How Everyone Became Depressed

The rise and fall of the nervous breakdown

What in the World Are We Going to Do With Schizophrenia?

This is a disease that doesn't really exist.

By now it’s become a major embarrassment, this disease that doesn’t really exist. Yeah, psychosis exists: losing contact with reality in the form of hallucinations and delusions. Chronic psychosis exists, and this is what we’ve been calling “schizophrenia.”

But there are so many ways of becoming chronically psychotic. It can happen to you later in life, in the context of what seems like depression. You can lose brain tissue, or not. You can suffer a personality deterioration, become unable to use your volition, or not. You might or might not require meds to stay on track. There are lots of variants.

Up to now, all these variants have been called “schizophrenia,” as though it were a disease as specific as mumps, with its own distinctive symptoms (comparable to swollen parotid glands), its own, predictable clinical course; its own, reliable response to medication.

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But none of this is true of our schizophrenia. There is no single symptom that all “schizophrenics” have. Some are psychotic, some not. There is no reliable response to meds: some lose their psychotic symptoms and get better; others remain inscrutable, unreachable, cut off, as though behind a glass plate, to use a frequent image.

These are clearly different illnesses! Calling them all “schizophrenia” is merely doing a service to the makers of agents such as Seroquel (quetiapine), the sales of which now mount into the billions of dollars. Schizophrenia remains incredibly profitable, yet not for the patients, who are often misdiagnosed and poorly treated.

What to do? Throw up our hands in despair, and pray for the triumph of the antipsychiatry movement, which maintains that “schizophrenics” are merely individuals with unusual gifts (news to the patients, who are often so wretched with their symptoms – the voices they cover their ears to keep out – that they are close to suicide)?

Sorting out schizophrenia is probably the second-largest challenge in psychiatry right now, the largest being sorting out “depression,” which, like “schizophrenia” is composed of several distinct illnesses, but is much commoner.

I’ve got an idea. It’s the same idea that occurred to German psychiatrist Ewald Hecker in 1871, when he labeled adolescent insanity “hebephrenia.” Hecker captured in a distinctive diagnosis an awareness that had been brewing in psychiatry over much of the nineteenth century: That there was a distinctive illness that happened to previously normal adolescent men and women: that around 17 they started to lose it: Their school work collapsed, they stayed alone in their bedrooms staring at the wall; they stopped seeing friends and family; and they became psychotic. The psychosis passed, but they were never really normal again, although they didn’t end up in the backwards of asylums either. There was no restitutio ad integrum, as they said in the day. And these young patients as adults occasionally relapsed with the delusive ideas and the voices.

Hecker nailed adolescent insanity, and gave it a name, hebephrenia, that subsequently became a “subtype” of schizophrenia. But hebephrenia is the core illness. There is no such thing as “schizophrenia.” The other subtypes – paranoia and catatonia – were illnesses of their own, with distinctive courses and outcomes.

The vast blunder of late nineteenth century psychiatry, the huge error of Emil Kraepelin in 1899 was lumping these three distinctive clinical pictures into the same diagnosis, and giving it a made-up name (Eugen Bleuler named it “schizophrenia” in 1908; Kraepelin’s term had been dementia praecox.)

Small groups of “nosological rebels” today challenge the Kraepelinian error. Demands are becoming loud to ditch schizophrenia in the same manner that “hysteria” was ditched thirty years ago, in DSM-3 in 1980. (Michael Alan Taylor et al., 2010)

But resistance is huge to a change of this magnitude. The American Psychiatric Association has really bet the farm on its new 5th edition of the Diagnostic and Statistical Manual (DSM-5). Kicking out schizophrenia would be kicking away one of the foundation stones of contemporary psychiatry. Almost all the “antipsychotics” will soon be off patent, so resistance from the pharmaceutical industry would be less, and might even open the door to pioneering new (profitable) diagnoses. But such patient groups as NAMI have their entire identity tied up in the search for “cures” of schizophrenia, and debunking the diagnosis would be as welcome to them as rat poison.

Yet the families would be happy: Your son or daughter may not have a lifelong, incurable illness, and there may be new treatments we can pioneer once the monolith is destroyed. Just between you and me, electroconvulsive therapy (ECT) is looking promising. We have to open our minds a bit here.

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

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