Kazanetz, Schizophrenia, and Soviet
Psychiatry
To the Editor.\p=m-\Ihave been asked by the Chief Editor to comment on "Dif-
ferentiating Exogenous Psychiatric Illness from Schizophrenia," by Etely Kazanetz, a Soviet psychiatrist (ARCHIVES 36:740-745, 1979), and to highlight the context from which the arti-
cle emerges. The focus and plea of the article, which discusses the confounding of acute and chronic schizophrenia and the dangers of applying the latter diagnosis to the former, are well known in the West and are, in any case, not news. What is news, though, is that there is dissent in Soviet psychiatry; it is this message that emerges most importantly from the report, and it is this message that endows it with historic importance and renders it worthy of our closest attention. Etely Kazanetz is identified as being a research psychiatrist at the Serbsky Institute of Forensic Psychiatry in Moscow. He apparently has published a number of papers on psychiatric diagnosis and a 1971 doctoral dissertation on the use of computers in psychiatry. In a general sense, one assumes that he works within the intellectual orbit of the Moscow school of psychiatry. The Moscow school deserves some introduction. Founded and headed by Andrei V. Snezhnevsky, who is now chief of the Institute of Psychiatry of the Academy of Medical Sciences, the Moscow school represents the domi¬ nant understanding of and approach to mental illness, particularly to schizophrenia, in the USSR. Snezh¬ nevsky, now in his mid-70s, developed his theories during the 1940s and 1950s while he successively taught at the Central Postgraduate Medical Institute in Moscow, the Soviet center for advanced training in psychiatry, became director of the Serbsky Insti¬ tute of Forensic Psychiatry (1950), head of the Department of Psychiatry at the Central Postgraduate^Medical
Institute (1951), and then, in 1962, head of the Institute of Psychiatry, the position he now holds. For many years, he has also been editor of the Korsakov Journal of Neuropathology and Psychiatry, the only psychiatric periodical in the Soviet Union, and has sat on the most important committees that advise the USSR Ministry of Health on issues of research, training, and treatment. By now, he has person¬ ally trained or worked with many of the leaders of Soviet psychiatry, including those who head the most important Soviet training, treatment, and forensic centers. His theories of mental illness, particularly his broad and genetically-based concept of schizophrenia, are widely accepted; his treatises and those of his colleagues in the Moscow school are widely read and quoted; and his diagnostic system is generally standard across the coun¬
try.-5
What Kazanetz does in this article is to strongly question the validity of that diagnostic system and its useful¬ ness in psychiatric practice. He argues
that it leads to an overdiagnosis of schizophrenia because it tends to iden¬ tify those with exogenous psychoses (those we probably would call acute schizophrenics) as chronic schizo¬ phrenics. He also argues that such overdiagnosis is dangerous because it leaves the patients so diagnosed subject to the labeling effects of the schizophrenia diagnosis itself. He says this directly from within the center of the Moscow school's zone of profes¬ sional influence: he challenges the essence of that school's diagnostic approach, and, by implication, its
right
to
professional hegemony.
Not that Kazanetz's arguments are without flaws. First of all, he bases his contention that the Snezhnevskyderived diagnostic system overdiag-
schizophrenia on his finding patients diagnosed as schizophrenic at the Gannushkin Hos¬ pital in Moscow during the 1950s were found, on follow-up and rediagnosis, really to have suffered only from exogenous psychoses. Although it is noses
that many
Downloaded From: by a Tulane University User on 01/19/2019
true that the Gannushkin
Hospital
the clinical psychiatric facility of the Central Postgraduate Medical Institute, whose department of psy¬ chiatry Snezhnevsky headed at that time, the theories of the Moscow school itself were not yet fully formed during that period, and to blame the overdiagnoses wholly on those theo¬ ries may not be fully warranted. In addition, Kazanetz focuses on the overdiagnosis of schizophrenia among patients who, he says, really have exogenous psychoses. But from other data, we have evidence that the major problem of overdiagnosis that arises from the Moscow school's diagnostic approach may be quite different. In the International Pilot Study of Schizophrenia (IPSS), which Kazanetz cites, the Institute of Psychiatry, which was the Soviet IPSS participant research center, did indeed sometimes give a Snezhnevskyan diagnosis of schizophrenia to persons who were was
considered,
on
rediagnosis by
a com¬
puter programmed along Western
(Schneiderian) lines, to have paranoid and other types of psychoses.6 The real problem of overdiagnosis among the Moscow school's diagnosticians, how¬ ever, seems to be their tendency to diagnose as schizophrenic those who are not even psychotic. What the IPSS computer found, in fact, was that the Moscow school diagnosticians tended to diagnose as schizophrenic persons who in other countries would have been considered neurotic or affective¬ ly ill, and that this tendency was particularly strong for the Snezhnev¬ skyan category of mild ("sluggish") schizophrenia, a category of patients all of whom the computer considered to be neurotic or depressed.7 Nev¬ ertheless, Kazanetz's findings in some way complement these and enrich our sense that broad diagnostic schemes tend to lead to broad diagnostic prac¬ tices, probably no matter where they are used. It is of some historical interest that, in identifying the "classical" Soviet school as made up of narrow diagnos¬ ticians, Kazanetz overlooks an impor-
tant feature of Soviet
past, in
psychiatry's
less classical: ways the tendency during the 1920s and 1930s to include within the schizophre¬ nia fold "latent" and "borderline" conditions. This was done particularly at the State Scientific Research Insti¬ tute of Neuropsychiatrie Prophylaxis, organized in Moscow in 1925 under the direction of L. M. Rosenshtein. As it happens, Rosenshtein's inclusion of the "minor" conditions within schizo¬ phrenia was finally condemned during the mid-1980s as being socially dan¬ gerous, since it was said to place too large a population at risk for the diagnosis. Very soon, that trend was snuffed out," as were so many trends, institutes, and professionals during that troubled time. Other difficulties of a methodologi¬ cal and substantive nature should also be mentioned. In some ways, these difficulties enhance the report's inter¬ est rather than diminish it, since they stem from its typically Soviet charac¬ teristics. For example, its findings some
no
legal liabilities of psychiatric labeling in Soviet society are striking at a time when his profession, includ¬ ing the members of the Moscow school and of his own institute, are being the
accused of misapplying their diagnos¬ tic scheme to bestow on those with politically deviant views diagnoses in the schizophrenic range." To be sure, the subject is hardly a closed one and, as I have suggested, may have more
and disturbing determinants than we have been led to believe ("Diagnosing Soviet Dissi¬
complex, universal,
dents," Harper's Magazine, Aug 1978, pp 31-37). But as reported in a recent article (W. Reich, "Soviet Psychiatry on Trial," Commentary, January 1978, pp 40-48) the World Psychiatric Asso¬ ciation, in a close vote, has already
issued its condemnation, and Kaza¬ netz's paper, which touches that controversy only inferentially, reveals a penumbral light about it that provokes our curiosity as well as our
deeper understanding.
REICH, MD Department of Psychiatry Yale University School of Medicine New Haven, CT 06519 WALTER
approach perfection or near perfec¬ tion. The schizophrenics that Kaza-
netz's group rediagnosed as belonging the exogenous category were almost all confirmed to be nonchronic on the basis of the follow-up chart studies, and almost all of those who were found to be genuine schizophren¬ ics by his group were confirmed to be to
genuine schizophrenics (see his Tables
on
follow-up
3 and 4). This is not uncommon in Soviet psychiatric stud¬ ies, in which family and chart investi¬ gations are often carried out by researchers who, it seems, may some¬ times be influenced in what they find
and in what
they conclude by the hypothesis at hand. Other problems in the study that might give a Western
reader pause include limited informa¬ tion with regard to diagnostic meth¬ odology, computer programming, and patient selection. This will be especial¬ ly disconcerting to the reader fasci¬ nated by Kazanetz's computer exer¬ cise, which seems a worthy one; however, some needed information either was not provided or was not available. And yet, the paper is extraordinari¬ ly interesting. Kazanetz's daring is notable, his dissent from the psychiat¬ ric mood and ethos that dominate his field important, and the study, as much as we can judge it, evocative, even when taken out of the Soviet context. In the Soviet
context, however, it absolutely remarkable and the implications he draws from it about seems
1. Snezhnevsky AV: Psychopharmacology and psychiatry. Int J Psychiatry Med 1:219-223, 1965.
2.
Snezhnevsky AV, Vartanyan
M: The forms
of schizophrenia and their biological correlates, in Himwich HE (ed): Biochemistry,Schizophrenias,
and Affective Illness. Baltimore, Williams & Wilkins Co, 1970, pp 1-28. 3. Snezhnevsky AV: Symptom, syndrome, disease: A clinical method in psychiatry, in Arieti S (ed): The World Biennial of Psychiatry and Psychotherapy. New York, Basic Books Inc, 1971,
vol 1, pp 151-164.
4. Snezhnevsky AV: The symptomatology, clinical forms and nosology of schizophrenia, in Howells G (ed): Modern Perspectives in World Psychiatry New York, Brunner/Mazel Inc, 1971, pp 425-447. 5. Nadzharov RA: Course forms, in Snezhnevsky AV (ed): Shizofreniya. Moscow, Meditsina, 1972, pp 16-76. 6. Report of the International Pilot Study of Schizophrenia. Geneva, World Health Organization, 1972, vol 1. 7. Reich W: The spectrum concept of schizophrenia: Problems for diagnostic practice. Arch Gen Psychiatry 32:489-498, 1975. 8. Galach'yan AG: Soviet psychiatry, in Kiev A (ed): Psychiatry in the Communist World. New York, Science House Inc, 1968. 9. Bloch S, Reddaway P: Psychiatric Terror. New York, Basic Books Inc, 1977.
MHPG Excretion To the Editor.\p=m-\Thearticle
by Pickar (ARCHIVES 35:1378-1383,1978) on the relationship of changes in excreet al
tion of
3-methoxy-4-hydroxyphenethylene glycol (MHPG) and remission of depressive symptoms at the time of
Downloaded From: by a Tulane University User on 01/19/2019
follow-up requires a cautionary note. The most important finding was that the ratio of follow-up-baseline levels of MHPG was higher in the six patients whose conditions were in remission than in the four whose conditions were not. The difficulty in interpreting this is that a variable known to affect outcome was not controlled: treatment with drugs. Three of the six patients whose conditions were improved had been receiving drugs before the 21day drug-free period prior to evaluation. Only one of the four whose conditions did not improve had received drugs. In the absence of a prospective study, holding known relevant variables constant, we cannot conclude that the finding by these authors is unambiguous. It may very well be true that the relationship of outcome to changes in MHPG excretion is causal, but this study cannot establish that as
assignment may be in
to treatment with drugs way related to MHPG
some
excretion changes. The authors do not claim more than that their findings "suggest" that urinary MHPG excretion represents an index of psychobiological state in depressed patients, which is a correct conclusion. But in not pointing out the ambiguity in the design, the reader might be mislead into considering the finding stronger than it is. ARTHUR RIFKIN, MD FREDERIC QUITKIN, MD Office of Mental Health New York State Psychiatric Institute 722 W 169 St New York, NY 10032 In Reply.\p=m-\ Several comments in response to Drs Rifkin and Quitkin's letter are in order. Their statement that "only one of the four (patients) whose conditions did not improve
received drugs" is not an accurate representation of the clinical data we presented. We stated that the medication of one of the four patients whose condition demonstrated
no change at follow-up was stopped as part of our study. In total, the conditions of none of the ten patients included in our study were treated with tricyclic antidepressants during the patients' baseline hospitalization; the remaining patient's condition was treated with
lithium. As described in our report, the medication of four patients was stopped during the course of the protocol. We did not assign patients to "responder" and "nonresponder"
Psychiatry
To the Editor.\p=m-\Ihave been asked by the Chief Editor to comment on "Dif-
ferentiating Exogenous Psychiatric Illness from Schizophrenia," by Etely Kazanetz, a Soviet psychiatrist (ARCHIVES 36:740-745, 1979), and to highlight the context from which the arti-
cle emerges. The focus and plea of the article, which discusses the confounding of acute and chronic schizophrenia and the dangers of applying the latter diagnosis to the former, are well known in the West and are, in any case, not news. What is news, though, is that there is dissent in Soviet psychiatry; it is this message that emerges most importantly from the report, and it is this message that endows it with historic importance and renders it worthy of our closest attention. Etely Kazanetz is identified as being a research psychiatrist at the Serbsky Institute of Forensic Psychiatry in Moscow. He apparently has published a number of papers on psychiatric diagnosis and a 1971 doctoral dissertation on the use of computers in psychiatry. In a general sense, one assumes that he works within the intellectual orbit of the Moscow school of psychiatry. The Moscow school deserves some introduction. Founded and headed by Andrei V. Snezhnevsky, who is now chief of the Institute of Psychiatry of the Academy of Medical Sciences, the Moscow school represents the domi¬ nant understanding of and approach to mental illness, particularly to schizophrenia, in the USSR. Snezh¬ nevsky, now in his mid-70s, developed his theories during the 1940s and 1950s while he successively taught at the Central Postgraduate Medical Institute in Moscow, the Soviet center for advanced training in psychiatry, became director of the Serbsky Insti¬ tute of Forensic Psychiatry (1950), head of the Department of Psychiatry at the Central Postgraduate^Medical
Institute (1951), and then, in 1962, head of the Institute of Psychiatry, the position he now holds. For many years, he has also been editor of the Korsakov Journal of Neuropathology and Psychiatry, the only psychiatric periodical in the Soviet Union, and has sat on the most important committees that advise the USSR Ministry of Health on issues of research, training, and treatment. By now, he has person¬ ally trained or worked with many of the leaders of Soviet psychiatry, including those who head the most important Soviet training, treatment, and forensic centers. His theories of mental illness, particularly his broad and genetically-based concept of schizophrenia, are widely accepted; his treatises and those of his colleagues in the Moscow school are widely read and quoted; and his diagnostic system is generally standard across the coun¬
try.-5
What Kazanetz does in this article is to strongly question the validity of that diagnostic system and its useful¬ ness in psychiatric practice. He argues
that it leads to an overdiagnosis of schizophrenia because it tends to iden¬ tify those with exogenous psychoses (those we probably would call acute schizophrenics) as chronic schizo¬ phrenics. He also argues that such overdiagnosis is dangerous because it leaves the patients so diagnosed subject to the labeling effects of the schizophrenia diagnosis itself. He says this directly from within the center of the Moscow school's zone of profes¬ sional influence: he challenges the essence of that school's diagnostic approach, and, by implication, its
right
to
professional hegemony.
Not that Kazanetz's arguments are without flaws. First of all, he bases his contention that the Snezhnevskyderived diagnostic system overdiag-
schizophrenia on his finding patients diagnosed as schizophrenic at the Gannushkin Hos¬ pital in Moscow during the 1950s were found, on follow-up and rediagnosis, really to have suffered only from exogenous psychoses. Although it is noses
that many
Downloaded From: by a Tulane University User on 01/19/2019
true that the Gannushkin
Hospital
the clinical psychiatric facility of the Central Postgraduate Medical Institute, whose department of psy¬ chiatry Snezhnevsky headed at that time, the theories of the Moscow school itself were not yet fully formed during that period, and to blame the overdiagnoses wholly on those theo¬ ries may not be fully warranted. In addition, Kazanetz focuses on the overdiagnosis of schizophrenia among patients who, he says, really have exogenous psychoses. But from other data, we have evidence that the major problem of overdiagnosis that arises from the Moscow school's diagnostic approach may be quite different. In the International Pilot Study of Schizophrenia (IPSS), which Kazanetz cites, the Institute of Psychiatry, which was the Soviet IPSS participant research center, did indeed sometimes give a Snezhnevskyan diagnosis of schizophrenia to persons who were was
considered,
on
rediagnosis by
a com¬
puter programmed along Western
(Schneiderian) lines, to have paranoid and other types of psychoses.6 The real problem of overdiagnosis among the Moscow school's diagnosticians, how¬ ever, seems to be their tendency to diagnose as schizophrenic those who are not even psychotic. What the IPSS computer found, in fact, was that the Moscow school diagnosticians tended to diagnose as schizophrenic persons who in other countries would have been considered neurotic or affective¬ ly ill, and that this tendency was particularly strong for the Snezhnev¬ skyan category of mild ("sluggish") schizophrenia, a category of patients all of whom the computer considered to be neurotic or depressed.7 Nev¬ ertheless, Kazanetz's findings in some way complement these and enrich our sense that broad diagnostic schemes tend to lead to broad diagnostic prac¬ tices, probably no matter where they are used. It is of some historical interest that, in identifying the "classical" Soviet school as made up of narrow diagnos¬ ticians, Kazanetz overlooks an impor-
tant feature of Soviet
past, in
psychiatry's
less classical: ways the tendency during the 1920s and 1930s to include within the schizophre¬ nia fold "latent" and "borderline" conditions. This was done particularly at the State Scientific Research Insti¬ tute of Neuropsychiatrie Prophylaxis, organized in Moscow in 1925 under the direction of L. M. Rosenshtein. As it happens, Rosenshtein's inclusion of the "minor" conditions within schizo¬ phrenia was finally condemned during the mid-1980s as being socially dan¬ gerous, since it was said to place too large a population at risk for the diagnosis. Very soon, that trend was snuffed out," as were so many trends, institutes, and professionals during that troubled time. Other difficulties of a methodologi¬ cal and substantive nature should also be mentioned. In some ways, these difficulties enhance the report's inter¬ est rather than diminish it, since they stem from its typically Soviet charac¬ teristics. For example, its findings some
no
legal liabilities of psychiatric labeling in Soviet society are striking at a time when his profession, includ¬ ing the members of the Moscow school and of his own institute, are being the
accused of misapplying their diagnos¬ tic scheme to bestow on those with politically deviant views diagnoses in the schizophrenic range." To be sure, the subject is hardly a closed one and, as I have suggested, may have more
and disturbing determinants than we have been led to believe ("Diagnosing Soviet Dissi¬
complex, universal,
dents," Harper's Magazine, Aug 1978, pp 31-37). But as reported in a recent article (W. Reich, "Soviet Psychiatry on Trial," Commentary, January 1978, pp 40-48) the World Psychiatric Asso¬ ciation, in a close vote, has already
issued its condemnation, and Kaza¬ netz's paper, which touches that controversy only inferentially, reveals a penumbral light about it that provokes our curiosity as well as our
deeper understanding.
REICH, MD Department of Psychiatry Yale University School of Medicine New Haven, CT 06519 WALTER
approach perfection or near perfec¬ tion. The schizophrenics that Kaza-
netz's group rediagnosed as belonging the exogenous category were almost all confirmed to be nonchronic on the basis of the follow-up chart studies, and almost all of those who were found to be genuine schizophren¬ ics by his group were confirmed to be to
genuine schizophrenics (see his Tables
on
follow-up
3 and 4). This is not uncommon in Soviet psychiatric stud¬ ies, in which family and chart investi¬ gations are often carried out by researchers who, it seems, may some¬ times be influenced in what they find
and in what
they conclude by the hypothesis at hand. Other problems in the study that might give a Western
reader pause include limited informa¬ tion with regard to diagnostic meth¬ odology, computer programming, and patient selection. This will be especial¬ ly disconcerting to the reader fasci¬ nated by Kazanetz's computer exer¬ cise, which seems a worthy one; however, some needed information either was not provided or was not available. And yet, the paper is extraordinari¬ ly interesting. Kazanetz's daring is notable, his dissent from the psychiat¬ ric mood and ethos that dominate his field important, and the study, as much as we can judge it, evocative, even when taken out of the Soviet context. In the Soviet
context, however, it absolutely remarkable and the implications he draws from it about seems
1. Snezhnevsky AV: Psychopharmacology and psychiatry. Int J Psychiatry Med 1:219-223, 1965.
2.
Snezhnevsky AV, Vartanyan
M: The forms
of schizophrenia and their biological correlates, in Himwich HE (ed): Biochemistry,Schizophrenias,
and Affective Illness. Baltimore, Williams & Wilkins Co, 1970, pp 1-28. 3. Snezhnevsky AV: Symptom, syndrome, disease: A clinical method in psychiatry, in Arieti S (ed): The World Biennial of Psychiatry and Psychotherapy. New York, Basic Books Inc, 1971,
vol 1, pp 151-164.
4. Snezhnevsky AV: The symptomatology, clinical forms and nosology of schizophrenia, in Howells G (ed): Modern Perspectives in World Psychiatry New York, Brunner/Mazel Inc, 1971, pp 425-447. 5. Nadzharov RA: Course forms, in Snezhnevsky AV (ed): Shizofreniya. Moscow, Meditsina, 1972, pp 16-76. 6. Report of the International Pilot Study of Schizophrenia. Geneva, World Health Organization, 1972, vol 1. 7. Reich W: The spectrum concept of schizophrenia: Problems for diagnostic practice. Arch Gen Psychiatry 32:489-498, 1975. 8. Galach'yan AG: Soviet psychiatry, in Kiev A (ed): Psychiatry in the Communist World. New York, Science House Inc, 1968. 9. Bloch S, Reddaway P: Psychiatric Terror. New York, Basic Books Inc, 1977.
MHPG Excretion To the Editor.\p=m-\Thearticle
by Pickar (ARCHIVES 35:1378-1383,1978) on the relationship of changes in excreet al
tion of
3-methoxy-4-hydroxyphenethylene glycol (MHPG) and remission of depressive symptoms at the time of
Downloaded From: by a Tulane University User on 01/19/2019
follow-up requires a cautionary note. The most important finding was that the ratio of follow-up-baseline levels of MHPG was higher in the six patients whose conditions were in remission than in the four whose conditions were not. The difficulty in interpreting this is that a variable known to affect outcome was not controlled: treatment with drugs. Three of the six patients whose conditions were improved had been receiving drugs before the 21day drug-free period prior to evaluation. Only one of the four whose conditions did not improve had received drugs. In the absence of a prospective study, holding known relevant variables constant, we cannot conclude that the finding by these authors is unambiguous. It may very well be true that the relationship of outcome to changes in MHPG excretion is causal, but this study cannot establish that as
assignment may be in
to treatment with drugs way related to MHPG
some
excretion changes. The authors do not claim more than that their findings "suggest" that urinary MHPG excretion represents an index of psychobiological state in depressed patients, which is a correct conclusion. But in not pointing out the ambiguity in the design, the reader might be mislead into considering the finding stronger than it is. ARTHUR RIFKIN, MD FREDERIC QUITKIN, MD Office of Mental Health New York State Psychiatric Institute 722 W 169 St New York, NY 10032 In Reply.\p=m-\ Several comments in response to Drs Rifkin and Quitkin's letter are in order. Their statement that "only one of the four (patients) whose conditions did not improve
received drugs" is not an accurate representation of the clinical data we presented. We stated that the medication of one of the four patients whose condition demonstrated
no change at follow-up was stopped as part of our study. In total, the conditions of none of the ten patients included in our study were treated with tricyclic antidepressants during the patients' baseline hospitalization; the remaining patient's condition was treated with
lithium. As described in our report, the medication of four patients was stopped during the course of the protocol. We did not assign patients to "responder" and "nonresponder"
