On Causality and Mental Illness

Those of you who followed Patrick's fascinating post (and the debate that ensued in the comments) on causal models of psychiatry and mental illness might be interested in the abstract of this dissertation:

In contemporary biological approaches to psychiatry it is rarely questioned that psychiatric disorders stem from biological "dysfunctions". This assumption appears to be confirmed by the fact that biological research has been successful at uncovering diverse biological disparities between the brains of persons with mental illnesses and normal controls. However, the fact that something is different or unusual does not mean it is dysfunctional. The thesis of the dissertation is that there is little warrant for the claim that psychiatric disorders stem from biological dysfunctions. This prompts a question of definition: what does it mean to say that something--e.g., a given part of the brain or nervous system--is "functioning properly" or that it is "dysfunctional"? The dissertation argues that the theory of function appropriate for psychiatry is one that holds that the function of an entity consists in that activity that, in the past, contributed to the differential persistence or reproduction of that entity or type of entity. A consequence of this view is that just because something is not adaptive in a given environment, it is not necessarily dysfunctional. Finally, the dissertation examines two major neurobiological perspectives on schizophrenia--a neurochemical perspective and a neurodevelopmental perspective. From a neurochemical perspective, it argues that even if the dopamine system is abnormal in schizophrenia, it is not dysfunctional. It also shows that on certain neurodevelopmental hypotheses, schizophrenia could be said to stem from a biological dysfunction, but on other neurodevelopmental hypotheses, it could not. The fact that there is currently not enough information to decide which of these multiple hypotheses is correct means that there is currently little warrant for saying that schizophrenia stems from a biological dysfunction. Since this has been shown to be unwarranted through detailed analysis of some neurobiological examples, then it is reasonable to suspect that careful attention to neurobiological details associated with other mental disorders might reveal the same thing. Consequently, it should not be assumed that psychiatric disorders in general stem from biological dysfunctions on the part of the brain unless there is evidence for this conclusion other than the existence of biological abnormalities.

(h/t H-SCI-MED-TECH listserv)

The debate between Patrick and myself referenced below quickly morphed, in my view, to a discussion about disease causality, which is really the crux of the matter, in my view.  What does it mean to say that biological factors cause illness? More to the point, what are biological factors? Can these factors be separated from social, cultural, and environmental factors? One of the most important insights of Lewontin's work is what he terms the ideology of biology, the idea that biological entities exist in a metaphysical sense apart from the social and cultural worlds we inhabit.  Lewontin argues that this view is ideological in the sense that it is poorly supported by our understanding of what biology (i.e., life) actually consists of.

Nancy Krieger makes a similar point in her work on the effects of racism on health (that biological "causes" of illness are irreducibly social, that we bear the imprints of our social lives in our embodies selves).  This material is briefly addressed at the beginning of Unnatural Causes, and should also go some length to explaining why I am partial to a phenomenological account of illness in general, but mental illness in particular.

For those who doubt the significance of this issue, just take a look at this recent NY Times article, and Philip Dawdy's analysis at Furious Seasons.  The Times article is just disastrous for a variety of reasons related to this discussion on causality, some of which Dawdy notes.  This emphasis on discrete biological entities as causes for mental illness is, IMO, part of a larger (post-Enlightenment) focus of scientific and medical culture on these discrete causes, which really took off during the bacteriological revoultion, and has recently transferred to discourse on genes.  For those interested in exploring this issue more, I heartily recommend Sylvia Tesh's work.

The key is that there is a great deal at stake in the causal attributions we make as to disease and illness.  These attributions also have a profound effect on all manner of social and cultural issues, including disparities, stigma, and justice.  The latter is easily demonstrated by the longstanding tradition of blaming immigrants and foreigners for causing outbreaks of infectious disease.  How -- and to whom -- we attribute illness and disease says a very great deal about the social and cultural fabric of any given society.  No wonder some medical anthropologists argue that by studying the meaning of disease in any given culture, we can learn virtually anything that matters to the particular culture in question.

Thoughts?

Comments

[Patrick S. O'Donnell]

While I would certainly like to hear the views of others and have neither the time nor the stamina for a debate (and, I hesitate to admit, the interest!), I will say that I'm personally drawn, in the main (there's still some conceptual confusion in his account), to the perspective of Allan V. Horwitz in Creating Mental Illness (2002) (he's been influenced by Jerome Wakefield, and both authors have, in turn, been criticized for various reasons by Murphy). There's a succinct and focused discussion of biology in relation to the DSM in Horwitz and Wakefield's book, The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder (2007). Please see Ch. 8, "The DSM and Biological Research about Depression," pp. 165-178.

[Daniel S. Goldberg]

Good lord, Patrick, we've found something you're not that interested in!