Physical Versus Mental Illness

In an unpublished email, Milo wrote this comment to me:

Personally speaking, i passed a kidney stone last year, and being dead honest here, i’d  much rather the physical illness than having a paranoid episode… i really really do. i tell you one thing Sara, the pain was absolutely horrendous, but no one laughed at me. i felt much more dignified than i ever did when i was locked up in a psych ward… dead honest…

I think that almost anyone who has had a mental illness of any significance would agree with that statement. And the odd thing is that anyone who hasn’t would think just the opposite. Unless you’ve been there, there is a tremendous underestimation of how much mental illness impacts the quality of life. After all, there are very few physical illnesses – even ones involving extremes of physical suffering and death – that are associated with suicide in a way that even the “common cold” of mental illness, a simple depressive episode, is.

It seems to me that a lot of people who are writing journals like this one – experience journals – about their mental illnesses have a higher than average level of physical illness comorbidity, though I’m not sure that has been epidemiologically proven. There are probably cofounding factors – people plagued by crazy moods usually don’t take the best care of themselves (I am guilty here), destructive behaviors, substance abuse, being ignored by doctors.

But I’m also struck by how quickly physical illness is legitimatized by society, bringing with it what public health sociologists call the “sick role,” which is a social convention that is acceptable to society. Something about the whole construct and theory bothered me in medical school when it was touched upon briefly. I don’t like the blanket statements; I think people should be seen as essentially healthy, and by defining a sick role, you are encouraging sick behavior.  No alternative models are presented in medical school. But it does apply on a societal level as a descriptive model, if not the ideal one.

Yet it doesn’t apply for mental illness – the main two “rights” afforded the ill are not applicable – whether society says it or not, mental illness is seen as, maybe not quite active malingering, but something akin – not quite a “real” illness, not something that justifies the exemptions.  And the second right – that the sick person is not responsible for their illness – it is politically incorrect to disagree with this statement, but hell, if I, medically educated, liberal, and a victim myself, in short,  someone who should know better, insist on blaming myself, well, what can you expect from a society at large?

The “responsibilities” are also problematic. The idea that one should cooperate with a medical model which is infantalizing and patronizing and paternalistic, and often negates the core of one’s very experience with its drugs as well as its conception of pathology (something that does not happen, or at least not as much, in physical illnesses), is equally problematic. I do not agree with my physician – who, according to these same sociological principles, has the ultimate word and is considered the only “technically competent help” I can seek in order to conform with the sick role. Therefore, I in some way abdicate my rights to the sick role.

That’s ok with me on some level. I don’t want the sick role anyway, and, while I know it will probably make a lot of my readers angry, I am often against the institutional reward for the sick role. (Again, another disagreement I have with the basic premise of the theory.)  I think that by making it easier to get benefits for illness – and NOT just mental illness by any means, we infantalize people and encourage sick behaviors, define people as ill, create a permanent and all-encompassing sick role. We create patients who will never get better.

I am all for help, care, love, and rehabilitation – all things that Western countries tend not to give as easily as they give money (which they don’t give that easily either). But the welfare system writes people off, makes them dead long before they are, often encourages them to give up the fight.  It also exempts us as a society from working to improve their health, because they are maintained indefinitely as ill. It is relatively easy to cut someone a monthly check; it is quite difficult to encourage and help them find suitable work – and by work I do not mean employment, but rather “work” in the sense of “to work and to love” – something that gives life meaning. One can be a “healthy adult” with a mental illness. A physical one, too. But not while clinging to the sick role.

Back to Milo: whether we accept the “sick role” concept or not, physical illness is afforded a legitimacy that is regularly denied to mental illness. Here’s my example: I’m not proud of it, but during this last year, while taking one of the meds that made me insanely restless, suicidally depressed, argumentative, and, on top of it all, physically miserable due to akathisia, I landed at one shrink appointment and ended up begging him to do something – anything, just to make it stop. Stop this med. Find another one, one that would work quickly. That I wouldn’t argue, I’d do anything he said, take anything, just to make it stop.

And what happened? I got an annoyed reaction. “You of all people should know that psych drugs take 4-6 weeks to work, that it just doesn’t work like that…and anyway, it seems to be doing you some good.”

This is from a psychiatrist – the kind of doctor supposedly most educated and aware of mental illness, the one who chose to specialize in mental disorders, who presumably thinks they are a source of suffering significant enough to devote his life to treating. If he can’t be sympathetic, how can we expect society at large to be?

I’m not blaming him. I am sure I was annoying and demanding and all that, and there was no easy solution that would have satisfied me. I have certainly lost patience with patients with unreasonable expectations and demands, which mine was. It happens. He also redeemed himself a few minutes later, saying something like, “I know you feel awful,” which was probably what I needed to hear in the first place.

My point: contrast this with the recent very physical side effects of some med or other he gave me, or, what it is looking most likely to be – a peptic ulcer. After all the misery of this last year, the depressions, the irritability, the instability, I hardly cared about the stomach pain and vomiting, which were occuring daily, often during 30 hour call nights. My mood had improved, and the physical shit, while not insignificant and certainly distressing, relative to what I had been through, was almost nothing.

And yet, when I reported these symptoms (which I did at first because I thought they were due to one or another of the psych meds), I was told to rush to a doctor on the same day, if not the emergency room. That got me the sick role, and pretty damn fast.

* * *

Stay tuned for the next post – this one went in a different direction than I intended. I intended to discuss Milo’s point more directly, the way psychiatric illness is seen in the emergency room, by the medical system, and instead ended up here, on a more theoretical note. Later I’ll try to write on comparative suffering – physical pain versus mental pain and whether they are the same or somehow qualitatively different – whether mental illness really is just another type of illness, legitimate suffering, and how doctors really see psych patients.



  1. Sara… i haven’t read the post yet. i wanted to say thanks before i even get there. thanks,
    love from Milo
    You did it!

  2. Lord bless you Sara. if i die today, i know that will die happy coz someone out there heard my (and millions of others, that’s i am sure of) cry. God bless you and thank you thank you thank you.

  3. The words, “I felt much more dignified” really struck me. It’s hard enough sometimes to seek treatment for a “mental” illness…this dichotomy is abhorrent.

  4. Yeah, that dignity issue was what I really wanted to write about and missed.

  5. No one has ever blamed me for my mental illness. People have blamed me for not doing something to get well, or how I might behaved when angry or depressed, but no one has ever blamed me for being bipolar per se. I don’t know if there’s much of a difference…

  6. I want to go into medicine one day. Psychiatry, specifically.
    Your words are invaluable to me.

  7. 5150: I think I mean being blamed for not getting better. I blame myself for my mental illness, emotionally if not quite rationally. People – at least the good ones – have been mostly forgiving of the behavior, but blame me for not being able to avoid it, be cured, or somehow overcome it. I’ve felt the blame much more on that end than aimed at specific behaviors. Of course, I mostly just do damage to myself during the episodes. I think there is a difference, but I’m not sure it matters much.

    I think also that some of my close friends who I told recently, who have never seen a full blown episode, also seem to think I exaggerate how horrible it can be. Jake said to me, after I mentioned something related to the shrink or a med or something, laughing, “Come on. You don’t really have anything, any illness.” I wasn’t sure quite what he meant – like, I exaggerate, or an optimistic kind of denial – like, it just can’t be, or if what he meant was that, like so many people, he just can’t believe that someone like me could have a serious mental illness.

    Miss Ash – I’d like to hear more on how and why you want to be a psychiatrist. It is an odd profession.

    One of the things I intended to mention in this post before it derailed was why I *didn’t* choose psychiatry – about the concept of mental pain, how when I did rotations as a med student and so on, it was just too painful. I had too much empathy or sympathy or whatever for that kind of pain. I guess that is another post.

  8. I agree with the “the system”, in general, is less shaming about physical illness, but I note that Milo had a kidney stone – a verifiable, identifiable, objective illness. Everyone knows kidney stones cause pain. And I assume (I could be wrong) that Milo is a man. When a woman goes to the ER with, say, abdominal or pelvic pain and “nothing shows up” on the scans, I suspect her experience is different.

    It’s not a black-and-white dichotomy. Some people – some physicians – are disdainful and blaming to people who suffer with physical illness, too, especially chronic “lifestyle illnesses” like diabetes or sleep apnea. And far too many of us think “people like us” don’t end up with any sort of illness. My father used to say “doctors don’t get sick”, and I don’t think he was joking. We have a lot invested in not being patients.

  9. But before a CT, a kidney stone wasn’t verifiable either, except maybe in retrospect.

    I know that even though I don’t mean to be, I also have subtle biases and prejudices – I doubt there are many physicians who don’t a little bit at COPD. Or psych things. I am certainly guilty of both. And what you said about people like us not getting sick, well, there’s a lot of that too. Since somewhere in medical school, I’ve pretty much stopped going to doctors. Probably a huge barrier to the shrink being at all helpful is my attitude.

    Where does it happen? Somewhere along the way, we get the attitude that it couldn’t happen to us, that somehow people do bring it on themselves. I have had this very thought about the manic depression myself – that somewhere, somehow, I am to blame. If I’d been more careful about sleep and exercise, not taken stress so hard…it wouldn’t have happened. And there is a contempt for the chronically ill – the illness behaviors that develop with time.

    I can’t put my finger on how we learn it – but it is certainly an ingrained attitude. I wish I could say I didn’t have it, but I do.

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