Psychiatry 2008 [ J U L Y ]62

ABSTRACTA popular canard among critics of

psychiatry is that psychiatricdisorders are never listed inpathology textbooks. This erroneousclaim is sometimes used to arguethat some diseases such asschizophrenia are not “real” diseases,but merely metaphorical inventionsof psychiatrists. In reality, manypathology and pathophysiology textsnow recognize schizophrenia as bonafide disease, and physicians shouldresist attempts to marginalizepsychiatry by those who claimotherwise. However, judgmentsconcerning the “reality” of diseaseought to be based on our everydayobservations of suffering andincapacity, not on pronouncementsin textbooks. Disease is properlypredicated of persons, not of minds,bodies, tissues, or organs.

INTRODUCTIONIn two earlier commentaries, I

took issue with the claims that majorpsychiatric diagnoses lack“objectivity,” and that there are nobiomarkers for major psychiatricdisorders.1,2 These misleadingnotions—widely promulgated in boththe professional and lay press—

Psychiatric Diagnosis and the

Pathologist’s View of

Schizophrenia

[ C O M M E N T A R Y ]

by RONALD PIES, MDProfessor of Psychiatry, SUNY Upstate Medical University, Syracuse, New York; and Clinical Professor of Psychiatry, Tufts USM, Boston,Massachusetts

ADDRESS CORRESPONDENCE TO: Dr. Ronald Pies, Box 332, Bedford MA 01730; E-mail: ronpies@massmed.org

KEY WORDS: psychiatry, reliability of diagnoses, validity of diagnoses, pathology, disease

62-65_Pies.qxp 7/16/08 11:41 AM Page 62

[ J U L Y ] Psychiatry 2008 6363

contribute to the marginalization ofpsychiatry as a medical specialty andmay impede our efforts to attractmedical students to the field.3

Another frequent claim putforward by some critics of psychiatryis that, unlike “real” diseases,psychiatric conditions (sometimesreferred to as “mental disorders”) donot appear in pathology textbooks.This claim is proffered as evidencethat mental disorders are, therefore,not bona fide diseases. I believe thiscanard is not only transparentlyfallacious, but demonstrably falsewith respect to schizophrenia—for atleast 15 years. In this commentary, Ipresent the results of my inspectionof various textbooks of pathology andpathophysiology, with respect towhether they mention or discussschizophrenia.

THE CLAIMS REGARDINGPATHOLOGY TEXTS

Critics of psychiatry have arguedfor more than 20 years thatpathologists do not recognizeschizophrenia as a brain disease, andfurther, that schizophrenia and/orbipolar disorder are not “listed” ordiscussed in standard pathologytexts. In more general terms,psychiatrist Thomas Szasz opined in1987 that “…ever since the earliestdays of psychiatry, psychiatrists haveclaimed that mental diseases arebrain diseases…[but] pathologistshave never been able to confirmthese claims…psychiatrists ought toconvince pathologists thatschizophrenia is a brain diseasebefore they take it upon themselvesto tell the public that it is such adisease.”4

Various versions of the claim thatschizophrenia and major mooddisorders are not “listed” ordiscussed in pathology texts haveappeared over the past decade. Thus,in 1998, psychology professor JeffreySchaler wrote that “If ‘mental illness’is really a brain disease, it would belisted as such in standard textbookson pathology. It is not listed as abrain disease because it does notmeet the nosological criteria fordisease classification.”5

Similarly, in a debate6 held in 1998,Szasz argued that “…depression isnot listed in textbooks of pathology.Maybe when it’s listed in textbooks ofpathology I might be willing toconcede…that it’s like neurosyphilisor epilepsy…”

Speaking in the same debate,Schaler questioned why putativeneuroanatomical abnormalities ofmanic-depressive illness were notdescribed in “standard textbooks ofpathology.” And, as recently as 2007,Schaler opined that, “If mental illnessrefers to a brain disease, then itwould be listed in a standardtextbook on pathology as such. It isnot listed as a brain disease preciselybecause mental illness refers tobehavior, not a cellular lesion.”7

HISTORICAL AND PHILOSOPHICALBACKGROUND

One might wonder how, in the firstplace, pathologists came to be seenas the ultimate arbiters of what is, oris not, a “disease.” Why, for example,are gynecologists or familypractitioners not accorded thisexalted status by critics ofpsychiatry? I believe the answer liesin the legacy of the renownedGerman pathologist, Rudolf Virchow(1821–1902), or rather, in a likelymisunderstanding regardingVirchow’s views on “disease.” In brief,those who argue from the Szaszianposition claim that for Virchow,disease was established bydemonstrating lesions, cellularpathology, or at the very least,pathophysiology. But as I arguednearly 30 years ago,8 Virchowbelieved cellular derangements to bethe basis of disease. It is far lessclear that Virchow saw these cellularderangements as disease; or asnecessary and sufficient conditionsfor ascribing disease. Indeed,Virchow himself wrote as follows:

“One can have the greatestrespect for anatomical,morphological, and histologicalstudies...But must one proclaimthem, therefore, the ones ofexclusive significance? Manyimportant phenomena of the bodyare of a purely functional kind.”9

[italics added] Moreover, for Virchow (unlike

Szasz), disease presupposes life. Withthe death of the cell or organism, thedisease also terminates, even thoughcellular pathology may persist. Thus,for Virchow, lesions and cellularderangements cannot be synonymouswith disease.10,11

Indeed, disease is a prebiologicalconstruct. It begins when ordinarypeople perceive that one of theirfellows is experiencing prolongedsuffering and incapacity, withoutevident external cause (such as anobvious wound).10 The “biology” ofdisease often eludes us for decades,or even centuries, after the conditionis widely recognized as a disease. Asthe physician Maimonides remindedus eight centuries ago, disease(etymologically, dis-ease) is properlypredicated of persons.10 When weattribute disease to the “mind” or“body”—or to organs and tissues—we balkanize the human experienceof disease and create greatconceptual mischief.10,11 Thus, thecommonly used terms brain diseaseand mental illness are bothconceptually unsatisfactory.Nonetheless, there is simply noquestion that pathologistsincreasingly recognize schizophreniaas a bona fide form of disease.

WHAT DO MODERN PATHOLOGYAND PATHOPHYSIOLOGY TEXTSSAY?

To be sure: one can find manypathology texts (mostly publishedbefore the mid-1990s) that do notinclude references to schizophrenia,bipolar disorder, or relatedpsychiatric conditions.12 It may alsobe technically true that pathologytexts do not categorically state,“Schizophrenia and bipolar disorderare brain diseases.” It may also betrue that pathology texts do not statethat “mental illness” is “really a braindisease,” as Schaler wants toformulate the issue.5 Indeed, thatinelegant formulation would raise—for pathologists as for philosophers—all sorts of logical and linguisticconundrums (e.g., “How couldsomething “mental” be localized in a

62-65_Pies.qxp 7/21/08 2:42 PM Page 63

Psychiatry 2008 [ J U L Y ]64

physical object like the brain?” etc.).Nonetheless, my review ofnumerous pathology texts beliesthe claim that they do notrecognize schizophrenia as a bonafide form of disease. Even bipolardisorder is gradually achievingrecognition as a disease in somerecent texts, though this is beyondthe scope of the presentcommentary.

Let us begin with Boyd’sIntroduction to the Study ofDisease, Eleventh Edition,published in 1992.13 The author, Dr.Huntington Sheldon, was at the timea professor of pathology at McGillUniversity. Dr. Sheldon classifiesschizophrenia under the rubric of“functional disorders.” He goes on toargue that schizophrenia “…might be

regarded as a cancer of the mind,gnawing into the very soul of thepatient.”13 Now, those who believethat schizophrenia is only a“metaphorical” disease may dismissSheldon’s vivid description as merepoetic imagery—not the stuff of hardscience. Yet Sheldon goes on to notethe beneficial effects of hemodialysisin “a small group ofschizophrenics…” leading him tohypothesize that there may be “…abiochemical substance…that directlyaffects the ordered functioning of thecentral nervous system” inschizophrenia.13

Almost a decade after Dr. Sheldonwrote this, we find anotherdiscussion of schizophrenia in thetextbook, Biology of Disease,Second Edition, by Phillips, Murray,and Kirk.14 Although this is arguablynot a standard textbook on pathology(it also aims to encompass elementsof clinical medicine), Dr. Murray wasthen in the department of pathologyat the University of Birmingham,

United Kingdom. All told, there areseven pages in the text that deal withschizophrenia. Schizophrenia isconsidered in detail in the chapterentitled, “Psychological and socialaspects of disease.” [italics mine]Phillips, et al., observe that, “Avariety of clinical investigations andimaging techniques…have revealed anumber of interesting findings [inschizophrenia], including evidence ofcerebral atrophy, left temporal lobedysfunction, [and] evidence ofneuronal loss and disorganization.”14

The text goes on to note that thesignificance of the “inconsistent”pathological findings inschizophrenia are “…a matter ofcurrent speculation;” however, therefollows a critically importantstatement: “…the biology of this

disease is as yet poorlyunderstood.”14 [italics added]

Now, critics of psychiatricdiagnosis may rush to seize upon thewords “poorly understood”—but thatwould be a philosophical error of thefirst magnitude. The biology of manydiseases, including some types ofcancer, is “poorly understood.” Thecritical words are “this disease.”There is simply no question that theauthors of the text viewschizophrenia as a disease—and thatthis classification is not dependenton our having a full understanding ofschizophrenia’s biology.

The meanings of words do notdrop on our heads like PlatonicForms falling from heaven. As thephilosopher Ludwig Wittgensteinargued,15 meanings evolve in humancontexts to serve human—andhumane—needs. That is preciselywhy Phillips, Murray, and Kirk14 cancomfortably use the term disease inreference to schizophrenia and haveconfidence that thousands of readers

will understand why they do so. Other references to schizophrenia

may be found in standard pathologytexts, such as the Oxford Textbookof Pathology.16 Interestingly, in thelatter, schizophrenia is brieflymentioned in the chapter entitled,“Molecular genetic analysis ofcoronary artery disease.” Theauthors are discussing a number ofmedical conditions and their familialpatterns: “Early heartattacks…noninsulin dependentdiabetes, hypertension,schizophrenia, and some types ofcancers often ‘run in families;’ but allof these disorders also have a strongenvironmental component.”16

Critics of psychiatry sometimesmake much of the distinctionbetween disease and disorder; infact, however, these terms are usedalmost interchangeably, if notpromiscuously, in the historicalliterature of medicine.10 It is evident,in any case, that for the OxfordTextbook authors, schizophrenia is inthe same basic “family” of conditionsas diabetes mellitus and some typesof cancer.

Arguably, the coup de grace forthe claim that pathology texts don’trecognize schizophrenia is deliveredby the book, The Neuropathology ofDementia edited by Esiri andMorris, in which 20 pages of text(including an entire chapter byHarrison) discuss theneuropathology of schizophrenia.17

Finally, even one textbook offorensic pathology18 includes a briefdiscussion of schizophrenia as anexample of “endogenous mentaldisease.”

OTHER MEDICAL TEXTBOOKS Pathology texts are by no means

the only non-psychiatric medicaltextbooks that include mention ordiscussion of schizophrenia.Consider, for example, Blumenfeld’stextbook, Neuroanatomy ThroughClinical Cases.19 This book contains17 pages with references toschizophrenia. In one of the casevignettes (Case 10.6, p. 403), we arepresented with a 64-year-old woman“talking ragtime.” She is said to have

...false claims that schizophrenia and relateddisorders are not recognized as diseasesoutside of psychiatry damage both ourprofession and those whom we treat.

62-65_Pies.qxp 7/16/08 11:41 AM Page 64

[ J U L Y ] Psychiatry 2008 6565

a history of “chronic schizophrenia,”which is noted to be a cause of“nonsensical speech.” In the sametext, we are told that “overactivity ofthe mesolimbic [dopamine] pathwayis thought to be important in the‘positive’ symptoms ofschizophrenia.”

Similarly, in Prezbindowski’sStudy Guide to Accompany Porth’sPathophysiology,20 we find five testquestions on schizophrenia,including one that discusses atrophyof brain tissue and enlargement ofcerebral ventricles. Strikingly, thistextbook also includes severalquestions on bipolar and unipolardepressive disorders, as well as onanxiety disorders.

CONCLUSIONSThe notion that, among

physicians, only psychiatristsconsider schizophrenia a real diseasecan easily be laid to rest with anhour’s work in a good medicallibrary. The textbook examplesprovided in this commentary are byno means exhaustive; others areprovided in my chapter in Dr.Schaler’s book.10 A failure to call thecritics of psychiatry on their falseclaims regarding medical textsfurther marginalizes psychiatry andreinforces pejorative myths aboutpsychiatric diagnosis. It also makesit more difficult to presentpsychiatry in a convincing way tomedical students.

Of course, the presence orabsence of printed words in atextbook does not impinge on the“ultimate reality” of conditions likeschizophrenia—any more than thesudden omission of the term cancerfrom pathology texts would meanthat the disease has disappeared. Wemust continue to refine ourdiagnostic criteria and greatlyintensify our search for validbiomarkers in schizophrenia, mooddisorders, and other psychiatricconditions.2,21 Nonetheless, falseclaims that schizophrenia andrelated disorders are not recognizedas diseases outside of psychiatrydamage both our profession andthose whom we treat—the

individuals who struggle bravelywith these all-too-real diseases.

ACKNOWLEDGMENTI wish to thank Mr. Darren Waters

for prompting my investigation of thisissue. I also wish to expressappreciation for the groundbreakingwork of Ahmed Aboraya, MD, onvalidity and reliability in psychiatry.

REFERENCES1. Pies R. How “objective” are

psychiatric diagnoses? (guess again).Psychiatry (Edgemont).2007;4(10):18–22.

2. Pies R. Beyond reliability:biomarkers and validity inpsychiatry. Psychiatry (Edgemont).2008;5(1):48–52.

3. Wigney T, Parker G. Medical studentobservations on a career inpsychiatry. Aust N Z J Psychiatry2007;41:726–731.

4. Szasz T. Insanity: The Idea and ItsConsequences. Hoboken NJ: JohnWiley & Sons, 1987.

5. Schaler J. Mental-health parity[Letter to the editor]. PhiladelphiaInquirer. August 22, 1998:A12.

6. Debate: Is Depression a Disease?Produced by Warren Steibel. TapedMarch 31, 1998, New York City.http://www.szasz.com/isdepressionadiseasetranscript.html. Access date:July 9, 2008.

7. Schaler J. Mental illness: philosophymasquerading as medicine. Br JPsychiatry. September 6, 2007.http://currentideas.blogspot.com/andhttp://bjp.rcpsych.org/cgi/eletters/191/3/271.Accessed July 9, 2008.

8. Pies R. On myths and countermyths:more on Szaszian fallacies. Arch GenPsychiatry. 1979;36(2):139–144.

9. Virchow R. In: Rather LJ (ed).Disease, Life and Man: SelectedEssays by Rudolf Virchow.Stanford, CA: Stanford UniversityPress, 1958.

10. Pies R. Moving beyond the myth ofmental ilness. In: Schaler JA (ed).Szasz Under Fire. Chicago, IL:Open Court, 2004:327–553.

11. Kendall RE: The myth of mentalillness. In: Schaler JA (ed). Szasz

Under Fire. Chicago, IL: OpenCourt, 2004:29–48.

12. Cotran RS, Kumar V, Robbins SL.Robbins’ Pathologic Basis ofDisease, Fifth Edition..Philadelphia, PA: W.B. Saunders,1994.

13. Sheldon H. Boyd’s Introduction tothe Study of Disease, EleventhEdition. Philadelphia, PA: Lea &Febiger,1992.

14. Phillips J, Murray PG Kirk P (eds).Biology of Disease, SecondEdition. Hoboken, NJ: Wiley-Blackwell, 2001.

15. Wittgenstein L. The Blue andBrown Books: Preliminary Studiesfor the PhilosophicalInvestigations. New York, NY:Harper Torch Books, 1965.

16. Talmud PJ, Humphries S. Moleculargenetic analysis of coronary arterydisease. In: McGee JO, Isaacson PG,Wright NA, Dick HM. OxfordTextbook of Pathology, Volume 1:Principles of Pathology. OxfordMedical Publications, 1992.

17. Esri MM, Morris JH (eds). TheNeuropathology of Dementia.Cambridge: Cambridge UniversityPress, 1997.

18. DiMaio VJM, DiMaio D. ForensicPathology, Second Edition. BocaRaton, FL: CRC Press, 2001.

19. Blumenfeld H. NeuroanatomyThrough Clinical Cases.Sunderland, MA: Sinauer Associates,2002.

20. Prezbindowski’s Study Guide toAccompany Porth’sPathophysiology, Seventh Edition.Philadelphia, PA: Lippincott,Williams & Wilkins, 2005.

21. Aboraya A, Rankin E, France C, etal. The reliability of psychiatricdiagnosis revisited: the clinician’sguide to improve the reliability ofpsychiatric diagnosis. Psychiatry(Edgemont). 2006;3(1):41–50.

62-65_Pies.qxp 7/16/08 11:41 AM Page 65