Can We Agree Who Has Schizophrenia?

In my previous post, I traced the origins of the term "schizophrenia" to Emil Kraepelin and Eugen Bleuler a hundred years ago. I documented how what they believed were symptoms of a new mental illness were really a long list of broken social norms and understandable emotional reactions.

Now we will look at the research since that time that has tried to establish that their invention is a reliable scientific construct. Reliability basically means the extent to which we can agree on what it is we are looking at. In this case, the question becomes: "Can we agree who has schizophrenia?"

As early as 1938, Anton Boisen, the chaplain at Elgin State Hospital near Chicago, published a paper documenting huge variations in the application of the "schizophrenia" diagnosis at different hospitals. He concluded, "It is clear that the Kraepelinian system is inadequate."¹

Despite widespread skepticism at the time about psychiatric diagnoses in general, the U.S. biostatistician Elvin Jellineck predicted in 1939:

“There always will be many who will use the existing system of classification irrespective of whether or not it has any meaning, and even those who decry the orthodox classification will invoke it as an atheist when off guard invokes God.”²

It seems his prophecy may have been accurate and remains rather pertinent today.

In 1949, an early reliability study established that psychiatrists agreed with other psychiatrists’ diagnoses in only between one-third and one-half of cases,³ with consistency for "schizophrenia" coming in at 37 percent.⁴

By 1968, esteemed British psychologist Don Bannister argued that:

“Schizophrenia, as a concept, is a semantic Titanic, doomed before it sails, a concept so diffuse as to be unusable in a scientific context.”⁵

Bannister emphasized the absurdity of a diagnosis that could be shared by people who have no symptoms in common. He pointed out that such "disjunctive categories" are "logically too primitive for scientific use." In my previous post, I explained how psychiatry’s current official definition of schizophrenia remains disjunctive half a century later, and is, therefore, in my view, scientifically meaningless.

Besides individual psychiatrists and hospitals using the construct differently from one another, there has been huge variation internationally over the years. In 1971, for example, 134 American and 194 British psychiatrists were given a description of a patient and asked to make a diagnosis. Sixty-nine percent of the Americans diagnosed "schizophrenia," but only 2 percent of the British did so.⁶ So until then, at least, schizophrenia researchers on opposite sides of the Atlantic had been studying completely different groups of people.

I am never sure whether to laugh or cry at the famous 1975 "On Being Sane in Insane Places" experiment by the rather naughty U.S. psychologist David Rosenhan.⁷ Many of my colleagues and I wish we had thought of it ourselves. But we would probably never get it through an ethics committee today.

Eight "normal" people phoned their local psychiatric hospital saying they heard the words "hollow," "empty," and "thud." All were admitted. Seven were diagnosed as "schizophrenic." Many of the patients, but none of the staff, recognized that the pseudo-patients were "normal."

A follow-up study, in which the psychiatrists were warned ahead of time that pseudo-patients would be admitted, produced a 21 percent detection rate by staff. But no "pseudo-patients" had been admitted. The first part of this ingenious experiment was replicated in 2004.⁸

Besides demonstrating again that this diagnosis has little reliability, Rosenhan’s work also reminds us of the power of this unscientific label. The eight were only allowed to leave the hospital if they agreed they were mentally ill and took antipsychotic medication.

Nevertheless, Rosenhan wrote, of the hospital staff:

"Their perceptions and behavior were controlled by the situation, rather than being motivated by a malicious disposition. In a more benign environment, one that was less attached to global diagnosis, their behaviors and judgments might have been more benign and effective."

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It has not only been psychologists who have called for the abandonment of the schizophrenia label. After a lifetime studying diagnoses, British psychiatrist Ian Brockington decried, in 1992, “a babble of precise but different formulations of the same concept" and concluded:

"It is important to loosen the grip which the concept of ‘schizophrenia’ has on the minds of psychiatrists. Schizophrenia is an idea whose very essence is equivocal, a nosological category without natural boundaries, a barren hypothesis. Such a blurred concept is not a valid object of scientific enquiry.”⁹

In 1996, U.S. psychiatrist Howard James¹⁰ demonstrated, in his "Requiem for Schizophrenia," why it is "an unscientific and unprovable nosological construct."

About this time, researchers found 16 different systems of classifying "schizophrenia" in use. Furthermore, of 248 patients, the number diagnosed as schizophrenic by these 16 systems ranged from 1 to 203.¹¹

In 2008, the Scottish psychiatrist Sir Robin Murray, the UK’s most prominent schizophrenia researcher, wrote:

“Some psychiatrists react to such criticisms by totally denying their validity and by reasserting a simplistic medical disease model of schizophrenia. However, this is less than satisfactory because there remains widespread confusion regarding the meaning, boundaries and even value of the term schizophrenia.”¹²

There is a range of alternatives to using this unscientific and stigmatizing diagnosis. They include: focusing on studying specific behaviors/experiences, such as hallucinations or delusions, rather than muddled, heterogeneous groupings; using formulations rather than diagnoses in general; and thinking in terms of dimensions rather than discrete, artificial categories.

Some organizations have already abandoned the term. These include the U.K. charity Rethink (formerly the Schizophrenia Fellowship) and the International Society for Psychological and Social Approaches to Psychosis, whose members voted overwhelmingly in 2009 to leave behind its 50-year old title—the International Society for the Psychological Treatments of the Schizophrenias and Other Psychosis. In 2002, Japan became the first country to officially discard the term, which in Japanese had been "Seishin Bunretsu Byo" ("mind-split-disease").

In 2012, psychopharmacologist Christian Fibiger, of the University of British Columbia, and ex-Vice President of Neuroscience at drug company Eli Lilly, wrote:

“Today, few would argue that syndromes such as schizophrenia and depression are single, homogeneous diseases... Concepts such as schizophrenia will surely be discarded and future generations will look back and might rightfully ask ‘What were they thinking?’” ¹³