It is a commonplace that John Nash, the Nobel-Prize winning mathematician and economist who recently died, had “schizophrenia.” All his obituaries repeat the formula, and the assumption of the book about his life and the subsequent movie, “A Beautiful Mind,” leave this assumption unchallenged.
But did he really have schizophrenia?
Core schizophrenia begins in adolescence or early adulthood, may involve a psychotic break, certainly involves diminished executive function, affective blunting and a thought disorder. (On this see Edward Shorter, What Psychiatry Left Out Routledge.) The concept of “thought disorder” means inability to think clearly, or in a consecutive manner. It does not necessarily mean the hallucinations and delusions of psychosis.
Now, what symptoms did Nash seem to have? His illness began in 1959 at age 30, a bit past the typical window. He had already fashioned his brilliant doctoral dissertation.
But 1959 was probably the very worst time in the history of American psychiatry to become ill. Psychiatry then was still drenched in Freudian dogma, and for the Freudian psychoanalysts “schizophrenia” was really a wastebasket diagnosis: They used it indiscriminately on all patients who did not seem to be suitable candidates for “The couch.”
So virtually every patient apparently incapable of having a “transference relationship” was called “schizophrenic,” and the inheritance of this ghastly tradition is still with us today. (Transference means coming to see your therapist as your parent.)
Nash was certainly delusional and evidently hallucinated as well. He filled the blackboards of Fine Hall at Princeton with indecipherable scribblings, and wandered about the campus in an apparent daze. He became known as “The Phantom of Fine Hall.”
But then he got better, looked back in astonishment at his own illness career, and was able to travel normally to Stockholm in 1994 to accept his Nobel Prize. Whatever it was that had seized his brain for this decades-long period had apparently lost its grip.
Now, this does not really happen in core adolescent-onset schizophrenia. Some of the patients don’t recover at all; others make only a “social recovery,” ending with what the Europeans call a “defect.” That you awaken magically from classical schizophrenia—often called “hebephrenia”—and go on to have a normal life: Maybe not.
So this is what gives me the willies about the Nash case, that we may have given him the wrong diagnosis. Or rather that his psychoanalytically oriented clinicians in 1959 gave him the wrong diagnosis and ever since this has been unthinkingly accepted.
This is the way psychiatry often works. The field has trouble with new ideas, unless they are heavily promoted by the pharmaceutical industry (think “neurotransmitters”). In 1893 Emil Kraepelin in Heidelberg popularized the concept of psychosis of adolescent onset as “dementia praecox,” premature dementia, the premature part meaning adolescence or young adulthood. Then Eugen Bleuler, professor of psychiatry in Zurich, relabeled Kraepelin’s dementia praecox as “schizophrenia” in 1908, and detached it from age.
We still have Bleuler’s “schizophrenia” with us today, more than a hundred years later. The field has made virtually no progress in unpacking chronic severe illness and differentiating out several distinct entities. In no other field of medicine would this be conceivable! DSM-5, the current edition, still refers to “schizophrenia” in the singular.
To be sure, other efforts at unpacking have been made, but they haven’t caught on. In 1957 East German psychiatrist Karl Leonhard proposed a complicated alternative to the Kraepelin-Bleulerian standard that still has some acolytes today. In the Leonhardian scheme, Nash would probably have received the diagnosis “affective paraphrenia,” but Leonhard said they don’t recover, and Nash did.
Nash has now passed on. Someday his patient records will be available for scholarly analysis, and then we’ll know a lot more. But we won’t know anything for sure because as yet we haven’t done the required unpacking and don’t have reliable new categories for classifying chronic illness: Some involve loss of brain tissue, others don’t. Some have to stay on meds, others don't. Some get well, others don’t. These are not all the same illness! But at least we can stop chanting that Nash had “schizophrenia,” when in fact we don’t actually know what he had.