24 August 1992
L S Pilowsky seems to reach a different conclusion from the biological evidence about the nature of schizophrenia1, than does Julian Leff in a recent commentary in Nature2. For Pilowsky it is clear that there are structural and physiological abnormalities present in the brain. By contrast, Leff suggests that schizophrenia remains a puzzle and recognises the plethora of hypotheses about the condition.
Some caution may be required when expressing the results of comparisons of the brains of schizophrenic and normal people. For example, although on average schizophrenics may have larger ventricles, a simple statement that "schizophrenics have larger ventricles than controls" will be marked wrong in an MCQ examination of the Royal College of Psychiatrists3, as the ventricles of the brains of most schizophrenics have scores within the normal range.
The difference between the positions of Pilowsky and Leff seems more than semantic. The current dominance of biological psychiatry obstructs the view of the patient as a person. In what sense can Pilowsky's editorial be entitled "Understanding schizophrenia" - knowledge of the brain may give no understanding of the person. Adolf Meyer was fond of seeing his philosophical approach to psychiatry, with its emphasis on the person, as an advance over the mechanistic philosophy of the 19th century4, but psychiatry seems to have slipped back since his time and his work is now largely neglected. He warned against going beyond statements about the person to wishful "neurologising tautology" about the brain. The link between mind and body is complex and the issue is unlikely simply to go away.
There is a danger that the bald statements of the organic nature of schizophrenia in Pilowsky's editorial will give a false impression. The inevitable uncertainty of the practice of psychiatry should be recognised. The misleading bias of biological psychiatry which may have been encouraged by her editorial needs to be countered.
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1. Pilowsky L S. Understanding schizophrenia. BMJ 1992; 305:327-328.
2. Leff J. Schizophrenia in the melting pot. Nature 1991; 353:693-694.
3. Birley J L T. Venricular size in schizophrenia. British Journal of Psychiatry 1992;161:278.
4. Meyer A. Collected Papers (ed Winters E.) Baltimore: John Hopkins Press, 1951 & 1952.