Recovery From Schizophrenia: Psychiatry And Political Economy

WHAT IS SCHIZOPHRENIA? 13publication in 1980 of the third edition of the American Psychiatric AssociationDiagnostic and Statistical Manual (DSM-III), American psychiatry switched fromone of the broadest concepts of schizophrenia in the world to one of thenarrowest—a diagnostic approach similar to the Scandinavian system. Nopsychotic patient, for example, could any longer be labeled as suffering fromschizophrenia if he or she had been continuously disturbed for less than sixmonths. Thus, a patient who had experienced several schizophrenia-like episodes,each briefer than six months, was not to be considered as having schizophrenia. Norwas a patient who did not show a clear deterioration in functioning. Patients whofailed to meet these criteria but appeared schizophrenic in other ways were to bediagnosed as suffering from brief reactive psychosis, schizophreniform disorder oratypical psychosis. Those patients who could not be definitely diagnosed assuffering from either manic-depressive illness or schizophrenia, having features ofboth conditions, were previously labeled as “schizoaffective” and included withinthe schizophrenia category; now they were to be excluded. 26 This narrowdiagnostic scheme was essentially unchanged by the publication in 1994 of fourthedition of the American Psychiatric Association Diagnostic and Statistical Manual(DSM-IV).A number of practical implications flow from these geographic and temporalvariations in the diagnosis of schizophrenia. In particular, whatever we have to sayabout the prevalence and course of the illness has meaning only if we definewhich diagnostic approach is being used. For every narrowly defined case ofschizophrenia in the population there can be as many as four more people who meetbroadly defined criteria for the illness. 27 Where the diagnostic concept isdeliberately shaped to exclude patients who recover, we must expect the outcometo be worse. In this book, the term schizophrenia, unless otherwise qualified,refers to a middle-of-the-road definition—not as exclusive as the Scandinavian ormodern American approach, nor as broad as the Soviet or earlier American systems.The definition used here will essentially be the one in use in British psychiatryand the one which, as the WHO Pilot Study shows, is most commonly usedaround the world. This definition, while clearly differentiating cases of bipolardisorder, does not exclude psychoses of short duration or those with features ofgood prognosis. It does, however, exclude patients who fail to show clear-cutpsychotic symptoms.COURSE AND OUTCOME OF SCHIZOPHRENIAA thorough analysis of the outcome of schizophrenic illness will be attempted inChapter 3. At this point it is necessary to give an idea of the wide variation thatoccurs in the course of the condition. A Swiss psychiatrist, Professor Luc Ciompi,provides a useful analysis of the course of schizophrenia followed into old age. Inthe late 1960s Dr Ciompi traced 289 patients, all more than 65 years of age, whohad been admitted for treatment of schizophrenia to the University PsychiatricClinic of Lausanne at various times throughout the century. For most of these