Can Symptoms Be Caused by Descriptive Syndromes? An Analysis

In this post I want to examine the question of whether it makes sense to say that a patient’s anxiety is caused by ‘Generalized Anxiety Disorder’.

Jonathan Shedler argues that it doesn’t.

Mark Ruffalo and Ron Pies argue that it does.

This is not a specific response to either, but simply a clarification of my own views.

1) The first thing I want to do is point to Hane Maung’s brilliant philosophical paper “To what do psychiatric diagnoses refer? A two-dimensional semantic analysis of diagnostic terms” (2016). Maung argues with great philosophical sophistication that reference of diagnostic terms in psychiatry can have two meanings or two intentions

“a diagnosis has a pre-theoretical mode of presentation that characterises the 1-intension, and an underlying structure that is discovered a posteriori and determines the 2-intension…. In the case of a diagnosis, the mode of presentation is the clinical manifestation and the underlying structure is the disease process that is responsible for the clinical manifestation.”

These two intentions have different necessities and different contingencies: “This can be captured by the idea that there are two sorts of necessity and two sorts of contingency, which respectively correspond to the necessity and contingency when the 1-intension of a term is assumed (1-necessity and 1-contingency), and to the necessity and contingency when the 2-intension of the term is assumed (2-necessity and 2-contingency)”.

To use the example of Panic Disorder, the DSM description is 1-intension in which the presence of panic attacks is necessary (you can’t have Panic Disorder without panic attacks). Yet “Panic Disorder” also has 2-intension reference, which refers to the hypothesized underlying causal network X. In 2-intension, it is the causal network X that is necessary and the symptoms are contingent, which means that in 2-intension sense of the word it is theoretically possible for a person to have Panic Disorder without having any panic attacks at all (just as you can have tuberculosis without necessarily having fever).

2) Ok, so I think Maung makes a very persuasive case that diagnostic terms can simultaneously have two different referents, descriptive and causal, and there is nothing inconsistent about that.

However, just because diagnostic terms can have two different referents doesn’t mean that they necessarily do all the time, or that the hypothesized 2-intension has anything of explanatory value to offer. (To be clear, this is not a claim that Maung makes. So, nothing going forward is intended as a criticism of Maung’s account by any means, which I, for all intents and purposes, adore).

Some diagnostic terms are so thoroughly descriptive that they have no coherent 2-intension.

Consider the term “fever of unknown origin”. A fever of unknown origin (FUO) is a fever of at least 101°F (38.3°C) that lasts for more than three weeks or occurs frequently without explanation.

Imagine saying to a patient, “You fever is caused by FUO.” That makes no sense at all. We know that this specific fever has some unidentified cause, yet that cause is so abstract, so distant, steeped in so much ignorance, that the mere knowledge that there has to be some cause doesn’t make it so that the mere use of the term offers us some causal explanation. Furthermore, the category by itself recognizes that there won’t be any unified causes for the entire category. The category knowingly refers to a rag bag of unidentified fevers.

Even when a coherent 2-intention may be hypothetically referred to, hypothesized 2-intension may have no explanatory value to offer.

Consider “obesity” as a medical diagnosis. You can define it as a BMI above 30.

Imagine saying to a patient, “Your plumpness is caused by obesity.” The only sensible response to that would be, “No shit, sherlock!”

Even if we imagine that when we say “obesity” we are referring to 2-intension, “the underlying cause of plumpness of BMI >30”, that’s not very helpful because “Your plumpness is caused by the underlying cause of BMI >30” is neither informative nor explanatory.

That doesn’t mean that this situation can’t change. If we can develop a sufficiently robust account of the causes of obesity, the presently uninformative and unexplanatory 2-intension can become informative and explanatory, but that would require the discovery of new knowledge & thereby an expansion in the meaning of obesity, whereby a ghostly, shadowy 2-intension takes on a more concrete form.

Imagine saying the following:

“Your attraction to same-sex individuals is caused by homosexuality.”

“Your attraction to pre-pubescent children is caused by pedophilic disorder.”

“Your panic attacks are caused by panic disorder.”

“Your anxiety is caused by generalized anxiety disorder.”

I would say that these statements are fairly similar to the statement about obesity. We can hypothesize 2-intensions for each of these terms, but they have no explanatory value to offer at present. It makes no sense to utter these words.

3) In ordinary language, we sometimes use “cause” in a very different manner. As something along the lines of “this is how to best make sense of it”.

An important thing about diagnoses in medicine is that they don’t just identify something, they also typically exclude other things.

For example, to say “you have unipolar depression”, also implies, “I don’t think you have bipolar depression”.

To say, “you have generalized anxiety disorder” also means “I don’t think your anxiety is secondary to psychotic symptoms”.

In this sense, to say “Your anxiety is caused by generalized anxiety disorder” can be interpreted as “The way I understand your anxiety, it seems to be best described as 'generalized anxiety disorder' rather than 'major depressive disorder with anxious features', or as 'panic disorder'.”

That, however, is a more colloquial, informal way of using “caused by” in medical contexts.

4)

So, to recap:

• Diagnostic terms can simultaneously have two different referents, descriptive and causal
• Just because diagnostic terms can have two different referents doesn’t mean that they necessarily do all the time, or that the hypothesized causal intension has anything of explanatory value to offer
• We sometimes colloquially use ‘caused by’ with the meaning of ‘this is how it best makes sense’ or ‘this is how it is best described’.