Creating A Mental Illness Called Schizophrenia
A brief history of an archetypal psychiatric diagnosis.
Posted Nov 27, 2020
During the pandemic, increased incidences of distress can be portrayed as proliferations of mental illnesses such as ‘Depressive Disorder’ and ‘Anxiety Disorder.' Alternatively, we can talk about our fears, worries, grief, pessimism, and despondency as understandable reactions to the general crisis and to our personal losses, actual and anticipated.
I prefer the latter framework. It locates the origin of our problems in the reality of our social contexts, rather than implying that there is some defect in us as individuals, in our genes or brains. Research shows that increased anxiety and depression during the pandemic is predicted by obvious social factors like loss of income and having children at home.1 Yet our mental health services, and research, remain dominated by the medical-model approach, which calls the labels it uses ‘diagnoses.'
Perhaps we should revisit the creation of the archetypal psychiatric diagnosis—schizophrenia—to understand how we went from understanding that depression, for example, is caused, for all of us, by depressing things happening, to the notion that depression is caused by some of us having something biologically dysfunctional inside of us called ‘depressive disorder.'
Two ‘grandfathers’ of psychiatry, Emil Kraepelin and Eugen Bleuler, were responsible for the invention (or, from their perspective, discovery) of ‘schizophrenia’.2 In 1893 Kraepelin presented his new mental disease, in which deterioration begins in adolescence and ends inevitably in dementia. Hence the name ‘dementia praecox’ (‘praecox’ means early). His immediate problem was that some people insisted on getting better. He made no claim to have cured them. So, he just changed the diagnosis if people recovered.2 The American psychiatrist Harry Stack Sullivan argued in 1927 that: ‘The Kraepelinian diagnosis by outcome has been a great handicap, leading to much retrospective distortion of data.'3
In 1911, Bleuler, working in Switzerland, published his famous Dementia Praecox or the Group of Schizophrenias.4 He rejected Kraepelin’s notion of incurability and demonstrated that Kraepelin had grouped together numerous, quite different, types of problems. This was soon ignored, however. It is ignored today every time the term schizophrenia is used as if it were a meaningful, unitary, explanatory concept.
Kraepelin eventually described no less than 36 groups of ‘psychic’ symptoms and 19 types of ‘bodily symptoms.'5 One patient could have symptoms entirely different from another's, but both supposedly had the same illness. Such constructs are known as ‘dysjunctive’ and are scientifically meaningless.2
The symptoms listed by Kraepelin and Bleuler read rather like a list of broken social norms. For example:
- "They conduct themselves in a free and easy way, laugh on serious occasions, are rude and impertinent towards their superiors, challenge them to duels, lose their deportment and personal dignity; they go about in untidy and dirty clothes, unwashed, unkempted, go with a lighted cigar into church".5
- "More in girls, there is reported irritability, sensitiveness, excitability, nervousness, and self-will . . . [and] those patients, belonging rather more to the male sex, who were conspicuous by docility, good nature, anxious conscientiousness and diligence, and as patterns of goodness".5
- "Patients are in love with a ward-mate with complete disregard of sex, ugliness, or even repulsiveness".4
- "Patients sit about idle, trouble themselves about nothing, do not go to their work".5
- "A hebephrenic [a subtype of schizophrenia] whose very speech was confusion, held the cigar-holder to the mouth of another patient suffering from muscular atrophy. . . with a patience and indefatigability of which no normal person would ever be capable".4
- "Many schizophrenics display lively affect. Among them are the active writers, the world improvers, the health fanatics, the founders of new religions".4
- "Perversions like homosexuality and similar anomalies are often indicated in the whole behaviour and in the dress of the patient".6
‘Flat affect’ and ‘inappropriate affect’ were ‘primary symptoms.' Feeling two opposite emotions was also abnormal, such ‘ambivalence’ being another defining characteristic of schizophrenia. Remembering too intensely was another symptom: "Even decades later . . . nuances of sexual pleasure, embarrassment, pain or jealously, may emerge in all their vividness which we never find in the healthy".5
There was no evidence to support their claim that they had discovered an illness with a biological cause. Bleuler wrote of a ‘schizophrenic cerebral disease’ but admitted that ‘Direct investigation for specific cause or factors has left us stranded’.4 Autopsies revealed no abnormalities.7 By 1913 Kraepelin conceded that the causes ‘are at the present time still wrapped in impenetrable darkness’.5 The words ‘at the present time’ are still used today by researchers permanently on the verge of finding a biochemical, neurological or genetic cause of schizophrenia.7, 8
Today’s definition of schizophrenia requires just two of five types of symptoms.9 So if I have just hallucinations and delusions, and you have just thought disorder and catatonia, we have nothing in common. Yet we get the same diagnosis. So schizophrenia remains, after 100 years of redefinitions, as scientifically meaningless as it always was. It explains or predicts nothing (except that you will definitely receive antipsychotic medication and probably be on the receiving end of some nasty prejudice and discrimination).
Today, when we experience severe levels of distress and grief, whether or not it is related to the pandemic, we deserve better than scientifically meaningless, medical-sounding labels that wrongly imply there is something biologically defective about us as individuals, which in itself is depressing, and that run the risk of unnecessary medical interventions.
International Hearing Voices Network www.intervoiceonline.org
1. SHEVLIN, M., et al. (2020). Anxiety, Depression, Traumatic Stress, and COVID-19 Related Anxiety in the UK General Population During the COVID-19 Pandemic. British Journal of Psychiatry Open, 6, 1-9. doi.org/10.1192/bjo.2020.109
2. READ, J. (2013). The invention of schizophrenia. In J. Read, J. Dillon (eds.). Models of Madness: Psychological, social and biological approaches to psychosis, pp. 20-33. . London: Routledge.
3. SULLIVAN, H. (1927). Tentative criteria of malignancy in schizophrenia. American Journal of Psychiatry, 84, 759-782.
4. BLEULER, E. ( 1950). Dementia Praecox or the Group of Schizophrenias (translated by J. Zinkin). New York: International Universities Press.
5. KRAEPELIN, E. ( 1919). Dementia praecox. In E. Kraepelin, Psychiatrica (8th edition) (translated by R. Barclay). Melbourne, FL: Krieger.
6. BLEULER, E. (1924). Textbook of Psychiatry (translated by A. Brill). New York: Macmillan.
7. BENTALL, R. (2009). Doctoring the mind: Why psychiatric treatments fail. New York: Allen Lane.
8. READ, J. (2013). Biological psychiatry’s lost cause. In J. Read, J. Dillon (eds.). Models of Madness: Psychological, social and biological approaches to psychosis, pp. 62-71. London: Routledge
9. AMERICAN PSYCHIATRIC ASSOCIATION. (2013). Diagnostic and Statistical Manual (5th edition). Washington DC: APA.