To the editor, New England Journal of Medicine
Although it may be true that the working hypothesis of most investigators of schizophrenia is that it is a disease of neural connectivity caused by multiple factors that affect brain development, the New England Journal of Medicine should not give its authority to such wishful thinking, as it did by publishing the editorial by Andreasen (1). Trite statements that schizophrenia is a brain disease have been made since the concept of schizophrenia was established. Despite Andreasen, understanding of the causes of schizophrenia has not been helped by this assumption
There is a real difference between schizophrenia and cancer, which means that understanding cancer cannot be a suitable model for schizophrenia. Psychosocial factors are integral to the causation of schizophrenia. Indeed the error of the "brain hypothesis" is the implication that psychosocial factors are irrelevant, or at least that they only precipitate the more consequential brain pathology. The advantage of the neurodevelopmental hypothesis is that it emphasises a maturational perspective, but neural circuits and neurotransmitter systems may be normal in schizophrenia, just as there are no visible neuropathological markers (2). The suggestion that misregulation of information processing is a final common pathway for schizophrenia is a tautology that does nothing to improve understanding. Nongenetic factors may have more significance than merely influencing brain development.
The "brain hypothesis" means that treatment tends to become impersonal, rather than leading to the improvements that Andreasen anticipates. Such ideology is defensive and avoids personal agency. Reducing relations between people to objective connections seems to make them more manageable. Adolf Meyer was fond of seeing his biopsychosocial model as scientific advance over reductionist views (3). However, modern psychiatry has again become so dominated by biologism that debate about the relationship between mind and brain is now rarely acknowledged, as evidenced by the bias of the editorial by Andreasen.
D B Double, MA, MRCPsych
Norfolk Mental Health Care NHS Trust, Hellesdon Hospital, Norwich NR6 5BE, UK
1. Andreasen N. Understanding the causes of schizophrenia. N Engl J Med 1999;340:645-7 [Full text]
2. Chua S E and McKenna P J. Schizophrenia - a brain disease? A critical review of structural and functional cerebral abnormality in the disorder. Br J Psych 1995;166:563-82
3. Meyer, A. Collected Papers (Four Volumes) (Ed. E. Winters). Baltimore: John Hopkins Press, 1951/2