brain disorders, mind disorders

Psychiatrists tell us that certain conditions are organic whilst others that look organic are actually psychological. Both attributions can at times catch a lot of flak - and in this sense they do rather 'get it from both sides'. Cases of depression which the psychiatrist holds to be organic are held by others to instead be rationally or psychologically intelligible life-reactions. And patients will sometimes strongly dispute psychiatric claims that certain conditions marked by fatigue, weakness, seizures, and pain are psychological rather than organic.

Now of course psychiatrists are fallible beings who sometimes get things wrong. But what I've noticed in disputes about these matters is a persistent failure to reflectively characterise what it even is for a condition to be organic or instead psychological. In what follows I try to put that right.

Regarding organic conditions, the main mistake I encounter is the claim that we shouldn't talk of organic pathology unless an underlying disturbance in the brain can be demonstrated. And because any psychological disturbance will enjoy a neurological instantiation, it must also be shown that the neurological disturbance is causally primary (i.e. comes before the psychological disturbance).

The difficulty with this latter claim is that it's hard to see why, when what we have is a psychological disorder, the neurological instantiation wouldn't anyway be contemporaneous with the psychological trouble. And the result of this is that it starts to look irrelevant to consider what's going on in the brain before definitively discerning whether or not a condition is organic.

One way around this is to insist that organic disturbance be characterised by gross, readily visible, lesions of a sort which arises from a stroke, cerebral injury, physical illness, neurodevelopmental abnormality, etc. This however just rules out by fiat that much severe mental illness is organic in nature.

Properly understanding what it means for something to be "organic" involves - and this is my first positive claim - our coming to see simply that it is not psychologically intelligible. This, and not the actual demonstration of neuropathology, is the essence of the organic. Why attribute someone's disturbance to their biology? Well, this is just a way of saying that it's not intelligible at a higher - either rational or psychological - level.

"But why should the organicity of my mental troubles hang on whether my psychiatrist has the wit to understand me?!" And "Are you saying that psychiatrists, of all people, are infallible when judging whether something's not rationally or psychologically intelligible?!" ... Now, such reactions are obtuse. My claim wasn't verificationist: there's an obvious difference between whether something is itself intelligible and whether some particular person has the wit to fathom it. ... And note, we also have to exercise caution in the other direction. That is, it's not uncommon for people to take an emotional state for meaningful when it really isn't. Hormonal and drug reactions are common examples. What we need, therefore, are people who are skilled in carefully making such determinations. Who knows, maybe some psychiatrists, what with all their experience, even score above average in that?!

And what of those other cases - where patients complain that medics are failing to recognise the organic nature of their fatigue, their pain, their immobility, their weakness? Have these medics really ruled out all organic disturbance before they chalk the troubles up to the mind? And what of these scans, these blood results, that show abnormalities? Why aren't they taking those into account?

Well, once again, we'll surely expect abnormal physiological markers in psychological conditions. So adverting to such physical differences needn't always get us anywhere. But more to the point - and here we see what in a sense is structurally the inverse of what's the case for organic conditions - there are positive psychological markers for, and not just an absence of gross physiological markers in, psychosomatic conditions. It's the character of your preoccupation, the way your condition changes when your attention or anxiety shifts, the way it ameliorates when your unconscious conflicts are made both conscious and tolerable, the way the pattern and location of your paralysis or tremor ignores actual neuroanatomy and conforms instead to popular ideas of neuroanatomy, or how, whilst voluntary limb movements have become radically restricted, automatic movements of the same limbs are fine, or how the eyes are closed during a functional seizure: all of this provides the positive basis for the diagnosis of a condition as psychological in character. Furthermore, and perhaps even more importantly, what it is for such a condition to be psychological is for the physical symptoms to stand in an expressive relation to the psychological troubles. (We might, in some particular case, not yet know what these troubles are, but that's another matter.) For sure, it's important to take diagnostic care and show clinical responsibility by ruling out certain organic difficulties, even when, say, the troubles started immediately on that intolerable romantic rejection or bereavement or bullying. But such exclusions don't by themselves get us to the essence of these conditions.

To summarise: What I've been saying is that in medical contexts like these, "organic" really means "not rationally or psychologically intelligible". (You can put the rider "...even to the most psychologically perspicuous observer ever" on if it makes you feel better.) And for a condition to be psychological, its symptoms must be expressive of an emotional state. (And here you can add the rider "and not just contemporaneous with such a state" if you must.)

Postscript: You'll have noticed that in this short piece I've deliberately used the words 'organic' and 'psychological' and avoided words like 'functional'. This is because I'm trying to avoid the midwit muddle of that semi-reflective clinician who over-confidently asserts that, say, you'd have to be a substance dualist to think that psychological conditions are not all anyway also through-and-through biological. What's obnoxious about such 'reasoning' is precisely its substitution, for a careful attention to the actual implicit norms governing the use of words in specific contexts of clinical thought, of some other far more general meaning of these terms - in which 'organic' allegedly just means, say, 'involves the brain'! Rather than performing extra labour to avoid such tiresome and unnecessary misunderstandings, I'd rather just continue to speak with the clinical tradition. Such people will always find ways to fuss over your language - they'll relentlessly claim it's outdated or stigmatising or inexorably embeds an undesirable metaphysic rather than begin to pay careful attention to the context-relative sense-determining implicit criteria for the use of the terms in clinical practice. Far better, surely, to simply ignore them!