The controversial term ‘medicalisation’ describes the branding of natural and non-pathological human conditions as diagnosable, treatment worthy diseases. A particularly strong supporter of this notion is psychiatrist Thomas Szasz (author of ‘The Myth of Mental Illness’). In a series of essays Szasz claims that modern psychiatry is entirely medicalisation, stating that ‘whatever aspect of psychiatry psychiatrists claim is not medicalisation, is not medicalisation only if it deals with proven disease, in which case it belongs to neurology, neuroanatomy, neurophysiology, neurochemistry, neuropharmacology, or neurosurgery, not psychiatry.’ To me this seems peculiar coming from someone who chose psychiatry as a profession – why would one wish to manage and treat diseases they believe are, in fact, purely a product of society’s entrenched desire to attach concrete diagnoses to natural (but undesirable) human behaviours? Nevertheless, Szasz is widely accepted to be at the forefront of the so-called ‘anti-psychiatry’ movement, arguing that phenomena such as alcoholism and depression are not in fact diseases and that the ‘business of psychiatry is coercion, not care’.
The pressing questions to ask here are twofold. Firstly, how problematic is this notion for those suffering with these psychiatric problems? Does it simply undermine their very real and tangible every day struggles, possibly even contributing to the stigma surrounding mental illness? Secondly, is this view merely misinformed? Has there been evidence since these publications to suggest an apparent structural or pathological issue in brain chemistry causing the psychiatric problem Szasz describes?
Although Szasz published his collection of essays in 1973, his general ideology of medicine seems to belong in a bygone age, where clinical interactions were far more paternalistic: hundreds of years ago, physicians would independently observe patients, form a diagnosis based on their signs and symptoms and prescribe what they alone deemed to be the necessary antidote. Modern medicine aims to be significantly more interactive, taking the ideas, concerns and expectations of the patient as first priority, even if it contradicts the physician’s expertise. Szasz and other proponents of the movement such as Franco Basaglia and R. D. Laing claim that without a macroscopic, visible lesion detectable at post-mortem, the set of symptoms the patient experienced cannot be termed a disease; they use schizophrenia, eating disorders and depression as examples of this.
However, this ignores the vast and varied literature suggesting microscopic lesions are indeed alive and abundant within these patients. For example, in the brains of those suffering with addictions, numerous cellular and molecular adaptations have been detected in the dopamine circuits that govern goal-directed behaviour. These dopamine circuits have a decreased response to the emotional reinforcement of less potent natural rewards such as food or sex, intensifying the response to addictive substances, increasing the motivation to seek them out again. This has been hypothesised to account for the futile influence of emotional stimuli on addicts’ decision making as substance seeking-and-taking behaviour becomes habitual and compulsive.
Even moving away from the cellular level, there is a wealth of evidence to suggest gross anatomical differences in the brains of patients with psychiatric problems. For example, functional MRI studies (where the active parts of the brain ‘light up’ on the scanner image) on patients with generalised anxiety disorder have shown far less distinct connections between sub-regions of the human amygdala – a part of the brain that plays a key role in emotional processing and sensory fear-related memories. In a similar vein, imaging studies have found the size of the hippocampus (a small organ in the temporal lobe of the brain that contributes to long-term memory and spatial navigation) is consistently reduced in patients with major depressive disorder; the degree of which has been found to be directly proportional to the number and duration of untreated depressive episodes.
It seems somewhat peculiar that Szasz and other proponents of ‘anti-psychiatry’ choose to dismiss the ample amounts of evidence pointing toward existing, tangible brain abnormalities. Perhaps our tendency to exclusively search for, interpret and favour information in a way that confirms one’s pre-existing beliefs is strong at work here. However, some argue these data only beg the classic question of chicken or egg: are such biochemical imbalances or aberrant connectivity the cause or additional symptoms of such illnesses? Are they structural differences that pave the way for damaging symptoms or are they physiological manifestations of a psychological origin?
However, a striking consideration here is the question of whether it should even be necessary to quote huge amounts of structural or biochemical data to validate the existence of such diseases. Is the clear and palpable infringement on the daily functioning of those suffering with such conditions not enough to warrant a ‘true disease’ status? It would surely be difficult to find a person denying that those who suffer, for example from severe depression, are ill. Even the physical symptoms (nausea, vomiting, chronic pain, fatigue, insomnia etc.) are indisputable.
Any doubt may stem from the paradigm on which the practice of clinical medicine was based: ‘the medical model’, founded in the era of Hippocrates. This is the assertion that pathological physiological processes cause diagnosable symptoms which can subsequently be treated, in order to eradicate or ameliorate the disease to reduce suffering and prolong life. Despite this model’s importance in modern medicine, I find its very literal application in psychiatric illness problematic. Even without knowing a concrete structural cause, visible on a CT scan, physicians surely owe it to their patients to provide the most efficacious treatment possible.
Psychopharmacology has numerous side-effects, is often unsuccessful and its mechanism in some cases remains unclear. Despite this, it has also been radically life-saving in a huge numbers of cases. Some argue this proves psychiatric illness is biological, as for the most part we know which exact neurotransmitters and pathways such medications target. However, taking major depressive disorder as an example, even medicated patients are at risk of further episodes: over 50% of people suffering their first major depressive episode will suffer another. This implies that there is an underlying susceptibility in such patients, which some argue is purely psychological.
What strikes me as sad whilst reading Szasz and the works of his supporters is the immense desire of society to discredit another human’s suffering. Nowadays this phenomenon is more prevalent than we think. It could even be perversely competitive: the notion that ‘my suffering is greater than your suffering’. Why would eminent psychiatrists such as Szasz deny the existence of illnesses that present with debilitating symptoms and can be treated through psychopharmacology or psychotherapy? They would simply diagnose it as one, treat it as one. Such as with most cancers, some patients will be cured and some will continue to relapse. The argument is simply unhelpful and socially problematic. It increases the stigma surrounding mental illness and the general public’s ignorance and scepticism towards those suffering from it.
Psychiatric illness should, of course, not be treated in the same way as diabetes, heart disease or cancer. Far more than pharmacological or surgical intervention is needed to successfully treat these conditions. They are not just physical but psychosocial in nature. This does not detract from the brain’s irrefutable biochemical, cellular and anatomical differences that can have devastating (and often fatal) consequences. These clearly require effective interventions.
Reading authors such as Szasz can be infuriating and frankly confusing but he has succeeded in challenging traditional thinking about the subject. As a medical student who has met a fair few psychiatric patients, I find it impossible to imagine that they are not experiencing a real pathological illness. Debate of conventional views is often healthy and encouraged, of course, yet I for one hope the ‘anti-psychiatry movement’ does not promote a society in which those suffering from debilitating psychiatric issues are ignored, mocked or even dismissed. Surely even Szasz, as a psychiatrist, would concede that.