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Ronald W Pies, MD, considers the evidence from pathology textbooks—and answers the critics.
Of the many canards directed against psychiatry in the late 20th century, one of the most enduring was the claim that psychiatric disorders are never included in pathology textbooks. For example, in 1998, a psychology professor confidently wrote: “If ‘mental illness’ is really a brain disease, it would be listed as such in standard textbooks on pathology. It is not listed as a brain disease because it does not meet the nosological criteria for disease classification.”1
However, as I argued in an article published more than 13 years ago,2 psychiatrists need not assert that the serious conditions we treat are brain diseases—only that conditions like schizophrenia and bipolar disorder represent bona fide disease, and that the term disease is most usefully understood as a collection of highly distressing and dysfunctional conditions of individuals, not just their brains.
Brains, of course, may show cellular pathology, but this is merely the physical substratum of some disease states.3 Cellular pathology is not disease in the holistic and experiential sense that so deeply concerns physicians and their patients. Indeed, those who argue that disease necessarily requires known structural abnormalities or cellular pathology should ponder this sweeping statement in the 8th edition of Harrison’s Principles of Internal Medicine: “The clinical method has as its object the collection of accurate data concerning all the diseases to which human beings are subject; namely, all conditions that limit life in its powers, enjoyment, and duration.”4
The editors go on to aver that the physician’s “primary and traditional objectives are utilitarian—the prevention and cure of disease and the relief of suffering, whether of body or of mind.”4
In so arguing, the editors were implicitly invoking the 12th century physician-philosopher Moses Maimonides, who taught that “a physician does not treat a disease; he rather treats a sick person.”5
Why Should We Care What Pathology Textbooks Say?
In my 2008 article, I presented several examples of pathology or neuropathology textbooks that recognized schizophrenia as a bona fide form of disease.6 In this article, I can update the list of pathology texts that clearly recognize schizophrenia as an instantiation of disease. To be clear: this is quite different than claiming that schizophrenia is a single, discrete disease like, say, pneumococcal pneumonia; it almost certainly is not.
Schizophrenia has been recognized as a form of disease for a long time. Eugen Bleuler, MD, referred to “the schizophrenias” (plural) more than 100 years ago, and most academics today see schizophrenia as a heterogeneous group of related disease entities.7 In addition, I am using schizophrenia as a kind of proxy for severe mental illness, which may include bipolar disorder, posttraumatic stress disorder, autism, and several other conditions.
But why bother with this exercise in the first place? I believe that the issue has great relevance to the place psychiatry occupies in the overall field of medicine. The voices of antipsychiatry are intent on extruding and excluding psychiatry from the realm of legitimate medical specialties, and they attempt to do so by denying that the conditions we treat qualify as genuine disease or illness.8 Antipsychiatry invokes the putative authority of pathology texts to make its case, as if only pathologists can fathom the true nature of disease. This deification of pathology should be viewed as the triumph of scientism over science.
Pathology Texts that Recognize Schizophrenia
If some pathology textbooks recognize psychiatric conditions like schizophrenia as legitimate examples of disease, antipsychiatry’s case is radically weakened. With that in mind, here are some updated entries from several pathology texts that recognize schizophrenia as bona fide disease.
Robbins and Cotran Review of Pathology: “Multifactorial inheritance does not have a well-defined recurrence risks, 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 to have an underlying genetic basis. This is particularly true of neurologic disease, where genetic variants have been shown to increase risk or directly cause schizophrenia, autism spectrum disorder and neurodegenerative diseases.”10
Pathology: Oxidative Stress and Dietary Antioxidants: “Schizophrenia is a mental illness that comprises 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
Textbook of Pathology: “There are no specific biochemical or morphological changes in common acquired mental diseases due to mental stress, strain, anxiety, overwork and frustration; eg, depression, schizophrenia.”12
Note how this last sentence gives the lie to 3 cardinal (and bogus) tenets of antipsychiatry: 1) real disease must be physical or bodily, not mental; 2) real diseases must demonstrate specific biochemical or morphological deviations from normal; and 3) schizophrenia and depression are not real diseases. That the author views mental diseases as acquired due to mental stress is certainly open to revision and refinement, but this is no obstacle to considering schizophrenia a type of disease.
To be clear: the reality of psychiatric disease is not dependent on what textbooks do or do not include as diseases. That reality is demonstrated every day in the suffering and incapacity of our patients.13 Nevertheless, it is important for psychiatry, as a profession, to correct the misrepresentations of its ill-informed critics—particularly those who seek to marginalize psychiatry by denying the reality of the diseases that grievously afflict our patients.
Dr Pies is professor emeritus of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical University; clinical professor of psychiatry, Tufts University School of Medicine; and Editor in Chief emeritus of Psychiatric TimesTM (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 view of schizophrenia. Psychiatry (Edgmont). 2008;5(7):62-65.
3. Reese DM. Fundamentals--Rudolf Virchow and modern medicine. West J Med. 1998;169(2):105-108.
4. Isselbacher K. Introduction. Harrison’s Principles of Internal Medicine, 8th ed. G.W. Thorn et al, eds. McGraw-Hill; 1977.
5. Kottek SS. Toward becoming an accomplished physician: Maimonides versus 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. Brain heterogeneity in schizophrenia and its association with polygenic risk. JAMA Psychiatry. 2019;76(7):739-748.
8. Benning TB. No such thing as 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. Review of Pathology, 4th ed. Saunders; 2014:130-146.
10. Solomon DA. Integrating 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, LS 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. Textbook of Pathology + Pathology Quick Review, 8th edition. Jaypee Brothers Medical Publishing; 2018:33-69.
13. Pies RW. What is “disease”? Implications of chronic fatigue syndrome. Psychiatric Times. March 2, 2015. Accessed April 22, 2021.