(PSYCHIATRIC TIMES) - What exactly is a “mental disorder”? For that matter, what criteria should determine whether any condition is a “disease” or a “disorder”? Is “disease” something like an oak tree—a physical object you can bump into or put your arms around? Or are terms like “disease” and “disorder” merely abstract, value-laden constructs, akin to “injustice” and “immorality”? Are categories of disease and disorder fundamentally different in psychiatry than in other medical specialties? And—by the way—how do the terms “disease,” “disorder,” “syndrome,” “malady,” “sickness,” and “illness” differ?
Anyone who believes there are easy or certain answers to these questions is either in touch with the Divine Mind, or out of touch with reality. To appreciate the complexity and ambiguity in this conceptual arena, consider this quote from the venerable Oxford Textbook of Philosophy and Psychiatry:
"The term 'mental illness' is probably best used for those disorders that are intuitively most like bodily illness (or disease) and, yet, mental rather than bodily. This of course implies everything that is built into the mind-brain problem!"1(p11)
In a single sentence, we are already grappling with the terms “illness,” “disorder,” and “disease,” not to mention Cartesian psychology! And yet—daunting though these issues are—they are central to the practical task now before the DSM-V committees: figuring out what conditions ought to be included as psychiatric disorders.
To prefigure one element of my own position, I again quote from the Oxford Textbook’s chapter 20, “Values in Psychiatric Diagnosis”:
"Our conclusion . . . [is] that the traditional medical model, and the claim to value-free diagnosis on which it rests, is unsupportable; and that, to the contrary, diagnosis, although properly grounded on facts, is also, and essentially, grounded on values. . . . [This] is consistent with late twentieth century work in the philosophy of science . . . showing the extent to which the scientific process, from observation and classification to explanation and theory construction, does not depend on merely passively recording data, but is instead actively shaped in complex judgments. . . ."1(p565)
The Oxford authors wisely observe that “adding values” does not entail “subtracting facts.” Thus, when we assert that someone with paraplegia has a pathological (from the Greek pathos, “suffering”) condition, we are making a claim grounded in a certain kind of value judgment; namely, that the inability to move one’s legs is in some sense “not a good thing.” In a society that greatly valued paralysis and devalued walking, paraplegia would not constitute “pathology.” On the other hand, we also “add facts” in reaching the conclusion that Mr Jones—who cannot move his legs—has suffered a fracture-dislocation of the lumbar vertebrae. In short, medical diagnosis is a matter of “facts plus values.”1 (Incidentally, we do not escape this evaluative dimension by appealing to some putative “evolutionary standard” based on notions of how we humans were “designed.”2 As clinicians, we must still make value judgments as to what degrees of departure from supposed evolutionarily designed responses should—or should not—count as “disease”).
Similarly, when psychiatrists adduce evidence of suffering and incapacity in diagnosing a psychiatric disorder, we implicitly invoke certain broad values; for example, that it is generally “not a good thing” when a human being is unable to eat, sleep, think, and work. At the same time, we “add facts”: we note that the patient has lost 20 lb in the last month; that she gets only 3 hours of sleep each night; that she cannot subtract serial 7s accurately; and perhaps, in some cases, that she shows marked elevation of her serum cortisol level.3 That the facts we adduce as psychiatrists often differ from the kind cited by, say, orthopedists, does not render our data less “factual”! Indeed, some of the most important facts about the suffering and incapacitated psychiatric patient are facts intrinsic to the person’s experience—the phenomenology or “life world” of the patient.4-6 Thus, when the depressed patient tells us, “I feel like I’m being suffocated by my depression” and “I feel like an empty shell about to be crushed,” we justifiably regard these as facts of the patient’s felt experience.
The notion that only conditions associated with anatomical lesions or abnormal physiology count as “real” diseases—the “lumps and labs” model of disease7—denigrates the phenomenological realm. Sadly, such misplaced positivism—based on a crude understanding of pathologist Rudolph Virchow’s views—has been used to whack psychiatry over the head for nearly 50 years.8,9 That said, in the model I shall develop, the search for abnormal neuroanatomy, physiology, and biomarkers does play an important role in the later stages of disease classification.
Mental disorders: essential definitions
Deciding what should “count” as a mental disorder is not the same as offering an essential definition of “mental disorder.” An essential definition is one that specifies necessary and sufficient conditions; for example, “a closed figure consisting of 3 line segments linked end-to-end” constitutes the necessary and sufficient conditions for ascribing the term “triangle.”
The philosopher Ludwig Wittgenstein (1889-1951) taught us that—with the possible exception of mathematical terms—commonly used words do not have essential definitions.10,11 For example, it is almost impossible to specify the necessary and sufficient conditions that define the term “game.” On the other hand, Wittgenstein argued, we can identify certain “resemblances” among members of a particular “family.” These family resemblances—blond hair, blue eyes, for example—help us to recognize the family, even though no single feature is present in every family member.
Wittgenstein likens a family resemblance to the long, overlapping fibers of a rope: no single fiber runs throughout the entire length of the rope, but the rope is still held together by these fibers.
Following the lead of the late Dr Robert E. Kendell,12 I believe that suffering and incapacity are the main “fibers” making up the disease concept. When prolonged and severe suffering and incapacity are present in the affective, cognitive, or interpersonal-behavioral realms, we are then entitled to speak generically of “psychiatric disease.” (For many reasons, I believe this term is preferable to “mental disorder” or “mental illness,” but I will retain the term “mental disorder” because it is used in the DSMs).
The failure to recognize the distinction between disease in its primordial, conceptual sense (in German, die Krankheit) and specific diseases (die Krankheiten) has led to much confusion, in my view.8,9 What we humans ordinarily “count” as disease (die Krankheit) represents a pragmatic existential decision. It is not a determination akin to observing a bacterium under a microscope. Indeed, the concept of disease (etymologically, dis-ease) does not originate in the realm of “expert” determination; rather, ordinary human beings decide that someone is “dis-eased” based on everyday observations and reports of suffering and incapacity. It does not take a microbiologist or pathologist, for example, to know that someone “has disease” or “is diseased”—even though both specialists may ultimately contribute to determining the particular type of disease.
In the words of Maurice Natanson,13 a philosopher who helped introduce the work of Jean-Paul Sartre and Edmund Husserl in the United States, “Disease [is originally recognized] not by experts, but by ordinary men.” Similarly, with respect to cognitive and emotional derangement, we do not require biological validators to identify the presence of psychiatric disease per se. Thus, my teacher, Dr Robert W. Daly,14 has written:
"To affirm that someone is mad is to make a practical judgment based on immediate and reflective knowledge of the activities, experiences, and circumstances of the person in question . . . as a particular human agent. "
The evolution of a specific mental disorder
So how do we develop a practical model for determining whether a condition represents, in the first place, dis-ease and, secondarily, whether it constitutes a specific disease, on a par with, say, bipolar I disorder? For example, how do we decide whether to consider “pathological bigotry” and “internet addiction” as specific mental disorders?
I have developed a pyramidal model (Figure) that illustrates the evolution of a condition from primordial dis-ease to a fully realized disease entity. At the base of the pyramid (stage 1) is the everyday recognition of substantial and prolonged suffering and incapacity. In my view, at least some of the “suffering” must be an intrinsic element of having the condition—not simply a consequence of society’s punitive responses to the person’s behaviors (eg, putting someone in jail because of certain sexual behaviors). We can specify “suffering and incapacity” in terms of social and vocational impairment, impaired vital functions, and distortions in the phenomenological realm (feeling “totally worthless,” “like I’m nothing.”
The next level of the pyramid (stage 2) consists of the general syndromal description of the condition; for example, people with (hypothetical) Syndrome X typically experience olfactory hallucinations, memory loss, impaired calculation, and loss of taste. At the syndromal level, we usually have evidence that these signs and symptoms reliably “hang together” over long periods and in geographically distant populations.
The next level (stage 3) consists of what I call the proto-disease. By now, we have characterized the syndrome in terms of usual course, outcome, comorbidity, familial pattern, and response to treatment. We may also have preliminary data on pathophysiology and biomarkers, and a more specific understanding of the afflicted person’s phenomenology.
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