The medical model and the diagnosis of illness

When a patient’s physical health is compromised, their GP is expected to prescribe, depending on the nature of the medical condition, a course of treatment that may involve such as analgesic, anti-inflammatory or antibiotic medication. For a patient whose mental well-being is compromised, their GP is expected to prescribe, depending on the nature of the mental health problem, a course of treatment that may involve such as tranquillisers, anti-depressants or anti-psychotics. In each case the GP is required to make a diagnosis, that is, the GP is required to identify the nature of the (mental) health problem and to assess its severity, in order to determine which course of treatment might be most appropriate (effective, affordable, fashionable), and in particular which medication to prescribe and how much of it the patient should take (dosage). In order to arrive at an accurate diagnosis, the GP needs:

1. some grasp of the range of mental health diagnoses;

2. some mechanism by which to distinguish between mental health diagnoses.

From this it follows that the GP must have an idea about what does and what does not constitute a mental health problem for a patient.

In order to arrive at a diagnosis, the kinds of factors that a GP may take into account include the mental health history of the patient (and maybe the mental health history of the patient’s genetic relatives); persistence over time of specific features (whilst one night of poor quality sleep is unlikely to be accorded much significance, a month of poor quality sleep may be accorded greater significance); proximity in time to past events (and/or their anniversaries), such as childbirth, trauma, bereavement, divorce; proximity in time to anticipated forthcoming events (examinations, major surgery, childbirth); the patient’s physical health, including diagnosis of conditions such as cancer, multiple sclerosis or Alzheimer’s disease; a description of the patient’s actions and behaviours (e.g. involuntary behaviours, such as tics, hyperventilating, poor quality sleep; voluntary behaviours, such as repeated washing, self-mutilation, making no effort to keep up appearances); the patient’s moods, feelings, styles of thought (e.g. morbid, paranoid), and attitudes to life and their own death (in particular, suicidal ideation).

However, there are several problems associated with gathering evidence in this way. Only after conclusions have been drawn and a diagnosis made does it becomes clear what information is relevant to the diagnosis and can therefore be considered as evidence. The relevance of any specific reported symptom regarding the patient ought to remain provisional until diagnosis. For example, were the patient to report symptoms of loss of appetite and weight loss, these symptoms would be considered highly relevant for a diagnosis of anorexia nervosa, of possible significance for a diagnosis of depression, and of little significance for a diagnosis of obsessive-compulsive disorder. As a consequence, the GP needs to collect as much information as possible in the hope that sufficient evidence will have been gathered to make a diagnosis. However, GPs do not have limitless time, and it may not be easy to determine when enough evidence, sufficient to make a diagnosis, has been gathered. In their haste, a GP may well formulate early a provisional diagnosis, subsequently seeking evidence to support the diagnosis and not listening to the warning bells of contradictions. The hapless patient, as much in the dark as the GP regarding what is relevant to an accurate diagnosis, could with ease occupy many a consultation with material that contributes nothing to an accurate diagnosis. In contrast, the guileful patient may know precisely what information to feed the GP in order to achieve a desired diagnosis.

Having gathered from the patient as much information as time allows, including the patient’s reported symptoms, the GP, supported by a directory of descriptions of mental health problems, attempts to match the evidence about the patient to evidence typical of this or that mental health problem. A poor match with a proposed diagnosis, with few features in common, accompanied by features that would tend to contradict the diagnosis (for example, were the patient to report that they regularly and frequently enjoy engaging in lively and outgoing socialising, a diagnosis of depression would be hard to sustain), is likely to rule out that diagnosis. On the other hand, a good match between the evidence and the directory description will inevitably make that diagnosis more likely. The more patient evidence there is that conforms to the evidence stated in the directory about the mental health problem, the more confidently the GP will be able to assert the diagnosis.

Having arrived at a diagnosis, the GP is in a position to determine whether the patient’s problems can be relieved by treatment. Patients whose problems are diagnosed as untreatable are considered to have a personality disorder. Patients whose problems are diagnosed as attributable to what are considered to be transient emotional circumstances (e.g. bereavement, house move, divorce) may be offered medication and/or counselling in order to alleviate the symptoms. Patients diagnosed with a treatable mental health problem may be offered psychotherapy and/or more likely medication to alleviate the symptoms.

It is easy to think of medication as a cure. After all, if I take an analgesic when I have a headache, the headache is likely to be ‘cured’. If, however, my headache is caused by meningitis or by a brain tumour it is unlikely that the headache will be relieved by an analgesic: I require treatment not of the symptom but of the cause of the symptom. A headache is a typical symptom of a wide variety of circumstances, occasionally serious, but usually trivial. In relieving the headache, the analgesic appears to have offered a cure to the problem. Antibiotics are intended to offer a cure to the problem of infection, ironically making us feel worse for the duration of the treatment. Vaccines offer the promise of inoculation against this or that medical condition, although often prompting ‘flu-like symptoms for a few days after the injection. Cough medicines are confusing because they come in two varieties: those that offer symptom relief by suppressing the cough, and expectorants that make the cough worse. However, neither variety of cough medicine primarily addresses the root cause of the cough (such as an infection) nor how my body came to be affected in the first place. Little, if any, medication for mental health problems addresses the root cause of the problem, instead the medication relieves key symptoms: tranquillisers calm, anti-depressants lift, anti-psychotics help people with a diagnosis of schizophrenia to be aware of the world outside of themselves. Remove the medication and the symptoms return.

It may seem puzzling that the GP should go to the trouble of establishing a mental health diagnosis, only to prescribe a medication that does not effect a cure, but merely alleviates key symptoms. The reason for this, however, is not hard to find, but may not be easy to accept: mental health problem / mental health issue are modern, politically-correct terms, that mask or at least point to past terms such as mental illness, psychiatric illness and madness. (Associated informal terms include: got a screw loose, round the twist, batty, loopy, wacko, gaga, mental breakdown.) Patients experiencing difficult symptoms to do with their mental health are considered to be unwell, ill, sick. From a scientific perspective, if a patient is sick then it should be possible not merely to describe the patient’s symptoms, but also to define the illness. Whilst it is tempting to think of ‘mental illness’ as analogous to physical illness, it is necessary only to read the directories of diagnostic criteria for mental health problems to recognise that most diagnoses are little more than sophistications of a cluster of symptoms. For instance, a patient is diagnosed as having a depressive illness if they report experiencing at least half the symptoms from a list of symptoms associated with depressive illness. However, does the cluster of symptoms constitute a specific illness? The concept of this uncertainty is familiar through the term ‘syndrome’, as in Gulf War syndrome. Thanks to the medical model, we have come to expect the root cause of mental health symptoms to be an illness. In general, if there is a term for something we expect the term to refer to some specific thing (such as a tree, a wombat, a perfume) or some quality (such as green, snugly, rancid), and consequently that things become something about which we can agree. With mental health issues, no such easy agreement exists because it is hard to show that mental health symptoms are due to an illness. Low mood, loss of self-esteem, insomnia and lethargy are a typical cluster of symptoms, but do not prove that there is an illness named depression. For example, a bereavement counsellor is likely to consider a client’s feelings of low mood to be a healthy response to a significant loss. A workplace counsellor is likely to consider a client’s heightened anxiety to be a healthy response to being bullied at work. A pastor might consider a parishioner’s increased use of alcohol to be a coping response to loss of meaning and spiritual direction in life. A shaman might consider the failure of villager to eat and thrive to involve that villager living their life out of balance.

In a re-assertion of the pre-eminence of the scientific medical model, the medical world has employed neuroscience to ‘prove’ that this or that chemical or neurotransmitter is or is not present in correct or incorrect concentrations (“My GP put me on Prozac, which is a selective serotonin reuptake inhibitor, because she says that my serotonin levels are too low and that’s why I feel depressed all the time.”) Science is not employed to establish the cause of the drop in the patient’s serotonin levels. The assumption is made that by restoring the patient’s serotonin levels the patient will feel better (treating the symptom) but nothing is done to ensure that when the medication is withdrawn from the patient, the restored levels of serotonin will be retained: nothing is done is because the ‘cause’ of the so-called illness cannot be scientifically established.

Much of the problem lies within the workings of the medical model itself. Working rationally within the scientific framework of the medical model, and being people who specialise in issues of health, medical people inevitably believe their responses to be superior to most, perhaps all, other responses to issues of health, including mental health. Further, the medical establishment also supports (and has become dependent upon) the trans-national pharmaceutical industry, one of the most lucrative economic sectors in the world, with its substantial vested interest in the prescription of medication, and therefore in diagnoses to which its products are treatments. The unwillingness of medical people to accord due validity to the necessarily subjective phenomenological experience of the person whose mental health is compromised exposes the assertions of medical people to critique and criticism from a variety of sources: patients, patients’ carers, and therapists from a plethora of both older and more newly-established welfare, pastoral, and counselling / psychotherapeutic models. This is not to dismiss medical thought, but rather to recognise that the medical voice is one voice among several deserving attention. Neither is it sufficient to suggest that the patient’s voice is the only voice that need be listened to:

1. Were the patient able to resolve their mental health problem without some fresh understanding/ intervention they are likely already to have resolved the problem. (This is not the same as suggesting that clients may lack the resources to resolve their own issues, for a client may have the resources but require skilful help to access those resources.)

2. A patient’s experience of their mental health problem might differ substantially from the experience of the patient’s carers. For example, it might seem obvious to the patient that their carer is attempting to poison the patient, whereas the carer is, in fact, offering the patient unwavering love and support; or a patient who is multiple may have no knowledge of ‘alter’ behaviours that are violent, self-destructive or highly sexualised.

In summary, the medical model:

1. existing within a scientific framework, places emphasis on diagnosis;

2. views the symptoms associated with compromised mental health as due to illness, whereas many mental health diagnoses are little more than descriptions of symptoms;

3. tends to view patients as an information resource for diagnosis of mental health issues, and regarding response to treatment;

4. places emphasis on the use of medication to alleviate symptoms associated with mental health problems;

5. tends to holds itself as the most (or only) valid perspective when considering mental health issues;

6. is only one voice among several: there are other ways of considering mental health issues that may offer a patient / client greater value than the medical model.

End of section 1.

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Peter Hughes: introduction

p.g.h@btinternet.com

This document in all parts is copyright © Peter Hughes from the date of construction given above. Please feel free to make use of them for solely personal purposes. However, should you wish to use them for teaching, training, commercial or other purposes, you are required to ask me first.