Recovery From Schizophrenia: Psychiatry And Political Economy

10 BACKGROUNDlimited. Patient self-reliance was encouraged and occupational therapy wasconsidered essential. “Every mental institution should have the kind of set-up thatwill make it possible to offer every patient some kind of work at all times.” 17 OnSundays, “generally a bad day” for the patients as there was no work, “special careshould be taken to provide sufficient opportunity for entertainment.” 18Although Bleuler demonstrated that the outcome of schizophrenia was oftenbenign, Kraepelin’s more pessimistic view has proven more popular. Why shouldthis have been so? Partly, perhaps, because patient management, economicconditions and community acceptance of the mentally ill in most places throughmany of the subsequent years have been sufficiently poor that outcome from theillness has seemed closer to Kraepelin’s experience than to Bleuler’s. (Thispossibility will be examined in some detail in subsequent chapters.) In part, themodern pessimistic view of the untreated course of schizophrenia may havedeveloped because the introduction of the antipsychotic drugs in the mid-1950sand their subsequent, virtually universal, employment in the treatment ofpsychosis has masked what was previously known of the natural history of theillness. Finally, some diagnostic reforms have tended to follow Kraepelin’s lead inattempting to limit the use of the term schizophrenia to only those cases that donot recover.DIAGNOSISIt is by no means universally clear what is schizophrenia and what is not, and beforewe can study the course of the illness in more detail it will be necessary toexamine the different approaches to defining its boundaries.Scandinavian psychiatrists have tended to use a rather narrow definition ofschizophrenia in an attempt to adhere to Kraepelin’s emphasis on poor outcome.In this they have followed the course set by psychiatrist G.Langfeldt in 1937. Hedistinguished between a core group of people with process or nuclearschizophrenia, on the one hand, who demonstrated an insidious onset of illnessand a deteriorating course and, on the other, a reactive group, who tended to showsigns of better social functioning before becoming psychotic, to have a more acuteonset and to display a better prognosis. Those with reactive psychosis, for whomthe outlook is brighter, have been separated from “true” schizophrenia inScandinavian psychiatric terminology and labeled as suffering from schizophreniformpsychoses. 19 In Britain this approach has not been generally adopted, nor was it muchused in the United States until recent years.Soviet psychiatrists, particularly in Moscow, also emphasized the course of theillness in developing their classification of schizophrenia. In this instance,however, the result was a broad definition. The Moscow-school psychiatristsspoke of periodic schizophrenia, consisting of acute episodes with normal remission;stepwise schizophrenia, in which each acute episode led to a period of loweredsocial functioning; and sluggish schizophrenia, with a course of progressivedeterioration. Among those with periodic schizophrenia were to be found