Why psychiatrists should mind their language

Allen Frances, contributor

Richard Noll's American Madness: The rise and fall of dementia praecox is the history of the old name for schizophrenia, showing the problems with such labels

"WE DON'T see things as they are, we see things as we are." This simple Talmudic saying summarises the essence of epistemology. Psychiatric disorders provide a striking example: they are not real things in nature, but labels we create to describe troubling aspects of human experience.

Sometimes labels take on a life of their own. People mistakenly think that naming a psychiatric problem shapes it into a simple disease with a reductionist, biological explanation. Labelling mental disorders is useful in providing a common language and guide to treatment. But psychiatric disorders are remarkably heterogeneous and overlapping in their presentations and complex in their causation. The human brain rarely reveals its secrets in simple answers.

All of which brings us to the wonderful book, American Madness, an artful analysis of the rise and fall of the label "dementia praecox" from its promising birth in 1896 to its unlamented death in 1927. Introduced by the German psychiatrist Emil Kraepelin, the term was used to describe an early onset of psychotic symptoms that presaged a tragic downhill course and poor outcome - as distinct from manic depressive illness, which has a more variable age of onset, cyclical course, and greater chance for a good outcome.

The label dementia praecox spread like wildfire and was briefly the darling of psychiatry until it lost out to schizophrenia, a broader concept that included milder and earlier cases and did not necessarily imply such a bleak future or bad outcome.

The defeat of one term and rise of the next resulted from a shift in diagnostic fashion promoted by leading American psychiatrists, dutifully followed by their flocks.

In retrospect, there was nothing inherently superior about either term. Schizophrenia won because it was less discouraging, implied therapy might help, was not of German origin when the US was at war with Germany and was of Swiss origin at a time when the two major figures in American psychiatry were Swiss immigrants. If it sounds arbitrary, it was. Human nature doesn't sort into neat and obvious categories.

The label schizophrenia is still with us, but hopefully not for too much longer. It is a tired, old concept that has outlived much of its usefulness. There is not one schizophrenia: more likely a hundred causes will gradually be teased out as research goes beyond description and discovers fundamental explanations.

Though set in the past, the lessons of this book are as fresh as the controversies over the new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5) and the very future of psychiatry. Like all of medicine, the history of psychiatry is a tale of faddish and false (but often temporarily useful) diagnostic theories and labels. Tracing the fate of dementia praecox provides historical perspective and keeps us on our epistemological toes. Today's psychiatric labels will one day seem just as quaint. We need them in our clinical work and research, but shouldn't be overly impressed with their explanatory value. And we should be on guard against making arbitrary changes based on frills and fashions.

Thus informed, perhaps we can avoid repeating the recursive ebbs and flows and instead achieve a rounded view of psychiatry.

Book Information
American Madness: The rise and fall of dementia praecox
by Richard Noll
Published by: Harvard University Press
?33.95/$45

Source: http://feeds.newscientist.com/c/749/f/10897/s/1af0a890/l/0L0Snewscientist0N0Cblogs0Cculturelab0C20A110C120Cwhy0Epsychiatrists0Eshould0Emind0Etheir0Elanguage0Bhtml0DDCMP0FOTC0Erss0Gnsref0Fonline0Enews/story01.htm

surrogates james garner veteran aircraft carrier apocalypse now happy veterans day happy veterans day