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Correspondence |
Department of Psychiatry, Keele University, Thornburrow Drive, Hartshill, Stoke-on-Trent ST4 7QB, UK
Kendell's (2001) editorial made two mistakes in its reasoning, which led to an unhelpful conclusion. One cannot say that mental and physical illness should be conflated because, irrespective of the balance, mental and physical symptoms are expressed in both. This is insisting that differences in degree are not differences at all. There are indeed many disorders that have both mental and physical expressions. However, to claim that anxiety-related chest pain and myocardial infarction are both physical disorders is to conflate precisely what we wish to distinguish, even if anxiety can cause both. We contrast the terms ‘mental’ and ‘physical’ because the contrast says what we mean, and we have good reason for meaning it. As Kendell himself points out, no alternative has been found.
Proposing that disturbances in bodily function are necessary for psychiatric disorder does not imply that psychiatric disorders are physical disorders. Consider a computer virus. It may exist as a series of electrical states in a computer, a set of statements in a computer language, even a series of thoughts in someone's head, so its existence is not dependent on any physical object. None the less, it may disrupt a computer's function despite there being no physical fault in the machine. It is generally accepted that such arguments show that mental states might themselves be functions (Heil, 1998), and so purely functional psychiatric disorders are quite possible.
These mistakes lead Kendell to suggest that stigma might be reduced if all psychiatric disorders were to be regarded as physical. This makes mental illness literally unspeakable. But not speaking of something true implies an attitude towards it of denial, shame and horror, not acceptance. The concept of mental health and its promotion is currently competing successfully with ‘madness’ in popular culture. By falsely declaring ‘mental’ to be meaningless, the editorial threatens this progress. It may also consign those of our patients who are not sufficiently biological in their pathology to that therapeutic underclass, the ‘worried well’.
REFERENCES
Heil, J. (1998) Philosophy of Mind: A Contemporary Introduction. New York: Routledge.
Kendell, R. E. (2001) The distinction between
mental and physical illness. British Journal of
Psychiatry, 178,
490-493.
Department of Psychiatry, University of Edinburgh, 3 West Castle Road, Edinburgh EH10 5AT, UK
I agree with much of what Dr Reynolds says and with Baker & Menken's view, to which he refers. I also, like him, look forward to the time when psychiatrists and neurologists speak the same language. Both will need to change a good deal for this to be possible, but increasing understanding of the cerebral substrate of emotions and cognition will eventually provide a powerful stimulus to both specialities. I was not, though, suggesting that we should talk of psychiatric illnesses instead of mental illnesses because I prefer Greek to Latin derivations. The term ‘mental illness’ implies a disorder of the mind. By substituting ‘psychiatric illness’ I wished to imply simply that these are disorders which, if they come to specialist attention, are normally treated by psychiatrists. I should emphasise, too, that my objections to the term ‘physical illness’ are almost as great as to ‘mental illness’. Both encourage doctors and patients alike to make inappropriate and damaging assumptions and to ignore the role of psychological and social influences across the whole spectrum of illness. That is why I do not think it is appropriate simply to combine mental and neurological disorders as ‘brain disorders’.
In reply to Dr Crichton, I did not quote Lady Mary Wortley Montagu with either approval or disapproval, but simply to illustrate the fact that in the mid-18th century it was still the accepted view that madness was no different from other diseases. More importantly, Dr Crichton is confusing the difference between mental and physical events and what are misleadingly called mental and physical illnesses. There are indeed still many mysteries about the relationship between mental and physical (cerebral) events and no unanimity among either philosophers or neuroscientists about the nature of that relationship (although Descartes' original ‘substance dualism’ has passed into history). But this, although important, is irrelevant to my argument that there is no fundamental or qualitative difference between the heterogeneous collections of illnesses we currently distinguish as physical and mental. Both physical and mental phenomena are conspicuous in both — as aetiological factors, as features of the illness itself and as influences on outcome. And pain is indeed a purely subjective phenomenon, even though there are good reasons for assuming that it usually, perhaps always, has physical (cerebral) concomitants.
In reply to Dr Foreman I can only say that he should have read my editorial rather more carefully. I did not argue that psychiatric disorders are physical disorders. Rather, I drew attention to the extensive evidence of somatic abnormalities in almost all common mental disorders and to the lack of any characteristic features of either the symptomatology or the aetiology of so-called mental illnesses that reliably distinguished them from physical illnesses (and vice versa). Nor did I declare "mental to be meaningless", or argue that there are no important differences between mental and physical illnesses. My argument was that "the differences between mental and physical illnesses, striking though some of them are, are quantitative rather than qualitative, differences of emphasis rather than fundamental differences, and no more profound than the differences between diseases of the circulatory system and those of the digestive system, or between kidney diseases and skin diseases". And far from wanting mental illnesses to be regarded as physical illnesses, I argued that both terms are misleading. Finally, I did not say that "no alternative has been found" for the term mental illness. On the contrary, I suggested that "we should talk of psychiatric illnesses or disorders" instead. Nor was this merely a suggestion. The most recent edition of the Companion to Psychiatric Studies, which I co-edited (Kendell & Zealley, 1993), deliberately refers to psychiatric illnesses or disorders rather than to mental disorders throughout its 950 pages, and explains the reasons for doing so.
REFERENCES
Kendell, R. E. & Zealley, A. K. (eds) (1993) Companion to Psychiatric Studies (5th edn). Edinburgh: Churchill Livingstone.
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