Correspondence

Book Review: Experiences of Schizophrenia

N Engl J Med 1994; 331:1594December 8, 1994

Article

To the Editor:

In his review of my book, Experiences of Schizophrenia (June 23 issue),1 Lewis misquotes me as saying that schizophrenia is a “metatheory.” What I said was, “I should like to propose as an alternative to monistic forms of thinking... a supraordinate or metatheoretical structure or viewpoint that respects pluralism in the human sciences.” My point is that it is impoverishing to try to reduce the complex phenomenon we call schizophrenia to a single explanation, whether that explanation involves psychological meanings or neuroscientific networks and transmitters.2 We need the contributions of all the human sciences, and I have elaborated them and proposed an integrative scheme derived from systems theory and from Engel's biopsychosocial model.3

Lewis says that I distrust quantitative research and experimental evidence. Actually, I draw heavily on the latest research data from all the human sciences, and the 20-page bibliography is full of neuroscientific citations. Because I believe that qualitative case material is important, too, I present five detailed reports. His statement that only two of these, which he claims involved psychotic depressions, had good outcomes, is also incorrect. All the cases met the criteria of the Diagnostic and Statistical Manual of Mental Disorders for schizophrenia. Three cases involved major personality changes, not simply compensation and rehabilitation, and the two failures were deliberately chosen for their didactic value and to represent the reality of work with patients who have schizophrenia.

Lewis says that I blame bad families for causing the disorder. My actual thesis is that there is a constitutional, probably genetic, vulnerability to the illness, and whether parenting is pathogenic or extraordinary and remedial may determine whether the outcome is clinical schizophrenia, atypical personality, or normal or exceptional personality.

Far from advocating psychoanalysis as the treatment of choice, I outline a process of triage designed to determine the particular combination of psychopharmacologic, supportive, and rehabilitative measures best suited to the majority of patients and to identify the minority of patients for whom a psychoanalytically informed focus, bolstered by other treatment approaches, may offer the fullest measure of recovery and growth. Lewis's implication that I reject psychopharmacologic and cognitive-behavioral therapies is also untrue; a chapter of the book is devoted to the former, and a section to the latter.

Michael Robbins, M.D.
Harvard Medical School, Boston, MA 02115

3 References

1. 1

   Lewis SW. Review of: Experiences of schizophrenia: an integration of the personal, scientific, and therapeutic. N Engl J Med 1994;330:1836-1837
   Full Text

2. 2

   Eisenberg L. Mindlessness and brainlessness in psychiatry. Br J Psychiatry 1986;148:497-508
   CrossRef | Web of Science | Medline

3. 3

   Engel GL. The clinical application of the biopsychosocial model. Am J Psychiatry 1980;137:535-544
   Web of Science | Medline