- The diagnosis of schizophrenia is in decline.
- Psychiatric classification systems seem to be shifting from categories to spectrums.
- The diagnosis of schizophrenia has become a matter of perspective.
Since the 1990s, epidemiologists, psychiatrists, historians, and journalists have wondered to what extent schizophrenia was disappearing as a medical diagnosis. An article in The Lancet titled “Is Schizophrenia Disappearing?” suggested a substantial decrease in the reported incidences of the disorder since the mid-1960s; a 2012 publication, Schizophrenia Is a Misdiagnosis, criticized the very validity of the diagnosis and bluntly announced its demise. 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. The editor of the leading journal in the field, Schizophrenia Bulletin, debated whether to rebaptize the journal and drop “schizophrenia” from its name. In the end, he decided to keep “schizophrenia” in the journal’s title while adding an explanatory subtitle as a disclaimer of sorts. With the added “The Journal of Psychoses and Related Disorders,” the editor seemed to anticipate where the field would soon be headed. Finally, a 2017 article in this very journal claimed that the word schizophrenia might eventually be relegated to the dustbin of history, as had once been the case with the medical use of the term “dropsy.”
Still lacking a laboratory test for diagnosing schizophrenia and having found no precise biomarkers for this collection of symptoms, we are now asked to reimagine schizophrenia as revealing not a different category of mental illness but a spectrum of disorders whose defining characteristics are part of a continuum rather than tokens of essential types or natural kinds. History teaches us that abnormalities in thoughts, emotions, and behaviors were always seen as either categorically different (in the same way that plants are different from animals and minerals, and various trees are different from each other) or as a variation on a spectrum (in the same way we measure height or weight, or high or low blood pressure).
But the decline of the diagnosis was driven not only by general shifts in psychiatric classification as it turned from categories and qualitative methods to spectra and quantitative models. In addition, psychiatrists, psychologists, social activists, survivors, ex-patients, and others argued that the stigmatizing label of “schizophrenia” should be abolished precisely because it carried connotations of hopelessness, chronicity, and even dangerousness that could not help but lead to therapeutic nihilism and the unjustified "counsel of despair."
Doctors and patients who advocate for a name change are searching and pleading for less discriminatory and more appealing diagnoses, with “extreme mental states,” “voice-hearing,” “non-ordinary states,” or “diverse identities” just a few of the suggestions that have been made. In addition, some have urged the American Psychiatric Association to follow the example of Asian countries such as Japan, where psychiatrists replaced the term and diagnosis “schizophrenia,” implying a “split-mind,” with that of “integration disorder,” inaugurating a momentous change that, by all accounts, has proved beneficial to both patients and doctors.
Yet while a genealogy of madness from its first appearance in the Bible presents us with two ways of imagining the difference between sanity and madness, namely as either one of categorical difference or one of a degree—in other words, as one of qualitative difference or one that could put on a quantitative scale—we might also seek to reimagine what kind of hopeful future this very alternation of models might still hold in stock for us. This means envisioning what picture emerges once one no longer takes the diagnosis of schizophrenia to be that of a stable identity per se, but possibly also one marked by a striking and sometimes changing shift of perspective.
This dual vision of one and the same complex phenomenon recalls the optic illusion, which Thomas Kuhn, following Ludwig Wittgenstein, borrowed from the psychologist Joseph Jastrow to demonstrate “the structure of scientific revolutions.” According to Kuhn, even when nothing in the environment has changed, the shift of attention of the scientific community transforms its perception of the studied phenomenon in question all at once. In Kuhn’s words: “[w]hat were ducks in the scientist’s world before the revolution are rabbits afterward.” As can be gleaned from Jastrow’s famous sketches and the subsequent interpretations of the duck-rabbit image, such ambiguous figures illustrate that the aforementioned alternative perceptions and theoretical or clinical models are not just the products of how given stimuli register on our visual field (i.e., sense data so-called). Rather, they show that what we see is, first and foremost, perceived with the mind’s eye. In other words, expectations, knowledge, and the direction of our attention all take part in what we are not only able but also willing or desiring to see. Just as children on Easter Sunday are more likely to identify a rabbit while they more readily see ducks on an average Sunday, scholars and practitioners in their respective fields tend to see one or the other of the available views on a matter in question depending on context. In so doing, it seems, they follow the spirit of the time, the Zeitgeist, the conventions (customs and habits), and perhaps even the prejudices of their own age.
During their extensive practical training, clinicians (myself included) who work with individuals suffering from what we have perhaps too crudely come to name and determine as “schizophrenia” learn that “if it looks like a duck, swims like a duck, and quacks like a duck, then, in all probability, it is a duck.” But witnessing the emerging of more general presentations and models of spectra, next to a more widespread generational resistance to labels and classifications (recall the analogous case of the spectrum of gender and sexuality), while also listening to the perspective of advocacy groups and hearing testimonies of patient-led movements, gives one pause: Instead of favoring one paradigm over the other, let alone slipping into relativism pure and simple, those who diagnose and treat mental disorders should accept and live or work with the undeniable paradox of having two seemingly exclusive accounts of severe mental conditions operating concurrently or alternatingly. Being “of two minds,” they may see either a rabbit or a duck, fully aware that both pictures and optics are a case of “now you see it, now you don’t.” After all, whether we diagnose patients as categorically different or on a spectrum with the normal, this diagnosis is nothing more than an incomplete sketch of what is, in “essence,” a much more complex and intractable phenomenon.
Adapted from Schizophrenia: An Unfinished History (Polity, 2022).
Orna Ophir (2022) Schizophrenia an Unfinished History. Cambridge, UK: Polity Press.