The first is Orna Ophir's new work, Schizophrenia: An Unfinished History. Just published last month by Polity, it is cogently written in a manner accessible to those with little background while also being grounded, in an unobtrusive way, in serious scholarship which is deftly handled. Because of these virtues, and because I cannot of course have my students read a history of every major disorder, and because schizophrenia is often described as the most serious and difficult concept and diagnosis in all of psychiatry and psychology, I have assigned this book to my students. I am eager to see what they make of it!
Introduction:
In promoting her new book, the author recently published a short essay about it on Slate. As invariably happens, the title chosen by her editor and the spin given to the article immediately made Ophir's work sound more inflammatory and "radical" than I very much think it to be. And as also invariably happens in this social media age, people were immediately projecting into that article's title their own ideas and then criticizing Ophir for her apparent disagreement with them. It's all very tiresome.
To come directly to the question thus raised on-line: does the author have an "agenda"? Almost certainly, but of which author is this not true? Is Ophir (a psychotherapist and psychoanalyst in private practice who also teaches at Cornell and NYU) crusading for the abolition of schizophrenia as a diagnosis, indeed even flatly denying that it is a disorder causing enormous distress for some patients? Not at all. (If she were, I would not assign such a book to my students because I would have to agree with a sentiment denied to me by my own private practice with psychotic and schizophrenic patients, whose suffering has stared me in the face.)
These two questions cause enormous controversy: should the diagnosis of schizophrenia, which has changed greatly through five editions of the DSM, each of which she reviews carefully, as we shall see, be altered or even abolished? And should we make such an abolition because schizophrenia does not actually exist as a disease in the way we might say diabetes or cancer exist as diseases or disorders?
Ophir handles both questions with skill and sympathy, after long reviews of the history and previous answers (going back to Greek antiquity, the Hebrew scriptures, the Latin Middle Ages, late Medieval and early-modern Europe and Byzantium, and right up through DSM-V). Her own highly provisional answers, are, to my mind, eminently defensible and worthy of ongoing discussion and debate. The singular virtue of this book is the author's lack of ham-fisted dogmatism in any of the matters she handles. Like a good psychoanalytic therapist, her practice of those sometimes misunderstood notions of "neutrality" and "abstinence" is well honed and expertly used throughout the book so that the reader never feels hammered by the author's views or compelled to agree with her. In that sense, her book is poor fodder for social media outrage and click bait, but excellent scholarship.
As such, it will also give no comfort to those who wish to get up on their hind legs and shout at the rest of us--either in favour of retaining current names and nosology, or as a way of pushing for the abolition of the same. Ophir says--rightly--that all of us involved in these discussions should participate with humility and a lack of defensiveness (p.238), and we should be asking ourselves what the "prudent--indeed, ethically responsible" ways of proceeding are so that we do not leave people in the lurch. Even as we can see problems with current diagnostic criteria and categories, and even as we might want to change those, we must "acknowledge that so many of its elements, of its debris, and scattered building blocks...remain of importance for us" (p.239). Thus--as she concludes the book, perhaps a touch too neatly--she says that those involved in this discussion must ourselves be "of two minds" (!) in seeing what is good and conserving it, while discarding what is not good in search of better alternatives (p.244).
Status Quaestionis:
But let us return to the beginning. The author begins by noting that for at least two decades now around the world more and more people have been wondering whether what we have (since 1911 only) called schizophrenia is in fact a distinct disease entity or not. There is not, she notes, any kind of objective test for it. There is no universal and unchanging agreement on what symptoms might--might--constitute sufficient evidence to make a diagnosis. Indeed, as she shows in detail, there is not even agreement on how to conceive of it in a basic nosological sense: should schizophrenia be seen as something radically other, a state or disease or disorder that in essence breaks with ordinary human experience and places one outside the realm of quotidian "reality"? Or is it a continuum on which people move around from time to time in life, never quite managing totally to leave shared human experience as they do?
For some, she says, what are described as symptoms of that disease are, rather, "extreme versions of normal human experience" (xi). She here notes that some parts of the world--notably Japan, to which she will return late in the book--have attempted to take account of that and change the name from schizophrenia to something else, a move that a few other countries (also briefly noted below) have also undertaken. That global behemoth, the American Psychiatric Association, has, however, not followed suit even though it has been inundated with hundreds of possible changes to the name and diagnosis since the 1990s.
History: From Ancient Israel through Byzantium and the Enlightenment:
Ophir begins the history section of her book (ch.1) with understandings of madness in Greek antiquity and in the Old Testament or Hebrew scriptures. Here she notes that for the latter text, the line between being cast as a "madman" and a "prophet" is vanishingly thin. The former is "other," likely under demonic influence, and often needs to be run out of town and destroyed. The latter, whose behavior is, curiously, often extremely similar to the former, will come to be seen--also after much suffering in many cases--as being divinely inspired and appointed rather than demonically disordered.
She has a very brief section on this thin line between madness and sanctity in the Byzantine and later East-Slavic figure of the "holy fool," to which I have elsewhere many years ago paid not a little attention. Scholars of that phenomenon agree that it is never easy, and often impossible, to tell if holy fools are indeed "mad" in a pathological sense, or "mad" in the sense of being "possessed" by the divine and having a righteous mission whose oddness is reflected in the audience's profound estrangement from divine and holy purposes. Holy fools, then, are usually thought merely to look mad: underneath they are (ostensibly!) the ones who are truly rational in that they are at one with the Logos himself--though this is never demonstrated with complete certainty, leaving the figure a perpetually ambivalent and ambiguous one, which likely explains their enduring attraction.
When she comes to the second millennium and the advent of what will come to be called the Scientific Revolution and the Enlightenment, Ophir notes that modern psychiatric nosology's problems begin here in attempting to pattern notions of mental disease after botanical classifications. At this point she introduces a metaphor that repeats regularly throughout the book: psychiatry's attempt to "carve nature at its joints." This, it will become plain, is--and perhaps only could be--a failed project. As she later puts it, "strictly speaking...there is no such thing as a single, stable object that corresponds to the word 'schizophrenia.' Rather, there is a complex description that has evolved through time (and does so to this very day)" (p.115).
Psychoanalysis and Schizophrenia:
In her description of various ways over the last century to understand schizophrenia, the author tips her hand just a bit in the review of several psychoanalytic theoreticians, who include Freud and Jung. But Ophir seems to suggest that Melanie Klein's notion of splitting might have been, and yet remain, one of the most important theoretical concepts to help us conceive of what might happen in a schizophrenic mind. Others of note here include Harry Stack Sullivan and Silvano Arieti, who gets a very brief mention, along with equally brief mentions of Harold Searles and Frieda Fromm-Reichmann. But Klein predominates and of her Ophir says that she "does not see schizophrenia as a different natural kind or disease entity" (p.106).
From here Ophir undertakes a careful, chronological review of each edition of the DSM.: Given the various axial configurations, DSM-IV could give us, she enumerates, 114 ways to be "schizophrenic"! For her DSM-V is only a slight improvement on this in some ways, but has other problems (p.148).
Ophir's chapter on stigma--primarily, but not exclusively with schizophrenic patients--is very powerful and deserves much wider discussion than I will attempt here. There is one sobering thing she has unearthed that merits additional mention: she documents various ways in which empathy for severely mentally ill people can be increased in the general population, but a mere increase in empathy does not seem to correspond to a change in the problem of social distancing and isolation. In other words, I might learn to feel for and with "these people" but I still do not seek them out or necessarily want them around--a kind of very bloodless empathy.
Ophir's careful handling of the Hearing Voices movement is fascinating and deserves deeper discussion. Equally fascinating were her reviews of the countries that have attempted name changes, including Japan (changed in 2002 to "integration disorder") and China. The new names are not without problems, to my mind, but Ophir does not really consider those. To be fair, I find it almost impossible to imagine that any change in nomenclature would not bring new or different problems.
There is, however, perhaps one way around some of these difficulties, and here she quotes two British psychiatrists, Mohammed Abou-Saleh and Helen Millar, who suggested we simply rename schizophrenia "Kraepelin's disease" (p.226) on the same model of Alzheimer's disease (etc). On this point, see the recent and suggestive paper by two other British clinicians arguing we not quite jettison Kraepelin's categories just yet.
Criticisms:
It is never acceptable to fault an author for not writing the book you think they should have written, or for not writing a book they never said they were going to right in the first place. But it is entirely within the bounds of legitimate criticism, in the constructive and scholarly sense, to suggest that when an author says they will do something, and stresses the importance of that thing in the book, but then fails completely to deliver on it, that they be called to account for such a lacuna. And this is the case with Ophir, who more than once (e.g., p.242) says we must attend to forms of treatment for schizophrenia, but then signally fails to enter into any substantial discussion of treatments and their efficacy. Perhaps she lost steam, or her editor told her the book would be rendered far too long, if she also looked in greater detail at the history of treatments? I would not fault her for failing to do this if she had not raised hopes early in the book that she would attend in some detail to treatments, but does not. Overall, this is a rather minor weakness, easily remedied elsewhere.
For such a remedy, we will have to turn to our second book, which does do this in some helpful ways, thus making this second book a very useful and important complement to Ophir's otherwise excellent text, which I am very grateful to have read and have profited greatly in doing so. It will bear re-reading and careful thinking about several important things.
That second book is Matthew M. Kurtz, Schizophrenia and Its Treatment: Where is the Progress? To read this book with Ophir's is to find them very complementary. There is a bit of overlap in one or two areas, but Kurtz also goes much more into two areas that Ophir only skims: the results of decades of neurological research on schizophrenia, and how fascinating but largely clinically useless it has been; and then certain recent treatments--beyond psychopharmacology--that are showing promise in the psychotherapy of schizophrenic and psychotic conditions.
Kurtz is also, in both tone and conclusions, much less hopeful than Ophir is, and this is already telegraphed in his subtitle: Where is the progress, indeed, in treating schizophrenia? A cursory review of the data are not encouraging. We shall return to this later.
Kurtz says in his preface he will ask, and seek answers to, four questions, and he does this with admirable cogency and clarity throughout the book: what is the history of the category of 'schizophrenia' and how was it derived? What does neurology tell us about the brains of such patients? What does cognitive and affective science tell us about such a condition and its patients? And finally what psychotherapies are there that actually work?
Already by the end of the brief preface, Kurtz says that "there remains no clear neural or psychological signature that is specific to the disorder of schizophrenia" (p.x). He hastens to add a little later--and will repeat this--that he is in no wise undermining or outright denying the idea that for some people this is a useful diagnosis. Kurtz is no anti-psychiatry radical--far from it: he attacks such zealots more than once (e.g., p.6).
The first chapter is devoted to the first question noted above, and opens with some sobering statistics about how many homeless in the US are schizophrenic; about how the WHO lists "schizophrenia as one of the top 10 leading causes of disability among adults worldwide"; and perhaps most appalling of all, "rates of improvement have been less than 50% and largely unchanged since the 1890s"!
From here Kurtz introduces an interesting discussion that Ophir did not: is schizophrenia actually one disease entity? He suggests that "there may not be a treatable core disease pathology in schizophrenia at all" (p.6). He will return to this later in suggesting possible reconfigurations in how certain symptoms might be considered and treated transdiagnostically. The chapter ends by asking how improvement in patients' lives might be meaningfully conceptualized and measured, and then how much (measured) hope we might have about possible progress and development of treatments. He cautions that any work on new or improved treatments cannot and must not be designed by academics and clinicians in isolation: here he nods to the Recovery Movement, and seems to agree with their slogan "no research on us, without us" (p.14).
Chapter two is the most historical and usefully reviews several large-scale long-term studies in the US, including the Iowa 500 study, the Chestnut Lodge studies, studies in Vermont, and in Western Europe. He pays particular attention to the Chicago Prospective Longitudinal Study, saying that at the "15-year follow-up nearly half of the schizophrenia sample...had experienced at least a year of recovery" (p.23). The upshot of this literature review is his recognition that "it is clear from the data collected to date that initial conceptualizations of schizophrenia as a disorder that has a largely downward course is clearly not supported. Recovery is very much possible" (p.27).
Ch.3 is devoted to the actual diagnosis of schizophrenia, noting that "the criteria for diagnosis...have changed radically over the past 100 years" before reviewing the five editions of the DSM and their indebtedness to Bleuler and Kraepelin. All this is situated within a broader context and wider consideration of psychiatric nosology. Kurtz says--somewhat staggeringly--of the early attempts to understand schizophrenia (roughly corresponding to DSM-I and DSM-II) that "accurate diagnosis was not seen as an essential first step for treatment" (p.44).
The chapter that unfolds from here is not quite as detailed in some periods as Ophir, especially on Hebrew scriptures and Greco-Roman antique notions of madness, but it is still quite serviceable. It also includes gratuitous and amusing mentions (without, alas, elaboration!) of such things as "wedding night psychosis" and "masturbatory insanity" (p.37). When he gets to the 20th century and America, Kurtz is indebted to Richard Noll's 2011 book American Madness: the Rise and Fall of Dementia Praecox. Kurtz claims--based on Noll--that Kraepelin's classification scheme "took the United States by storm" and has exerted a lasting, and perhaps unduly strong, hold ever since. Others who have had influence here include John Feighner and Kurt Schneider, he of the (infamous?) first-rank symptomology.
The result of this lengthy and fair-minded survey is to claim that "there remains no reliable medical test for diagnosing schizophrenia or any other psychotic disorder" (p.52). But from this it does not follow that schizophrenia necessarily disappears as an actual disease: at most he says we can claim to have "modest evidence that an underlying disease entity might exist" (p.53). With equal care he ends this third chapter by arguing that "critiques of the category must balance calls for new nomenclature with the potential cost of losing a label that, with all of its limitations, rapidly identifies a group of individuals a large proportion of whom have profound disability and need for care" (p.58).
The fourth chapter reviews early (pre-revolutionary onward) asylums and treatments in the United States, including many things that rightly horrify us today. But he returns here to Bleuler and Kraepelin to make note that the latter "devoted only 5 out of 328 pages of text to treatment" and the former was little better: Bleuler's nearly 500-page text offered a scant 18 pages devoted to treatment of dementia praecox.
Kurtz then looks at postwar developments, beginning, of course, with the invention in France of what became the first generation of neuroleptics. Psychoanalytic approaches get a wholly inadequate and totally unsatisfactory look-in here, along with R.D. Laing and Harry Stack Sullivan.
Chapter 5 is devoted to biological mechanisms and the fascinating research that has been done here in the last several decades. Ch.6 is focused on the cognitive and affective dimensions of schizophrenia. This reviews data on neurocognitive functioning and testing before turning to recent attempts to theorize and treat schizophrenia as a disorder of self-cognition. This leads Kurtz to end the chapter with a brief look-in at a new approach developed largely here in Indiana with which I have some familiarity.
This part of the book already needs updating in light of the ongoing research into metacognition, which is indebted to and very similar in some (not all) ways to Fonagy's famous mentalization treatments. Lysaker and others have been publishing at an impressive clip as they amass randomized control trials around the world to test their metacognitive approach, which is nicely outlined in the handbook linked at left. I have read it once, and want to read it again when I have time.
Ch.7 looks at somatic treatments, reviewing the famous dopamine hypothesis and others. Along the way he notes what is already notorious: how huge numbers of patients in clinical trials discontinue their neuroleptics on their own because of absolutely intolerable side-effects.
Ch.8 looks at psychological and psychosocial treatments of schizophrenia, and is perhaps the most hopeful chapter of the book. What Kurtz calls "evidence-based psychosocial treatments" include family interventions, social skills training, and CBT. He claims here, without any evidence, that "in recent years, the psychoanalytic approach has been supplanted by CBT."
I do not buy that and the history does not bear Kurtz out on this. There are dynamic psychotherapies being successfully used right now, including those I discussed in some detail here, here, and here; and those developed by Andrew Lotterman; and then mention must also be made of the integrated approach of Psychotherapy for Psychosis: Integrating Cognitive-Behavioral and Psychodynamic Treatment by Michael Garrett. Still others could be mentioned, most notably and encouragingly those outlined in Downing's invaluable book.
The chapter ends by noting--too briefly to be helpful--that international models, including that of Hans Brenner in Switzerland, might point the way to show us what future therapeutic models need to include. Kurtz then moves into a very brief epilogue where he laments the "profound lack of services available to so many people," especially in the US (p. 183) where "the science-to-practice gap has vastly widened" and where there is an appalling "absence of even minimal housing and institutional supports for people with schizophrenia" and equally appalling "very low rates of reimbursement provided for treatment of the...severely mentally ill" (p.184).
Taken together, both of these are carefully written books by Ophir and Kurtz who have judiciously weighed competing theories and evidence, and done so with real concern for suffering human beings. They are not anti-psychiatry zealots, nor blind apologists for biological psychiatry either. Both books overlap but only modestly, and thus both books must be seen as more complementary than anything. Both books are at their most useful in reminding us of the appalling long-standing gaps in treatment and the fact that far from making progress, treatment seems to be stalled or even regressing (where, that is, it even exists at all). There is much work to be done if the past is not to be prologue to a future of continued, repeated failure.
