Monday, 4 January 2016

Unpacking the "illnessy intuition"

Last summer I wrote a post examining why, in the face of fairly wide dissatisfaction, the concept of schizophrenia seems to show such tenacity. As part of that argument I invoked the idea of an intuition that people have about schizophrenia; namely that it seems there is often something "illnessy" there:

"There is a way in which the diagnosis is very convincing; on the face of it many people who meet criteria for schizophrenia seem to be seriously unwell and many of them will testify to that fact.
...even with skepticism about the DSM construct [of schizophrenia], many people's intuitions are that there is something illnessy about the experiences which commonly attract the diagnosis."

At the time, someone rightly pointed out that this is a weak point in the inferential chain.

To some extent this does not matter, as my post was not an attempt to justify the continued "success" of the schizophrenia concept, but rather to explain it. Thus, I do not need to show that the "illnessy intuition" is scientifically valid, only that it has a hold on people's imaginations. However, if you detected a note of endorsement in my post, that is because it was there. I do not really believe in the notion of schizophrenia as illness, but unlike some critics, I do not think it is warranted to conclude that no-one who meets the diagnostic criteria is ill. In some cases the illnessy intuition is valid. Here's how.

Defining illness is slippery, and I am not going to get into philosophical debates here about how to arrive at a definition. For my purposes I don't need to. Some phenomena are so widely agreed to be illnesses that to describe them in any other way seems redundant. I could argue, for example, that leukemia is not an illness, but generally we accept it is because that framework has remained the most useful game in town.

The same appears to be true of some of the phenomena which can give rise to a diagnosis of schizophrenia. It has recently been suggested that some proportion of individuals with "schizophrenia" may actually have a form of NMDA-receptor encephalitis, a brain disorder which is treatable. If these people are not considered ill then two harms arise; they are denied effective medical treatment, and they are denied an adequate narrative account of their distress.

It is this fact that gives rise to the "illnessy intuition" in the case of schizophrenia, and for two reasons. The first is that some unknown (and possibly quite high) percentage of cases clearly arises from biological states of affairs which it will prove useful to describe as illnesses. Think not only of NMDA receptor encephalitis, but also of the conditions, and pharmacological treatments, which are yet to be discovered. The second is a sort of reasoning by analogy. If the set of symptoms associated with schizophrenia can be produced by an illness then it stands to reason that even cases which are not produced by the same phenomena might reasonably be construed as illness, pending a fuller explanation.

None of this speaks against the project of providing alternative non-medical narratives for understanding the suffering associated with psychosis. As I said in the original post, we don't yet know how (or if) all cases of schizophrenia will wind up being explained. 

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