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Why Psychiatric Disorders Are Not the Same as Physical Diseases

Even when their causes are organic. Our minds make us who we are.

by
Theodore Dalrymple

Bio

October 6, 2012 - 12:00 am

A great deal of effort has gone into persuading the general population that psychiatric conditions are just like any others: colds, arthritis, and so forth. I have never found this convincing; psychiatric disorders, including organic ones, are precisely what it is that makes us most ourselves. No one boasts that his symptoms are of psychological origin, though any of us may suffer such symptoms.

In 1982, the neurologist and writer Oliver Sacks wrote a book A Leg to Stand On, in which he described an accident while walking in Norway. He injured the tendon of one of his thigh muscles which was repaired by operation; but afterwards he found that he could not walk because he could not move his leg. He had “forgotten” how to do so. In addition, he no longer experienced his leg as part of himself, but as a completely alien object.

In his book, he rejected the hypothesis that his paralysis was hysterical, that is to say by unconscious mental conflict. Rather he preferred to believe that his peripheral nerve and muscle injuries had somehow affected his brain, and therefore his inability to move his leg was not psychological but physical.

In the latest edition of the Journal of Neurology, Neurosurgery and Psychiatry, three neuroscientists, including a neurologist and a psychiatrist, reinterpret Sacks’ symptoms and say that they were indeed psychogenic, or what used to be called hysterical. They say that his pattern of symptoms was incompatible with a purely neurological explanation, indeed that they were typical of hysterical paralysis, though they emphasize that this does not mean in the least that they were “fake” or “imaginary.” As a 19th century doctor put it of female patients with hysterical paralyses (most patients with such paralyses were female): “She says, as all such patients do, ‘I cannot’; it looks like ‘I will not’; but it is ‘I cannot will.’’’

Sacks was given the right of reply to the authors and he sticks by his original contention that the paralysis from which he suffered was not psychological in origin. One has the impression that he does not merely disagree with this idea, but finds it uncomfortable and does not like it. Even if hysterical paralysis existed, it would be confined to others.

A third paper in the same journal by the Professor of Cognitive Neuropsychiatry at the Maudsley Hospital Anthony David has an interpretation that might not have pleased Dr Sacks:

Is it not one of the mechanisms whereby a minor injury can lead to major disability that it sows the seeds of what it might be like to be disabled and hence to be looked after, pitied, lionised? None of us is immune to this but like Sacks perhaps, most having glimpsed what life might be like on the “other side” returns with haste to the land of the healthy.

We have two attitudes to psychological vulnerability: either we assume it to an extraordinary degree to demonstrate our superior sensitivity, or we deny it altogether, believing ourselves to be completely invulnerable.

I tend to the latter; but once learned differently when I was in a distant land famed for its inefficient bureaucracy. There was a problem with my ticket home and it took days to sort out. During those days I suffered from severe and almost incapacitating backache that I did not connect to the problem with my ticket. The backache, which was severe, disappeared, however, within minutes of the problem having been sorted out. As Dr. Chasuble put it in The Importance of Being Ernest:

Charity, my dear Miss Prism, charity! None of us are perfect. I myself am peculiarly susceptible to draughts.

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Theodore Dalrymple, a physician, is a contributing editor of City Journal and the Dietrich Weismann Fellow at the Manhattan Institute. His new book is Second Opinion: A Doctor's Notes from the Inner City.
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