Schizophrenia. Orna Ophir
schizophrenia, undifferentiated schizophrenia, and residual schizophrenia, the diagnosis of paranoid schizophrenia became obsolete in the DSM-5. Formally speaking, there are no longer any “paranoid schizophrenics” among us. Since 2013, the kind or type of people (genus and species) that Dr. Brewster had labeled Tony with is nowhere to be found.
According to Hacking, the human sciences (including psychology, psychiatry, the social sciences, and clinical medicine) are driven by nine engines of discovery, and involved in a process of “making up people.”24 By counting people (say, 1 per 100 people in America suffers from schizophrenia); by quantifying them (age of onset before 45, duration of psychotic symptoms longer than a month), by creating norms; by correlating data about them (schizophrenics are 10% more likely to die of suicide); by medicalizing, biologizing, and geneticizing these subjects while trying to normalize deviance, by bureaucratizing these individuals, they invent new kinds of people. When “autistics,” “hoarders,” “the obese,” or “paranoid schizophrenics” emerge as new kinds of people, new types of experts who then identify, assess, and treat them, also appear. Newly instituted organizations then develop, which are specifically set up to cater to these new kinds of people, or patients.
While it was possible to be a “paranoid schizophrenic” after this kind of person was made up by psychiatry in 1968, this is no longer an option after 2013. With the change of the “ecological niche,” the conditions no longer exist for this specific diagnosis to thrive. It thus disappears, in what could be termed a process of “unmaking of people.”25
The present study and its title, Schizophrenia: An Unfinished History envisions the end of this diagnosis, with the double meaning of end as both the purpose of a diagnosis, and its possible termination or demise. Modern psychiatry has moved from carving out categories of mental illnesses to delineating spectra of these disorders, which is considered a remarkable paradigm shift in its classification system. In this book, we will examine whether this shift from a qualitative categorical diagnosis (based on descriptive symptoms) to a spectrum-like, dimensional classification (based on biological or psychological dimensions and scales) is at least partly responsible for the effort of bringing an end to the diagnosis of schizophrenia.
Since the 1990s, epidemiologists, psychiatrists, historians, and journalists have all been asking if schizophrenia is disappearing as a medical diagnosis. An article in the Epidemiology section of The Lancet, titled “Is schizophrenia disappearing?” suggested a substantial decrease in the reported incidences of schizophrenia since the mid-1960s.26 By the same token, a 2012 book titled Schizophrenia Is a Misdiagnosis criticized the validity of the diagnosis and announced its end.27 Other articles appeared with titles such as “‘Schizophrenia’ does not exist,”28 published in 2016 in the British Medical Journal, and “The concept of schizophrenia is coming to an end,” published in The Independent in 2017. This latter piece stated that schizophrenia might face the same fate as dementia praecox, the very diagnosis it had historically come to replace.29 Lastly, in the Schizophrenia Bulletin, a 2017 article suggested that the word might eventually be confined to history, not unlike the medical use of the term “dropsy.”30
A Difference in Kind or in Degree?
Schizophrenia: An Unfinished History, then, aims to investigate two opposing ways of understanding mental health and its abnormalities, that have framed our perception from antiquity to the present day. Each of these views is paradigmatic, with different sets of shared commitments, practices, symbolic generalizations, models, and so-called exemplars.31 The first, which we will call the categorical view, characterizes abnormal mental states and behaviors as different in kind from normal ones, just as elm trees are different from pine trees, and trees, more generally, are different from minerals or from animals. The second, the clinical-dynamic view, defines the difference between normal and disordered states as one of degree, placing it on a spectrum within a wider dimension of mental phenomena, in the same way that in medicine hypertension is different from hypotension.
These two intuitions (of a difference in natural kind – of given qualities, or essence, on the one hand – and in degree – of quantitative, scalar variations, on the other), have produced two very different ways of representing mental health and sickness. As distinct and, at times, irreconcilable ways of seeing and talking about mental illnesses, they rise and fall, in response to the different social and cultural milieu in which they are discussed, and intellectually or institutionally supported. One of the aims of this book is to ask whether we currently find ourselves in a milieu or climate that may provide the conditions for the disappearance of schizophrenia as a helpful critical and clinical term of diagnosis and treatment.
Several experts attribute the decline in the reported incidences of the diagnosis of schizophrenia to the growing availability of better psychopharmacological treatments, while others place more emphasis on reduced accessibility to the treatment centers that record these numbers, or even to higher rates of suicide. Still others argue that the underlying cause of this decline is not so much due to a reduction in the number of individuals who exhibit what psychiatrists came to define as symptoms of schizophrenia, but to a dramatic change in the classification culture of psychiatry as a medical professional discipline. The “twin pillars” of psychiatry’s nosology (which provided the conditions for the birth of the term schizophrenia) are crumbling, some argue, and a new biomarkerbased classification system should be reconstructed, brick by brick.32
It is important to keep in mind, however, that the vast majority of authors who criticize the diagnosis of schizophrenia agree that some individuals indeed do experience delusions, hallucinations, and disorganized speech that make them sound irrational. They admit that such individuals may also exhibit disorganized or catatonic behavior, flat affect, or the failure to maintain basic self-care. And yet, a growing number of authors maintain that, as a presumed disease entity – as an identifiable state, a natural kind – schizophrenia does not “exist.” And while some claim that it could be considered and called an “end stage” of other untreated mental disorders (in the same way that heart failure is the terminal stage of various heart diseases), others won’t even go that far, proposing instead to abolish the term schizophrenia altogether.33
To this day, the integrity of schizophrenia as a diagnosis is unproven, as there is no valid objective test for it. The failure to identify schizophrenia’s biological markers, despite volumes of accumulated research data, has led professionals and laymen to propose discarding the label, both as a useful term, and as a biological or psychological category in its own right. Unsurprisingly, others have argued that to discard the concept and diagnosis of schizophrenia altogether would be premature and, hence, unwise and impractical. Indeed, it would represent a radical shift away from the current, predominantly categorical disease model of psychiatry, whose scientific and medical credentials (not to mention, institutional presence and prominence) are still largely unchallenged, forming a public and political reality to be reckoned with. As an alternative to the categorical method, the dimensional model still faces an uphill institutional battle to establish itself as a paradigm that carries similar weight in classifying mental illnesses. Yet, several examples and practices of this alternative model can already be found.
One such example is the diagnostic approach developed by the American National Institute of Mental Health (NIMH), the largest research organization in the world specializing in mental illness, whose mission is to study, understand, and treat mental illnesses – and thereby, to pave the way for prevention, recovery, and cure of these ailments. The NIMH’s “Research Domain Criteria” (RDoC),34 although intended as a research framework for new approaches to investigating mental disorders rather than a clinical diagnostic guide per se, aims to explain mental health and illness in terms of varying degrees of dysfunction in systems of emotion, cognition, motivation, and social behavior. The RDoC tries to identify basic dimensions of medical and psychological functioning that span the whole range of human behavior, from normal to