Do psychiatrists treat illnesses?
Of the many ducks directed at psychiatry in the late 20th century, one of the most persistent was the claim that psychiatric disorders are never included in pathology textbooks. For example, in 1998, a professor of psychology wrote confidently: “If ‘mental illness’ is really a disease of the brain, it would be listed as such in standard pathology textbooks. It is not listed as a brain disease because it does not meet the nosological criteria of classification of diseases. “1
However, as I explained in an article published over 13 years ago,2 psychiatrists do not need to assert that the serious conditions we treat are diseases of the brain – only that conditions like schizophrenia and bipolar disorder represent a bona fide illness and that the term disease is most usefully understood as a set of very distressing and dysfunctional conditions of individuals, not just their brains.
Brains, of course, can show cellular pathology, but this is only the physical substrate of some pathological conditions.3 Cellular pathology is not a disease in the holistic and experiential sense that so deeply concerns physicians and their patients. Indeed, those who argue that the disease necessarily requires known structural abnormalities or cellular pathology should reflect on this sweeping statement in the 8th edition of Harrison’s Principles of Internal Medicine: “The purpose of the clinical method is to collect precise data concerning all the diseases to which human beings are subjected; namely, all the conditions which limit life in its powers, its enjoyment and its duration. “4
The editors go on to state that “the primary and traditional goals of the physician are utilitarian – the prevention and treatment of disease and the alleviation of suffering, whether bodily or mental”.4
In arguing thus, the editors implicitly invoked the 12th century physician-philosopher Moses Maimonides, who taught that “a doctor does not treat disease; rather, he is treating a sick person.5
Why should we care what the pathology textbooks say?
In my 2008 article, I presented several examples of pathology or neuropathology textbooks that recognized schizophrenia as a true form of the disease.6 In this article, I can update the list of pathology texts that clearly recognize schizophrenia as an instantiation of the disease. To be clear: it is quite different than claiming that schizophrenia is a single and distinct disease like, for example, pneumococcal pneumonia; this is certainly not the case.
Schizophrenia has long been recognized as a form of illness. Eugen Bleuler, MD, referred to “schizophrenias” (plural) over 100 years ago, and most scholars today view schizophrenia as a heterogeneous group of related disease entities.7 In addition, I use schizophrenia as a sort of proxy for serious mental illness, which can include bipolar disorder, post-traumatic stress disorder, autism, and several other conditions.
But why bother with this exercise in the first place? I think the question is very relevant in relation to the place occupied by psychiatry in the general field of medicine. The voices of anti-psychiatry intend to extract and exclude psychiatry from the realm of legitimate medical specialties, and they attempt to do so by denying that the conditions we are dealing with are characterized as genuine. disease or illness.8 Antipsychiatry invokes the putative authority of pathology texts to make its arguments, as if only pathologists could fathom the true nature of the disease. This deification of pathology must be seen as the triumph of scientism over science.
Pathology texts that recognize schizophrenia
While some pathology textbooks recognize psychiatric conditions such as schizophrenia as legitimate examples of illness, the case for antipsychiatry is drastically weakened. With that in mind, here are some updated entries from several pathology texts that recognize schizophrenia as a bona fide illness.
Robbins and Cotran Pathology Review: “Multifactorial inheritance does not have a well-defined risk of recurrence, but tends to run in families and is more characteristic for diseases such as diabetes or schizophrenia.”9
Practical surgical neuropathology: a diagnostic approach: “Human disease is increasingly appreciated as having an underlying genetic basis. This is especially true of neurological diseases, where genetic variants have been shown to increase risk or directly cause schizophrenia, autism spectrum disorders, and neurodegenerative diseases. “ten
Pathology: oxidative stress and dietary antioxidants: “Schizophrenia is a mental illness that includes positive, negative and cognitive symptoms. Hyperactive dopaminergic signal transduction in the mesolimbic system and OS [oxidative stress] among other factors, are associated with the neurobiology of schizophrenia. “11
Pathology manual: “There are no specific biochemical or morphological changes in common acquired mental illnesses due to mental stress, tension, anxiety, overwork and frustration; for example, depression, schizophrenia. “12
Note how this last sentence belies 3 cardinal (and false) principles of antipsychiatry: 1) true illness must be physical or bodily, and not mental; 2) actual illnesses must exhibit specific biochemical or morphological deviations from normal; and 3) schizophrenia and depression are not real illnesses. Whether the author takes mental illnesses for granted due to mental stress is certainly subject to review and refinement, but that is not an obstacle to considering schizophrenia as a type of illness.
To be clear: the reality of psychiatric illness does not depend on what the textbooks include or do not include as illnesses. This reality manifests itself every day in the suffering and incapacity of our patients.13 Nonetheless, it is important that psychiatry, as a profession, correct the misrepresentation of its ill-informed critics – especially those who seek to marginalize psychiatry by denying the reality of the illnesses that plague our patients.
Dr Pies is Professor Emeritus of Psychiatry and Lecturer in Bioethics and Humanities, SUNY Upstate Medical University; Clinical Professor of Psychiatry, Tufts University School of Medicine; and editor emeritus of Psychiatric timeTM (2007-2010).
1. Schaler J. Mental health parity. Philadelphia Inquirer. August 22, 1998: A12. Accessed April 22, 2021.
2. Pies R. Psychiatric diagnosis and the pathologist’s perspective on schizophrenia. Psychiatry (Edgmont). 2008; 5 (7): 62-65.
3. Virchow R. Introduction. In: Rather LJ, trans. Disease, life and man: selected essays by Rudolf Virchow. Stanford University Press; 1958.
4. Isselbacher K. Introduction. Harrison’s Principles of Internal Medicine, 8th ed. GW Thorn et al., Eds. McGraw-Hill; 1977.
5. Kottek SS. To become an accomplished doctor: Maimonides against Galen. Rambam Maimonides Med J. 2011; 2 (4): e0060.
6. Esri MM, Morris JH, eds. The neuropathology of dementia. Cambridge University Press; 1997.
7. Alnæs D, Kaufmann T, van der Meer D, et al. Cerebral heterogeneity in schizophrenia and its association with polygenic risk. JAMA Psychiatry. 2019; 76 (7): 739-748.
8. Benning TB. No mental illness? Critical reflections on the major ideas and legacy of Thomas Szasz. BJPsych Bull. 2016; 40 (6): 292-295.
9. Klatt EC, Kumar V. Diseases of infancy and childhood. In: Robbins and Cotran, eds. Pathology examination, 4th ed. Saunders; 2014: 130-146.
10. Solomon DA. Integration of molecular diagnostics with surgical neuropathology. In: Perry A, Bratt DJ, eds. Practical surgical neuropathology: a diagnostic approach, 2nd edition. Elsevier; 2017: 71-90.
11. M. Moretti, Mat 1 Rodrigues. Ascorbic acid as an antioxidant and applications to the central nervous system. In: Preedy V, ed. Pathology: oxidative stress and dietary antioxidants. Academic press; 2020: 159-168.
12. Mohan H. Cellular adaptation and cell injury. Pathology manual + rapid pathology review, 8th edition. Jaypee Brothers Medical Publishing; 2018: 33-69.