A Presentation by Ronald Pies, MD
OK, how many of you would like to be sipping that beer on a nice, warm desert island somewhere in the S. Pacific? Well, I’m planning to take you to just such an island for a little while—but I have to warn you, things will get pretty strange really fast. By the way, I’m aware that many issues related to psychiatry and mental health are very highly-charged, controversial, and sometimes painful, for many people. After all, where do psychiatrists get off, telling people that they are crazy? That’s the job of your husband, your wife, or your in-laws, right? And of course, there are a number of hot-button issues involving psychiatry, civil liberties, and the law, which I am not planning to talk about tonight. I know that for many people, issues such as involuntary hospitalization, forced medications, the insanity defense, etc. inspire some deeply-held beliefs and feelings. Any or all of these topics are fair game in the discussion period, of course, provided the discussion isn’t accompanied by tomatoes flying across the room. What I do want to discuss in my talk is a more abstract idea—the nature of disease, as it’s understood in general medicine and in psychiatry. But although this is an abstract topic, I believe it has important medical, legal, and social implications. I’ll say more about this later, but right now, there’s that desert island I promised to take you to.
So there you are, marooned on a beautiful desert island. There’s plenty of fruit and other foods to keep you going, and it happens you have your pen and notebook with you, so you decide to work on that great American novel you’ve never had time for. Things are going great for the first month—but then, you start to feel a little strange. You find that you can no longer concentrate on your writing. Your thoughts seem jumbled and confused. And as for that raft you had started to build, well—you find you no longer have the interest or motivation to work on it. Worse still, you begin to sense a presence on the island—you feel you are being watched…menaced by something or someone, even though you haven’t seen anything threatening. Over the next few days, you begin hearing a voice in your head, saying, “The Evil One will Find you.” The voice seems very real to you, and you begin to fear for your life. Over the next few weeks, you start to lose your appetite, and notice that your shorts are much looser on you…you’ve lost a lot of weight. Your sleep has been terrible, too—you toss and turn throughout the night and wake up each am exhausted. The voice is growing louder, and you begin having thoughts about throwing yourself in to the sea.
OK, this is probably sounding like an episode of “Lost”. Let’s freeze the frame here, and ask a question. How may of you, if you were to experience what I have described, might wonder if you had developed some kind of illness, malady, or disease? (Raise hands). OK, how many of you would conclude that, in fact, you had developed some kind of disease?
Well, I took a bit of a gamble here, but not much of one. I was fairly confident that at least some of you would reach the same conclusion I would reach, and, indeed, that most physicians would reach: this sounds like the beginning of a serious disease. We don’t know at this point, what kind of disease—maybe you got bitten by some island parasite, and have developed something like Lyme Disease, which, by the way, can cause neuropsychiatric symptoms. Or maybe you are developing something like a psychotic depression or acute schizophrenic episode. It doesn’t matter for our purposes. We agree that you have developed a disease of some type—or as I like to say, “dis-ease.” I believe that in our ordinary language use of the term disease, this scenario fits the bill. Well, if I’m right, what does that tell us about how we use the word disease? Notice that in this scenario, there was no doctor, no psychiatrist, no CAT scan of the brain, no laboratory tests, no nothing—except your experience. That is to say, we reached the conclusion you were developing a disease based on a phenomenological account—that is, an account of your conscious experience. And what was that experience? Essentially, it was one of suffering and incapacity. And believe me, when people hear frightening auditory hallucinations, they do suffer. And when they can’t concentrate, or eat, or sleep, they become relatively incapacitated. And so, I want to propose to you that our ordinary language sense of the term, disease is a state of suffering and incapacity, not explained by some obvious external cause. I add on this last qualifier, since we don’t ordinarily say that someone has a disease when they are suffering and incapacitated because, say, they have a knife stuck in their leg, or when they are buried by an earthquake, or held captive by kidnappers. We attribute disease to ourselves or to others when we are experiencing suffering and incapacity in the absence of such obvious external causes; or when we observe others to be in such a state of suffering and incapacity.
Now, to be sure, this is far from a universally held view. In fact, historically, two competing views of disease have held sway since the time of Hippocrates; namely, the “organic” view of disease as disordered structure (or more recently, as “pathophysiology”); and the “phenomenal” view of disease as an enduring disturbance in the overall well-being of the individual, characterized by suffering and incapacity. Yet some critics of psychiatry—notably my friendly adversary and teacher, Tomas Szasz—have argued that diseases are established solely on the basis of our finding lesions—essentially lumps, bumps, tumors, and the like—or by demonstrating abnormal physiology.
Thus, in his book, Schizophrenia, Szasz (1976, p. 3 ) argues that
The accepted scientific method for demonstrating… diseases consisted, first, of identifying their morphological characteristic by post-mortem examination of organs and tissues; and second, of ascertaining, by means of systemic observations and experiments.., their origins and causes. (Szasz, 1976, p. 131)
Note that Szasz has used the term “diseases” (plural) in the passage I just quoted. Now listen to this further passage, which is from the website for the Thomas S. Szasz MD Cybercenter for Liberty and Responsibility (http://www.enabling.org(link is external)):
Mental illness is a metaphor (metaphorical disease). The word “disease” denotes a demonstrable biological process that affects the bodies of living organisms (plants, animals, and humans). The term “mental illness” refers to the undesirable thoughts, feelings, and behaviors of persons. Classifying thoughts, feelings, and behaviors as diseases is a logical and semantic error, like classifying the whale as a fish. As the whale is not a fish, mental illness is not a disease. Individuals with brain diseases (bad brains) or kidney diseases (bad kidneys) are literally sick. Individuals with mental diseases (bad behaviors), like societies with economic diseases (bad fiscal policies), are metaphorically sick.
Notice that in this second passage, Szasz has used the term ‘disease’. He says, “disease” denotes a demonstrable biological process that affects the bodies of living organisms. Now, I believe Szasz has made a fundamental error here—that is, confusing disease with specific diseases. Because, whereas “disease” is, in my view, a prescientific construct, based on the presence of suffering and incapacity; it is arguably the case that the identification of specific diseases—such as tuberculosis or Alzheimer’s Disease—depends on the sort of “demonstrable biological process” or lesion that Szasz appeals to. Actually, even something as specific as Alzheimer’s Disease is diagnosed every day on the basis of clinical signs and symptoms—we don’t do brain biopsies, in most cases, or even brain imaging studies in many cases, in order to reach a diagnosis of “probable Alzheimer’s Disease.” In fact, when neurologists make this diagnosis, they usually reach it on the basis of taking a careful history, conducting a neurological exam, talking to the patient’s family. True, many doctors would also rule out other disease processes by means of a brain MRI or CT scan. But this is actually quite similar to the process many psychiatrists go through when making a diagnosis of , say, schizophrenia.
Well, since the late 1970s, I’ve been writing about why I believe Tom Szasz’s ideas about disease are not only wrong, but also logically incoherent and harmful to those who suffer with conditions like schizophrenia. I’m not going to beat you over the head with these arguments tonight, but if you want references to some of the writing that I and others have done, I’ve given you a bunch of refs. on the handout sheet.
Instead, what I would like to do now is build a bridge from the issue of how disease is recognized to what we mean by “objective” data in medicine and psychiatry. But before talking about the concept of “objectivity”, I want to pose a basic question to you. Why is all this of any importance? Why should we give a damn? Why should anybody care about what we mean by “disease”? Well, I chose the topic of this talk in the context of a very difficult social and political environment for folks who have mental illnesses or psychiatric diseases. You are aware, I’m sure, of the remarks made by actor Tom Cruise—that’s actor, by the way, not doctor—to the effect that psychiatry is a “pseudoscience”, and that people who get severely depressed—like Brooke Shields, for example—these people should just take vitamins and get over it. You may be aware that Congressman Ron Paul of Texas—who trained as an obstetrician and who should know better—recently insisted that diagnosis in psychiatry was “inherently subjective”…All these trends threaten to undermine not merely the status of psychiatric diagnosis, but the way we speak of and treat those who suffer with mental illness. If, as Szasz claims, there is no “real” mental illness—if it’s all just metaphorical disease–then there is no real suffering as a consequence of mental illness…Furthermore, this argument goes, those who purport to treat individuals claiming to have mental illness are not real doctors. And Szasz has said as much of psychiatrists. So why should state legislatures, or the general public, commit real money to help these people who claim to be hearing voices or who believe that the KGB has planted a computer chip in their brain? I still recall, many years ago, hearing Tom Szasz describe individuals with schizophrenia as “bad actors”…as if they could turn their symptoms on or off with an act of will, and were somehow trying to deceive us with their performance.
So, I maintain there are excellent reasons why we should care about the reality of so-called mental illness. By the way, for those of you who are interested in mind-brain issues, I am using terms like “mental illness” as a convenient shorthand. My own belief is that all so-called “mental” illnesses are essentially brain dysfunction of some type. In another context, I have proposed the term “encephiatrics”—literally, brain healing—to describe what present-day psychiatrists actually do. But that’s a topic for another night. Right now, I want to return to the issue of “objectivity” in psychiatry, and in general medicine.
What do we mean by “objectivity”? The philosopher and economist Amartya Sen—who used to teach at Harvard, by the way—has described two essential features of objectivity: observation dependence and impersonality. “Objectivity demands taking observations seriously,” Sen argued. Objectivity also requires that there be “some invariance” with respect to the person carrying out the observation. By “invariance,” Sen meant that the observer’s conclusions should be more or less reproducible by other observers, within the natural limits of human perception. To put it in the more technical language of the philosopher Thomas Nagel (in his book The View From Nowhere), “The wider the range of subjective types to which a form of understanding is accessible.. .the more objective it is.” In short, if one observer sees a quacking, waddling bird and says, “It’s a duck,” that’s a relatively subjective statement. If a hundred observers can agree it’s a duck, we have a more objective basis for hypothesizing that “it’s a duck.”
To use another example: when I say, without having observed your house, “I truly and deeply believe that your house is on fire,” I am making a subjective claim. In contrast, if two people simultaneously witness what they believe is smoke coming from your house, and say, “We believe your house is on fire,” they are making a type of objective statement. This does not necessarily mean that your house is on fire—after all, someone inside might have been producing a gray-colored vapor of some sort that merely resembles smoke. Thus, the veridical nature or “truth value” of objective statements cannot automatically be assumed. But whereas, in theory, we might choose to run that gray-colored vapor through an electronic “vapor analyzer” at some point, we surely would not hesitate to call 911 immediately.
Well, I would argue that psychiatry more than meets the two tests proposed by Prof. Sen. First, psychiatrists take observation very seriously—indeed, it is the art and science we live or die by in our profession.
From the moment the patient walks into our office, we are compiling a staggering array of empirical observations: The patient appears disheveled, he walks with a slightly ataxic gait, he appears agitated and confused, there is an odor of alcohol on his breath, his thought processes are difficult to follow, he is unable to subtract 7s serially from 100, he whispers to himself and glances over his shoulder frequently, his speech is loud and pressured, he picks constantly at his clothing, and so on. Depending on the case, many of us will supplement our own observations with neuropsychological testing, laboratory studies to rule out underlying medical disorders, and brain imaging studies to detect tumors, strokes, and dementia.
So far, so good—but do psychiatric observations meet Sen’s second test—what scientists would term “interrater reliability”?
There is a huge literature addressing this issue, but a comparison of two recent studies is instructive. The first one (by van Jaarsveld et al. in the December 1999 Journal of Hypertension) examined the degree to which three “experienced radiologists” could agree on the interpretation of 312 renal angiograms; for example, whether and where renal artery stenosis was present. The second study (by Majet et al. in the January-March 2000 Journal of Affective Disorders) assessed the degree to which two psychiatrists could agree on whether 150 patients met DSM-IV criteria for three conditions: schizoaffective disorder, mania, and major depression.
Suffice to say that for two of the three psychiatric diagnoses—mania and major depression—interrater reliability was better between the psychiatrists than it was among the radiologists in the first study.
Now—how does all this apply to the actual diagnostic process in clinical psychiatry? For philosophers such as Sen, if I say, without having assessed you, “I believe deep in my heart that you have a thought process disorder,” I am making an essentially subjective claim. On the other hand, if my chief resident and I sit with you for an hour, attending carefully to your speech; and neither of us has a clue as to what you have been saying, we are beginning to develop an “objective” frame of reference. If both the resident and I can point to your use of frequent neologisms and unconventional syntax, as well as to your shifting from idea to idea within the same sentence, we are continuing to develop an “objective” basis for saying that you have a thought process disorder of some sort—our agreement being a modest example of “inter-rater reliability”. If, upon standardized neurolinguistic testing, we can confirm that, indeed, your use of grammar, syntax, logic, and concept formation are all abnormal, we have further objective evidence of a thought process disorder.
Does all this mean that you have a “mental illness” or a “disease” of any kind? Of course not. To determine that, we need a much broader construct than that of “thought process disorder”, and a much wider array of objective data. In philosophical terms, we need many more observations that can be confirmed by multiple observers. For example, the resident and I may agree that a thought-disordered patient also has a blunted or flat affect (based, in part, on our shared experience of “normal” affect). We also observe that he is muttering to himself when sitting alone. We may learn, from a spouse or family member, that the patient has not been showering, feeding himself, or changing his clothes for the past month, and that this represents a dramatic change in his usual behavior. We may learn, from both the patient and the family member, that he is “hearing voices” when nobody is in the room, and that these voices are telling him, “You deserve to burn in Hell for all eternity!” We may also learn that, on more than one occasion, the patient has broken into tears and slashed himself with a razor, upon hearing these “voices.” At this point, we have built a stronger objective case for saying that the patient has an illness or disease of some sort—perhaps a schizophreniform or psychotic depressive disorder, though other possibilities must be considered (an endocrine disturbance, a brain tumor, a dementing process, etc.).
If, in addition, we can find abnormalities on neurological testing, brain imaging, or laboratory testing, so much the better. Indeed, in the past 30 years, we have found many abnormalities in brain structure and function, in patients diagnosed with schizophrenia, major depression, bipolar disorder, and other related conditions. With such testing, we certainly would be strengthening our objective data base—but laboratory studies are not necessary for objectively claiming, in the first place, that the patient has “disease” of a psychiatric nature. I hope it’s clear that, on this view, “objectivity” is not an all-or-none quality, but one that exists along a continuum of evidence.
So, to recap: the construct of “disease” developed from the notion of significant and enduring suffering and incapacity, in the absence of an obvious external cause. The term disease was originally derived from the notion of “dis-ease” or discomfort. Once upon a time, we even had a word called “diseasy”—you will find it in the Oxford English Dictionary—but it has fallen out of use. It’s no coincidence that the word patient is derived from the Latin pati, meaning “to suffer” or “to bear”. As physicians, we first recognize dis-ease and treat suffering, based on our clinical (from Gk. kline, “bed”) observations. In general, it is only subsequently that we invoke imaging or laboratory studies to bolster or confirm our diagnosis. As psychiatrist Michael Schwartz and philosopher Oswald Wiggins have argued, “…we legitimately reason about people’s experiences and behaviors in the same manner that we might reason about breathing problems…such reasoning might—or might not—lead us to lesions. But the goal is the relief of suffering, the promotion of health, and the amelioration of the illness…” Of course, a neuropathologist might not offer a diagnosis of “neuroborreliosis” until the organism causing Lyme Disease had been reliably identified. But even a neuropathologist would not deny that a patient who complained, without dissimulation, of profound memory impairment, disorientation, visual hallucinations, and paresthesias had disease of some kind—much less deny that this individual merits our care and treatment.
Indeed, when the average neurologist diagnoses, say, “migraine headaches”, he or she rarely uses laboratory or imaging studies, except to rule out other disease entities, such as a central nervous system lesion. Rather, the neurologist relies, in the first place, on the patient’s subjective (or phenomenological) claims; e.g., “Doc, I get a persistent, throbbing, left-sided pain in my head, along with nausea and sensitivity to light”. This claim is then weighed in the context of objective data derived from the medical history and neurological examination. This process is not radically different from the holistic approach a psychiatrist takes in diagnosing schizophrenia or major depression. Nor does it differ from the way most emergency room physicians would make a presumptive diagnosis of angina pectoris, even if the patient’s EKG were normal. That some “researchers” may successfully fool clinicians –as in the infamous 1972 Rosenhan experiment—by presenting bogus complaints of hallucinations, headache, or chest pain does not impugn the objective basis of medical diagnosis. Neither does the sad fact that some clinicians fail to gather a sufficiently detailed set of phenomenological and objective data, prior to making a diagnosis or offering treatment.
In psychiatry, as in the rest of clinical medicine, it is the patient’s unique experience of suffering and incapacity—not a blood test or MRI result–that first prompts diagnosis and treatment. When we are out on that desert island, hearing those terrifying voices, we don’t need an MRI to tell us that we are sick. We don’t even need a doctor to tell us that we are sick. But to get better, we probably will need a good physician who is willing to sit down and listen and empathize…indeed, we need a physician of the soul…the literal translation of the word, “psychiatrist.” And in that spirit, I would like to conclude with a quote from that great medieval physician and philosopher, Moses ben Maimon, known as Maimonides. “The physician,” he said, “does not cure a disease, he cures a diseased person.”
Thanks very much.