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SCHIZOPHRENIA: AN UNFINISHED HISTORY

By Orna Ophir

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The Montréal Review, October 2022

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SCHIZOPHRENIA: AN UNFINISHED HISTORY 
BY ORNA OPHIR
(Polity Press, 2022)

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Since the 1990s, epidemiologists, psychiatrists, historians, and journalists have been wondering to what extent schizophrenia is disappearing as a medical diagnosis. An article in The Lancet under the title “Is schizophrenia disappearing?” suggested a substantial decrease in the reported incidences of the affliction since the mid-1960s. Indeed, a 2012 publication entitled Schizophrenia is a Misdiagnosis criticized the very validity of the diagnosis and bluntly announced its end. Articles with similar titles, such as “Schizophrenia Does Not Exist” and “The Concept of Schizophrenia Is Coming to an End,” appeared in the British Medical Journal and The Independent in 2016 and 2017, respectively. And a 2017 article in Schizophrenia Bulletin claimed that the word might eventually be relegated to the dustbin of history, like the medical use of the term “dropsy.”

Even if most authors who criticize the diagnosis agree that some individuals do experience delusions, hallucinations, and disorganized behavior and speech that make them sound and look irrational, an ever-growing number of scholars maintain that, as a presumed disease entity, schizophrenia fundamentally does not exist. And while some claim that it could be considered an “end stage” of other untreated mental disorders in the same way that heart failure is the terminal stage of various heart diseases, others propose to abolish the term “schizophrenia” altogether.

Known as the paradigmatic form of madness, schizophrenia was first used as a medical classification by the Swiss psychiatrist Paul Eugen Bleuler in 1908 and has since shapeshifted remarkably. The diagnosis was originally conceived as describing a group of various psychological disorders in which the common characteristic was a splitting of the psychic functions. Generations of psychiatrists and other mental health providers learned to diagnose the disease based on “Bleuler’s four A’s:” a disturbance of Associations (i.e., thought disorders), disordered Affect (i.e., reduced and inappropriate emotional response), Ambivalence (a paralysis of the ability to make decisions or act intentionally), and Autism (the withdrawal from reality to the world of fantasy). Hallucinations and delusions were initially seen as secondary manifestations and not at all unique to schizophrenia.

The first edition of the Diagnostic Statistical Manual of Mental Disorders (DSM), published in 1952, was influenced by Adolf Meyer, another Swiss-born psychiatrist. Based on his model, the schizophrenias were reclassified as “schizophrenic reactions” to bio-psycho-social stressors. Only during the 1970s, when the American Psychiatric Association worked on a revision of this original psychoanalytic view and turned towards a bio-medical model, did schizophrenia come to be seen as a disease entity – and, hence, not a psychic reaction to external stressors – and only at that point did American society begin to associate the diagnosis with violence and dangerousness. As Jonathan Metzl showed in his book The Protest Psychosis, it was in the context of the Civil Rights movement that schizophrenia also became a “Black disease.” Ever since, African American men have been diagnosed with this disorder four times as often as others.  

During the 1980s, schizophrenia was increasingly believed to be primarily a disorder of the brain. In his Presidential Proclamation 6158 of 1990, titled “The Decade of the Brain,” President George H.W. Bush listed schizophrenia among the disorders of the brain, an organ he urged scientists “to conquer.”

Yet lack of convincing clinical findings as well as the failure to discover the unique genetic makeup of schizophrenia made it abundantly clear that the lines drawn to create boundaries between the different psychiatric disorders remained somewhat arbitrary. Gradually giving up on the idea of distinct identifiable mental illnesses, the latest, 2013 edition of DSM 5 therefore placed schizophrenia on a continuous spectrum. The different types of schizophrenia (paranoid, catatonic, disorganized, etc.) were finally dropped. Instead, a broader diagnosis of the “Schizophrenia Spectrum and other Psychotic Disorders” was offered, with the implication of an underlying normal distribution of disturbances, with individuals at either end of the bell curve.

But the decline of the diagnosis was driven not only by the general shift in psychiatric classification from categories and qualitative methods to spectrum and quantitative models. In addition, psychiatrists, psychologists, social activists, survivors, ex-patients, and others argued that the label “schizophrenia” was stigmatizing, because it carried connotations of hopelessness, chronicity, and even dangerousness.

While in other fields of medicine it is crucial to get the correct diagnosis to determine the suitable treatment, psychiatric diagnoses are unable to offer such clear and definitive diagnostic accounts, guaranteeing the precise treatment. Yet the danger exist that, once they are created, such seemingly “real” diagnoses wield disproportionate influence, so that doctors are inclined to use them even if they doubt their fundamental validity.

History shows that psychiatric diagnoses rise and fall according to ever-changing social, cultural, and historical conditions. There are good reasons why psychiatric diagnoses such as “drapetomania” (literally translated: the madness of the runaway-slave), “hysteria,” and “homosexuality” have fallen into disrepute as time and good sense further progressed.

Doctors and patients agree that words can hurt and that “schizophrenia,” schizophrenia to the extent that it implies hopelessness, can harm patients. In their response, they seek less discriminatory and more appealing diagnoses. “Extreme mental states,” “voice-hearing,” “non-ordinary states” or “diverse identities” are but a few of the alternative designations that were suggested. Others suggest following the example of Asian countries such as Japan where psychiatrists replaced “schizophrenia” with the diagnosis of “integration disorder,” a change that proved beneficial to both patients and doctors.

Some have argued that schizophrenia is in essence no more than the manifestation of chronic stress, traumas, social isolation, and other social or environmental factors. These experiences, they claim, can express themselves in physical changes. With the decline of the schizophrenia label as a diagnosis that correctly identifies and classifies a distinct brain illness in the individual, more and more emphasis should be placed on diagnosing and treating social failures. Addressing poverty, racism, sexism, estrangement, unemployment, and all other forms of powerlessness, while facilitating stress reduction, self-care, and support in the community, are thus seen as necessary ingredients of more promising and salutary solutions. And yet, as these shifts in diagnostic emphasis and therapeutic care are taking place, patients and doctors must still be of two minds when it comes to the phenomena we call “schizophrenia.” For the time being, they will be using labels and diagnoses when these are beneficial for the patient (insurance reimbursements or the distribution of disability benefits remain realities to reckon with), while also challenging these diagnoses when and where they are harmful.

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Orna Ophir is an Associate Director of the DeWitt Wallace Institute of Psychiatry: History, Policy & the Arts, Weill Cornell Medical College, and an Adjunct Associate Professor at New York University, where she teaches at The Gallatin School for Individualized Studies and is affiliated with the Department of Comparative Literature. Ophir is a psychoanalyst in private practice in New York City and a member of the International Psychoanalytical Association (IPA), serving on its Committee on the History of Psychoanalysis.

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