How Everyone Became Depressed

The rise and fall of the nervous breakdown

Breaking Up “Schizophrenia”

Following science will soon lead to other ways of describing chronic psychosis

It has been maddening that a disease first announced by German psychiatrist Emil Kraepelin in 1893 as “dementia praecox” —then baptized as “schizophrenia “ by Zurich psychiatrist Eugen Bleuler in 1908—has survived unmodified to the present. Have we made no progress? No advances in the description of psychiatric diseases, no insights from the literally thousands of studies done on this massive block of stone, apparently incapable of being carved into component pieces?

Finally, NIMH director Thomas Insel has had enough. In a recent blog posting he said, we’ve got to chisel it into its component parts. “It appears that what we currently call ‘schizophrenia’ may comprise disorders with quite different trajectories.” (Insel,”Director's Blog", Aug 28, 2013).

Well, hello! It has been apparent for decades to observers with a historical overview of these thousands of studies that different diseases were concealed under the blanket term schizophrenia. Some of the patients stabilized at a relatively low level and led normal lives. Others ended up “demented” on the back wards. Some required antipsychotics to stay well, others didn’t.

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It is this particular difference that Insel picked up in his blog, citing a Dutch study in which a number of schizophrenics in remission were randomized to non-treatment and treatment groups. The non-treatment group had better social results, though both groups continued to be symptomatic. (Lex Wunderink et al., 2013). As well, the Chicago Follow-up Study monitored 70 schizophrenic patients at various times over 20 years: Many had gone off their meds over this time, and they did no worse than those who stayed on. (M Harrow et al., 2012).

Now, neither of these studies, pace Insel, shows that there are different disease types, merely that meds may stand in the way of remission and recovery, or at the least, that meds are not really necessary, though in the early years of treatment they may reduce the symptoms. And neither study justifies Insel’s big statement that there may be different disorders in “schizophrenia.”

Yet there may be! This is the point. What the German and Swiss big domes described more than a hundred years ago as a single disease entity—and that the latest edition of DSM continues unmodified—may represent quite different forms of chronic psychotic illness. To their credit, the Dutch group do not talk of “schizophrenia” but of following up patients with “first-episode psychosis.”

From the very first day that Kraepelin described “dementia praecox” he was challenged. He included paranoia, hebephrenia, and catatonia as “subtypes” of dementia praecox, and argued that they all had a similar downhill course: Their course and outcome was what made them the same disease! This was wrong. They did not all run irreversibly downhill. And people pointed this out. Yet such was the majesty of the Kraepelinian synthesis that its architectural beauty conquered all the nagging doubters, and “schizophrenia” went on to become a terrifying diagnosis. If your kid had it, he or she was fucked, not to put too fine a point on it.

So finally the battleship is being turned around. The schizophrenia dreadnought is being halted, slowly, and with great resistance on the part of the pharmaceutical industry, which has made billions of dollars from “antipsychotics,” read “antischizophrenics.” And the academic resistance to breaking up schizophrenia is also considerable, given that many academic psychiatrists have made careers from studying what is usually abbreviated as “SZ.”

It’s like the academics who made careers studying “hysteria.” Today, they’ve been forgotten. So you can see that there is horror in academe about schizophrenia being dismantled and carted away in chunky pieces.

There are big stakes here. But following the high road of science will soon lead to other ways of describing chronic psychosis, and the rotting corpse of schizophrenia will be left at the wayside.

Edward Shorter, Ph.D., is the Jason A. Hannah Professor in the History of Medicine at the University of Toronto.

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