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TheProblemOfDefiningSanity

Medicine and psychiatry have self-admitted difficulties defining sanity. Your author hopes to explore some of the possible reasons for this and poses the question:  could a definition be developed upon which most would agree?

"SanIty" has been variously defined as; the quality of a sound or healthy mind, rationality, the ability to discern right and wrong, "believing and thinking as one is authorized to believe and think" and other definitions which users find expedient.
 
The word itself comes from the root adjective "sane," which stems from Latin "sanus," or "healthy." The implication, then, is that a sane mind is a healthy mind. This is, in fact, part of most medical definitions.  Sanity is also defined as being mentally "normal."  Health, in general, denotes strength, soundness, proper functioning, especially of biological systems. As the mind is generally regarded as the seat of awareness and reasoning, your author posits that its proper function might be said to entail clarity of awareness and accuracy of reasoning. If this thesis holds, one might expect to find these qualities in a sane individual. 

It may be instructive to examine what constitutes clear and accurate awareness and reasoning and what constitutes inaccuracy in these areas. Further, it may be helpful to understand to what degree errancy must intrude into mental function before one can reasonably be determined to no longer be sane. 

There are a number of objective criteria whereby one may assess the workings of a mind and determine their accuracy, but the largest portion of these have been declared to be more useful in determining IntelliGence than sanity. While a degree of IntelliGence may be implicit in the concept of sanity, this would not be the only measure.  One's ability to perform mathematical computations, identify shapes, find the next in a series of deductive steps, identify patterns in data, all are related to mental accuracy, but may be poor indicators of sanity. The kinds of tasks which one performs accurately, then, may have an impact on the perception of one as sane or not. 

The most prominent aspects of accurate mental function which have been used by ordinary people as indicators of sanity over the centuries appear to have related to the areas of interpersonal relations and bodily safety of self and others. These criteria are frequently examined by courts in commitment proceedings, determination of fitness to stand trial, hearings on competency and other such undertakings.  More recently, especially in medically related fields, personal mental composure has come to be included, as well.  One sees diagnoses based on subjective mood, and drugs advertised to improve outlook.   

Criteria other than accuracy of function have been also employed as determinants of sanity. Conformance and agreement with societal norms have played as great a role in the determination of sanity historically as any other criteria. In some contexts, societal norms loom large. For example, in WesternCivilization?, one would generally find it unsettling if a friend began to speak of voices telling him things, of demons tormenting him, or how he was cured by someone burning incense, shaking rattles, and chanting. Modern psychiatry lists such reported experiences among the symptoms of SchizoPhrenia? - a serious mental disorder. In many regions of the ThirdWorld?, however, shamanistic tradition accepts and reinforces such experience. One who declared to the members of such a culture that these subjective experiences were invalid might find his sanity called into question by the local chief or medicine man. 

The impact of a culture or cultures are evident when one examines what the modern western medical (psychiatric) community uses as a measure of sanity. In a medical/psychiatric context, the most general means of identifying sanity is that a person's mentality is "normal."  A search of the meaning of "normal" leads us to a definition by exclusion - that is, absence of functional mental illness, defect or disorder. The word "functional" (denoting abnormality in function, but not in form) is important, as dysfunction which is traced to a uniformly remediable or replicable physical cause generally is reclassified as a medical problem rather than a mental one, with concomitant change in diagnosis and approach to treatment. Such medical issues are removed from the criteria for judging "sanity." Conversely, when one displayes an apparent symptom or limitation for which no physiological cause is indicated, doctors refer to the problem as "functional."  That is, it is not related to a physical problem, but rather a mental one.  The medical/psychiatric definition just stated will seldom be satisfied in the absolute, as will be seen below. 

The problem of identifying a concise,positive, functional definition for sanity, a key element in the more general issue of MentalHealth?, is perhaps best illustrated by comparison. In identifying "sanity" with "health," one invites comparison with known standards of health in other organs and systems. A contrast is immediately apparent between the certainty and objectivity with which one can identify physical health, as opposed to mental health. One may examine, for example, a liver. Its normal role and functions, uniform from one person to the next, can be determined through the methods of physical science. It can be x-rayed or biopsied. Liver enzymes in blood samples can be measured. Hepatitis antibodies can be tested for. In the extreme, exploratory surgery may be performed. The proper functioning of a liver can be quantatively measured. While the mind is usually associated with a body organ, the brain, science to date has been unsuccessful in attempting to develop brain testing protocols which are definitive in predicting or measuring sanity. Part of the reason for this is that "normal" mental function may vary from person to person and from one context to another. Therefore, contextual observations, tests and measurements remain the standards of choice. 

The standard for mental diagnosis in psychiatry is the Diagnostic and Statistical Manual (DSM). It has undergone a substantial evolution in the last half-century. From the few mental disorders defined in Freud's time, the number of psychiatric determinations of aberrant human behavior has expanded. When the DSM was first published in 1952, it listed 112 mental illnesses or disorders. The 1994 issue of DSM (IV) specifies more than 370 disorders. And the psychiatric community has not always agreed on how these should be classified. For example, concerning "schizophrenia," DSM-II states, "Even if it had tried, the Committee could not establish agreement about what this disorder is; it could only agree on what to call it." DSM-III says "there is no satisfactory definition that specifies precise boundaries for the concept 'mental disorder'.... For most of the DSM-III disorders... the etiology [cause] is unknown. A variety of theories have been advanced... not always convincing, to explain how these disorders come about." DSM-IV states that the term "mental disorder" continues to appear in the volume "because we have not found an appropriate substitute." Diagnoses which appear in the manual were developed, in part, by a majority vote of those attending DSM conferences. As a result, short attention span, questions about one's spirituality, difficulty with writing or mathematics, defiance of one's parents, fidgeting, excessive neatness, all have found a place in the manual among symptoms and diagnoses. In contrast, homosexuality or the unreasonable desire of a slave to escape, once defined as mental defects (the former in early editions of the DSM), do not appear in today's DSM. 

In 1995, Dr. Rex Cowdry, then director of The National Institutes of Mental Health, stated to a U. S. House of Representatives appropriations subcommittee hearing that, regarding mental illness, "We do not know the causes. We don’t have methods of ‘curing’ these illnesses yet." This should not be surprising. It has been without doubt a cultural process, within the fairly limited culture of psychiatry and psychology, which has taken place in an effort to define the boundaries of sanity. Diseases with cultural definitions may not respond to medical science. 

And defining sane behavior must always be done, at least in part, in the context of the subject's culture. If one is raised in a given cultural environment, educated in a given fashion, and exposed to certain norms, then behavior which is inconsistent with these factors may well indicate some defect in the capacity to accurately process the information available to the mind. 

In recent times, more recognition has been given to the concept of sanity as a subjective manifestation, evidenced by mental quietude, peace of mind, and resiliancy - an ability to survive the vicissitudes of life without such mental discomfort that one's ability to function is impaired. 

In the legal community, a culture unto itself, an entirely different effort has been undertaken to define sanity. Generally speaking, the most broadly known and publicly accepted standard for sanity under law is "the ability to discern right and wrong." This has been broadened, extended, shaped and colored in widely scattered juristictions internationally in an effort to establish standards which will punish the guilty and forgive those whose temporary or permanent mental state deprived them of the requisite ability to form intent, or "mens rea" (guilty mind) under the law. 

Defenses based on various findings of mental defect by medical professionals have been offered by criminal defendants with varying levels of success, in an effort to avoid being found sane, and thus escape a death penalty or any form of punishment at all. Multiple personality disorder, sugar addiction, somnambulance, amnesia, excitement or passion, obsessive-compulsive behavior of varying kinds, all have been pled as defenses before the bar of justice. 

Finally, various governments, particularly authoritarian ones, have undertaken to use political or public policy standards to define sanity, and have underwritten psychiatric efforts to restore sanity under such definitions by remedying behaviors which betray a mindset declared unacceptable by the state. The treatments employed toward this end are typically aversive, punitive, and/or coercive. The argument supporting such definitions of sanity and resulting efforts to restore same is generally this: "The state functions for the good of the people. Proper functioning of the state requires conformance and compliance with state aims and policies. Fomenting disagreement with state aims and policies interferes with the proper functioning of the state. Any sane person would desire the good of the people and would therefore not foment disagreement." As experience quickly reveals that talking therapies fail to restore the sanity of a person who openly disagrees with the state and encourages others to do so, the therapies employed necessarily become those that the deviant citizen, given his choice, would avoid. Failing this, state hospitals may resort to treatments which nullify the patient's ability to engage in unauthorized expression. Thus sanity by political definition may be restored. 

Political definitions of sanity have not been confined to openly authoritarian governments. In otherwise putatively democratice countries which have a history of democratic elections and peaceful transfer of power, state-sanctioned and state-funded mental treatement has been imposed upon political dissidents and upon members of racial and ethnic minorities whose activities and efforts to achieve equal treatment and equal rights to those enjoyed by favored elements of these societies have been felt to be a threat to civil order or state security. 

Political definitions of sanity are a reflection of the earliest attempts by humans in a social setting to live in comfort, unmolested by disquieting behavior by those around them. As far back as history has been recorded, mentions of "lunatics" (for the Latin meaning "moon-touched," after the belief that undue exposure to the full moon could damage the mind) appear. These persons fail their compatriots' test for sanity on purely objective grounds. Their bevavior is erratic, unpredictable, unsettling, and cannot be rationally understood by those around them. The discomfort that they impose upon the society around them disqualifies them from being considered sane. The very concept of sanity, as a condition, may have developed first and foremost in contrast to these early observations of it apparent absence. This primary identification of a health issue by others than the affected person is somewhat unique. One may complain of a headache, sore stomach, excessive weariness or various aches, pains, or numbness. One may notice a rash or falling hair, or be unable to keep food down. One may even be unable to concentrate or attend the utterances of others with clarity. These subjective symptoms, reported by their sufferer, translate to bodily illness of one kind or another and drive the individual to seek relief. Absent social indoctrination, however, one seldom will complain of a defect in their own sanity. 

A common thread runs through the foregoing. Sanity, or health of mind, as evidenced by proper functioning is measured in each case by the ability of the individual to successfully cope with the demands of his society in a manner which coexists harmoniously with that society. To the degree that one inputs data faithfully, processes it accurately, and assesses the impact on others of his actions and reactions so as to avoid unnecessary friction or harm, he could be called sane. One could go so far as to say that errant mental function in any or all of these fields would not move an idividual over the line from the "sane" category to the "not-sane" category as long as the incidence of errant function was in the substantial minority, and proper function was in the majority. Add to this the element that the proper functioning necessary to cope does not place undue stresses or demands on the individual, require undue effort, nor cause excessive discomfort, and both objective and subjective criteria for sanity are met. 

There is lively debate as to whether physical intervention is necessary or effective to achieve, maintain or restore sanity in the absence of quantifiable biolgical damage or dysfunction. The three main schools of thought in this arena could be called the "healthy brain - healthy mind" school, the "healthy mind - healthy brain" school and the "spiritual" school. The first maintains that mental function is a product of biologial function, and that therefore brain health and biochemical balance determines sanity. The second holds that observed changes in the brain and biochemical status are the product of mental function, and that mental health can therefore be addressed without treating the brain. The third holds that the mind is independent of the physical existence of the brain, and that the brain merely permits the mind to be expressed in the body. Organic damage to the brain would necessarily impair this expression. Various practitioners and researchers may adhere to a combination of the foregoing schools. How a society approaches its effort to maintain viabililty and cohesiveness through the sanity of its members would be determined by which school of thought enjoys the broadest acceptance in that society. -- AyeSpy 

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See also SanityTalk.