Schizophrenia: Diagnosis or Delusion?
Much as psychiatrists would like to help the afflicted, it doesn’t help to affix an empty label to an imprecise condition.
“Is schizophrenia a ‘real’ illness?” That’s the eye-catching title of Huw Green’s article in The Conversation. Green, a PhD student and “trainee” clinical psychiatrist at the University of New York, surveys competing groups of psychiatrists, from honest critics who want to update the definition, to radical revolutionaries who want to junk the term altogether. For instance, Thomas Szasz said that schizophrenia didn’t exist until psychiatrists invented the word.
In 1979, the trenchant critic of psychiatry Thomas Szasz called it “psychiatry’s sacred symbol” and wondered at length how psychiatry was able to get away with the perpetration of a crucial and profession-sustaining “myth”.
How can this be possible? Aren’t schizophrenics real people who lose touch with reality, have delusions and think they can defy gravity? Aren’t there genes for schizophrenia? How can we junk a health problem that has become as real in popular parlance as the common cold?
It’s a lesson in scientific interpretation of observations. What causes a set of behaviors? How should they be treated? By inventing a new word, do scientists reify the speculations of their own minds about causes and effects? For instance, a new word “phrenology” (notice the common stem with schizophrenia) gave a false sense of reality to someone’s theory about skull shape as a cause (or perhaps effect) of intelligence. Are psychiatrists repeating history by using a concocted word to reinforce their own speculations?
In other words, is it the psychiatrists who are delusional?
Classification is a messy business. In diagnosis, symptoms with different causes might be lumped under one term. One condition with one cause might manifest itself in different ways and be classified under multiple terms. And some conditions might be purely fictional. The ancient theory of “humors” linked temperaments with bodily fluids. The fluids were real, but the theory had misguided notions of cause and effect, like the idea that a person of “sanguine” temperament was predominantly influenced by blood, and a “melancholy” person by black bile. To add to the confusion, some ancient doctors linked these temperaments to their misguided ideas of the four elements—earth, air, fire, and water. Confusion reigned when combinations of the temperaments had to be explained with combinations of elements or fluids. In their time, ancient doctors imagined they “understood” the phenomena, when by today’s standards, they understood nothing, but were off on rabbit trails.
So how do psychiatrists “know” what schizophrenia is? We’re all much wiser now, aren’t we? Some clues that confusion still reigns can be seen in the way the definition of “schizophrenia” has evolved:
Schizophrenia has been a controversial and shifting diagnosis since the word was coined by Eugen Bleuler in 1911. Its name has undergone quite radical changes in meaning, moving from being seen as a progressive brain disease, to being thought of as a series of “reactions” in the first DSM (the American manual of mental disorders) to increasingly being defined since the 1980s as a neuro-developmental disorder in psychiatric research.
Green refers to a 1991 book by Mary Boyle with the provocative title, Schizophrenia: A Scientific Delusion? While Green does not take sides with the revolutionaries like Szasz and Boyle, he is keenly aware of the controversy. He sees two groups: revolutionaries and reformers. Their main difference is “the degree of urgency they respectively feel about getting rid of the label ‘schizophrenia’.” Reformers think the term is still useful, and indicates a need for psychiatric intervention. Revolutionaries think the term is “more of a barrier than an effective tool for clinical communication, useless at best and a form of denigration at worst.” Sadly, the patients may suffer the most:
“Schizophrenia” is used to justify coercive treatments, it exacerbates mental health stigma, and it has even evolved to become a moderately racist label. Suggestive research on the phenomenon of “stereotype threat” points to the possibility that being known to have the diagnosis may even, under certain conditions, have an exacerbating effect on the psychological and social difficulties of people who meet the criteria. “Get rid of the idea altogether!” say revolutionaries.
There’s an old joke about a teenager whose counselor told him his problem was that he was just plain lazy. The teenager responded, “Now give me the scientific term so I can tell my parents.” One can imagine the teenager coming under the spell of that term and acting out its implications. Telling someone he or she is schizophrenic might similarly lead a patient to act like one. Is the diagnosis worse than the disease? But for the false label attached to him or her, the patient might grow out of it, or otherwise be able to work out a suitable life, as John Nash famously was portrayed doing in the film, A Beautiful Mind. Taking responsibility to discipline his mind worked much better than the cruel electrical shock treatments that the psychiatric consensus of his day prescribed.
Green ends by pointing out that junking the term “schizophrenia” leaves open the problem of what to replace it with. There is no consensus on that. In fact, he says, there is no consensus on what “mentally ill” means: “in the absence of a widely agreed upon definition of “mentally ill” it’s hard to see how the question could be resolved one way or another” —
To ask whether schizophrenia “really exists” is somewhat beside the point. Revolutionaries can, with good reason, say “no”; Schizophrenia is a metaphor, and an often misleading, overly reified one at that. However, reformists can justly point out that while DSM schizophrenia is a historically contingent construction, there is nonetheless an important, often debilitating, set of experiences in its vicinity which we cannot wish away. Arguments over terminology aside, it is the nature of these experiences which holds the most interest to researchers and clinicians, and we still know far too little.
One can hear Galen and Hippocrates chuckling in the background from the junkyard of debunked theories. Humors, indeed.
Depressing all around: On a related subject, Nature revealed that psychology has no good explanation or treatment for depression. One patient cited was helped with a drug combination, but that may indicate an underlying physical problem rather than a psychological problem. Even though Cognitive Behavioral Therapy (CBT) in treating depression is considered “one of the clear success stories” in psychiatry, according to another article in Nature, nobody knows how it works, or why it only works for some people. “Cognitive behavioural therapy is the best-studied form of psychotherapy,” Emily Anthes writes. “But researchers are still struggling to understand why it works.” The answer doesn’t seem to lie in drugs or neuroscience, but rather helping patients in “critically examining those negative beliefs” about themselves. It would seem any good parent, friend, or pastor could do that without the aura of “therapy” or “psychology” giving a false sense of expertise. As usual, promised solutions are out there in the misty future: “Learning more about how CBT works — and why it does not work for everyone — could ultimately help doctors to deliver better care.” In other words, it ain’t here yet. That’s downright depressing.
Update 12/02/14: A Yale team, publishing a paper in PNAS, studies “mental health clinicians” and finds that the more they learn about biological bases for mental disorders, the less empathy they have for patients (see summary on Medical Xpress).
“Biological explanations are like a double-edged sword,” said Matthew Lebowitz, a Yale graduate student in psychology and lead author of the study. “They tend to make patients appear less blameworthy but the overemphasis on biology to explain psychopathology can be dehumanizing by reducing people to mere biological mechanisms.“
Clinicians also viewed psychotherapy as less likely to be effective when provided biological explanations for illness rather than psychosocial ones. This is problematic because many studies suggest certain types of psychotherapy are important and effective treatments for many mental disorders, the authors note.
There are other downsides of biological explanations. According to the authors’ research published last year, depressed individuals tend to be more pessimistic about their prognoses the more they attribute their symptoms to biological causes.
Apparently it’s depressing to be thought of as a clump of cells without control. Depressed people want to be understood as human: “it’s crucial to understand biology as something that’s part of all human experience, rather than something that separates so-called mentally ill people from everyone else,” a co-author said.
We think people should know this: psychiatry is a delusional pseudoscience (see 5/10/13); even more so is psychology (5/22/14). This is not to disparage the motives of any intelligent, well-educated, caring person in those fields. It’s just to point out that, in one of their peer’s admissions, their field is clueless. They don’t know what mental illness is. They don’t know what schizophrenia is. They don’t know if it is just an evolving metaphor. Even if it’s real, they don’t know how to treat it, and some of their treatments are cruel to patients who, for whatever reason, are crippled by debilitating experiences.
As for what leads to those debilitating experiences, in one sense, we’re all delusional in our dreams, which can seem very real, but most of us snap back to reality upon waking up. Who knows but that some children make early choices not to let go of their dreams, and became slaves of that habit? Habits begin with choices, but can become cruel masters. Biblical counselors believe the experiences are either caused by physical brain damage, or are spiritual in origin. If they are physical, get a doctor; medicine can help alleviate symptoms. If they are spiritual, the last person you want to see is a materialist who fools himself into thinking the cause is material when it isn’t. Find a godly pastor or Biblical counselor instead. Ultimately, though, the patient will have to choose whether to obey the Creator’s prescription. The tragic death of pastor Rick Warren’s son was not a reflection on the Bible’s counsel; ultimately, the young man made a choice against all he knew, breaking the hearts of his parents and church members who had showered so much love, prayer and help on him. Countless others have chosen differently, and have found Christ’s promise to be true: “Come unto me, all you who are weary and heavy laden, and I will give you rest… you will have rest for your souls” (Matthew 11:28-30).
This entry about schizophrenia points out serious issues in the philosophy of science that apply to other scientific fields. “Science” is a big tent, conveying a great deal of respectability in our culture. There are people under this tent who wiggled their way in to share that respectability who don’t belong there. There are others who deserve to be there but are expelled by the consensus. Remember what the late novelist Michael Crichton told Caltech: “If it’s consensus, it isn’t science. If it’s science, it isn’t consensus. Period!” As we seek to understand our minds and the minds of our fellow inhabitants of the planet in order to show compassion, let us follow the evidence where it leads, within an overarching world view that alone can account for the body and the mind: Biblical creation. Unlike the secularists, we have the Creator’s own instruction manual, His Word.