Schizophrenia is not a mental disorder?

There has been a lot of debate over the past decades about the reliability and validity of the diagnosis of schizophrenia. There has been the Campaign for the Abolition of the Schizophrenia Label, books such as Schizophrenia: A Scientific Delusion?, and most recently a 2016 paper in the British Medical Journal with a very unambiguous title:

van-os

Despite such arguments, these authors typically only call for schizophrenia to be renamed, as happened in Japan recently. And what it is renamed as will still be classified as a mental disorder.

This is why the recent reports that the Pakistan Supreme Court had ruled that “schizophrenia is not a mental disorder” came somewhat out of left-field.

news-reports

What is happening here?

Are the views of the Pakistan Supreme Court being misreported? If so, what did they actually say?

Or, if this is what the Court said, how did they reach this decision?

It is a simple matter to access the actual judgement to find out, which is what we will try to do here.

 

The background

In 2002 Imdad Ali (pictured below, as held by his wife) was convicted of killing a religious teacher. He received the death sentence (I have not been able to access any court records pertaining to this original trial).

image-22-10-16

On 21 October 2016 the Supreme Court of Pakistan turned down a plea to delay his execution (by hanging). Extracting the court’s reasoning from media reports, we can piece together the following:

  1. The Supreme Court said schizophrenia was an “imbalance”, exacerbated by stress, that could be treated by drugs.

Whilst one could argue with this, it is consistent with mainstream views, such as that of the US National Institute for Mental Health (see below) who publicly endorse the chemical imbalance idea.

nimh-website

2. The Supreme Court therefore determined that schizophrenia is “not a permanent mental disorder”

Recovery from schizophrenia happens, so this too is not necessarily a controversial statement. That said, it is worth noting the grim results of a recent review that found only one in seven people diagnosed with schizophrenia was achieving a comprehensive recovery and that recovery rates had not improved over time.

3. The Supreme Court hence concluded that it must be “a recoverable disease, which… does not fall within the definition of ‘mental disorder”.

As we noted above, schizophrenia clearly is something that people can recover from, but the issue is how we then get to the idea that it is not a mental disorder. The reasoning behind this is somewhat opaque in media reports. This lack of clarity understandably led to this claim being met by a public outcry.

 

The reaction

This story was met by widespread disbelief. But not disbelief of the veracity of the story, but rather by disbelief that anyone could say that schizophrenia was not a mental disorder.

In a Press Release, a Director of the UK human rights organisation Reprieve commented that:

“It is outrageous for Pakistan’s Supreme Court to claim that schizophrenia is not a mental illness, and flies in the face of accepted medical knowledge, including Pakistan’s own mental health laws. It is terrifying to think that a mentally ill man like Imdad Ali could now hang because judges are pretending that schizophrenia is not a serious condition.”

Professionals were brought out to state that schizophrenia was a mental illness. The President of the Pakistan Psychiatric Society, Dr Sultan, said:

“It is a serious disorder which affects how a person thinks, feels and acts. Someone with schizophrenia may have difficulty distinguishing between what is real and what is imaginary; he or she may be unresponsive or withdrawn; and may have difficulty expressing normal emotions in social situations. In its most chronic form, schizophrenia can a life-long disease in which the patient does not feel normally or react like normal people”

It was shown that the public also thought that schizophrenia was a mental disorder. For example, The Express Tribune in Pakistan did a reader poll:

express-tribune-poll

No-one seems to have considered the alternative response; “is that really what the court said?” So let’s now back up a bit.

What did the court actually conclude, and how did it reach this conclusion?

 

What the Supreme Court judgement actually said

  1. The Supreme Court starts by stating the grounds of the appeal.

The basis of the appeal, made by Imdad’s wife, was that Imdad had schizophrenia and therefore needed medical treatment so that he could make a will before he was executed.

2. The Supreme Court reviews previous courts’ rulings

The Supreme Court states that Imdad’s claim he had schizophrenia (or as the Court puts it, that he was a ‘lunatic’) had been satisfactorily addressed by all previous courts and was hence not grounds for appeal.

previous-consideration

Later in the judgement the court makes clearer that Imdad had previously argued that he had schizophrenia, but the lower courts had discarded this.

paranoid-sz

The Supreme Court then argues that, even if Imdad did have schizophrenia, by Prison Rules officials should have noted this and taken appropriate steps, but they didn’t.

We may have expected that, having deemed that previous courts had addressed the schizophrenia issue, the Supreme Court would have wrapped up its judgement there and then.

But, oddly, it didn’t.

Instead, the Supreme Court next spent a long time giving its own view as to why schizophrenia is not always schizophrenia. It is initially unclear why it felt the need to take this on.

3. The Supreme Court comes to the conclusion that someone with a psychiatric diagnosis of schizophrenia doesn’t always meet the legal criteria for mental disorder.

Here we come to the crux of the transcript in relation to the media headlines. It turns out the court is not denying that schizophrenia is a severe mental disorder (indeed, they cite such a definition in their judgement). Instead they state that someone with a psychiatric diagnosis of schizophrenia does not always meet the legal criteria for having a mental disorder.

Here’s the relevant excerpt from the court’s judgement. The key phrase is ‘in all the cases’:

not-sz

Let’s now work through how the court arrived at this judgement.

It drew on (old) arguments from American psychiatrists and previous case-law.

Their first move was to cite an American psychiatric textbook saying there are degrees of schizophrenia. Here the court cites the following  (quite why they use a textbook from 1966 is unclear);

degrees-of-schizophrenia

The second move is to cite from the same textbook that recovery is possible:

recovery

The third move is to say that each case of schizophrenia needs to be considered on its own merits. Here they cite precedent and the famous American psychiatrist Karl Menninger (1893-1990):

menninger

The Court has now reached the point where it has established that merely saying someone has schizophrenia does not necessarily prove anything about the person. To ram this home it goes on to give an example of a case when simply having a diagnosis of schizophrenia was not deemed in and of itself to be indicative of anything. In said case, a husband applied for a dissolution of marriage on the basis that his wife had a diagnosis of schizophrenia and was therefore “unfit for married life”. This previous case concluded as follows:

schizophrenia-is

Schizophrenia is what schizophrenia does? An interesting idea. What are the implications of such a statement though?

Anyway, given all this, the Court can now reach its conclusion, in relation to schizophrenia, which to reiterate, was:

not-sz

Two things puzzle me here.

The first is why they took this route to reach their conclusion. The latest version of Psychiatry’s Bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) explicitly states that just because someone has a diagnosis of a mental disorder, this doesn’t mean they will necessarily meet the legal criteria for a mental disorder. Here is the relevant except from the DSM-V:

dsm-v-mental-disorder

I don’t see why the Court couldn’t have just referred to this.

The second thing that puzzles me is why the Court is even concerned to make this point.

The question is surely not whether or not someone with a diagnosis of schizophrenia always meets legal criteria for mental disorder, but rather whether Imdad specifically met the legal criteria for mental disorder.

As far as I can see, the Court seems to be trying to find if there was a way that earlier courts could have reached the seemingly paradoxical conclusion that Imdad had schizophrenia but that this wasn’t a barrier to his execution. Yet, whether this was how earlier courts came to their conclusions is unclear, and more importantly, whether or not Imdad meets/met diagnostic criteria for schizophrenia is not clearly established.

 

The final judgement

The court then sums up its final decision, and its reason for rejecting the appeal, as follows:

court-ruling

This is also confusing to me.

If, as the Court states, rules relating to mental illness can’t delay an execution, then why has so much of their judgement been spent trying to find a way to argue that schizophrenia isn’t always schizophrenia?

 

Post-judgement reaction

That it urgently needs determining whether or not Imdad meets the diagnostic criteria for schizophrenia, and if this meets the legal definition of mental disorder in his case, now seems to have been recognised by the Court.

On 31 October 2016, the Supreme Court postponed Imdad’s execution after a fresh petition from his lawyers, and a review petition from the government of Punjab province (where he is held). This latter petition claimed the Supreme Court’s definition of schizophrenia had “resulted in a grave miscarriage of justice”, because it was contrary to the universally accepted medical definition of ‘mental disorder’ and alleges that prison medical records show Mr Ali has “consistently displayed symptoms of schizophrenia” and “is not showing signs of improvement and has active psychotic symptoms”. http://www.ekklesia.co.uk/node/23565).

On 14 November 2016 the Supreme Court ordered a panel of doctors to examine Imdad’s mental health (http://www.ekklesia.co.uk/node/23580)

On the 18 November 2016 the Supreme Court said that if psychiatrists find Imdad is mentally ill, his execution will be delayed until recovery (http://www.ekklesia.co.uk/node/23580)

It seems likely that he will be deemed to have schizophrenia.

Imdad’s sister describes that their father had schizophrenia. When Imdad was just two years old, his father died after jumping in front of a train because he thought he was invincible. He left a widow and six children.

The genesis of Imdad’s own mental health problems are also described by his sister:

sister-describes-what-happened

Furthermore, Reuters reports that Government doctors in 2012 certified Imdad as having paranoid schizophrenia. For example, it cites a Dr Tahir Feroze, a government psychiatrist who has treated Ali for the last eight years of his incarceration, who says he and two other doctors certified Ali’s condition in 2012. Imdad suffers from delusions that he controls the world, is persecuted and he hears voices in his head that command him, according to Dr Feroze and Imdad’s wife. Yet Imdad’s lawyer says the government report certifying his condition had never been presented in court before 2016.

 

Conclusions

Bearing in mind a number of caveats (I am not a lawyer, I have limited access to information to this case, and so this is just a lay-reading of what is going on), here are my own take-aways from all this.

1. The Supreme Court was saying someone diagnosed with schizophrenia may not meet the legal definition of mental disorder. They were not saying that schizophrenia is not a mental disorder in the psychiatric sense.

There is nothing controversial about this, although the Court did reach this conclusion in something of an idiosyncratic way. If reporters had read the freely available court documents, this misunderstanding would not have arisen.

2. Progressive arguments may have regressive effects.

It is notable that the court drew on a lot of progressive arguments, such as the potential for recovery from schizophrenia, and that schizophrenia does not a priori define a person, in order to make the case that Imdad should die. We should be aware that progressive arguments, which humanise and empower people diagnosed with schizophrenia, also run the risk of misrepresenting people’s degree of agency and may end up blaming them for things they were not responsible for. We need a discussion of the relation between mental illness and criminal responsibility that acknowledges shades of grey.

3. It is unclear why the Supreme Court undertook a consideration of what schizophrenia is.

This seems to have been irrelevant to the actual basis of their judgement.

4. It is unclear why a consideration of the relation between schizophrenia and legal definitions of mental disorder was undertaken which did not then go on to consider this in relation to Imdad specifically.

Although the Court has now allowed that if Imdad is deemed to have schizophrenia then his execution can be delayed until he has recovered, little is being mentioned about whether Imdad was suffering from a mental disorder (in the legal sense) when he killed the religious teacher. If so, this could commute the death sentence, rather than just delay it. An independent and authoritative assessment of Imdad’s current and historical mental health state clearly needs to be made.

5. If Imdad had schizophrenia at the time of his offence, or has it now, international law says he should not be executed.

As Amnesty International note, citing the examples below, the execution of someone with a mental illness is clearly prohibited by international law:

International Resolutions Year Excerpt
UN Safeguards Guaranteeing Protection of the Rights of Those Facing the Death Penalty 1984 ” …nor shall the death sentence be carried out… on persons who have become insane.”
UN Special Rapporteur on Extrajudicial, Summary or Arbitrary Executions 1997 Governments that continue to use the death penalty “with respect to minors and the mentally ill are particularly called upon to bring their domestic legislation into conformity with international legal standards.”
UN Commission on Human Rights 2000 Urges all states that maintain the death penalty “not to impose it on a person suffering from any form of mental disorder; not to execute any such person.”

 

Media reporting of this story typically went for sensationalist headlines that did not convey that the Court was uncontroversially saying that someone with a diagnosis of schizophrenia may nevertheless fail to meet the legal definition of mental disorder.

Yet there are clearly many other problems with this case, and the media spotlight has engendered a passionate response from public and human rights bodies who have put pressure on the Pakistan Supreme Court to rectify a genuine problem, namely that Imdad’s mental health does not seem to have been fully assessed, addressed, and taken into account. This response has very plausibly extended Imdad’s life and may even contribute to saving it.

At the time of writing, 31,000 people have signed a petition calling for Imdad to be saved.

I will update the blog for what happens next.

 

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