Secondary Schizophrenia (9 page)

recognized to commonly occur in association with
The problem is again because of the false dichotomy
17

a cerebral disorder and more often than chance
that “organic” tends to perpetuate. We know that
Introduction – Section 1

psychiatric illnesses have multiple etiological factors –
“functional” or “nonorganic.” This alternative deals
genetics, coarse cerebral disease, personality, stress –
with some of the identified problems. Although a
some of which would be recognized as organic in most
primary–secondary dichotomy remains, it does not
cases. We are, therefore, not dealing with discrete etio-have the connotation of a duality of mind and brain.

logical categories, and it is wrong to treat them as such.

“Primary” implies (or so I hope) “idiopathic,” that is,
It was this tendency that led to the paradoxical situa-the cause is not known, which in general is an accu-tion that an apology had to be included in ICD-10: “use
rate acknowledgment of our ignorance. It does not
of the term ‘organic’ does not imply that conditions
connote lack of cerebral dysfunction of some kind. It
elsewhere in this classification are ‘nonorganic’.” It begs
groups psychiatric disorders more logically, yielding
the question: What is “organic” and what is not? A cat-classes that are characterized by phenomenology and
egorical answer is impossible because the dichotomy
not putative etiology. It makes all psychiatric disorders
itself is false. Birley
[7]
calls it the problem of scholasti-secure within the field of psychiatry. It has many paral-cism, that is, treating what is vague as if it were precise.

lels in medicine in which “idiopathic or primary” and
I have already referred, in part, to the semantic
“secondary” categories of hypertension, respiratory
problem. Proponents of “organic” have had to seek
failure, hyperparathyroidism, and other disorders are
suitable antonyms. “Functional” is much used but is
recognized.

disliked by some because of its long association with
But this strategy only goes some of the way. The
physiological function, and the argument that func-dichotomy between “functional” and “organic” that
tion is impaired in organic disorders as well. The term
is present in the minds of mental health profession-

“nonorganic” was suggested to cover everything that
als is not necessarily addressed. As Spitzer and col-fell into the other basket, but the proponents were
leagues
[7]
admit, “the (ICD-10) definition of ‘organic’

apologetic for it, as mentioned above. Furthermore,
is in complete agreement with our definition of ‘sec-what is considered “organic” has been referred to by
ondary’.” The only hope DSM-IV has is to leave behind
many other terms including brain damage, cerebral
the baggage associated with “organic,” but it is perhaps
damage, brain dysfunction, and brain injury. It seems
only a question of time before “secondary” assumes
there is no term that will satisfy us all.

this burden. The practical problem of deciding what
The problem of stigma remains. However loudly
constitutes “secondary,” and the problems of method
patients and professionals have demanded destigma-and scholasticism remain. We exchange old seman-tization of mental disorders, society’s attitudes have
tic problems with new ones. A more radical change
been slow to change. A dichotomy between “organic”

is necessary for these problems to go away; we need
and “nonorganic” certainly does not assist the process.

to change paradigms rather than replace terms with
Nor does it help the remedicalization of psychiatry.

others that signify the same concepts. One sugges-The final problem I can identify is the threat of
tion is to treat neurobiological causes of mental disor-takeover. Although psychiatrists continue their affair
ders on a continuum, which comments the degree to
with Descartes, other professions are waiting in the
which known neurobiological etiology is attributable
wings – neurologists to take over our “organic” disor-to a particular disorder. The known neurobiological
ders and psychologists and social workers to take over
disorders or causes could be separately listed, as on
our “nonorganic” ones. Psychiatry must consider this
Axis III. This strategy is certainly an adequate response
when defining its territory, as that will determine how
to the problem of dichotomy, and with it the problems
solid the fences are.

of method and scholasticism. The major problem it
does not deal with, and perhaps the one that makes it
a worse choice is that of practice. First, the difficulty
The alternative

of deciding upon the significance of an identifiable
Having listed so many problems with “organic,” I must
cerebral disorder in the causation of a psychiatric syn-argue, like Spitzer and colleagues
[8],
that it is now
drome is not helped by this change. That will have to
“time to retire the term . . . ” But what must take its
await an increase in our knowledge of brain function –
place? Two terms that have been considered seriously
normal and abnormal. Second, the proposed strategy
are “symptomatic” and “secondary,” the latter havis likely to prove very unreliable, as one would expect a
ing won out in DSM-IV. Primary psychiatric disor-low agreement between psychiatrists regarding the rel-

18

ders are, thereby, the disorders that were previously
ative significance of neurobiology in individual cases.

Chapter 2 – The concept of organicity and its application to schizophrenia

Classifiers are unlikely, therefore, to adopt the sugges-molecular mechanisms remain inadequate to explain
tion. An alternative is to regard all psychotic disorders
higher-level phenomena in their entirety; and iii) our
as being neurobiological, and indicate on a separate
dialogue occurs in a language born in a dualist age, and
axis what contributions – on a continuum again –
this is difficult to transform. This may seem to be the
interpersonal, social, and cultural factors may have
position of a pessimist, but the hope that I see is in
made in a particular case. This position is complemen-the debate that has already been generated. The initial
tary to the above, and the associated difficulties are
moves, as in DSM-IV, are in the right direction, but we
similar.

have further to travel. For this book, the prefix “sec-I feel that we are condemned to an unsatisfactory
ondary” to schizophrenia will have to suffice because
position, and the reasons are not difficult to under-it acknowledges the contribution of the “organic” fac-stand: i) positron emission tomography notwithstand-tor while at the same time accepting that the syndrome
ing, our understanding of brain function and that of
may be no different from the idiopathic schizophrenic
the etiology of psychiatric disorders is still very rudi-disorder. It challenges us to rethink schizophrenia
mentary; ii) even as neuroscience is progressing, the
while providing clues to its pathophysiology. My hope
realization is prevalent that we have to continue con-is that these clues will lead to insights that will provide
ceptualizing brain function at multiple levels because
a deeper understanding of this enigmatic disorder.

19

Introduction – Section 1

References

4.

Starkstein S. E., Mayberg H. S.

language in psychiatry: Results

(1993). Depression in Parkinson

from the field trials accompanying

1.

Searle J. R. (1992). The

disease. In Depression in

the clinical guidelines of mental

Rediscovery of the Mind.

Neurologic Disease, Starkstein

and behavioural disorders in

Cambridge, Mass: The MIT Press.

S. E., Robinson R. G. (Eds.).

ICD-10. Arch Gen Psychiatry,

2.

Slavney P. R., McHugh P. R.

Baltimore: The Johns Hopkins

1993.
50
:115–24.

(1987). Psychiatric Polarities:

University Press, pp. 97–

Methodology and Practice.

116.

7.

Birley J. L .T. DSM-III: from left

Baltimore: The Johns Hopkins

to right or right to left? Br J

University Press.

5.

Slater E., Beard A. W., Glither E.

Psychiatry, 1990.
157
:116–
The schizophrenia-like psychosis

8.

3.

World Health Organization

of epilepsy. Br J Psychiatry, 1963.

(1992). The ICD-10 Classification

109
:95–150.

8.

Spitzer R. L., First M. B., Williams

of Mental and Behavioural

J. B. W.,
et al.
Now is the time to
Disorders: Clinical Descriptions

6.

Sartorius N., Kaelber C. T.,

retire the term “organic mental

and Diagnostic Guidelines.

Cooper J. E.,
et al.
Progress

disorders.” Am J Psychiatry, 1992.

Geneva: WHO.

toward achieving a common

149
:240–4.

20

Section 1

Introduction

Mark Walterfang, Ramon Mocellin, David L. Copolov, and Dennis Velakoulis
Facts box

acteristics that distinguish them from related phenomena such as imagery and pseudohallucinations. Slade
1. Infrequent hallucinations – auditory as well
and Bentall
[2]
crystallized these features in their def-as visual – are common in the general
inition, proposing that hallucinations are perceptual
population and do not necessarily signify a
experiences that occur in the absence of appropri-psychiatric disorder.

ate stimuli, have the full force or impact of the cor-2. Hallucinations occur in a number of
responding real perception, and are not amenable to
psychiatric disorders, and are most common
direct and voluntary control. This definition, although
in schizophrenia.

widely used, has been subject to suggested amend-3. Hallucinations in the setting of brain disease,
ments, for example, by David
[3]
who defines hallu-that is, of organic etiology, are uncommon in
cinations as “sensory experiences which occur in the
general practice but are frequently

absence of corresponding external stimulation of the
encountered on hospital wards, especially
relevant sensory organ, have a sufficient sense of real-among the elderly.

ity to resemble a veridical perception, over which the
4. Although hallucinations may occur in a
subject does not feel that he or she has direct and vol-number of modalities within the individual,
untary control and which occur in the awake state.”

the etiological, biological, and treatment
By providing a less rigid boundary in relation to the
facets differ somewhat for auditory, visual,
reality-like aspect of the symptom, this definition takes
olfactory, gustatory, and tactile

into account the spectrum along which such stimulus-hallucinations.

independent perceptions are described. It also accom-modates the fact that a significant minority of halluci-5. A number of neurological or systemic
nators are able to use coping mechanisms to modulate
disorders have been associated with

their hallucinations
[4]
even though they may not feel
hallucinations of different modalities.

they can control them.

6. The models of pathogenesis of hallucinations
are drawn from a range of different disorders
such as delirium, dementia, and

Epidemiology of hallucinations in the

substance-induced states, and bear

community

significant homology to some of the

emergent neurobiology of

In the community, hallucinations most commonly
schizophrenia-spectrum disorders.

occur in the absence of psychiatric or neurological disorders. Several major studies have revealed a higher
community prevalence of hallucinations than would

be expected if they were only reflective of psychiatric
The term “hallucination,” which derives from the
or neurological disease. Ohayon found that 18% of
Greek alyein via the Latin hallucinari, to “wander in
a large sample of 13,057 subjects in the nonhospi-the mind”
[1],
was first used in the English language
talized population across three countries – the UK,
in 1572 to describe visual phenomena – “ghostes and
Germany and Italy – experienced daytime halluci-spirites walking by nyghte”
[2].
The essential feature of
nations
[5]
. Among this group, infrequent daytime
hallucinations is that they are percepts in the absence
hallucinations (less than once a week) occurred in
21