By analogy: if we posit that the term “migraine headache” refers to a doctor’s judgments regarding a set of pain-related behaviors—eg, the patient complains bitterly of left-sided head pain, winces, squints, places ice packs on his head, cries “Owwww!”—it does not follow that migraine headache is nothing over and above the doctor’s judgments, or the set of pain-related behaviors being judged. Migraine may, as a matter of ontological and etiological fact, entail certain reversible changes in vascular nerves, inflammatory substances in the brain, etc. This ontological claim holds, whether such physiological findings have actually been confirmed.
Errors arising from a false dilemma
Finally, critics of psychiatry sometimes construct a sophistical and quite fallacious trap for psychiatrists. They create an apparent dilemma, by arguing thus:
Schizophrenia is not a real disease, because real disease requires a demonstration of clear and consistent neuropathology or pathophysiology [proposition 1], and this has never been convincingly demonstrated for schizophrenia [proposition 2]. But, if neuropathology or abnormal physiology should someday be demonstrated for schizophrenia, then schizophrenia will obviously not be a mental illness—because minds cannot contain lesions—but a brain disease, like Alzheimer disease [proposition 3]. Now, consistent neuropathology either (a) cannot be shown for schizophrenia, or (b) may someday be shown. Therefore, schizophrenia is either (now) not a real disease, or will someday be shown not to be a mental illness. Therefore, the claim that schizophrenia is a real disease or a mental illness is necessarily false.
This dodgy argument—which, admittedly, I have condensed from several sources—is trivially fallacious on several levels.3,10 First, as I have already argued, the term “disease” need not entail the presence of abnormal pathoanatomical or pathophysiological findings [proposition 1]. Second, if there is no such thing as schizophrenia, there is no way, even in principle, that schizophrenia can “someday” reveal consistent brain pathology. (If there is no such thing as a unicorn, there is no empirical study that someday could show a unicorn to be a horse!)
An additional fallacy is seen in proposition 3: it is simply not the case that a condition necessarily ceases to be a mental illness simply because its putative etiology has been traced to neuroanatomical or pathophysiological abnormalities. Once again, we are sorely in need of ordinary language. When we say that Jones has a mental illness, we need not posit some immaterial entity called “mind” or “mentality,” which, to be sure, would be incapable of containing material lesions or neuropathology. We may mean simply that Jones’s particular form of suffering and incapacity expresses itself in the sphere of thought, cognition, mood, or reality-testing—usually as some combination of impairments in these domains. We may additionally mean that these impairments render it difficult or impossible for Jones to secure his “prudential interests”; eg, Jones is unable to secure his own safety, avoid serious injury, achieve enduring relationships, or hold down a job.24
Finally, with respect to proposition 2: I believe it is simplistic and misleading to insist that no consistent neuropathological abnormalities have been linked to schizophrenia or other serious psychiatric illnesses—alas, a canard credulously accepted by many psychiatrists. In fact, one recent study concluded that “enlarged ventricles and reduced hippocampal volume are consistently found in patients with first-episode schizophrenia [italics added].”25 (The literature far exceeds the scope of the present article but is reviewed in other publications.25-27)
The concept of metaphor is too ambiguous and unstable to provide a sound basis for criticizing psychiatric nosology or the concept of mental illness.The locution, mental illness, may sometimes be used metaphorically, but need not be; nor must it denote something immaterial or metaphysical. In ordinary language, mental illness may refer to pronounced suffering and incapacity in the sphere of thought, mood, cognition, and reality-testing; and to the resultant inability to secure one’s prudential interests. There is nothing metaphorical in such affliction, and nothing mythical in the construct of psychiatric disease.
Acknowledgments—My thanks to Prof Tim Thornton, Prof Stephen Greenblatt, Prof Robert Daly, Prof Joel Kraemer, and James L. Knoll IV, MD, for their helpful comments on drafts or aspects of this paper, and to Neil Pickering, PhD, for his useful book and correspondence. Thanks also to Prof Amanda Pustilnik for her essays, and to Mr Jason Kuznicki for his editing of Cato-Unbound.
Note 1: In his preface the new edition of The Myth of Mental Illness,10 Thomas Szasz, MD, analyzes these same passages from Macbeth, focusing on the doctor’s conclusion that the mad person “must minister to himself.” Szasz sees this as evidence that, for Shakespeare, Lady Macbeth’s madness was a consequence of her “internal rhetoric,” which must be cured with therapeutic internal rhetoric. But even supposing this interpretation is correct, it does not impugn my claim that the phrase “mind diseased” was to be taken literally, not metaphorically, in Shakespeare’s time; and, indeed, that it may still be taken literally in our time.
For more on metaphor and mental illness in the 16th century, see Bridget Gellert Lyons’ book, Voices of Melancholy.28 Lyons highlights the risk of assuming that we can confidently recognize figurative language in Elizabethan writing. For example, in Macbeth, the statement, “The grief that does not speak/Whispers the o’er fraught heart and bids it break” (IV,iii) is not merely or simply a metaphor; rather, the locution “. . . is based on the belief that the heart of a bereaved sufferer who could not unburden himself by speech was literally oppressed and suffocated by [bodily] humours. . . . [italics added]”28 Thus, Lyons identifies “. . . the physiological basis of this metaphor. . . .” suggesting that even metaphorical utterances may be grounded in putative physical abnormalities.
Note 2: I believe Prof Tim Thornton argues along roughly the same lines as I do, when he writes: “. . . even if mental illness is defined by, or identified through, psycho-social norms, this need not imply that it is identical to or constituted by such deviation. It may be that the illness is the cause of the deviation such that, even though it is picked out by its characteristic effects, it is not identical to them.”29