From: sasghm@theseus.unx.sas.com (Gary Merrill)
Subject: Re: Peter Breggin, _Toxic Psychiatry_ (Q)
Originator: sasghm@theseus.unx.sas.com
Date: Mon, 4 Jan 1993 14:56:52 GMT
Organization: SAS Institute Inc.



Well, I'm back -- but not for long.  Having been excoriated for even
suggesting that there are fundamental methodological problems in psychiatry
and that perhaps there are not so very good grounds for claiming that
such "conditions" as schizophrenia and depression are diseases, such
terms as "ignorant", "fool", "buffoon", and "crackpot" have been used
pretty freely.  Moreover, claims about "near universal agreement" have
been made with abandon.

As I said earlier, I can be swayed by reasonable argument and clear
evidence.  As promised, I have done some additional research.  The
result is that far from changing my views on the medical/disease model
in psychiatry and the status of mental "illness", my views seem to
be considerably strengthened by the contemporary literature.  I don't
really want to continue in this debate any further since it now seems
to me that those with whom I have been debating are either even more
ignorant than they have accused me of being or (since some seem to have
a claim to knowledge of these fields) their objectivity and integrity
are seriously suspect.

In parting, I would like to leave a very brief summary of just *some*
of the relevant literature virtually anyone can stumble across with
little difficulty.  For the most part, this is intended for anyone
who has been following this thread and who has an objective interest
in the issues raised pertaining to the nature of mental illness, the
medical/disease model in psychiatry, and the classification of such
conditions as depression and schizophrenia as "diseases".

Notice that the approach I have taken is to ignore any source that
could be felt to come from an "antipsychiatrist".  My focus
was on literature well within the field itself and recent (within
10 years, preferably within 2 or 3 years).  There is abundant literature
of this sort.  Below is a brief review of just a few of the things one
can find in this area.  It gives an impression wholly different from
the one we have been treated to in this thread.

'Bye now.

--------------------------------------------------------------------------


_Models of Mental Illness_, T. E. Weckowicz (Charles C. Thomas, 1984)

This book is a detailed exposition of the various models of mental illness
that have been used in psychiatry.  In particular, Chapter 3 is devoted
to the "medical model", and within that chapter two sections deal with
the concept of disease (pp. 50-56) and the disease model in psychiatry
(pp. 57-82).  The book presents a neutral view of the models discussed
and considers issues pertaining to the success and failures of those models.
Without going into more detail here, let me just mention that fundamental
problems with the disease model in psychiatry are discussed beginning on
p. 65 and a section beginning on p. 66 is devoted to the problems of the
etiology (causation) of mental disease within the disease model.  Beginning
with the last paragraph on p. 67 an analysis is provided of fundamental
problems pertaining to the characterization of schizophrenia as a disease.

Weckowicz's book seems to have achieved a significant degree of respect
and is frequently to be found in the bibliographies of other books and
research papers in psychiatry.  It is a good place to start in getting a
grip on the models psychiatrists have attempted to use and in identifying
the strengths and weakness of those models.

-----

_Why Psychiatry is a Branch of Medicine_, Samuel B. Guze (Oxford University
Press, 1992)

This is a remarkable book and certainly should be read by anyone with an
interest in the nature of psychiatry and its status as an empirical science.
The publication is very recent, and the author is listed as "Spencer T. 
Olin Professor of Psychiatry, Washington University School of Medicine".
The purpose of the book is to establish that indeed psychiatry *is* a branch
of medicine and that it deals with genuine *diseases*.  The author presumably
is one who has intimate knowledge of the state of the art and who is speaking
from a knowlegable perspective.  Moreover, Guze appears to be quite widely
read in the areas of sociology and philosophy of science, and he is very
sensitive to the fundamental methodological issues in psychiatry.  It appears
that he has been concerned with the foundations of his discipline for more
than twenty years since his publication record on these matters dates back
to at least 1970.

The very first chapter is devoted to the medical model and its application
in psychiatry.  Guze realizes that all is for naught if he cannot establish
that psychiatry is as much a part of medicine as is internal medicine.  In
fact, most of the remainder of the book (after the first chapter) is concerned
not with establishing the status of psychiatry as a medical science, but with
exploring the *consequences* and *advantages* of the medical model for
psychiatrists.  Certainly the first chapter of this book is the most explicit
and sustained attempt to encompass psychiatry within a medical/disease model
that I have seen.  Is it successful?  Unfortunately, no.

Oddly enough, Guze's approach to subsuming psychiatry into medicine is to
begin by attacking the very concept of disease itself.  He argues at some
length that this is a *vague* concept with poorly defined boundaries.
And his arguments are initially quite plausible.  He then goes on to
argue that since the general concept of disease is so vague it is
easy to include the various psychiatric conditions within this
concept.  He further points out that even though the *general*
concept is vague, nonetheless there are clear cases of disease.

In the end this position (a kind of sophistry employing a tu quoque approach)
is incoherent.  However much we concede that there is a spectrum and
vagueness to the *general* concept of disease in medicine, there are *clear*
examples of genuine diseases (e.g., measles).  Such is *not* the case with
psychiatry where the strength of calling something a disease rests merely
upon an analogy to disease in internal medicine and where the very paradigm
of a psychiatric disease (schizophrenia) is vague and confused (about which
see below).  If we were to fully embrace Guze's arguments we would
need to agree that it is not only *incorrect* to say that
schizophrenia is disease, but that it is *meaningless* to say this
(in virtue of the vagueness of the concept).

This failure of Guze's to firmly establish the disease model in psychiatry
should not be taken to detract severely from the importance of his book.
In fact, often throughout the book it appears that Guze is describing how
psychiatry *could* become a genuine branch of medicine rather than arguing
that it already *is* a branch of medicine.  He clearly and carefully describes
the methodological criteria that must be met and the various pitfalls that
await the unwary.  Frequently he speaks of what needs to be done, of what
is beginning to be done, and what we can hope for in the future.
This is a thoughtful and well written book.  A "must read" for those interested
in the issues with which it deals.

-----

_Schizophrenia Research (Advances in Neuropsychiatry and Psychopharmacology,
Volume 1)_, ed. by C. Tamminga and S. C. Schulz (Raven Press, 1991).

This text is a collection of 35 recent research papers in the area of
schizophrenia.  It makes for fascinating reading.  Without going into too much
detail I recommend the following samples:

   "Gene Expression:  Implications for the Study of Schizophrenia and
    Other Neuropsychiatric Disorders" by Edward I. Ginns

   An interesting example of the type of methodology that may be employed in
   schizophrenia research.  A careful account of gene expression in relation
   to Gaucher's disease is given, and then in the last two paragraphs some
   vague things are said about schizophrenia (which in no way has been
   shown to be similar to Gaucher's disease).  The question is,
   "Could not schizophrenia or, for that matter, other psychiatric disorders
   be explained by either mutations at a single locus or in multiple gene
   loci?"  Maybe, maybe not.  Who knows?  The final paragraph goes on to
   describe the care that must be taken in schizophrenia ("where no definitive
   biochemical marker exists and where genetic heterogeneity and phenocopies
   are common") when attempting to extend the type of research
   described for Gaucher's disease.  Psychiatric methodology at its best?


   "The Biology of the Boundaries of Schizophrenia" by Larry J. Siever
   and
   "The Schizophrenia Spectrum Concept" by Thomas H. McGlashan
   
   Interesting reading for anyone who wishes to maintain that schizophrenia
   is a single disease.

   "Nonschizophrenic Psychotic Disorders" by Peter Berner
   and
   "Ex Multi Uno:  A Case for Neurobiological Homogeneity in Schizophrenia"
   by David G. Daniel and Daniel R. Weinberger

   Interesting reading for anyone who wishes to maintain that schizophrenia
   is a disease at all.  At the very least these papers make it clear that
   not only is it far from obvious that schizophrenia is a disease,
   but in addition there is not even agreement upon what "schizophrenia"
   *means*.
 
Turning from schizophrenia to depression (which we have also seen to
be claimed to be a genuine disease), I recommend looking at

-----

_Models of Depressive Disorders_ ed. by J. John Mann (Plenum Press, 1989)

In his introduction Mann (who is listed as being at the Laboratory of
Psychopharmacology, Department of Psychiatry, Cornell University
Medical College) repeats the litany of "Depressive disorders are an illness".
However, his own contribution to the volume (Chap. 7: Neurobiological Models)
discusses some fundamental problems with this view, and throughout
this chapter the language used is consistently timid and inconclusive:
"It is difficult to interpret the significance of ...", "It is not
clear ...", "These data do not support ...", "It is possible that ...",
"..., and therefore this discussion is speculative", "... were probably
suffering from", "... remains to be worked out".  How such sweeping conclusions
as "Depression is an illness" can arise from this type of research is something
of a methodological mystery.  Pages 144-147 contain some explicit admissions
concerning the methodological problems of the studies.

Mann's introduction provides a good description of what a model *should*
do.  The remainder of the book demonstrates quite conclusively that no
models of depression satisfy the criteria enumerated by Mann.

-----

_Depression, the Mood Disease_ by Francis M. Mondimore (Johns Hopkins Univ.
Press, 1990)

This book is truly scary.  Written by a practicing psychiatrist, it is intended
partly as an introduction to depression disorders and partly as a self-diagnosis
text.  It too contains the litany of psychiatric disease in its
preface.  And then the fun begins.  Early on (pp. 12-13) there is an explicit
admission of the lack of any direct evidence that depression is a disease.
An argument is then advanced (containing the classic fallacy of
affirming the consequent) to the effect that there is "indirect evidence".
(Note that this argument is not "inference to the best explanation"
as one might expect in empirical science.  It's just a genuinely
faulty argument.  See pp. 12-13.).  Pages 27-29 contain a chilling description
of diagnosis (rather *mis*diagnosis) resulting in drug treatment that
is then withdrawn.  The cavalier approach taken in the case, and in its
subsequent description, is stunning.  On p. 41 may be found an
admission that the current taxonomy for the depressive disorders is hopelessly
confused and vague, but that the term "depression of affective
disorder" will be used to refer to "depression that seems rooted in abnormal
chemistry of the brain".  *Seems*????  How about, "If this discussion
of the classification of depression seems confusing to you, it's confusing
to clinicians also ...".  Wonderful!  But we can all rest confident that
depression (whatever it is) is a *disease*.

The book continues in this vein.  Pages 62-63 contain both a
description of Electroconvulsive Therapy and an admission of
ignorance about how it works.  There is a truly preposterous analogy
to the electrical system of the heart that should make any
cardiologist depressed immediately.  Read this book as a giggle or as
a horror show, but it's the authentic stuff.


-- 
Gary H. Merrill  [Principal Systems Developer, C Compiler Development]
SAS Institute Inc. / SAS Campus Dr. / Cary, NC  27513 / (919) 677-8000
sasghm@theseus.unx.sas.com ... !mcnc!sas!sasghm