Why Disease and Illness Are Concepts of the Body

Joanna Moncrieff, MD

The fifth in a series of blogs presenting a philosophical analysis of the modern mental health system.

In this blog I want to come back to the work of Thomas Szasz. The last two blogs argue that bodily states and processes need to be understood in a different way from the way we understand what human beings think and do. Mental ‘illness’ consists of things that people say and do. For Szasz, an ‘illness’ means a condition of the body, and hence mental illness is not an illness.

According to Szasz, the term ‘disease’ (in its proper and coherent use) refers to changes in bodily structures or mechanisms that produce unwanted physical sensations and experiences, otherwise known as ‘symptoms.’ ‘Illness,’ on this account, is the subjective experience that arises as a consequence of the presence of disease in the body.

On this view, a disease, in its core sense, is a property of the biological system known as the body. Hence, diseases can be described in material terms, and can be understood according to general biological principles that are independent of the individuals they affect. Diseases unfold in more or less predictable ways according to their biological nature. Cancer cells multiple and disseminate, eventually impinging on other cells to such an extent that the organs cease to function. Narrowing of the arteries supplying the heart leads to angina and heart attacks, known as coronary heart disease. It may be possible to influence the course of a disease by modifying one’s body and its environment, such as stopping smoking or getting treatment, but you cannot simply wish a disease away (or so it is generally believed). Biological systems, like chemical and subatomic reactions, are governed by predictable regularities that have nothing to do with the desires and purposes of human beings.

Little attention has been paid to the question of whether or not a disease is necessarily a bodily condition. This seems to be because philosophers of biology or disease who are not principally concerned with mental disorder just assume it to be the case, whereas those that focus on mental disorder usually ignore the issue. The French philosopher of biology, Georges Canguilhem, for example, states that “one can speak with reason of ‘Greek Medicine’ only from the Hippocratic period onward—that is to say from the moment when diseases came to be treated as bodily disorders.”1

Many thinkers who are concerned to encompass the realm of mental disorders within medicine implicitly suggest that the terms ‘illness’ and ‘disease’ do not need to refer to the body. They argue that what is essential to these concepts is the fact that they represent disvalued or unwanted states. Peter Sedgewick, for example, points out that there are no diseases in nature.2 Beyond their ability to cause pain and death, the consequences of physical conditions depend on social expectations and demands. Mild arthritis in the hands may be highly problematic to a violinist, but irrelevant to most of the rest of us. Industrialised societies organised around the productivity of wage labour heighten the impact of chronic conditions that reduce performance, which may be better tolerated in rural societies with more communal traditions.

Sedgewick is right to point out that whether the body functions adequately depends on its environment and the demands it has to meet, and these demands in turn depend on the conventions and expectations of a given society. Simply being a feature of the body is not enough to qualify something as a disease. There is also a value judgement involved about the consequences of that condition and the benefits of treating it, which will differ from one context to another.

But Sedgewick and others take the argument a step further and suggest that it is the disvalued nature of disease that is central to the concept, and therefore that other situations involving a negative value judgement can also be called a disease or illness. This is tantamount to saying that any unwanted situation can be considered to be a disease.

In response to this value-based definition of disease and illness, some thinkers have tried to reinstate objective criteria that can encompass mental disorders alongside bodily conditions. Arguing that physical or biological mechanisms and ‘psychological mechanisms’ can be thought of as equivalent, they extend the concept of illness to include situations, such as those we refer to as ‘mental disorders,’ that are defined by the presence of unwanted behaviours. Hence psychiatrist Robert Kendell argues that “the differences between mental and physical illnesses, striking though some of them are, are quantitative rather than qualitative, differences of emphasis rather than fundamental differences.”3

Jerome Wakefield’s much-discussed concept of ‘harmful dysfunction’ is an example of this thinking.4 Wakefield elides bodily dysfunction and psychological dysfunction by claiming that both are objective situations that can be defined by a failure to fulfill evolutionary purposes. However, just as the fact that cancer and crime are both negatively valued situations does not render them the same kind of thing, the idea that mental and physical mechanisms might both be evolved also does not confirm their equivalence. Our ability to be flexible and adaptable, in other words our free will, can be seen as an evolved phenomenon, but this doesn’t make human behaviour the same sort of thing as the structure of the eye or the dexterity of our hands.

Moreover, Wakefield’s reliance on evolutionary theory adds no value to the understanding of physical diseases, let alone the definition of mental disorder. Medicine uses mechanistic not adaptive explanations of function. We define the normal function of the heart, for example, as the level of functioning required to keep the rest of the body alive and well. There is no need to postulate natural selection or an evolutionary teleology.5 Indeed, evolutionary psychology has been the subject of extensive criticism, and its claims to objectivity have long been recognised as spurious. It is shot through with evaluative judgments about what ‘normal,’ ‘natural’ or ‘proper’ mental functions and behaviour consist of.6

By equating psychological and biological dysfunction Wakefield is ultimately suggesting, like Sedgewick, that there is no value in the distinction between an unwanted condition of the body and other problematic situations. Yet this is surely not true. It is evident that in real life we find it important to distinguish situations that arise as a consequence of a bodily state or event, and those that are manifestations of what we recognise as human behaviour; that is, activity initiated by an autonomous, self-directing individual. Consider the importance of distinguishing ‘real’ epileptic fits from ‘pseudo-seizures’, for example! We treat people who ‘fake’ fits, consciously or unconsciously, differently from people whose fits originate from abnormal electrical impulses in the brain.

Working in a drug detoxification unit this is a real, everyday problem. People who have been using large amounts of alcohol or benzodiazepines are liable to have epileptic fits during detoxification, which can be dangerous and life-threatening and need immediate treatment with benzodiazepines or other anti-epileptic agents. People with a history of addiction may also fake fits in order to obtain these substances, however. If you give people who fake fits anti-epileptic drugs, you not only expose them to unnecessary harm, you also undermine the ethos of the recovery programme for everyone in the unit.

We make an effort to distinguish these different situations because they call for a completely different understanding and response. Making the distinction matters.

Szasz did not deny, as is sometimes implied, that the concepts of disease and illness are what is referred to as normative — that is, they incorporate value judgements about what is ‘normal’. He merely observed that wanted or unwanted, bodily conditions can be described in material, biological terms: “although the desirability of physical health, as such, is an ethical norm, what health is can be stated in anatomical and physiological terms.”7 If you loosen the association between the concepts of illness and disease and the body, you empty them of their distinctive meaning. They are no longer able to pick out a particular category of unwanted situations and become synonymous with generic terms like ‘problem’ or ‘difficulty’. Divorced from the body, the words cease to have any discriminative power. They become meaningless.

In the next blog I shall address the idea that mental disorders are, in fact, diseases of the body — in particular that they are brain diseases.

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  1. szasz says————–“and hence mental illness is not an illness”..I don’t think that is proven yet…
    my problems with depression
    involved biological and psychological and social factors….and I was treated/helped in all three areas…I have a mental illness…and I pay attention to all of the above…

      • Were we to ask the questions, how much of it is biological, how much of it is psychological, and how much of it is social? We hit a brick wall. In lieu of hard evidence, we can’t say, in the main. In lieu of hard evidence which sugar cube is it that dissolves? Is it the biological, the psychological, or the social? None, either, or all? I’d say, actually, it’s all speculation. So much for that.

        • The only reason there is a bio-psycho-social model is that psychiatrists themselves have come to admit that so-called “mental illness” is not all biological. They say to hold such a view would be to take an extreme position. The problem is that we are stuck with the question of identifying a locus of concern in the psychological or social body. Psychiatrists are medical doctors, and the sphere that medicine covers is that of anatomy, that is, biology. You can’t say psychological anatomy, or social anatomy, without resorting to a metaphor, a figure of speech. If there is no physiological problem, no source in the anatomy, psychiatrists become redundant, so they can’t go there, as a rule, and thus, bio-psycho-social model. We have the bio-psycho-social model of psychiatry because it supports psychiatrists in their roles as medical doctors, not so much because so called mental disorder itself has been shown to be bio-psycho-social. I don’t think anybody can say that it has.

    • Few people would argue that the biological has nothing to do with what are called “mental illnesses.” The difficulty is one of objectivity. Even if the number’s arbitrary, you can at least say that someone has “high blood pressure” when their blood pressure exceeds a certain agreed-upon standard. There is no such standard for “mental illnesses.” In fact, just taking the biological aspect of depression, you are no doubt aware that depression can be caused or made worse by sleep loss, physical pain, vitamin deficiency, poor diet, lack of exercise, thyroid problems, low testosterone, other hormonal variations, and other physiological things? Does it make sense to say you “have depression” when your problem is low thyroid, and that someone else “has depression” when they are suffering from chronic sleep loss due to chronic leg pain? Why would these conditions be lumped together as being the same thing? They have different causes and different effective treatments. So how could you possibly develop an objective scale to measure something that is not really the same thing? It’s like diagnosing “pain” instead of looking for the cause of the pain.

      That’s not even getting into the wide range of psychological/social reasons someone may be depressed. Does the person who was sexually abused as a child need the same kind of intervention as the one who is currently being beaten by her husband weekly or the one who is using methamphetamine or the one who is in a dead-end job and sees no future for him/herself? What about the one who is using heroin because she’s got chronic pain and looses sleep because her husband broke her jaw and she’s afraid to go to the hospital to get it repaired? How could these extremely variable presentations be considered the same “disease?”

      Again, no one is denying that biological factors play a role. But to reduce “depression” to a disease denies the fact that people are depressed for a hundred different reasons and need a hundred different interventions. What is the point of defining a “disease” when the diagnosis doesn’t tell you what kind of help the person would need?

      Hope that makes some sense to you.

      — Steve

      • Again, no one is denying that biological factors play a role.

        I disagree. Whether we’re dealing with biological factors, psychological factors, or social factors is undetermined as of yet. Eyewitness evidence is notoriously unreliable. Ditto, personal testimony. Biological psychiatry would give statistics for how biological it is, and how less psychological and social it is, but these percentages are, in my opinion, largely arbitrary, and not based on any sort of rigorous scientific investigation. Rather than X = unknown, you’ve got X = genes, ‘bizarre’ thinking, and people pressure. In all actuality, X doesn’t have to be, and shouldn’t be, so biased from the start.

  2. Thomas Szasz has a very important point to make here, namely, that if you divorce your concept of “illness” and “disease” from the body, from a bodily organ, from materiality itself, you cease to be objective because you are no longer dealing with an object. This would tend to turn any disease or illness you came up with into a subjective matter. If we seek a definition for subjective we get something like this, “based on or influenced by personal feelings, tastes, or opinions.” Hardly a good basis for anything that would be considered scientific. Search for objective, and you get something like, “(of a person or their judgment) not influenced by personal feelings or opinions in considering and representing facts.” Were one looking at the difference between subjectivity and objectivity the distinction becomes even clearer. If objectivity is “the quality of being objective.” Subjectivity is “the quality of being based on or influenced by personal feelings, tastes, or opinions”, and “the quality of existing in someone’s mind rather than the external world.” Right there, as we’ve left the planet earth, one has to wonder about relevance. This would lead us to another word, BTW, imaginary, and the definition there is, “existing only in the imagination”, which to my way of thinking must be somewhere in the vicinity of “someone’s mind rather than the external world.” Psychiatry still has no way of taking any sort of reliable measurement when it comes to ‘illnesses of the mind’, and thus, one has to find the whole endeavor somewhat suspect. If “mental illness” exists in the anatomy, we haven’t found “it” yet, not really. In this endeavor, we’re still pretty much stuck with our own little personal patch of ‘middle earth’.

  3. Things are further confused by the DSM 5 categories. Some “diseases” listed–mostly as “personality disorders”–are actually forms of criminal behavior and have no business in a medical manual. The popular standbys like “Bipolar” and “Schizophrenia” are emotional in origin it seems. Dr. Glasser and others have successfully brought these people back to sanity by making them happier and showing them that they DO have control over their own actions. (When I was craziest I couldn’t believe this.)

    Other “mental illnesses” are social constructs. Homosexuality was a disease until–it suddenly wasn’t. Remember Drapetomania? It was a legitimate mental illness in the 1800’s; as real and legitimate as many today. Unhappy housewives had Hysterics. In the Soviet Union if you weren’t happy with the oppressive government you had Sluggish Schizophrenia.

    Just to keep things confusing the shrinks threw a very few real brain problems into the mixture of the DSM 5. Traumatic Brain Injury and Alzheimers for example. Both can be avoided by steering clear of psychiatry!

  4. With all due respect, Joanna, you need to read Szasz more carefully. For Szasz, disease or illness is not a “subjective” experience, rather, it is an objectively measurable biological reality based on scientific observation. That is one thing that distinguishes real disease, such as cancer, diabetes, and so forth, from the mythical mental illnesses. There is simply too much confusion of Szasz and other philosophers in these posts to begin to address them in one comment. Instead, I will simply ask, what is the purpose of these posts? Why are you writing them? No amount of sophistry can justify the atrocities that are perpetrated in the name of psychiatry.

    But let me address at least one glaring problem in your article:

    “Working in a drug detoxification unit this is a real, everyday problem. People who have been using large amounts of alcohol or benzodiazepines are liable to have epileptic fits during detoxification, which can be dangerous and life-threatening and need immediate treatment with benzodiazepines or other anti-epileptic agents.”

    What is the basis for your justification of psychiatric coercion and force? Isn’t it obvious that these poor souls are suffering as a direct result of psychiatry and psychotropic drugging? To pretend that psychiatry offers any solution for this suffering is simply disingenuous or downright deceitful. It seems as though you are trying to justify psychiatric coercion through philosophy. If this is not what you are doing, then I apologize for my misunderstanding. If this IS what you are doing, will you please explain why? Thank you.

  5. dr Moncrieff said something very important———–“when negative emotions or unusual behaviors are not driven by a specific bodily mechanism we should approach them as we approach other human behavior”….at this time neuroscience is just getting underway…we don’t know a lot about bodily mechanisms and brain mechanisms…I think that much of the anxiety and depression we are seeing may be a MIX of bio/psych/soc …americans are not behaving in healthy ways and this may be effecting the way their brains are working….the CDC says that 86 million adult americans have pre-diabetes and 9 out of 10 don’t know it…how might that effect the way people are feeling and behaving…and I would like to add that I don’t like the term mental illness …and I am having trouble withdrawing from my last little bit of celexa…

  6. Psych drugs frequently cause diabetes. Somehow I escaped without it. I have lost 10% of my body weight effortlessly thanks to going off that crap so that should help too.

    Good luck going off the Celexa Littleturtle. “Slow and steady wins the race.” ~Aesop.

    If psychiatry is able to establish a provable bio-marker there would be justification for trying to fix it. Until then they should leave healthy brain tissue alone! Those mind altering drugs are not magic bullets and created psychotic symptoms in me when I took them. I believe Dr. Moncrieff wrote about this phenomenon called tardive psychosis.

    • That’s where I’m at, too. There might be some minority percentage of depressed people who have something demonstrably wrong with their brains, but until there is evidence that this is the case, and these people can accurately be identified, medical approaches are dangerous and inappropriate except perhaps in acute and very temporary situations (like pain killers for a broken leg). Using psychiatric drugs to “treat” depression is like doing surgery with a jigsaw. You don’t even know what you’re fixing but you start throwing stuff at it and hope it goes away. We can all accomplish this at the corner bar. It’s not medicine.

  7. Regarding the bio-psycho-social model: All ‘mental illnesses’ are purely psychological. Social factors contribute to these psychological issues (because we have social pressures to achieve status, avoid being seen as worthless, etc.).

    Regarding the biological – it is psychological factors that bring about changes in biology (if we disregard things like tumour growth, etc., which are rare and purely biological – these of course have to be treated in a biological manner, such as surgery). In other words, psychological stresses, etc., bring about changes neurons and brain chemistry and these changes are reversible through psychological means. To take one example study: mice subjected to various psychological stresses (e.g. being restrained) show dendritic atrophy and loss of dendritic spines in the brain (reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3645314/ ). However, these changes are reversible through psychological means (e.g. when stressed, restrained animals are released as described in the same article).

    As I have mentioned before (in my previous comments to this series of blogs), Buddhist teachings from 2600 years ago explain the mind in great detail – such as how our attachments (whether it is towards our physical body, or for gaining pleasant feelings, social pressures, etc.), influence the manifestation of the mind-stream – all psychological stresses (that we refer to as ‘mental illnesses’ or ‘mental suffering’) happens as manifestations within this mind-stream that is changing moment by moment [reference: Theoretical Foundations to Guide Mindfulness Meditation: A Path to Wisdom, published in ‘Current Psychology’ (MindRxiv archive link: https://mindrxiv.org/mfs63/ ].

    • My caveat to that is that there ARE biological events and processes which affect “mental health,” such as sleep, nutrition, physical pain, other drugs, toxic environmental exposures, thyroid problems, etc. These should be looked at as potential causes or exacerbating factors. But the concept that you’re depressed or whatever because your brain is acting badly is pitifully lacking in any scientific validity. The vast majority of psychological/emotional issues are indeed stress-induced, as any bright 10 year old already understands. The amazing thing is how marketing techniques have overridden the commonsense understanding that most people have of how and why people get depressed/anxious/angry and how deeply this biological brain disease concept has become embedded in our society!

  8. Biological systems, like chemical and subatomic reactions, are governed by predictable regularities that have nothing to do with the desires and purposes of human beings.

    But if the consciousness manifesting in a particular body desires to stop doing so, those predictable regularities will cease. No “biological system” exists for no reason.

  9. Good point Nancy99.

    As Bob Whitaker wrote in Anatomy of an Epidemic if we have actual brain problems we see neurologists or brain doctors. Not psychiatrists.

    If you went to see a psychiatrist because you suffered from a cancerous tumor he would ask you to describe your symptoms. Chronic headaches, lethargy (can’t sleep from pain), problems concentrating, extreme sadness….

    Aha! You must have depressive disorder. Take 150 mg of Effexor every day and see me 3 months from now for refills.

    So you go home, take the magical SNRI he prescribed and die of brain cancer.

  10. Joannna, what do you make of Stephen Porges ‘Polyvagal Theory’ as a biological marker of mental distress; the idea that one’s vagal tone is a measure of how “uptight” or “depressed” one is? Its early days yet, but this idea looks promising.
    The idea that mental disorders are the domain of medicine is I think, an accident of history. If we had followed Tuke and not Pinel, we may well have placed mental disorder under the welfare, as Tuke was closer to Seikkula. Its a breakdown of human caring – and as Tuke and Seikkula have adequately demonstrated ‘being there’ is what makes a difference. Psychiatry offered the government with a mechanism to predict dangerousness, and this is what gained to the key to the asylums (even though they couldn’t).

    • The Public largely believes psychiatric “experts” have the role of John Anderton in The Minority Report played by Tom Cruise (Oh the irony!)

      This would be more accurate if John Anderton’s police force had been based on a fraud. They staged a few crimes to predict first. Then they set up an agency to arrest innocent people for arbitrary reasons. Great way to control society!

    • You know what I’ve found the best marker of distress to be? I ask the person, “How are you feeling?” If they tell me they’re depressed, or describe a depressing outlook, I conclude they are depressed. I think this whole biological marker idea is just a waste of time. People know how they feel, even if they have a hard time explaining it to you. The only real thing a therapist can do for a person is to help them become aware of their own observations, and perhaps become aware that they can view the situation from a different perspective. I think biological changes are usually effects, not causes, and as such deserve very little scrutiny. And those that ARE causal (such as thyroid problems, lack of sleep, chronic pain, etc.) should be treated in their own right and not in the context of “depression.”

    • William Tuke (like Philippe Pinel) was on the Reform Train, not the Abolition Train, not the Freedom Train. The aim of reform is more reform. The aim of abolition is an end to the charade of diagnosing disease where there is no disease in actuality. The Reform Train, unlike the Abolition Train, runs on Intolerance Railroad Company tracks. Let people be themselves, and the stress problem evaporates.

    • I dunno…

      And then we’ve got Omnipotent Bully Disorder (even the Anti-Social Personality type thing) or, together with Pedophilia, Sexual Addictions of one sort or another. Harvey’s out to get treatment remember. I figure it’s probably better if we catch criminals rather than make a General Criminality Disorder out of it, and then “offer””treatment”.

      “Sexual harassment” though is making advances towards a person who doesn’t want such advances made towards them by the person making the advancements. Uh, so-called unwanted advances. One could sigh, “Oh, the humanity.” but still, that’s just it. Barring an all around denaturing of humanity, when the dog is away the cat will play, and preferably with a mouse.

        • Our “law and order” ethos has created 1. a prison overcrowding problem (mostly having something to do with the so-called “war on drugs” and it’s complementary ‘3 strikes you’re out’ policy, and 2. the quasi-legal quasi-medical (out of control and growing) “mental health” system. If I were you, I’d worry about that zero tolerance thing of yours coming around to bite you in the ass.

          All sorts of words are used to demonize people caught up in the criminal justice system, presumably because they are thought to have crossed some line or other, all the same, I have yet to see a real demon. Innocent until proven guilty beyond a reasonable doubt says the constitution. There’s an Innocence Project out there, too, because even 12 presumably impartial people can make the same mistake sometimes.

  11. “If I were you I’d worry about that zero tolerance thing of yours coming around to bite you in the a__.” No fear of that. In order for that to happen I would have to be able to implement it first.

    Frank, I’ll bet you never had to “run the gauntlet” in school. Walk down the hall amidst wolf whistles and cat calls, guys describing in graphic detail not only parts of your body but how they would love to drag you off and….

    It’s not just “human nature.” Victorian teens didn’t act that way. So, yes, guys CAN refrain from acting like monsters if they put their minds to it.

    Sexual harassment is not rape or assault. But all three are acts of hatred for women. In my case I didn’t recover for years and got sucked into the psychiatric system because of this. Not just eccentric behavior from partying too hard.

    Guys who laugh off this kind of thing as no big deal and something “those dumb broads” should shut up and take make me want to puke!

    • I tend to agree, bullying is more or less a consequence of our industrialized society where communities have been undermined by the need for mobile workers and homogeneous (if shallow) belief systems. I find it interesting that bullying programs in schools always focus on bullying of kids by other kids, but never address bullying of kids by adults, or the bullying of one adult by another. Kinda missing a big part of the picture, IMHO.

    • If a ‘come on’ is wanted, it’s horse play, if it’s unwanted, it’s harassment. There’s a thin line there. Some women will cry rape, too, and try to entrap men in compromising situations. Also, personal survival issues are at stake. Posterity doesn’t exist for a monastery or a cloister.

      There’s a lot of competition for, you name it, up to and including items on the meat market. Without it, whatever it is, a person is not a success in the eyes of the world. People will do all sorts of things to be accounted a success. Losing, after all, is not the object of the ball game. One could say it is winning, but I rather think it is playing.

      A “kinder, gentler” world, well, that kind of went out with kindergarten, didn’t it?