The logic of the disease perspective is, strictly speaking, categorical. Its goal is to group conditions into diagnostic categories based on the pathological conditions found in individuals. Ultimately, the disease perspective seeks to state whether a person has—or does not have— a particular disease. Does this person have tuberculosis, yes or no?
To make this determination, the reasoning of the disease perspective follows three stages:
- it identifies the symptoms – viagra in australia;
- it links the symptoms to some abnormal body structure or function;
- it determines the underlying cause of the pathological process.
McHugh describes these three steps as the conceptual triad that organizes the disease perspective: clinical entity, pathological condition, and etiology. The clinical entity is the cluster of signs and symptoms present in the individual. Identifying clinical entities is the empirical work of observing and noting phenomena. In the mental status examination, for example, attention is given to the manner of dress, speech rate and rhythm, bodily movements, and any other physical quality or behavior.
■ Frank consulted the clinician for an evaluation of his premature ejaculation. His marriage of twelve years was stable, and the premature ejaculation had developed over the past six months. During the evaluation, he sweated profusely and seemed to be physically agitated. He was referred for a long-overdue physical examination and was found to have hyperthyroidism. As the thyroid function was normalized with medication, the premature ejaculation resolved.
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Certainly, no clinician would diagnose hyperthyroidism based on sweating and agitation alone. But attention to these clinical entities should alert one to the need for further physical and laboratory evaluation in a patient who has not recently had a complete medical examination
The pathological condition is the abnormal somatic function or diseased organ that is linked to the cluster of observed symptoms. For Frank, the excessive secretion of thyroid hormone was the pathological condition. The hyperactive thyroid produced his sweating, agitation, and premature ejaculation and also produced poor sleep and weight loss despite an increased appetite. The pathological condition was linked with these symptoms or clinical entities through laboratory studies of his thyroid function.
The etiology is the causative factor—not the hyperthyroidism, which is the pathological condition, but what is causing the hyperthyroidism. Unfortunately, the exact cause of Frank’s hyperthyroidism was unknown. Although many causes of diseases can be identified (e.g., Mycobacterium tuberculosis causes tuberculosis), unknown causality is not uncommon. Indeed, finding etiological factors is the ongoing work of medical research. Until the causes are found, clinical medicine is limited to treating the symptoms. Fortunately for Frank and for others with thyroid diseases, medication can greatly reduce the symptoms and allow normal functioning.
Application of the disease perspective to sexual disorders is the work of ensuring that the somatic factors, disease processes, and physiological functions, as they may relate to the cause or expression of the sexual disorder or dysfunction, have been identified. It entails linking the clinical entities with a pathological condition. In sexual problems, the clinical entities of the sexual dysfunction and the patient’s medical history may indicate the pathological condition. The linking of the two is the task of the disease perspective. Table lists some common linkages between sexual problems (clinical entities) and medical illnesses (pathological conditions).
Treatment in the disease perspective is to cure the disease or, when that is not possible, to alleviate the symptoms. When sexual dysfunction is present as a helpful sign or symptom (clinical entity) of an underlying pathological condition, treatment is given to address the pathological condition. When one cannot successfully treat the underlying condition (e.g., peripheral neuropathy), symptomatic treatment is given (e.g., oral medication for erectile function). Another clinical case can illustrate the work of the disease perspective.
The disease perspective is the perspective most often used by physicians. For this reason, application of the disease reasoning process to psychiatric or behavioral disorders is often referred to, disparagingly, as the “medicalization” of psychological problems. Is this a fair critique?
If, in fact, the disease perspective is the only reasoning method in the mental health clinician’s armamentarium, then his or her diagnostic reasoning will be reductionistic. But attempting to understand all problems as ultimately rooted in a bodily disease is not the disease perspective’s rationale. As I will repeat often in this book, a particular perspective—in this case, the disease perspective—is but one way to understand and sometimes even causally explain a disorder. Ralph’s case is a good example of this.
Ralph’s low libido was the symptom that disturbed him (and his wife) and alerted the physician. He clearly was not as interested in either thinking about or having sex as he had previously been. While Ralph’s low desire might have been attributed to a combination of aging, alcohol consumption, pressure at work, and tension at home, his physician ordered the proper tests. The low serum testosterone was the abnormal hormonal function responsible for his reduced sexual desire.
The physician then sought to explain why the testosterone level was so low. He discovered that high prolactin levels, hyperprolactinemia, were suppressing it. But what was the underlying cause of the high prolactin? The MRI indicated that a small, benign tumor—an adenoma— was growing on Ralph’s pituitary gland, located deep within the subcortical area of his brain. Fortunately, surgery was not indicated and Ralph responded well to the oral medication.
If the disease perspective had not been employed here as the primary diagnostic and treatment perspective, then an expenditure of many months and dollars, and perhaps a further deterioration of the relationship between Ralph and his wife, might have followed. Hours of sexual or marriage counseling might have been spent on asking how much did Ralph really drink, were husband and wife taking each other for granted and not communicating well, was Ralph too involved in his work? While all these questions might be worthy of attention, it would have been a major therapeutic error to think that addressing them and attempting to make changes in these areas could have any substantial effect on Ralph’s sexual desire. In addition to low libido, therapy-induced frustration would have been added to the symptom cluster.