Oxford Handbook of Psychiatry Fourth Edition by David Semple and Roger Smyth
The role of the psychiatrist
What is illness?
Doctors, being generally practical people, busy themselves with the diagnosis and treatment of various types of illness. They rarely ask ‘what is illness?’ or ‘what is health?’ For several reasons, this type of questioning is more germane for psychiatrists:
• While all illnesses have subjective components, psychiatric disorders are usually completely diagnosed by the patient’s subjective experiences, rather than objective abnormalities.
• There is a non-absolute value judgement involved in the diagnosis of mental disorder, e.g. wheeze and dyspnoea are abnormal and signs of disease, but some degree of anxiety at times is a common experience and the point at which it is pathological is debatable.
• Mental illnesses have legal consequences.
• It is important psychiatrists are clear about which behaviours and abnormalities are their province. Psychiatrists have been involved in human rights abuses in states around the world when definitions of mental illness were expanded to take in political insubordination.
Disease, sickness, and illness behaviour
The distinction between disease (or disorder) and sickness should be understood. Disease encompasses either a specific tissue lesion or a characteristic constellation of symptoms. Sickness, on the other hand, encompasses the suffering and functional deficit consequent on symptoms. One may exist without the other, e.g. a patient with undiagnosed, asymptomatic breast cancer undoubtedly has disease but is not sick; a patient with chronic fatigue syndrome may see themselves (and be considered) as sick but does not have an identifiable lesion.
Patients generally present complaining of symptoms, and this process is called illness or illness behaviour. Patients need not be suffering from a disease or disorder in order to do this, and sometimes illness behaviour may be abnormal (even when the patient does have a disease). Subject to certain social conventions (e.g. attending a doctor), they are then afforded the ‘sick role’, which allows them to relinquish some of their normal obligations. This is a man-made concept, encompassing the special rights and expected behaviour of both someone who is sick and the doctor who is treating them (see Table 1.2). Difficulties arise when a person adopts the sick role to gain the rights afforded to them, while neglecting their duties. Another concern relates to the process of diagnosis—causing someone who is not currently ill to adopt the ‘sick role’. Doctors should understand their special responsibility to act in the patient’s best interests and not to stray outside their area of expertise.
Clarity of roles
It is all too easy for psychiatrists to slip into other roles than that which is properly theirs—an expert in mental disorder. These may include: substitute parent, ‘friend’, guardian of public morals, predictor of future criminality, arbiter of normal behaviour. Psychiatrists have special training and experience in mental disorder and should avoid being drawn outside this remit in their professional role. Psychiatrists are properly occupied in the business of diagnosing and treating significant psychiatric disorders. As gatekeepers to mental health resources, there are often pressures to validate distress or medicalize normal experience. Saying someone does not satisfy the criteria for a specific mental disorder does not mean that they do not
have significant problems; rather, the problems do not fall within the scope of psychiatry and would be best dealt with by help or advice elsewhere.
Good mental health is more than simply the absence of mental disorder; it requires:
• A sense of self-sufficiency, self-esteem, and self-worth.
• The ability to put one’s trust in others.
• The ability to give and receive friendship, affection, and love.
• The ability to form enduring emotional attachments.
• The ability to experience deep emotions.
• The ability to forgive others and oneself.
• The ability to examine oneself and consider change.
• The ability to learn from experience.
• The ability to tolerate uncertainty and take risks.
• The ability to engage in reverie and fantasy.