James Poskett: Abandoning disease

Imagine you are diagnosed with type 1 diabetes. Your weight loss, lethargy and occasionally-blurred vision are all finally explained and your treatment, regular injections of insulin, prescribed.

A month later you go back to your doctor. They open their clinical handbook, flick through the index and, rather unfortunately, ‘diabetes’ has been omitted from the latest edition. They tell you your disease no longer exists, your symptoms no longer fit a specific category and it’s back to the drawing board with regards to treatment.

Diabetes may be here to stay but other diseases, particularly psychiatric, are abandoned on a much more regular basis. In fact, the next edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is currently set to dispense with Asperger’s syndrome as well as a number of schizophrenic subtypes.

All this highlights an interesting problem for the medical humanities: what’s happening (socially and epistemologically) when the medical profession abandons a disease?

In some instances, the disease is simply subsumed under a different name with an altered set of criteria or symptoms. Asperger’s syndrome may go, but doctors will be encouraged to make use of autism spectrum disorders. This seems to suggest a model of disease in which symptoms are the focus. The medical profession may abandon one cluster of symptoms (Asperger’s) in favour of another (autism) for various reasons be they social, economic or evidence-based.

But does the buck stop with symptoms?

The answer, when we recall one of the most famous deletions from the DSM, appears to be no. Put plainly: in 1972, sexual activity with the same sex was a symptom of a psychiatric disorder. Today, thankfully, it is not. In 1973, bowing to pressure from activists, homosexuality was removed from DSM-II. Whilst it hung around in various guises up until DSM-IV, it is fair to say that the ‘symptoms’ associated with the ‘disorder’ are no longer a part of medical science. Such a change suggests that even symptoms are not free from social and political influence.

So in the end it seems easier to answer the social rather than epistemological question. Diseases and symptoms serve clear social, political and economic purposes: they dictate and allow for the prescription of drugs, they criminalise and pardon certain behaviour, and they delineate fields of academic research. But in the cases discussed above, and in light of the impending arrival of DSM-5, it seems the real challenge will be in developing an epistemology which can account for both the addition and the abandonment of disease.