Saturday, March 14, 2020

All mental disorders involve cerebral processes

The ICD-10 Classification of Mental and Behavioural Disorders made clear that:
Use of the term "organic" does not imply that conditions elsewhere in this classification are "nonorganic" in the sense of having no cerebral substrate. In the present context, the term "organic" means simply that the syndrome so classified can be attributed to an independently diagnosable cerebral or systemic disease or disorder.
Nonetheless, DSM-IV wrongly abolished the distinction between functional and organic mental disorder (see eg. previous post) because it suggested the term 'organic' perpetuated a false dichotomy and implied that the remaining categories included in the diagnostic manual represented nonorganic conditions. Organic disorders are in fact distinguished on the basis of their aetiology as psychopathological manifestations of cerebral disease or disorder. Functional disorders lack such an aetiological basis.

Zbigniew Lipowski was the member of the DSM-III task force responsible for the revision of the organic category (Lipowski, 1990a). He recognised that affective, personality or delusional symptoms could be due to somatic disease or a toxic factor. The organic category was not abolished in DSM-III.

Lipowski (1990b) expressed concern about the "far reaching changes" proposed to organic mental disorders in DSM-IV. As he said, abolition of the organic category was a radical step which should not have been undertaken lightly. There were no new findings to support such a change, instead "idiosyncratic views".

There was further correspondence between Spitzer et al and Lipowski (1991). As Lipowski pointed out, DSM-IV was at variance with ICD-10. But Spitzer et al's (1992) proposal to retire the term "organic mental disorders" held sway. Lipowski suffered for several years from frontotemporal dementia and amyotrophic lateral sclerosis before he died in 1997 (see Wikipedia entry) and I wonder whether his dementia explains why there doesn't seem to have been a response from him.

Spitzer et al (1992) wrongly relate the distinction between organic and functional to Cartesianism. As Lipowski (1990a) pointed out, Georg Stahl was the first to distinguish mental conditions that are psychological from those that are organic (see previous post). In a way, Spitzer et al (1992) were more interested in avoiding the vitalism of Stahl, rather than adopting a more integrative position in psychiatry (see another previous post). Spitzer el al (1992) did acknowledge the importance of attention to underlying physical disorder or toxic factors. But they did not realise that functional/structural and psychological/biological distinctions are not the same as mind/body dualism.

Instead Spitzer et al (1992) proposed seeing functional disorders as primary mental disorders and organic disorders as secondary mental disorders. I'm not sure how much this distinction has really been taken up. To be clear, I'm not against the more widespread use of the term 'primary mental disorder'. As Spitzer et al (1992) pointed out, Lipowski's definition of organic is in agreement with their definition of secondary. However, there may well be potential misunderstandings with the term 'secondary mental disorder', because, for example, a functional depression may be said to be secondary to a physical illness, in the sense that it follows becoming physically ill because of the nature of being ill. What worries me is that a mistaken fear of dualism seems to have driven the abolition of the term 'organic' (see eg. previous post). At least Spitzer et al (1992) realised that their proposal was not solving the mind-body problem.

The trouble is that the fudging of the distinction between organic/functional has suited biomedical psychiatry which claims that neuroscience is moving us towards having a biological and genetic understanding of primary mental disorders, when, in fact, there are no such clear established biological causes (see eg. previous post). This is why I have argued that critical psychiatry's essential message is that functional mental illness should not be reduced to brain disease (see previous post). In the interests of clarity, I am happy to say that the essential message of critical psychiatry is that primary mental illness should not be reduced to brain disease. I don't want to get caught up in semantic arguments to divert attention from the fact that psychiatry can be practised without the justification of postulating brain pathology as the basis for primary/functional mental illness.

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