Gin S. Malhi: A critical analysis of concepts in psychiatry.
Gin S.Malhi and Erica Bell: Schizoaffective disorder in not "SAD" just bad
Edward Shorter’s comment
At Hartford Hospital, Hartford, CT, the director once said, “No more schizophrenics.” So, the staff changed all the diagnoses to “depression” (Wiesel 1990). We have long known that schizophrenia and serious depression look a lot alike. Kraepelin’s university psychiatric hospital in Heidelberg had great difficulty distinguishing them and both diagnostic terms were used in an interchangeable manner. So, this would give rise to some kind of “combo” diagnosis. But, please, not “schizoaffective disorder."
Among insiders, “schizoaffective disorder” has always been something of a joke. Paula Clayton, a member of the DSM-III Task Force, considered it a “wastebasket kind of diagnosis without (diagnostic) criteria, to be used when you couldn’t decide” (Shorter 2015).
With Gin Malhi and Erica Bell’s excellent piece, the joke becomes public. At the very least, they say, we can relabel it “schizoaffective dysfunction,” so that what is, essentially, an overlap of psychotic schizophrenia and psychotic depression (melancholia) doesn’t sound like a disease of its own.
Indeed, we can go one step further and say that the whole distinction between serious depression and schizophrenia into watertight compartments has been a bad idea. Two points:
1. The overlap is mainly psychotic depression. “Schizophrenia” as a separate disease, like mumps, doesn’t really exist and is a kind of basin within which a number of separate disease entities swim around. Catatonia has already been extracted from that basin. Childhood schizophrenia will probably be next, as much of it turns out to be autistic catatonia. Who knows what else will follow. The nosological big wigs should get off the conference circuit and start observing their patients closely.
2. Depressive symptoms are so completely interlaced within schizophrenia that, for all intents and purposes, they really are a single disease. The youngsters are often depressed before frank schizophrenic symptoms emerge. Episodes of depression are interleaved within the schizophrenic course; and the depressive symptoms may continue well after the schizophrenia has cleared. These conclusions are undergirded by an enormous psychiatric literature going back at least to Kraepelin and before. This literature is rarely cited because it contradicts completely the DSM conventional wisdom that mood disorders and “schizophrenia” are separated by a firewall.
In an effort to chart this overlap, I compiled a not very systematic catalogue of the literature and the discussion contributions in which the authors noted a significant overlap. I searched between 1954 (the year in which Willi Mayer-Gross, Elliot Slater and Martin Roth’s Clinical Psychiatry was published) and 1992, when Michael Alan Taylor’s classic article was published. I came up with 49. This is a significant number and in the face of this potent but buried body of literature one would have to be very careful about asserting that there are three disorders: schizophrenia, depression and schizoaffective disorder. In fact, there may just be one, if we are talking about serious illness: psychotic depression and its cousins that are variants on that theme.
As the editors of this very well-conceived INHN series, “A critical analysis of concepts in psychiatry” point out, “In the absence of a deep understanding of the pathophysiology of mental illnesses, therapies target psychopathology with the aim of achieving symptomatic improvement. Hence, the distillation of syndromes into diagnoses has prematurely accorded disorders the status of diseases.”
Beneath the symptoms that swim on the surface of illness, such as “psychosis” and “depression” there may well be deeper currents — real diseases — that converge in their flow. From time to time, these deeper currents may throw off “mood” symptoms, on another occasion “madness” or “agitation.” The coming task of psychopathology is tracing the locus and course of these deeper currents and it will not be done with the study of “amine neurotransmitters.”
It would be an error to reduce these deeper currents to “Einheitspsychose” (unitary psychosis), because there may well be more than one deeper current that is producing symptoms. Can we discover a treatment for any of them?
References:
Mayer-Gross W, Slater E, Roth M. Clinical Psychiatry. Pl. XVI. London : Cassell & Co., 1954.
Shorter E. What Psychiatry Left Out. New York: Routledge, 2015, pp. 138-9.
Taylor MA. Are schizophrenia and affective disorder related? A selective literature review. Am J Psychiatry. 1992;149(1):22-32.
Wiesel B. Oral History Interview. Archives of Hartford Hospital, Hartford, CT. August 16, 1990. In: Shorter E. What Psychiatry Left Out of the DSM-5: Historical Mental Disorders Today. Routledge/Taylor & Francis Group. 2015, p. 13.
July 2, 2020