Jfournal ofmedical ethics, 1992, 18, 94-98

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A proposal to classify happiness as apsychiatric disorderRichard P Bentall Liverpool University

Author's abstractIt is proposed that happiness be classified as a psychiatricdisorder and be included in future editions of the majordiagnostic manuals under the new name: major affectivedisorder, pleasant type. In a review of the relevantliterature it is shown that happiness is statisticallyabnormal, consists ofa discrete cluster ofsymptoms, isassociated with a range ofcognitive abnonnalities, andprobably reflects the abnormal functioning of the centralnervous system. One possible objection to this proposalremains - that happiness is not negatively valued.However, this objection is dismissed as scientificallyirrelevant.

IntroductionHappiness is a phenomenon that has received verylittle attention from psychopathologists, perhapsbecause it is not normally regarded as a cause fortherapeutic concern. For this reason, research on thetopic of happiness has been rather limited and anystatement of existing knowledge about thephenomenon must therefore be supplemented byuncontrolled clinical observation. Nonetheless, I willargue that there is a prima facie case for classifyinghappiness as a psychiatric disorder, suitable forinclusion in future revisions of diagnostic manualssuch as the American Psychiatric Association'sDiagnostic and Statistical Manual or the World HealthOrganisation's International Classification of Diseases.I am aware that this proposal is counter-intuitive andlikely to be resisted by the psychological andpsychiatric community. However, such resistance willhave to explain the relative security of happiness as apsychiatric disorder as compared with less secure,though established conditions such as schizophrenia.In anticipation of the likely resistance to my proposal Iwill therefore preface my arguments with a briefreviewof the existing scientific literature on happiness. Muchof the following account is based on the work of Argyle(1).

It is perhaps premature to attempt an exact

Key wordsHappiness; major affective disorders; psychiatry.

definition of happiness. However, despite the fact thatformal diagnostic criteria have yet to be agreed, itseems likely that happiness has affective, cognitive andbehavioural components. Thus, happiness is usuallycharacterised by a positive mood, sometimes describedas 'elation' or 'joy', although this may be relativelyabsent in the milder happy states, sometimes termed'contentment'. Argyle, in his review of the relevantempirical literature, focuses more on the cognitivecomponents of happiness, which he describes in termsof a general satisfaction with specific areas of life suchas relationships and work, and also in terms of thehappy person's belief in his or her own competence andself-efficacy. The behavioural components ofhappiness are less easily characterised but particularfacial expressions such as 'smiling' have been noted;interestingly there is evidence that these expressionsare common across cultures, which suggests that theymay be biological in origin (2). Uncontrolledobservations, such as those found in plays and novels,suggest that happy people are often carefree,impulsive and unpredictable in their actions. Certainkinds of social behaviour have also been reported toaccompany happiness, including a high frequency ofrecreational interpersonal contacts, and prosocialactions towards others identified as less happy (3). Thislatter observation may help to explain the persistenceof happiness despite its debilitating consequences (tobe described below): happy people seem to wish toforce their condition on their unhappy companions andrelatives. In the absence of well-establishedphysiological markers ofhappiness, it seems likely thatthe subjective mood state will continue to be the mostwidely recognised indicator of the condition. Indeed,Argyle has remarked that 'If people say they are happythen they are happy' (4). In this regard, the rules foridentifying happiness are remarkably similar to thoseused by psychiatrists to identify many other disorders,for example depression.The epidemiology of happiness has hardly been

researched. Although it seems likely that happiness isa relatively rare phenomenon, exact incidence ratesmust depend on the criteria for happiness employed inany particular survey. (In this respect happiness is alsonot unique: similar problems have been encounteredwhen attempts have been made to investigate the

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epidemiology of other psychiatric disorders such asschizophrenia (5)). Thus, although Warr and Payne (6)found that as many as 25 per cent of a British samplesaid that they were 'very pleased with thingsyesterday', Andrews and Withey (7), studying a largeUS sample, found that only 5.5 per cent of theirsubjects rated themselves as scoring maximum on anine-point scale of life-satisfaction. One problem withthese kinds of data is that they have been generated inthe absence of good operational criteria for happinessand have focused on the cognitive components of thecondition (perhaps because these are comparativelyeasy to measure) rather than the affective andbehavioural components. It is therefore quite possiblethat informal observation is a better guide to theprevalence of happiness in community samples.Certainly, if television soap operas in any way reflectreal life, happiness is a very rare phenomenon indeed inplaces as far apart as Manchester, the East End ofLondon and Australia. Interestingly, despite all theuncertainty about the epidemiology of happiness,there is some evidence that it is unevenly distributedamongst the social classes: individuals in the highersocio-economic groupings generally report greaterpositive affect (8) which may reflect the fact that theyare more frequently exposed to environmental risk-factors for happiness.

Further light might be shed on the nature ofhappiness by considering its aetiology. Although thecause or causes of happiness have yet to be identifiedaetiological theories have implicated bothenvironmental and biological factors. With respect tothe environment, there seems little doubt that discreteepisodes of happiness typically follow positive life-events (9). However, the observation that some peopleare generally happier than others suggests that lesstransient factors may also play an important role.While it has been suggested that a general dispositiontowards happiness is related to self-esteem (10) andsocial skills (1), two variables which presumably reflectearly learning experiences, the finding thatextroversion is a good predictor of happiness evenyears in the future (1 1) suggests that biological factorsmay be implicated.

Evidence that happiness is related to cognitiveabnormalities will be outlined below when I discuss theproposition that happiness is irrational. Geneticstudies of happiness are a neglected avenue of researchbut neurophysiological evidence points to theinvolvement of certain brain centres and biochemicalsystems. Thus, stimulation ofvarious brain regions hasbeen found to elicit the affective and behaviouralcomponents of happiness in animals (12) as has theadministration of drugs which affect the centralnervous system such as amphetamine and alcohol (13).Taking the environmental and biological evidencetogether it may be necessary to discriminate betweenvarious different types of happiness. Thus, it may beuseful to distinguish between reactive happiness,usually manifesting itself as an acute episode followed

by a rapid remission of symptoms, and endogenoushappiness which may have a relatively chronic onsetand which may be less often followed by symptomaticimprovement. The differential diagnosis of these twotypes of happiness is an obvious project for futurestudies. Given the apparent similarities betweenhappiness and depression, it seems possible thatendogenous happiness will be characterised by positivemood first thing in the morning, a heavy appetite, andpersistent erotomania.

Happiness as a psychiatric diseaseSince the emergence of the profession of psychiatry inthe nineteenth century it has commonly been assumedthat psychiatric disorders are forms of disease. Whilstthis assumption has not gone unchallenged in recentyears (14) it remains so pervasive within the mentalhealth professions that the demonstration thathappiness qualifies as a disease would be a powerfulargument for including it within future nosologies ofpsychiatric disorder.

Historically, there have been two approachestowards the definition of disease (15). The first, whichis best exemplified by the work of the doctor ThomasSydenham in the eighteenth century, involves theidentification of syndromes consisting of clusters ofsymptoms that occur together. The second, which isbest exemplified by the later work ofVirchow, involvesthe identification of a pathological process that iscausally implicated in a disturbance of body orbehaviour. In practice, medical scientists usually hopethat the two types of classification will converge toenable the generation of causal models of disease.However, for most psychiatric disorders this prospectlies somewhere in the future (16). For this reason,when considering the evidence that happiness is adisease, it will be useful to bear in mind for comparisonthe evidence pertaining to the disease status ofrecognised psychiatric disorders such asschizophrenia.The question of whether or not it is possible to

identify a meaningful syndrome of happiness has beenthe subject of only very limited research. According toArgyle (1), most investigators agree that happiness isbest thought of as a dimension of affect, rather than asa discrete category ofemotional disequilibrium: in thisrespect at least happiness appears to be similar to bothschizophrenia and perhaps the majority of psychiatricdisorders (17). However, the relationship between thedimension of happiness and other affective dimensionsremains unclear. Thus, in a factor-analyticinvestigation (8) it was observed that reports ofhappiness and reports of negatively valued affectivestates loaded on separate factors, suggesting that theyare independent of each other. Interestingly, peoplewho report high-intensities of happiness also reporthigh intensities of other emotions (18), which might beregarded as evidence for the hypothesis (to bediscussed below) that happiness is related to aneurophysiological state of disinhibition. Nonetheless,

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the frequencies with which people report happiness andthe negatively valued affective states appear to benegatively correlated (19). Some confusion also existsabout the relationship between happiness and thepsychiatric disorder of mania; although it might beexpected that these are related conditions Argyle (1)has noted that mania, in contrast to happiness, ismainly characterised by excitement. Nonetheless, thediagnostic criteria for hypomanic episodes employedby the American Psychiatric Association (20) seem toallow happiness to be regarded as a subtype ofhypomania. Taking all this evidence together, it mightbe argued that there is only modest empirical supportfor the notion ofa discrete happiness syndrome. On theother hand, the evidence is really quite favourablewhen compared with the evidence supporting otherwidely accepted psychiatric syndromes such as

schizophrenia (21).Some evidence that happiness is related to a

disturbance of the central nervous system has alreadybeen noted. Just as it is possible to elicit schizophrenicsymptoms in some individuals by stimulating theparietal lobes, so too it is possible to produce happinessby brain stimulation, though of subcortical centres(12). Cortical centres also seem to be implicatedhowever, as both left hemisphere seizures and righthemispherectomy have been associated with prolongedeuphoric states; indeed it has been suggested thatemotional states in general are regulated by a complexbalance of excitatory and inhibitory centres in bothhemispheres, and that abnormal affective states of anykind reflect a disturbance of this balance (22). Clearly,further biological research is needed to specify in anydetail the role of neuropsychological abnormalities inhappiness but a promising start has been made, andquite a clear picture is apparent in comparison to themixed results of nearly one hundred years of researchinto schizophrenia (21).

Indeed, it is the lack of progress in identifying a

biological pathology for schizophrenia and otherpsychiatric disorders that has led some authors to rejectthe notion that schizophrenia is a disease (14) andothers to argue that the criteria for disease should notrequire the identification of an underlying biologicalpathology (23). Clearly, if, as I have argued, happinessmeets the narrower criteria for disease employed inphysical medicine it is also likely to meet any suchbroader criteria advocated for psychiatry. Forexample, it has been suggested that, for the purposes ofpsychiatric research, a disease be simply regarded as

any deviation from the norm by way ofexcess or deficitwhich confers upon the sufferer some form ofbiological disadvantage (24). Evidence that happinessis statistically abnormal has already been discussedand, despite the lack of clear data, there is at least somereason to suppose that happiness confers a biologicaldisadvantage, at least in the short term. Consistentclinical evidence of an association between happiness,obesity and indulgence in alcoholic beverages hasexisted from before the time of scientific medicine

(Julius Caesar, for example, is reputed to have askedfor the company of fat men on these grounds (24)).Given the well-established link between both alcoholand obesity and life-threatening illnesses it seemsreasonable to assume that happiness poses a moderaterisk to life. The common observation that happinessleads to impulsive behaviour is a further cause forconcern.More clear evidence that happiness confers a

biological disadvantage can be discerned from theliterature relating various cognitive measures to moodstate, but before discussing this evidence it will first beuseful to consider the proposition, advocated by somephilosophers, that irrationality rather than disease beconsidered the criterion for psychiatric disorder.

Happiness, irrationality and cognitionMainly because of persisting doubts about the value ofapplying the concept of disease to psychiatricdisorders, a number of philosophers have suggestedthat the quality of rationality is the most appropriatecriterion for distinguishing between such disordersand types of behaviour and experience not worthy ofpsychiatric attention. According to Radden (26),behaviour may be described as irrational if it is bizarreand socially unacceptable, reduces the individual'sexpected utilities, or is not grounded on good (ielogically consistent and acceptable) reasons; in thelatter case, in particular, Radden believes that thebehaviour should be the subject of psychiatricscrutiny. A similar view has been taken by Edwards(27) who claims that bona fide cases of psychiatricdisorder are characterised by actions that fail to realisemanifest goals, thinking that is illogical and repletewith contradictions, beliefs that should be falsified byexperience, the inability to give reasons for actions,unintelligible or nonsensical thinking, and a lack ofimpartiality and fairmindedness.Some definitions of irrationality clearly make more

sense than others. Bizarreness and social disapprovalare weak criteria for irrationality because they areculturally constrained and difficult to apply with anyconsistency: the Lancastrian's predilection for driedpig's blood may seem bizarre to the Hotentot, whoprefers to eat slugs. Against this, some authors haveargued that delusional beliefs should be tested againsttheir cultural background, although this has thedisadvantage of allowing totalitarian regimes todiagnose political dissidents as insane (28).

In testing whether or not happiness is irrational itmay therefore be safer to fall back on the otherapproaches to defining irrationality outlined byRadden and Edwards. Thus, although there is a lack ofrelevant data, it seems reasonable to assume thathappiness often results in actions which fail to realisemanifest goals, and which therefore decrease the happyperson's expected utilities. The potentially life-threatening consequences of happiness have alreadybeen discussed. In addition, happy people mayexperience great difficulties when faced with mundane

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but essential tasks.Both Radden and Edwards imply that irrationality

may be demonstrated by the detection of cognitivedeficits and distortions of one sort or another. There isexcellent experimental evidence that happy people areirrational in this sense. It has been shown that happypeople, in comparison with people who are miserableor depressed, are impaired when retrieving negativeevents from long-term memory (29). Happy peoplehave also been shown to exhibit various biases ofjudgement that prevent them from acquiring a realisticunderstanding of their physical and socialenvironment. Thus, there is consistent evidence thathappy people overestimate their control overenvironmental events (often to the point of perceivingcompletely random events as subject to their will), giveunrealistically positive evaluations of their ownachievements, believe that others share theirunrealistic opinions about themselves, and show ageneral lack of evenhandedness when comparingthemselves to others (30). Although the lack of thesebiases in depressed people has led many psychiatricresearchers to focus their attention on what has come tobe known as depressive realism it is the unrealism ofhappy people that is more noteworthy, and surely clearevidence that such people should be regarded aspsychiatrically disordered.

Possible objectionsI have argued that happiness meets all reasonablecriteria for a psychiatric disorder. It is statisticallyabnormal, consists of a discrete cluster of symptoms,there is at least some evidence that it reflects theabnormal functioning of the central nervous system,and it is associated with various cognitiveabnormalities - in particular, a lack of contact withreality. Acceptance of these arguments leads to theobvious conclusion that happiness should be includedin future taxonomies of mental illness, probably as aform of affective disorder. This would place it on AxisI of the American Psychiatric Association's Diagnosticand Statistical Manual (20). With this prospect inmind, I humbly suggest that the ordinary languageterm 'happiness' be replaced by the more formaldescription major affective disorder, pleasant type, in theinterests of scientific precision and in the hope ofreducing any possible diagnostic ambiguities.There are two possible objections to the proposed

inclusion of major affective disorder, pleasant type, asa psychiatric disorder. First, it might be argued thathappiness is not normally a cause for therapeuticconcern. Therapeutic concern has in fact beenproposed as a criterion for disease by Kraupl-Taylor(31) because of the difficulties of formulating a lessarbitrary criterion. However, Kendell (15) hascriticised this definition as worse than no definition atall because of its obvious circularity and because of theinevitable implication that diseases are culturally andhistorically relative phenomena. On this account,sickle-cell anaemia, anorexia nervosa and psychopathy

(to name but three unequivocal examples of diseasedescribed only in recent times) were not diseases beforetheir discovery. In any event, once the debilitatingconsequences of happiness become widely recognisedit is likely that psychiatrists will begin to devisetreatments for the condition and we can expect theemergence of happiness clinics and anti-happinessmedications in the not too distant future.The second, related objection to the proposal that

happiness be regarded as a psychiatric disorder pointsto the fact that happiness is not normally negativelyvalued. Indeed, it is testimony to the insidious effectsof happiness on some of the greatest minds in historythat some philosophers have argued that the pursuit ofhappiness is the ultimate aim of all human endeavours.However, it is notable that even some of those whohave been rash enough to advocate the greatesthappiness for the greatest number have been explicit inrejecting those extreme forms of happiness associatedwith gluttony of the senses (32). More importantly, theargument that happiness be excluded from futureclassifications of mental disorder merely on thegrounds that it is not negatively valued carries theimplication that value judgements should determineour approach to psychiatric classification. Such asuggestion is clearly inimical to the spirit ofpsychopathology considered as a natural science.Indeed, only a psychopathology that openly declaresthe relevance of values to classification could persist inexcluding happiness from the psychiatric disorders.

Richard P Bentall is Senior Lecturer in the Department ofClinical PsycholoV, Liverpool University.

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