Getting a Grip on Schizophrenia

By Alfie Kohn

WORCESTER, Mass. — At a conference titled “What Is Schizophrenia?” held here earlier this month, the first speaker paused at the podium to ask for the next slide, which he said would show a list of “established facts” about the disorder. Instead, the screen suddenly went blank, prompting wry laughter to ripple through the auditorium.

Just what has been “established” about schizophrenia was the subject of serious and sometimes sharp-edged discussions during this two-day gathering, which took place nearly 80 years after the term was coined by the Swiss psychiatrist Eugen Bleuler.

Each year about 100,000 Americans are newly diagnosed as schizophrenic, which means that they are said to believe things that aren’t true, to see or hear things that aren’t there, to have disorganized thoughts and speech, to exhibit various disturbances of emotion, and to withdraw from others. Most people we think of as “crazy” or “demented” are likely to be diagnosed as schizophrenic.

But here at Clark University, where Freud gave a famous lecture in 1909, 16 psychiatrists, psychologists, philosophers, and social scientists gathered to debate whether schizophrenia is actually a disease and whether it has a biological basis.

Challenging the conventional wisdom in the field, some participants proposed that the disorder actually does not meet the criteria for a disease. They also charged their colleagues with giving short shrift to environmental factors that lead to a diagnosis of schizophrenia. The mavericks in the field of mental health even questioned whether the word schizophrenia is meaningful or useful.

“What is the ‘it’ we talk about as schizophrenia?” psychologist Morton Wiener, a co-host of the conference, asked his colleagues. “We talk about outcome and we talk about effects, but what’s the animal itself?”

The animal may be a unicorn, argued Theodore Sarbin, professor emeritus of psychology at UC Santa Cruz. “Schizophrenia is a social construction to deal with people whose conduct is unacceptable” to those in positions of power, he said. “My recommendation is that we banish the term to the musty historical archives.

“In the 1930s, I might have believed you,” retorted psychiatrist Joseph Zubin, an influential researcher in the field. “In 1990, what you say is complete nonsense.”

Part of the controversy results from the slipperiness of the diagnosis. In a paper presented at the start of the conference, Manfred Bleuler, Eugen’s son, observed that two people who are both classified as schizophrenic may have very different sets of symptoms – and many of these features may be shared by people regarded as normal. These are facts, he noted, “which it would be pleasant to forget.”

Psychiatrists who define and refine the diagnostic category of schizophrenia often have trouble agreeing among themselves about such things as whether a given delusion (a false belief) qualifies as “bizarre.” This was conceded by Thomas McGlashan, who sits on the committee now preparing the fourth version of the Diagnostic and Statistic Manual, the practitioner’s handbook.

Later, in an interview, he acknowledged that the list of diagnostic criteria for schizophrenia resembles “a Chinese menu and you see that there’s something arbitrary about it.”

Still, Zubin and others insisted that psychiatrists are making progress in establishing a systematic procedure for understanding and diagnosing the disorder, which they refer to as a disease. “It’s a line of reasoning that will eventually lead to something, even if the word schizophrenia doesn’t last forever,” said Paul McHugh, who heads the department of psychiatry at Johns Hopkins medical school.

Yet McHugh admitted that “schizophrenia is difficult to describe and define even as a clinical concept” – partly because no one knows why people act in ways that lead to that diagnosis.

Most psychiatrists now believe that some neurobiological problem is responsible, but several conference participants warned about relying too heavily on such theories. “Scientists have been too facile in invoking biology to explain schizophrenia,” argued Robert Carson, a Duke University psychologist who has written widely on the subject.

The reason, he said, has a lot to do with what kind of research gets funded. The National Institute of Mental Health, which hands out about 85% of all money used to study mental disorders, tends to pay for people to look at brains rather than at families, to emphasize genetic rather than cultural factors.

“Biological psychiatry is very much in the saddle, particularly with respect to funding,” Carson said. “The best way to get money from a politician is to say, ‘Give me five more years and we’ll lick schizophrenia because it’s a genetic disease.’ But we’ll never have a miracle cure because schizophrenia is too involved with the whole life of the person.”

Watching schizophrenics whose symptoms come and go, largely in response to what is happening around them, has led Yale psychiatrist John Strauss to repudiate “metaphors like ‘the broken brain.’ ” Strauss described how a raving paranoid schizophrenic used to beat him at chess, proving that he could calm down and think clearly when the situation called for it.

The story is also told of a psychiatrist who had to examine a catatonic schizophrenic in order to pass an examination. The patient sat frozen, ignoring all questions, until the psychiatrist finally got down on the floor with him and shouted, “Look, I’m going to flunk this exam unless you say something” – whereupon the patient began to speak.

In short, therapists need to see “the patient as a goal-directed being who’s trying to solve problems” rather than as someone simply “suffering from happenings in the brain,” Sarbin said.

Even critics of mainstream psychiatry tend to agree that genetic predisposition plays some role in determining who becomes schizophrenic. But the studies of twins that led to this conclusion have been severely criticized. “They’re so full of errors as to be almost worthless,” said Carson, who, along with other dissident researchers, has identified numerous problems with the best-known studies.

Carson also pointed out that even genetic researchers concede that nearly 90% of schizophrenic patients have no close relatives with the disorder. Most researchers believe that some genetically vulnerable individuals react badly to stress, which means that both biology and environment contribute to the appearance of schizophrenia. But some specialists emphasize the role of the latter, rejecting the view that schizophrenia is simply a brain disease that “happens” to people—a view that has found favor among organizations made up of the families of schizophrenics.

A study published in the New England Journal of Medicine last March, for example, used a new scanning technique to compare the brains of 15 sets of identical twins, one of whom in each case was schizophrenic. Differences in the brains were noted in almost every case even though identical twins have identical genes. Clearly, something other than genetic factors must have produced those differences.

When researchers discover a neurological abnormality in people with behavioral disorders, it is usually assumed that this feature of the brain is responsible for the behavior. In fact, though, it may work the other way around. In the schizophrenia study, it might even be that the anatomical difference resulted from drugs given to the schizophrenics, Zubin conceded.

Also cited at the conference was a recent Finnish study that followed 271 children of schizophrenic mothers, all of whom were put up for adoption. Of the children who were placed in families judged as psychologically healthy, not one became schizophrenic.

Contrary to the impression given in many popular articles on the subject, UCLA psychologist Michael J. Goldstein concluded in a 1988 review of three major studies that “variations in the rates of schizophrenia are predictable” not only from genetics but “in part from prior estimates of disturbances in the ‘family’ environment.”

Moreover, said McGlashan, director of the Chestnut Lodge Research Institute, “the schizophrenia-as-brain-disease theory is taken to mean that all you have to do is give them a drug—you don’t have to worry about the patient as a person.”

University of Chicago psychiatrist Laura Miller, who was not at the conference, agrees that psychotherapy, and not merely medication, “makes sense for some schizophrenics even when there does appear to be a biological basis.” Therapy can address the psychological purposes that some symptoms serve and can help patients cope with the day-to-day effects of delusions, impaired communication, and loneliness.

Miller has also uncovered other evidence that suggests the schizophrenic is an active subject rather than the helpless object of an illness. In an unpublished study, Miller found that many schizophrenics value their hallucinations, and that as a result these people “find some way to continue hallucinating” despite their treatment.

While Carson and others dismissed the idea that a “cure” will ever be found for schizophrenia—largely because this reflects a. misconceived notion of the nature of the disorder—Zubin emphatically rejected the pessimistic idea that schizophrenics rarely get better.

“It is not a permanently chronic condition leading to deterioration,” he said. In fact, “from 23% to 50% of schizophrenics never relapse after their first episode.”

But some of the sterner critics at the conference pointed out that even to talk about a “first episode” or about “symptoms” is to assume the existence of an ongoing disease—an assumption not proved to everyone’s satisfaction.

A clever researcher who chose to attribute madness to supernatural causes could “prove” that demonic possession runs in families and that its effects were mitigated by taking certain medications, according to Carson. This no more demonstrates the value of invoking the devil than similar findings justify invoking neurobiology.

According to Daniel Miller of Wesleyan University, some theorists see schizophrenia as a “clear-cut, static entity” with a cause that can be pinned down—which reflects 19th-century scientific thinking. Others see it in terms of evolving social arrangements and interactions. Which of these two basic models is preferred ultimately comes down to “a matter of faith,” he maintained.

To be notified whenever a new article or blog is posted on this site, please enter your e-mail address at www.alfiekohn.org/sign-up .