What Is a Disease?
During the course of my career, addiction treatment professionals (with a few notable exceptions) have consistently advocated on behalf of “the disease model.” As a professor, I have often asked seminar students to explain to me why they believe addiction is a disease. The results are sometimes surprising, not only because these future physicians seem puzzled, but also because they have a difficult time defining the word disease.
The ancient Greek academies had differing views of disease. Hippocrates emphasized the sick individual with his particular kind of misery. Others saw disease as a specific pathological process, evidenced by a visible sign such as a tumor, wound, or physical symptom. To this day, the definition of disease remains controversial. The AMA Council on Science and Public Health recently addressed the question, “Is obesity a disease?” The Council’s response: “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.”
This is also true for the vast majority of psychiatric disorders, particularly the addictions. The individual’s degree of suffering and incapacity—or distress and dysfunction—defines a state of disease. Although we now have some clues about the causes of mental disorders, and neuroimaging studies are making great strides, the American Psychiatric Association takes this position:
“The exact causes of mental disorders are unknown, but an explosive growth of research has brought us closer to the answers. We can say that certain inherited dispositions interact with triggering environmental factors. Poverty and stress are well-known to be bad for your health—this is true for mental health and physical health. In fact, the distinction between “mental” illness and “physical” illness can be misleading. Like physical illnesses, mental disorders can have a biological nature. Many physical illnesses can also have a strong emotional component.”
The National Alliance on Mental Illness (NAMI) seems to agree: “A mental illness is a condition that impacts a person's thinking, feeling or mood may affect and his or her ability to relate to others and function on a daily basis. Each person will have different experiences, even people with the same diagnosis. Recovery, including meaningful roles in social life, school and work, is possible, especially when you start treatment early and play a strong role in your own recovery process. A mental health condition isn’t the result of one event. Research suggests multiple, interlinking causes. Genetics, environment and lifestyle combine to influence whether someone develops a mental health condition. A stressful job or home life makes some people more susceptible, as do traumatic life events like being the victim of a crime. Biochemical processes and circuits as well as basic brain structure may play a role too.”
These questions highlight the importance of seeing the suffering person as more than a diagnosis or a label. This is the message I emphasize in my presentation, “Four Sides to Every Story,” available on request. Diagnosis is helpful, because we know that certain treatments are effective for certain diseases. For example, some fevers are caused by infection, and if we kill the offending bug we can cure the disease. Other fevers are caused by inflammation—as in rheumatoid arthritis or drug reactions—and if we calm the inflammation we can ease the fever.
At the same time, the psychiatrist should see much more than a label or a diagnosis (what the patient has in terms of the disease model). The psychiatrist—or any mental health professional—should also take the other three perspectives into account: who the person is, what the person does, and what the person has encountered. Using all four perspectives, the disease model can be valuable. It’s just not the whole story.
The ancient Greek academies had differing views of disease. Hippocrates emphasized the sick individual with his particular kind of misery. Others saw disease as a specific pathological process, evidenced by a visible sign such as a tumor, wound, or physical symptom. To this day, the definition of disease remains controversial. The AMA Council on Science and Public Health recently addressed the question, “Is obesity a disease?” The Council’s response: “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.”
This is also true for the vast majority of psychiatric disorders, particularly the addictions. The individual’s degree of suffering and incapacity—or distress and dysfunction—defines a state of disease. Although we now have some clues about the causes of mental disorders, and neuroimaging studies are making great strides, the American Psychiatric Association takes this position:
“The exact causes of mental disorders are unknown, but an explosive growth of research has brought us closer to the answers. We can say that certain inherited dispositions interact with triggering environmental factors. Poverty and stress are well-known to be bad for your health—this is true for mental health and physical health. In fact, the distinction between “mental” illness and “physical” illness can be misleading. Like physical illnesses, mental disorders can have a biological nature. Many physical illnesses can also have a strong emotional component.”
The National Alliance on Mental Illness (NAMI) seems to agree: “A mental illness is a condition that impacts a person's thinking, feeling or mood may affect and his or her ability to relate to others and function on a daily basis. Each person will have different experiences, even people with the same diagnosis. Recovery, including meaningful roles in social life, school and work, is possible, especially when you start treatment early and play a strong role in your own recovery process. A mental health condition isn’t the result of one event. Research suggests multiple, interlinking causes. Genetics, environment and lifestyle combine to influence whether someone develops a mental health condition. A stressful job or home life makes some people more susceptible, as do traumatic life events like being the victim of a crime. Biochemical processes and circuits as well as basic brain structure may play a role too.”
These questions highlight the importance of seeing the suffering person as more than a diagnosis or a label. This is the message I emphasize in my presentation, “Four Sides to Every Story,” available on request. Diagnosis is helpful, because we know that certain treatments are effective for certain diseases. For example, some fevers are caused by infection, and if we kill the offending bug we can cure the disease. Other fevers are caused by inflammation—as in rheumatoid arthritis or drug reactions—and if we calm the inflammation we can ease the fever.
At the same time, the psychiatrist should see much more than a label or a diagnosis (what the patient has in terms of the disease model). The psychiatrist—or any mental health professional—should also take the other three perspectives into account: who the person is, what the person does, and what the person has encountered. Using all four perspectives, the disease model can be valuable. It’s just not the whole story.