- Email: [email protected]
Semantics and schizophrenia
TINS- November 1978
In the first Point of View, T. Szasz replied to R. E. Kenddl's account of schizophrenia, as it is considered by most clinicians today, by suggestinf. /nter aria, that many diagnoses of schizophrenia are "political', and that for many being a schizophrenic is a career. Kendell (p. 55) and others (pp. 68, 69, 131) have written to Trends in NeuroSciences to voice the strong disagreement which most scientists and clinicians have with Szasz' viewpoint. However, we have also received letters, published below, that indicate that there are others who would question some of our present views concerning schiz3phrenia - ED.
Concept of schizophrenia Reply to R. E. Kendell By calling my essay a 'lampoon on schizophrenia" Professor Kendell ~ illustrates, at the very beginning of his response, the psychiatric propensity to replace reasoned disagreement by epithetic derogation. That, of course, is a temptation when one's beliefs are belied by facts. i began my analysis of the concept of schizophrenia by following the wellaccepted linguistic-philosophical perspective according to which the meaning of a word lies in, and may be inferred from, its use. Professor Kendell calls this approach "seriously misleading" and offers his own definition of the term schizophrenia couched in the jargon of psychiatry. At the core of his definition lies the term 'abnormalities of behaviour'. It is obvious, however, that 'abnormalities of behaviour" are not like pebbles on the sea-shore waiting to be picked up by anyone interested in doing so. The term 'abnormalities of behaviour' is itself a judgment, albeit often a well-concealed one. It is the formation, nature, and uses of that judgment to which I have called attention. Kendell asserts that the defining characteristic of schizophrenia "Like [that of] .many other d i s e a s e s . . , is its syndrome." In fact, many disea___u,s-for example, diabetes, syphilis, tuberculosis, leukaemia are sometimes first detected in routine laboratory examinations of persons who do not display any symptoms of these diseases.
129 Kendell claims that it is mainly American psychiatrists who misuse ~.he term schizophrenia, and attributes special responsibility for this to psychoanalysts. In view of the current Russian uses (or misuses) of the term schizophrenia, and of the Russians' hostility both towards America and towards psychoanalysis, that is a daring claim indeed. To be sure. since the term schizophrenia was not coined until 191 !, it could not have been misused before the psychoanalytical era. However, terms such as "mad', "insane', "demented', and "paranoid' were used (or misused) before the time of Freud, in exactly the same way as "schizophrenia" is now u~ed (or misused)*. In fact, Albert Schweitzer's medical dissertation "The Psychiatric Study ¢,f Jesus" published in 1913, was devoted to refuting three prominent psychiatrists (only one of whom was American !) who claimed that the Saviour suffered from paranoia 2. Kendell's final rejoinder-that with respect to compulsory treatment and nonresponsibility for crime, people who are medtcally ill are treated the same way as those who are psychiatrically ill- leaves me puzzled. He even asserts that my claim that there is an ascertainable and important distinction between these two classes of illnt~f,es, their treatments, and their legal implications for criminal responsibility, is
"quite untrue". However, Kendell's own examples support my the~;is. Epileptics and persons with brain tumours, unliLe schizophrenics (and other "psychotics'), have the same political rights and legal duties as anyone else. if and when their criminal responsibility is considered to be reduced or absent it is not because they have epilepsy or a brain turnout, but because they have beer, declared "mentally ill'. This is why mental illness (and especially schizophrenia) i~ a pivotal concept deserving of our attention. The plain fact remains that if a person's circulation fails, doctors say he has ischaemia: if his kidneys fail, they say he has uraemia; and if his life fails, they say because they look at life itself as a medical problem - that he has schizophrenia. Kendell, seemingly more concerned with proving me wrong than with scrutinizing psychiatry and the modern secular states in which it flourishes, denies this fact. THOMAS SZASZ
Department of Ps.bcl,iatgy. SUNY Up;tote Medical Ceme,. Syracuse. N Y 13210. USA.
I. Kenckll. R. E (t978) Trends NeuroScL I. 55. 2. Schw¢itzer. A. (1913) The Psychiatric Study of Jesus. Trans. (1948) by Charles R. Joy. Beacon Press. Boston. 3. Szasz. T. (1973) The Age of MadneJs. Doubleday Anchor, Garden City. New York.
Semantics and schizophrenia R. E. Kendell's reply t to 'Schizophrenia a c4tegory error', by Thomas Sntsz s reveals that Professor Kendell not only misunderstands Szasz's argument but that he is also a quite willing, if unwitting, party to the very abuses of language and logic which the concepts of schizophrenia and mental ilhwss represent. With 'The Myth of Mental Illness" and subsequent works Thomas Szasz has provided a linguistic analysis of the phenomena generally known as psychopathology, psychiatric diagnosis, and psychotherapy, and has concluded that the behaviour of both the psychiatric patient and the psychiatric doctor are more properly the subjects for study by moralists. theologians, and philosophers than by biomedical scientists. Notwithstanding the likelihood of metabolic, nutritional, and other biological abnormafities being discovered at some future time to be the underlying causes of certain behavioural abnormalities, the cmtcept of mental illness, and its accompanying rhetoric, will remain a significant moral and political problem. To the extent that the term 'schizophrenia" is used as an
injunction, epithet, and prescription (rather than description), it represents such a problem in precisely the manner elucidated by SzasL Involuntary hospitalization and treatment is the surest signal of the continuing social and political use of such terms.
/
'
1
130
TIN$- November1978
A supm~'ial analysis of Professor Kendell's reply to Professor Szasz helps to illumate tl~ semantic manipulation which Szasz has asserted as the "defining churacteristic' of both psychotics and psyddatrists. Professor Kendelrs first sentenc~ denigrates Szasz's article by calling it a lampoon, revmling at the least his attitude Wward opinions which conflict with his own, but also suggesting that the article ought not to be taken seriously. Further along in the first paragraph he state~, "'Like many other d i s e a s e s . . . " . again revealing his bias but, more importantly, imroducing the circularity of his reasoning (which is shared by many other contemporary physicians and medical scientists). For, in the language of logic, to assume that schizophrenia i~ a disease as the basis for an argument which concludes that schizophrenia is a disease is not only fallacious, but is also meaningless. The logician differentiates between extensional and intentional definitions of words. The former refer to the class of things to which the word applies, while the latter refer to the collection of properties which determine the things to which the word applies. In medicine, the intentional definition is usually an explicit definition: i.e. giving another word or phrase which means the same as the word being defined for example, diabetes can be defined as a specific abnormality of carbohydrate metabolism (physiological} or of pancreatic structure (anatomical) and function (physiological). Schizophrenia lacks such an explicit definition and belongs, therefore, in a semantically different class from the names of other disease states such as diabetes and pneumonia. It is precisely this difference, between the extensional definition of schizophrenia, as the word is currently used, and the intentional definilions of terms, to which Szasz has alluded in his attempts to distinguish "bodily' illness from 'mental' illness: it is precisely this absence of explicit, intentional definition, which requires contextual definition in terms of a word's referents. This is the basis for the 'three distinct ideas" in Szasz's first sentence, to which Professor Kendell so strongly objects. Without resort to formal logical analysis, the reasÙning of Professor Kendelrs third paragraph is quite questionable. Although the Cartesian dichotomy may be in fact false, to introduce this as a reason to dismiss Szasz's semantic distinction between "mental" and 'bodily' illness is unreasonable and represents a form of the genetic falla~. The remainder of this paragraph, comparing physical and mental @ BmWm/Nemb4lons~ ~
Pros 191e
'symptoms" and concluding "Schbophrenia, therefore, is neither a disease of the body nor a disease of the mind. Like other diseases it is a disease ofthe person" is not only specious but returns the reader to the first paragraph which assumes the conclusion "schizophrenia is a disease" as an apparent premise to the argument. The couching of this statement in the form of syllogistic argument only exemplifies further the nature of psychiatric rhetoric. From this point, the comments of Professor Kendell regress remarkably, resulting in the justification for regarding schizophrenia as a disease because "quite simply . . . it shares the general characteristics of disease in general [sic]". This is a very unfortunate statement and one which is quite adequately addressed by Szasz in "The Myth of Mental Illness'. it bears a strong resemblance to the argument that counterfeit money is real money because it looks like real money and can be mistaken for real money by ordiuary people as well as by bank tellers. While the es,xntial philosophical and linguistic dfferences between bodily illness and mental illness are being debated, a very practical application of these concepts, and the confusion between them, occurs with alarming frequency. This application is involunt=ry, or compulsory, hospitalization and treatment, which I have called a signal of the politi~l and social use of terms such as schizophrenia. Whereas
Professor Kendell states that involuntary treatment and excuse from legal responsibility are not reserved only for people declared "mentally ill', the lanm~age of his next to last paragraph helios this claim. Although delirious and demented persons are frequent~ treated against tbeir Will, this is done only because it i5 assumed and accepted, in such instances, that "mentar compmency is impaired as a secondary phenomenon. The diabetic who refuses treatment for his primary (physic,d) illness is provided a psychiatric diagnosis prior to initiating involuntary treatment for diabetes. And, to quote Professor Kendell, "The legal definition of "mental illness" or "unsound mind" embraces many conditions - l i k e deliria, dementias, and epileptic psychoses and twilight states," and " . . . the court is more likely to accept a defence plea of diminished responsibility or mental illness if the presence of brain disease can be proved...'" (my italics). Rather than refuting Professor Szasz's point of view regarding the differences between 'physical' and "mental" illnen and the treatment of those so diagnosed, Professor Kendelrs reply provides strong suppon. J~ISEPH DEVEAUGH-(;EI$$
Department of P~ycblatr¥, SUNg Upstate Medical Center. Syracuse, N Y 13210, U.S.A.
I. Kendcll, R. E. 0978) Trendf NeuroSci. J, 5J. 2. SzaJz, T. (1978) Trendt NeuroScL l, 26-28.
S c h i z o p h r e n i a as a disease -- m e r e speculation? in my opinion many of the arguments presented by R. E. Kendell s to justify the equation schizophrenia -- disease are mere speculation. Let us examine them: I. "it (schizophrenia) is a recognizable deviation from normality which occurs throughout the world regardless of differences in language, c u l t u r e . . , " This is not valid proof that schizophrenia is a disease. As for every other species, we do indeed have a set of predictable behavioural patterns: if we feel happy, we will probably laugh, if we feel sad we may cry, and so on. Such hehaviour occurs widely throughout the world and is not recognized as disease simply because many of us share iL The point is that schizophrenia is more unusual, but still recognizable, behaviour. This does not come as a surprise since we are all human beings, members of
the same species and as such fimited to a certain set of behavioural patterns. Scientifically, we cannot exclude the possibility that if placed under certain stressful conditions we would all develop schizophrenia; thus it may be that schizophrenics are merely individuals who have encountered similar difficulties in lite and, because of their very similar neural organization, as members of the same species, they develop quite similar abnormal behaviour everywhere in the world, regardless of their culture. If that were so then the proper question to ask would be: what are the social parametem which can lead to schizophrenia? And schizophrenia would be considered a learned disabling behaviour instead of a real disease. A recognizable deviation from normality is not necessarily a disease, otherwise we might well regard
T I N S - November 1978
Copernicus, Galileo, or Newton: and other creative individuals, as diseased because we are not usually so creative. Or maybe are we sick. then? Perhaps! 2. "It (schizophrenia) has also been proved beyond doubt to be genetically transmitted .. "" This is not a serious argument, it is a fact of everyday life that we are sensitive to certain diseases, depending on our genetic susceptibility (HLA system). If someone is particularly responsive to, let us say, tuberculosis, and if you place him in a suitable environment then it is no wonder when he contracts the disease! Thus one individnal may be more suscgptibl¢ to certain stressful situations than another. This is not astonishing. 3. "'Schizophrenia can be effectively treated, though not cured, by drugs which inhibit transmission in dopaminergic systems in the brain". And so what? Of course chlorpromazine and other substances can alleviate the symptoms of the persons suffering from the phenomenon usually called "schizophrenia', and of course they act on dopaminergic systems! But again i seriously ask the question: so what? Is this sufficient to establish schizophrenia as a disease: more precisely, an organic illness? I think this is the main point of the whole debate, But what is meant by organic? Here ! would adopt the opinion of Henri LaboritS: schizOphrenia seemsto Ix a learned hehaviour in response to stress. Of course it is organic in the sense that it has a definite.physiological basis but it is not organic in the sense of having a lesion. To dates no organic lesion has ever been found and this is why ! prefer to adopt Laborit's working hypothesis which correlates well with the clues we have at the moment on that peculiar behaviour. It is simply not scientific to state that schizophrenia is a disease i f no lesion has ever been demonstrated.
We can call Parkinson's disease a disease because we do have evidence of a
lesion. If this were not the case it would have been mere speculation, which is at present the case for schizophrenia. Professor Kendell also stated that "the prolonged failure to find any underlying biochemical or physiological abnormality has led some people, mostly disillusioned psychotherapists or social scientists with little first hand experience of the disorder, to suggest that there is no biological abnormality there and that "schizophrenia' is merely a way of escaping from intolerable parental or social pressures..'"
13 !
i would like to reply that Dr Laborit. for instance, is not someone with little experience, in fact he is the one who suggested the use of chlorpromazine in psychiatry! Moreover he seems more aware of Information Theory and Cybernetic Concepts* than the average psychiatrist and how can one realistically pretend to understand the brain without prev;ous knowledge of such disciplines? After all. the brain is a system whose essential function is to receive and compute information. Thus the concepts of computer sciences should be of thLutmost importance in the field of neuroscience. I thus wonder why there are no computer scientists on the Editorial Board of Trends in NeuroScences. i have always been shocked to find so few of these scientists in this branch of knowledge. Studying the brain without Information Theory is like trying to do maths without any knowledge of arithmetic! This is not serious business, in my opinion, the neurc~ sciences should follow the example of the physical sciences which were soon divided into theoretical physics and experimental physics. Theoretical neurosciences should rely mainly on the work and concepts oi computer scientists and the like. while experimental neurosciences should rely on the work of physiologists, bi(~!,~gists. etc. ! have always regretted that one neuroscientist who combined both approaches in his study of the brain, John C. Lilly, the one-time famous dolphin specialist, abandoned all the traditional methods of science to fade away into "the lunatic fringe'. This was surely a great loss for all of us who are interested in the functioning of the brain. Perhaps it is that as we move towards the fringe of scientific knowledge, we become more inclined to abandon our scientific rationality and satisfy our more primitive limbic needs through magic and anthropomorphic attitudes. At any rate if ! cite this example it is to show that when we abandon the strict methodology of science we are no longer useful to our fellow scientists and this is surely what psychiatrists in general are doing when they say that schizophrenia /s a disease. The evidence to support this statement is still missing. Therefore the debate as to whether schizophrenia is a disease is not a genuine debate _t~,c_a _ use there is still nothing to debate. It is just idle talk. Finally ! think that labelling schizophrenia as a disease is more a question of personal opinion and philosophy than of
scientific rationality. At the moment there is no serious argument to the effett that schizophrenia is a disease. The real fact is that the evidence is still lacking and as long as this co'ltinues it might, perhap:. be more useful to follow Laborit's views. if certain social constraints lead certain indkiduals into schizophrenia then it is the ~ociety that must be cured (this of course does not preclude, in the meantime. curing existing schizophrenics!)... CLAUDE RIFAT 13 bis ave Miremont. Geneva 1206. Swit:erland.
I. Barchas. J. D.. Akil, H.. Elliott. G. R.. Holman. R. B. and Watson, S. J. (1978j Science 200. 969
2. KenCcll. R. E. (1968) lrend~ NeuroSci. i. 24 26 and 55. 3. Laborit. H. (iq73) l.es Comportements: biologic, physiologie, pharmacologie. Masson. Paris. pp. 184-189. 4. Laborit.H (1974) La N~,u,'elleGallic Laffont. Paris.
Beer is beer! The points of view expressed side by side by R. E. Kendellt and T. Szasz' bring valuable elements for the rethinking of ~hizophrenia Howe~er, global consideration of the two positions rai~,~ doubts concerning the unificauon of p,ychiatric philology: Kendell consider., that Bleuler thought ~chizo. phrenia "'as a ps~cholosical disorder". Szasz fcch that Bleuler thought it "'a disease of the brain", (I am in favour of Kendell's reading.) A debate on the nature of that real entit~ which is schizophrenia cannot go in a profitable direction if one attempts to demonstrate that it is organic what was thought psychological, and the other psychological what was thought organic, both in reference to the same phenomenon. So. a third point of view may be expressed by a caption to "Brain Drain" in the same issue: "Although being myself a hallucination, and you a delusion, dear doctor, still i maintain beer is beer". L, ANGELUCCl istitulo di Farnmcolugia Roma. Italy
•
Farmacolnosia,
i. Kend¢ll, R. E. (1978) Trends lVeuro$ci i. 24--26. 2. Sza~z, T. (1978) Trends NeuroSci. I, 26-28.
In the first Point of View, T. Szasz replied to R. E. Kenddl's account of schizophrenia, as it is considered by most clinicians today, by suggestinf. /nter aria, that many diagnoses of schizophrenia are "political', and that for many being a schizophrenic is a career. Kendell (p. 55) and others (pp. 68, 69, 131) have written to Trends in NeuroSciences to voice the strong disagreement which most scientists and clinicians have with Szasz' viewpoint. However, we have also received letters, published below, that indicate that there are others who would question some of our present views concerning schiz3phrenia - ED.
Concept of schizophrenia Reply to R. E. Kendell By calling my essay a 'lampoon on schizophrenia" Professor Kendell ~ illustrates, at the very beginning of his response, the psychiatric propensity to replace reasoned disagreement by epithetic derogation. That, of course, is a temptation when one's beliefs are belied by facts. i began my analysis of the concept of schizophrenia by following the wellaccepted linguistic-philosophical perspective according to which the meaning of a word lies in, and may be inferred from, its use. Professor Kendell calls this approach "seriously misleading" and offers his own definition of the term schizophrenia couched in the jargon of psychiatry. At the core of his definition lies the term 'abnormalities of behaviour'. It is obvious, however, that 'abnormalities of behaviour" are not like pebbles on the sea-shore waiting to be picked up by anyone interested in doing so. The term 'abnormalities of behaviour' is itself a judgment, albeit often a well-concealed one. It is the formation, nature, and uses of that judgment to which I have called attention. Kendell asserts that the defining characteristic of schizophrenia "Like [that of] .many other d i s e a s e s . . , is its syndrome." In fact, many disea___u,s-for example, diabetes, syphilis, tuberculosis, leukaemia are sometimes first detected in routine laboratory examinations of persons who do not display any symptoms of these diseases.
129 Kendell claims that it is mainly American psychiatrists who misuse ~.he term schizophrenia, and attributes special responsibility for this to psychoanalysts. In view of the current Russian uses (or misuses) of the term schizophrenia, and of the Russians' hostility both towards America and towards psychoanalysis, that is a daring claim indeed. To be sure. since the term schizophrenia was not coined until 191 !, it could not have been misused before the psychoanalytical era. However, terms such as "mad', "insane', "demented', and "paranoid' were used (or misused) before the time of Freud, in exactly the same way as "schizophrenia" is now u~ed (or misused)*. In fact, Albert Schweitzer's medical dissertation "The Psychiatric Study ¢,f Jesus" published in 1913, was devoted to refuting three prominent psychiatrists (only one of whom was American !) who claimed that the Saviour suffered from paranoia 2. Kendell's final rejoinder-that with respect to compulsory treatment and nonresponsibility for crime, people who are medtcally ill are treated the same way as those who are psychiatrically ill- leaves me puzzled. He even asserts that my claim that there is an ascertainable and important distinction between these two classes of illnt~f,es, their treatments, and their legal implications for criminal responsibility, is
"quite untrue". However, Kendell's own examples support my the~;is. Epileptics and persons with brain tumours, unliLe schizophrenics (and other "psychotics'), have the same political rights and legal duties as anyone else. if and when their criminal responsibility is considered to be reduced or absent it is not because they have epilepsy or a brain turnout, but because they have beer, declared "mentally ill'. This is why mental illness (and especially schizophrenia) i~ a pivotal concept deserving of our attention. The plain fact remains that if a person's circulation fails, doctors say he has ischaemia: if his kidneys fail, they say he has uraemia; and if his life fails, they say because they look at life itself as a medical problem - that he has schizophrenia. Kendell, seemingly more concerned with proving me wrong than with scrutinizing psychiatry and the modern secular states in which it flourishes, denies this fact. THOMAS SZASZ
Department of Ps.bcl,iatgy. SUNY Up;tote Medical Ceme,. Syracuse. N Y 13210. USA.
I. Kenckll. R. E (t978) Trends NeuroScL I. 55. 2. Schw¢itzer. A. (1913) The Psychiatric Study of Jesus. Trans. (1948) by Charles R. Joy. Beacon Press. Boston. 3. Szasz. T. (1973) The Age of MadneJs. Doubleday Anchor, Garden City. New York.
Semantics and schizophrenia R. E. Kendell's reply t to 'Schizophrenia a c4tegory error', by Thomas Sntsz s reveals that Professor Kendell not only misunderstands Szasz's argument but that he is also a quite willing, if unwitting, party to the very abuses of language and logic which the concepts of schizophrenia and mental ilhwss represent. With 'The Myth of Mental Illness" and subsequent works Thomas Szasz has provided a linguistic analysis of the phenomena generally known as psychopathology, psychiatric diagnosis, and psychotherapy, and has concluded that the behaviour of both the psychiatric patient and the psychiatric doctor are more properly the subjects for study by moralists. theologians, and philosophers than by biomedical scientists. Notwithstanding the likelihood of metabolic, nutritional, and other biological abnormafities being discovered at some future time to be the underlying causes of certain behavioural abnormalities, the cmtcept of mental illness, and its accompanying rhetoric, will remain a significant moral and political problem. To the extent that the term 'schizophrenia" is used as an
injunction, epithet, and prescription (rather than description), it represents such a problem in precisely the manner elucidated by SzasL Involuntary hospitalization and treatment is the surest signal of the continuing social and political use of such terms.
/
'
1
130
TIN$- November1978
A supm~'ial analysis of Professor Kendell's reply to Professor Szasz helps to illumate tl~ semantic manipulation which Szasz has asserted as the "defining churacteristic' of both psychotics and psyddatrists. Professor Kendelrs first sentenc~ denigrates Szasz's article by calling it a lampoon, revmling at the least his attitude Wward opinions which conflict with his own, but also suggesting that the article ought not to be taken seriously. Further along in the first paragraph he state~, "'Like many other d i s e a s e s . . . " . again revealing his bias but, more importantly, imroducing the circularity of his reasoning (which is shared by many other contemporary physicians and medical scientists). For, in the language of logic, to assume that schizophrenia i~ a disease as the basis for an argument which concludes that schizophrenia is a disease is not only fallacious, but is also meaningless. The logician differentiates between extensional and intentional definitions of words. The former refer to the class of things to which the word applies, while the latter refer to the collection of properties which determine the things to which the word applies. In medicine, the intentional definition is usually an explicit definition: i.e. giving another word or phrase which means the same as the word being defined for example, diabetes can be defined as a specific abnormality of carbohydrate metabolism (physiological} or of pancreatic structure (anatomical) and function (physiological). Schizophrenia lacks such an explicit definition and belongs, therefore, in a semantically different class from the names of other disease states such as diabetes and pneumonia. It is precisely this difference, between the extensional definition of schizophrenia, as the word is currently used, and the intentional definilions of terms, to which Szasz has alluded in his attempts to distinguish "bodily' illness from 'mental' illness: it is precisely this absence of explicit, intentional definition, which requires contextual definition in terms of a word's referents. This is the basis for the 'three distinct ideas" in Szasz's first sentence, to which Professor Kendell so strongly objects. Without resort to formal logical analysis, the reasÙning of Professor Kendelrs third paragraph is quite questionable. Although the Cartesian dichotomy may be in fact false, to introduce this as a reason to dismiss Szasz's semantic distinction between "mental" and 'bodily' illness is unreasonable and represents a form of the genetic falla~. The remainder of this paragraph, comparing physical and mental @ BmWm/Nemb4lons~ ~
Pros 191e
'symptoms" and concluding "Schbophrenia, therefore, is neither a disease of the body nor a disease of the mind. Like other diseases it is a disease ofthe person" is not only specious but returns the reader to the first paragraph which assumes the conclusion "schizophrenia is a disease" as an apparent premise to the argument. The couching of this statement in the form of syllogistic argument only exemplifies further the nature of psychiatric rhetoric. From this point, the comments of Professor Kendell regress remarkably, resulting in the justification for regarding schizophrenia as a disease because "quite simply . . . it shares the general characteristics of disease in general [sic]". This is a very unfortunate statement and one which is quite adequately addressed by Szasz in "The Myth of Mental Illness'. it bears a strong resemblance to the argument that counterfeit money is real money because it looks like real money and can be mistaken for real money by ordiuary people as well as by bank tellers. While the es,xntial philosophical and linguistic dfferences between bodily illness and mental illness are being debated, a very practical application of these concepts, and the confusion between them, occurs with alarming frequency. This application is involunt=ry, or compulsory, hospitalization and treatment, which I have called a signal of the politi~l and social use of terms such as schizophrenia. Whereas
Professor Kendell states that involuntary treatment and excuse from legal responsibility are not reserved only for people declared "mentally ill', the lanm~age of his next to last paragraph helios this claim. Although delirious and demented persons are frequent~ treated against tbeir Will, this is done only because it i5 assumed and accepted, in such instances, that "mentar compmency is impaired as a secondary phenomenon. The diabetic who refuses treatment for his primary (physic,d) illness is provided a psychiatric diagnosis prior to initiating involuntary treatment for diabetes. And, to quote Professor Kendell, "The legal definition of "mental illness" or "unsound mind" embraces many conditions - l i k e deliria, dementias, and epileptic psychoses and twilight states," and " . . . the court is more likely to accept a defence plea of diminished responsibility or mental illness if the presence of brain disease can be proved...'" (my italics). Rather than refuting Professor Szasz's point of view regarding the differences between 'physical' and "mental" illnen and the treatment of those so diagnosed, Professor Kendelrs reply provides strong suppon. J~ISEPH DEVEAUGH-(;EI$$
Department of P~ycblatr¥, SUNg Upstate Medical Center. Syracuse, N Y 13210, U.S.A.
I. Kendcll, R. E. 0978) Trendf NeuroSci. J, 5J. 2. SzaJz, T. (1978) Trendt NeuroScL l, 26-28.
S c h i z o p h r e n i a as a disease -- m e r e speculation? in my opinion many of the arguments presented by R. E. Kendell s to justify the equation schizophrenia -- disease are mere speculation. Let us examine them: I. "it (schizophrenia) is a recognizable deviation from normality which occurs throughout the world regardless of differences in language, c u l t u r e . . , " This is not valid proof that schizophrenia is a disease. As for every other species, we do indeed have a set of predictable behavioural patterns: if we feel happy, we will probably laugh, if we feel sad we may cry, and so on. Such hehaviour occurs widely throughout the world and is not recognized as disease simply because many of us share iL The point is that schizophrenia is more unusual, but still recognizable, behaviour. This does not come as a surprise since we are all human beings, members of
the same species and as such fimited to a certain set of behavioural patterns. Scientifically, we cannot exclude the possibility that if placed under certain stressful conditions we would all develop schizophrenia; thus it may be that schizophrenics are merely individuals who have encountered similar difficulties in lite and, because of their very similar neural organization, as members of the same species, they develop quite similar abnormal behaviour everywhere in the world, regardless of their culture. If that were so then the proper question to ask would be: what are the social parametem which can lead to schizophrenia? And schizophrenia would be considered a learned disabling behaviour instead of a real disease. A recognizable deviation from normality is not necessarily a disease, otherwise we might well regard
T I N S - November 1978
Copernicus, Galileo, or Newton: and other creative individuals, as diseased because we are not usually so creative. Or maybe are we sick. then? Perhaps! 2. "It (schizophrenia) has also been proved beyond doubt to be genetically transmitted .. "" This is not a serious argument, it is a fact of everyday life that we are sensitive to certain diseases, depending on our genetic susceptibility (HLA system). If someone is particularly responsive to, let us say, tuberculosis, and if you place him in a suitable environment then it is no wonder when he contracts the disease! Thus one individnal may be more suscgptibl¢ to certain stressful situations than another. This is not astonishing. 3. "'Schizophrenia can be effectively treated, though not cured, by drugs which inhibit transmission in dopaminergic systems in the brain". And so what? Of course chlorpromazine and other substances can alleviate the symptoms of the persons suffering from the phenomenon usually called "schizophrenia', and of course they act on dopaminergic systems! But again i seriously ask the question: so what? Is this sufficient to establish schizophrenia as a disease: more precisely, an organic illness? I think this is the main point of the whole debate, But what is meant by organic? Here ! would adopt the opinion of Henri LaboritS: schizOphrenia seemsto Ix a learned hehaviour in response to stress. Of course it is organic in the sense that it has a definite.physiological basis but it is not organic in the sense of having a lesion. To dates no organic lesion has ever been found and this is why ! prefer to adopt Laborit's working hypothesis which correlates well with the clues we have at the moment on that peculiar behaviour. It is simply not scientific to state that schizophrenia is a disease i f no lesion has ever been demonstrated.
We can call Parkinson's disease a disease because we do have evidence of a
lesion. If this were not the case it would have been mere speculation, which is at present the case for schizophrenia. Professor Kendell also stated that "the prolonged failure to find any underlying biochemical or physiological abnormality has led some people, mostly disillusioned psychotherapists or social scientists with little first hand experience of the disorder, to suggest that there is no biological abnormality there and that "schizophrenia' is merely a way of escaping from intolerable parental or social pressures..'"
13 !
i would like to reply that Dr Laborit. for instance, is not someone with little experience, in fact he is the one who suggested the use of chlorpromazine in psychiatry! Moreover he seems more aware of Information Theory and Cybernetic Concepts* than the average psychiatrist and how can one realistically pretend to understand the brain without prev;ous knowledge of such disciplines? After all. the brain is a system whose essential function is to receive and compute information. Thus the concepts of computer sciences should be of thLutmost importance in the field of neuroscience. I thus wonder why there are no computer scientists on the Editorial Board of Trends in NeuroScences. i have always been shocked to find so few of these scientists in this branch of knowledge. Studying the brain without Information Theory is like trying to do maths without any knowledge of arithmetic! This is not serious business, in my opinion, the neurc~ sciences should follow the example of the physical sciences which were soon divided into theoretical physics and experimental physics. Theoretical neurosciences should rely mainly on the work and concepts oi computer scientists and the like. while experimental neurosciences should rely on the work of physiologists, bi(~!,~gists. etc. ! have always regretted that one neuroscientist who combined both approaches in his study of the brain, John C. Lilly, the one-time famous dolphin specialist, abandoned all the traditional methods of science to fade away into "the lunatic fringe'. This was surely a great loss for all of us who are interested in the functioning of the brain. Perhaps it is that as we move towards the fringe of scientific knowledge, we become more inclined to abandon our scientific rationality and satisfy our more primitive limbic needs through magic and anthropomorphic attitudes. At any rate if ! cite this example it is to show that when we abandon the strict methodology of science we are no longer useful to our fellow scientists and this is surely what psychiatrists in general are doing when they say that schizophrenia /s a disease. The evidence to support this statement is still missing. Therefore the debate as to whether schizophrenia is a disease is not a genuine debate _t~,c_a _ use there is still nothing to debate. It is just idle talk. Finally ! think that labelling schizophrenia as a disease is more a question of personal opinion and philosophy than of
scientific rationality. At the moment there is no serious argument to the effett that schizophrenia is a disease. The real fact is that the evidence is still lacking and as long as this co'ltinues it might, perhap:. be more useful to follow Laborit's views. if certain social constraints lead certain indkiduals into schizophrenia then it is the ~ociety that must be cured (this of course does not preclude, in the meantime. curing existing schizophrenics!)... CLAUDE RIFAT 13 bis ave Miremont. Geneva 1206. Swit:erland.
I. Barchas. J. D.. Akil, H.. Elliott. G. R.. Holman. R. B. and Watson, S. J. (1978j Science 200. 969
2. KenCcll. R. E. (1968) lrend~ NeuroSci. i. 24 26 and 55. 3. Laborit. H. (iq73) l.es Comportements: biologic, physiologie, pharmacologie. Masson. Paris. pp. 184-189. 4. Laborit.H (1974) La N~,u,'elleGallic Laffont. Paris.
Beer is beer! The points of view expressed side by side by R. E. Kendellt and T. Szasz' bring valuable elements for the rethinking of ~hizophrenia Howe~er, global consideration of the two positions rai~,~ doubts concerning the unificauon of p,ychiatric philology: Kendell consider., that Bleuler thought ~chizo. phrenia "'as a ps~cholosical disorder". Szasz fcch that Bleuler thought it "'a disease of the brain", (I am in favour of Kendell's reading.) A debate on the nature of that real entit~ which is schizophrenia cannot go in a profitable direction if one attempts to demonstrate that it is organic what was thought psychological, and the other psychological what was thought organic, both in reference to the same phenomenon. So. a third point of view may be expressed by a caption to "Brain Drain" in the same issue: "Although being myself a hallucination, and you a delusion, dear doctor, still i maintain beer is beer". L, ANGELUCCl istitulo di Farnmcolugia Roma. Italy
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Farmacolnosia,
i. Kend¢ll, R. E. (1978) Trends lVeuro$ci i. 24--26. 2. Sza~z, T. (1978) Trends NeuroSci. I, 26-28.