The Concept of Disease and its Implications for Psychiatry

It has often been suggested in recent years that there is no such thing as mental illness; that the conditions psychiatrists spend their time trying to treat ought not, properly speaking, to be regarded as illness at all, or even to be the concern of physicians. Szasz is the best-known exponent of this viewpoint, and the core of his argument is essentially this: that as prolonged search has never demonstrated any consistent physical abnormality in those regarded as mentally ill, and as their ‘illness' consists simply in behaving in ways that alarm or affront other people, or in believing things which other people do not believe, there is no justification for labelling them as ill, and to do so is to use the word illness in a purely metaphorical sense (Szasz, 1960). Schneider had previously been led by the same reasoning to the conclusion that neurotic illness and personality disorders were ‘abnormal varieties of sane mental life’ rather than disease, but he took care to exempt schizophrenia and cyclothymia by assuming that both would in time prove to possess an organic basis (Schneider, 1950). The argument Eysenck puts forward in the first edition of his textbook, though written from the quite different standpoint of academic psychology, is a similar one. After observing that ‘the term psychiatry does not denote any meaningful grouping of problems or subjects of study’ he went on to suggest that the traditional subject-matter of psychiatry should be divided into a small medical part ‘dealing with the effects of tumours, lesions, infections and other physical conditions' and a much larger behavioural part ‘dealing with disorders of behaviour acquired through the ordinary processes of learning’, thereby implying that most of what doctors regarded as mental illness was really learnt behaviour rather than disease, and therefore much better understood, and dealt with, by psychologists than by physicians (Eysenck, 1960). A third line of attack is provided by R. D. Laing, and a fourth is exemplified by the sociologist Scheff. Laing argues that schizophrenia, far from being a disease or a form of insanity, is really the only sane or rational way adolescents have of coping with the intolerable emotional pressures placed on them by society and their families (Laing, 1967). Scheff has developed the somewhat similar argument that what psychiatrists call mental illness is largely a response to the shock of being labelled and treated as insane and the expectations this produces; in other words that schizophrenia is created by the people and institutions that purport to treat it (Scheff, 1963).