1 Boring Old Man

Schizophrenia: a critical psychiatry perspective

Current Opinion – Review

by Joanna Moncrieff and Hugh Middleton

2015

[full text on-line]

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.

^{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…}
^{VNS Therapy in Treatment-Resistant Depression [2006]}
^{by Sally Laden for Nemeroff et al}

^{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.}

^{«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»}

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.