[From Bill Powers (2001.08.04.0600 MDT)]
Hi, Tim.
I'm taking the liberty of replying via CSGnet (minus personal references),
because I think your post raises interesting and important issues that are
relevant to PCT.
As I've been going over my book, I've begun to think a little more deeply
about the psychiatric disorders. It's commonly claimed that these disorders
can't be considered diseases because there is no underlying physical
abnormality associated with any of them. I'd always gone along with that
but I've been giving it some more thought. I thought I'd contact you to
see >what your angle on it was.
It seems to me that if the only reason that they
can't be considered diseases is because a physical abnormality hasn't yet
been identified, couldn't people argue that historically most of the
medical diseases were identified long before the underlying physical
abnormality was found. I imagine, for example, that the symptoms of
diabetes were around for a long time before the pancreas was identified as
the culprit.
One thing you're asking is whether we should consider all psychological
problems to be medical issues until proven otherwise (the default diagnosis
commonly assumed by doctors). The whole approach based on the idea of
standard "disorders" is an expression of this idea, not to mention the
concept of using drugs as the final solution to "behavioral" problems. Most
often, as you mention, no specific abnormality can be found (especially for
psychiatric disorders), but the assumption is that there must be one. This
is equivalent to saying that the abnormality must be either genetic or the
result of a trauma -- it is never assumed (as far as I know) that it
resulted from normal operation of the part in question under abnormal
circumstances, or simply from mistakes made while trying to solve some
other problem.
The human system, at all levels, is highly adaptive -- that is, it can
alter its own behavior and even physical details (such as muscle size) to
counteract disturbances that disrupt the control of important variables.
This applies to somatic systems, but most of all to brain-controlled
systems, for the brain acquires almost all of its functional organization
from interacting with its environment as it defends the body's intrinsic
state. But while this "plasticity" is widely-known and acknowledged, it is
simply ignored by those who assume all disorders to be physical. To ignore
it is to assume that the brain is hard-wired and that similar symptoms
imply similar causes, neither of which ideas stands up to scrutiny.
Further, tracing the cause of a problem to a physical abnormality by no
means solves it. There is still the question of what caused the
abnormality. But the medical approach typically does what you describe
above: it traces the cause of a symptom back to some physical abnormality
(here in the pancreas), and then tries to treat or compensate for the
abnormality without knowing what caused it. If the abnormality is the
result of the system's trying to solve some other problem, the treatment
that restores the part to normal operation may be counteracted as the body
increases its efforts to solve the same problem, which (but for luck) the
treatment has not affected. Low thyroxin in the bloodstream comes to mind.
When doctors tried to treat this condition directly, by supplying thyroxin
in pills, the thyroid gland simply shut down its own output of thyroxin,
and if the treatment were continued for a long time, atrophied --
physically shrank in size. We would recognize that this implies some other
control system that sets the reference level of thyroxin to a low value, as
it tries to correct some other error.
Of course there can always be a physical problem inside the thyroid gland.
If the input of TSH (Thyroid Stimulating Hormone) is normal, but the output
of thyroxin is too low, or too high, then the gland is not responding
normally and there is some biochemical problem. But even that is not
necessarily a medical/disease problem, as the Swiss discovered when their
diet was found deficient in iodine, making the thyroxin useless no matter
how much of it was produced by an enlarged thyroid, a goiter. This problem
was solved behaviorally -- the brain learned to make and ingest iodized
salt (hope I haven't garbled that story), so we could argue that the
problem was behavioral. There was nothing wrong with the basic
thyroxin-control system, only a lack of raw materials.
It's not that easy to separate "physical" causes from "mental" ones. A
person who is gradually losing weight may have the illusion of weighing too
much, and almost cease eating. The physical cause of reduced food intake
explains the weight loss, but what explains the reduced food intake? There
could be a perceptual disorder, or a higher system, for various reasons,
might have selected a lower reference level for weight (for example, to get
a job as a fashion model, a jockey, or a featherweight wrestler).
Is there any way it can be argued that in time we may find an underlying
abnormality for things like ADHD and depression? Can it be argued that our
measuring equipment, for example, is just not sensitive enough yet?
You really ask two questions here, the first being "Are ADHD and depression
really objective conditions?" The answer to the first is probably "no" and
to the second, "yes." But whether or not there is really an identifiable
condition, the question remains whether it is genetic/traumatic in origin,
or functional. That question is not answered by failure to find any
physical cause with existing instruments; it's just as legitimate (or as
much an error) to say that the physical abnormality hasn't been found
because there isn't one. A lack of evidence is not evidence of anything.
I had thought for a while that they couldn't be considered diseases because
a diagnosis of depression was made on the basis of a collection of
behaviours and from a PCT perspective, behaviours aren't what a person is
doing. Many medical diseases, however, are diagnosed initially from an
examination of physical symptoms. There are certainly tests done to check
for various anomalies but again that brings us back to the argument that we
may just not have sophisticated enough measuring devices yet.Is there something I'm missing? Is there some reason, why, even if an
abnormality was found that things like depression still could not be
considered diseases.
A good deal of this question stems from the word "disease." We tend to
think of a disease as something that happens to us because of an outside
agency like a virus or a bacterium, or from lack of some ingredient of food
such as a vitamin, or from a toxin, or from a genetic abnormality. But if a
person can't keep a job, or has failed in a personal relationship, can we
think of that person's depression as a physical problem, to be cured with
Prozac? Perhaps Prozac could relieve the feelings, but then where would the
reason be to find out the real causes of the depression, assuming that
learning to keep a job or have a successful relationship would (somehow)
also remove the symptoms?
Your main question, however, relates to diagnosis from behavior, which we
in PCT see as an error because organisms _vary_ their behavior to control
their experiences, so changes in behavior reflect mainly changes in
conditions such as disturbances. That doesn't really answer your question,
however. It merely says that an abnormal behavior may result from abnormal
perceptions, reference signals, comparisons, or output functions, so those
abnormalities could still be considered "diseases."
I think the best answer comes from pondering this word which I pronounce
"Dih - zeez". I have a dih-zeez, meaning that a dih-zeez got into me and
made me "sick." But the word is really "dis - ease," meaning a loss of ease
or comfort, which isn't something that gets into me, but simply a way I
feel, for some unknown reason.
With Glasser's needs, for example, even if it was discovered that there
were 4 (or 5 or 6) needs that were genetically encoded then Glasser still
wouldn't be right because he argues that these genes control behaviour and
it can be demonstrated from PCT that people aren't designed that way.Is there a similar argument for the psychiatric conditions or is the only
reason that they can't be claimed to be diseases because no underlying
physical abnormality has been found?
_All_ diseases involve physical abnormality. A person who believes in
demons, magic, and spells has a physical abnormality -- the way the
physical neurons in that person's brain are firing is different from the
way most people's physical neurons fire. But can this sort of disease be
cured by ingesting the right chemicals, or be prevented by protecting the
body from toxins? Especially with regard to prevention, the only real
solution requires interacting with other people and being helped to
reorganize, or being given, early in life, more reliable information about
how the world most probably works. Not all diseases can be treated with
drugs or surgery.
But most important to me, not all diseases should necessarily be cured. If
a patient is diagnosed as having the dis-ease of resisting authorities
(such as psychologists or psychiatrists), who is made uneasy by this
behavior? Who should be treated -- the patient, or the doctor?
Best,
Bill P.