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.