Critical psychiatry position on schizophrenia

Joanna Moncrieff and Hugh Middleton, the co-chairs of the Critical Psychiatry Network, have produced a critical psychiatry perspective on schizophrenia (see article). They argue that the concept of 'schizophrenia' is neither valid, nor useful, and suggest replacing it with more generic concepts such as 'psychosis' or 'madness'. The replacement of the term 'schizophrenia' by 'psychosis' has already happened to some extent in everyday clinical practice, as reflected in the updating of NICE guidance, now called Psychosis and schizophrenia in adults: treatment and management, whereas previous editions just referred to schizophrenia. The recent BPS report was also entitled Understanding psychosis and schizophrenia (see previous post).

Psychosis, like schizophrenia, is of course not an absolute concept and there may well be clinical disagreement about whether mental symptoms should be seen as psychosis. Jo and Hugh argue against the suitability of seeing mental disorders as illness and disease. As I have said before (see eg. previous post mentioned above), I do not have a problem with the term 'mental illness'. As I see it, the critical psychiatry position is that mental illness, such as schizophrenia, is not a brain disease.

It is true, as Jo and Hugh note, that Emil Kraepelin formulated the concept of dementia praecox (which was renamed schizophrenia by Eugen Bleuler) "with the goal of delineating something whose biological origins could then be uncovered". What they don't mention is that Adolf Meyer argued at the time against the attempt to create disease entities in psychiatry (see eg. Meyer's 1906 paper). As expressed by Susan Lamb (whose paper I have mentioned in a previous post) in her book Pathologist of the mind (see her website):-

A patient did not contract a disease called schizophrenia any more than he or she became a schizophrenic, both of which implied that the disorder was an ontological entity distinct from the person. He [Meyer] urged that many prevalent forms of psychopathology were not the result of an attack on the organism (like syphilitic insanity, for example) but developed as part of its adaptive performance. "Every individual is capable of reacting to a very great variety of situations by [adopting] a limited number of reaction types," Meyer proposed in 1906, and he deemed this true of both healthy and pathological reactions. Schizophrenia ... described a particular type of maladaptation. Rather than a nosological term, then, he suggested a diagnostic adjective that would precede the term reaction-type. Instead of schizophrenia, he proposed "schizophrenic reaction-type."

Bleuler, like Kraepelin, also assumed that schizophrenia ultimately derived from an unknown organic cause. He nonetheless attempted to understand the psychological conflict that triggered the latent disease. Against Kraepelin, he disputed that schizophrenia was a degenerative condition. Schizophrenia has always been essentially a phenomenological diagnosis, even if the assumption is made that an underlying biological cause will be found. Jo and Hugh concede that "certain patterns might be recognised". The usefulness or validity of the term schizophrenia may depend on the identification of these patterns. Like Meyer, though, I agree the problem with any attempt at psychiatric classification is the reification of psychiatric concepts, such as schizophrenia. If the concept 'schizophrenia' is of value, it does not represent an entity or a thing.