COMMENTARY

Positivism, Humanism, and the Case for Psychiatric Diagnosis

Ronald W. Pies, MD

Disclosures

August 20, 2014

In This Article

The Positivist Prejudice

As for the first claim -- that only bodily lesions or demonstrable pathophysiology define "real" disease -- I consider this a well-debunked vestige of misguided positivism,* thoroughly covered in many essays and articles cited below.[8,9,10,11] But I was amused recently to find one blogger attributing to me a definition of disease that has been a foundational belief throughout the history of medicine: namely, that disease is best conceptualized as prolonged or intense suffering and incapacity, whether of known or unknown etiology, body or mind.

For most of the history of medicine, physicians hadn't the faintest notion of what was causing their patients' suffering and incapacity, and virtually never observed the microscopic pathophysiology that underlies many diseases. Were these physicians therefore not treating "real" states of disease? For example, did epilepsy become a "real" disease only after the invention of EEG and MRI? (By the way, the diagnosis of epilepsy, like that of migraine headache, has always been and remains a clinical one[12] -- based primarily on the patient's history, signs, and symptoms, as with most psychiatric disease.)

Alas, the positivist prejudice thrives in the enclaves of antipsychiatry. Now, some of these critics reasonably raise the objection that "suffering and incapacity" may be the result of many things, such as floods, famine, terrorism, or extreme poverty -- yet we do not typically call victims of such conditions "diseased." Fair enough; we need to limit the reach of our imperfect definition to situations in which obvious, noxious external factors (such as a visible knife wound) are not causing the suffering and incapacity.[11]

But contrary to my critic's flattering claim, I am hardly the originator of the "suffering and incapacity" criterion of disease. Indeed, in the edition of Harrison'sTextbook of Medicine that I used when I was a resident, the following breathtakingly broad definition of disease is put forth: "The clinical method has as its object the collection of accurate data concerning all the diseases to which human beings are subject; namely, all conditions that limit life in its powers, enjoyment, and duration"[13] (italics added).

The editors go on to say that the physician's "...primary and traditional objectives are utilitarian -- the prevention and cure of disease and the relief of suffering, whether of body or of mind..."[13] (italics added).

So, nothing in Harrison's regarding lumps, bumps, lesions, or lab findings as prerequisites for "disease" -- and, crucially, nothing limiting the disease concept to the body. Indeed, as the late psychiatrist Robert Kendell has observed, "The distinction between mental and physical illness is ill-founded and damaging to the interests of patients themselves, whatever kind of illness they are suffering from."[14]

Some positivist critics of psychiatry also cherish the jejune notion that doctors in other medical specialties know precisely what "disease" is, and how to define it. Sorry, but this is nonsense on stilts! Consider the debacle that arose recently when the American Medical Association, in its deliberations on obesity, requested an advisory opinion from its Council on Science and Public Health. The question before the Council was, "Is obesity a disease?" The Council's considered response was a lesson in both the limits of language and the merits of humility: "Without a single, clear, authoritative, and widely accepted definition of disease, it is difficult to determine conclusively whether or not obesity is a medical disease state."[15]

Similar uncertainty marks controversies in other medical specialties, even ones in which scientific "objectivity" is often taken for granted. For example, it is far from clear that what is called "ductal carcinoma in situ" (DCIS) is actually cancer. Recently, the lead author of an article on DCIS, Dr. Laura J. Esserman, a professor of surgery and radiology, asked, "Ductal carcinoma in situ is not cancer, so why are we calling it cancer?"[16] Similar classification conundrums arise in medical specialties ranging from addiction medicine to rheumatology.

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