Are Mental Disorders Brain Diseases or Trauma Reactions?

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Mental Disorders as Reactions

These days, there’s a lot of talk and debate about whether mental disorders ought to be thought of as biological diseases versus “understandable” and even “normal” reactions to life events. One common claim is that since there’s no established biological basis or pathophysiology to explain mental illness, psychiatric disorders shouldn’t be called brain diseases or even illnesses at all. Meanwhile, since trauma is increasingly recognized as a common life experience among those who have been diagnosed with psychiatric disorders, it’s also sometimes claimed that the “biomedical model” of psychiatry is guilty of “over-pathologizing” or “over-medicalizing” distress and wrongly localizing disorder or dysfunction to an individual or their brain rather than more properly attributing the cause of distress to trauma.

The irony of this claim is that back in the 1950s, when psychiatry was still heavily influenced by psychoanalytic theory, the idea that mental disorders were “reactions” to environmental or developmental stressors was a core concept. Even schizophrenia was listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM) as a “reaction” (which led to the unfortunate and wrong-headed theory that schizophrenia was caused by “schizophrenogenic mothers”) under the heading of “disorders of psychogenic origin or without clearly defined physical cause or structural change in the brain.”

As psychiatry turned away from its psychoanalytical origins and aligned itself as a medical subspecialty in the 1960s, with psychiatric training requiring a medical degree, it abandoned the idea that mental disorders are mere “reactions.” Nowadays, the word “disorder” has replaced "reaction" in the DSM to describe most of the conditions listed in its pages, deliberately steering clear of the word “disease” or even “illness.” Instead, mental disorders are recognized as “syndromes” that represent constellations of co-occurring symptoms, in most cases without any direct claims about their cause. The main exception has been the DSM's enduring recognition of trauma reactions in the form of post-traumatic stress disorder (PTSD), acute stress disorder, and adjustment disorders, making clear that while psychiatry stops well short of discussing the potential role of trauma in all mental disorders, it clearly acknowledges the importance of trauma as a cause of some mental disorders.

Broken Bones and the Biopsychosocial Model

Despite occasional claims to the contrary, it's not true that psychiatry employs a reductionistic “biomedical” model that only regards mental disorders as brain diseases. In reality, psychiatry uses a “biopsychosocial” model that allows clinicians to consider biological, psychological, and social contributors to individual cases of mental disorder and distress.

To explain how the biopsychosocial model works in psychiatry and in medicine, I like to compare how psychiatrists really think about mental disorders to how we think about broken bones. Bones break when, for example, we’re hit by a car. So, that can rightly be thought of as a trauma reaction. But while an elderly person with reduced bone mineral density might sustain a fracture, someone with a genetic predisposition to thicker bones might not, even when exposed to the same impact or force. And sometimes "pathological fractures" occur where a diseased bone—like, for example, in cases of severe osteoporosis—breaks in the absence of any significant trauma. Biology is therefore relevant to broken bones, whether or not trauma occurs.

There are also social determinants of broken bones and medical illness. Whereas one individual with good medical care who's being treated for osteoporosis might not get a fracture, the bone of someone of the same age who lacks access to good medical care might be much more likely to break. And let's say someone breaks their leg not because of being hit by a car but because they're an "adrenaline junkie" who likes to take risks and sustained a fracture from a hard landing while sky diving. That's where psychology comes in. Within the biopsychosocial model, biology, environmental stressors, social factors, and individual psychology can all conspire to break a bone.

So, it is with mental disorders. Psychiatry doesn't limit our understanding of mental disorders to only one cause. According to the biopsychosocial model, we can best understand an individual's suffering from a condition like major depressive disorder or schizophrenia by considering all the biological, psychological, and social factors that might be relevant to that individual and their circumstances.

Localizing Pathology, Localizing Blame

Curiously, when we talk about broken bones, we rarely hear anyone debating biological versus environmental causes and insisting that fractures should be reframed as “understandable reactions to trauma” without referring to the bone as “broken” or “disordered.” And the same is true for other medical conditions like high blood pressure, diabetes, heart disease, or cancer, where environmental factors like salt or caloric intake, exercise, or cigarette smoking interact with genetically-influenced biological factors to result in illness.

Why is it, then, that some are so averse to thinking of mental disorders as “brain disorders” that they're calling for efforts to “drop the disorder” but are perfectly comfortable calling a broken bone “broken”? One reason is that localizing disorder to the brain is often conflated with localizing the cause of the disorder to the brain. But those aren't the same thing—just as we can call a bone broken without claiming that the bone broke itself, we can say that a brain is disordered without the brain necessarily being the cause of a mental disorder.

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Another key reason relates to stigma and the localization of pathology and blame. As the physician Mark Vonnegut noted in his 1975 memoir The Eden Express:

“Most diseases can be separated from one’s self and seen as foreign intruding entities. Schizophrenia is very poorly behaved in this respect. Colds, ulcers, flu, and cancer are things we get. Schizophrenia is something we are.”¹

Just so, while we can externalize pathology to an infectious cause or a dysfunctioning body part when we have a medical illness, it can feel like we’re talking about something much more core to who we are when we speak of dysfunction in mental disorders.

In a 2016 paper I co-authored with Dr. Allen Frances, we wrote:

“In the value-laden language of disease, where health is always 'good' and illness is 'bad,' stigma will always remain a concern. A person with heart disease might say, 'I’ve got a bad ticker.' But we’re loath to accept labels of mental illness because psychiatric disorders affect our brains and our behavior, where our very identity is rooted.”²

In other words, when people object to calling mental disorders “disorders,” they seem to be rejecting the implication that, unlike when a heart is diseased or a bone is broken, when we have a psychiatric disorder, the very essence of ourselves is broken. Calling mental disorders "trauma reactions" allows people to instead externalize pathology, dysfunction, and blame so that people who suffer from mental disorders can instead be recognized as victims of circumstance or—in the case of abuse—mistreatment by other people.

But while the therapeutic value of such disparate narratives is important to consider, we don’t have to think of mental disorders in such a reductionistic, "either/or" fashion. Just as we're more than our brains, the causes of mental disorders are more complex than mere reactions to trauma. And there's no reason that we have to think of having a mental disorder as meaning that we’re broken in some fundamental, irreparable way. As with a broken bone, we always have the potential to heal, regardless of whether it’s our brains that are disordered or whether we’re victims of trauma or whether—as is often the case—both are true.