Disease, Mental Illness Or Disorder?

A couple of weeks ago, I noted that Britney Spears was reportedly being treated for bipolar disorder, although to date there is has been no confirmation from Spears herself (People has her on the cover this week and declares in a subhead that she is "bipolar"). I wrote at the time that I was troubled that one entertainment web site had described Spears as having a "disease."

"But talking about this as a disease....Oh, well, looks like the fine entertainment media in this country may need a wee bit of education about the chemical imbalance theory and what it isn't."

Yesterday, a reader left the following comment:

"Why do you not want it called a disease? Is illness that different a term? Bipolar in indeed a mental illness."

Every so often, I feel the need to explain the terms I use when writing and talking about mental illness. Hopefully, I can explain myself once again in a respectful way.

When writing about schizophrenia, bipolar disorder, depression and all the other DSM maladies, I use the terms mental illness and disorder to describe them. I almost never use the term "disease" and I certainly never use the term "brain disease." My reasons are a mix of the personal, the scientific and the political.

Once upon a time, back in the early-1990s, I believed in bipolar disorder as a brain disease and that it had a specific, identifiable pathology, as many researchers theorized then. I turned myself over to the medical model of disease management, convinced that I had a disease caused by deficiencies of chemicals in my brain and that I was a victim of bad genes (even though no one in the entire known history of my family had ever been diagnosed with so much as depression), and that none of my behavior was my fault. I had a disease and couldn't help myself. All I needed to do was find the right combination of meds and I'd be back to my old self. Important researchers said so. Who was I to argue with them? In the meantime, couldn't people just stop the stigma and understand that I was helpless and offer me love and acceptance?

This mindset of mine damn near killed me, as I was undone by meds several times. I've written about this elsewhere and don't feel like repeating myself. I'm fine with describing bipolar disorder, depression and schizophrenia as mental illnesses some of the time, although I believe that in its subsyndromal forms bipolar disorder, for example, more closely resembles a personality disorder, at least for metaphorical purposes, than it does a true illness that renders the sufferer a helpless victim. I'm often use the term "disorder" as well to describe mental illnesses such as depression and schizophrenia. That's my deal these days on a personal level with the nomenclature of mental illness.

On a scientific level, my deal is that when someone can prove the biological mechanism of a mental illness to me and prove to me that said mechanism is the cause of the disorder (and this research is then appropriately replicated), then I'll consistently call use the term disease. I'm well aware that the brain and brain chemistry is connected to and associated with mental disorders, but I've never seen convincing evidence that they are the principle drivers. If they were, I think it would be safe to assume that 100 percent of patients (or, hell, 80 percent) would respond positively to anti-depressants, to use one example. This is not the case on any planet I am aware of. The short story is that psych researchers have never established the central lesion of mental diseases, and I don't believe that I am dipping into anti-psychiatry by saying so.

On a political level, I think insisting on the term disease as a proxy for mental illnesses and mental disorders sets patients up to be one-trick ponies in the medical model and on their knees for the rest of their lives awaiting the magic pill and the magic genetic fix that I believe will likely never arrive, not in my lifetime at any rate. I'm not interested in living my life on my knees and not too long after I stopped using disease as a metaphor for what I was going through, I felt better.

So if you want to use the term disease, go ahead. Whatever gets you through the night. Just don't expect me to use that terminology very often.

Another reader replied to the above commenter, arguing:

"Bipolar Disorder is a label used to take civil rights away from people, not a medical disease. Mental illness is a sane reaction to insane situations, not a medical disease. This does not mean human suffering is not real, it doesn't even mean it's wrong for people in extreme emotional pain to take drugs, but there is no evidence that there's a disease called bipolar disorder."

I am sympathetic to this argument, but I don't fully buy it either. After all, I've never had my civil rights taken away via forced hospitalization (or voluntary hospitalization for that matter) or forced treatment and I've never been arrested for anything connected with the disorder. In fact, the only time I've ever been arrested was after I beat the hell out of a guy at a party who picked a fight with me in 1985. It was self-defense as I argued to the police outside on the sidewalk, so they couldn't arrest me--except that I was drunk on a public sidewalk so they arrested me for that, took me to the Salt Lake City jail and beat the shit out of me in the jail's parking garage while I was still cuffed (I still have chips in my teeth). I was never charged with any offense. Gee, I wonder why.

Anyway, I agree with the commenter that in some cases mental illness sure seems to be kicked off by someone having an off-the-wall response to life's insanity (aka stress), but I'm not sure that explains all cases of mental illness. As for the evidence of a disease called bipolar disorder, I'd say there's abundant evidence of a disorder and maybe an illness, but much less evidence of a dominant disease state regardless of what all those PET scans, fMRIs and so on show.

Some would argue, "But the meds treat the disorder, so it must be a brain disease." That may be true for the minority of patients who are well-treated by meds, although I am dubious of that over time. But then how would you explain people who are well-treated and achieve subsyndromal states for long periods of time without meds at all or who achieve the same state via psychotherapy or psychotherapy with meds or by vitamins alone (yes, there are a few of those apparently). In these cases, where the meds are a supporting actor at most if at all, it sure doesn't sound to me as if the use of meds establishes a disease state.

If you think I am off-base, consider: I have some authoritative child psychiatrists telling me that what's called childhood bipolar disorder is in fact a blend of oppositional defiant disorder or conduct disorder, and, in their experiences, is the result of truly awful environments. So would that be a disease? Sure doesn't sound like it to me.

For me, the whole matter of diseaseing a disorder just boils down to the fact that disease is any excessive term. That said, I have certainly seen cases of schizophrenia, depression, OCD, anxiety and bipolar disorder that appear so profound and so awful that the term disease is almost warranted.

But almost only counts in horseshoes not in life.

Posted by Philip Dawdy at February 12, 2008 12:05 AM
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