Thomas Szasz takes on his critics.

I appreciated Jacob Sullum's thoughtful and generally balanced review of Szasz. Under Fire ("Thomas Szasz Takes on His Critics," May). But it is critical to distinguish Szaszian claims about the nature of "disease" from claims regarding the appropriate medical, legal, and social response to disease.

Citing my example of migraine headaches as a medical condition diagnosed almost exclusively on the basis of the patient's subjective reports, Sulhun objects that "migraine sufferers are not treated against their will." Neither are most patients with schizophrenia and bipolar disorder at least, most are not treated under some kind of court-ordered mandate or commitment. If one of the symptoms of migraine were, say, severe self-mutilation, does anyone seriously believe that involuntary commitment would not at least be considered for a migraine patient who refused admission to a hospital?

Sullum finds disingenous my claim that commitment decisions are ultimately judicial, not psychiatric. But most psychiatrists have been involved in many cases in which their petition for commitment was flatly turned down by the judge. Moreover, such petitions may also be brought to the court by police officers, next of kin, other physicians, psychologists, social workers, or even "interested parties."

Sullum wrongly asserts that psychiatric diagnoses "generally imply that the 'patient' either does not properly understand his own interests or is not capable of acting on them" and that therefore "the threat of involuntary treatment always bangs in the background." Providing a psychiatric diagnosis--even a serious one, such as schizophrenia categorically does Hot entail a claim that the patient does not understand his own interests or is in some pervasive way "incompetent."

Indeed, the notion of competence is fundamentally a legal, not a psychiatric one. Surely a diagnosis of delirium, rendered by an emergency room

physician, carries a much higher connotation of mental incompetence and also presents the "threat" of involuntary treatment. Yet we do not find many screeds condemning the motives or practices of such emergency room physicians.

Ronald Pies, M.D.

Clinical Professor of Psychiatry

Tufts University School of Medicine 

Boston, MA

It is not accurate to say that I was "once a Szasz admirer," as reason's review of Szasz Under Fire suggests. I continue to admire him for his outspoken criticism of many psychiatric practices. These include "diagnosis creep," whereby increasing numbers of undesirable human behaviors are given official diagnostic labels in order to qualify practitioners for insurance claims, and the potential for the political abuse of psychiatric labels, such as occurred in the former Soviet Union.

On the subject of schizophrenia, however, I am indeed "one of his most vocal critics." Szasz ignores a vast amount of evidence, much of which became available in the last decade, that schizophrenia is a disease of the brain in exactly the same sense that Parkinson's and multiple sclerosis are diseases of the brain. By continuing to hold to his 1961 view that schizophrenia is a "myth," Szasz is increasingly viewed as anachronistic. This allows critics to discredit him on other issues on which he has much to contribute. Dr. Szasz thus risks being confused with Dr. Seuss, which would be a loss to the psychiatric profession.

E. Fuller Torrey, M.D.

Bethesda, MD

Jacob Sullum's rich review of Szasz Under Fire is an unusually sophisticated piece, but there are some subtle points that deserve a little elaboration.

Sullum repeats the now accepted empirical observation that "insanity pleas are offered only in about 1 percent of criminal cases." He might have added that they are successful in only about 25 percent of those cases. This misleading fact, which has been utilized tendentiously to indicate that because of its rare use the insanity plea is not invalid, hides the tremendous involvement of psychiatry in the criminal justice system, from mitigated sentences to incompetence to stand trial.

The most difficult issue in evaluating Szasz and his critics is this: What about schizophrenia, which Szasz calls "The Sacred Symbol of Psychiatry"?

The early E. Fuller Torrey seems more reasonable that the later Torrey on this matter, but one dilemma remains the issue of whether there is a discrete somatic illness called schizophrenia, and how much its morbidity constitutes an exception to Szaszian theory, since there are psychiatrists who diagnose schizophrenia falsely and promiscuously.

Richard E. Vatz, Ph.D.

Professor of Rhetoric and Communication

Towson University

Towson, MD