Psychiatric disorders and organic aberration
Whoever considers organic aberration a criterion for illness, as does Szasz, removes most psychiatric disorders from the realm of illness. The structure and organization of our knowledge is such that those sciences that deal with experience and behavior employ different methods of investigation and language than the physical sciences. This complicates the search for a link between psychiatric disorders and bodily aberrations. It equally renders difficult any conclusion about the relevance of such a link. This is what led Szasz to suggest in Pain and Pleasure that psychiatry should be considered sociopsychology and entirely separate from medicine.
Let us examine more closely some physical aberrations seen in connection with psychiatric disorders. A reduction of psychic and bodily functioning often accompanies what the DSM-III calls “major depression with melancholia.” This reduction is recognizable by diminished secretion of perspiration, constipation, and a dry mouth, among other things. These are observable, physical aberrations, as are the increased levels of corticosteroids. Heavy anxiety is accompanied by an increase in pulse rate, secretion of perspiration, and adrenaline levels. In anorexia nervosa we see loss of body weight and amenorrhea.
All these bodily aberrations are the accompanying phenomena of some people’s psychic functioning. After all, people also respond to all sorts of sociopsychological influences in a bodily way. This, however does not constitute an argument for supposing an organic disorder. In other words, these physical aberrations are not considered relevant. Which criterion for relevance is posed here? There are also many physical illnesses in which the bodily aberration is not the cause of the disease. (See 2.4.) We are in fact treading on extremely complex ground where, it seems to me, the dualistic view poses insoluble problems. Only when we assume that man is composed of two very different kinds of being, body and mind, can there be a “relationship” between these two beings. Then the question can be asked: what is primary – the physical or the psychical manifestations of anxiety? Or do they run parallel? Much has been done to “unveil” these extraordinarily difficult relationships. It would be convenient if this discussion could be postponed until such time as we have a better theory about human functioning than dualism. However, the need to determine whether psychiatric disorders must be viewed as diseases is contemporary. It cannot be deferred to some (distant) future. The significance of the physical aberration that occurs in some psychiatric disorders is of course extremely important in everyday practice.
The most important aspect of the theoretic foundations of the link between bodily aberrations and psychiatric disorders is that virtually nothing is known about the true nature of such a relationship. Therefore equally little is known about the relevance of these organic aberrations. This means that the existence of a relevant link between physical aberrations and psychiatric phenomena as a criterion for the disease/health classification poses indomitable problems. To date, we have no choice but to reject this criterion as unusable.
The word organic here has an additional meaning. As psychical experience and functioning can be perceived only through human contact, and as such contact always involves the body as well, we can know the expressions and functioning of the mind only indirectly, namely through others’ and our own physicality. No psychical or social functioning is perceivable without our bodies, or as Van Dijk says, our “biotic substrate.” Szasz assumes the same: “Let me make clear that I do not contend that human relations, or mental events, take place in a neurophysiological vacuum. It is more than likely that if a person, say an Englishman, decides to study French, certain chemical (or other) changes will occur in his brain as he learns the language. Nevertheless, I think it would be a mistake to infer from this assumption that the most significant or useful statements about this learning process must be expressed in the language of physics.” (The Myth of Mental Illness, pp. 102-103)
I would like to take this thought one step farther. Suppose that in a certain, not French-speaking population, someone has learned French, and that the corresponding phenomena of the biotic substrate are demonstrable. In that case, this French-speaking person will be found to have a brain function (or structure) that deviates from the statistical norm. It is not, however, pathological, but rather should be considered as a superior variation (of course this is a value judgment). Reasoning the same way, the phenomena of a developing phobia in the biotic substrate would in principle have to be demonstrable. These, too, would deviate from the statistical norm but the complex of phenomena of psychical functioning and the biotic substrate together would be harmful and undesirable, bringing suffering and dysfunction. Therefore, it would not only satisfy the criteria of the biopsychosocial disease concept, but also of the biomedical one. It may well be that these phenomena in the biotic substrate should be marked as relevant physical aberrations.
This reasoning is admittedly exceedingly speculative. To be able to claim validity it should be stated thus: if normal behavior and psychical functioning are unthinkable without a biotic substrate, then abnormal or pathological behavior and psychical functioning is equally unthinkable with a biotic substrate. Because in the psychical realm, much more even than in the bodily realm, that which is considered normal is tied to social and cultural norms and value judgments, one must wonder whether that biotic substrate can be called aberrant. This is probably what led Van Dijk to posit, “It is theoretically not refutable, yes, even very likely, that a psychical disorder occurs on the basis of a normal, undisturbed somatic substrate.”
However, let us not be inhibited from our line of reasoning by this. It went like this: if, in a certain culture, normal behavior X has a biotic substrate, then behavior Y does too. If in a given culture or social milieu Y is considered abnormal behavior, and it can be shown that the somatic representation of that behavior is different from the somatic representation of behavior X, then formally, logically, there is no longer anything preventing behavior Y from being declared also an organic aberration. The somatic representation of Y need in itself only deviate from the statistical and/or individual norm. The corresponding undesirable and abnormal phenomenon is behavior Y and as a cluster satisfies the criterion of a biomedical concept of disease. If that is not accepted – for instance by Murphy, who uses the example of vegetarianism for what here is called behavior Y – then this can only mean that the value judgment as decisive in determining what is disease and what is not has been set. This is exactly what Szasz wishes to avoid at all costs. Reasoning on yet another step, it can be posited that such organic “disorders” and their corresponding behavior may be influenced by physicochemical means. If that were so, then a specific, relatively perfected effect, compared to current psychoactive drugs, would be possible, rendering this somatic representation to be of the highest practical relevance.
Some remarks are necessary regarding this line of reasoning. It is easier to postulate a somatic representation than to form an image of its specific nature. Our current state of knowledge and understanding does not allow insight into how the epistemological gap between body and mind might be bridged by a specific somatic representation of psychical events. On the other hand, constantly considering psychical processes and events as a totally different entity from somatic events, as does Szasz, risks that body and mind will be viewed as two different kinds of entities, linked to each other only in function, like a television station and a television set, but otherwise mutually foreign. And if psychical and bodily functioning are indeed inseparably linked, then a representation of the one in the other is the most obvious way to imagine that inseparability.
These speculations beg some questions. Suppose it were possible to define some patterns of behavior or psychiatric disorders inside a biomedical disease concept this way. Would that mean that all psychological and social theories regarding these disorders have become irrelevant and that the influencing or treatment should happen only through biomedical techniques? These questions should be answered in the negative. The search for the significance of certain experience and behavior remains relevant, whether the disorder is considered rooted in a biomedical or in a different disease concept. This applies to the understanding of the disordered behavior as well as to the treatment of it.
If it is assumed that experience and behavior do not take place in a neurophysiological vacuum then it must be concluded that demonstrating neurophysiological aberrations corresponding with abnormal behavior does not in fact change the category of that abnormal behavior. That is in spite of the fact that formally a relevant physicochemical disorder has been demonstrated. This means that Szasz’s contrast between disease in the biomedical sense as something that happens to somebody, and of which a value-free description is possible, on the one hand, and on the other, “mental illness” as something that someone is or does, and which is always in a moral category, is in principle a pseudo-contrast regarding psychiatric disorders in the above sense.
In conclusion, it can be posited that in our current state of knowledge and insight, the presence of demonstrable bodily aberrations can be neither a necessary nor a sufficient condition for the existence of disease, also regarding psychiatric disorders. Precisely because of the epistemological gap between the sciences that deal with somatic substrates and those that deal with psychical and social functioning dependence on finding empirical connections remains. Therefore the application of the conjunctive cluster mentioned in 2.1, namely suffering, dysfunction, and abnormality as a classifying criterion for ill/healthy remains decisive, also regarding psychiatric disorders.
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