jettison schizophrenia? no thanks…

Posted on Friday 27 March 2015

Picking up where I left off in jettison schizophrenia?…, I’m talking about my objections to getting rid of the diagnostic category called Schizophrenia for the last century. First, some case examples:
  1. Recently, I mentioned the first case assigned to me as a psychiatry resident, a woman I called Gloria [back to the drawing board…] who was hospitalized awaiting a transfer to a long term facility as a NGRI [Not Guilty by Reason of Insanity] case after drowning her son during a psychotic episode. I came to my residency after a tour of duty in an overseas Air Force hospital where I was an Internist. When I decided to change specialties, while still there, I read everything I could get my hands on about psychiatry. There was a copy of Eugen Bleuler’s 1911 Dementia Praecox or the Group of Schizophrenias in the hospital library, and I read it from cover to cover. Why it was in the small library of our small hospital in rural England is unknown to me. But I was taken with his description of the premorbid personality of patients who went on to develop Schizophrenic illnesses, and what he called the Primary Symptoms [the four As: loosened Association of thought, inappropriate Affect, global Ambivalence, and Autism – private logic]. I also read the Psychiatry Textbook of the day, Friedman and Kaplan, that had a detailed discussion of the "psychotic break" in the Schizophrenic patient. In back to the drawing board…, I mentioned a conversation with Gloria’s mother, but that was only one of several. Her mother came at every visiting time, and would often catch me and talk about her daughter. It seemed to help her tell the story, and I was more than happy to listen. She described her daughter exactly as Bleuler and the text I had read – schizoid features in her persona, periodic temper outbursts, a long period of seeming confusion prior to "the break." I was amazed at the concordance of her description and Bleuler’s century-old writings.
  2. A few years ago, I described a case I saw not long after finishing my residency [see 1. from n equals one, 2. from n equals one, etc]. She was hospitalized after she had been stopped from jumping from the 14th floor of the atrium in a downtown hotel. I was the fourth psychiatrist to see her and none of us quite knew what was going on. From my previous post:
    She was confused. My friend was confused. So was I. She didn’t seem depressed and had no explanation for her behavior. At the time I saw her, she was completely focused on getting out of the hospital because she didn’t want to be a financial burden on her parents. It was over thirty years ago, but I recall  the interview clearly. She was coherent with no signs of psychosis. She was ill-suited and untrained for her job, but mainly felt she’d failed her parents who had been instrumental in getting it through a friend at the bank. She had no explanation for her behavior. What I mainly recall from the interview was that she tried very hard to answer every question I asked her, but looked at me oddly, as if to say, "Why are you asking that?" I saw her several times, still feeling somewhat lost. By this time, the pressure to leave the hospital had escalated and they set up a plan. She would go home to her parents house, take a leave from her job, and see both my friend and I as an outpatient. Once home, she refused both options, or to take any medicine, or to see anyone else. She told her parents that she would see me in the future, when she’d "sorted things out."
    I had a hunch that this was the prodrome to a schizophrenic break based on her history, presentation [and reading Bleuler]. She had already been tried on an antipsychotic with no effect. I saw her parents as something as an advisor while she lived at home, obviously uncomfortable but steadfast in her resolve to sort things out by herself. Then one day, she asked to see me, appearing in my waiting room that afternoon in a psychotic state and was admitted for the first of several hospitalizations. I followed her at varying intervals until I retired some  twenty plus years later.
  3. In the recent weeks, we’ve finally seen the case of Dan Markingson being definitively dealt with [from Minnesota: Dan Markingson revealed…, ethics…, making sense…]. In making sense…, I was discussing the last several moths of his life. He was apparently not overtly psychotic. There’s no mention of hallucinations or the bizarre delusions that had been apparent in the earlier period of his illness. But he was not doing well at all. There are indicators from most of the venues where he was seen and his own journal that he was decompensating without the psychotic symptoms he’d had on admission – instead he had the "Primary Symptoms" as described by Bleuler.
So when Moncrieff and Middleton say [see jettison schizophrenia?…]…
    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»
… I wonder if they’ve seen the same kind of patients I’ve seen over the course of my career. I share their outrage with those in this generation of psychiatrists who have made such a mess of things by allying themselves with the pharmaceutical industry, or who have steadfastly stuck with the silly notion that all mental illness has some biological basis, or who think that the solution to mental illness will come in a pill bottle or a long acting injection. But I can’t imagine seriously suggesting that Schizophrenia is on a continuum with normality as we heard about in the BPS Report [Understanding Psychosis and Schizophrenia], or not even really a distinct syndrome as suggested here – merely psychosis or madness. We know a whole lot about Schizophrenia, and a lot about being Schizophrenic, and a lot about the difficulties that can come as a consequence. Rather than jettison the diagnosis, we would be better placed to jettison the mistakes of the past that may have lead to a generic and simplistic approach to this prevalent and sometimes devastating illness.

In case 2. above, if I hadn’t suspected that this patient was in the throes of an incipient Schizophrenic break, I wouldn’t have been able to work with her parents to put here in an environment that could catch her the minute she fell through the ice instead of making another forray to a 14th floor balcony and plunging to her death. I wish we knew how to short circuit the breakdown, but we don’t [at least I don’t]. In case 3., if Dan Markingson’s caretakers had been more knowledgeable about this illness and more attentive to Dan in those latter months, they might have recognized that he was decompensating in front of their very eyes, even in the absence of the psychosis and delusions that he’d shown them earlier. If they had, they would’ve removed him from the study and gotten him the treatment he clearly needed [which in this case would’ve likely involved more and/or different medication, for one thing]. And Gloria and her mother [1.] will be haunted for all times by what she did in the midst of a psychotic decompensation. If only she’d been seen by someone who knew what was happening. That’s what her mother wanted to talk to me about in those evening chats, "Why didn’t I know what I was seeing?" Throwing out the baby with the bathwater just isn’t the right way to go about things.
    March 27, 2015 | 9:31 PM

    Psychiatrists could recognize and treat schizophrenic patients without the label (only descriptions) if they could get paid without doing so. If they could do so with the knowledge that some people can recover without drugs or with limited drug use, well then reality will have been acknowledged.

    John Nash recovered without medication, but the screenwriter for A Beautiful Mind credited new medications for his recovery. That was a lie, but the screenwriter’s mother was a psychiatrist (or psychologist) who didn’t want to “encourage” people to go off their meds. This kind of lying is unethical, inhumane, and not scientific.

    It’s the baggage that goes with the label, and the failure to acknowledge that medication is not the only answer that contributes to the stigma and patronizing of people who suffer with schizophrenia. The psychiatrist isn’t the only person in the lives of people who suffer schizophrenia.

    James O'Brien, M.D.
    March 27, 2015 | 9:49 PM

    300 or so questionable diagnoses in DSM and they go after one out of the group of fifteen or twenty that are pretty bonafide clinical categorical clusters…one that Feighner et al signed off on as pretty legit…

    Why don’t we go after the marginal stuff first and leave the more statistically valid and reliable constructs alone for now?

    I do have to agree there is a certain Schadenfreude to watching the irrationalists go after each other….

    berit bryn jensen
    March 28, 2015 | 6:50 AM

    The field trials ahead of DSM 5 were unimpressive. Validity. None. Reliability. Weak. The scientificsounding label of schizophrenia is heavily loaded. Negatively. Diagnosis as self fulfilling prophecy. Discarded in Japan and some other Asian countries. The first time I protested an illegal intervention here in Norway, the then chief medical doctor at the local hospital answered thus: Do you really think that he’ll ever recover? My answer was that neither he nor I could predict the future, but that treatment to make it possible is a human right. The local standard of heavy drug treatment killed my then 28 year old son. Another doctor called to offer his condolences, saying: It’s the better (outcome) that he died. I do not trust orthodox psychiatry or mainstream psychiatrists, brainwashed by training and practice, too often blind to the iatrogenic harm they visit on the patients. Richard Wagner has documented that political economics play a huge part in how patients fare. The paradox is that the richest countries produce worse outcomes, as medicine sold its soul to industrial interests, a truly Faustian bargain.

    March 28, 2015 | 9:06 AM

    Wait for it, the plane massacre this week will thrust mental health issues into the employment debate once again, and thus villainize any and all with psychological distress. God forbid one is schizophrenic and trying to gain employment…

    Su Gadlfy
    March 28, 2015 | 11:53 AM

    I’m honestly a little astounded that M & M’s article got through peer review. They demonstrate little or no understanding not only of Bleuler’s work, but seem more or less completely unaware of the entire phenomenological psychiatry tradition (Minkowski, Schneider, Kimura Bin, Gerd Huber and the German Basic Symptoms group, Josef Parnas, Louis Sass, Thomas Fuchs, etc.). Instead, the recourse to psychosis seems to align with the broader British clin psych trend of re-centering and reframing all “psychosis” (including severe schizophrenia) in terms of precisely those symptoms or syndromes that leading phenomenologists would never have classed as schizophrenia–i.e. dissociative voices, non-bizarre paranoia (which the authors themselves arguably evince) and poor coping. Nowhere in their tacit re-definition of psychosis does one see autistic symptoms (truly idiosyncratic logic & communication), full-fledged formal thought disorder, mannerisms and disorganization, ontologically bizarre delusions, etc. etc. Nowhere do we see the pronounced self-neglect that so often leads to tragedy; again, precisely not through acute suicidality, suicide attempts or homicide.

    Ultimately, then, M & M’s piece is not only unscholarly and disconnected from clinical realities, but verges on a not insignificant moral ‘violence’ of it’s own.

    berit bryn jensen
    March 28, 2015 | 12:02 PM

    The pilot is said to have received medical treatment, possibly, likely for depression. We can ask what kind of therapy, psychotherapy, music therapy, meditation, …. with or without drug therapy? Which drug/drugs? Will there be evasions, denial, silence…as so often before, or will the bereaved, Lufthansa and European governments demand and get the truth?

    Dr Hassman, I respectfully ask if you would please refrain from saying that a person “is schizophrenic”. I know quite a few persons who have been labelled with the diagnosis, who have come to harm by it and the coercive treatments accordingly meeted out, which the UN CRPD is in position to rectify and ensure that prejudice does not pass off as difference.

    James O'Brien, M.D.
    March 28, 2015 | 12:23 PM

    Are we objecting to the clinical reality or the euphemism? I agree that “split personality” is an unfortunate etymology, but does “chronic progressive paranoid psychosis” really sound that much better?

    What coercive treatments are you talking about? Have you ever tried to keep a floridly psychotic and homicidal/suicidal person in the hospital for more than three days?

    This facile and uninformed attitude is exactly why the mentally ill end up in prisons and jails.

    March 28, 2015 | 3:13 PM

    While I apologize if the term is seen as perjorative, I think as a Psychiatrist it does have some applicability. But, I will not use it again at this blog.

    However, if the debate is whether there is such an illness to begin with, I will not go down that cul de sac of insidious intent. Sorry, 22 years of working with patients who fit the diagnosis will not be denied, minimized, or rationalized away to fit an agenda that does not help these patients.

    And if you read me with any regularity, I am NOT about meds first and only with any psychiatric illness. If I read you wrong, then ignore this comment past the first paragraph.

    March 28, 2015 | 6:49 PM

    After reading Dr. Nardo’s last two posts, my second reaction was this: I think it’s important not to panic.

    Because that was exactly what my first reaction was after reading that Moncrieff and Middleton would prefer to do away with the diagnosis of schizophrenia.

    We live in an age when we seem to have lost the ability to learn from our own folly, when we can only hastily patch over one error with an error of a different order. Mental health has become a very dangerous business, but every attempt to correct it seems to lead to greater confusion. Every mission seems to turn into Apollo 13. I know it’s like that in many other disciplines as well, but it’s frightening.

    “I wonder if they’ve seen the same kind of patients I’ve seen over the course of my career.” Yes– or in my own personal life, because these clients are well outside my scope of practice.

    I had very close two friends develop almost identical symptoms of schizophrenia in the mid 1980s. Both had messianic delusions involving religious iconography and themes of alien invasion. Both would speak in near word-salad, and then– maddeningly– become nearly lucid, lulling their friends, family and treatment team into a false sense of remission. Neither of them knew the other, and both had unremarkable histories of recreational drug use. Both did not begin treatment with antipsychotic medication until their illness was very advanced, and for both of them, it appeared to have absolutely no impact on the course of the disease.

    Both could not be trusted to lock doors, either from the inside or outside of our apartment. Both craved junk food, particularly anything containing refined sugar, and chain smoked. Both would abruptly disappear and take to the streets, and then reappear unpredictably– in other cities, at nightclubs, in mental hospitals, in the cockpits of planes at small airports– often after walking dozens of miles in their bare feet.

    Anyone who met these two people would never doubt for an instant that they had the same disease. And personally, I don’t have a problem with giving that disease a very serious label, because both of those guys I just described were very good friends of mine, and it killed one of them and I have no idea what happened to the other.

    The pain that disease caused still echoes through my family and friends. I know it’s hurt other people I love terribly, who lost their friends or family members, and caused them a kind of pain I can do nothing stop, and that fills me with rage and frustration.

    I agree with Berit that it’s more respectful to avoid the term “schizophrenic” and speak of the disease as something apart from the person. That’s part of the training now, and I think it’s important to conceptualize the disease as an “it” and the patient, or client if you prefer, as a person.

    But I would no more deny the existence of schizophrenia than I would turn my back on any other dangerous adversary.

    Berit, I am terribly sorry for your loss. My heart goes out to you and your family.

    I am very grateful for this blog. Su, thanks in particular for your elegant critique.

    Brett Deacon
    March 28, 2015 | 9:07 PM

    I can tell what a loaded issue this is for those used to approaching schizophrenia from a biomedical perspective. I’m not here to critique arguments on either side, though I can’t help noting that the scientist in me is intensely uncomfortable when people offer cherry-picked case examples to prove a given point. What I would like to ask those who defend the brain disease approach to schizophrenia/psychosis is this: what real-world outcomes support the value of this approach? I don’t mean subjective impressions gleaned from clinical work, the results of clinical trials, or findings from meta-analyses, I mean real-world, population-level outcomes (e.g., severity/disability rates, mortality, life expectancy, stigma, long-term treatment outcomes, etc.). As I understand it, such outcomes are quite poor in the US despite the decades-long near-complete dominance of the brain disease approach. If this is the case, why is support so strong for this approach?

    March 28, 2015 | 9:20 PM


    Do you see this as a Brain Disease post? I don’t, and I wrote it. I see it as a defense of the syndromatic condition we know as Schizophrenia. That does not equate with Brain Disease in my book. Likewise, were I to be writing about the Borderline Personality Disorder, I would see it as a syndrome, yet argue until the cows came home that it’s not a Brain Disease. I don’t know what Schizophrenia is caused by, but I know it as a syndrome – and that’s the point of the post. I find knowing it useful clinically, and my examples are, as you say, picked – picked to show places where it was helpful to know it. I’m actually not a biomedical doctor. A reading of this blog will attest to that. I’m an internist/psychiatrist/psychoanalyst who spent my practice career primarily doing psychotherapy.

    “What I would like to ask those who defend the brain disease approach to schizophrenia/psychosis is this: what real-world outcomes support the value of this approach? I don’t mean subjective impressions gleaned from clinical work, the results of clinical trials, or findings from meta-analyses, I mean real-world, population-level outcomes (e.g., severity/disability rates, mortality, life expectancy, stigma, long-term treatment outcomes, etc.). As I understand it, such outcomes are quite poor in the US despite the decades-long near-complete dominance of the brain disease approach. If this is the case, why is support so strong for this approach?”

    I don’t think defending the syndromatic nature of “Schizophrenia” says anything about the Brain Disease approach [and maybe your question isn’t directed at me]. Because I’m as put off by a lot of that stuff as you are. Again, a reading of this blog would tell you that. But I don’t see the way to argue with the Jefferey Lieberman’s of the world being to undo a time honored syndromatic definition that is helpful and much more descriptive of the patients I’ve seen than “psychosis” or “madness.” If they’ve equated “syndrome” with “causality,” raise holy hell about that. If the current ways of defining that syndrome are amiss, refine the description.

    I would add that revising diagnoses because of implications is in general a mistake. That’s what Spitzer did in 1980 and it remains as the disaster of MDD…

    Later thoughts: I suppose that a syndrome does imply a unified cause, and that unified cause might well be “biological.” It might well be “psychosocial” too. But I don’t think that the fact that certain aspects of psychosis respond to antipsychotic medications says anything about etiology. It says something about symptomatic medicines. In another venue, CPN/Moncrieff argue that antipsychotics are drug specific, not disease specific. I agree with that point, but don’t much see the import of it unless there are still people around who think it’s a dopamine deficiency [I don’t know any of those]. As an Internist, I can think of very few disease specific medications – Vitamins in deficiency states. Hormones in deficiency states. Maybe insulin? But most medications are poisons being used for their effects, and all should be used with care because of that fact.

    And irrespective of the etiology of Schizophrenia, I think that for many of those patients, a psychotherapy informed by a thorough and in-depth understanding of the syndrome itself and the problems it brings is just what the doctor ordered. Psychotherapy doesn’t necessarily mean “fix.” Often, it means “help with” or “help live with” [And sometimes “fix”].

    Brett Deacon
    March 28, 2015 | 10:27 PM

    Mickey, I see I wasn’t sufficiently clear in my last post. I did not mean to imply that you were advocating the brain disease approach. I understand and appreciate the nuance in your position on these issues. I was referring to what seems to be the general response among psychiatrists (like Lieberman, Frances, some commenters here) who have criticized the BPS report and now the Moncrieff/Middleton article. From my reading of such criticisms, it seems that defense of the status quo/biomedical paradigm is part of the basis for rejecting the BPS report. This is the issue raised in my last comment – why does this approach enjoy such strong support given the poor outcomes associated with it?

    Thanks for this clarification! I always enjoy hearing your perspective and almost always agree with you.

    I could say much more about the interesting issue of the language we use to describe psychological problems (disease/illness/syndrome), the different kinds of scientific evidence required to validate these terms, and how using these terms affects the people who hear them. I conduct research on these issues and have learned that both laypersons and symptomatic individuals make assumptions about blame, prognosis, dangerousness, unpredictability, agency, and so on based on the language we use to construe a given problem. Once we reify a psychological problem by labeling it as a categorical syndrome or disorder (and more obviously, as an illness or disease) the person “has”, assumptions about biological causality, the need for biological treatment, and the perception of a chronic course may soon follow whether we intend them to or not. The BPS report and the Monrieff/Middleton article interest me because research suggests that adoption of the language they propose would likely have important, beneficial psychological effects on the public and symptomatic individuals.

    March 28, 2015 | 10:29 PM


    “is a schizophrenic” can be used as an epithet or discounting label. I appreciate your highlighting that point. It’s a point easy to forget and it can be harmful.

    March 29, 2015 | 5:43 PM

    Challenging the use of terms legitimately applicable in psychiatry is just trying to chip away at legitimate boundaries. Schizophrenic as a word itself is not an insult, but, if it is used in a sentence or phrase that has derogatory or inciting intent along with the word, then the argument has merit for that situation.

    Dr N, read up on Alinsky tactics, you might find it interesting.

    Bernard Carroll
    March 29, 2015 | 5:59 PM

    We can tell what a loaded issue this is for Brett Deacon. Dr. Mickey caused him to walk back his insinuation that he (Dr. Mickey) favored Deacon’s straw man “brain disease approach to schizophrenia/psychosis.” Deacon then proceeded to sound off about “some commenters here… who have criticized the BPS report and now the Moncrieff/Middleton article.” Brett Deacon charged that “From (his) reading of such criticisms, it seems that defense of the status quo/biomedical paradigm is part of the basis for rejecting the BPS report…” “Some commenters here…” would include me.

    This is not the first time that Brett Deacon has given us untrue statements about what I said. He did it here before. In relation to the BPS report, I was clear that a biopsychosocial approach is needed. As for the Moncrieff/Middleton paper, any competent reader of my comment would recognize that I was not defending the status quo/biomedical paradigm. My critiques of both the BPS report and of the Moncrieff/Middleton paper had nothing to do with guild issues and everything to do with the weakness of their science.

    Brett Deacon also gave us another cockeyed framing of an issue with his challenge to produce “real-world, population-level outcomes…” resulting from the biomedical, brain disease approach. I have two comments here. First, whatever the outcomes are, they are produced not just by a brain disease approach but by the entire health system, and they are in any case far superior to what they were before the antipsychotic drugs (with all their drawbacks) appeared. Second, schizophrenia is a terrible disease that has eluded definitive understanding of its mechanisms, much like multiple sclerosis. So we work on whatever points of leverage we have for controlling symptoms, and any assessment of “real-world, population-level outcomes…” must take account of the intractability of the problem, just like in multiple sclerosis. Brett Deacon makes a logical error when he indicts the approach to research in schizophrenia for the slow progress of knowledge. Some scientific problems just are very difficult, and schizophrenia is one of them. Deacon has no basis to begrudge funding of research on schizophrenia any more than he has a basis to begrudge funding of research on multiple sclerosis, where progress is equally slow. And if he has something really new and incisive to offer then I for one am all ears!

    March 29, 2015 | 7:26 PM

    I agree with that point, but don’t much see the import of it unless there are still people around who think it’s a dopamine deficiency [I don’t know any of those].

    Oh, but the general public believes this and promotes it as a scientific fact.

    Brett Deacon
    March 29, 2015 | 8:04 PM

    Bernard, I will respond to your post because you called me out as a liar. I am tired of your misleading statements and your disrespectful communication style. You seem to fancy yourself as a policeman of sorts here, a heroic guardian of truth who must forcefully brush aside ideas that are contrary to your favored version of reality. You insult others, like Moncrieff and Middleton, with vile taunts dressed up in academic language. Your aggressive, vitriolic presence on this blog discourages a more lively and substantive exchange of ideas in the comments section, which is a real shame given the exceptional quality of Mickey’s posts. I will not be engaging with you further once this comment is submitted, on this or any future post.


    A few comments above, I wrote this: “What I would like to ask those who defend the brain disease approach to schizophrenia/psychosis is this: what real-world outcomes support the value of this approach?”

    Mickey responded by asking if construed his post, and/or him personally, as advocating the brain disease model. I clarified that I did not. I know Mickey’s perspective well and I did not mean to imply – and I contend that I did not imply – that Mickey supports this model. If I thought he supported this model, I would have asked him directly. I didn’t walk anything back, I clarified a misunderstanding. That much should be obvious to “any competent reader.” But I understand that mischaracterizing our exchange better serves your goal of discrediting me.

    You went on to claim that the above misunderstanding is not the first time I have given “untrue statements.” Here we see the above misunderstanding elevated to the status of a lie, which is apparently indicative of my propensity to lie. What are my other lies? I will review those below, my first I note your claim, “I was not defending the status quo/biomedical paradigm. My critiques of both the BPS report and of the Moncrieff/Middleton paper had nothing to do with guild issues and everything to do with the weakness of their science.” That’s nice. And also tangential. I did not mention your name in my comments, nor did I accuse you of defending the status quo/biomedical paradigm, or pursuing guild issues. You volunteered yourself as a target of my previous comment when you were not, then criticized me for directing my comment at you. I shake my head at the oddness of your response.

    Now, regarding my alleged lies:

    -Our previous exchange involved a mistake on my part: I misread your passage and did not notice that your case example was a real patient, so I accidentally characterized your case example as fictitious. You took strong offense at this. I was unable to clarify my mistake because the comments had closed.
    -I read the rest of the exchange as involving differences of opinion about specific claims. I don’t see any other examples of statements that could be construed as lies. But I do see numerous examples of arguments from you that I consider questionable, such as:
    -If a drug that alters brain chemistry helps a problem, that problem must be caused by faulty brain chemistry (reasoning backwards from what works is a well-known logical fallacy).
    -Delusional thinking and grandiose behavior must “come from the brain” (this statement is a tautology).
    -I was wrong to claim the DSM diagnostic system attributes mental health problems to biological disease and is explicitly atheoretical (I actually claimed that within the biomedical approach, DSM diagnoses are attributed to biological disease; also note that classifying mental health problems as categorical entities is far from atheoretical).
    -Steven Sharfstein was not lying when this exchange took place (I’m paraphrasing, transcript here:

    Katie Couric: Tom Cruise says there’s no such thing as a chemical imbalance.
    Joseph Glenmullen: That’s right.
    Steven Sharfstein: I disagree.

    As we all know, there is, in fact, no such thing as a “chemical imbalance.” Sharfstein was either lying, or has a breathtaking misunderstanding of the science in this area (not likely for an APA president). Given that he was on the Today Show for damage control purposes, one of those explanations seems more likely than the other.

    It is clear there is no point in engaging you in a rational, scholarly discussion of the issues raised in my previous comments, so I will end my comment here.

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