MENTAL HEALTH A question of diagnosis

New Internationalist Editor: Debbie Taylor

Madness and badness
One per cent of all people in the world are thought to be suffering from schizophrenia, the archetypal insanity.  Debbie Taylor visits a modern mental hospital and asks whether we treat the mentally ill because we judge them mad, or whether we treat them as mad because we judge them.

AT 9.30 the daily ward meeting begins. The motley collection of chairs, some with foam rubber oozing through broken springs has been pushed into a big circle Outside the circle a woman in a pink nightdress, brown cardigan and slippers shuffles noisily and unsteadily towards the coffee machine, her mouth and tongue contorted in a series of eery grimaces. Everyone else is seated.

Mary has a complaint to make. Peter has broken the switch on her record player. She speaks rapidly, petulantly, tapping a cigarette against the overflowing pedestal ashtray, glancing around anxiously for support: ‘If Peter’s mother loves him so much, why doesn’t she buy him a record player for himself? Why did he have to break mine?’

In the pause that follows all that can be heard is the shuffle of the woman, still trying to force her legs towards the coffee machine, and a rhythmic wet sucking noise from the opposite side of the room. It comes from Brian - well-dressed, thickset, middle-aged - bent over cupped hands and sucking desperately at a small cigar.

Mary continues. ‘I just don’t understand Peter. Why does he break everything? Can’t anyone tell me why?’

Brian stops his sucking and lifts his head. ‘I’ll tell you why’, he says at last. ‘It’s because he’s a bleedin’ schizophrenic like me, that’s why.’

An overweight man in a green suit interrupts: ‘Now then, Brian’, he begins, in a tone that immediately identifies him as a psychiatrist, ‘Nobody is a schizophrenic. Schizophrenia is a disease. You all have schizophrenia.’

This is the acute admissions ward, containing - in the words of one social worker - ‘the most damaged people in the hospital’. All have the diagnosis of schizophrenia somewhere in their case notes - a term that is synonymous in most people’s minds with insanity. But schizophrenia does not mean a sort of Jekyll and Hyde ‘spit personality’: It might be better to think of schizophrenia as being the absence of a split - between fantasy and reality - since one of its most dramatic characteristics is that events happening in the mind are treated as though they were actually happening in the real world. Someone suffering from schizophrenia might hear voices, believe their brain is rotting, that they are the reincamation of Napoleon, that the Queen is in love with them.

In other categories of mental illness - apart from severe depression - this split from reality is much less severe. That is the reason this article is about schizophrenia - about the Brians and Marys and Peters: because schizophrenia is madness par excellence and because its status as a disease is the major raison d’etre for the entire psychiatric profession. Neurosis and depression might be better treated with a bit of psychotherapy and a change of lifestyle. But schizophrenia, says the psychiatrist, is a real illness calling for a real treatment.

The idea that madness might be a physical illness requiring medical treatment began nearly 200 years ago when aristocratic families parcelled up the embarassingly crazy relatives, sent them to private madhouses and hired doctors to treat them.

Since then medicine has maintained its monopoly on madness and established specialisations like psychiatry and neurology. Hundreds of surveys and experiments have been done, thousands of brains put under the microscope. But the sheer ignorance of the medical profession - about the nature of insanity in general and schizophrenia in particular - is as profound as it was in the 18th century. At every stage - from diagnosis, to investigating causes, to providing cures - the medical profession has demonstrated its inability to understand or help the mentally ill.

Take diagnosis for instance. The World Health Organisation (WHO) lists five types of schizophrenia. The American Psychiatric Association (APA) used to list 150 types of mental illness, including homosexuality and 15 types of schizophrenia. But when the proportion of schizophrenics in US mental hospitals was discovered to be much greater than in European ones, the Americans changed their classification to include only six types of schizophrenia. Though these six are completely different to the WHO’s five, the proportion of US schizophrenics is now on a par with Europe.

So deciding what sort of insanity a person is suffering is hard enough. But psychiatrists have shown themselves to be just as bad at deciding whether a person is insane at all. Eleven years ago psychologist David Rosenhan and seven others - none with any history of mental illness - got themselves admitted to a mental hospital in the US complaining they could hear faint voices. Once admitted, they behaved normally, told everyone they felt fine, openly interviewed other patients and took copious notes. All were diagnosed schizophrenic and the hospital staff were completely taken in, interpreting all their behaviour as part of their disease: ‘patient engages in writing behaviour’, for instance, appeared on several sets of case notes.

Appalled at his success, Dr. Rosenhan tried something else. He warned staff - including the psychiatrists - of another hospital that he planned to repeat the experiment and challenged them to spot the fake patients. Now very much on the alert, the staff identified 41 fakes out of a total of 193 admissions. In fact none of Rosenhan’s stooges made any attempt to get into the hospital.

This sort of evidence raises a big question mark over research into the causes of schizophrenia: if you cannot be sure of who is schizophrenic, how can you look for the cause of their disease? This small point has not deterred the investigators, however, who, with great energy and dedication, have put every conceivable part of the schizophrenic’s physiological and social life under the microscope.

From these myriad studies has emerged a rather complicated picture: it appears that schizophrenia could be caused:

• by gentics (if one identical twin is schizophrenic, the other is more likely to become schizophrenic even if they are raised by different families)

• by a virus (the remains of an organism has been isolated in the nervous system of schizophrenics that will kill other cells)

• by a chemical imbalance in the schizophrenic nervous system, caused in turn by genetics, a virus, food allergy or diet (numberless experiments investigating the effects of anti-schizophrenic drugs suggest they act on the chemical that determines the transmission of nerve impulses)

• by birth damage

• by stress (schizophrenia is associated with living in inner city areas, being of a lower social class, having a cold, controlling mother, and so on).

But if we step outside the debates about what causes schizophrenia, it is evident that the logic of these investigations is completely circular. It assumes what has to be proved: that certain mental states ought to be regarded as illnesses. Indeed, if you search long enough you could probably find the physical or social causes of laughter or anger. But that doesn’t mean that either are a disease.

Having, however,declared schizophrenia to be a disease, the next step is to try to cure it. And here, too, the ignorance of psychiatry is woeful. Take drug treatment: there is no doubt that drugs stop whatever it is the patient is doing, or thinking or feeling. And the advent of mass drug therapy has transformed mental hospitals from places of restraint to places of narcotic repose and rendered many thousands of patients manageable enough to go home. But a person who has stopped behaving crazily,who sits quietly at home staring out of the window, unable to get involved in anything, is not necessarily back to normal. In one of the few studies that looked at the quality of life of the patient rather than whether s/he had to be readmitted to hospital, it was shown that schizophrenic patients given no drug treatment at all functioned better socially and at work than those given conventional phenothiazine doses.

None of this will come as any surprise to schizophrenics like Brian and Mary and Peter. They know all about the drugs routinely administered to 90 per cent of diagnosed schizophrenics, that make it hard to think, read and talk sensibly; that are so powerful and imprecise that other drugs have to be taken to counteract their ‘Parkinsonian’ side effects. They may also suspect that the woman in the pink nightie’s ‘Thorazine shuffle’ is due to her medication and that her weird facial grimaces are the result of a type of irreversible brain damage - tardive dyskinesia - suffered by up to 40 per cent of people on anti-schizophrenic medication.

Electroconvulsive therapy, of course, is another treatment just as dangerous as drugs. Once administered indiscriminately for any kind of mental illness (after a doctor was impressed by the way it quietened pigs being prepared for slaughter), it has recently been ‘refined’ and now tends to be given only to people with depression. It has been estimated that well over one million treatments are administered every year in the US alone. The aim of the treatment is to produce an epileptic fit by passing an electric current through the brain. This has such a strong intuitive appeal - giving the brain a good shake-up - that the fact it is based on no knowledge at all is often overlooked.

In fact an ECT machine in a London teaching hospital was used ‘successfully’ for two years in the early 1 970s before someone noticed that it was not delivering its ‘therapeutic’ electric current at all. Actually where the current is passed through the brain has undergone an interesting evolution. It used to be passed through the temporal lobes - the seat of memory, just behind the ears. Unfortunately this made people lose their memory. So then they tried the frontal lobes - behind the forehead. This had the same ‘therapeutic’ effect, without the memory loss, but with some disturbance of language. Now ECT is recommended to be performed only on the right frontal lobe. Because that has been shown to be better for the patient? No, because no-one really knows what the functions of the right frontal lobe are.

So, there are at least three major problems with the prevailing attitudes towards, and methods. of treating, schizophrenia:

• they do not allow for accurate diagnosis;

• they are based on the unproven assumption that schizophrenia is a disease;

• the usual treatments of this alleged disease are crude assaults on the brain that are both dangerous and probably ineffective at bringing a cure.

Of these three the most important is the belief that schizophrenia is a disease in the first place. So let us take a closer look. Deciding schizophrenia is a disease involves making two judgements about the nature of schizophrenic thought and behaviour. The first is that it is crazy, not amenable to interpretation or understanding. If it were understandable then the schizophrenic would simply be different, not mad at all. The second judgement is that schizophrenic behaviour is involuntary or driven - outside the schizophrenic’s control. If it were not the schizophrenic would be simply eccentric, perverse, disruptive - in a word - bad.

The so-called anti-psychiatrists of the 1960s - Ronald Laing, David Cooper, Thomas Szasz, for instance - put a great deal of effort into questioning the judgement that crazy thoughts and behaviour are not amenable to interpretation. Cooper went so far as to declare that ‘all delusions are political statements and all madmen are political dissidents’. Laing pointed out that a schizophrenic’s ‘paranoid delusion’ that her doctors are trying to poison her is an entirely rational belief given side effects and danger of brain damage associated with much psychoactive medication. And a true story is told of a patient with an ‘irrational fear’ of rats who was visited at her home by her psychoanalyst. When the door opened, out jumped - a rat! In the words of the old saying: just because you’re paranoid, it doesn’t mean they’re not out to get you.

So it may be possible to understand all socalled mad behaviour and therefore judge it to be sane on some level. That takes us onto the second judgement about schizophrenic behaviour: that it is out of control. This is what the trial of Peter Sutcliffe, the Yorkshire Ripper, was all about: could he have stopped himself slaughtering those women? If he was in control then he was bad and should be punished. Ifhe was out of control then he was sick and should be helped. In the end the jury decided that he was bad.

But most schizophrenics are not given the benefit of a trial. It is assumed that they cannot be understood and that they cannot help themselves; that they are just objects tossed passively on a sea of biochemical and social forces. Seeing them as objects like this makes it possible to treat them with drugs or ECT. Seeing them as frightened people trying to make sense of a terrifying and confusing world, or as tormented people trying to cure themselves by immersing themselves in their fantasies, or angry people protesting against their pain, makes it impossible to prescribe phenothiazines across the board.

Now any of these ways of seeing schizophrenia could be - to coin a term - completely crazy. Or they might be a very accurate description of what is happening. The point is we have no way of knowing. The things we are seeking to explain are hidden away inside another person’s mind. What we have to decide is how to treat someone who appears to think crazy things and behave in a crazy manner. Do we treat them as communicating human beings or as sick objects?

The dilemma is clearly expressed in the case of homosexuality. Until recently the APA defined homosexuality as a mental illness. And its causes were researched, its diagnosis debated and its ‘victims’ treated - just as schizophrenics are treated today - as though they had a medical problem: with hormones, aversive conditioning, psychotherapy, ECT. With the advent of the gay movement - who demanded the right to chose who they had sex with, who refused to be called deviant or sick - attitudes began to change. Today, though still treated with fear, hatred or contempt by many people, homosexuals have begun to be accepted as healthy human beings. And, finally in 1973 - after a great deal of discussion and ballyhoo - the APA struck them off their list of illness categories. Homosexuality was declared to be normal.

Could it happen with schizophrenia? I can hear the arguments now: schizophrenics are very unhappy. They are haunted by their delusions, tormented by their paranoid fears. Simply declaring them sane would not help them at all.

The simple retort is that declaring them insane hasn’t helped them either. But perhaps it has helped us, the socalled ‘sane’. We now have an excuse to hire - just as our 18th century ancestors hired - a band of professionals to take away our embarassing relatives and quell their embarassing behaviour.

It is not surprising that psychiatry has made so little progreess over the last 200 years. Its task has been to justify and make ‘scientific’ systematic discrimination against people who think and behave differently to the majority.

As for the suggestion that schizophrenics are dangerous: Peter Sutcliffe was a rare exception. One survey of 14,000 ex mental patients in New York found them to be 14 times less likely to be arrested than the general population. To dose people with drugs and incarcerate them in a mental hospital just in case they might commit a crime is to violate one of the most fundamental of human rights - to be assumed innocent until proven guilty.

So let’s imagine, for a moment, that schizophrenia was declared not to be a disease. Schizophrenic thought and behaviour would not disappear, obviously - any more than homosexual behaviour did when homosexuality was declared sane. But the experience of being schizophrenic might begin to change - just as the experience of being homosexual has. It might become less of a torment. And the problems created by schizophrenic thought and behaviour would be different too. They would be the problems of non-schizophrenics as well as schizophrenics: problems of self-expression, responsibility, tolerance and discrimination. Not problems of treatment and control, sickness and health.