Sad, Mad, or Bad?*

Until the last century, and really to any large extent not until somewhere around the middle of it, people were lucky if their physicians did them more good than harm. But then medicine achieved great triumphs and claimed immense cultural authority and prestige. This happened when biological science enabled physicians to identify specific disease processes and offer targeted, effective treatment.

The huge win was antibiotics, which became widely available and effective around the time of World War II. People can argue about whether streptococci or mycobateria are really the ultimate cause of disease, or if it isn't the strength of our immune systems or our conditions of hygiene, but there is no doubt that if you give people the right antibiotics -- at least until lately -- the symptoms caused by infection with these organisms will disappear and the people will be all better.

The magic we can work with heart disease, the various diseases in the broad category of cancer, autoimmune diseases, and others, is less wondrous. Still, doctors understand fairly well what is going on with these afflictions and often they can do a lot to extend life, relieve disability and suffering, and even in some cases cure them. Sure, there's diagnostic uncertainty and controversy about the clinical or lab findings that merit a disease label and call for treatment, but these are largely pragmatic arguments over costs and benefits, the interpretation of statistics, or the reliability of observations, rather than deeply philosophical quandaries.

In most fields of medicine, however, we encounter entities called syndromes -- collections of symptoms which are often seen together, for which the cause is not understood, but for which people have proposed names. Some current notable examples are fibromyalgia, which is usually treated by rheumatologists, and metabolic syndrome, which may end up in the purview of an endrocrinologist. People often argue over whether these are "real diseases," or perhaps coincidental co-occurrences, or two or more unrelated processes that look similar, or perhaps separate processes with common risk factors. Further investigation often resolves these questions. For example, we now know that tertiary syphilis is not the same thing as schizophrenia, and it has passed from the purview of psychiatrists to infectious disease specialists.

In psychiatry, alas, the problem of classifying and naming diseases is ubiquitous. Suffering occurs in the brain and according to the scientific world view is the subjective manifestation of physical processes. However, psychiatrists generally have no idea of what these processes really are, and to the extent that they're starting to get an inkling, they can't point to or specifically treat any known abnormalities of the brain or its functioning. All they can do is propose clusters of complaints or behavioral observations and give them names.

In The Book of Woe, my friend Gary Greenberg tells the tale of the latest revision. I won't attempt to summarize the twists and turns -- it's a good read, goes down easy, and says most of what needs to be said, so give it a look. I will just make a couple of framing observations.

Psychiatrists not only have the difficulty of deciding whether the thing exists, they also have to decide whether it should be called a disease. Obviously we're all unhappy sometimes, but when exactly do we need our heads shrunk? It might be easy enough to say, whenever somebody shows up asking for help, they should get it, but there are many problems with this. One is that insurance companies won't pay for treatment if you don't have a disease. But labeling somebody with a psychiatric disease has all sorts of social implications. If you're homosexual, you don't want to be labeled with a disease because you don't think there's anything wrong with you. If you believe you have Asperger's syndrome, you want a label because you want to get special education services and you'd rather be known as having a disease than be called a dork. If you commit a crime, claiming that a disease made you do it might be seen as exculpatory. Alternatively, it could let the authorities lock you up indefinitely, as a risk. In fact, people may get psychiatric disease labels who aren't even suffering subjectively -- they're just making other people suffer. All this is a lot to wrestle with, and I'll demur for now, but Gary does it all.

Another problem is that if you don't have real diseases and the expertise to treat them, you aren't a real doctor. Having the power to name your pain and the purported unique scientific expertise to select the One True Treatment is essential to the prestige of the medical profession. Psychiatrists desperately want to be members of the club.

Alas, as Gary probably doesn't need to tell you, people become unhappy, or anxious, or lonely, or obnoxious to others because their unique selves, as forged by inheritance processed through their youthful environments confront shit that happens. A wise counselor might be able to help, but putting you into a box first and sticking a label on it is unlikely to help.

*I'm sure somebody has used that title before, but it's obvious and I made it up anew.