Psychiatry - July 2008 - (Page 63)

contribute to the marginalization of psychiatry as a medical specialty and may impede our efforts to attract medical students to the field.3 Another frequent claim put forward by some critics of psychiatry is that, unlike “real” diseases, psychiatric conditions (sometimes referred to as “mental disorders”) do not appear in pathology textbooks. This claim is proffered as evidence that mental disorders are, therefore, not bona fide diseases. I believe this canard is not only transparently fallacious, but demonstrably false with respect to schizophrenia—for at least 15 years. In this commentary, I present the results of my inspection of various textbooks of pathology and pathophysiology, with respect to whether they mention or discuss schizophrenia. Similarly, in a debate6 held in 1998, Szasz argued that “…depression is not listed in textbooks of pathology. Maybe when it’s listed in textbooks of pathology I might be willing to concede…that it’s like neurosyphilis or epilepsy…” Speaking in the same debate, Schaler questioned why putative neuroanatomical abnormalities of manic-depressive illness were not described in “standard textbooks of pathology.” And, as recently as 2007, Schaler opined that, “If mental illness refers to a brain disease, then it would be listed in a standard textbook on pathology as such. It is not listed as a brain disease precisely because mental illness refers to behavior, not a cellular lesion.”7 HISTORICAL AND PHILOSOPHICAL BACKGROUND One might wonder how, in the first place, pathologists came to be seen as the ultimate arbiters of what is, or is not, a “disease.” Why, for example, are gynecologists or family practitioners not accorded this exalted status by critics of psychiatry? I believe the answer lies in the legacy of the renowned German pathologist, Rudolf Virchow (1821–1902), or rather, in a likely misunderstanding regarding Virchow’s views on “disease.” In brief, those who argue from the Szaszian position claim that for Virchow, disease was established by demonstrating lesions, cellular pathology, or at the very least, pathophysiology. But as I argued nearly 30 years ago,8 Virchow believed cellular derangements to be the basis of disease. It is far less clear that Virchow saw these cellular derangements as disease; or as necessary and sufficient conditions for ascribing disease. Indeed, Virchow himself wrote as follows: “One can have the greatest respect for anatomical, morphological, and histological studies But must one proclaim them, therefore, the ones of exclusive significance? Many important phenomena of the body are of a purely functional kind.”9 THE CLAIMS REGARDING PATHOLOGY TEXTS Critics of psychiatry have argued for more than 20 years that pathologists do not recognize schizophrenia as a brain disease, and further, that schizophrenia and/or bipolar disorder are not “listed” or discussed in standard pathology texts. In more general terms, psychiatrist Thomas Szasz opined in 1987 that “…ever since the earliest days of psychiatry, psychiatrists have claimed that mental diseases are brain diseases…[but] pathologists have never been able to confirm these claims…psychiatrists ought to convince pathologists that schizophrenia is a brain disease before they take it upon themselves to tell the public that it is such a disease.”4 Various versions of the claim that schizophrenia and major mood disorders are not “listed” or discussed in pathology texts have appeared over the past decade. Thus, in 1998, psychology professor Jeffrey Schaler wrote that “If ‘mental illness’ is really a brain disease, it would be listed as such in standard textbooks on pathology. It is not listed as a brain disease because it does not meet the nosological criteria for disease classification.”5 63 [italics added] Moreover, for Virchow (unlike Szasz), disease presupposes life. With the death of the cell or organism, the disease also terminates, even though cellular pathology may persist. Thus, for Virchow, lesions and cellular derangements cannot be synonymous with disease.10,11 Indeed, disease is a prebiological construct. It begins when ordinary people perceive that one of their fellows is experiencing prolonged suffering and incapacity, without evident external cause (such as an obvious wound).10 The “biology” of disease often eludes us for decades, or even centuries, after the condition is widely recognized as a disease. As the physician Maimonides reminded us eight centuries ago, disease (etymologically, dis-ease) is properly predicated of persons.10 When we attribute disease to the “mind” or “body”—or to organs and tissues— we balkanize the human experience of disease and create great conceptual mischief.10,11 Thus, the commonly used terms brain disease and mental illness are both conceptually unsatisfactory. Nonetheless, there is simply no question that pathologists increasingly recognize schizophrenia as a bona fide form of disease. WHAT DO MODERN PATHOLOGY AND PATHOPHYSIOLOGY TEXTS SAY? To be sure: one can find many pathology texts (mostly published before the mid-1990s) that do not include references to schizophrenia, bipolar disorder, or related psychiatric conditions.12 It may also be technically true that pathology texts do not categorically state, “Schizophrenia and bipolar disorder are brain diseases.” It may also be true that pathology texts do not state that “mental illness” is “really a brain disease,” as Schaler wants to formulate the issue.5 Indeed, that inelegant formulation would raise— for pathologists as for philosophers— all sorts of logical and linguistic conundrums (e.g., “How could something “mental” be localized in a [JULY] Psychiatry 2008 63

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Psychiatry - July 2008 Editor's Message Editorial Advisory Board Contents PsychRx Letters to the Editor Reliability of Diagnoses: Do Psychiatrists Use Structured Interviews In Real Clinical Settings? Trend Watch: Use of Atypical Antipsychotics in the Elderly Review: The Struggle for Mental Healthcare in New Orleans-One Case at a Time Psychotherapy Rounds: Psychotherapeutic and Adjuntive Pharmacologic Approaches to Treating Posttraumatic Stress Disorder Original Research: Baseline Dissociation and Prospective Success in Special Forces Assessment and Selection Commentary: Performance-Enhancing Drugs: Where Should the Line Be Drawn and By Whom? Commentary: Psychiatric Diagnosis and the Pathlogist's View of Schizophrenia Journal Watch Classified Advertising Information for Authors

Psychiatry - July 2008

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