Mind-Body Dualism, Psychiatry, and Medicine
Michael Sharpe
Jane Walker
Introduction
Patients usually attend doctors because they are concerned about symptoms. When these symptoms are associated with persistent distress or disability we refer to the patient as having an illness. When assessing the patient’s illness the doctor aims to make a diagnosis, on the basis of which management can be planned and prognosis made. The diagnoses available to doctors are conventionally defined as either ‘medical’ or ‘psychiatric’. This division of illness into two types is such an accepted feature of current medical practice that we tend to take it for granted. But is it really the best way to think about patients’ illnesses and to plan their care?
In order to answer this question we will examine what is meant by ‘medical’ and ‘psychiatric’ diagnoses and the assumptions underpinning this division. The disadvantages of this dualistic approach will be considered and solutions proposed.
Diagnosis
Medical diagnosis
A medical diagnosis is a label for a condition that is: (a) conventionally treated by medical doctors and (b) listed in the classifications of medical conditions such as ICD-10. Most medical diagnoses are based on identifiable bodily pathology (abnormal structure and/or function). Therefore, to make a medical diagnosis (such as cancer) doctors will seek specific bodily symptoms before confirming the presence of bodily pathology with physical signs and biological investigations (such as X-rays).
Psychiatric diagnosis
Similarly a psychiatric diagnosis is a label for a condition that is: (a) conventionally treated by psychiatrists and (b) defined in the psychiatric diagnostic classifications of ICD and DSM. Psychiatric diagnoses are not based not on bodily pathology. They are however associated with the idea of ‘psychopathology’, that is proposed abnormalities of the mind. Unlike bodily pathology these abnormalities of the mind cannot be objectively identified and have to be inferred from the patient’s mental symptoms and their behaviour. Investigations play little or no role in diagnosis. Psychiatric diagnoses are therefore defined on the basis of symptoms and syndromes.
When is an illness psychiatric?
Why are some illnesses regarded as ‘mental’ or ‘psychiatric’ as opposed to ‘medical’? Examination of the criteria for diagnoses listed as psychiatric reveals that readily observable factors common to most ‘psychiatric’ illnesses are:
an absence of known bodily pathology
an abnormal mental state as inferred by the patient’s report
a presentation with disturbed behaviour
Mind-body dualism
The underlying assumption of this dichotomous view is that it is both valid and useful to divide human illnesses into those of the body and those of the mind.(1) This idea of mind-body dualism is commonly attributed to the writings of the philosopher Descartes. So-called Cartesian dualism has exerted a profound influence on Western medical thinking and still shapes our thinking, training, and service provision.
However, dualism is at best an oversimplification and at worst a source of serious theoretical and practical problems. It may be argued that there is no such thing as a purely ‘bodily’ or purely ‘mental’ illness and that all illnesses have mental and bodily aspects.(2) Furthermore, the assumption that bodily symptoms indicate bodily pathology and that mental symptoms indicate psychopathology gives rise to specific problems: (a) when bodily symptoms occur without bodily pathology and (b) when mental symptoms occur together with bodily pathology (see Table 5.1.1).
Bodily symptoms with no bodily pathology: somatization
When patients present with bodily symptoms and bodily pathology is confirmed they are given a medical diagnosis. When patients have bodily symptoms but there is no evidence of bodily pathology the terms ‘somatization’ or ‘somatoform disorder’ are used to describe their illness. It is unclear, however, whether these illnesses are properly regarded as ‘psychiatric’ or as ‘medical’ as they do not clearly fulfil criteria for either. One solution to this dilemma is to allocate these illnesses to psychiatry. The assumption is made that their somatic symptoms are really explained by psychopathology. The absence of mental symptoms, from which psychopathology
can be inferred, is explained by the idea that the psychopathology is hidden and ‘converted’ into bodily symptoms by a process called ‘somatization’ (literally making the mental somatic). Clearly these are questionable assumptions.(3)
can be inferred, is explained by the idea that the psychopathology is hidden and ‘converted’ into bodily symptoms by a process called ‘somatization’ (literally making the mental somatic). Clearly these are questionable assumptions.(3)
Table 5.1.1 Diagnoses symptoms and bodily pathology | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
A second solution is to assume that the patients really do have bodily pathology in some form (even though is it unknown) and to give them a medical diagnosis of a so-called ‘functional disorder’ such as fibromyalgia.(4) As with somatization this approach is based on questionable assumptions.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
