Summary and Conclusion on Conceptualization
Szasz bases his premise that mental illness is a myth on the biomedical disease concept. He chooses an apparently value-free concept, and the professional concept. I, on the other hand, base myself on concepts of being ill and healthy using the meanings that those terms have for ill people themselves and the non-professionals around them. By characterizing the typical phenomena of being ill from a phenomenological, behavioral, and biological point of view, I reach the conclusion that ill can be distinguished from healthy by means of a conjunctive cluster of three factors, i.e. suffering, dysfunction, and abnormality.
In consequence, illness is considered a conceptualization, a theory about being ill, the purpose of which is to understand what is happening to someone who is ill. This conceptualization in medical science leads to a pattern of assumed links between etiology, pathogenesis, appearance, progress, end state, and therapy. In different diseases this pattern is more or less completely present.
The position that disease is a concept is supported by the fact that, also inside medicine, different concepts of disease exist. These concepts influence the way being ill is viewed. In the nineteenth and twentieth centuries there was a strong tendency to emphasize the factual, and in particular physicochemical aspects of illness, culminating in the biomedical disease concept. However, when the ill person’s point of view is taken, suffering and the negative value judgment in respect of being ill are found to be lacking in this biomedical disease concept. For inclusion of these aspects of being ill in the conceptualization the holistic or biopsychosocial disease concept is preferable.
Further examination of the significance of a physicochemical disorder to the pattern of disease reveals three limitations when this classifying criterion is used. The disorder must be demonstrable, relevant in respect of the phenomena of illness, and have the nature of a process. These limitations render the physicochemical disorder as a classifying criterion unsuitable and lead to classification in three groups: the group of “real” diseases (demonstrated and relevant physicochemical disorder), the group of “probable” diseases (physicochemical disorder not yet demonstrated, but the expectation is that it will be found), and the group of “probably not” diseases (physicochemical disorder not demonstrated, and not expected to be found). At the same time it became apparent that even when a physicochemical disorder is an objectively demonstrable fact, the word “disorder” and similar terms imply a negative value judgment. Thus the main advantage of the biomedical disease concept – that it is value-free – is lost.
The disease status of many psychiatric disorders is doubtful in a biomedical disease concept. This raises the question whether the conditions and processes in which physicochemical disorders were expected to be found, but which to date proved not demonstrable, must be regarded as not diseases, or whether a change in the definition of disease is necessary. Disease is not only an ontological concept. It is also a value concept. The latter is expressed all the more clearly in the absence of a demonstrated physicochemical disorder. A consequence of the fact that illness is a concept is that this dilemma cannot be solved by research but only by making a choice.
Next some problems which arise when psychiatric disorders are conceptualized as illnesses were discussed. Examples are the normative element implied by many psychiatric symptoms and syndromes; the imprecise lines between normality and illness; the definition of normality; the need to maintain supplemental considerations such as motivation, the meaning of symbols, the purpose of complaints and phenomena; and the influence which the examiner and his examination may exert on the examined psychiatric disorder. Although these problems occur (much) less in respect of physical illnesses, they nevertheless occur.
Closer examination of the connection between psychiatric disorders and physicochemical aberrations renders first of all the difficulty of determining the significance of physicochemical aberrations. Next, assuming that behavior and experience do not take place in a neurophysiological and neurochemical vacuum, it should in principle be possible to identify the corresponding neurophysical and neurochemical processes. Were that realized, then certain behaviors would be describable as linked to certain processes in the brain. When such a behavior is labeled abnormal, a cluster of abnormal behavior plus the corresponding neurophysiological changes is formed. This cluster complies with the criteria of the biomedical disease concept, without changing the category of the behavior, and without disqualifying sociopsychological theories. In other words, the significance of behavior remains the same whether or not the corresponding neurophysiological process is known. In a biomedical sense, however, the behavior would change categories, namely, it would be considered a disease.
The conclusion drawn is that the biomedical disease concept no longer suffices as a general medical paradigm, that illness as a value-judgment cannot be further eliminated without greatly damaging the patient and medicine, and that there is an immense need for an all-encompassing concept of disease which accommodates both the value aspects and the existential aspects of being ill and illness. The holistic, and even more, the biopsychosocial disease concepts satisfy this need.
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