Psychiatry in the mirror

An announcement from the Belgian Superior Health Council caused a minor Twitter stir recently, with some exalted voices of how revolutionary it is. In contrast to the amazement, I am rather underwhelmed by the text, and I can’t see the revolution.

The aspect of the statement I want to deal with here is the message that mental disorder categories should be seen as constructs, rather than categories of the natural kind. I read it (and the Twitter gasps of wonder related to it) and I thought: Is this the revolution? I mean, I am no historian of medicine, but debates on the nature of disease/illness (these are not the same and disease tends to be seen as what medicine cure and illness as our experience of ‘unhealth’) have been going throughout human history and included sin as a source of disease/illness. Indeed, as Mildred Blaxter tells us in her book on health, even within the biomedical model, understanding of what disease is has been a matter for much debate and medicine’s views have been changing. When we get to more holistic views on health and illness, illness can be viewed as a series of losses, as bodily transformation, as being towards death (see Havi Carel’s books). Michael Bury sees illness in terms of a biographical disruption, Kathy Charmaz talks about the loss of self.

A few years ago, I attended a lecture by the philosopher Lennart Nordenfelt, who argued that health and illness/disease should be understood in terms of life goals and our ability to realise them. I enjoyed the plenary, but I didn’t take to the proposal. It would seem to me that the definition is so wide that it medicalises old age. Indeed, as I grow older, there are all sorts of things I will no longer do, even though I would still like to do them.

After the lecture, I asked the question about it. Nordenfelt said that as we grow older, we adjust our life goals. And as we do the adjusting, old age cannot become a disease/illness. I didn’t like the answer at all, as it homogenises old age. So, I retorted: speak for yourself. I’m telling the story as I want to make clear that the debate on what constitutes a disease/illness is live and well. I’m not following it closely, still I don’t think it’s anywhere near over and there still is no accepted definition of what a disease, or indeed, an illness is.

Of course, we can take a pragmatic view and say that diseases are all those things that medicine defines as diseases. Indeed, medicine provides us with useful catalogues of diseases/disorders. Such catalogues, such the American DSM or WHO’s ICD, offer an all-or-nothing view of diseases (it’s either there or not). Yet, also such lists are far from finite. We all remember that homosexuality used to be a disease and it was, famously, removed from the mental disorder list by the American Psychiatric Association (there is very interesting account of the process in the book by Kutchins and Kirk). Discussions on what should be included continue and there were major debates before the publication of the current, fifth, iteration of the DSM about what new disorders should be created (indeed, a few were).

The chronic fatigue syndrome has had an even more turbulent history. It was put in ICD-9, then removed from ICD-10, now it’s going to be reinstated in ICD-11 as a fully authorised disease. How natural is that?

More recently, such discussions have re-appeared in the case of obesity. Should obesity be a disease? Medicine still hasn’t decided in favour, yet the discussion is on-going. A similar discussion is going on about suicide. Is suicide (or suicide behaviour) a disorder in its own right or is it mere a symptom, for example of depression? So far, psychiatry answers with the latter, but the American Psychiatric Association has indicated it is prepared to change its mind. Paradoxically, it seems that only one physical act could be enough to count as a mental illness.

But you could argue that all those examples are somewhat fuzzy, so, what about hard-core empirical evidence? Well, things are complicated here too. Take blood pressure, for example. In the UK you’re ill with hypertension if your blood pressure exceeds 140/90 mmHg. Simple? Well, no, because you will be treated when it exceeds 150/100 mmHg. The question what constitutes hypertension is not trivial, is it?

It’s even funnier with cholesterol levels. Years ago now, I was told by my GP that my elevated cholesterol level became normal. Overnight. Hurray? Hardly. The norms have changed and hypercholesterolemia has been re-constructed differently. Finally, there is some evidence of manipulation of sperm count norms. What counted as low or very low sperm count in, say, 1980s is now taken as normal. It might well be that we are able to take better measurements, still, the norms have changed. The hard facts somehow had to given in.

And so, whether you side with the naturalist view of disease or its constructivist counterpart (see a thorough account here), you must see that things are at least complicated and the current ‘maps of disease’ are unlikely to stay as they are forever. Even if you’re fully committed to the idea of disease-as-natural, you must understand that even tomorrow we might discover a yet more fantastic set of diagnostic tools that will not only blow our minds but will also re-write (at least parts of) medicine. And, say, the troponin levels currently defining myocardial infarction (i.e., a heart attack) will need re-adjusting.

The final example I want to use is the co-called long-covid. Last year saw fierce debates, including those led by patients, arguing that their experience is a new category of illness and disease and should be seen as such. And indeed, through medicine, our societies are more and more prepared to invoke a long-covid disease to being. But, what’s crucial, and there is nothing natural about it. In fact, the process is social/discursive. A new construct, a new story, was created and people’s experiences can now be told and re-told in a particular way. We created an illness.

It’s time to go back to the Belgian Superior Health Council. First, I think it’s quite clear that what the Council says, at least with regard to the diseases-as-constructs, is hardly revolutionary. What I’ve been describing is hardly news at all. In fact, regardless of where your theoretical allegiance is, members of the Council basically say what has been known for a significant period of time. And here I come to the point when I would like to offer a speculation as to why the Council would decide to make such a statement. I would imagine (hope?) that it is very unlikely that its members do not know all that I have written.

So, my first speculation is that the statement is to maintain a particular story of a divide between psychiatry and the ‘real’ medicine. Regardless of the fact real medicine’ doesn’t simply deal with hard facts, quite a lot of people like to describe psychiatry as different in this respect. I am not certain it’s particularly helpful to ‘real medicine’, but it might be helpful to psychiatry and its ‘moreorlessness’. Indeed, I keep reading tweets from eminent psychiatrists that mental illness is not a disease, because mental illness is a construct. So are other diseases, for pity’s sake, but perhaps I should not spoil the story of psychiatry, should I?

Such statements seem to be intended more to say something about psychiatry and not about other medicine. Psychiatry is softer, more-or-less, more tentative, tread with care. That’s fine, but perhaps this story needs a better background, rather than the crude division between mental-illness-construct and disease-natural-thing.

My second speculation follows the above in that perhaps the Council’s statement is to reach all those psychiatrists who might trust too much in their power to diagnose. Perhaps it’s supposed to tell them to hold back a little. But if this is so, perhaps, instead of making such crypto-messages, it would be better to encourage shrinks to reflect more on what it is that they do. What exactly is a diagnosis and whether, as Allen Frances keeps repeating, it is written in pencil.

If there is one message that recurs in my blogs on medicine in general and in psychiatry in particular, I keep encouraging psychiatry to look in the mirror. Will you really like what you see? The context of such questions has changed, and I ask it with some trepidation, I must admit. Now, as we read continually about hero doctors healing patients with their fragrant hands, I still do miss the question: do you, as medicine, and particularly psychiatry, like what we see when we look in the mirror? As much as I do admire a clinician who selflessly continues to help their patients, sometimes against the odds, I also admire one who stops to think, to reflect on and understand better what they do. These are also heroes, and I root for them, too.

I also root for the news stories they will (inevitably) come up with.





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