Introduction: The Ends of a Diagnosis

"It's a word, that's all, a word that covers a large, loose category," the psychiatrist explained, "it's like saying 'tree.' There are all kinds, firs, elms, pines. So there are many kinds and degrees of schizophrenia." (Louise Wilson, This Stranger, My Son, 1968)1

If You Want a Label

When Tony was discharged from the hospital, his father, Jack Wilson (a surgeon by profession), had enough of the conflicting reports and wanted a "real diagnosis." Dr. Brewster, the psychiatrist, who thought Tony's parents surely realized he was "very sick," concluded: "schizophrenia, if you want to label it. The boy is a paranoid schizophrenic." Shocked by the doctor's response, Tony's mother, Louise, echoed the expert's words: "schizophrenia, if you want a label," thinking all the while about her son's dark blue eyes, his beautiful, rare smile, but also about the "ugly contortions of his rage," his terror and fear.

What was this strange phenomenon of Tony's illness? Was it "a thing," of a natural, biological, or ontological, kind? Was it a phenomenon to be understood as a matter of degree, as part of a broader spectrum, a scale or continuum? The psychiatrist's choice to describe it as a "loose category" (just a "word") certainly had not made things easier to decide. Neither had his comparison with the natural kind of a "tree," or his evoking the "many kinds and degrees" of schizophrenia. Did the name "schizophrenia" or "paranoid schizophrenia" offer an adequate characterization in and of itself, a genuine definition, of the ailment Tony appeared to be suffering from? Or did it merely introduce another label (if one "wanted" one), adding on to the numerous, equally apt or vague, preexisting ones? In other words, what is - and what was - "schizophrenia," precisely?

While this book is intended for a broader interested audience, it makes informative excursions here and there into topics that may speak to specialists and therapists alike. It will ask a few simple questions, to shed light on the different ways in which Tony and his family's situation might be understood: can the term schizophrenia be considered as a natural kind in its own right, whose members are constituted by a similar set of biological mechanisms, and can its application to a particular case be determined with certainty? Can paranoid schizophrenia, for instance, be considered as a subspecies of a kind that shares a similar natural causal structure and, hence, as a biological classification rank of schizophrenia (just as an "elm" or a "pine" are types of trees)? Or does schizophrenia have many kinds and (unlike trees), many degrees, as Dr. Brewster seems to suggest? Is it a category (in the same way that "tree" is one), albeit composed of distinct kinds and varying degrees? Was Dr. Brewster diagnosing a natural disease ("schizophrenia") or was he diagnosing Tony as a type of person (a "paranoid schizophrenic"), taking the latter as part of a wider spectrum of mental deviancy that differs only in degree (rather than in kind) from psychological "normalcy," broadly construed? Or should we consider schizophrenia (as did some American psychiatrists in the 1960s) as no more than a "word," that covers a "large, loose, category"?

To answer these questions, we will abstain from trying to draw out some timeless essence of schizophrenia, an implausible enterprise if ever there was one. Rather, we will limit ourselves to examining its genesis as a medical and psychiatric diagnosis, and describe and evaluate its uses in the clinical and therapeutic professions over time. In so doing, we will try to understand not only its history and present characteristics, but also what kind of future this diagnosis and the proposed treatment for it might still hold in store. In other words, we will aim to see what picture emerges once one no longer takes the diagnosis of schizophrenia to be that of a stable identity per se, but also one of perspective. At times, the diagnosis will be, and perhaps needs to be, placed on a continuum or a spectrum with the normal and, at other times, be seen and appreciated as if it were a fixed category of illness, a natural kind, of sorts.

This dual vision of one and the same phenomenon recalls the picture shown in figure 1, which Thomas Kuhn, the philosopher and historian of science, following Ludwig Wittgenstein, borrowed from the psychologist Joseph Jastrow, to demonstrate "the structure of scientific revolutions." According to Kuhn, even when nothing in the environment has changed, the shift of attention of the scientific community transforms its perception of the phenomenon all at once, and "[w]hat were ducks in the scientist's world before the revolution are rabbits afterwards."2 The relationship between the two distinct paradigms of diagnosing schizophrenia may be just that, with the important difference that in the case of the latter it is increasingly evident that the two pictures somehow continue to alternate - that is, flip back and forth - throughout history.

Figure 1 Joseph Jastrow, The duck-rabbit illusion (1899)

Source: Wikimedia Commons

Carving Nature at Its Joints

Schizophrenia, also known as the paradigmatic form of madness,3 the "sacred symbol,"4 or "heartland"5 of psychiatry, was first used as a medical classification by the Swiss psychiatrist Paul Eugen Bleuler in 1908.6 It was coined as a diagnosis exactly a century after the name "psychiatry" (from psykhe, meaning soul, and iatreia, connoting medical treatment) was first used by the German physician Johann Christian Reil. In his seminal 1808 paper, "On the Term of Medicine and its Ramifications, Particularly with Regard to the Revision of the Topic in Psychiatry," Reil called for the establishment of a specific subdivision of medicine to treat mental illnesses.7 Ever since, psychiatrists in Europe and around the world have been engaged in an ongoing collective effort to classify - that is, to identify and name, describe, and treat - such psychological ailments.

Nevertheless, attempts to classify specific mental disturbances and the ways in which they affect the behavior of those suffering from them have a much longer history. One of the first attempts to classify different types of mania - the Greek term for madness - can be found in Plato's dialogue Phaedrus (c.370 BC). In the text, Socrates defines eros or Love as a form of madness, and thus as a disturbance of our conventions and conducts.8 Socrates then distinguishes between madness that is caused by human ailments, and madness that is sent by the gods:9

SOCRATES: . we said did we not that love is a kind of madness, didn't we?
PHAEDRUS: Yes.
SOCRATES: And that there are two kinds of madness, one caused by human illnesses, the other from a divine release from the norms of conventional behavior.
PHAEDRUS: Quite so.
SOCRATES: And we divided the divine kind of madness into four parts, each with its own deity. We attributed prophetic inspiration to Apollo, mystical inspiration to Dionysus, poetic inspiration to the Muses, and the fourth kind to Aphrodite and to Eros.10

In Phaedrus, Plato derives his definitions of mania from contemporary Greek medical writings, which began with the generic concept of madness, before proceeding to differentiating its species. Just as he distinguishes between two methods of reasoning, Plato defines the method of collecting diverse elements under a single generic term as one method, and that of dividing this genus into further species as the other. However, this second method of division should not be applied crudely, like an unskilled butcher indistinctly carving up an animal. Rather, Socrates claims, when we make divisions or classifications, we should carve nature at its joints. Even when we think we are looking at a single physical body, on closer scrutiny, we see that it contains pairs of organs. And even though these separate organs may share the same name, they are still distinct, in the same way that a left hand is distinct from a right hand. The same holds true for madness, as Socrates argues. Although we have a single name for it (a generic form), we can carefully divide it into further parts, "carving its nature at the joints."

During the Enlightenment, attempts to order elements in the natural world expanded significantly. These efforts were undertaken in different disciplines, from chemistry to mathematics, and applied to various objects of study, from minerals and animals, to human diseases. The first psychiatric classifications of mental diseases followed the early medical nosology (from the Greek nosos, "disease"), which was inspired not by anatomy but by botany. Indeed, they drew on the model of plant taxonomy, or classification.11 Despite these systematic ambitions, however, it was soon realized that when it comes to mental illnesses, constructing a valid "family, genus, species" along...