Schizophrenia Karl Lydén
Schizophrenia is a psychiatric diagnosis dating back to the 19th century, denoting a severe psychological disorder characterized by delusions, hallucinations, disorganized speech, and other disturbances in thought, emotions, and behavior. Despite its etymology—the Greek roots σχίζειν, schizein, and φρεν, phren, respectively mean “to split” and “mind,” “brain,” or “diaphragm”—schizophrenia is not to be confused with dissociative identity disorder or, as it is often called, “multiple personality disorder.” The split of schizophrenia does not run between two or more distinct personalities, but rather on a general level of psychic functioning; it is conceived as a split within thought. In 1908, the Swiss psychiatrist Eugen Bleuler substituted the earlier term “dementia praecox,” popularized by the German psychiatrist Emil Kraepelin in 1896, with “schizophrenia”: “For the sake of further discussion I wish to emphasize that in Kraepelin’s dementia praecox it is neither a question of an essential dementia nor of a necessary precociousness. For this reason, and because from the expression ‘dementia praecox’ one cannot form further adjectives nor substantives, I am taking the liberty of employing the word ‘schizophrenia’ for revising the Kraepelinian concept. In my opinion the breaking up or splitting of psychic functioning is an excellent symptom of the whole group.”1
According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, hereafter DSM-IV-TR (please note: the DSM-IV‑TR offers the perhaps most influential definition of schizophrenia worldwide; while not necessarily wishing to reinforce that definition, I do consider it to be of indisputable interest, and for this reason, paired with my inability to do anything but more or less quote in such a complicated, important, and delicate matter as schizophrenia, everything recounted below refers to DSM-IV-TR, when not otherwise stated), the onset of schizophrenia can be abrupt; in most cases, however, there is a gradual development, typically occurring between the late teens and mid-thirties. During such a gradual onset, people close to the affected person may notice signs of social withdrawal, loss of interest in schoolwork, deterioration in hygiene and grooming, unusual behavior, and outbursts of anger. Successively, the state worsens. Schizophrenia is considered a psychotic disorder; thus, delusions and hallucinations occur, and they occur without the affected person being aware of them, of his or her pathological state. As defined in the briefest way, schizophrenia lasts for at least six months, with an active phase of at least one month of two or more of the following symptoms:
1. delusions 2. hallucinations 3. disorganized speech 4. grossly disorganized or catatonic behavior 5. negative symptoms (affective flattening, alogia, and avolition).
Besides the “psychotic dimension” of delusions and hallucinations, there is a “disorganized dimension” of disorganized speech and behavior as well as other negative symptoms. Persecutory delusions are the most common; people suffering from them believe they are being followed, tricked, or ridiculed. People with referential delusions see “signs” in newspapers, books, and other cues that they believe are exclusively directed to them. All sorts of hallucinations may occur, but auditory hallucinations are by far the most common, usually in the form of voices being heard. Disorganized speech may derail, “slip off the track” and contain loose associations; answers to questions may be completely unrelated and, on rare occasions, speech may be so severely disorganized as to be nearly incomprehensible. Disorganized behavior includes unusual ways of dressing such as dressing for the wrong season, unpredictable shouting or swearing, and inappropriate sexual behavior. Catatonic behavior, a form of disorganized behavior, includes rigid, inappropriate or bizarre postures and excessive motor activity. Negative symptoms (“negative” should be understood in terms of a loss or decrease in what is considered normal behavior; conversely, the first four symptoms are defined as “positive” as they are added to normal behavior) include affective flattening (an unresponsive face, poor eye contact, and reduced body language); alogia (poverty of speech); and avolition (the inability to partake in goal-directed activities).
The causes of schizophrenia are unclear, and probably numerous. Research confirms links to genetics, environment, drug use, neurology, and social processes. Schizophrenia has been observed worldwide, and a rather constant 1% of the population seems to suffer from it, making it a significant cause of disability. Schizophrenia is equally common among men and women, but expresses itself differently in each; for example, the typical onset age for men is between 18 and 25, and for women it is between 25 and 35.
People affected with schizophrenia have a higher rate of nicotine dependency, higher rates of pulmonary diseases and higher rate of suicide than the general population; their life expectancy is therefore 10–12 years less than that of the general population. The chances of recovering from schizophrenia are low. Complete remission or full recovery is, to quote DSM-IV-TR properly before turning to its critics, “probably not common in this disorder.”2
Schizophrenia, therefore, is a psychiatric diagnosis based on symptoms reported by the affected person him- or herself, along with symptoms recorded by a psychiatrist; no stable biological or neurological link (such as a “schizophrenia gene” or common brain damage) to these symptoms has been established. Furthermore, it is a highly variable disorder, both in terms of onset, course and symptoms; Bleuler himself talked of a group of schizophrenias, and today schizophrenia is generally divided into five or more subtypes. Thus, quite predictably, the notion of schizophrenia has been criticized by psychiatrists such as Marius Romme and Paul Hammersley, associated with the Campaign to Abolish the Schizophrenia Label for lacking in uniformity and scientific validity; for suggesting an uncertain link to brain disease and causing overmedication rather than psychological treatment; and for stigmatizing patients and being highly associated with violence, dangerousness, unpredictability, inability to recover, constant illness, constant need for medication, and an inability to work.3 Also, Richard Bentall, professor of experimental clinical psychology at the University of Manchester, has stated: “I think the concept is scientifically meaningless, clinically unhelpful, and ultimately has been damaging to patients.”4 In Japan, the category of schizophrenia was abolished in 2004 and replaced by “integrated disorder.”
1 / Eugen Bleuler, as quoted by Paolo Fusar-Poli and Pierluigi Politi in The American Journal of Psychiatry 165/11 (2008), p. 1407.
2 / The American Psychiatric Association’s Diagnostic and Statistic Manual of Mental Disorders (DSM-IV-TR), p. 307.
3 / Marius Romme, Paul Hammersley, statement issued for the Campaign to Abolish the Schizophrenia Label (CASL),http://www.psychminded.co.uk/news/news2006/oct06/Abolish.htm.
4 / R. Bentall, as quoted on the BBC News, October 9 (2006), http://news.bbc.co.uk/2/hi/health/6033013.stm.