Bathwater and the baby

Response to the Editorial: The ‘continuum of psychosis’: scientifically unproven and clinically impractical.The British Journal of Psychiatry (2010) 197, 423-425

This response was published  in the Br J Psychiatry

This is a timely and welcome editorial from Stephen M. Lawrie et al.[1] I see this debate two ways: as a doctor needing ‘order’ to help ease suffering I agree that it is better, for the time being, to keep existing diagnostic categories of disorder however imperfect they may be. As a patient I of course want care, but I also want to be understood. Many of us are now considering that too much of life is being branded disorder: here none of us diminishes suffering, but we do look for better ways of explaining. Certain scientists may hate it – but our lives do have narrative. I think we underestimate mankind if we say that we cannot accept symptom based descriptions of suffering. I hope I am not wrong to suggest that most of the treatments that today used to improve mental health are not ‘disease specific’ but rather act upon either mood, thought, or both.

Nevertheless the cry for a spectrum approach to psychosis I would agree is premature and does not fit with my experience of so many troubled lives encountered. Peter Tyrer our Editor is correct to raise the potential problems of premature abandonment; both clinical and pragmatic.[2] However there remains a need to reconsider the neo-Kraepelinian model, if nothing more than to bring greater alignment with the technology that Lawrie et al now hope will be to our greater mental good. As the classification system is at present, it is my belief that neurobiological research cannot fully address complexity. My own view is that we have rather given too much attention to what Steven Rose has termed ‘neurogenetic determinism’ rather than applying biological research to life (baby and the bath water, however dirty). [3]

I would contest the presentation of the neurobiology literature as presented here by Lawrie in the opening paragraph of the Editorial, and quote: “based on highly replicable neurobiological differences.” This cites the paper ‘Schizophrenia, ‘just the facts’; what we know’ by Tandon, Keshavan and Nasrallah.[4] I have read this paper several times, but found, for all the studies and indeed all the words, neither one simple biomarker of any utility nor indeed anything even approaching specificity. Perhaps we should ask why this may be? Could it be that categories, clinically practicable, and needed for now, do not match the complex epigenesis of psychosis?

In concluding I would suggest that we do not forget history. James Clerk Maxwell was bold enough to stop looking for matter and to consider the energy fields that now govern our lives and indeed the technology which has been to our collective good. Do we need another Clerk Maxwell moment, scientifically brilliant, religion free, willing to see matters as simple as possible, but not simpler?

I have no such moment to offer. But brilliant Edinburgh folk like Lawrie have that tradition and they perhaps raise the chances that such scientific inspiration can help us once again.

James Clerk Maxwell: a scientific giant for Hole Ouisia