A Case of Pseudo-Neurotic Schizophrenia
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These doctors took the opportunity to invent a new kind of illness: the pseudo-neurotic schizophrenic, or, in the usage of others, the borderline. This is an example of trying to convince oneself that we know something about a condition if we give it a name. Initially, the term Borderline was used differently by different psychiatrists; but then a consensus formed. This is a summary of the way Borderline is described in the DSM A pervasive pattern of instability of interpersonal relationships, self-image , and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts as indicated by five or more of the following: There is not space here to describe all nine of the behaviors singled out for inclusion but they involve: 1.
Efforts to avoid abandonment 2. Unstable and intense relationships. Unstable self-image 4.
Impulsivity that is likely to be self-destructive 5. Recurrent suicidal or self-destructive behaviors. Instability and reactivity of mood. Inappropriate anger 9. Transient paranoid ideation. Can the diagnosis be made with only four of these behaviors? Would that be the Borderline Borderline alluded to above?
Are some of these behaviors present, at least transiently, in most people? I think so. Speaking of behaviors or feelings or other qualities of mind as if they constitute a thing is called reification. The unconscious is not just an inclination to remember, or not remember, or behave in a certain way, it is treated as an object, something that has an existence with all the features of an object—a place, a shape, a kind of weightiness.
This sort of logical error can lead people to misunderstanding.
Questions and Answers
Has this happened with the diagnosis of Borderline? Before someone invented this term, A Borderline patient might have been described simply as depressed, or impulsive, or, even, immature. Do some of these symptoms appear together? But they may be a developmental stage in some people rather than a mental condition in its own right. What is also true is that some Borderlines no longer exhibit these behaviors after a time, whether or not they have been in treatment.
Is it reasonable to describe it as a particular condition, like schizophrenia is a condition? Yet, this diagnosis has become popular. One would think that the diagnosis of an illness would not become popular or unpopular, in the same way a particular author or a band might become popular or unpopular, simply because of the tastes of other people all changing at the same time, but in the matter of psychiatric diagnoses, that is the case. There was a time when the diagnosis of manic-depressive illness vs.
The British were more likely to call a patient described in a particular way as a manic-depressive. The same description presented to American psychiatrists led to a diagnosis of schizophrenia. When lithium was discovered to be an effective treatment for manic-depressive illness, that condition was diagnosed more readily by everyone. If one did not know about the use of lithium, it would have seemed that the condition had suddenly become rampant.
What’s the difference between psychosis and schizophrenia? | Here to Help
Currently, popular diagnoses include attention deficit disorder and bipolar disorder. This is likely to represent a fashion in diagnosis rather than an increased incidence of those conditions. The reason why it is possible to decide arbitrarily that a condition is present or not is the fact that there are no objective tests for these conditions. The psychological tests for ADD are not reliable, or valid; and there is no objective test for bipolar disease at all. In fact, the reason why there is a new Diagnostic and Statistical Manual, and there have been four previous attempts to write such a manual, is that most of the disorders described in these compilations are descriptive only.
Nevertheless, some psychiatrists are inclined to take the matter of diagnosis quite seriously. I saw a patient recently who had been treated successfully for a paranoid schizophrenia for many years with a relatively high dose of a neuroleptic. His first psychiatrist died, and he went to another who decided the patient was really bipolar. Because the first line drugs for bipolar disease are somewhat different than those prescribed for schizophrenia, he switched the patient to a different drug. The patient began to hallucinate and talk to himself.
Shortly thereafter, he came to me; and I put him back on the first drug, after which he did okay. As it happened, it seemed to me clear enough that he was really a paranoid schizophrenic. But, suppose he was not. Why would someone stop a drug that was working simply because he thought the diagnosis was wrong? The fact is, I think psychiatrists are usually in the position of treating symptoms—agitation, depression, dementia , etc.
It is the symptoms that cause distress; and many of the same symptoms are present in different conditions. Making meaningful diagnoses requires a true understanding of the illness. There was even a time when tuberculosis, when it presented primarily as a gastrointestinal disease from unpasteurized milk, could be confused with other intestinal diseases. It was only when the bacterial cause was discovered that that condition could be delineated accurately. Similarly, I think psychiatry has simply not advanced far enough to distinguish sensibly one condition from another.
We now have psychological syndromes that are called disorders. Many of the psychological symptoms referred to in these conditions are present in varying degrees in normal people. I think that when the biological causes —of the psychoses, at least—are delineated successfully, there will turn out to be different kinds of schizophrenia, for example, and depression.
The patterns of thought, feeling and behavior that are now thought to be defining characteristics of these disorders will turn out to be a final, common pathway of different disorders. For example, I have seen schizophrenic patients who did very well. Some have had one psychotic episode that left no sequelae and were not followed by further attacks.
On the other hand, I have seen schizophrenic patients who deteriorated steadily despite good treatment into a chronic, disabled state which required permanent hospitalization. My hunch is that these extremes will be discovered to be caused by different biological defects—and will, therefore, appear someday in DSM 28 under different names.
Reliability: A diagnosis should call to mind the same clinical picture whoever uses that term. If one psychiatrist calls a patient a Borderline, other psychiatrists should be able to understand what he means. For this purpose, at least, the DSMs serve a useful purpose. But I think, by that standard, these extremely carefully written catalogues fail. Look at the definition of Borderline written above.
What one clinician calls a Borderline is likely to differ considerably from the picture of a Borderline that the other clinician imagines.
Reexamining Schizophrenia as a Brain Disease
In an attempt to make these diagnoses seem more specific than they really are, they are given identifying numbers. For instance, These numbers are used on insurance forms. If the diagnoses were reliable, at least we could make some inferences about the prevalence of a particular condition, and so on. But, judging from my experience, such an attempt would be futile. I was treating a patient for Obsessive-Compulsive Disorder. I put the code They returned it to me saying this code, which I had been using for years, was superseded by a new code.
They explained this to me over the phone. I spent the next few days trying to locate a more recent copy of the international psychiatric code book, which is what I presumed had superseded DSM 4. Finally, although I did not feel sure, I filled out the form with The form was returned to me about two weeks later. I called again to find out why.
Once again, I tried It was returned again. Prolonged exposure to stress, such as physical trauma or emotional abuse, causes the brain to increase production of certain hormones, such as steroids. Conversely, if a person is relaxing, his steroid output may decline. The same results can be found examining brain waves. If a person is excited, the brain is likely to generate fast, low-amplitude electrical waves on an electroencephalogram EEG. If the person then relaxes, the EEG will show alpha waves—slower, with a higher amplitude.
Again, in the case of brain waves, the emotional state influenced how the brain reacted, rather than vice versa.
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However, the biopsychiatrists, without realizing it, usually just assume that a change in the brain means the existence of a disease entity called schizophrenia. This is why they search for physiological abnormalities in the brains of people so diagnosed, such as dopamine hyperactivity and ventricular enlargement. It is an unfortunate truth that many young psychiatrists today are unfamiliar with the vast literature from psychoanalytic psychiatrists on the human problem of schizophrenia, written by intellectual giants like Silvano Arieti, Harry Stack Sullivan, Theodore Lidz, and Thomas Szasz.
I contend that what is called schizophrenia is a complex human condition that has at its locus a breakdown in interpersonal communication. Despite common belief, many patients diagnosed as schizophrenic go on to do quite well, and a substantial minority of them regain full functioning. Sadly, there is no sign that the field is ready or willing to adopt a non-biological explanation of schizophrenia. There is, it seems, no room in American psychiatry for those who voice disagreement with the biological theory of schizophrenia. Loren Mosher, former chief of the schizophrenia research branch of the National Institute of Mental Health NIMH , was fired from his post after advocating a psychosocial approach to psychosis.
He remained a clinical professor of psychiatry at the University of California at San Diego until his death in Psychologists and social workers, many of whom had been steadfast proponents of psychosocial theories of mental distress, now mainly endorse the biological model of schizophrenia. The reasons for this are complicated but involve the increasing medicalization of these fields and the natural tendency to consider human experiences beyond normal appreciation as being biological aberrations rather than understandable differences.
Common misconceptions notwithstanding, the evidence is dwindling—not expanding—that schizophrenia is a brain disease of biochemical origin.