Schizophrenia- the ultimate delusion?

January 30, 2003

The Institute of Psychiatry yesterday (Wednesday) held a public debate in London on the question of whether 'schizophrenia exists'. Dr Jonathan Bindman, clinical senior lecturer with the institute's section of community psychiatry reveals there was significant swing in opinion among those who attended...

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'Taxonomy, i.e. the classification of the natural world, is a system of order imposed by man and not an objective reflection of nature.Its categories are actively applied and contain the assumptions, values, and associations of human society' (Mark Dion)

'Oh! Let us never, never doubt what nobody is sure about' (Belloc)

"Yesterday the Institute of Psychiatry hosted the latest in its popular series of free public debates.

An opening vote showed that 86 members of the audience supported the motion that 'this house believes that schizophrenia does not exist', while 134 opposed it and 44 abstained.

Jim van Os, professor of psychiatry in Maastricht, opened in support of the motion by noting that the long lists of criteria in diagnostic 'bibles' such as the International Classification of Diseases (ICD) can be used to assign the diagnosis of schizophrenia to over a hundred distinct permutations of symptoms. While up to 30% of the population have 'delusional ideas', psychiatrists arbitrarily select the 1% they decide are 'ill'. Scientific studies show they often disagree with each other, as do the various 'bibles'.

The diagnosis is often assumed by professionals and service users to imply permanent disability, and this has a damaging effect on people who are given the label, and obstructs their recovery. While studies show that some people do recover, this often leads to the circular argument that they didn't have schizophrenia in the first place.Rather than apply a damaging label with limited scientific value, psychiatrists should concentrate on identifying 'needs for care'.

Dr. Peter McKenna, a consultant psychiatrist, then argued in support of schizophrenia. He started by describing the origins of the term in Kraepelin's careful observations of distinct groups of patients- those with intermittent illness (later labelled bipolar disorder, BPD) and those with chronic illness or paranoia.

He then outlined the arguments of his opponents, perhaps in the hope of demolishing them, but never quite got around to doing so. Though he used an international study of schizophrenia in the 1970s to show that the symptoms of schizophrenia occurred in all cultures and were clearly distinct from bipolar or depressive illness, he failed to live up to his initial promise to make his case through a 'scientific, factual' approach.

Richard Bentall, professor of clinical psychology in Manchester, also used historical arguments against schizophrenia. Kraepelin had believed that the diagnosis based on symptoms and course would lead to the demonstration of a common pathology and aetiology (cause), but in fact these have never been demonstrated and the meaning of schizophrenia has shifted over the century.

Bentall suggested that if a diagnosis is to be of any value, it should have a distinct cluster of symptoms, predict outcome and response to treatment, and be associated with aetiology. However the symptoms of schizophrenia overlap with BPD, outcome is on a continuum from severe disability to complete recovery, and choice of drug treatment is more reliably based on symptoms than diagnosis.

The aetiology of schizophrenia is very uncertain, but those physical, biochemical and genetic abnormalities which have been inconclusively linked with it have also been (equally inconclusively) linked with BPD. While it is sometimes assumed that there is no alternative to the use of diagnosis, in fact an individuals symptoms can often each be understood and treated separately, and the need for diagnosis disappears.

Finally, Professor Tony David of the Institute of Psychiatry argued that while many in the general population agree with statements like 'I feel as if I am controlled by others', this should not be confused with schizophrenic delusions which are more firmly held, preoccupying and distressing. It is not helpful to assume such symptoms are on a continuum; some are clearly abnormal, and a categorical diagnosis is the best way of ensuring that people get the right care and treatment. The case of Christopher Clunis illustrated how the failure to make a diagnosis can lead to failure to treat, with disastrous consequences.

As is usually the case with Maudsley Debates, powerful and moving contributions from the diverse audience illustrated points on both sides of the argument. Several carers described the way diagnosis had changed over time or been argued over by doctors but had ultimately proved irrelevant, stigmatising and disempowering, and had hindered the recovery which their relatives had eventually achieved. A service user pointed out however that there seemed universal acceptance of the reality of symptoms; from his point of view psychiatric illness was an ugly reality and psychiatrists should be fighting stigma rather than arguing over terminology.

Another service user effectively ridiculed labelling and genetics by giving his name as 'Schizoaffective', 'because I'm the son of a manic depressive and a schizophrenic', and gave the apposite quote from Dion at the head of this article.

A psychiatrist argued from the floor that the use of the term schizophrenia to communicate and to aid research was not incompatible with providing optimistic, humane, symptom led treatment, though another supported the view that the case for a reductionist single diagnosis had not been made, and that the issue was how to provide care rather than attach labels.

Richard Bentall made the important point during the discussion that while a diagnosis of schizophrenia might have got care for Christopher Clunis, diagnosis was also used to deny it to Michael Stone.

A final vote was taken and 97 were for the motion, 97 against, with 49 abstentions, a substantial shift away from the initial majority support for schizophrenia. Closing the debate the Chair, Professor Robin Murray, declined to use his casting vote, since despite (or perhaps because of) his many years of research experience, he has yet to make up his mind whether it exists."

(C) Dr Jonathan Bindman.

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