Schizophrenia

What is schizophrenia? 

Surprisingly, given its supposed  prevalence, there is no universally accepted definition of  what schizophrenia is (Hill, 1983; Johnstone, 2000b). A full seventy years after Bleuler first coined the term, Dr Ming T. Tsuang (1982) could observe: "There is still no unanimously accepted definition of schizophrenia".  Incredibly, in the twenty-first century, this remains true today.  This is because, as Doctor Rob Youngston (1996) commented: "Schizophrenia is not...a disease in the normal medical sense and has no fixed characteristics.  Definitions vary widely and the condition is constantly being officially redefined".

Signs and symptoms

Early theorists such as  Kraepelin and Bleuler (who originally 'discovered' schizophrenia) cited behaviour as diverse as entering church with a smoking cigar and falling in love with ugly people as being symptomatic.   Amazingly, even today, no symptoms at all need actually be present for a diagnosis of schizophrenia to be made. Although doctors in the former Soviet Union were rightly berated for diagnosing 'schizophrenia without symptoms' by  British psychiatrists, patients in the UK have been diagnosed as schizophrenic despite manifesting none of the recognised symptoms.   Regrettably psychiatrists have simply inferred symptoms where none were present.

Dr. Dorothy Rowe (1987) has revealed that "psychiatrists...often have their own idiosyncratic methods of diagnosis". She cites the example of a psychiatrist who assured her that he knew that a certain woman was schizophrenic "by the shape of her eyebrows" (Rowe, 1987; p349).

Lucy Johnstone (1989), a senior NHS clinical psychologist, has revealed that people may be diagnosed on the basis of information supplied by their relatives. QUDOS knows of a  well-documented case where a depressed and withdrawn - but non-psychotic - young man was asked during a psychiatric interview if he heard voices. Later, accessing his case notes, this 'diagnosed schizophrenic' discovered that his honest denial had simply been disregarded. (The consequences of a false diagnosis to this particular individual were far-reaching and horrendous.)

Like suspects in mediaeval witch trials, those deemed to be schizophrenic cannot disprove the allegation.  While it is now accepted as integral to due process of law that the burden of proof should rest with one's accusers; that those at risk of loss of  liberty should be safeguarded by jury trials, defending counsel and cross-questioning of witnesses; the diagnosis of schizophrenia may be based solely on the subjective opinion of a single psychiatrist. The protestations of the accused are liable to be dismissed because, after all, the patient is mad.

Given lack of scientific precision with which the diagnosis of schizophrenia may be invoked, it is unsurprising if mental health workers are sometimes struck by the amazing diversity of character, personality, and symptoms displayed by people who who have received this diagnostic label. As Professor Mary Boyle (1990; 1996) observed: "...we have such consistent reports of how very heterogeneous are people who are grouped under the same [diagnostic] category, indeed to the point where some people may have virtually nothing in common with others given the same diagnosis".

Heads they win: tails you lose

Unfortunately, alleged schizophrenics cannot clear themselves by pointing out, for example, that not only had they never exhibited psychotic symptoms at the time of diagnosis, but that their friends and workmates report that they never displayed them subsequently. Psychiatrists have conveniently decreed that a percentage of schizophrenics will  not experience further episodes. So even if these supposed schizophrenics are manifestly clear of any signs of psychosis at some future date, they cannot  prove that they were not previously insane. Not surprisingly,  psychiatrists are sometimes reluctant to concede that anyone has ever been wrongly diagnosed, despite the manifest prevalence of false diagnoses.  Significantly, most of the bogus psychotics in the notorious Rosenhan experiment were discharged from hospital with a diagnosis of 'Schizophrenia in remission' (Rosenhan, 1973).

Defensive medicine

Media manipulation by opponents of community care has created a climate of fear in which doctors are now under considerable pressure to practice defensive medicine by ensuring that they never fail to spot a case of  'schizophrenia '.   Consequently, while diagnostic techniques in more traditional branches of medicine are continuously being refined and are generally becoming more reliable, there is concern that false diagnoses of  'schizophrenia' may have proliferated in recent years.

The implications of false diagnosis for research

Because schizophrenia has been diagnosed in a slapdash and inconsistent way,  it is difficult for researchers to find regular patterns of physiological or behavioural makers in samples of patients with this diagnosis.   Consequently, almost any research group of  randomly selected so-called schizophrenics is likely to contain un-typical and asymptotic individuals who will bias the sample.  

Researchers have complained:  "The problem of understanding the etiology of schizophrenia and a rational investigation of its treatment and prevention is made vastly more difficult, perhaps even hopelessly tangled, by the extraordinary latitude and naivety of diagnostic criteria".

Some genuine medical conditions which may be confused with schizophrenia:

Substance-induced psychoses: these may result from ingesting amphetamines, barbiturates, belladonna, cimetidine, cocaine, digitalis or phencyclidine (PCP); disease embolism; epilepsy or brain tumours; Creuzfeldt-Jacob disease (CJD); AIDS, syphilis, herpes encephalitis; Alzheimer's disease, carbon monoxide poisoning; deficiency of vitamin B12; tuberculous meningitis; endocrinopathies -particularly adrenal and thyroid abnormalities e.g. hyperthyroidism; Fahr's Syndrome; Hallervorden-Spatz disease; poisoning from heavy metals e.g. arsenic, manganese, mercury; Humtington's disease, hydrocephalus; metachromatic leukodystrophy; Pick's disease, Cotard's syndrome; Uremia; Wernicke-Korsakoff syndrome and Wilson's disease.

(The above list is not comprehensive: we've included only a few conditions to illustrate the potential for mis-diagnosis. Note that it is not necessary to have anything medically wrong at all to be diagnosed as schizophrenic: symptoms may merely be inferred by the psychiatrist.)

So does schizophrenia really exist?

Some distinguished psychiatrists such as Thomas Szasz (1976) have claimed that schizophrenia does not exist;  that it is a label used to classify people whose behaviour they find bizarre and who are difficult to treat (Hill, 1983).  Even so, distressed, disorientated and deluded people with a range of symptoms do, undoubtedly exist and require help.

Unfortunately the cavalier way in which the diagnosis  has sometimes been used has tended to devalue the whole concept of schizophrenia:  The term has become debased through being employed with a lack of  precision. Consequently, some  mental health workers now regard it as being virtually meaningless as a clinical description. 

SOURCES

Boyle, M. (1990) 'Schizophrenia:  A Scientific Delusion?' Routledge.

Boyle, M (1996) 'Diagnosis, Science and Power' Asylum, Vol 10 No1 1996/7.

Boyle, M (2002) 'It's All Done with Smoke and Mirrors. Or, How to Create the Illusion of a Schizophrenic Brain Disease'. Clinical Psychology, Issue 12, April, 2002, pp 9-16. (The full text of this can be found in the 'article' section on the Critical Psychiatry website at: http://www.critpsynet.freeuk.com/).

Hill, D. (1983) 'The Politics of schizophrenia' University Press of America.

Johnstone, L (1989) 'Users and Abusers of Psychiatry' Routledge.

Johnstone, L (2000a) 'Users and abusers of Psychiatry: A Critical Look at Psychiatric Practice' (2nd. edition) Routledge.

Johnstone, L (2000b) 'What is Wrong with Psychiatry?' Mental Health Practice October 2000 Vol.4 No.2

Rosenhan D L (1973)  'On being Sane in Insane Places' Science, 179 250-258.

Rowe, D (1987) 'Beyond Fear' Fontana.

Siebert, A (2000) 'What is Wrong with Psychiatry?' Journal of Humanistic Psychology, Vol.40, No1, Winter, pp.34-58.

Szasz, T (1976) 'Schizophrenia: The Sacred Symbol of Psychiatry' Basic Books.

Thomas, P (1997) 'The Dialectics of Schizophrenia' Free Association Books.

Tsuang, Ming, T (1982) 'Schizophrenia, The Facts' Oxford University Press.

Youngston, R and Schott, I (1996) 'Medical Blunders' Robinson.