shooting diagnostic fish in_23

Shooting diagnostic fish in the psychiatric barrel: part two

More thoughts on this article. (Part one is here.) Dr. Savodnik

writes:

"All medicine rests on the premise that disease is a manifestation

of diseased tissue. Hepatitis comes down to an inflamed liver,

while lung tissue infiltrated with pneumococcus causes pneumonia.

Every medical student learns this principle. Where, though, is the

diseased tissue in psychopathological conditions?

Unlike the rest of medicine, psychiatry diagnoses behavior that

society doesn't like. Yesterday it was homosexuality. Tomorrow it

will be homophobia. Someone who declares himself the messiah, who

insists that fluorescent lights talk to him or declares that she's

the Virgin Mary, is an example of such behavior. Such people are

deemed -- labeled, really -- sick by psychiatrists, and often they

are taken off to hospitals against their will. The "diagnosis" of

such "pathological behavior" is based on social, political or

aesthetic values.

This is confusing. Behavior cannot be pathological (or healthy, for

that matter). It can simply comport with, or not comport with, our

nonmedical expectations of how people should behave. Analogously,

brains that produce weird or obnoxious behaviors are not diseased.

He's not just shooting the fish. He's attacking the barrel.

I'm no philosopher. I can't offer a discourse on the meaning of

illness or disease. But I wonder: why dismiss the mounting evidence

(hormonal, neurochemical, and genetic) that's converging on a

physiologic mechanism for so many mental disorders? (See here and

here...and my current favorite bit of thought along these lines:

here.) The work is far from done. (Will it ever be done?) But why

dismiss what we've already discovered?

Here's Dr. Peter Kramer (of Listening to Prozac fame):

Some of the brain research that we have seen in the past seven or

eight years has really made it clear that depression is a

disease--there are neuroanatomical changes that are associated with

depression, either causing it or being caused by it. But we don't

have the kind of consistent marker that allows us to say in the way

we can say with polio, `You have the symptoms of the disease, but

you don't have the disease,' because we don't have the biological

marker...

For some, the argument ends there. No biological marker? Then no

disease called "depression." Yet so many lines of research have

offered up clues. We seem so close...

So, Dr. Maurice, since you asked: here (finally) is my response. Yes,

I think that we psychiatrists tend to over-pathologize. Yes,

psychiatry must take responsibility for this behavior, and be vigilant

about exposing and preventing it. No, I don't think that mental

illness is a myth. I don't think personal responsibility is a myth,

either. One of our most important jobs is to help patients take

responsibility for their behavior. (And one of our thorniest issues

is: when does illness impair a person's capacity to take

responsibility?)

Yes, I think that research actually tells us something about the

pathological basis of certain behaviors (unless the research was done

by this guy.) As I've said before: the debate most certainly does not

end here.

(APA President Dr. Steven Sharfstein answers Dr. Savodnik here. I