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15

Section 1

Introduction

to schizophrenia

Perminder S. Sachdev

Facts box

the schism between the brain and the mind, and it
has a certain power to maintain the philosophical bag-1. The term “organic” psychiatric disorder has a
gage of Cartesian dualism (the duality problem). The
number of problems that can be described as
dichotomy of mind and body (or brain) has a long
problems of duality, method, practice,

tradition in Western thought and it has shaped much
scholasticism, semantics, and stigma.

of our earlier thinking and the terminology we use.

2. The term “functional” disorders is

Cartesian dualism presents a polarity in the mind–
inadequate as all disorders are associated
brain problem that is seemingly impossible to bridge.

with functional impairment.

This polarity is reflected in the other dichotomies we
3. The term “secondary,” implying idiopathic or
have come to accept: structure and function, psycho-as yet insufficiently understood etiology,
logical and biological, organic and functional. Most
overcomes some of the problems of

recent philosophers have abandoned property dualism
“organic.”

and accept some shade of materialist monism, accord-4. A definitive classification of the psychoses
ing to which they either attempt to “naturalize” con-must await a greater understanding of
sciousness and intentionality, that is, reduce them to
etiopathogenetic mechanisms.

some form of physical phenomena
[1],
or at the very
least accept that the basis of the mind and conscious-ness is in the neurophysiologic processes occurring in

the brain. There are many shades of materialism with
This book is on “secondary” schizophrenia, and it is
which we do not have to concern ourselves, but in all
important to examine what constitutes a secondary
of these, there is no place for an organic–functional
rather than a primary psychiatric syndrome. This term
dichotomy. There is, on the other hand, an interaction
has a tortuous history that is worth revisiting, both
between structure and function, whereby no disorder
for its explanatory power and its limitations. In many
of the brain (or mind) is based solely on disturbance
minds, “secondary” equates with the older concept of
of structure or function. The term “organic” steadfastly
“organicity.” The term “organic” was a product of the
persists in maintaining the dichotomy against all rea-move in late-nineteenth and early-twentieth centuries
soned argument.

to distinguish “functional” (or psychological) disor-Then there is the problem of method. The distinc-ders from real “brain” disorders, which was rooted
tion between organic and functional disorders carries
in Cartesian dualism and propelled by the increasing
with it an implication that different methodologies are
influence of psychodynamic theory. Since then, we
applicable to the two: those of natural science to the
have moved further both in the philosophy of mind
former and those of the humanities or social science
and in the major paradigms that guide the discipline
to the latter. There are tensions between these methods
of psychiatry.

that are not easily reconcilable
[2],
but for true psychiatry, both aspects are important. The mental lives of
individuals have their origins in the brain but belong
Why not “organic”?

equally in a phenomenal world, and the study of the
We have chosen not to use “organic psychosis” as a
two aspects complement each other. The brain mech-title for this book, even though it is still commonly
anisms underlying psychotic disorders are important,
16

used in practice. The use of “organic” is a legacy of
but they present an incomplete picture if the nature
Chapter 2 – The concept of organicity and its application to schizophrenia

and content of the symptoms, their meaning to the
would have it. This was the approach used by Slater
individual, and his or her adaptation to them are not
and colleagues
[5]
in attempting to establish an eti-examined. Any term, such as “organic,” that implies a
ological relationship between epilepsy and chronic
polarity and incompatibility and thwarts the process
schizophrenia-like psychosis. It has produced uncer-of application of both the natural and social science
tain results, and many important relationships are
methodologies to psychiatric disorders, has outlived
still controversial, including that of epilepsy and psy-its usefulness.

chosis. Moreover, a group association is only diffi-

“Organic” also presents a serious problem in its
dently applied by the clinician to an individual case, as
practical usage (the practice problem). What is an
evidenced by the difficulty one encounters in address-

“organic mental disorder”? ICD-10
[3]
attempts to
ing the question: Is the psychosis in my patient due to
define it as “a range of mental disorders grouped
epilepsy, cannabis use, or the head trauma he/she suf-together on the basis of their having in common a
fered some years ago?

demonstrable etiology in cerebral disease, brain injury,
A third guideline hopes to yield insight in retro-or other insult leading to cerebral dysfunction.” It fur-spect, that is, if the treatment of the cerebral or sys-ther goes on to say that “the term ‘organic’ means no
temic disorder leads to an improvement in the psy-more and no less than that the syndrome so classi-chiatric syndrome, the two were probably etiologically
fied can be attributed to an independently diagnosable
related. Not only is such retrospective diagnosis useless
cerebral or systemic disease or disorder.” The working
clinically, in practice, this guideline frequently fails. It
hypothesis is that the cerebral or systemic dysfunction
is not uncommon for the schizophrenia-like psychosis
is directly responsible for the disorder and not a “fortu-associated with, for example, cannabis abuse to persist
itous association with such a disease or dysfunction, or
after the latter has been discontinued. In another case,
a psychological reaction to its symptoms”
[3].
In prac-the patient may improve, only to relapse after a short
tice, however, the situation is hardly as clear-cut as this
interval in spite of normal laboratory data. That the
may suggest.

attribution of “significance” to a recognized “organic”

First, consider the case in which a cerebral dis-factor is not a very reliable process is indicated by
ease is clearly demonstrable and a psychiatric dis-the results of the field trials of ICD-10
[6]
in which
order such as psychosis is present. How does one
the kappa coefficients for the organic syndromes were
establish that the former is etiologically related to the
lower than their nonorganic counterparts, contrary to
latter? For instance, when is a psychosis that develops
what one might anticipate.

in a patient with temporal lobe epilepsy organic? Is the
The practical difficulty in establishing the “real”

schizophrenia-like psychosis that develops in some-role of a “physical” disorder is compounded by the
one after traumatic brain injury, even though full clin-varying opinions among clinicians regarding which
ical recovery from the injury has occurred, organic in
disorders to look for, in which situations, and how hard
origin? These questions are not easy to answer. One
to search. Further, does the suggested need to exclude
guideline often repeated is the temporal association
“organicity” imply that every patient with psychosis,
(weeks or months) between the psychiatric syndrome
depression, or anxiety should undergo an extensive
and the putative organic factor. An examination of the
battery of tests before a firm diagnosis can be made?

psychiatric disorders associated with epilepsy, cere-And, how does one deal with the “enlarged ventri-brovascular disease, Parkinson’s disease, and so on,
cles” in a patient with “nonorganic schizophrenia”?

invalidates such an approach. We recognize that cere-Diagnosticians have differing views on this, and not
bral disease may be present for years before a psychi-everyone digs to the same depth in the search for
atric disorder develops, and yet the two may be eti-

“organic” gold. Extensive exploration, using the latest
ologically related. The so-called “organic psychosis”

technology, often yields “findings” that may be inci-associated with epilepsy may antedate, occur concur-dental and can be difficult to interpret. Investigating
rently or postdate the onset of the clinical features of
elderly psychiatric patients with MRI is likely to yield
epilepsy
[4].

abnormalities that may be no different from those
A second guideline has been “common associa-seen in a nonpsychiatric population, and yet may be
tion,” such that a particular psychiatric syndrome is
impossible to ignore, thus producing a major dilemma.