Szasz treats the concept of mental illness very literally as being purely a disease of the mind (and thereby an impossibility). This notion harks back to an old and outdated view that was generated from a psychoanalytical outlook of mental illness, which was the dominant psychiatry paradigm in the 1950s, when Szasz came up with his critique. There are 2 ways in which Szasz’s argument goes awry when applied to our current understanding of mental disorders. First, the concept of disease is not restricted to the presence of a physical lesion; second, the term “mental disorder” is now conceptualized in a manner that transcends mind-body dualism.
For the most part, disease is understood largely in terms of suffering and functional impairment, which may or may not be associated with a structural lesion. R. E. Kendell explains this view succinctly6: “For most of human history disease has been essentially an explanatory concept, invoked to account for suffering, incapacity, and premature death in the absence of obvious injury, and suffering and incapacity are still the most fundamental attributes of disease.”
Once we conceive of disease in terms of substantial or enduring states of suffering and incapacity, we are justified in applying it as a label to conditions in which disturbances in cognition, emotion, or behavior are associated with distress and impairment.
The notion of mental illness began to change with the emergence of biological psychiatry. Most psychiatrists today do not believe in the mutual exclusivity of mental illness and brain disorders. Most mental disorders are presumed to have a neurobiological basis even in cases in which this basis is poorly understood. Although the terms “mental illness” and “mental disorder” are still used, the manner in which they are understood is very different from the old psychoanalytic view (and for that reason many psychiatrists argue that the terms should be abandoned). The notion of mental illness as distinct and divorced from the notion of a biological disorder reflects a dualistic understanding of the mind-body relationship, a dualism that has become increasingly untenable given the advances of neuroscience. While it may be true that in the 1950s, when Szasz came up with his critique, this particular dualistic understanding of mental illness was in fashion, psychiatrists have long abandoned such a view. Szasz failed to appreciate that in his critique and held on to his original position until his death in 2012.
We still do not have fully satisfactory definitions of either disease or mental disorder, and I do not attempt to argue that the current conceptualizations are unproblematic. The aim instead is to show that the conceptualizations have changed in a manner such that Szasz’s assumptions are rendered invalid.
To get an idea of how contemporary psychiatry understands mental disorders, let us look at what DSM has to say about it. DSM-IV acknowledges several things. The term “mental disorder” is misleading in the sense that it implies a distinction between mental disorders and physical disorders, reflective of a reductionistic anachronism of mind-body dualism. The distinction between mental and physical is untenable. “Mental disorder” continues to be used because there is no appropriate substitute for it.
“A compelling literature documents that there is much physical in mental disorders and much mental in physical disorders. The problem raised by the term ‘mental disorders’ has been much clearer than its solution, and, unfortunately, the term persists in the title of DSM-IV because we have not found an appropriate substitute.”7
DSM-IV accepts that no definition adequately specifies precise boundaries for the concept of mental disorder. This concept, like many others in medicine and science, lacks a consistent operational definition that covers all situations. Because mental disorders are a heterogenous category of disorders, no single definition captures the entire range of conditions that are currently included in this term. This lack of a precise definition is not restricted to psychiatry but can be found in the rest of medicine as well, where medical conditions are defined in various levels of abstraction.
While acknowledging that no definition can capture all aspects of all disorders currently classified as mental disorders, DSM-5 provides us with a list of minimal criteria that must be met for a condition to be called a mental disorder:
• A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning
• The condition leads to significant distress and/or disability in social, occupational, or other important activities of daily life
• The condition is not an expectable or culturally approved response to a common stressor or personal loss
• Socially deviant behavior (such as political, religious, or sexual) by itself is not a mental disorder; it can, however, be the symptom of a mental disorder, if it can be shown that the deviant behavior is a part of a clinical syndrome reflective of an underlying dysfunction of mental functioning
• The diagnosis of a mental disorder should have clinical utility; that is, it should assist psychiatrists in developing treatment plans and help them in the determination of expected treatment outcomes and prognoses (however, DSM-5 clarifies that the diagnosis of a mental disorder does not by itself indicate a need for treatment)
Dr Aftab is Resident in Psychiatry at the Hamad Medical Corporation in Qatar; he is a graduate of King Edward Medical University in Lahore, Pakistan. He reports no conflicts of interest concerning the subject matter of this article.
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