

The mystery grows when you consider we actually don’t understand the basic physical functions of the brain and it’s appendages.   Seeing or hearing are facilitated through the “special sense organs” called the eyes and the ears.   When a sound vibration reaches the apparatus of the inner ear it converts it from air born to physical vibrations in the hearing organs themselves.   From there they pass through nerve circuits to auditory, memory and numerous other centers within the brain.    The question is:  “what actually becomes conscious of the sound?”   If the person is unconscious or asleep, the activity of sound vibrations moving through space into the ear and the deeper recesses of the brain still occur, but the person is not known to actually hear it.   The question of consciousness also plays an essential role in understanding the connections between bio-molecular brain behavior and our mental health status.   When it comes to consciousness does the brain serve as a transmitter, a receiver or an intermediary of something more subtle than cerebral organ tissue, the nerve circuitries and the bio-molecular chemicals that form the networks of communication within and with the outside world?

I am not a kabbalist nor do I know more than a few rudimentary concepts of kabbalah but I have heard descriptions of spiritual entities that are the constituents of consciousness.   They are the spiritual pathways or emanations called “Sefiros,” and are the basic channels whose source is none other than G-d Himself.    The various transformations from a totally non-physical and infinitely capable G-d to the smallest limited physical particles occurs through these sefiros.   This flow of energy from spiritual to vibratory to physical is seen to become the substance of our souls that animate our physical bodies.   This is the consciousness that forms the link between being to non-being and back again. In some ways this consciousness knows no boundaries.   In mental illness one or more of the sefiros is somehow blocked from it’s nature to flow freely through space and time.   One scenario is some defect in an attribute, such as a sefirah.   Another mentioned by Rabbi Yitzchak Ginsberg in his book,  “Body, Mind and Soul” states “illness and disease derive from a spiritual state of deficiency or emptiness, and since the Hebrew word meaning “sick” (Choleh) has the numerical value of 49, this indicates that the sick person lacks the “fiftieth gate of understanding.”  We can thus conclude that to heal is “to fill” or “to complete” one’s consciousness by reaching the fiftieth gate of understanding…

“The power in the soul to fill all states of spiritual and physical emptiness must derive from a place of consummate “satiation”, a place in the soul where all is present, nothing lacks.   This is the super conscious level known as the “higher crown” (keter elyon), which, upon entering the conscious aspiration to reach this level is the spiritual service of teshuvah or repentance.  This ties in with article #18 on Psychiatry and Repentance.

Each of the organs of the body corresponds to a sefirah, a number,  a letter or part and a spiritual color.   It would take volumes to even begin to explain the system of kabbalah but it is enough for the purposes of this article to point at spiritual consciousness as a requirement to understand mental health.   Consciousness and dealing with any obstacle to its fulfillment plays a pivotal role in achieving mental health or “balance.”  Therefore repentance defined in the broad sense is the unifying central factor in achieving mental health.

Conventional psychiatry, lacking any consistent or operational tools to integrate spiritual elements into clinical practice will never achieve full understanding of mental health.   As it develops as a science, it may learn more about the “small world” of molecules and neurotransmitters yet the actual connection between brain and behavior will continue to elude it.

Gershon Freedman, M.D.