Understanding the Disease Model

By Dr David Laing Dawson

I had a friendly argument with a colleague the other day. He reminded me that we had been arguing about this topic for 40 years. I think our arguments are mostly ways of clarifying our own thoughts about a very complicated question involving concepts of mind, of cognition, and of the brain, that organ who’s function makes us human.

Mental illness, disease, disorder, serious mental illness, continuum, spectrum, problem, affliction – when is it both valid and useful to consider aberrations (or non-typical) variations in behaviour and thought, illnesses? In some ways these words are just words, and few would care if we referred to arthritis in any of these terms. But when it comes to behavior, thought, and communication (rather than joint flexibility and joint pain) our dearly held beliefs about self, autonomy, will, power, consciousness, and mortality come into play. The discussion becomes political.

Before the medical disease concept evolved in the 18th and 19th century most afflictions were considered very personal and specific, and the causes very personal and specific. An obvious grouping of afflictions might mean God was particularly disappointed in a whole family or tribe. The Miasmists thought that perhaps God did not have that much control over everything and proposed that the causes might be found in the atmosphere, the miasma, physical, spiritual, emotional. An excess or a deficit. The Naturopaths liked this idea but knowing nothing of physiology, metabolism, or nutrition, concocted potions and powders with dozens of ingredients positing that the body might choose from the lot that which it needed. Each of these ideas continues to echo in the pursuit of health today. Especially in the commercial exploitation of our pursuit of health.

The disease model is founded on the idea that if a number of people suffer the same symptoms and signs, and if their affliction follows the same course with the same outcome then perhaps these people suffer from the same “thing”. This in turn raises the possibility that the cause is the same in all cases and that a treatment that works for one will work for the others. To study this we need to name (diagnose) the thing and describe it’s symptoms, signs, and natural course. Given that we are biological beings it is reasonable to think that some of the signs of these diseases will be biological, and that the causes might be as well. But first the chore is to observe, study, collate, find groupings and test this hypothesis.

In a sense the disease model has picked off all the low hanging fruit, those illnesses with very specific causes and courses and, of course, those for which we have found specific treatments, cures and prevention.

The disease model, and some rudimentary epidemiology, led Dr. John Snow to the source of an outbreak of cholera and then to speculate that the cause, residing in the water supply, “behaved as if it were a living organism”. This before we knew about bacteria, let alone viruses, prions, DNA, and neurohomones.

The same disease model has led to the near eradication of Polio. Drs. Alzheimer and Kraeplin applied the disease model to older people with failing cognitive processes and singled out an illness we now call Alzheimers. Dr. Alzheimer had the advantage of being able to examine the brains of his patients soon after diagnosis. Dr. Kraeplin went on to apply the disease model to a younger group of patients with peculiar cognitive difficulties, some similar to dementia, some not, and singled out a group he called dementia praecox, and another group he called manic depressive. Similarly and more recently the disease model singled out autism from the broader group of mentally handicapped children.

The disease model also allows us to study afflictions and find remedies before, sometimes long before we establish with certainty the causes of the affliction. Who on earth but a cruel idealogue would want us to stop treating and reducing suffering until we find an exact and specific cause of the affliction in question, be it cancer, arthritis, or schizophrenia. Yet that is the cant of the anti-psychiatry folks.

Yet the disease model allows us, sometimes by accident, to find remedies that work, can be proven to work, before we nail down etiology. Now, as mentioned earlier, the disease model has picked off the low hanging fruit, those afflictions caused by single alien organisms, and very specific genetic aberrations. We are left with those that are undoubtedly the product of complex combinations of genetic vulnerability, epigenetic influences in the womb, environmental influences, developmental timing, excesses, and deficits.

But we should no more give up on the disease model for schizophrenia and depression than for heart disease, cancer, arthritis, ALS, and dementia.

Our argument was actually about OCD. Having some Obsessive and Compulsive traits can be an asset of course, and of great help in medical school, while extreme OC traits can be debilitating. The “D” of OCD is the initial for “disorder” of course, but is OCD, in annoying to debilitating form, a disease?

Unfortunately the word “disease” has become freighted with negative association, and for my friend, too much associated with “biological cause”.

Ultimately he may think of OCD as a mind problem, while I may think of it as a mind/brain problem, but it is the discipline of the medical disease concept that allows us to study it and find remedies we can test.

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3 thoughts on “Understanding the Disease Model

  1. Very thoughtful article. Thank you. In my not so humble opinion The antipsychitry people may only see the light, if there are clinica ( biological )l tests. In the meantime we must plod on with treatment available which often works , which is infinitely better than the untreated conditions which often torture the individual. Relief often comes with treatment. Alas insight may not.

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  2. clinical biological tests will not be sufficient, it fact…

    go back to Davids words about what is left after the lowhanging fruit has been admitted to biological causation. “We are left with those that are undoubtedly the product of complex combinations of genetic vulnerability, epigenetic influences in the womb, environmental influences, developmental timing, excesses, and deficits.”

    I hope the Mad in America rants have conditioned you to notice “excesses and deficits” in that quote, for here is one area they have exhibited great effort to twist the narrative. If any conversation exhibits the excesses of political weaponization, it is this. I believe it rises to near the top as a “big lie.”

    Second place in this flat earth resistance is taken by “environmental influences.” Second only because the rhetoric is less confrontational though it looks to me more wide spread and more insidious. Not just those in the trenches, but non-partisans will be found saying mother caused it,Freud was right. Family dynamics will repeat it and pretend to be totally neutral. Last night I read a dual diagnosis recovery center site and the founder, a man of traditional medical background was quoted: “we’re all a little bipolar.” before the page went on to explain the nexus of untreated trauma and mood swings. I first encountered this belief system as a wisecrack in the 60’s movie West Side Story” when a gang member laughs ” I got a social disease” in response to a beat cop expounding the theory in general form.

    Of curse Szasz and sociologists and post-modernists and Durkheim had paved that road for the officer. Mad in America maintains it and you often see the mad people cursing their parents for the ills done to their minds and wills and joy of life. True to form they don’t mention epignetics or genetic heritage, just bad mom, bad dad, bad child rearing.

    With diseases that do not present in a clearly recognizable form, we have another front of the Flat Earth mind set. “It cant be AIDS, there is no set course, there is no defining presentation, the evidence of a so called virus is not consistent.” Of course they were not versed in disease of the immune system (think also Lymes and Fibromyalgia, CFS etc and etc) Nor were they versed or open to the concept of virus lying dormant. That there are perhaps scores nwt of such viruses documented is no reason to change religions (what we fight wars and politick over) now.

    No, the picking of these not so low hanging fruit will not “shed a light” that those with eyes closed to demonic glamor will find truth by. As “addicted” as America is to the myth of the invictus spirit of individualism, and a free will incorruptable but by sin envited by heeding the devils call… don’t expect mass conversion to the idea that mind is as fragile as those few ounces so easily broke by impacts like football, so easily deprived of function by a small little bullet in the wrong place. As for a donward trend even with treatment by the poisons of industrial pharmacy? The devil is in the factory and the front offices.

    If you point to a high achieving alcoholic or addict, you probably will be told they could achieve more without the drink or heroin, for it is recieved doctrine that use is abuse and abuse diminishes achievement. Likewise, that a treated patient might not fully recover or get worse is proof that the fake medicine led to the worsening condition or stimied ‘recovery by other means.’

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  3. A word from “the friend” in the “argument”. I would rather say that what we had was an vigorous discussion which, though too brief, maintained some of the nuance necessary for any intelligent exchange in search of truth rather than mere combat between equally rigid ideologies!

    It was dear old Robert Dole who said that “the real devil in this world is either/or”. Let’s stay away from emotionally charged binary thinking and look at mind AND brain, thereby being neither mindless nor brainless.

    There is a brain with vulnerabilities and limitations, most likely genetically determined. There is a mind, animated by consciousness, which is not a thing or a chemical reaction. Children are affected deeply by their developmental experience, something for which parents are inescapably responsible as accountability, not blame. “Blame” is a weapon used to avoid simple, honest accountability. Blame is a defence; accountability heals.

    The medical-illness model has many convenient hiding places for avoiding accountability which is the simply exercise of what belongs where and who is responsible for what–a process which is good for all concerned. The developmental model also has hiding places, such as projecting actual accountability onto others, which is the true meaning of blame. I say to my patients, “You are not responsible for your parents’ shortcomings; you ARE responsible for dealing with the effects of them.”

    I said to my friend, “I have never seen a patient with OCD who did not have a tyrannical parent and whose OCD symptoms could not be seen as a mental defence mechanism designed to keep homicidal rage from being dangerously released.” What genetic vulnerabilities my be present are not necessarily causes per se; that is, we make our defences out of what we are naturally good at. The tyrannical parent does not usually come across as OCD themselves but as massively controlling, which could be the same thing. Regardless, you cannot exclude from consideration the developmental effect on a child of such a parental experience, whatever its source–mind or brain.

    The truth will make you free. You can witness this regularly in any real therapy.

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