All Commentary
Monday, November 1, 1999

Is Mental Illness a Disease?

Only in Psychiatry Can Behavior Be Considered a Disease

“You can know the name of a bird in all the languages of the world, but when you’re finished, you’ll know absolutely nothing whatever about the bird. . . . So let’s look at the bird and see what it’s doing—that’s what counts. I learned very early the difference between knowing the name of something and knowing something.”

—Richard Feynman

Tipper Gore says that “One of the most widely believed and most damaging myths is that mental illness is not a physical disease. Nothing could be further from the truth.” Similarly, the National Alliance for the Mentally Ill (NAMI), the most influential mental health lobby in the nation, states: “Mental diseases are brain disorders.” Are these assertions true? And if they are, what are their logical and practical implications?

I say that “mental illnesses” are not diseases, despite the fact that medical and legal authorities call them “diseases,” that they are treated with drugs, that those receiving these drugs are called “patients,” and that the professionals treating them are called “physicians.” Why do I say this? Because the established scientific criterion for disease is a derangement in the structure or function of cells, tissues, and organs—a criterion mental illnesses fail to meet, as they can be neither detected nor diagnosed by examining cells, tissues, or organs.

Rather, mental illnesses are identified by certain behaviors, and what concerns Mrs. Gore, NAMI, and others is not the theoretical question of what counts as a disease, but the practical problems posed by these behaviors. In fact, whether a person who has a disease feels well or ill, accepts or denies that he is ill, consults a doctor or not, benefits from or is harmed by drugs are all issues important to the practice of medicine but not to the definition of disease. Likewise, whether a person obeys or breaks the law is irrelevant to the definition of disease. Disease is a physical concept and verifiable phenomenon. Accordingly, gastroenterologists study the abnormal states of the digestive system—not gluttony. Urologists study the abnormal states of the genito-urinary system—not prostitution. Neurologists study the abnormal states of the brain and nervous system—not murder or suicide.

What do psychiatrists study? Do they, as Nancy Andreasen, professor of psychiatry at the University of Iowa, puts it, study “the brain rather than the mind, . . . molecules and chemical transmitters rather than drives and fantasies”? Or do they, as Shakespeare put it, study the persons who suffer “the slings and arrows of outrageous fortune”? This is the crucial distinction masked by equating brain with mind. If “mental illness” means brain disease, then it is not a disease of the mind and psychiatry would be absorbed into neurology and disappear. But this is patently not the case. Psychiatrists regularly occupy themselves with personal conduct of social interest, such as homosexuality, aggression, racism, suicide, and murder.

Expanding “Disease”

It is an elementary principle of logic that one cannot prove a negative. One cannot prove the nonexistence of mental illnesses, just as one cannot prove the nonexistence of ghosts. One can only point out that a belief in mental illness as a disease of the brain is a negation of the distinction between persons as social beings and bodies as physical objects, in the same way that a belief in ghosts is the negation of the distinction between life as activity and death as the cessation of it. What happens when we negate the distinction between social beings and physical objects is that the concept of disease ceases to be limited to the dysfunction of cells, tissues, and organs and is expanded to include “dysfunctional” conduct, especially behavior people in authority find troublesome.

Interestingly, the pioneers of psychiatry understood this distinction, accepted that the scientific concept of disease was restricted to the malfunction of the body, and acknowledged that the term “mental illness” was a figure of speech. In 1845, the Viennese psychiatrist Ernst von Feuchtersleben (1806–1849) wrote: “The maladies of the spirit (Geist) . . . can be called diseases of the mind only per analogiam. They come not within the jurisdiction of the physician, but that of the teacher or clergyman, who again are called physicians of the mind only per analogiam.” And in his classic, Lectures on Clinical Psychiatry (1901), Emil Kraepelin (1856–1926)—who created the first modern classification of mental diseases—acknowledged: “It is true that, in the strictest terms, we cannot speak of the mind as becoming diseased.” In short, a sick mind, like a sick economy, is a metaphor.

Mind Is Not Brain

Treating the metaphor as the thing itself—the metaphorization of disease, in our case—has led to the confusion of production with product, person with body, and mind with brain. Note that unlike the term “brain,” the term “mind” implies agency, intentionality, and motivation. Accordingly, behavior per se that may result in disease is often categorized as a mental disease, but is never categorized as a medical disease. For example, excessive drinking is considered a mental disease, not a gastrointestinal disease—though cirrhosis of the liver is. A competent speaker of English may thus assert that schizophrenia has caused a person to kill an innocent bystander and excuse him of his deed, but he would never say that diabetes has either caused such lawless behavior or excuses it. Herein lies one of the most important philosophical-political consequences of the concept of mental illness: it removes, with one fell swoop, motivation from action, encompasses it within illness, and thus destroys the very possibility of separating disease from non-disease, since it offers the possibility that any intentionality or motivation is a potential “disease.”

In 1924, the great Eugen Bleuler (1857–1939), the inventor of schizophrenia, declared: “Those who simulate insanity with some cleverness are nearly all psychopaths and some are actually insane.” The idea that pretending to be ill is, itself, an illness became socially acceptable during World War II and has since become psychiatric dogma. Kurt Eissler (1908–1999), a world-famous psychoanalyst and psychiatrist, framed the doctrine thus: “It can be rightly claimed that malingering is always the sign of a disease.”

Behavior is not—and cannot be—a disease, except in psychiatry. Controlling behavior, with or without a person’s consent is not—and cannot be—a treatment, except in psychiatry. And faking illness is not—and cannot be—an illness, except in psychiatry.

  • Dr. Thomas Szasz (1920-2012) was a Psychiatrist, academic, and champion of individual rights. He devoted much of his life to campaigning against many aspects of conventional psychiatry, in particular involuntary psychiatric treatment and commitment.