Sunday, 19 June 2016

What do we talk about when we talk about schizophrenia?

I have been gleefully reading Kieran McNally's book on the history of schizophrenia, which turns out to be a compendium of great detail and fascination. As someone who has spent a few years now trying to seriously orient myself in the history of this weird and sprawling concept (I was lucky enough to be allowed to devise and teach an undergraduate course on the history of schizophrenia), I am staggered by the scale of McNally's erudition on the subject. It makes the book enormously valuable both as a treasure trove (in addition to an almost 30 page long reference section, there is a further 10 pages of recommended reading) and as a contribution to our understanding of this unwieldy but influential idea.

The topics of madness and psychiatry have long had their groups of dedicated historians, but the history of schizophrenia itself can get sidelined. Often it is told as part of a broader narrative by people with an axe to grind (witness Jeff Lieberman's casually whig history "Shrinks" from last year), or with other, bigger fish to fry (Richard Bentall's Madness Explained contains a nice conceptual history of schizophrenia, but it is not the main focus of the book). Such histories are, in any case, often predominantly externalist, meaning they focus on the social and economic context of madness (or on the personalities of famous psychiatrists), and not on the development of the ideas. McNally's book is avowedly internalist about schizophrenia. This means you won't find many colourful anecdotes about wacky doctors and their extraordinary patients, but the story of the concept's development (filling a space that has been peculiarly vacant) is no less entertaining. The book is built partly out of papers which McNally has published on specific historical questions, but it still comes together into a satisfying and revealing narrative.

Things Are More Complex Than They Seem:

This is a "critical" history in the best sense of that term; that is, McNally introduces layers of complexity and nuance to a narrative we already think we know. The rough outline of schizophrenia's past is well rehearsed: at the turn of the 19th/20th centuries, Kraepelin separates Dementia Praecox from Manic Depression, and Bleuler re-names it "schizophrenia", partly to avoid the degenerating quality implied by "dementia". Psychiatrists disagree wildly about how to define it, until a series of refinements (Schneider's first rank symptoms, the Feighner criteria) lead into a universally accepted definition in DSM-III. There are two major waves of disruption (Poland's "socio-political" critics in the 1960s, and "scientific" critics from the 1980s to the present), and a future rendered uncertain by the rise of NIMH's RDoC initiative.

Several major strands in this story are unwound by McNally, revealing how official psychiatric knowledge transmission warps the field's history. To begin with, it is convincingly demonstrated that the notion of schizophrenia as "split personality" (which psychiatrists have spent decades defining schizophrenia against) is not some popular misconception perpetrated by an unwitting public but was, for many years, built firmly into the professional understanding of the category. Thus psychiatric textbooks spent about the first 3rd of schizophrenia's lifespan describing it in terms of psychic splitting, and the next two 3rds repudiating that conception.

Officially Hecker's idea of Catatonia (which was incorporated into schizophrenia) has been "disappearing" from the diagnostic scene, possibly because of improved medication. In fact, argues McNally, it may never have been very prevalent, nor very conceptually coherent ("Taxonomy, consequently, made visible to science, in a ceremonial space, categories of people who were not in fact there." - p.95), and was only reluctantly accepted as part of the broader schizophrenia classification in the first place. In another vein meanwhile, the popular Bleulerian mnemonic, the "four As" (disorders of association, affect, ambivalence and autism), is at least an over-simplification of Bleuler's writings, and at worst a distortion. Some texts have five As, and others disagree over what the As actually are. In any case, Bleuler did not write in such glib snippets, and the acronym only appears some fifty years after his text, probably for the benefit of trainee psychiatrists who felt bad that they couldn't find time to read the original.

These are just headline findings. It is not possible to do justice to the richness of the text, which brings out much needed detail from schizophrenia's murkiest period, that space between the appearance of Bleuler's 1911 book, and the emergence of the first DSM. During those forty something years, psychiatrists were particularly divided over what schizophrenia meant, and how it stood in relation to the idea of dementia praecox (which actually survived in some dusty corners until into the late 1960s). Importantly, McNally can read German and French, and can thus go back to original source material in a way that is rarely done. So much of the self-recounted history of psychiatry (Lieberman's book is a prime example) hews closely to the living memory of the teller. Thus anything much before the 1950s has been increasingly excluded from the profession's autobiography.

Ahistorical Psychiatry:

One theme that runs throughout is what McNally describes as "the ahistorical nature of psychiatric thought" (p.126). Psychiatry, he points out, has persistently neglected the development of its own concepts, leading to simplification and dilution of its ideas (some psychiatrists have also lamented this tendency). This is how ideas pertaining to catatonia, split personality, and Bleuler's "four As" can be so awry.

It's tempting to hope this doesn't matter. As Thomas Kuhn pointed out, all successful scientific research is in the habit of forgetting its history ("Why dignify what science's best efforts have made it possible to discard?" - The Structure of Scientific Revolutions, p.138). But it does matter deeply. There is serious doubt about whether psychiatry is a scientific enterprise (a psychiatrist once told me that he had chosen his profession because it was the only branch of medicine prepared to admit it was not a science), and no good can come from simplistic reification of ideas at the expense of describing real experiences. Recent research by Nev Jones has highlighted the peculiar and disquieting effect when people doubt the validity of their experience because it fails to match canonical DSM descriptions. To accurately describe people's subjectivities, psychiatry needs depth, and for all its flaws, the detail one can find in Bleuler's clinical writing conveys a sense of people, and what ails them, that checklist diagnoses are sorely lacking.

Contra Metzl?

It is peculiar that McNally devotes a whole chapter to the issue of how schizophrenia fed into social discrimination, and a section therein to its specific racial biases, but nowhere mentions Jonathan Metzl's The Protest Psychosis. Metzl's thesis is that schizophrenia became a "black disease" during the late 1960s, when DSM-II took away the suffix "reaction" from the diagnosis, and psychiatrists implicitly came to associate paranoid projections (an important concept in understanding psychosis at the time) with the representations of black political activists. Possibly he does not concur with Metzl. By McNally's reading, schizophrenia was already a black disease long before DSM-II or even DSM-I, being over-diagnosed in black populations in studies in 1925 and 1931.

Beyond the Horizon

There is sometimes a sense that McNally over-does the ludicrous quality of schizophrenia research (though, I would hasten to add, not by very much). For instance, in an entertaining early chapter he reviews the extraordinary litany of long forgotten sub-divisions and related concepts. Speaking of a schizaxon, schizothymia, schizomania, schizonoia, schizobulia, schizophasia, shizoparagraphia, or of a schizovirus all seem rather absurd now (especially when you put these schizo prefixes together). McNally groups Meehl's (1962) schizotaxia in with these redundant concepts, painting a picture of one more another junk idea in the scientific dustbin. But although it's fair to point out that no-one now speaks of schizotaxia, it is misleading to suggest that Meehl's idea fell by some historical wayside, just because the term didn't catch on. In teasing apart a conceptual referent for "schizotypy" (a sub-clinical, at-risk phenotype) as opposed to schizophrenia (a clinical disorder) and schizotaxia (a heritable disposition), the framework presented in Meehl's paper provided a powerful organising principle for schizophrenia research ever since. Whether they know it or not, contemporary investigators are indebted to the idea of schizotypy (which is actually very popular right now). Schizotaxia (even if undesirably named) is perfectly conceptually coherent. Nobody now talks in terms of Albert Ellis' "musturbation" (to mean the anxiety provoking feeling that one should achieve some unreasonable thing), but that doesn't mean Albert Ellis didn't play an important role in re-conceiving the function of psychotherapy.

As I mention above, McNally is not interested in pushing an agenda for researchers, though one suspects he thinks they should be more historically literate. However, it's impossible to read this book without wondering about the problem of schizophrenia's conceptual unwieldiness. McNally is, at the very least, skepitical, and wonders in his conclusion whether the side effects of medication are too high a price to pay for treatment given the idea of schizophrenia has "often failed to justify itself" (p.210). The validation of schizophrenia is frequently postponed for the future, a shining technological breakthrough when psychiatry anchors its concepts once and for all. Once again, the idea of abandoning schizophrenia is in the air; should we stop talking about it? Should we call for a paradigm shift? If only it were so simple.

I have argued before that schizophrenia's flaws are undeniable, but we lack a compelling alternative. Paradigm shifts (at least in the Kuhnian sense) take place when a theoretical framework arrives that makes it untenable to speak in terms of its predecessor. Schizophrenia is just over 100 years old, which isn't that long in the tooth for a productive but strictly false programme of research. Phlogiston theory organized research in chemistry from 1667 to 1780, though researchers probably had a sense it was flawed for a while before they could figure out a better way of thinking. Unlike Oxygen theory, none of the competitors currently being mooted in the psychiatric domain (a focus on specific symptoms or complaints, or on individual formulations) is formally incommensurate with a theoretical disorder called "schizophrenia". Until a theory arrives that makes tighter predictive claims, we are stuck with a hot mess.

Friday, 3 June 2016

Medication, Phenomenology and the Nocebo Effect

A great recent paper by Gibson and colleagues undertook a thematic analysis of people's responses to being asked about taking antidepressants. Some of what they described was very negative. This is not a surprise (it is well known that many antidepressants have a significant side effect profile), though it is important that it has been documented. Here, for example, is a striking description:
Each one has had a worse effect than the previous…. I can’t remember them all. It started with memory loss then progressed to me becoming borderline catatonic staring at the wall for hours unable to stand up. Within a few weeks and genuinely terrified. It was a relief to go back to the misery of depression after these experiences
In addition to descriptions of what we can designate as direct negative physiological effects, another negative theme that emerged was "loss of authenticity/ emotional numbing". This is a more slippery experience; a sort of phenomenological unease arising from taking medications. Authenticity is an important part of our sense of who we are. To interfere with it may be less physically dangerous than a side effect like weight gain, but feels somehow more metaphysically perilous. Take my body, but leave my self alone!

The authors of the study point out "This research points to the inadequacy of asking the simple question: ‘Do antidepressants work?’ Instead, the value or otherwise of antidepressants needs to be understood in the context of the diversity of experience and the particular meaning they hold in people’s lives." I agree, but I think even this form of the question can be complicated further.

We have become accustomed to thinking about the effects of antidepressant medications in terms of the placebo effect. Since (at least) a famous meta-analysis by Irving Kirsch (and a subsequent book), many have suggested that the benefits of antidepressants are not the result of an positive, active drug effect, but the mysterious workings of the various expectancy effects we call "placebo".

It's a popular idea, albeit one that has become fraught with controversy. I am not going to wade into the question of how effective antidepressants really are (if you want to think about that then you are in for a long puzzling road. You could do worse than to start with James Coyne's provocative critique of Kirsch here). but I do want to suggest that, when it comes to expectancy effects and antidepressants, there may be a kind of asymmetry in how we customarily think.

Drugs also have nocebo effects; harmful outcomes that arise from the expectations of the people taking them. The nocebo effect (placebo's evil twin) is not something to be fooled around with. For a vivid account read this case study of a young man who needed hospitalisation after he overdosed on the inert pills he was given during an antidepressant trial. If expectations about a sugar pill can do that, then without doubting the flat reality of antidepressants' severe physical effects, we might wonder whether some negative effects, including feelings of phenomenological unease, could also result from a such a phenomenon.

There is a veritable culture of suspicion about the phenomenology of antidepressants, and a strand of cultural commentary on psychiatric medications that sounds a shrill moralising note. Taking medications for depression is regarded by some as an inherently suspect thing to do. Two notorious skeptical pieces in The Guardian (by Will Self and Giles Fraser), around the time of the publication of DSM-5, both hinted at the idea that taking antidepressants was the result of false consciousness:
At worst, they pathologise deviations for normalcy, thus helping to police the established values of consumer capitalism, and reinforcing the very unhappiness that they purport to cure.
It is hard to imagine that none of this would loop back round and influence people's experiences of what it is like to take medication. Ineeded, psychiatrist Linda Gask writes beautifully about the internal struggle over self-authenticity that can result from these ideas:
There are times still when I wonder whether the medicated me I’ve been for so long is the ‘real’ me, or are these tablets simply suppressing the person I truly am?
Contrast the Gibson study with the miraculous seeming accounts of the experience of taking SSRIs when they were brand new. Peter Kramer's 1994 "Listening to Prozac" included the now famous (and oft-derided) claim from one patient that the drug made them feel "better than well".

Could it be that when drugs first appear, they not only benefit from a sort of placebo boost (in virtue of their novelty value), but also from the absence of a culturally inherited, nocebo baggage? Research on this question seems just as important as teasing out the beneficial effects that arise from inert substances. If there are such effects, what are the moral obligations that arise for how we talk about treatments and shape the expectations of those who take them?