jettison schizophrenia?…

Posted on Thursday 26 March 2015

Current Opinion – Review
by Joanna Moncrieff and Hugh Middleton

Purpose of review The term ‘schizophrenia’ has been hotly contested over recent years. The current review explores the meanings of the term, whether it is valid and helpful and how alternative conceptions of severe mental disturbance would shape clinical practice.
Recent findings Schizophrenia is a label that implies the presence of a biological disease, but no specific bodily disorder has been demonstrated, and the language of ‘illness’ and ‘disease’ is ill-suited to the complexities of mental health problems. Neither does the concept of schizophrenia delineate a group of people with similar patterns of behaviour and outcome trajectories. This is not to deny that some people show disordered speech and behaviour and associated mental suffering, but more generic terms, such as ‘psychosis’ or just ‘madness’, would be preferable because they are less strongly associated with the disease model, and enable the uniqueness of each individual’s situation to be recognized.
Summary The disease model implicit in current conceptions of schizophrenia obscures the underlying functions of the mental health system: the care and containment of people who behave in distressing and disturbing ways. A new social framework is required that makes mental health services transparent, fair and open to democratic scrutiny.
It would be foolish to argue with Drs. Moncrieff’s and Middleton’s point that diagnostic labels can and have been used to imply a biologic causes, particularly when the Director of our National Institute of Mental Health proposes we look at Psychiatry as a Clinical Neuroscience Discipline, or when commentary like this …
    Major depression is now recognized as a highly prevalent, chronic, recurrent, and disabling biological disorder with high rates of morbidity and mortality. Indeed, major depression, which is projected to be the second leading cause of disability worldwide by the year 2020, is associated with high rates of mortality secondary to suicide and to the now well-established increased risk of death due to comorbid medical disorders, such as myocardial infarction and stroke…
    by Sally Laden for Nemeroff et al
… abounds in the contemporary psychiatric literature and dialog. The bio-psychiatry that Moncrieff and Middleton are arguing against is actually quite a leap from Dr. Spitzer’s introduction to the DSM-III in 1980:
    For most of the DSM-III disorders, however, the etiology is unknown. A variety of theories have been advanced, buttressed  by evidence – not always convincing – to explain how these disorders came about. The approach taken in DSM-III is atheoretical with regard to etiology or pathophysiological process except for those disorders for which this is well established and therefore included in the definition of the disorder. Undoubtedly, with time, some of the disorders of unknown etiology will be found to have specific biological etiologies, others to have specific psychological causes, and still others to result mainly from a particular interplay of psychological, social, and biological factors…
    Robert Spitzer, in the DSM-III, p 6.
It’s now well known that one agenda of that DSM-III effort was to remove the influence of psychoanalysis from American psychiatry, an effort that was largely successful. And it’s also clear that the biological agenda of the neoKraepelinians was a powerful force in shaping the form of that revision. In fact, one of the enduring flaws in the DSM-III system – the lumping of the Major Depressive syndromes with the much more common reactive depressions – was driven by the zeal to remove depressive neurosis from the diagnostic system [see a mistake…]. The net result was to shut down productive research on those major syndromes [by dilution] and to open the door [by inclusion] to industry and their minions [like Dr. Nemeroff and ghost·writer Sally Laden above] for a decades·long antidepressant marketing spree. We were not led from «atheoretical with regard to etiology» to «a highly prevalent, chronic, recurrent, and disabling biological disorder» by scientific discovery – it was by rhetoric, extrapolation, and the persistent vilification of defeated enemies.
    «Schizophrenia is a label that implies the presence of a biological disease, but no specific bodily disorder has been demonstrated, and the language of ‘illness’ and ‘disease’ is ill-suited to the complexities of mental health problems»
Again, I’m not arguing with their assertion that diagnostic labels in psychiatry have come to imply the presence of a biologic disease in many circles. That bothers me as much as it seems to bother them. But it doesn’t take an Etymologist to see that the "language of ‘illness’ and ‘disease’" doesn’t come from biological causation. Both ‘ill-ness’ and ‘dis-ease’ describe how a patient feels, not what is causing the discomfort. They are symptom words. And that’s no minor point – one that describes Medicine from the dawn of time. In fact, the word diagnosis itself [Greek diagnôsis, discernment, from diagignôskein, to distinguish : dia-, apart] has nothing to do with cause. It literally means to know apart.

I came to psychiatry from a career in Internal Medicine [formerly known as Diagnosticians]. And my first encounter [in my life] with the phrase medical model of disease or the idea that a diagnosis implied biological causation came from a fellow first year psychiatry resident [whose copy of Szasz’s The Myth of Mental Illness was always within arms reach – see Szasz by proxy…]. The idea that disease was certified by objective biosignatures was foreign to me. So I read Szasz’s books and I think I gained some things by pondering the questions he raised, but his were forced arguments to me. Diagnosis didn’t lead to cause for me in either career – it lead to action, to treatment. If I were a surgeon at the Battle of Gettysburg and you were brought to me with a gunshot wound to the leg, I sawed your leg off. It wasn’t because I knew anything about infection. During our Civil War, Louis Pasteur was still studying wine-making [it was well after Appomattox when he came up with his germ theory of disease]. I sawed off your leg because I knew you’d die if I didn’t.

And as a Rheumatologist in that former life, there were only a few lab tests that helped at times, but the main guideposts for treatment and prognosis came from careful clinical diagnosis. So although like Moncrieff and Middleton, I can see that psychiatric diagnosis has been jury-rigged to imply biological causality by too many people in high places, I see that as a perversion of the meaning of medical diagnosis – something that needs to be fixed and clarified.

And agreeing with the problem they describe doesn’t lead me to necessarily agree with their solution. If they were talking about the DSM-III-IV-5 category Major Depressive Disorder, I’d jump on the train in a blue second. But I’m balking at following along with Schizophrenia. One reason for my hesitation is that their reason to jettison the diagnosis relies heavily on their aversion to the implications of the diagnosis – implications imputed there without solid scientific back-up, as perversions of the traditional meanings and uses of medical diagnosis. It’s a reaction against something. I felt the same way about the BPS Report [Understanding Psychosis and Schizophrenia] which was also driven by a reaction against that same something [see <to be continued>…, back to the drawing board…]. That’s what Dr. Spitzer’s DSM-III did, reacted so strongly against something that the result was the creation of some big problems [this one included] that we still deal with some thirty-five years later. Likewise, Moncrieff and Middleton clearly have some «alternative conceptions of severe mental disturbance» that remain as speculative as those of their biologically inclined counterparts.

But neither of those things get at my main objection to their recommendation to jettison the diagnosis of Schizophrenia. I still find that diagnosis clinically useful, much more useful than «‘psychosis’ or just ‘madness’» would be. I’ll try to flesh out why I say that in the next post…
    Bernard Carroll
    March 27, 2015 | 2:19 AM

    There is a perverse rightness about seeing Joanna Moncrieff and Hugh Middleton waste their time railing against the likes of Charles Nemeroff and Thomas Insel. The latter two and their cronies should never be taken seriously, while the former two have nothing of substance to offer in replacement. Moncrieff and Middleton are the founders of the self-styled Critical Psychiatry Network in the U.K. Their paper featured in this post by Dr. Nardo simply repeats many of the airy and tendentious generalities for which CPN is well known. Do they give us any data in support of their narrative? No, but they are quick to import impressions and tendentious speculations that favor their narrative. Do they describe well-conceived and well executed studies of alternatives to diagnosis? No, it is impossible to find any hypothesis being rigorously tested. To my awareness they have no record of ever articulating hypotheses that meet the criteria of practical testability and logical falsifiability. Are they clinical scientists? No. Instead, they sign on to the most literal-minded and pedantic of Szasz’s stale objections to clinical psychiatry as a medical discipline. Then they back that up with gauzy hand waving about social justice and personal freedom.

    There is a revealing passage in this article that reveals their cockeyed framing of the issue: “…the medical framing of mental disturbance and its management acts as a smokescreen behind which the control and manipulation of some people by others can go unscrutinized.” Well, it’s not mainly about control and manipulation. Neither is it mainly about “a variety of behaviours that society has deemed abnormal and undesirable.” It’s mainly about patients seeking help for psychological pain, perplexity, anxiety progressing to terror, depression progressing to suicide, alien perceptual and cognitive changes, and general ego disintegration. Can we all agree on that much?

    March 31, 2015 | 9:28 AM

    Mickey: I’d love to hear your thoughts on the diagnosis of schizoaffective disorder. In practice, in community psychiatry, it seems like it’s used for anybody with psychosis who also has mood problems, and then lots of anger outbursts get called mania.

    Does schizoaffective disorder as a diagnosis have clinical utility?

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