Schizophrenia: 100 Years On
"2011 marks the 100th anniversary of the introduction of the diagnosis of schizophrenia, the most severe, enigmatic and controversial of mental disorders. At a time when biological and neuroscientific accounts of schizophrenia dominate, there is a risk that crucial questions are closed off as we await the promised conquering of madness and distress by scientific and technological advances.
Through exploring schizophrenia from a variety of perspectives including cultural theory, psychotherapy, sociology, psychiatry and philosophy, this series of talks aims to open up key questions and reinvigorate debate on this fascinating and most important of subjects."
So went the blurb on the flyers for a series of four monthly talks held in a slightly dilapidated function room above a pub in Newcastle-upon-Tyne between February and May of this year. The talks were held in collaboration with the Newcastle Philosophy Society (www.newphilsoc.org.uk) and attracted in the region of 50 people to each of the talks, many of whom had received a diagnosis of schizophrenia or were close to someone who had. The high turn-out suggests that the topic remains of considerable public interest.
Angela Woods from the department of Medical Humanities at Durham University kicked things off with her talk ‘Schizophrenia – 100 Years of Controversy’. Angela initially highlighted the huge diversity of ways in which schizophrenia can and has been explored – from the experiences of people and their narratives to psychoanalytic theories of psychosis to the politics of the anti-psychiatry movement to the literary and cinematic representations of schizophrenia to the consumer/survivor/ex-patient and mad pride movements. Given all these different understandings, an obvious question arises: how have we arrived at the dominant picture of schizophrenia as a disease of the brain?
Angela then took us on a whirlwind tour of the history of schizophrenia from the early confidence in the imminent discovery of the genetic, neurochemical and physiological lesions underlying the ‘disease’, to the scandals of Nazi psychiatry and the human rights violations of certain therapeutic regimes, to the rise of DSM and psychopharmacology to the renewed confidence and optimism characteristic of the age of neuroscience and the genome, a time when schizophrenia can finally be ‘understood and conquered’. In more sober moments, psychiatry may of course reflect that the decade of the brain has passed and they have still not offered us any definitive account of schizophrenia’s origins or any ‘cure’ for its symptoms.
A key point that emerged from Angela’s paper is that conflict is not something that has just surrounded schizophrenia in the therapeutic, clinical, scientific, personal and political spheres, but is in fact the very essence of this most enigmatic of psychiatric diagnoses. Using her idea that schizophrenia is the sublime object of psychiatry (explored in her forthcoming book The Sublime Object of Psychiatry: Schizophrenia in Clinical and Cultural Theory), Angela argued that the way that psychiatry since Kraepelin has framed schizophrenia as an object or disease entity waiting to be discovered has diverted attention from the fact that the category of schizophrenia is not neutral, nor self-evident. And further that the widespread assumption that schizophrenia is a brain disease has important implications beyond mere theoretical musings: the fixation on a brain disease model means that there is little support or incentive for people to investigate the environmental and social factors involved in psychotic experience. In addition, the aggressive promotion of a biological model of schizophrenia has had the effect both of increasing stigma and the desire for social distance as well as doing little to offset, and maybe even contribute to, the myth that schizophrenia is strongly associated with violence.
Trauma has long been a central theme in the lives of those individuals who are diagnosed as schizophrenic. One psychiatrist has even recently proposed re-naming schizophrenia as post-traumatic psychosis. Tony Wright, a clinician from the charity ‘Freedom from Torture’, gave the next talk, ‘Survivors of Torture: Broken Bodies and Broken Minds’, in which he focused on the experiences of some of his clients who displayed behaviours and patterns of thinking that may be understood as schizophrenic. He explored how it was possible to re-frame these behaviours within an understanding of normal reactions to extreme circumstances and how this offered us possibilities for fresh understanding beyond the realm of psychopathology. Since R.D. Laing, there have been consistent (albeit generally marginalised) efforts to re-frame our understanding of psychosis – to make the ‘un-understandable’ comprehensible. There is of course the risk that with an increasing focus on biology, psychiatry will move towards becoming a discipline that deals primarily with causes at a neural level rather than meanings at a person level.
Tony explored the ways in which many of his clients' experiences such as hallucinations and delusions can be understood within the context of a torture narrative: the smell of kerosene in the room; the hands of the torturer on the back; the smell of death; the sound of a bullet whistling past the left ear; the persecutory and paranoid narratives of spies in the streets or ears in the walls. While the current psychiatric understanding of schizophrenia tends to focus on internal factors while paying lip service to external ones, torture narratives provide a chilling example of how traumatic experiences can act as the crucial agent in the aetiology of the signs and symptoms listed in the DSM and ICD.
Using a single case study of a client who displayed all the key behaviours that fall within the diagnosis of disorganized/hebephrenic schizophrenia, Tony highlighted a key tension lying at the heart of his work: that he both wanted and did not want psychiatric intervention for his client. He wanted it because his client was highly suicidal but he was also scared that psychiatric intervention would mean seeing his client specifically as a set of schizophrenic symptoms. If this was the case, then help would most likely be limited to that symptomology without understanding the torture narrative and the normality of his reactions given his experiences of trauma. Too often in current mainstream mental health services even therapeutic (as opposed to pharmacological) interventions have a tendency to ignore the ways in which clients make sense of their situations as the emphasis shifts to 'fixing' people and returning them to productivity.
Tony also highlighted a tragic paradox: that although his clients regularly report suicidal feelings, they are frequently refused mainstream medical care under the official position that their distress is a reasonable response to what they have experienced and therefore not to be dealt with by mental health services. One could also read a political decision into this: a refusal, if at all possible, to provide mental health services to asylum seekers.
Mark Cresswell from the School of Applied Social Sciences at Durham University is heavily involved in the politics of mental health. In his talk, ‘Between Sedgwick and Szasz: Schizophrenia as ‘Illness’ and ‘Myth’’, Mark addressed the apparent conflict between his endorsement of both the position of the libertarian Thomas Szasz that schizophrenia is a myth and the position of the socialist Peter Sedgwick that schizophrenia should be seen as an illness in order to politicise the field of mental illness and make demands upon health and welfare services. Which slogan is better suited to the needs of people who have a diagnosis of schizophrenia?
1) Schizophrenia is a myth
2) Schizophrenia is an illness like any other
Mark’s talk explored the complexities of the politics of mental illness and how the survivor movement’s position on schizophrenia may usefully shift depending on the political context. Is it even useful to have a fixed position on the status of schizophrenia as an illness or myth? Maybe in times of economic downturn and cuts to health services, it is useful to defend it as an illness in order to make demands on the health and welfare services, as Sedgwick suggested. At other times, this position may be less politically useful, especially as the term ‘illness’ obscures the possibility of radicalizing how we view human distress and thus to challenge how psychiatry has colonized this area of our lives. Back in 1982, Sedgwick famously wrote that ‘the future belongs to illness’. Mark highlighted how in fact with the growth of the survivor movement, political demands need no longer be made in the name of illness, but could equally be made in the name of experience, distress or trauma.
The final talk of the series was given by the writer, psychiatrist and co-founder of the Critical Psychiatry Network, Phil Thomas. Phil’s talk, ‘Enlightenment’s Shadow: Dementia Praecox, Degeneration and the Birth of Schizophrenia’, explored the cultural significance of degeneration at the time when Emil Kraepelin was formulating his ideas surrounding schizophrenia (or dementia praecox, as he termed it). Kraepelin held a very pessimistic view of the possibility of recovery from schizophrenia, believing that the disease was characterised by deterioration in the social and cognitive functioning of the sufferer over time. This view of schizophrenia has broadly endured to today with it still being generally seen as a condition with a high risk of recurrence and poor prognosis. While clinicians no longer use terms like ‘degeneration’, they regularly use terms like ‘deficits’, ‘deterioration’ and ‘end stage’.
Phil questioned the scientific evidence surrounding Kraepelin’s notion of degeneration in dementia praecox, comparing it with the psychiatrist and criminologist Cesare Lombroso’s arguments that criminal traits were degenerative features identifiable in the physiognomy of the individual through skull measurements and physical abnormalities affecting the ears and face. It appeared recently that some of Kraepelin’s ideas may be supported by scientific evidence when it was discovered that people with schizophrenia had reduced brain volumes compared with healthy people and that these reductions become more pronounced as the disease progresses. It was only later discovered that the greatest decrease in brain volumes were seen in those patients who had received the highest doses of neuroleptic medication. So this example of degeneration is nothing to do with the disease process, but rather with physical treatments.
Phil also explored and critiqued the idea that the self is fundamentally narrative in nature. He pointed to a case where a person diagnosed as schizophrenic and considered to be displaying significant ‘blunting of affect’ and ‘poverty of speech’ was understood by a psychiatrist to have deteriorated over time to the point where it no longer made any sense to speak of a narrative self. In other words, as this person no longer chose to communicate with people around her, she was considered no longer to be in possession of a self. She was in a sense no longer a person, properly understood. Phil countered this presumption by suggesting that silence can in fact be a very useful way of coping with feelings of powerlessness. People in great distress may experience the world as so harsh and lacking in love and compassion that withdrawal from it may be seen as the most useful way of restoring meaning, purpose and richness to their existence, especially when the people around them - worried family members, nurses, psychiatrists and so on - may be perceived as threatening. To speak of prolonged periods of withdrawal in terms like ‘deficit’, ‘dysfunction’ and ‘deterioration’ and to suggest it may be attributed to a brain disorder is, as Phil highlighted, a potentially grave moral error. Perhaps as a culture it is time we heeded the words of Sara Maitland from her recent A Book of Silence (2009):
We are terrified of silence, so we encounter it as seldom as possible, even if this means losing experiences we know to be good ones, like children wandering alone or unsupervised in the countryside. We say that silence is a lack of something, a negative state. We deny the power and meaning of silence. We are terrified of silence and so we banish it from our lives (p.130-1)
Phil’s talk highlighted the need for a more detailed understanding of the historical and cultural origins of psychiatric knowledge. Many of the ideas we take for granted may have arisen in very different narrative and cultural contexts and many may be hopelessly out-dated and potentially detrimental to the recovery of people given a diagnosis of schizophrenia.
It is difficult to sum up any overall themes that arose from this series of talks. All of the talks came from a position that was largely critical of mainstream ways of thinking about the diagnosis of schizophrenia. All of the talks confirmed that key questions still remain and need to be asked – that any confident assertion of the inevitable conquering of schizophrenia is both premature and even fundamentally misguided. Ultimately all of the talks confirmed what Angela had suggested in the first talk: that conflict is in fact the very essence of this diagnosis. As it reaches its 100th year, there is no sign of this changing. And this is no bad thing.
Anthony Morgan, July 2011