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Mental Disorders Are Not Diseases

USA Today (Magazine) January 2000.

MENTAL DISORDERS ARE NOT DISEASES

Thomas S. Szasz, M.D.

Psychiatrists and their allies have succeeded in persuading the scientific community, courts, media, and general public that mental illnesses are phenomena independent of human motivation or will.

THE CORE CONCEPT of mental illness--to which the vast majority of psychiatrists and the public adhere--is that diseases of the mind are diseases of the brain. The equation of the mind with the brain and of mental disease with brain disease, supported by the authority of a large body of neuroscience literature, is used to render rational the drug treatment of mental illness and justify the demand for parity in insurance coverage for medical and mental disorders.

Reflecting the influence of these ideas, on Sept. 26, 1997, Pres. Clinton signed the Mental Health Parity Act of 1996, which took effect on Jan. 1, 1998. "This landmark law," according to the National Alliance for the Mentally Ill, "begins the process of ending the long-held practice of providing less insurance coverage for mental illnesses, or brain disorders, than is provided for equally serious physical disorders." Contrary to these views, I maintain that the mind is not the brain, that mental functions are not reducible to brain functions, and that mental diseases are not brain diseases--indeed, that mental diseases are not diseases at all.

When I assert the latter, I do not imply that distressing personal experiences and deviant behaviors do not exist. Anxiety, depression, and conflict do exist--in fact, are intrinsic to the human condition--but they are not diseases in the pathological sense.

According to the Oxford English Dictionary, disease is "a condition of the body, or of some part or organ of the body, in which its functions are disturbed or deranged; a morbid physical condition." Diagnosis, in turn, is "the determination of the nature of a diseased condition ... also, the opinion (formally stated) resulting from such investigation."

The core medical concept of disease is a bodily abnormality. Literally, the term "disease" denotes a demonstrable lesion of cells, tissues, or organs. Metaphorically, it may be used to denote any kind of malfunctioning of individuals, groups, economies, etc. (substance abuse, violence, unemployment, et al.).

The psychiatric concept of disease rests on a radical alteration of the medical definition. The mind is not a material object; hence, it can be diseased only in a metaphorical sense. In his classic, Lectures on Clinical Psychiatry, Emil Kraepelin--the founder of modern psychiatry--wrote: "The subject of the following course of lectures will be the Science of Psychiatry, which, as its name implies, is that of the treatment of mental disease. It is true that, in the strictest terms, we cannot speak of the mind as becoming diseased."

If we accept the idea that the diagnoses of mental illnesses refer to real diseases, we are compelled to accept them as diagnoses on a par with those of bodily diseases, albeit the criterion for what counts as a mental disease is completely different from what counts as a bodily disease. For instance, in Psychiatric Diagnosis, Donald Goodwin and Samuel B. Guze, two of the most respected psychiatrists in the U.S., state: "When the term `disease' is used, this is what is meant: A disease is a cluster of symptoms and/or signs with a more or less predictable course. Symptoms are what patients tell you; signs are what you see. The cluster may be associated with physical abnormality or may not. The essential point is that it results in consultation with a physician." According to these authorities, disease is not an observable phenomenon, but a social relationship.

In contrast to Goodwin and Guze's assertion that mental illness need not be associated with physical abnormality, Allen Frances, the chief architect of the American Psychiatric Association's Diagnostic and Statistical Manual, DSM-IV, states: "The special features of DSM-IV are ... elimination of the term `organic mental disorder' because it incorrectly implied that other psychiatric disorders did not have a biological contribution."

Linguistic considerations help to illuminate the differences between bodily and mental disease, as well as between disease and diagnosis. We do not attribute motives to a person for having leukemia, do not say that a person has reasons for having glaucoma, and would be uttering nonsense if we asserted that diabetes has caused a person to shoot the President. However, we can and do say all of these things about a person with a mental illness. One of the most important philosophical-political features of the concept of mental illness is that, at one fell swoop, it removes motivation from action, adds it to illness, and thus destroys the very possibility of separating disease from non-disease and disease from diagnosis.

Diseases are physico-chemical phenomena or processes--for example, the abnormal metabolism of glucose (diabetes). Mental diseases are patterns of personal conduct, unwanted by the self or others. Psychopathology is diagnosed by finding behavioral, not physical, abnormalities in bodies. Disease qua psychopathology cannot be asymptomatic. Changing the official classification of mental diseases can transform non-disease into psychopathology and psychopathology into nondisease (i.e., smoking from a behavioral habit into "nicotine dependence"). In short, medical diseases are discovered and then given a name, such as acquired immune deficiency syndrome (AIDS). Mental diseases are invented and then given a name, such as attention deficit disorder.

Nowadays, names routinely are given not only to somatic pathology (real or bodily diseases), but to behavioral pathology (psychopathology or mental diseases). Indeed, if we propose to treat misbehavior as a disease instead of a matter of law or social policy, we name it accordingly (for instance, "substance abuse"). Not surprisingly, we diagnose mental illnesses by finding abnormalities (unwanted behaviors) in persons, not abnormalities (lesions) in bodies. That is why forensic psychiatrists "interview" criminals called "patients" (who often do not regard themselves as patients), whereas forensic pathologists examine body fluids. In the case of bodily illness, the clinical diagnosis is a hypothesis, typically confirmed or disconfirmed through an autopsy. It is not possible to die of a mental illness or to find evidence of it in organs, tissues, cells, or body fluids during an autopsy.

To summarize, anthrax is a disease that is biologically constructed and can, and does, kill its host. Attention deficit disorder, on the other hand, is socially constructed and cannot kill the patient.

If we fail or refuse to distinguish between literal and metaphorical diseases, we confuse and deceive ourselves and others not only about the differences between treatments influencing the body and those influencing the person, but about the differences between medical treatments (such as performing an appendectomy for acute appendicitis) and medical interventions (performing an abortion terminating a healthy, but unwanted pregnancy). To be sure, there is something to be gained by not distinguishing between diseases and diagnoses, complaints and lesions, and/or treatments and interventions. It permits creation of a therapeutic utopia--a medical fairyland with "miracle cures" not only for diseases, but for non-diseases as well.

Mental diseases are behaviors

No one believes that love sickness is a disease, but nearly everyone believes that mental sickness is, and virtually no one realizes that, if this were true, it would prove the nonexistence of mental illness. If mental illnesses are brain diseases (like Parkinsonism), then they are diseases of the body, not the mind. A screwdriver may be a drink or a tool, but it would be foolish to do research in the hope of discovering that some cases of orange juice and vodka are hitherto unrecognized instances of carpenters' implements. contemporary American is so thoroughly psychiatrized that it is quite useless to demonstrate the logical-linguistic misconceptions inherent in the claim that "mental illness is like any other illness." Unless people are prepared to defy the combined forces of the state, science, medicine, law, and popular opinion, they must believe--or at least pretend to believe--that mental illnesses are brain diseases; scientists have identified the somatic lesions that cause such illnesses; and psychiatrists possess effective treatments for them. Conventional wisdom as well as political correctness preclude entertaining the possibility that mental illness, like spring fever, is a metaphor.

In short, psychiatrists and their allies have succeeded in persuading the scientific community, courts, media, and general public that the conditions they call mental disorders are diseases--that is, phenomena independent of human motivation or will. Because there is no empirical evidence to back this claim (indeed, there can be none), the psychiatric profession relies on supporting it with periodically revised versions of its pseudo-scientific bible, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders.

The official view is that these manuals list the various "mental disorders" that afflict "patients." My view is that they are rosters of officially accredited psychiatric diagnoses, constructed by task forces appointed by officers of the American Psychiatric Association. Psychiatrists thus have constructed diagnoses, pretended that the terms they coined were morally neutral descriptions of brain diseases, and few in political power have challenged their pretensions.

My argument may be put another way: The existence of John Smith's bodily disease--say, astrocytoma, a nerve tissue tumor--is discovered and empirically verified. Radiologists identify the tumor; neurosurgeons verify its presence by observing the lesion with their naked eyes; and pathologists confirm the diagnosis by examination of the tissues. In contrast, the existence of John Smith's mental disease--say, schizophrenia--is declared and socially verified. His alleged illness is identified by psychiatrists, who diagnose his behavior as schizophrenia; other psychiatrists verify its presence by committing him to a mental hospital, where he acquires the right to refuse treatment, which he exercises; and a judge confirms the diagnosis by declaring him mentally incompetent to refuse treatment.

Because the idea of mental illness combines a mistaken conceptualization (of nondisease as disease) with an immoral justification (of coercion as cure), the effect is two-pronged--it corrupts language and curtails freedom and responsibility. Because psychiatrists have power over persons denominated as patients, their descriptive statements typically function as covert prescriptions. For instance, psychiatrists may describe a man who asserts that he hears God's voice telling him to kill his wife as schizophrenic. This "diagnosis" functions as a prescription--for example, to hospitalize the patient involuntarily (lest he kill his wife) or, after he has killed her, to acquit him as not guilty by reason of insanity and again hospitalize him against his will. This coercive-tactical feature of psychiatric diagnosis is best appreciated by contrasting medical with psychiatric diagnosis. Diagnosis of bodily illness is the operative word that justifies a physician to admit to a hospital a patient who wants to be so admitted. Diagnosis of mental illness is the operative word that justifies a judge to incarcerate in a mental hospital a sex criminal who has completed his prison sentence.

So long as there are no objective, physico-chemical observations shown to be causally related to depression and schizophrenia, the claim that they are brain diseases is unsubstantiated. In the absence of such evidence, psychiatrists rest their claim that these major mental diseases are brain diseases largely on the contention that drugs keep the disease processes "under control." The absurdity of this claim lies in its own consequences.

Diabetes is kept under control by insulin. When patients stop taking their medication, the disease process flares up and kills them. Lupus is kept under control by steroids. When patients stop taking their medication, the disease process flares up and kills them.

This is not what happens when patients with serious mental diseases stop taking their medication. Depression is kept under control by antidepressants. When patients stop taking their medication, the disease process flares up, but the disease does not kill them. They kill themselves, an act psychiatrists attribute to their so-called mental illness. Schizophrenia is kept under control by anti-psychotic drugs. When patients stop taking their medication, the disease process flares up, but the disease does not kill them. They kill someone else, an act psychiatrists attribute to their supposed illness.

If we restrict the concept of treatment to a voluntary relationship between a medical practitioner and a competent client, then a coerced medical intervention imposed on persons not legally incompetent is, by definition, assault and battery, not treatment. Psychiatry is thus a systematic violation of this legal-political principle, one that is especially odious because most persons treated against their will by psychiatrists are defined as legally competent--they can vote, marry and divorce, etc. It is important to keep in mind that, in a free society, the physician's "right" to treat a person rests not on the diagnosis, but on the subject's consent to treatment.

Regardless of psychiatric diagnosis, the typical mental patient is entitled to liberty, unless convicted of a crime punishable by imprisonment. If that patient breaks the law and is convicted, then he or she ought to be punished for it as prescribed by the criminal law. In a free society, a person ought not to profit from psychiatric excuses or suffer from psychiatric coercions.

Thomas Szasz is professor of psychiatry emeritus, State University of New York Health Science Center, Syracuse.