Disease is necessarily a “historical” concept; that is, any disease represents an imagined sequence of events. Signs and symptoms are the objectively observable manifestations of an inferred process. One class of events is made up of those events that are termed etiologic. Etiologic events are those that are necessary and those that are sufficient to initiate the inferred disease process. The relations among etiologic events are quite complicated. Here’s the first part of the seven-part erudite research by Prof. Ashoka, a renowned Psychiatrist, in the regular column. A Different Truths exclusive.
What is a disease? I commend to you an answer to that question I once received from a student who somewhat hesitantly said to me, “There is no such thing as a disease.” The important word is “thing.”
Too often in medicine, we reify diseases, whether tuberculosis, infantile paralysis, or schizophrenia as if they were tangible entities to be finally discovered and directly observed someday. I probably do not need to remind you that as physicians we observe only signs and symptoms and only particular instances of these. The disease itself any disease, I am not just talking about the psychiatric disease, is a concept, some ideal type we have in our minds (as physicians, we too are deeply involved with symbolisation). We refer to this symbolic representation or ideal type whenever we encounter a particular instance to see to what extent instance and concept match. Some investigators (Charcot, for example, in studying hysteria), confusing concept and instance, recommend studying the most extreme forms of a disease, as if the exaggeration of clinical features will reveal the “true” disease to us.
Disease is necessarily a “historical” concept; that is, any disease represents an imagined sequence of events. Signs and symptoms are the objectively observable manifestations of an inferred process. (Do you think it would be correct to say that signs are interpreted by us to signify that a particular kind of event or moment in a sequence has occurred or is occurring, while symptoms are the patient’s symbolic representations of his conception of what has occurred or is occurring?) One class of events is made up of those events that are termed etiologic. Etiologic events are those that are necessary and those that are sufficient to initiate the inferred disease process. The relations among etiologic events are quite complicated. A necessary event may occur without initiating the disease process if other events that must occur with it or in some relation to it—perhaps even in a certain order—for such initiation to take place are absent. Events that are sufficient in the presence of a necessary event to initiate the disease process may in the absence of the necessary event have no such effect. Certainly, in part because of the way we think, we find that we conceive etiologic events to be located someplace—in the situation of the system or in a part or parts of the system itself. For example, as far as the personality system itself is concerned, an etiologic event may occur in its situation. That is, it may occur in the physiological behavioural organism, a system of physicochemical entities which conceptually must be regarded as outside of or an aspect of the situation of the personality system. The etiologic event may also occur in the physical or social environment of the personality system. On the other hand, an etiologic event may be thought to arise in a part or parts of the system itself. So, in the personality system, motivational dispositions or tendencies (or, more properly, the symbolisation of such dispositions or tendencies), or a combination of kinds of dispositions or tendencies (again, more properly, a combination of kinds of symbolisations), occur that are held to be necessary, sufficient, or both, to initiate dysfunctional consequences for the personality system.
Etiologic events occurring in the situation of the system initiate a dysfunctional or disease process by altering the availability of means, resources, or capacities required by the system if functions are to be performed, ends achieved, or goals attained. Etiologic events occurring in a part or parts of the system initiate a dysfunctional or disease process by altering internal arrangements between parts of the system required by the system if functions are to be performed, ends achieved, or goals attained.
I remind you now that such distinctions between systems and between a system and its situation are theoretical and the location of events according to such a schema, while no doubt heuristic and perhaps the only way we can think about these matters, is also theoretical. I beg you not to ask me if personality systems and physiological behavioral organisms are “really” distinct, existent entities—I never expect to see either one, any more than I expect to see a disease—or whether an etiologic event actually occurs in a personality system or in a physiological behavioural organism. Although an organism probably seems real to you and a personality system fictive, I assure you that both are abstractions and neither is a thing or a place.
It is important to remember that when the focus is on the personality system and, therefore, upon symbolic processes an etiologic event may be the occurrence of a symbolic representation and not an actual event.
Piaget has stated that the purposive, compensating activities of a psychological system are, frequently, a response to virtual intrusions rather than actual intrusions. That is, because man symbolises, he anticipates future states of affairs; he is able to imagine the possibility of inimical states of affairs; he responds to his symbolic representations of such states of affairs with purposive activities meant to compensate for such disturbances in advance of their actual occurrence. Since man is above all a symbolizing animal, such symbolized or virtual intrusions and the compensatory activities in response to them, which may have significant dysfunctional consequences, constitute an important kind of disease process.
A radical view of psychological disease or mental illness is that the etiologic event is always symbolic: symbolizations, anticipated or virtual intrusions, pathogenic phantasies, psychic reality. The human misery that is simply that is, with no significant dependence upon symbolic mediation—a coerced response to actual environmental or organic intrusion would not be regarded as a psychological or mental illness. Such a view follows from the effort to remain consistently within the conceptual framework of the personality system. Since, however, human behaviour is almost always to some extent symbolically determined, one probably must conceive a continuum involving varying proportions of symbolic and non-symbolic etiologic events. Our interest, insofar as we examine human behaviour from the point of view of the personality system, is concentrated upon the symbolically dominated end of that continuum.
A second class of events in the disease process is made up of the altered states of the system said to be diseased. These events are thought to follow, to be responses to, etiologic events. As suggested by the previous discussion, these altered states are dysfunctional. They are states of malintegration or states of maladaptation or (usually) both. That is, they are states in which the arrangements or relations between parts of the system have departed from some optimal state, or states in which the relation of the system and its environment has departed from some optimal state, or (usually) both. One may further distinguish, on the one hand, responses to the etiologic event that represent departures from optimal states perhaps one such departure in a system of interdependent entities leading to still another kind or degree of departure from the optimal and that to still another. On the other hand, some responses represent tendencies in the system to return to an optimal state. The aim is reparative or restitutional. Though the actual as distinct from the intended consequences of the action of such a tendency may be either functional or dysfunctional. In this connection, I remind you of the reparative scarring tendency set into motion by a wound that nevertheless may result in the dysfunctional keloid.
A third class of events includes the system’s response to the responses, sometimes inimical, of others (some of these others are physicians) to the diseased state. The system’s response to such interventions by others may again, be a further or different kind of departure from an optimal state or a compensatory effort to prevent such a departure; that effort also may have functional or dysfunctional consequences.
A fourth class of events includes the more or less permanent end-states of the disease process conceived to be possible, likely, or inevitable, along with some notion of the kind of events that are thought to influence the possibility, likelihood, or inevitability of various end-states. To understand a disease, then, is to have a concept of a process or sequence of events and a theory with verifiable implications that correlates particular signs and symptoms with particular classes of inferred events. A transient sign or symptom is ordinarily not considered a manifestation of disease unless the inference is made, and verifiable, that such a sign or symptom has significance in terms of a sequence of events, a disease process in time, however long or short. One may make the inference that a disease continues silently, exists in latent form, or is in remission during periods free of signs or symptoms. Different conceptions of a particular mental illness (for example, schizophrenia) may attribute different meanings to a given sign or symptom with respect to the inferred disease process. Thus, a particular sign or symptom may be regarded by different investigators as evidence, for example, of the destructive effects of an etiologic event, an effort at compensation or repair by the affected system, or an end-state.
Incidentally, you will recognise that the concept of the disease involves an equilibrium model. It is hard to think about any aspect of man without recourse to such a model. In varying forms, it is central, for example, in psychoanalytic theory, Parsons’ theory of action. Cannon’s formulations about homeostasis, and Bertalanffy’s general system theory.
(To be continued)
Prof. Ashoka Jahnavi Prasad
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