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Debate No.6 (Jan/Feb 2003) - Schizophrenia?

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This debate is based on the forthcoming 18th Maudsley Debate to be held on the 29th January 2003.

The title of the debate is: Schizophrenia - the ultimate delusion: This house believes that schizophrenia does not exist!

Please debate as appropriate. *** If you fancy attending the Maudsley Debate, click here for full details. ***

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From the Maudsley press release:

Does schizophrenia exist?

Our understanding of schizophrenia comes from ideas developed by psychiatrists in the 19th century. Yet, despite over 100 years of research, its causes are still poorly understood.

Many now question the value of schizophrenia as a diagnosis. Is it a distinct form of mental illness or simply a man-made construct? Is the concept of schizophrenia actually doing more harm than good – both to those trying to understand it and those suffering from it?

These controversial questions clearly present an enormous challenge to the field of mental health. They are among the issues to be raised at this key public debate chaired by Professor Robin Murray, Professor of Psychiatry at the Institute of Psychiatry, London.

Speaking in favour of the motion are: Professor Jim Van Os, Professor of Psychiatry at Maastrixht University, The Netherlands, and Visiting Professor at the Institute of Psychiatry, London, and Professor Richard Bentall, Professor of Experimental Clinical Psychology, University of Manchester. Speaking against are: Dr Peter McKenna, Consultant Psychiatrist, Cambridge, and Professor Anthony David, Professor of Cognitive Neuropsychiatry, Institute of Psychiatry, London.

Biographies and Background

Professor Robin Murray is Professor of Psychiatry at the Institute of Psychiatry and GKT School of Medicine. He is responsible for more academic papers on the topic of schizophrenia than any other researcher over the last decade. He also heads the National Psychosis Unit at the Bethlem Royal Hospital which receives referrals of patients from around the UK.

Professor Jim Van Os is Professor of Psychiatry at Maastrixht University in The Netherlands and Visiting Professor at the Institute of Psychiatry in London. He has pointed out that the term schizophrenia is increasingly being reserved for cases with the most severe illness course. This he relates to the medical researchers’ psychological need to link schizophrenia to clearly identifiable brain abnormalities and genetic mutations, despite equivocal scientific evidence. He also believes that the term has become a symbol of a passive patient role in lifelong disability, which clearly dissatisfies patients.

Dr Peter McKenna is a Consultant Psychiatrist in Cambridge with clinical and research interests in schizophrenia. He is the author of a book, Schizophrenia and Related Syndromes, and has carried out research into the neuropsychology of the disorder. He believes that studies carried out mainly in the 1960s and 1970s have established the existence of schizophrenia as a clinical entity beyond reasonable doubt.

Professor Richard Bentall is Professor of Experimental Clinical Psychology at the University of Manchester and a fellow of the British Psychological Society. In a number of publications, Professor BentalI has argued that categorical systems of psychiatric classification such as DSM-IV have very little scientific value. He has therefore advocated research targeted at specific psychological symptoms.

Professor Anthony David is Professor of Cognitive Neuropsychiatry at the Institute of Psychiatry and GKT School of Medicine. He is also an honorary clinical consultant at the Maudsley Hospital. Professor David has a wide and diverse range of research interests including schizophrenia, neuropsychiatry, medically unexplained syndromes and neuroimaging. He is especially interested in the concept of insight in schizophrenia.

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Its a debate that reflects psychiatry in the United Kingdom today...The fast evolving community psychiatry and the devolving training system, and research into mental illness is bound to raise these doubts, which ratify the statement: 'Ignorance is Bliss'

The ICD -10 is a classificatory system designed after consultation with many experts all over the world, the DSM IV, after series of field trials reached similar conclusions as to criteriae for diagnosis of mental illnesses. So to question the validity of the diagnostic systems is questioning the credibility of these world experts!!

Agreed that even after 50 years of research, there is no biological marker for schizophrenia, but there are many medical disorders which do not have biological markers, epilepsy for example. But never see a neurologist questioning the existence of epilepsy.

Just because the nature of symptoms in schizophrenia is psychological, i.e., delusions and hallucinations, does it make it less of an illness and more of a myth.

The research into schizophrenia has found repititive findings ( MRI, Genetic markers, Evoked potentials, Neurological signs etc..) not only in patients with schizophrenia (as diagnosed by ICD 10 and DSMIV), but also their unaffected relatives, proves beyond doubt the existence of a brain disorder, i.e., schizophrenia.

The current knowledge is not 'if' it exists, but 'which part of the superior temporal gyrus' is affected, or ' is it the chromosome 8, 2 6...' lets let the ignorance behind and dwell deeper into finding the etiology and hence the correct modality of treatment of schizophrenia...

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Well, I hate to abng about linguistic realism, but the justification for systems like ICD and DSM is encompassed by this doctrine, and makes them legitimate. But to reduce the systems to dictionaries with extremely learned contributors is to lessen the significance of the practical implication, agreed.

However, I don't think that you can say that because the distinguished say something is so, it is so, (even if in this case it is.) We're not yet an objective enough society to assume that the higher echelons of academia exist in wierd altruistic vacuums, apolitical in extremis, and lacking in the need to bolster their own position in the context of assault from below. Consider the accepted wisdom of creationism, flat-earthism (I know, probably never really a common belief at all, but you get the point) and you have to accept that questioning is legitimate.

I think much of the debate is not about whether there is an organic entity which is capable of manifesting as 'classical' schizophrenia, you'd have to be pretty zealously anti psychiatry to consider that, and probably a little prejudiced, but whether a single entity is appropriate given the diversity of expression on a hermeneutical level (?) and also the probably multiple causative mechanisms of psychosis.

the second issue seems to revolve around whether schizophrenia is an illness unto itself, or whether it is subject to society. This is seen in that, in, rather airy, utopian societies it's probably possible to wander around in whatever state, and expect a well paid job in advertising and pretty cat waiting at home. in a way it's redundant to even enter into such a debate, as we are (metaphysics aside) rather much where we are, and if society makes madness 'a bad thing,' then to an extent it's because it wants/needs to. On the same emprical lines, categorising schizophrenia as an entity which perhaps encompasses a spectrum of underlying illnesses is as relevant as categorising fractures as an entity encompassing a number of different bones. The skills needed to sort either out are specialised and cross compatible, to an extent.

So then, even if conceptually schizophrenia remains an arbitrary and broad category, subject to fluctuation in the future, and realistically more relevant as something possesed by medical professionals, rather than 'suffered' by their clients, it serves a useful and valid purpose. If schizophrenia did not 'exist' then we would need to create something to fill its place.

Babel Fish

dx

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The debate in question is a scientific exploration of ideas to agree/disagree to a topic. If only metaphysical chatter could solve the debate on psychological issues, Freud would probably be still worshipped!!!!!!

Time to speak in a valid and relevant manner, that psychiatrists can decipher...

Questioning is but legitimate, but the same questions for 50 years, not bother to check the scientific revelations that have taken place since the last time this particular question was asked...seems appaling//or should I say..Thomas Szaz revisited.....

Pity

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Agreed, there are relevant contributions which make retreading old ground fruitless, and, agreed, metaphysics doesn't impact upon daily management of disabling illness, or even the public realtions issue that blights us all.

No, I don't agree with Szaz, neither do I dismiss nor diminish the scientific evidence. None of this removes the concept of psychosis as a sign of illness, rather than necessarily an entire illness unto itself. The debate about the existence of schizophrenia has no relevance if the actual question is expressed in only the terms, 'does schizophrenia exist?' because it must exist since it is recognised to exist, in one form or another. What the debate ought to concentrate on is whether the wealth of information, and capacity for contradiction within this, for example in regard to receptor populations, periventricular white matter hyperintensities, empirical evidence from pharmaceutical response, differentially sized ventricles, differing courses of illness process, Liddle, dissociative psychosis, (the list is long and as yet not wholly cross compatible) actually clarifies the existance of a discreet entity of schizophrenia, or whether it illuminates areas wherein we might subdivide legitimately. The flip side is that even within the 'same' pathological process the ultimate expression of the illness is defined in terms of a person's culture and individual personality, and the treatment modality being simple, its implementation is determined by interpersonal and individual applications of a skilled-doctor-patient relationship. (see the Maudsley's guidance on compliance therapy for example.)

So really the whole debate is not of daily relevance to 'practicing' psychiatrists except in that this question has been raised outside of the medical environment on so many occasions. It would be grand if one could express the answer in terms that convinced the scientific community of the existence of schizophrenia as an entity, and if the corrollary was that the wider public came to accept this also.

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I agree with dandy

leaving aside the metaphysics. The question of schizophrenia existing is 'rather like asking whether a submarine swims' (pitsfof).

I like the point about utopias. It seems to show that this illness/collectionof illnesses could become a retrospective social construct.

What exists perhaps is not schizophrenia but the need for human beings to care for their fellows, the ones who can not fend for themselves.

The way we can sense others pain and not bear it indifferently. The way we like to feel good about ourselves, and others too.

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call it 8) DOPAMINE ABERRATION SALIENCE DISORDER ::) KAPUR AJ PSYCH JAN 03

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