A Social Perspective in Research and Practice

To the Editor: The thoughtful and important piece by Carl I. Cohen, M.D. (1), in the January 2000 issue articulates what many of us have urged for years: a broad-based biopsychosocial view of psychiatric illness. The author rightly emphasizes the social perspective as one that enriches and complements the biomedical model.

However, Dr. Cohen's claim that "diagnoses in psychiatry are starkly different from diagnoses in physical medicine" is just the sort of statement some health maintenance organizations will seize on in order to extrude psychiatry from the realm of general medicine and to discriminate against both psychiatric patients and their clinicians. Furthermore, despite Dr. Cohen's evident distaste for Cartesian thinking, his statement erects a conceptual wall between psychiatric and physical illness, which is both a tactical and a philosophical error. Indeed, the difference between psychiatric diagnosis and diagnosis in other areas of medicine is far less stark than Dr. Cohen's analysis suggests (2).

Temporal lobe epilepsy is a good example. Contrary to a misconception prevalent even among physicians, the diagnosis of epilepsy is not based primarily on abnormal electroencephalogram (EEG) findings, pathology identified by magnetic resonance imaging, and related physical evidence. As Tucker and McDavid (3) remind us, "The diagnosis of epilepsy is basically a clinical one, much as is the diagnosis of schizophrenia… while the EEG can confirm the diagnosis, it cannot exclude it." Indeed, 20 percent of patients with epilepsy will have normal EEGs, and 2 percent of patients without epilepsy will have spike and wave formations.

Neurologists diagnose epilepsy in essentially the same way psychiatrists diagnose schizophrenia or bipolar disorder: by taking a careful history, consulting with family and other observers, and observing the communications and behaviors of the patient. The same is largely true in the diagnosis of migraine (2). Even current Centers for Disease Control and Prevention criteria for chronic fatigue syndrome rely in part on the communications and behaviors of the patient, insofar as they include the patient's levels of occupational, educational, social, or personal activities.

Although the relationship between mind and brain (4,5) is clearly too complex to delve into here, I see no philosophical problems in the position that while so-called mental illnesses are indeed brain diseases, the brain is uniquely an organ that receives constant social and cultural input, both in health and in disease. Dr. Cohen eloquently reminds us that we should pay appropriate attention to the psychosocial dimensions of psychiatric illness. But we must also acknowledge that many of the most impressive therapeutic gains in the last century have come about through application of the biomedical model to schizophrenia and the major mood disorders.

In the end, the utility of the social perspective will be measured not by appeals to "postmodern" theorizing (1), but by empirical studies demonstrating that the social perspective helps our patients. As Maimonides has taught us: "The physician does not cure a disease; he cures a diseased person."