Category Archives: schizophrenia

What’s Really Wrong with DSM-5

By Liah Greenfeld

The essence of the DSM-5 consists in the modifications it introduces in the extensive psychiatric nosology, specifically adding diagnostic categories to diseases of unknown biological origin and uncertain etiology. But the real problem lies much deeper – in the understanding of such diseases itself. It is the problem with the old, fundamental, and universally accepted diagnostic categories of thought disorder- vs. affective disorders, or schizophrenia vs. manic and unipolar depression, on which all the other diagnostic categories of mental illness of unknown etiology, new and not so new, are based. DSM-5’s approach is similar to attempting to salvage a house, falling apart because it is built on an unsound foundation, by adding to it a fresh coat of paint and new shutters.

What Mind, Modernity, Madness does, in contrast, is to dismantle the structure, establish a sound foundation, and then rebuild the house on top of it. I begin by questioning and analyzing the fundamental diagnostic categories themselves, consider them against the existing clinical, neurobiological, genetic, and epidemiological evidence, bring into the mix the never-before-considered cultural data, and on this basis propose that the two (schizophrenia and manic-depressive illness) or even three (schizophrenia, manic depression, and unipolar depression) discreet diseases are better conceptualized–and therefore treated–as the same disease, with one cause, which expresses itself differently depending on the circumstances in which this cause becomes operative. Psychiatric epidemiologists, at least, have long suspected that “the black box of culture” is an important contributing factor in these diseases. However, as the phrase indicates, they lack the means to understand or even examine its contribution. By unpacking the “black box” (and showing, specifically, how it is reflected in the logically necessary structures of the mind, such as identity, will, and thinking self), I add a missing yet essential dimension to the diagnostic tool-kit, which the DSM-5, like the previous editions, disregards.

Love, Madness, Terrorism: Connected?

By Liah Greenfeld

In the 16th century, in England, several remarkable things happened:

Social mobility, inconceivable before, became legitimate and common;

The ideal of Romantic love between a man and a woman emerged and “true love,” as we understand it today, was added to the human emotional range;

The word “people,” which earlier referred to the lower classes, became synonymous with “nation,” which at the time had the meaning of “an elite”;

Numerous new words appeared, among them “aspiration,” “happiness,” and “madness”;

The English society, previously a society of hierarchically arranged orders of nobility, clergy, and laborers under the sovereignty of God and his Vicar in Rome, was redefined as a sovereign community of equals;

The nature of violent crime, personal and political, changed, with crime that was not rational in the sense of self-interested becoming much more common;

The attitude to pets, especially dogs and cats, changed, transforming these animals in many cases from living multi-purpose tools to our friends and soul-mates;

The pursuit of growth — rather than survival, as was the case before – became the goal of the economy;

Mental diseases which were later to be named “schizophrenia,” “manic-depressive illness,” and “depression” were first observed, shifting the interest of the medical profession, in particular, from other, numerous, mental diseases that were known since the times of antiquity.

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Identity Construction and Cultural Madness

From the Harvard University Press Blog:

It sometimes seems as if each day brings a new raft of articles proclaiming yet another biological or genetic explanation for human behavior and activity. To Liah Greenfeld, that barrage is just a new bubble, and in Mind, Modernity, Madness: The Impact of Culture on Human Experience, she does her best to burst it. While not entirely dismissing biological factors in mental illness, Greenfeld argues that the phenomenon that was for a long time called simply “madness”—today’s schizophrenia, bipolar disorder, and major depression—is actually a symptom of modernity, an effect of our cultural environment.   Continue reading

Understanding Schizophrenia

From “Throughout History, Defining Schizophrenia Has Remained a Challenge [Timeline]” in Scientific American Mind:

Less than two hundred years ago, schizophrenia emerged from a tangle of mental disorders known simply as madness. Yet its diagnosis remains shrouded in ambiguity. Only now is the Diagnostics and Statistical Manual of Mental Disorders, psychiatrists’ primary guidebook, shedding the outdated, nineteenth-century descriptions that have characterized schizophrenia to this day. “There is substantial dissatisfaction with schizophrenia treated as a disease entity, it’s symptoms are like a fever—something is wrong but we don’t know what,” says William Carpenter, a psychiatrist at the University of Maryland and chair of the manual’s Psychotic Disorder Workgroup. Psychiatrists may discover that this disorder is not a single syndrome after all but a bundle of overlapping conditions.

Liah Greenfeld in “Madness in its Pure Form,” Chapter 3 in Mind, Modernity, Madness:

The root of the schizophrenic experience, from the earliest stages and throughout the episode, is the problem with the self, specifically the acting self: the dissolution of the will. The difference between the early, middle, acutely psychotic, and elaborate delusional stages for the patient consists in that, during the prodrome, the loss of the acting self is experienced indirectly, through changed experience of the outside world, becoming more and more direct through the middle stages, culminating in the sense of the loss of the mind (and both relationally-constituted self and the thinking self) in the stage of acute psychosis, and continuing in a partial restitution of identity and the thinking self, or the reconstruction of the self-in-the-world in the elaborate delusion. The structure of self-consciousness or the “I of Descartes” is involved at every stage in the disease process, but it changes its function from that of the thinking self to the one of the “eye of an external observer” and back, or, in other words, transforms from the part of the mind (individualized culture) to culture in general and back, confusing the levels of the mental and symbolic process. The different phases or stages of the illness, obviously, cannot be strictly separated but seamlessly flow and transmogrify one into another.

I would like to draw the reader’s attention to two points. 1. Seen in this light, as a mental, rather than a brain, disease, as the disorder of the mind, and therefore, a cultural phenomenon, schizophrenia appears to be of a piece. All of its symptoms (however contradictory they may seem when seen in other frameworks) can be accounted for by the loss of the acting self and related to each other through this overarching relationship to the impairment of the will. One is no longer forced to consider the extreme variability of abnormalities to be the single invariable characteristic of schizophrenia. There is, after all, an organizing principle which makes it possible to integrate all of its features into an understandable whole. 2. To arrive at this interpretation of schizophrenia and depict its underlying psychological structure, there was no need to step outside the theory of the healthy mind as outlined in Chapter 2, “The Mind as an Emergent Phenomenon.” No abnormality was interpreted ad hoc, proving the sufficiency of this theory. The analysis of schizophrenia, it is possible to claim, provides a strong support for its hypotheses regarding the structure of the mind.

It still remains to us, of course, to explain schizophrenia causally. As was stated in the Introduction, the explanation I propose is that modern society, based on the principles of nationalism, is profoundly anomic and, as such, makes the formation of identity (the relationally constituted self) problematic. Malformed identity, in turn, necessarily impairs the will. This hypothesis will be tested in two stages: first, through an examination of a well-documented contemporary case (the case of John Nash) and then, much more thoroughly, on the basis of comparative-historical analysis of the development of relevant aspects of the modern culture.

Schizophrenia and Manic-Depressive Illness: What do We Know about Biological Causes?

By David Phillipi

While the technological advancements of recent decades allow us to map the human genome and look at the brain on the molecular level, the enormous amount of data that has been amassed is virtually useless for psychiatrists trying to diagnose their sick patients because the assumed biological causes of schizophrenia and manic-depressive illness have not been found. No brain abnormalities that are specific to either illness or present in all cases have been identified. Nevertheless, the experts who study and treat schizophrenia and manic-depressive illness (MDI) keep the faith (quite literally) that a breakthrough is just around the corner.

For years, genetic research has appeared to be the most promising of the recently opened avenues, but the excitement seems unwarranted by the findings. The relatively large number of chromosomal regions which may be implicated in susceptibility for bipolar disorder means that hope of finding a specific bipolar gene or even a small number of genes must be given up. Some researchers think the way to go is to narrow the search by looking for genes associated with specific aspects of the disease. Of course, this further refinement is only possible because of the huge variation in symptoms and experiences of those who fall under the MDI/bipolar umbrella, and we are once again reminded of the difficulty of defining what this illness or group of illnesses even is. Furthermore, even the distinction between schizophrenia and MDI seems to collapse in light of the genetic linkage data. In Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression (2nd Edition), Drs. Frederick Goodwin and Kay Redfield Jamison write:

While the search for predisposing genes had traditionally tended to proceed under the assumption that schizophrenia and bipolar disorder are separate disease entities with different underlying etiologies, emerging findings from many fields of psychiatric research do not fit well with this model. Most notably, the pattern of findings emerging from genetic studies shows increasing evidence for an overlap in genetic susceptibility across the traditional classification categories. (49)

Genetic studies in the schizophrenia research community lead to pretty much the same hypothesis as with bipolar: genetic susceptibility is most likely polygenic, meaning dependent on the total number of certain genes which may contribute to vulnerability. It must be noted that genetic vulnerability is a condition, not a cause of schizophrenia and bipolar – something else must be acting on this vulnerability. In one way or another, this fact is usually noted in the literature that deals with genetic data, but it is often obscured by a tone of confidence which suggests the information may be more meaningful and explanatory than it truly is.

Even when a specific gene has been well studied across illnesses, its usefulness in understanding genetic susceptibility may be extremely limited. Some studies in both schizophrenia and MDI have found an increased risk of illness for those who possess the short form of the serotonin transporter promoter gene 5-HTT. The thing is, each of us has two copies of this gene, and over two-thirds of us have one long and one short form, meaning that having the normal variant of the gene is the risk factor! If most of us possess a gene which puts us at risk for an illness which only a small minority of people have, then this particular trait is obviously not much of a causal explanation.

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Psychiatric Disorders Linked Genetically

By Gil Press

In the Wall Street Journal today, Shirley S. Wang reports on a new study published today in The Lancet, which “provides early evidence that several disorders  thought to be distinct appear to have some genetic overlap, and it may help in one day diagnosing mental illness based on faulty biological processes, and not just on behavioral symptoms.”

The study compared the genes of some 33,000 people with schizophrenia, bipolar disorder, major depression, autism or attention-deficit hyperactivity disorder, and also compared them with a group of nearly 28,000 controls. It “identified several regions of the genome that were associated with all five diseases.”

In Mind, Modernity, Madness, Liah Greenfeld came to a similar conclusion that viewing manic-depressive illness and schizophrenia as distinct illnesses, each with its own biological causes, is wrong. Instead, she argues that they should be placed on a continuum of the complexity of the will-impairment caused by the anomie inherent in modern culture. This argument, linking mental illness to individuals’ (varied) response to the pressures of modern society, could also explain why “the findings don’t mean that an individual with one or more of these gene variants has or will develop the condition,” as the Wall Street Journal article–and the authors of the study–conclude.