A Social Perspective in Research and Practice

In Reply: I appreciate Dr. Pies' corrective to my paper that the division between psychiatric and medical diagnoses is not as stark as I may have implied. However, if that is true, I believe it is not because psychiatric diagnoses are more biological, but rather because medical diagnoses are more socially based than is commonly acknowledged.

Both medical and psychiatric diagnoses are actually hybrid diagnoses. They include social and biological categories. Thus, the biological underpinnings of medical diagnoses are likewise based on various social and political conventions about what constitutes physical abnormalities, techniques for determining such abnormalities, and so forth. Western culture generally reclassifies hybrid categories into physical or social categories (1). Although mainstream psychiatry has been trying to move psychiatric disorders into the physical realm, it is hampered by the fact that mental categories are less amenable to this shift than are medical categories.

Although I agree with Dr. Pies that our methods of diagnosing mental disorders do not diverge appreciably from those of our medical colleagues in diagnosing medical conditions, it is the differences in their basic categories—mental and physical—that distinguish the two fields. Although we may sometimes treat the symptoms of medical disorders, there is always an assumption that there must be an underlying biological (structural or physiological) abnormality. This assumption holds even if our probes do not reveal the disorder.

On the other hand, the diagnosis of mental disorders is based on abnormal mental symptoms. As I described in my paper, mental symptoms are social concepts; that is, they are historically and contextually bound. If we wish to base psychiatric diagnoses on nonmental categories, we must find biological mechanisms by which to make such diagnoses. Nevertheless, in theory, this could lead to our making diagnoses without the person manifesting the any mental symptoms.

My concern about Cartesian thinking arose because some leaders in biological psychiatry have conflated mind and brain or, at best, treated mind as simply a manifestation of brain function. I believe this in part stems from their fear that mind will be perceived as a nonmaterial, ethereal phenomenon. However, mind should be viewed as another level of material organization that cannot be reduced to brain functioning, much like chemical structures and processes cannot be reduced to the level of physics. Because mind is inherently social as well as biological, it is not necessary to construct a biological (brain) abnormality for every psychiatric disorder.

There is a critical difference between Dr. Pies' view that the brain receives social and cultural input and my view that social and biological integration takes place at the level of mind. The former implies primacy for the biological realm and is akin to believing that thought can be reduced to biological (brain) processes. In any event, some disorders may have a predominantly biological etiology whereas others may be caused primarily by social or psychological factors. As Dr. Pies notes, these questions must be resolved by empirical studies.

Finally, Dr. Pies' assertion that we must be circumspect about characterizing psychiatric diagnoses as distinct from physical diagnoses because health maintenance organizations may seize on the distinction underscores my contention that social, economic, and political factors are enmeshed in our conceptualization of mental disorders.