Blurring The Boundary Between Mental and Physical.

Welcome to 2003 everyone. Over the past year, you may have followed the political debates concerning mental health parity in the USA. Mental health parity is the idea that mental disorders should be treated with the same level of respect (and insurance coverage) as are physical disorders. Though progress has been made in this debate (with President Bush making public his support for parity legislation), we've yet to see any real action or reform take place. On this front, (in the words of Counting Crows singer Adam Duritz), "Maybe this year will be better than the last".

The reason that the parity debate exists at all is because our institutions (governmental, legal, medical, insurance/financial, etc.) are and have been (for hundreds of years!) invested in the idea that mental disorders (such as depression, psychosis, and anorexia) are somehow fundamentally different (less real, more the fault of the victim/patient, and less deserving of support) than physical disorders. Though we know today that this view (that mental disorders are different and/or inferior to physical disorders) is false, the legacy of these older prejudiced beliefs still rules:

  • Within any given health insurance plan, the coverage for mental disorders is inferior to that provided for physical health concerns.
  • Many health insurance providers don't even underwrite their own mental health coverage, but rather 'carve it out' (sub-contract it) to other specialized companies.
  • Mental and physical disorders are actually diagnosed using separate diagnostic books. In no other field of medicine (that I'm aware of) is this done! Mental disorders are diagnosed using the "Diagnostic and Statistical Manual of Mental Disorders (the DSM)", and physical disorders are diagnosed using the "International Statistical Classification of Diseases and Related Health Problems (the ICD)". Last I understood, the DSM is also considered a 'carve-out' of the ICD in that the DSM (published separately) is considered a code-compatible sub-section of the larger ICD which covers physical disorders.
  • While there is stigma involved with all illness, you get stigmatized (discriminated against) by employers and society at large more when you have a mental illness as compared to when you have a physical illness. No one thinks less of you for consulting a physician for diabetes, but they generally will if you consult a psychiatrist for depression.

Where did this division between mental and physical disorders come from anyway? How did we get saddled with this schism? I can't say for sure, but a few ideas I've picked up over the years may perhaps help make some sense out of the situation.

First, we've got to keep in mind that the same culture that brought us the difference between mental and physical disorders, also came up with a similar, more fundamental idea; the division between mind and body. Popularized by the major world religions several thousand years ago, and then by the philosopher Rene Descartes several hundred years ago (He of, "I think, therefore I am" fame), the mind-body split has to do with the idea that the conscious part of a person (their soul, or mind) is completely different than the physical part of a person (their body). While the body grows old and dies, the soul never ages, and persists beyond the death of the body (either going to heaven/hell, or to be reborn into another body). In the context of the mind-body split, the mental-physical disease split and the stigma surrounding mental disease makes perfect sense. Since the body and the soul/mind are seen as fundamentally different things, one can become diseased without the other being affected. The "you" that counts is your soul/mind. Your body is just a vessel that gets you from birth to death; here to there. If your body becomes diseased, well - it's just your body - it's not that important in the scheme of things. However, if your mind/soul becomes diseased, that is scary because that is the 'permanent' part of you.

Second, we've got to keep in mind that early doctors were pretty unsophisticated by modern standards. They had only gross tools; no microscopes, MRIs or vast array of psychoactive medicines. They had very mistaken ideas about how the body worked (for instance, thinking that the (physical organ) heart was a source of emotion and thought). Physical disease was relatively easy for them to visualize (being in the form of tumors, wounds, irritations), whereas 'mental' disease (which today we know has very subtle genetic/biological origins in brain tissue at the cellular level) could not be visualized at all. Treating the causes of physical illness (tumors, wounds, irritations) proved effective in getting rid of the physical disease. Mental diseases (on the other hand), did not have any clear causes or things that could be treated and so were often attributed to non-physical causes (demon possession, punishment by God, moral weakness, etc.) probably because that was part of how the larger (European) culture made sense out of the world. Knowing this, you can guess that it would be easy for the medical establishment to separately categorize physical disorders (where there is something obviously wrong to treat) and mental disorders (where there doesn't appear to be anything physically wrong). Once this distinction was in the culture it would be (and has proven) hard to dislodge.

Today, we know that the classical distinction between physical and mental disorder is mostly inaccurate; a problematic medieval hangover we've had trouble shaking off. Advances in our scientific understanding now make indisputable the strong genetic, neurochemical and biologically driven bases of many 'mental' disorders. We know much of the architecture of the brain and a fair amount about how it operates. We know the physical mechanics of mood and thought now to the point where we can directly manipulate moods through medication. Through the use of fMRI and PET scan techniques we can watch areas of the brain light up differently when someone is in a manic vs. normal, vs. depressed state, and we can measure the brain volume loss involved in (negative symptom) schizophrenia. We also know that memory is a physical brain process (We can, for instance) remove a specific part of the brain and cause someone to never form a new memory ever again (a condition known as anteriograde amnesia)). In other words we can now visualize and 'fix' the mental disorders, and in so doing, reclaim them as physical in nature. Even though the science of all this is tight, the ramifications of this knowledge have yet to really trickle into the culture and effect people where they live. The case-in-point is the failure of our country to have yet enacted mental health parity laws insuring that mental disorders are accorded the same protections as are physical disorders.

Mental health advocacy groups supporting parity legislation like NAMI argue that many mental disorders are 'brain-based' disorders (physical diseases of the brain and nervous system) and should on that basis be provided parity with other physical disorders. NAMI isn't wrong in taking this sort of position, but I'm not sure that the direction their rhetoric points is fully a good one either. There is good science available to support the biological and genetic bases of many 'mental' disorders. Parity is a good idea which needs to be enacted. But if mental disorders are really (only?) 'stealth' physical disorders (as NAMI seems to argue), then several questions remain (at least in my mind): "Is there any further utility to the concept of mental disorder? (Should we throw the concept of 'mental disorder' out on the trash heap of history?)", " Is there a mental component to mental disorders? (and if there is, does the existence of that mental component invalidate arguments for parity?)". "Is it possible that there might even be mental components to the physical disorders?"

Is the concept of 'mental' disorder irrelevant?

If we now know that many diseases that were thought to be the result of demon possession and moral weakness are actually firmly rooted in the physical (genetic inheritance, brain chemicals, etc.) does that mean that the concept of mental disease is now irrelevant? I don't think so.

At one level it is indisputably true that most all (mental) disorders fundamentally involve physical (brain, neurochemical) processes. Still - it is probably a good thing to discriminate between mental disorders that are the products of obvious 'gross' wrong wiring of neural circuitry, or an over- or undersupply of brain chemicals and those where the malfunction is not based directly on faulty brain hardware.

Most of us are familiar with the basics of how computers work. We know that for a computer to work properly both the physical hardware and the 'mental' software parts must be present. If either hardware or software component gets out of order you know you are likely to find yourself with a broken computer. Just as computer disorders can be caused by either software or hardware problems, mental disorders can be similarly thought of as caused by some combination of 'hardware' (physical) and 'software' (mental) malfunctions.

Schizophrenia is very much a 'hardware' disorder (having to do with a genetically inherited difficulty with certain brain chemicals). Posttraumatic Stress, and Borderline personality disorder are probably examples of more of a 'software' disorder than not, but definitely do involve biologically based personality temperaments, and (in many cases) involve permanent neurochemical brain changes secondary to being exposed to extreme environments (abuse, rape, war, etc.). If you do a brain scan on a schizophrenic you might see the disorder (in terms of less brain volume or a particular type of problematic brain activation - then again you might not find much of anything). If you do the same scan on the personality disordered person's brain you will almost certainly not see anything 'imperfect' in terms of physical structure - even though these two may have a roughly equally difficult time navigating through life.

There is no definitive physical problem in the personality disordered or post traumatized person's brain - rather they have a 'mental' problem - in the form of their memories and how those memories and experiences add up to a map of the world and their place in it, and how 'accurate' that map of the world is in relation to the actual stuff happening in the world. There likely isn't anything wrong with the memory process itself but the relationship of these memories to how the world is shaped adds up to trouble for the individuals possessing the memories. I'm not disrespecting PTSD or BPD by saying this - these are very real, very troubling disorders. They just aren't necessarily about broken physical brain structures. This last example is my attempt at a way to hold on to a meaningful definition of 'mental' disorder that makes sense during a time when every disorder is wanting to be seen in a purely physical light.

To take the point farther, if we can agree that there are both 'hardware' and 'software' aspects to our mental disorders - then might we also admit that there are mental aspects to many problems that are traditionally seen as physical? Heart disease is a great example. If you look at heart disease in purely physical terms you will see nothing less and nothing more than tissue damage. But what about the lifestyle that (often) leads to the development of heart disease? Is that not the 'mental' or software part of this very pervasive physical problem? Many health professionals will recognize that it is indeed just that. Still - the culture at large doesn't seem to be quite ready to think thoughts like, "Gee, I'd have to be mentally ill to eat at (insert name of fast food joint here)".

The Psychiatric diagnostic system described by the DSM and in wide use within the mental health field is sophisticated in this way because it forces the doctor to make five separate diagnosis judgments across five different categories (including mental, and physical and social dimensions of life). I don't have any idea if straight medical doctors are taught to diagnose in this manner, but they should be if they aren't now.

As far as I can tell, most all disorders have both mental and 'medical' or biological aspects with different disorders coming out weighting heavier on one side or the other of the spectrum. Many 'mental' diseases have very real and treatable physical components that go under-recognized. Also, many physical diseases have very real and treatable 'mental' components that go under-recognized or at least which are less-than-fully appreciated.

In rejecting the 'mentalness' of mental disorders, and arguing that mental disorders are physical disorders, NAMI's position seems to accept that the basic division between mental and physical disorders is real and that it is better to be a physical disorder than a mental one. And from a political analysis NAMI's position makes total sense: They want measurable, enforceable reform that will help them care for their families. They want mental health parity. They are confronted by two accepted categories of illness (the mental and the physical) which they cannot undermine. In gaining the results they want, it is far more expedient for them to try to get mental disorders legally 'reclassified' as physical ones (or to get the laws governing discrimination between mental and physical categories changed) than to try to undermine the reality of those categories. All I can really say is, "Go Team NAMI!". I hope that parity (and similar reforms) will appear soon.

Beyond the positive political aspects to the NAMI position, however, I think it is important to see the other issue here as one which has to do with whether or not the accepted categories (physical, mental) make good sense in the first place. For myself, I'm not so sure that the boundaries between mental and physical causes should be drawn so boldly in the first place.

What do you think?