{"id":69605,"date":"2016-12-19T15:21:55","date_gmt":"2016-12-19T20:21:55","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=69605"},"modified":"2016-12-19T15:21:55","modified_gmt":"2016-12-19T20:21:55","slug":"klerman-1978-schizophrenia","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2016\/12\/19\/klerman-1978-schizophrenia\/","title":{"rendered":"Klerman 1978: schizophrenia…"},"content":{"rendered":"\n

Psychiatry was obviously ripe for the the medicalization<\/font><\/em> ushered in by the neoKraepelinians and the DSM-III released two years after this article. Changes in reimbursement schedules, a burst of new psychotropic drugs certified by industry funded clinical trials, and a focus on neuroscience research soon followed. The disappearance of the public mental hospitals was matched by similar closings in the private sector. And the boundaries between academic psychiatry, guild organizations, and the pharmaceutical industry became increasingly indistinct.<\/p>\n

In the period since this chapter was written, the large mental institutions closed for good, replaced, with the reinstitutionalization of many chronic mental patients in our jails and prisons. Psychiatry did indeed medicalize<\/font><\/em> to the point that most psychiatrists became primarily involved in pharmacologic and other biological treatments. And the neuroleptic drugs used in the treatment of psychosis in Klerman’s time were for the most part forgotten, replaced by a string of new Atypical Antipsychotics.<\/p>\n

Although The Evolution of a Scientific Nosology<\/a>] is a broad commentary about nosology in general, it’s in a book called Schizophrenia: Science and Practice<\/font><\/em>, sandwiched among a number of different perspectives [though it would soon become the dominant point of view]. Here’s what Klerman had to say about Schizophrenia in 1978:<\/div>\n
\n
What has been the influence of the disease approach on understanding schizophrenia? The neo-Kraepelinian answer has been another question: Does the concept of schizophrenia have any meaning, and if it does, what are the data that give it meaning? In other words, the concern has been with what one might call the epistemology of diagnosis; namely, what are the rules of the game? In the disease approach, there are six steps toward validating a concept of an illness such as schizophrenia.<\/div>\n
    \n
  1. \n
    Define the theoretical bases with clarity. It is very important to make explicit the assumptions on which the many conceptual views of schizophrenia are based. But unfortunately much of psychiatric discourse until the middle of this century* has never moved beyond these theoretical debates. In order to move psychiatry beyond philosophy and into science, the second step must be taken.<\/div>\n<\/li>\n
  2. \n
    Translate the general concept into specific hypotheses that can be operationally tested. For example, what is the meaning of borderline schizophrenia? What are its components? How does it manifest itself?<\/div>\n<\/li>\n
  3. \n
    Put the hypothesis to empirical testing to determine its reliability. How well do several observers agree that a borderline patient does have ego deficits, is using splitting or denial?<\/div>\n<\/li>\n
  4. \n
    Subject the data to various statistical tests to determine whether we are dealing with one syndrome alone or a mixture of syndromes.<\/div>\n<\/li>\n
  5. \n
    Attempt to validate the statistics by follow-up studies, family and genetic investigation, correlates in childhood development, and so on<\/div>\n<\/li>\n
  6. \n
    Undertake epidemiological studies to ascertain the patterns of incidence and prevalence.<\/div>\n<\/li>\n<\/ol>\n
    How well, then, does schizophrenia meet the criteria of a chronic disease in the medical model? It meets it well but not completely. Before one can conclude definitively that schizophrenia is a disease, conclusive evidence will have to be presented as to etiology and clinical course. While such evidence exists for many other disorders in psychiatry, it does not yet exist for schizophrenia — nor for many other clinical conditions with which medicine deals, such as hypertension, arthritis, and leukemia. That is to say, it is an obviously disordered state with multiple determinants in which there is not certainty as to the exact etiology. Moreover, schizophrenia as we now’ define it is similar to hypertension in that it is likely to comprise various disorders. As the specific etiological principles come into scientific investigation, we will probably reaffirm Bleuler’s concept of a group of schizophrenias. Nevertheless, it is likely that within this group of schizophrenias there is a core group that has a strong genetic component. This genetic factor creates a vulnerability that becomes manifest in psychosis when precipitated by environmental stresses.<\/div>\n<\/blockquote>\n
    In his introduction to the chapter, Klerman had said of Emil Kraepelin…<\/div>\n
    \n
    His textbook was significant in tlie history of psychiatry not because it was the first textbook of psychiatry but because it was one of die first to approach mental illness in terms of causation and etiology, using the principles of modern scientific medicine.<\/div>\n<\/blockquote>\n
    and<\/div>\n
    \n
    After classifying as many cases of mental illness as possible by etiology — those due to infection, to endocrine disorders, and so on — Kraepelin was left with a large group of patients whose psychoses began in young adulthood and went on for many years but who had relatively few deaths… Kraepelin proposed that these psychotic conditions with no established etiology be further divided into two groups, which he called “dementia praecox” and “manic-depressive insanity.” He justified this division on the basis of clinical features during the acute illness, long term course, and outcome.<\/div>\n<\/blockquote>\n
    … capturing the conundrum that continues to haunt these discussions – from among the psychotic cases with no established etiology<\/font><\/strong><\/em>, Kraepelin was a pioneer for approaching them in terms of causation and etiology<\/font><\/strong><\/em>. In the snippet from his section Schizophrenia as a Disease <\/font><\/em>quoted above, he lays out a pathway to define such Diseases<\/font><\/em>.<\/div>\n

    Most psychiatrists have traditionally accepted the disease model based on the syndromatic constellation and predictable course, suspecting a biological etiology to show itself sooner or later. The critics are less taken with the homogeneity of the syndromes [see a guest post from Sandy Steingard…<\/a>], many seeing guild hegemony and medical training as unacknowledged complicating factors. That conflict is, if anything, more intense now than it was in 1978.<\/p>\n

    Gerald Klerman and the neoKraepelinians had an unprecedented impact on the subsequent course of psychiatry itself. On the other hand, the plight of the patients with the schizophrenias, particularly those with its chronic forms, have not seen much change in the four decades that followed.<\/div>\n","protected":false},"excerpt":{"rendered":"

    Psychiatry was obviously ripe for the the medicalization ushered in by the neoKraepelinians and the DSM-III released two years after this article. Changes in reimbursement schedules, a burst of new psychotropic drugs certified by industry funded clinical trials, and a focus on neuroscience research soon followed. The disappearance of the public mental hospitals was matched […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[5],"tags":[],"class_list":["post-69605","post","type-post","status-publish","format-standard","hentry","category-opinion"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/69605","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=69605"}],"version-history":[{"count":10,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/69605\/revisions"}],"predecessor-version":[{"id":69615,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/69605\/revisions\/69615"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=69605"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=69605"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=69605"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}