Here are a few highlights of the history of schizophrenia as well as how we understand it today.
Schizophrenia or Schizophrenias?
When it comes to classifying schizophrenia, there are lumpers, who like to group things into broad categories, and splitters, who divide things into smaller categories. Lumpers view schizophrenia as a unitary or single disorder while splitters say it is different disorders conveniently grouped under one category. The best way to understand these points of view is to review the historical development of the schizophrenia concept.
1852, Rouen, France
In Études cliniques (1852; “Clinical Studies”), Bénédict Morel, a French physician and the director of the mental asylum at Saint-Yon in Rouen, first used the term démence précoce (premature dementia) to describe the clinical picture of a group of young patients with thought disorganization and an overall disorder of will (perhaps what we refer to as “avolition” today). At that time, dementia had a different meaning than it does today. It did not imply a chronic and irreversible course or cognitive problems (e.g. difficulties in the areas of memory, attention, concentration, problem-solving).
1891, Prague, Austro-Hungarian Empire
This was the first recorded use of the term dementia praecox by Arnold Pick, a Czech neurologist, and psychiatrist who reports on a patient with a clinical presentation consistent with what would today be diagnosed as a psychotic disorder.
1893, Heidelberg, Germany
Emil Kraepelin moved from grouping mental disorders based on superficial similarities between major symptoms to grouping mental disorders based on their course over time. He became known for distinguishing dementia praecox (a “premature dementia” or “precocious madness”) with its chronic and persistent course from manic depression. What’s more, he distinguished dementia praecox from dementia paranoides (paranoia) and catatonia, which align with many of the symptoms we see in people with schizophrenia today. Kraepelin, who initially had a splitter view of the disorder, eventually grouped the different presentations as “clinical forms” of essentially one disorder: dementia praecox, which is the official predecessor of schizophrenia.
1907, Zürich, Switzerland
Eugen Bleuler (in photo) coined the term schizophrenia and described the distinct subtypes of the disorder, stating that schizophrenia “is not a disease in the strict sense, but appears to be a group of diseases. Therefore, we should speak of schizophrenias in the plural.” Bleuler introduced the concept of primary and secondary schizophrenic symptoms, defining the four primary symptoms of schizophrenia (the four A’s). He also stated that loss of association between thought processes and emotion and behavior were central symptoms and could lead to secondary disease manifestations like hallucinations, delusions, social withdrawal, and diminished drive. A notable difference between Bleuler and Kraepelin is that Bleuler conducted clinical observations, practically living in the people’s surroundings, while Kraepelin collected information from patient records.
1960s and 1970s
In the 1960s and 1970s, the demographics of the disease shifted from an illness of mostly White, middle class women to an illness of urban Black males. This shift directly reflected national political events and played a role in how the illness is conceptualized by the lay public and how it is diagnosed and treated today.
20th Century to Recent Past
Mental health experts continued to redefine the definition of schizophrenia as well as its classification and agreed (and continue to agree) on four main categories of symptoms that occur in schizophrenia:
Positive symptoms Negative symptoms Cognitive symptoms Affective symptoms
Positive versus negative schizophrenia and deficit and non-deficit schizophrenia were also proposed as different schizophrenia types. The ”lumpers” believe that, despite differences in presentation, disease course, and response to medications, these symptoms (or types) are in fact different forms of one common underlying abnormality that are characteristic of schizophrenia, but yet to be determined On the other hand, the “splitters” believe that schizophrenias as opposed to schizophrenia better describes the differences in presentation, course, prognosis, and response to treatment for different groups of patients. The Diagnostic and Statistical Manual of Mental Disorders (DSM III through DSM-IV) proposed five different types of schizophrenia:
ParanoidDisorganizedCatatonicResidualUndifferentiated
The AntiPsychiatry View
The term “antipsychiatry” was coined in 1967 by David Cooper who questioned the diagnosis and treatment of schizophrenia. Copper and the many others involved in the antipsychiatry movement in the 1950s and 1960s viewed psychiatric practices like electroshock therapy and psychosurgery (frontal lobotomy) as inhumane and demanded improvements in shabby state hospitals or asylums. The discovery of antipsychotics in the 1950s also prompted an outcry, as these drugs were found to produce neurological side effects. To many, psychosis was “understandable” and a way of coping with a “sick society” or “schizophrenogenic parents” who harmed their offspring. Activists also believed that psychiatry deprived people of their rights, calling it “subversive, left-wing, anti-American, and communist.” These concepts were also appealing to many religious folks who viewed mental illness as a “moral issue” handled by the church rather than a medical issue treated by doctors.
Understanding Schizophrenia Today
Today, schizophrenia is viewed as a “prototypical mental disorder.” This means that people with schizophrenia experience significant thought and mood variations and, as a result, have different degrees of psychosocial disability (disorders that impact emotions, behaviors, and cognitive abilities). While most mental health experts believe that schizophrenia is a mental disorder with biological roots, others say it is a social construct, a product of cultural norms and expectations imposed on a non-conforming individual. The most recent version, DSM V (released in 2013) has taken a lumper’s approach when it comes to classifying schizophrenia. There are no longer subtypes of schizophrenia (paranoid schizophrenia, disorganized, catatonic, residual, undifferentiated), which were determined unhelpful in regard to treating schizophrenia or predicting treatment outcomes. This isn’t to say the splitting-lumping debate is over. With increased knowledge about genetic differences and advances in patient-centered medicine, it is possible that the pendulum might swing back to a splitting perspective of schizophrenia in the future.
