Sam Thompson (University of Liverpool) posted the following tweet on April 27:
Can anyone point me to a good, succinct summary of the case for equating mental distress with illness? (serious, non-sarcastic question)
On the face of it, this looks like a straightforward question, and one might think that a straightforward answer could be found. But this is not the case, because ultimately it boils down to a matter of definition. And psychiatry is a field where definitions are notoriously fuzzy.
Contrary to widespread belief, the APA’s Diagnostic and Statistical Manual is not a listing of “mental illnesses,” but rather of “mental disorders.” However, for the last 20 years or so, almost all psychiatrists have conceptualized the problems they treat as illnesses (specifically, chemical imbalances in the brain) and have routinely expounded this untruth to their clients.
It is noteworthy that the APA has never issued any kind of clarificatory statement on this matter, and in practice the terms are used interchangeably. But the confusion is no accident. By interchanging these terms, the psychiatrists have allowed the medicalization of the identified problems by implication rather than by fiat, which makes it easier for them to extricate themselves should the medical model ever come under serious scrutiny – which, incidentally, is what’s happening at present.
The protest against the spurious medicalization of virtually every life problem is loud, focused, and growing. And, predictably, the psychiatrists are beginning their extrication process.
Ronald Pies, MD, is a well-known US psychiatrist who blogs on Psychiatric Times. On the illness terminology, he had this to say on July 11, 2011:
“In truth, the ‘chemical imbalance’ notion was always a kind of urban legend- – never a theory seriously propounded by well-informed psychiatrists.” (link)
And on April 18, 2013:
“But on the whole, I believe the medicalization narrative is philosophically naive and clinically unhelpful.” (link)
He blames the “chemical imbalance” notion on pharma:
“And, yes—the ‘chemical imbalance’ image has been vigorously promoted by some pharmaceutical companies, often to the detriment of our patients’ understanding.” (link) ( 7/11/2011)
So the spurious medicalization of clients’ problems is in no way the responsibility of psychiatrists. It’s the fault of pharma.
But like most psychiatrists, Dr. Pies is experiencing some inner conflict in this general area. Here’s another quote from the April 18 paper:
“So long as the patient is experiencing a substantial or enduring state of suffering and incapacity, the patient has disease…”
And there you have it. For Dr. Pies, suffering + incapacity = disease, which presumably is synonymous with illness. Dr. Pies quotes a reference in support of this position. It’s an essay he wrote in January 2013. You can see Part 1 here, and Part 2 here. In these papers he doesn’t actually produce arguments in support of this position, but simply asserts it to be so. For instance:
“Regardless of context, once a certain threshold of suffering and incapacity is crossed, physicians justifiably apply the term ‘disease’ (or ‘disorder’) to the person’s condition. (For purposes of this discussion, I am using the terms ‘disease’ and ‘disorder’ more or less synonymously, although the medical literature is remarkably inconsistent in how these terms are applied.“
There it is: once a “…certain threshold of suffering and incapacity is crossed…” a sub-optimal behavior or feeling becomes a disease/illness. And also notice that “disorder” and “disease” have become synonymous.
I mention Dr. Pies’ work in this context not because of any intrinsic value, but because he managed to put into words many of the unspoken assumptions inherent in modern psychiatry. What’s particularly striking in Dr. Pies’ writing is the notion that one can consider a condition an illness even in the absence of any demonstrable physical pathology.
This is echoed in the APA’s definition of a mental illness/disorder:
“…a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress… or disability … or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.” (DSM-IV-TR, p xxxi)
There are a number of noteworthy features to this definition.
– a behavioral or psychological pattern (i.e. any kind of human activity)
– that occurs in an individual (as opposed, say, to in a family or in society)
– that is associated with (not necessarily causally associated)
– distress or disability or significantly increased risk
– of death or pain or disability or loss of freedom
Note the multiplicity of “ors”, so only one of the factors listed is needed for a condition to be a mental illness/disorder.
It is truly difficult to think of any sub-optimal human activity that would not be embraced by this definition. Habitually wearing shoes that are too tight, for instance, is a behavior pattern; it occurs in an individual; and is associated with pain. Playing one’s car radio too loud is associated with disability (hearing loss). Any kind of criminal activity is clearly embraced by the definition on the grounds that it entails the risk of incarceration. Mountain climbing is associated with increased risk of death. Etc., etc., etc… The definition is so broad that it can embrace any activity that the APA chooses to include in the DSM.
As with Dr. Pies’ writing, there is no requirement of physical pathology for a condition to be called a mental disorder/illness.
Over the past 30 years or so, various attempts have been made to prove that the conditions listed in DSM are illnesses. These proofs usually involve showing that the activity in question has a characteristic neural underpinning, and “therefore” the activity is an illness. Most of the attempts have foundered under scrutiny. For instance, the brain damage theory of “schizophrenia” collapsed when it was demonstrated that the characteristic damage was actually caused by neuroleptics. But even if characteristic neural or hormonal or genetic correlates were accurately and reliably identified, this will never be the full story.
Consider the case of violent behavior. Let’s say person X kicks person Y in the head quite viciously, and the question arises: why did X kick Y? An explanation might be offered along the following lines:
The muscle fibers in X’s thigh contracted and rapidly released; this muscular activity was caused by the organized firing of various neurons, coupled with the presence of adequate reserves of potassium ions in the blood stream. The neuronal activity was initiated by synaptic activity in the cerebral cortex which in turn was influenced by sensory input signals. And all of this activity was made possible by the fact that the digestive tract was primed and functioning and was providing energy to various bodily systems via the blood stream. The adrenal glands had secreted adrenaline … etc..
This kind of account if developed in detail might easily run to a million words; could be 100% true, and would indeed constitute an explanation of the act of kicking. Behavioral patterns are indeed underpinned and driven by corresponding physiological patterns. This is true whether the behavior is functional or dysfunctional; productive or counterproductive, helpful or unhelpful. The fact that a behavior can be explained in physiological terms does not make the behavior an illness. All behavior can be explained in physiological terms. One could, for instance, conduct a physiological analysis (similar to the one above) for the activity of riding a bicycle. This would not prove that bike-riding is an illness. Nor would it be the full story or even the main story.
Another way of explaining the kicking incident, for instance, might go like this:
X grew up in very violent surroundings, and he acquired the habit of responding violently to anything or anybody who seemed threatening. Y was speaking loudly and aggressively and had begun to assault X, so X knocked him down and kicked him in the head.
I suggest that while the physiological explanation would have a great deal of interest for physiologists, the latter (behavioral) explanation has more usefulness and relevance for people working in the human service field, and indeed for people generally who are trying to understand human behavior, feelings, conflict, etc…
A complication in this area is the fact that biological malfunctions can and do occur, and occasionally these malfunctions can cause psychological/behavioral problems. A number of such conditions are known, and the underlying biological damage/malfunction has been identified with various degrees of precision.
But, and this is the critical point, the vast majority of behavior that meets the APA’s criteria for a mental disorder is not associated with known biological pathology.
But then there’s yet another complication, which stems from the fact that people can learn. We can acquire new skills and behaviors. This process has been studied extensively by psychologists and others, but the underlying physiology/neurology is not well understood.
However, it is obvious that there is some neurological basis to every item of new learning. If I take a walk in some place where I’ve never been before, and afterwards I can recall details of the area or even draw a map of the place, clearly there is something inside my brain that has changed. Similarly newly acquired skills and habits, whether they are functional or dysfunctional, are underlain with some kind of neural “program”. And this fact, though seldom articulated, is the basis for the psychiatric medicalization of all human problems.
Suppose I have, for instance, an extreme fear of public speaking. This is an acquired fear (i.e. I wasn’t born with it), and it is likely that I have acquired this fear in the same general way that people acquire other fears (i.e. through social conditioning). But there is something in my brain that corresponds to, and indeed causes, physiologically, this particular fear response.
Getting rid of this fear is generally not difficult. I could design a program of systematically increasing exposure; I could ask a psychologist to help me; or I could join Toastmasters. Assuming that the retraining is successful, then the neural underlay will also be removed, or disabled, or modified in some way.
Psychiatry’s approach, however, is to get rid of the fear by directly targeting the neurological basis, and they apply this approach to all human problems – not just fears. The methods they use are drugs, electric shock, and scalpels. It is a central theme of this website that their efforts in this regard are not only unsuccessful, but also do a great deal of harm. But for now, let’s continue to explore the conceptual issues.
I have a picture “in my head” of a school I attended as a child. Let’s say I have truly horrendous memories of this school, and let’s say that the neurological trace of this building is confined to one minute spot in my brain. A neurosurgeon might conceivably be able to go in with a tiny electrode and burn out the offending tissue, and I would never again be troubled by this memory.
I’m not suggesting that anything of this sort is, or ever will be, possible (if for no other reason than that the bad memories are probably not confined to one tiny neural location). But this is the essential reasoning behind the illness theory: that painful memories, bouts of depression, counterproductive habits, etc., are all best understood in terms of their neural underpinnings, which have to be removed, damped down, rebalanced, adjusted, burned out, or whatever, even though they are not in themselves pathological, either with regards to genesis or functioning. My horrendous memories of the school are actually adaptive, and might conceivably help me avoid aversive situations of this sort in the future.
At the present time, and I suggest in the foreseeable future, the tools used by psychiatrists in their efforts to effect these adjustments are more analogous to soup spoons, or even jackhammers, than tiny electrodes.
Some of these issues can be clarified with a computer analogy. I can take a photograph of my house and put it into my computer. (Well, to be honest, I would have to ask my wife to do this.) But the picture is in the computer in the form of a string of on or off magnetic fields. If I decide to delete this picture, I (or Nancy) can press the various keys and the picture is gone. In other words, I remove the picture using essentially the same technology that was used to store it in the first place. This is analogous to helping people free themselves from fears, negative feelings, counterproductive habits, etc., by means of human contact, dialogue, support, etc…
Alternatively, I might in theory be able – if I knew a great deal about hardware – to go inside the physical apparatus with tiny drills, etc., find where the picture was stored, and physically obliterate the 1’s and 0’s, so that the picture would be destroyed. Inevitably I will damage a good deal of the surrounding hardware and, of course, other information stored on this hardware. Again, I’m not suggesting that any of this is even possible. It would probably just destroy the computer! But the point is that this tactic is analogous to the psychiatric/biological approach: tampering with the brain in a misguided attempt to get rid of unhappy thoughts or counterproductive habits, even though there is nothing wrong with the brain. A person with a perfectly ok brain can acquire an extreme fear. Remember Little Albert (here).
So finally, let’s get back to Sam’s question: What proof is there that mental distress is illness? The question can be rephrased as follows: If a person’s behavior or feelings are causing him distress, should the neural underpinnings of these behaviors/feelings be considered an illness? And it is immediately clear that this is not something that admits of proof; rather it is a matter of semantics. Not long ago the International Astronomical Union decided that Pluto is no longer to be considered a planet. It is now a dwarf planet. This was not something that had to be proven. It was a decision about the use of the terms. If someone were to ask the astronomers to prove that Pluto was not a planet, the only possible way to respond would be to elucidate the meanings of the various terms.
Psychiatrists choose to call all human problems illnesses (“just like diabetes”). Normally, like Dr. Pies, they make no attempt to justify this position. They simply state it to be so.
When psychiatrists do try to rationalize their practice of calling human problems illnesses, it is always along the lines of “correcting” brain structure, physiology, or programming, even though there is no evidence of a neural pathology. If the neural entities are causing distress or pain or disability or the risk of incarceration, then by definition, they are illnesses.
And that’s all there is to it. Human problems are illnesses because the APA say so.
The common usage of the term “illness,” however, implies physical pathology, i.e. something wrong with the structure or functioning of the organism. Psychiatrists implicitly endorse this notion when they tell their clients that depression (or ADHD, or anxiety, etc.) is a real illness “just like diabetes.” What does the phrase “just like diabetes” mean in this context? I suggest it means real physical pathology. And psychiatrists routinely push this notion even though it is false, and even though there is no requirement of physical pathology in their definition of a mental illness. Within the APA’s conceptual framework, human problems are illnesses because the APA say so. There really is nothing more to it than that.