Heroes Not Zombies

The dominant concept of disease is still a lesional one. The first task for a doctor is to diagnose. This should mean “to understand” or “to explain” but the way doctors are educated and trained gives priority to pathology ie to disease within cells, tissues or organs. Almost all the technologies used to “diagnose” aim to illuminate and/or identify a physical lesion. So, when you present to your doctor with some disturbing symptoms, he or she will set off on a hunt for the physical lesion. If they find a pathology, they will use their knowledge and experience to settle upon a conclusion that your symptoms are the manifestation of that pathology. Treatments offered will be chosen according to this understanding. The intention of the treatment is to either remove the pathology or to act against the symptoms which the pathology is assumed to be producing.

But what happens if there is no physical lesion? If the “diagnosis” from either the story and the physical examination, or from the “normal” findings produced by the investigative instruments, excludes (or, more realistically, fails to identify) any pathology, any physical lesion? Well, the default is to say the problem lies in the mind. In other words, there are two options – either a physical cause, or a psychological/psychiatric one.

This model is creaking at the seams. Increasingly we are demonstrating how diseases do not fall into one of those two neat compartments. The symptoms experienced, and the sense a patient makes of those symptoms, usually involves both the body and the mind.

If you’ve ever had pain which lasts for some time, you’ll know how that affects every aspect of your life. If part of your body doesn’t work because of damage to nerve fibres, then living with the resulting paralysis affects every aspect of your life. The simplistic view is that if the physical cause is treated the psychological distress will just go away. Life actually isn’t that simple!

The other direction is explored through psychosomatic medicine – the physical manifestion of the diseases of the mind. If you are anxious, or depressed, then your physical body is affected – breathlessness, pain, diarrhoea, palpitations etc etc.

As we improve our understanding of human beings, we discover that this old “cartesian” model is not as helpful as we used to think. Problems which have a focus in the body affect the mind and vice versa. In fact the body and the mind are so intricately interconnected that it would be rare for a problem to be so isolated into one of our “compartments”!

I’ve written before about some of the interesting work on the links between symptoms and diseases – see the posts about Meaning-full Disease and Why Do People Get Ill?

It’s also true that as human beings are intensely social beings, that sometimes the problem lies not within a single being but within a relationship, a family, or a community – see the work of Eric Cassell who has illuminated a lot of this by focusing on the patient’s “suffering”; and the work of Wilkinson on inequality.

However, let me postulate another explanation – maybe sometimes the problem lies in the “system”. Thanks to the explanatory model of the complex adaptive system, we now see that an organism can dysfunction, not because single parts of it have gone wrong but because the way everything works together has become damaged or disordered. This is still a new idea in medicine. There aren’t any scientific tests to help us “diagnose” such a problem. But look at all those chronic disorders where no lesions are found and there is really not a reasonable psychological explanation either. The fact that many people are ill without lesions and without psychological disorders shows us that there is something else going on which we have so far failed to grasp. This should undermine those who make psychological diagnoses in everyone who has normal “tests”! It’s intensely frustrating for an ill person to not be taken seriously or to be told that something is “all in your head”.