A Critical History of Schizophrenia

Kieran McNally

• Publisher: Palgrave Macmillan
• Year: 2016
• Print ISBN:
  9781137456809
• eBook ISBN:
  9781137456816
• Topic: Psychology
• Subtopic: Psychiatry & Mental Health
• Index: Psychology

Schizophrenia was 20th century psychiatry's arch concept of madness. Yet for most of that century it was both problematic and contentious. This history explores schizophrenia's historic instability via themes such as symptoms, definition, classification and anti-psychiatry. In doing so, it opens up new ways of understanding 20th century madness.

1

Schizoidia: The Lexicon

To understand the history of any concept we must necessarily interface with the words through which the concept was articulated. Twentieth-century schizophrenia, for all its perceived objectivity, was first and foremost linguistically encoded. Yet it needs to be understood that twentieth-century schizophrenia had a peculiar relationship with words. For most of the twentieth century, an absence of clear biological markers meant that language played a dominant role in schizophrenia conceptualisation. This almost certainly gave rise to certain excesses of vocabulary and a variety of problems that would probably not have existed otherwise.

Let’s begin with the ‘schizophrenic’. From the beginning of this concept’s articulation, people diagnosed with schizophrenia were indistinguishably merged with their disorder. They became referenced as an object known as the ‘schizophrenic’, or less commonly the cognate ‘schizophrene’. On rare occasions such usage could facilitate an intentioned display of affection, as in The Listener’s ‘you dreamy schizophrene’ (‘Dreamy Schizophrene’, 1968). Yet ultimately the results of such objectification were perceived as negative. A person is simply not a disease (imagine being called ‘the cancer’). And that’s leaving aside the stigma of the split personality (see later).

In a worthwhile, if belated, attempt to rehumanise their object, the APA’s DSM-III-R would reject ‘schizophrenic’ in favour of ‘a person with schizophrenia’ (American Psychiatric Association, 1987, p. xxiii). There were no longer schizophrenics—only people suffering from schizophrenia. As it happens, the creation of the adjective had not been accidental. Bleuler—doubtless thinking of the adjectival challenges presented by ‘dementia praecox’—had deliberately chosen it. For without such a new term, a differential diagnosis ‘would be hard to write and even harder to read’ (Bleuler,1911/1952, p. 7). Yet in creating the schizophrenic, Bleuler had conveniently embodied a concept that was still merely theoretical. And alongside the catatonic, a new class of person was placed on the psychiatric stage.

Language impacted upon the concept in other ways. By 1968, the APA’s DSM-II now interchangeably referred to the concept as schizophrenia (singular), and the ‘schizophrenias’, a group of disorders (plural). The use of the term ‘schizophrenia’, explained Bellak and Loeb, had helped to perpetuate a tendency to think of ‘this syndrome as a discrete, single, unitary disease’ (1969, p. i). In research, it had led to looking for one aetiological or pathogenic factor. In clinical practice, ‘the pseudo unity has helped obscure differential diagnosis, prognosis, and treatment; it also confounds and often sadly misleads the general public’ (ibid). (In fact, the pseudo unity stemmed from Bleuler’s own writing not clinical practice per se.) Bellak’s use of ‘syndrome’ emerged from a literature review of 3200 papers (Noll, 2015). Yet others were less certain, and for them there remained, ‘the vexing problem of whether we are dealing with a single disease entity or with a different number of “schizophrenias”’ (Brill et al., 1969, p. 110).

Other problematic weaknesses in the articulation of schizophrenia were noted in the twentieth-century literature. And for some, rather than facilitating communication, the language of schizophrenia would come to be seen as disrupting communication. In 1913, Brissot, reporting criticisms by Trénele, would affirm that the invention of the ‘misty’ concept of schizophrenia encompassed a large number of conditions and that what had occurred was the replacement of a word (dementia praecox) with aetiological pretensions by one with pathological pretensions (Brissot, 1913). In 1971, Bannister claimed the logical utility of the ‘already vague’ concept or ‘omnibus’ had not been improved by making it a qualifier, via ‘schizoid’ or ‘schizophreniform’ (Bannister, 1971). While in 1975 French psychiatrists argued that using the adjective schizophrenic over the substantive schizophrenia contributed to an abusive expansion of the concept in American psychiatry. This, it was declared, had resulted in a loss of its comprehensibility (Ey et al., 1977). Such complaints hinted at a deep unease with the conceptualisation of schizophrenia and at times with psychiatric language itself. Indeed, the iconoclast Szasz would accuse Bleuler and his followers of having transformed our idea of illness and our vocabulary for describing and defining it. For Szasz they had displaced lesion by language (Roth, 1977).

We need to contextualise such a claim in order to understand it better. As this twentieth-century concept unfolded, a schizophrenia-reifying lexicon developed within a vast and wide-ranging research literature. Some of it was trivial, merely work-a-day jargon and conceptual froth. Yet other aspects of this lexicon took on greater meaning. The lexicon described traits peculiar to ‘schizophrenics’ and other theoretical suppositions that added legitimacy to the concept. It codified both schizophrenia and the social identity of those who conceptualised it. The magnitude of authority and confidence it projected was enormous. This can be understood by merely examining observations, theoretical presumptions, behaviour, or phenomena labelled with variants stemming from schizophrenia or more often ‘schiz’. In itself, the prefix ‘schiz’ was not unknown prior to the turn of the twentieth century. Stedman’s dictionary, for example, included terms such as schizaxon—a neuraxon divided into two branches. It further included schistocephalus (a monster with a cloven head) and schistotrachelus (a monster with a cleft of the neck) (Stedman, 1911). By the end of the twentieth century, however, its variants had proliferated wildly.

From as early as 1910 for example, a person with a mild variant of schizophrenia could be considered ‘schizoid’ (Bleuler, 1972/1978). This was followed quickly by the usage of ‘schizothymia reactiva’ to describe a tendency to particular types of psychic splitting with acute onset (Bornstein, 1917). Such a hypothesised psychic disposition or tendency, which could be accentuated with posthypnotic suggestion but differed from hysteria, gave us the ‘schizothymic personality’. And later, by extension, it gave the ‘schizothymic family’.¹ In 1924, Claude would speak of morbid dream states and dissociation integral to ‘schizomanie’ or ‘états dits schizomaniaques’. In such a scenario patients would flee reality and create their own imaginary worlds. This so-called schizomania was not to be confused with mania (Minkowski, 1927, p. 193). Claude would also speak of the ‘schizoses’ to embrace all things schizophrenic, although the term later referenced an intermediate group supposedly existing between neurosis and psychoses (Soccaras, 1957). Elsewhere, early twentieth-century Soviet psychiatry would speak of a ‘schizoid neurosis’ as a normal response to abnormal circumstances (Zajicek, 2014).

In 1925 Lewis discussed the graphic art productions of patients with schizophrenia. In doing so, he used the term ‘schistic production’ to represent art drawn by schizophrenics. Hence, ‘The schistic production is strangely fantastic and unreal or frankly infantile’ (Lewis, 1925/1928, p. 367). Schizonoïa, or the ‘schizonoiac’, argued Laforgue (1927), referenced individuals whose development was disrupted in early emotional relations with their mother. And in the spirit of Fritz Schulhof, ‘schizobulia’ came to refer not only to a split of will, but also to a pathological inability to make decisions (Beigel, 1971; Schulhof, 1928). In 1930, Bleuler declared that the degrees of psychopathy in evidence could best be described as a ‘schizopathy’ (schizopathie) (Bleuler, 1930a).

In 1931 Jacques Lacan and colleagues introduced the word ‘schizographie’, to describe a special form of ‘schizophasia’ (schizophasie), that is, certain forms of more or less incoherent language (sometimes called ‘schizophrenese’, which for some, such as Hill (1955), was also a quality of thought). In certain cases such incoherence only manifested itself in written language (Lacan, 1975, p. 365). Schizophasia itself was sometimes used to describe a regressed from of language (Bleuler and Claude, 1926/2001, p.54). And elsewhere deviations in syntax and diction could suggest ‘schizophrenicity of communication’ (Forrest, 1976). Similarly, Bobon’s investigations of spontaneous drawings would produce schizoparalexia, schizoparagraphia, and schizoparaphasia (Bobon, 1952, 1967). The term ‘schizophrenic surrender’ was used to designate the impression of self-abandonment, of surrender, and of acceptance of life at a lower automatic level. This was due to constitutional inadequacy (Campbell, 1943). Harry Stack Sullivan would speak of states of ‘schizophrenic perplexity’ that made observable the regression of the personality processes. In this vision the patient lived in a world and participated in interpersonal relations, which were dreamlike in varying degrees (Sullivan, 1939/1953).

Such euphonic terms appeared as symbolic incantations in a seemingly unassailable body of knowledge. They are now often entirely redundant. But they represent useful historical markers for anyone trying to understand the history of the concept. It is consequently important that in introducing the concept we remember their historical presence. Not only will this contextualise our initial introductory understanding of schizophrenia as a concept, but it will also further serve as contextual support for the book’s later critical attention towards historical attempts to conceptualise schizophrenia in other ways. There are a few more examples worth mentioning briefly.

In 1943, Mira’s Psychiatry in War would speak of acute active organic processes, which led to the ‘schizophrenization’ of the individual. By using ‘Myokinetic psycho diagnosis’ (essentially drawing various lines) the prognosis of the course of schizophrenic syndromes could be found. This involved the persistence or absence of ‘schizopraxic’ signs in the left hand, corresponding to the deeper layers of the personality (Mira, 1943). Jaspers, could sense a ‘schizophrenic atmosphere’ in the works of Van Gogh and Hölderlin (Jaspers, 1949/1977). Features of the ‘Schizophrenic style’ were sometimes found in the works of art produced by schizophrenic patients (Mayer-Grosset et al., 1960). The term ‘schizophrenoid psychosis’ found favour with Bellak. It distinguished, ‘a particularly acute, brief, and benign disorder with schizophrenic symptomatology, but characterised by a dream-like confused state with a prominence of symptoms resembling a hysteria’ (Bellak, 1947/1952, p. 447.) ‘Schizokinesis’ described an inherent conflict between general emotional responses and more adaptive responses. Among other things, this led to the symptom of negativism (Grant, 1953). A regressed portion of the schizophrenic’s ego was, for Guntrip (1969), ‘the schizoid citadel’.

For Deleuze and Guattari, ‘schizoanalysis’ was a keyword. It treated, ‘the unconscious as an acentered system, in other words, as a machinic network of finite automata (a rhizome)’ (2004, p. 19). It arrived, ‘at an entirely different state of the unconscious’ (ibid). For Johnstone, early life experiences from the first few weeks of life, recalled under methylphenidate, and without which it was theorised that schizophrenia could not occur, were labelled ‘schizexperiences’ (Anon, 1972a, p. 263). Meehl gave us an inherited neural integrative defect known as ‘schizotaxia’. He also gave us the ‘schizogene’, although ‘schizophreniologists’ would renounce the possibility of there being a Mendelian disorder at play (Gottesman and Shields, 1976, p. 376). The ‘schizophrenic float’, referred to the fact that some patients had a peculiar way of walking (Meehl, 1973). The ‘schizophrenic smell’, reminiscent of stale sweat in unwashed clothes, could be used to distinguish the chronic schizophrenic from ‘normals’ (Jonas and Jonas, 1975). [On Ludwig Binswanger and smelling schizophrenia see Minkowski (1927).] A schizogen or schizomimetic was a drug that produced a state, ‘resembling or mimicking naturally occurring psychosis, especially schizophrenia’ (Hinsie and Campbell, 1970, p. 633). A disruption in neural circuitry between the cortex and cerebellum would be hypothesised as ‘a schizophrenia that is due to a schizencephaly’ (Andreason, 1999, p. 782). Yet others would speculate on the existence of a ‘schizotoxin’ (Gillin et al., 1976), or ‘viral schizophrenia’ (Anon, 1978a). This would lead to the hunt for a ‘schizovirus’ (Torrey, 1988). With respect to the latter, Torrey informs us that the term ‘schizovirus’, along with the term ‘schizococcus’, were initially whimsically applied to his research for a virus by his colleagues. Even historians of psychiatry became infected, as when, in 1986, Roudinesco could speak of schizophilic theories (Roudinesco, 1986).

The creation, use, and demarcation of terminology constituted a serious attempt to claim new knowledge. Accordingly, the British Medical Journal would happily publish letters like Felix Post’s nuanced argument ‘that we should speak of “complete” rather than of “idiopathic’ schizophrenias”’ (1963, p.1734). Similarly, Post argued that ‘The term “partial” schizophrenia should be substituted for “symptomatic” as well as for “paranoid” schizophrenia’ (ibid). Elsewhere, individual articles might also carefully attempt to clarify terms in use. Hemphill, for example, wrote, ‘In this paper the term puerperal schizophrenia excludes cases of mixed affective schizophrenia, which appear to belong more to the affective psychoses than the true schizophrenias’ (1952, p. 1234). Conversely, and complicating matters, terms could often be considered synonyms. For example, ‘Situational schizophrenia’ (a hysterical psychosis of wish fulfilling nature) was also considered a form of the schizophrenia precipitated by a severe physical, social, or sexual trauma, known as ‘postemotive schizophrenia’ (Milici, 1939; Milici and von Salzan, 1938). We will see more of synonymy in relation to schizophrenia and dementia praecox imminently.

The list of incestuously cited terminology was then nigh endless. Hence, the existence of schizophrenia or otherwise was, to paraphrase Dorothy Rowe (1980), as much a battle of words as it was of facts. Recognising this, a frustrated Karl Jaspers, in his magisterial General Psychopathology, would complain of pseudo insight through terminology (Jaspers, 1962). [Although in Strindberg and Van Gogh, Jaspers himself proposed the possible existence of two dubious categories of schizophrenia. Jaspers wrote: ‘Hölderlin and van Gogh represent a type which contrasts sharply with that illustrated by Strindberg and Swedenborg’ (1949/1977, p. 194).] Yet for all that, psychiatry did not necessarily despair. The ever-possible discovery of a simple healing chemical or ‘magic bullet’ might helpfully sweep the whole lexicon into the dustbin of history.

Theoretically, the lexicon was entirely dispensable. Yet while it lasted, this shared hermetic output functioned as an interface to debate and evidence of learning, progress, and expertise. It functioned as currency across diverse networks of people, discourses, and institutional practices. Trainees were initiated into it (necessarily). And where swallowed uncritically, it facilitated, among other things, the ultimate form of professional deception—self-deception. But even when the research in question faded, a fossilised vocabulary left the illusion of an accretion of knowledge. And, at times, it left a false sense of certainty that for some made the validity of schizophrenia seem ever more authoritative.

The schizophrenia lexicon would not function by itself to legitimise the behavioural professions’ incorrigible claims to social authority over twentieth-century madness. Other forces were also in play. Nevertheless, for patients and families, all encounters with the conceptualisation of twentieth-century schizophrenia would meet this daunting and incessant articulation. And yet, as we shall see later, for all its seeming authoritativeness, nothing was quite as certain as it seemed.

2

The Split Personality

In the twentieth century, many members of the North American populace came to believe that schizophrenia signalled a ‘split personality’. Sometimes even a ‘Jekyll and Hyde personality’. By contrast, late twentieth-century students of the mind quickly discovered that this immensely stigmatising belief was not the case. Instead, psychiatric textbooks, public campaigns, and psychological course materials cautioned the student of psychology about making such an elementary error. In one way or another, students learned that violence was rare (true). They learned that schizophrenia was commonly misinterpreted by the public as a ‘split personality’ and that ‘the schizophrenic does not suffer from split personality’ (Carlson et al., 2004, p. 779). Introductory texts on schizophrenia pretty much left it at that. However, there is a little more to the story behind this divergence between the public and professionals in their understanding of the term schizophrenia. And it makes a useful and necessary point of departure for further easing ourselves into the history of the concept.

The Metaphor of Splitting

The metaphor of splitting can be readily found in various nineteenth-century disciplines, including scientific psychology, philosophy, and literature (Berrios et al., 2003). Most pertinently to schizophrenia, the metaphor took on its most vivid form in Robert Louis Stevenson’s 1886 (1994) supernatural horror story The Strange Case of Dr. Jekyll and Mr. Hyde. A criticism of Victorian morality, possibly inspired by ergot poisoning, it drew on theological and literary influences concerning humanity’s primitive capacity for good and evil. It also drew on conclusions found in Charles Darwin’s Descent of Man (1871/1981), as well as the work of Herbert Spencer. Similarly, it drew on communication with the French psychiatrist Pierre Janet (Hacking, 1995). Stevenson speculated that ‘man will ultimately be known for a mere polity of multifarious, incongruous, and independent denizens’ (1886/1994, p. 70).

In the work, Stevenson speaks of ‘man’s dual nature’ (1886/1994, p. 68): ‘I now had two characters’ (1886/1994, p. 74) and ‘My two natures had memory in common but all other faculties were most unequally shared …’ (1886/1994, p. 79). Only once does he use the term ‘personality’, which was then emerging as a conceptual rival to ‘character’ and as a quality of being somebody (Susman, 1984). That’s when he states, ‘I shall again and for ever re-endure that hated personality …’ (Stevenson, 1886/1994, p. 88). However, Stevenson does not use the words ‘split’ or ‘splitting’ anywhere in the text. Nor does he use the terminology ‘split personality’. Instead he uses the closely related term ‘dissociated’: ‘in the agonised womb of consciousness, these polar twins should be continuously struggling. How, then, were they dissociated?’ (Stevenson, 1886/1994, p. 71). The story became a best seller in Great Britain and America, when it was published in 1886. As such, the idea of the Jekyll and Hyde personality quickly passed into popular mythology.

There is obviously no evidence to suggest that the public at this time conceived of the Jekyll and Hyde personality as schizophrenia. This is simply because the word schizophrenia had yet to be coined. In fact, the Jekyll and Hyde personality would first become bound to the idea of multiple personality—now called dissociative identity disorder. [The history of multiple personality and schizoph...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Acknowledgements
• Introduction
• Chapter: 1 Schizoidia: The Lexicon
• Chapter: 2 The Split Personality
• Chapter: 3 Definitions of Schizophrenia
• Chapter: 4 Catatonia: Faces in the Fire
• Chapter: 5 Chasing the Phantom: Classification
• Chapter: 6 Myth and Forgetting: Bleuler’s ‘Four As’
• Chapter: 7 Social Prejudice
• Chapter: 8 Contesting Schizophrenia?
• Chapter: 9 Manufacturing Consensus in North America
• Conclusions: Twentieth-century Schizophrenia
• Epilogue: Consider Nijinsky
• Appendix: Goodbye to Hebephrenia
• Notes
• Further Reading
• References
• Index