Schizophrenia - a figment of our imagination?
14 Mar 2003
It’s a sad fact that schizophrenia is greatly misunderstood by the public, but even doctors are divided over whether it’s a real disease. So does it exist, and if so what are the symptoms?
The term covers an apparently bewildering variety of behaviour and can be applied to a wide range of cases – from people who can barely move or speak to those who suffer confusing delusions and hallucinations.
There are five recognised forms of the disease – catatonic, hebephrenic (also called disorganised), paranoid, undifferentiated and residual – yet psychiatrists rarely feel the need to specify the type because the medication in each case is identical.
Some doctors say grouping the different forms of the disease under the term “schizophrenia” is actually damaging to both patients and research, since it does not force the various aspects to be treated and viewed differently. Others say schizophrenia does exist and trying to split it up only makes the job of learning about it more difficult.
A brief history
So how did we get here? Thousands of years ago mental illness was often attributed to supernatural forces or beings. It was only recently that the brain was actually seen as the organ responsible – the Greeks thought it was the liver.
In the mid to late 1800s experts decided that mental illness was a form of early dementia and there were four basic types – people were either extremely quiet and withdrawn; fearful and paranoid; unable to concentrate or think clearly; or hardly moved or expressed emotion.
The term “schizophrenia” was first coined in 1911. It comes from the Greek words meaning “split” and “mind” – which is why some people still equate schizophrenia with “split personality”, even though split personality disorder is rare and only one small part of the condition. The term was intended to distinguish the illness from dementia, since schizophrenia is not something that necessarily grows worse with time or age.
Experts who acknowledge the existence of schizophrenia consider it to be one of the main subsets of psychotic disorders – conditions where a person’s thoughts or beliefs lead them to become separated from reality. In the big scheme of mental illness, psychotic disorders form one of three main groups – the others being mood disorders and neurotic disorders.
Diagnosis of schizophrenia is based on observing symptoms that tend to occur together – as opposed to identifying specific causes. The guidelines from the early 20th century are still those used most widely today, albeit in a modified form.
This is the modern world
However, from the early 1900s to today, this model has come under increasing pressure.
Professor Anthony David, professor of cognitive neuropsychiatry at the Institute of Psychiatry in London, explains that doctors really began to argue over the existence of schizophrenia in the 1980s – some claiming it was nothing more than an artificial construct.
He himself has no doubt it exists and has spent years researching the disease. “There are mountains of evidence from social sciences and research that it exists,” he says. “Families have no doubt it exists and sufferers know it exists.”
Even though schizophrenia cannot be diagnosed from blood tests or brain scans, he argues that doctors are “pretty reliable” about what schizophrenia is – and are in greater agreement about the disease than they are about many other illnesses. “Yes, schizophrenia is a very broad category but mental illness is a bit like that,” he says.
However, some pre-eminent psychiatrists see things differently. Professor of psychiatry at the University of Maastricht, Jim Van Os, views the long list of criteria for assessing schizophrenia as evidence that clinical practice has been “fudged” to fit in with the idea of schizophrenia, rather than the other way round.
The Atlantic split
His argument has some weight: there are two different “bibles” for assessing the disease, one European and the other American. One surprising variation is that the European version requires the symptoms to be present in a patient for just one month whereas the American version says six.
The European model says someone is schizophrenic if they have at least one of four main symptoms or, failing that, two or more lesser symptoms. And the symptoms are fairly vague – one, for example, is whether a person’s “thoughts are interfered with”, another whether they have “delusional ideas”.
Prof Van Os argues that up to 30 per cent of the population have “delusional ideas” and that psychiatrists’ selection of the 1 per cent deemed to be ill is “arbitrary”.
Professor of clinical psychology at the University of Manchester, Richard Bentall, is also unconvinced. He argues that schizophrenia was originally considered a single disease with a discernible cause but this has never been adequately demonstrated in the intervening 100 years.
He says, therefore, it may be necessary to review the whole way we look at mental illness. Professor David, however, sees the longevity of the term as proof that it has significant value to the study of mental illness.
Misconceptions and misunderstandings
But possibly the biggest problem is the terrible stigma attached to the term schizophrenia – which often conjures up images of knife-wielding maniacs who believe people around them are putting thoughts into their minds – the tabloid cartoon view of a very complicated disease.
In fact, schizophrenics are far more likely to hurt themselves than anyone else, with 15-20 per cent of sufferers committing suicide. With modern medication, however, around 70 per cent of sufferers can lead normal lives.
Modern research into the strong genetic link of the disease (you have a 35 per cent chance of developing the condition if both your parents have it), the biological signs, and the as-yet unexplained environmental variations (schizophrenia is more common in city dwellers), all mean we are beginning to understand more about the illness.
It is perhaps only this research that will put an end to discussion over how this type of mental disorder should be classified. Whether the use of the term “schizophrenia” is something that will aid or impede this study is something that we will only find out with hindsight.
The Institute of Psychiatry, South London and Maudsley NHS Trust
The Schizophrenia Society of Canada’s guidebook for families