Recovery From Schizophrenia: Psychiatry And Political Economy

WHAT IS SCHIZOPHRENIA? 5syphilis, no specific cause of the condition could be identified; in contrast to thepsychogenic psychoses, dementia praecox did not appear to be an acute responseto stress; and it was to be distinguished from manicdepressive insanity by itsprogressive deteriorating course and by the absence of clear-cut mood swings fromelation to melancholia.Emil Kraepelin’s description of dementia praecox continues to serve us well,with some exceptions, as a picture of modern-day schizophrenia. Some of thecharacteristic features that he identified are listed in Table 1.1. Where hisobservations no longer appear relevant is in his description of the symptomsassociated with catatonic schizophrenia—automatic obedience, stereotypicmovements, waxy flexibility, echolalia and echopraxia (see Table 1.1). Kraepelin’streatise on dementia praecox is illustrated with photographs of catatonic patientssitting and standing rigidly in bizarre and contorted postures, preserving poses intowhich they were set by the photographer. It was not unusual for Kraepelin’spatients to repeat involuntarily the words and movements of those around them orto stand or kneel for days or longer in the same spot. 5 Patients with such featurescould still be seen on the wards of old-style institutions after the Second WorldWar, but they are now very rarely seen in the industrial world. Catatonicschizophrenia, however, is still one of the commonest forms of the disorder in theThird World.It is possible, as social psychiatrist Julian Leff argues, that these catatonicsymptoms are a somatic expression of delusions of influence, symbolic thinkingand pathological fear, much as the bodily symptoms of hysteria are a somaticconversion of anxiety. Both hysteria and catatonic symptoms have receded in theWest, Dr Leff suggests, as the population has developed a capacity for expressingemotions in verbal and psychological terms rather than as somatic symptoms. 6 Itmay also be true that the harsh and regressive conditions of asylums around thebeginning of the twentieth century tended to provoke and worsen catatonicsymptoms, which persisted as a physical expression of the patient’s dependentstatus and barren existence.Even more probable, these same asylum conditions may have brought aboutthe deteriorating course that Kraepelin saw as central to his concept of the illness.Therapeutic nihilism, extended hospital stays and coercive management withinthe asylum walls, and poverty and unemployment beyond them, during theseyears of the late nineteenth-century Great Depression combined to limit thechances of recovery from dementia praecox. Few psychiatrists since Kraepelin, aswe shall see in Chapter 3, have found the course of schizophrenia to be asmalignant as originally portrayed. As Kraepelin’s classification was adopted aroundthe world, nevertheless, so was the impression that the illness was inevitablyprogressive and incurable. To varying degrees the same view holds sway today—that without treatment the outlook is hopeless—despite considerable evidence tothe contrary.