Thursday, April 02, 2015

Psychiatrists do believe psychosis is a brain disease

Ronald Pies (whose recent book I have reviewed) has criticised the BPS report on psychosis (see previous post) in a Psychiatric Times article for underestimating the potential seriousness of psychosis and misconceiving its nature by focusing on hearing "voices". I agree that the report, for example, does not try and distinguish psychosis from dissociative identity disorder, in which people may also hear voices.

Pies also says that the report's argument against descriptive diagnosis is "historically ill-informed and medically naive" for suggesting psychiatric diagnosis should provide an explanation of people's problems. Again, I agree that psychiatric diagnosis is primarily phenomenological, in that it involves assessment of a person's mental state. Nor, as Pies says, is the "existence of societal prejudice and discrimination" a valid argument against psychiatric diagnosis, as inevitably the implication of a psychiatric diagnosis is that something has 'gone wrong' with the person's psychosocial functioning.

As I have explained in my book review, where I do have a problem with Pies is that I do not think he sufficiently knowledges that minds are not reducible to brains. For example, in another Psychiatric Times article on the BPS report, he says that "schizophrenia is often associated with neuropathology". He deliberately highlights the word "associated" because he does not want to imply causation necessarily. However, he tends to imply just that and it's difficult to see that he means otherwise. Psychiatrists do believe schizophrenia and psychosis are brain diseases and I think Ronald Pies does as well.


(With thanks to Around The Web post on Mad in America)

38 comments:

Ron P said...

Hello, Dr.Double,

First, let me say thanks for taking the time to review my book, Psychiatry on the Edge. Though I sense we agree on a number of areas and disagree on several others, I did feel that your review was a good-faith attempt to describe many of my positions.

With regard to your current post, however, please allow me to correct your mistaken perception that I believe schizophrenia is a "brain disease." That is not how I would state the matter, though, as you correctly note, some psychiatrists do say just that.

The issue is much more complex than psychiatry's view of schizophrenia; rather, it necessarily involves us in a discussion of the thorny "mind/brain" conundrum, which philosophers and neuroscientists have been debating for many years, as you know. It also involves a discussion of what the term "disease" means--a topic, as you know, that I explore in detail in my book.

As a proponent of the later work of Ludwig Wittgenstein, I do not believe that words have "essential definitions"; i.e., that their meaning is specified by a series of necessary and sufficient conditions. For this reason, I don't believe there is a single, veridical definition of the term "disease." Much depends on the use to which the word is put, and this varies considerably among epidemiologists, patholo-gists, and, yes-- psychiatrists!

Following the lead of the late Dr. R.E. Kendall, I believe that the most clinically useful definition of "disease" is one that predicates this of persons--that is, of sentient human beings (and other sentient organisms). For this reason, I do not like to say, "Schizophrenia is a brain disease." Of course, I most certainly would argue that many people who experience DSM-5 signs and symptoms of schizophrenia often show demonstrable neuropathology, far in excess of control subjects, and reliably so on a number of brain and psychometric measures (e.g., abnormal smooth pursuit eye movements).

But the "dis-ease" is a condition of the entire person; it is the neuropathology that we can localize in the brain. This is so, whether or not the neuropathology is "causal" with regard to the person's condition.

And, as you know, it is always difficult to demonstrate a strict cause-and-effect relationship between neuropathology and clinical symptoms--even in ALzheimer's Disease--and this is not necessary for the point I am making, which is really a linguistic one; i.e., that it is more useful to use the term
"disease" (etymologically, a lack of "ease") as a description of persons, and to refer to associated neuropathology in the brain. (Brains do not have "ease" or "dis-ease", to put it in somewhat facetious terms).

I hope this clarifies my position, while acknowledging that some of my colleagues do indeed argue that schizophrenia is a "brain disease." "Psychosis" is a different matter--it is a symptom, not a disease or a formal diagnosis.

Best regards,
Ronald Pies MD
Professor of Psychiatry
SUNY Upstate Medical U.
and Tufts University

Duncan Double said...

Ron P

Thanks for clarifying that schizophrenia is not a brain disease. However, I'm still struggling with your position. What is the status of biological markers that you think there are for schizophrenia? You're right, I am not convinced there are specific biological markers.

I find it helpful to distinguish "illness" and "disease" following Arthur Kleinman, Eric Cassell and others (e.g. see my previous post on BPS report). I think we're agreeing that schizophrenia is an illness. I also totally agree with your quote from Wittgenstein that words don't have essential definitions, but I find it difficult to understand why you're not implying that schizophrenia is a brain disease, using "disease" in my sense. I suppose what you're saying is that there is no proof of biological markers but you seem to believe that they will be established.

Duncan

Ronald Pies MD said...

Hi, Duncan (if I may...)

You are raising some important issues, of course, and I can only touch on some tentative responses. First, though, it helps to distinguish two very different sorts of questions that arise from your comments: (1) the philosophical/linguistic/historical issue of what constitutes “disease”, as distinct from “illness”, “disorder”, “malady”, “morbus”, etc.; and (2) whether what we call “schizophrenia” (as defined, say, by DSM-5) has demonstrable “biomarkers”, reliably identifiable pathophysiology, etc. With regard to the first question, you cite Art Kleinman’s work, with which I am quite familiar. I realize this is a popular distinction in medical sociology and medical anthropology; e.g,

David Field defines the two terms thus:

'Disease' ...refers to a medical conception of pathological abnormality which is indicated by a set of signs and symptoms. 'Illness', on the other hand refers primarily to a person's subjective experience of 'ill-health' and is indicated by the person's feelings of pain, discomfort and
the like. ... to say that a person is ill implies that the consequences of such a state transcend the merely biological and physical consequences of organic malfunction and affect his whole social life in important ways. (Field 1976: 334 in Tuckett D, Introduction to Medical Sociology, 1976]

But I don’t find the Field/Kleinman/Cassell distinction very useful clinically, nor do I think it accurately represents either “ordinary language” or the way most physicians think about “illness” and “disease”. In ordinary language, “illness” and “disease” are more or less synonymous [see, e.g., http://dictionary.cambridge.org/dictionary/british/disease ; disease is defined as “(an) illness of people, animals, plants, etc., caused by infection or a failure of health rather than by an accident]. And, for most physicians, I do not believe there is much of a distinction made between the two terms. In 33 years of psychiatry, I have never heard a physician say, “My patient is very ill, but has no disease,” or, “My patient is diseased, but has no illness.” Rather, I am of the view that the concept of disease arose, as pathologist L.S. King noted,
''... it seems likely that the concept of disease originated as an explanation for the onset of suffering and incapacity in the absence of obvious injury.'' [Pies R: "On Myths and Countermyths: More on Szaszian Fallacies. Arch Gen Psychiatry 1979 Feb;36(2):139-44.]
I believe this is how most physicians understand the concept of disease (which is different from the underlying basis of a particular disease—a distinction I believe Virchow also appreciated).
On this view, schizophrenia—or, to give Bleuler his due, the “schizophrenias”, since this is likely a heterogeneous group of pathological processes—is an instantiation of disease just in so far as it entails substantial suffering and incapacity. Further, no “biomarkers” or demonstrable pathophysiology is required in order to attribute “disease” to someone with the signs and symptoms of schizophrenia—or any other instantiation of “disease.”
Of course, the specific disease entity may (or may not) eventually yield to biological investigations, revealing specific pathophysiology, abnormal cell structure, etc. But we do not--in ordinary language or in medical parlance--insist on this as a requirement for saying, “Jones has very serious disease” in the generic sense. At least, we should not so insist, in my view.
[end part 1]

Ronald Pies MD said...

Part 2:
As to the second question, re: biomarkers and the like in schizophrenia(s), here I think we may read the literature in different ways. I have no doubt that individuals identified by the term “schizophrenia” using DSM criteria, will, more frequently than “normal” control subjects, demonstrate cerebral pathology and/or psychometric abnormalities in a high percentage of cases. We need not show that one specific biomarker is uniquely associated with schizophrenia, as it is likely that schizophrenia-like syndromes overlap considerably, on a genetic and neuropathological level, with other psychotic affective disorders [see, e.g.,Goodkind et al, Identification of a Common Neurobiological Substrate for Mental Illness. JAMA Psychiatry. 2015 Apr 1;72(4):305-315.]. But notwithstanding such overlap, I think the evidence of various biomarkers and/or cerebral abnormalities in DSM-identified schizophrenia is overwhelming; see, e.g., Guidotti et al, Toward the identification of peripheral epigenetic biomarkers of schizophrenia, J Neurogenet. 2014 Mar-Jun;28(1-2):41-52]: “Schizophrenia (SZ) is a heritable, nonmendelian, neurodevelopmental disorder in which epigenetic dysregulation of the brain genome plays a fundamental role in mediating the clinical manifestations and course of the disease.” This is but one of literally scores of studies that support this view—but again, such biological findings are neither necessary nor sufficient for the ascription of “disease” per se, on the view I have put forward.
So, again, I don’t like the description of schizophrenia as a “brain disease”, because it doesn’t capture the human dimension of “dis-ease” (which Kleinman sought—I think mistakenly--to capture in his concept of “illness.”). As Maimonides once put it, “The physician does not cure a disease; rather, a diseased person.”

Best regards,
Ron


Ronald Pies MD said...

Sorry for the out of order or redundant posting!

This is part 1:

Hi, Duncan (if I may...)

You are raising some important issues, of course, and I can only touch on some tentative responses. First, though, it helps to distinguish two very different sorts of questions that arise from your comments: (1) the philosophical/linguistic/historical issue of what constitutes “disease”, as distinct from “illness”, “disorder”, “malady”, “morbus”, etc.; and (2) whether what we call “schizophrenia” (as defined, say, by DSM-5) has demonstrable “biomarkers”, reliably identifiable pathophysiology, etc. With regard to the first question, you cite Art Kleinman’s work, with which I am quite familiar. I realize this is a popular distinction in medical sociology and medical anthropology; e.g,

David Field defines the two terms thus:

'Disease' ...refers to a medical conception of pathological abnormality which is indicated by a set of signs and symptoms. 'Illness', on the other hand refers primarily to a person's subjective experience of 'ill-health' and is indicated by the person's feelings of pain, discomfort and
the like. ... to say that a person is ill implies that the consequences of such a state transcend the merely biological and physical consequences of organic malfunction and affect his whole social life in important ways. (Field 1976: 334 in Tuckett D, Introduction to Medical Sociology, 1976]

But I don’t find the Field/Kleinman/Cassell distinction very useful clinically, nor do I think it accurately represents either “ordinary language” or the way most physicians think about “illness” and “disease”. In ordinary language, “illness” and “disease” are more or less synonymous [see, e.g., http://dictionary.cambridge.org/dictionary/british/disease ; disease is defined as “(an) illness of people, animals, plants, etc., caused by infection or a failure of health rather than by an accident]. And, for most physicians, I do not believe there is much of a distinction made between the two terms. In 33 years of psychiatry, I have never heard a physician say, “My patient is very ill, but has no disease,” or, “My patient is diseased, but has no illness.” Rather, I am of the view that the concept of disease arose, as pathologist L.S. King noted,
''... it seems likely that the concept of disease originated as an explanation for the onset of suffering and incapacity in the absence of obvious injury.'' [Pies R: "On Myths and Countermyths: More on Szaszian Fallacies. Arch Gen Psychiatry 1979 Feb;36(2):139-44.]
I believe this is how most physicians understand the concept of disease (which is different from the underlying basis of a particular disease—a distinction I believe Virchow also appreciated).
On this view, schizophrenia—or, to give Bleuler his due, the “schizophrenias”, since this is likely a heterogeneous group of pathological processes—is an instantiation of disease just in so far as it entails substantial suffering and incapacity. Further, no “biomarkers” or demonstrable pathophysiology is required in order to attribute “disease” to someone with the signs and symptoms of schizophrenia—or any other instantiation of “disease.”
Of course, the specific disease entity may (or may not) eventually yield to biological investigations, revealing specific pathophysiology, abnormal cell structure, etc. But we do not--in ordinary language or in medical parlance--insist on this as a requirement for saying, “Jones has very serious disease” in the generic sense. At least, we should not so insist, in my view.
[end part 1]

Duncan Double said...

Ron

I guess we'll just have to agree to differ. I don't think schizophrenia is a neurodevelopment disorder as such in the sense that you use it, and I think it's misleading to suggest it is. Maybe we need to debate more the neuropathological evidence you quote, but I'm 'underwhelmed' by it and you're 'overwhelmed'. History is on my side, considering the number of claims that have fallen by the wayside.

Duncan

Ron P said...

Hi, Duncan,

Thanks,and yes--I think we do see the neurodevelopmental evidence on schizophrenia in different ways; there is certainly room for debate on how strong it is, but I think most experts in the area agree that there are convincing data to support the statement from Guidotti et al, at least in part.

For some reason, the first part of my reply didn't get posted. I am trying to repost now:

Hi, Duncan (if I may...)

You are raising some important issues, of course, and I can only touch on some tentative responses. First, though, it helps to distinguish two very different sorts of questions that arise from your comments: (1) the philosophical/linguistic/historical issue of what constitutes “disease”, as distinct from “illness”, “disorder”, “malady”, “morbus”, etc.; and (2) whether what we call “schizophrenia” (as defined, say, by DSM-5) has demonstrable “biomarkers”, reliably identifiable pathophysiology, etc. With regard to the first question, you cite Art Kleinman’s work, with which I am quite familiar. I realize this is a popular distinction in medical sociology and medical anthropology; e.g,

David Field defines the two terms thus:

'Disease' ...refers to a medical conception of pathological abnormality which is indicated by a set of signs and symptoms. 'Illness', on the other hand refers primarily to a person's subjective experience of 'ill-health' and is indicated by the person's feelings of pain, discomfort and
the like. ... to say that a person is ill implies that the consequences of such a state transcend the merely biological and physical consequences of organic malfunction and affect his whole social life in important ways. (Field 1976: 334 in Tuckett D, Introduction to Medical Sociology, 1976]

But I don’t find the Field/Kleinman/Cassell distinction very useful clinically, nor do I think it accurately represents either “ordinary language” or the way most physicians think about “illness” and “disease”. In ordinary language, “illness” and “disease” are more or less synonymous [see, e.g., http://dictionary.cambridge.org/dictionary/british/disease ; disease is defined as “(an) illness of people, animals, plants, etc., caused by infection or a failure of health rather than by an accident]. And, for most physicians, I do not believe there is much of a distinction made between the two terms. In 33 years of psychiatry, I have never heard a physician say, “My patient is very ill, but has no disease,” or, “My patient is diseased, but has no illness.” Rather, I am of the view that the concept of disease arose, as pathologist L.S. King noted,
''... it seems likely that the concept of disease originated as an explanation for the onset of suffering and incapacity in the absence of obvious injury.'' [Pies R: "On Myths and Countermyths: More on Szaszian Fallacies. Arch Gen Psychiatry 1979 Feb;36(2):139-44.]
I believe this is how most physicians understand the concept of disease (which is different from the underlying basis of a particular disease—a distinction I believe Virchow also appreciated).
On this view, schizophrenia—or, to give Bleuler his due, the “schizophrenias”, since this is likely a heterogeneous group of pathological processes—is an instantiation of disease just in so far as it entails substantial suffering and incapacity. Further, no “biomarkers” or demonstrable pathophysiology is required in order to attribute “disease” to someone with the signs and symptoms of schizophrenia—or any other instantiation of “disease.”
Of course, the specific disease entity may (or may not) eventually yield to biological investigations, revealing specific pathophysiology, abnormal cell structure, etc. But we do not--in ordinary language or in medical parlance--insist on this as a requirement for saying, “Jones has very serious disease” in the generic sense. At least, we should not so insist, in my view.
[end part 1]

Duncan Double said...

I'm not disputing that most so-called experts might believe schizophrenia to be a genetic neurodevelopment disorder but I don't think the speculation is going anywhere.

Ron P said...

And you shall have the last word, sir! Thank you for the opportunity to post my views,

Best regards,
Ron

Log said...

How creepy and disgusting to see one of the most evil psychiatrists in the world come to this blog and comment. Yuck.

The alleged "doctor" Pies said:


"I think we do see the neurodevelopmental evidence on schizophrenia in different ways; there is certainly room for debate on how strong it is"

There's no fucking room for debate if Pies has decided to lock you up and forcibly drug you is there? I think of all the lives this ideologue has destroyed. May they find peace.

Bradford said...

....yada, yada, yada, blah, blah, blah....
What a crock of psychobabble & gobbledygook....

Ron P said...

Hi, Duncan,

After our civilized debate, I was surprised to find comments posted that seem inappropriate for a professional website;e.g, the comment posted on 14 April. I would be interested to know your thoughts on such vituperative, anonymous remarks, and whether they really belong in such a forum.

Best regards,
Ron Pies MD

Duncan Double said...

Ron

I'm sorry about the incivility. There are many advantages of the Internet but this is one of the disadvantages. I appreciate your willingness to debate with me.

Duncan

Ron P said...

Thanks, Duncan--believe me, I am painfully aware of the incivility issue, and have an article on that for your (and readers') perusal.

http://www.medscape.com/viewarticle/768163

Best regards,
Ron

Polly Oliver said...

It is interesting that telepathy which is understood as commonly occurring between twins and others receptive to this phenomonon is not justifiably considered, in a malicious form, as the source of 'hearing voices'.

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PJ A said...

Ron P,
I feel I desperately need to step in to defend everyone, those from both sides of the despute here that being to defend you and the people responding to you. You are both being misunderstood by each other. The way people have responded to you (Ron) is because they, along with all of us actually variably, have been inflicted by hurt and have been misguided into thinking that there are bad people who have malintentionally uninfluentially caused their hurt and they are unknowingly misguidedly attributing that to you. Ron is not evil (this is very farfetched and only actually without realizing it it actually serves to keep both sides in conflict which is the real problem, that neither side is communicating in the others language, there are like gaps between the views and bridges are the solution bringing people together) nor a bad person but really is as equally human as we all are, in fact to dehumanize him is like the very act we are all hurt by at one time or another whether it be by being forced drugs or just misuderstood or mistreated (etc..), and surge my best feelings to him and every living being on earth. To paraphrase Jacue Fresco; there are no good and bad people, only people raised in environments that are maladaptive.

My ultimate aim is all life on earth to flourish as soon as possible as much as is realistic in spite of their being dehumanized and hurt, I don't know how to socially acceptably say this but all the little acts of kindness around in your lives mean the most I appreciate those actions and I feel a bit of love now about those good actions which can show the potential of a world where there is more weight on the side of the scales of loving moments and more togetherness and less on the side of misunderstanding and so conflict between everyone, cheers

Polly Oliver said...

I have just found my comments and a number of others' have been deleted. I have to question why debate and discussion is quelled if it is conflict with your own opinions.

Perhaps my comments related to my opinion that so-called 'mental illness' is a misnomer and that distortions of personality, mood, behaviour did not have a mysterious cause but were the consequence of sustained psychological abuse - fully understood and treatable by competent psychiatry.

I questioned also if, in your opinion, the cause of Depression is known. Why would you delete such a question? For your information, the cause of Depression is fully understood by competent psychiatrists and fully treatable to the point of rendering patients symptom- and medication-free - with few exceptions upon which I will not, here, elaborate.

It reflects badly on you that you feel the need to delete comments which challenge your own opinions.

Duncan Double said...

Polly

What it says is that your comments have been deleted by you and also others have deleted their comments. If it wasn't you that deleted your comments, I don't understand what's happening!

Duncan

Polly Oliver said...

I did not delete my comments. They were put there to make a statement and to invite meaningful responses.

Polly Oliver said...

I did not delete my comments. I put them there to make a statement and to invite meaningful responses.

Duncan Double said...

As I said, if you did not delete your comments, I don't know how this has happened. Do you want to repost them?

Duncan

Polly Oliver said...

My comments of 26 September have already done so.

Polly Oliver said...

I have come to the conclusion that Psychiatry is like interpretations of the bible - every christian has an interpretation which they adapt to their needs - even when it is apparent it contradicts, is a misinterpretation or is based on ignorance. As long as it sounds authoritative.

I like the term 'psychobabble' as used in another's post. I don't think there is any field where outcomes are so lacking in independent monitoring or where treatments so vary that one psychiatrist cures what another considers untreatable - or incorrectly considers of unknowable causation.

It seems that in psychiatry, broadly, there are no consequences for incompetence. Nor even twinges of conscience.

That medication is seen to be the treatment of choice by so many psychiatrists is inexcusable. Medication merely reduces symptoms. It does not address cause.

To see people's lives brought to ruin by the psychological abuse they have suffered breaks my heart.

That so much of society considers that qualification in psychiatry equals competence is alarming.

Polly Oliver said...

In using the term 'psychobabble' I was referring to the constant hair-splitting, the intensity of analysis of one person's writings or another's. As though we understand nothing really and should simply go on debating.

I am interested in, for instance, how one psychiatrist considers that the cause of depression is unknown and another can cure it.

How homosexuality, trans-gender disposition, transsexuality are considered personality disorders by some but not others. How if an individual wanted a healthy limb amputated because they were disassociated from it, it would not be permitted and would be considered a psychological disorder - yet if he/she wanted amputation of organs of gender as in transsexuality it would be granted - thus losing the problem rather than solving it.

I also wonder why the 'foetal position' is interpreted as a return to the security of the womb instead of the reality of the individual reducing surface area and thus exposure to a world hostile to them.

I wonder why if a parent and child suffer the same disorder - depression, for instance, that it is interpreted as having a genetic origin instead of as both experiencing the same causative factors.

I wonder too how mental breakdown and nervous breakdown have morphed into being understood as the same disorder. They were different in earlier times. They still are.

And I wonder why 'mental illness' is not correctly described as suffering the consequences of sustained psychological abuse with resultant disorders of personality, behaviour and mood.

And I wonder why successful psychiatric treatment is a matter of luck of the draw - of the luck of being referred to a competent psychiatrist over one who just thinks he is.

How can these - and so many other - differences of opinion be curative for patients? Everyone can't be right. So why is there so much discord? And how has it been it permitted to continue?

I invite your critical comment and debate, Doctor.

Duncan Double said...

I suppose psychiatric practice is inevitably uncertain.

Polly Oliver said...

Not in my world.

Duncan Double said...

I agree it's difficult to get psychiatrists to admit the uncertainty. I suppose they feel too threatened by it.

Polly Oliver said...

Threatened - with a strong desire to maintain the status quo in all its ramifications.

Ronald Pies MD said...

Hi, Duncan,

I hope this finds you well. I would like to correct one mis-attributed quotation in an earlier comment of mine. The statement "’… it seems likely that the concept of disease originated as an explanation for the onset of suffering and incapacity in the absence of obvious injury” should be attributed to the late Dr. R.E. Kendell, and appeared in The British Journal of Psychiatry Oct 1975, 127 (4) 305-315; DOI: 10.1192/bjp.127.4.305. I apologize for the confusion, at this late date!

Best regards,
Ron

Ronald W. Pies MD
Professor of Psychiatry