Exit exceptionalism: mental disease is like any other medical disease

In their well-written editorial,1 Malla, Joober and Garcia argue that mental disease is different from other medical disease. Although interesting, their arguments hardly undermine the claim that mental disease is like any other medical disease. Moreover, in their eagerness to demarcate psychiatry from somatic medicine they miss a crucial opportunity for psychiatry.

Their main arguments are as follows: mental disease involves the self, it cannot be explained in neurobiological terms, it is not situated in an organ, and biological explanations are not helpful (e.g., for reducing stigma).

Here is where their arguments fail. Mental disease involves the self. The authors argue that the hallmark defining features of mental disorders are “the changes in how the patients feel, think and act and how these changes affect their relation to themselves and to others.” Although perfectly right, these characteristics are not unique to mental diseases. A person who is in pain and distress due to cancer can have a significantly altered way of thinking, feeling and relationship to others and him/herself. The point is that all diseases involve the self. Disease is a basic attack on the human being, not only on our mental selves. Disease alters who we are and who we can be — physically, morally and socially — not only mentally. A person with an incapacitating infection cannot pick up his children from school, be a devoted husband, a caring son or a dedicated employee.

Mental disease cannot be explained in neurobiological terms, particularly not “many of the behaviours and experiences that constitute the core presentations of mental disease.” Although the authors may be perfectly right in this claim, it does not bolster the uniqueness of mental disorders. A wide range of other diseases cannot be explained in neurological (or other biological, physiological or bimolecular) terms either. Using causal explanations as a sine qua non for disease would eliminate a wide range of diseases.

Mental disease cannot be situated in an organ. Again, there are numerous diseases that cannot be situated in a specific organ. Neurofibromatosis is but 1 example. The point is that not all diseases are organ-specific, so this is hardly unique for mental disease. The same goes for the argument that biological explanations are not helpful. Malla, Joober and Amparo may very well be right that biological explanations may have negative consequences for (the self-conception of) some people with mental diseases. First, the opposite may also be the case (i.e., it may have good consequences). Second, this hardly buttresses the uniqueness of mental diseases. On the contrary, it points to deficiencies in “somatic medicine” not paying attention to self-inflicting consequences of any disease. Third, the history of psychiatry is full of misguided and unhelpful explanations.

It is important to note that I am not saying that there are no good arguments for the uniqueness of mental diseases. I have argued only that the arguments presented by opinion leaders in the field may not do the job. They do not demonstrate the uniqueness of mental diseases. The main flaw, as I see it, is not that they do not address core aspects of mental diseases. On the contrary, I do think that the self-affecting aspects the authors refer to are essential to mental diseases. However, the mistake is to make them exclusive to mental disease. All disease, mental or otherwise, appears to affect the human self.

The danger of exceptionalism: One reason to undermine unwarranted exceptionalism in psychiatry is the harm that it can do. Historically psychiatry has allowed too much, for example, resulting from slack demands for rigour and evidence. No doubt, self-affecting aspects of disease are core to psychiatry, but they are not unique. This is where psychiatry could make a significant contribution to medicine in general: teaching us to pay attention to the self-affecting aspects of disease. Hence, mental disease is like any other medical disease. All diseases are self-afflicting. This makes psychiatry crucial for understanding and handling all diseases. Don’t miss this pivotal opportunity!