Schizophrenic Disorders: Sense and Nonsense in Conceptualization, Assessment, and Treatment

260 Pages·1992·30.081 MB·English

by  Leighton C. Whitaker (auth.)

Diagnostic Criteria for Schizophrenia
A. Presence of characteristic psychotic symptoms in the active phase: either (1),
(2), or (3) for at least one week (unless the symptoms are successfully treated):
(1) two of the following:
(a) delusions
(b) prominent hallucinations (throughout the day for several days or sev
eral times a week for several weeks, each hallucinatory experience
not being limited to a few brief moments)
(c) incoherence or marked loosening of associations
(d) catatonic behavior
(e) flat or grossly inappropriate affect
(2) bizarre delusions (i.e., involving a phenomenon that the person's culture
would regard as totally implausible, e.g., thought broadcasting, being
controlled by a dead person)
(3) prominent hallucinations [as defined in (1 )(b) above] of a voice with
content having no apparent relation to depression or elation, or a voice
keeping up a running commentary on the person's behavior or thoughts,
or two or more voices conversing with each other
B. During the course of the disturbance, functioning in such areas as work, social
relations, and self-care is markedly below the highest level achieved before
onset of the disturbance (or, when the onset is in childhood or adolescence,
failure to achieve expected level of social development).
C. Schizoaffective Disorder and Moo(j. Disorder with Psychotic Features have
been ruled out, i.e., if a Major Depressive or Manic Syndrome has ever been
present during an active phase of the disturbance, the total duration of all
episodes of a mood syndrome has been brief relative to the total duration of
the active and residual phases of the disturbance.
D. Continuous signs of the disturbance for at least six months. The six-month
period must include an active phase (of at least one week, or less if symptoms
have been successfully treated) during which there were psychotic symptoms
characteristic of Schizophrenia (symptoms in A), with or without a prodromal
or residual phase, as defined below.
Prodromal phase: A clear deterioration in functioning before the active phase
of the disturbance that is not due to a disturbance in mood or to a Psychoac
tive Substance Use Disorder and that involves at least two of the symptoms
listed below.
Residual phase: Following the active phase of the disturbance, persistence of
at least two of the symptoms noted below, these not being due to a distur
bance in mood or to a Psychoactive Substance Use Disorder.
Prodromal or Residual Symptoms:
(1) marked social isolation or withdrawal
(2) marked impairment in role functioning as wage-earner, student, or home
maker
(3) markedly peculiar behavior (e.g., collecting garbage, talking to self in
public, hoarding food)
(4) marked impairment in personal hygiene and grooming
(5) blunted or inappropriate affect
(6) digressive, vague, overelaborate, or circumstantial speech, or poverty of
speech, or poverty of content of speech
(7) odd beliefs or magical thinking, influencing behavior and inconsistent
with cultural norms, e.g., superstitiousness, belief in clairvoyance, telep
athy, "sixth sense," "others can feel my feelings," overvalued ideas, ideas
of reference
(8) unusual perceptual experiences, e.g., recurrent illusions, sensing the
presence of a force or person not actually present
(9) marked lack of initiative, interests, or energy
Examples: Six months of prodromal symptoms with one week of symptoms
from A; no prodromal symptoms with six months of symptoms from A; no
prodromal symptoms with one week of symptoms from A and six months of
residual symptoms.
E. It cannot be established that an organic factor initiated and maintained the
disturbance.
F. If there is a history of Autistic Disorder, the additional diagnosis of Schizo
phrenia is made only if prominent delusions or hallucinations are also present.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Third
Edition, Revised. Copyright 1987 American Psychiatric Association.
Schizophrenic
Disorders
Sense and Nonsense in
Conceptualization, Assessment,
and Treatment
PERSPECTIVES ON INDIVIDUAL DIFFERENCES
CECIL R. REYNOLDS, Texas A&M University, College Station
ROBERT T. BROWN, University of North Carolina, Wilmington
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Sense and Nonsense in Conceptualization, Assessment, and Treatment
Leighton C. Whitaker
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Schizophrenic
Disorders
Sense and Nonsense in
Conceptualization, Assessment,
and Treatment
Leighton C. Whitaker
Swarthmore College
Swarthmore, Pennsylvania
With a chapter by
Antonio E. Puente
University of North Carolina at Wilmington
Wilmington, North Carolina
Springer Science+Business Media, LLC
Llbrary of Congress Cataloglng-ln-Publlcatlon Data
Whltaker, Lelghton C.
Schlzophrenlc dlsorders : sense and nonsense In conceptuallzatlon,
assessment, and treatment / Lelghton C. Whltaker ; wlth a
contrlbutlon by Antonia E. Puente.
p. cm. -- <Perspectlves an Individual differences)
Includes blbllagraphlcal references and index.
1. Schlzaphrenla. 2. Schizaphrenla--Dlagnasls. 1. Puente,
Antanla E. II. Tltle. III. Serles.
[DNLM: 1. Schlzaphrenla--diagnasls. 2. Schizophrenla--therapy.
3. Schlzophrenlc Psychalagy. WM 203 W577s1
RC514.W433 1992
616.8S'82--dc20
DNLM/DLC
for Llbrary of Congress 92-17021
CIP
ISBN 978-1-4419-3222-8 ISBN 978-1-4757-2159-1 (eBook)
DOI 10.1007/978-1-4757-2159-1
©1992 Springer Science+Business Media New York
Originally published by Plenurn Press, New York in 1992
Softcover reprint ofthe hardcover Ist edition 1992
AlI rights reserved
No part of this book may be reproduced, stored in a retrieval system, or transmitted
in any form or by any means, electronic, mechanical, photocopying, microfilming,
recording, or otherwise, without written permission from the Publisher
For
Suzanne, Corinne, Priscilla, and Benjamin
Preface
No diagnosis of mental disorder is more important or more disputable than that of
"schizophrenia." The 1982 case of John Hinckley, who shot President Reagan,
brought both aspects of this diagnostic dilemma to the forefront of national attention.
It became evident to the general public that the experts engaged to study him
exhaustively could not agree on whether Hinckley was schizophrenic. General public
outrage ensued, as schizophrenia, "the sacred symbol of psychiatry," in the words of
Thomas Szasz (1976), emerged as a king of Alice in Wonderland travesty. Schizo
phrenia seemed not to be a legitimate diagnostic entity but some sort of facade erected
to protect the guilty.
In 1973, David Rosenhan had already shown the readers of Science that schizo
phrenia was a label that could be given to normal people presenting with a supposed
auditory hallucination on even one occasion. In Rosenhan's studies, mental health
professionals were outclassed by the regular psychiatric hospital patients, who cor
rectly saw the false schizophrenics as imposters while the professional diagnosticians
continued to fool themselves.
These events are not isolated. Despite the many claims to diagnostic certainty,
universally accepted criteria for calling someone a schizophrenic do not exist. At
most, a high rate of agreement occurs only when a group of mental health profes
sionals in the same institution are trained rigorously to use certain diagnostic criteria
to rate information obtained in a certain way. However, so many systems are used for
diagnosis that, although one group of experts may agree substantially among them
selves, no two groups are likely to agree with each other. A patient clearly defined
as schizophrenic by the experts at one institution may easily be diagnosed differently
at another institution. Our confidence falls still more when, as usually happens in
ordinary practice, diagnoses are generally made quickly, often by someone in training
who sees the patient for perhaps 15 minutes in an emergency room. Once made, the
diagnosis tends to stick, or if changed, it may be changed, for example, to "manic
depressive illness" just as arbitrarily as the original diagnosis was given. The un
wittingly primitive nature of much ordinary diagnostic practice results in little or no
information about the degree of disorder, its position on the dimension of acute to
chronic, motivational and situational considerations, or the patient's strengths, though
vii
viii Preface
all of these individual differences are crucial to meaningful assessment and treatment.
Although there are notable exceptions to these all-too-typical practices, vagueness of
definition makes possible many varieties of uses and misuses of the label schizo
phrenia.
Many experiences have led to my writing this book, including various clinical
and research undertakings at six psychiatric hospitals over a period of 15 years, plus
many years of outpatient work with severely disturbed persons. One of my first
experiences was with a 23-year-old woman who had two children and was in the
process of a divorce, and who was accurately diagnosed as having Hodgkin's disease
in the fourth or terminal stage back when no cure existed. She was expected to live
for less than two years. Her only "skill' was dancing, which she had to give up
because of her disease. She became severely withdrawn; was admitted to a psychiatric
hospital, where she was diagnosed as "schizophrenic"; and was told by the chief
psychiatrist-trained at an elite psychiatric institution-that she would always be
schizophrenic. But her psychotherapist, who agreed that she had become schizo
phrenic, predicted a successful outcome. Her hope and hard work enabled her to
become quite normal psychologically, according to independent observation, until
more than 11 years later, when she finally died of Hodgkin's disease. Her physician,
a hematologist, ascribed her surprising longevity to her great will to live. He said that
she was the most normal person he had ever known, and he credited her with keeping
up his morale and that of his colleagues, and of other terminal patients, for whom she
had begun a group support program. He refused to believe, at first, that she had ever
been diagnosed as schizophrenic or had ever been in a mental hospital. This case and
many others impressed on me the need to go far beyond the simple diagnostic label
schizophrenia, with its stereotyped connotations.
Whereas, traditionally, "schizophrenics" have been grouped together as if they
were a homogeneous lot of creatures vastly different from "normals," I know of no
other diagnostic group in which the individuals are more different, both intraindi
vidually and interindividually. Careful observational studies show that the intraindi
vidual differences are enormous, as exemplified in changes within the individual over
time-sometimes from one day to another as well as over the years. As Silvano Arieti
(1974), the late psychiatrist who devoted most of his life to trying to understand and
help schizophrenics, said, "A striking characteristic of schizophrenia is the great
variability of its course" (p. 49).
Interindividual differences are also marked. A diagnosis of schizophrenia may
be distinguished, ironically, from other psychiatric diagnoses by the heterogeneity of
the people given that label. As Arieti (1974) stated, "The symptomatology of schizo
phrenia assumes a large number of clinical forms" (p. 30). Psychiatrists Strauss and
Carpenter (1981) declared that
Heterogeneity of patients classified as schizophrenic is almost the haIlmark of the disorder;
yet, the modal schizophrenic patient is often processed through the health care system with
surprisingly little attention paid to him or her as an individual and with unwarranted
assumptions that the individual represents primarily one case in a homogeneous group
phenomenon (p. 208).
Preface ix
Professional opinions about the concept of schizophrenia tend to fall into two
schools: The first opinion, of believers in schizophrenia as a meaningful diagnostic
category, is that "schizophrenics" have enough in common to be addressed ade
quately by nomothetic science; the second is that they do not. Some members of the
first school tend to overemphasize the sameness among people called schizophrenic,
whereas members of the second school tend to disdain the term altogether in favor
of emphasizing individual differences. I propose that both nomothetic science and
idiographic science should be used, and that these two approaches must be integrated
if the concept of schizophrenic disorders is to make sense.
The result, politically, of emphasizing the nomothetic approach to the virtual
exclusion of the idiographic is to homogenize "schizophrenics," usually for purposes
of biological theory and treatment, as if they literally have physical diseases of the
mind. Single-minded emphasis on the individual differences, however, has often
enabled professionals and society at large to deny responsibility for providing any
treatment or care. The deinstitutionalization movement in the United States, which
emphasizes freedom and deemphasizes care and treatment, has left most patients
without any viable care-whether inpatient or outpatient-quite as if the patients
have no really disabling deficits and can essentially take care of themselves. Despite
claims to the contrary, there is little evidence that the care and treatment that society
provides people called schizophrenic is much better today than that provided in
previous eras.
I decided, after reading much of the literature, doing research, working directly
with schizophrenic persons for many years, and teaching courses on schizophrenic
disorders, to write a book that would present a primarily psychosocial perspective on
schizophrenic disorders, emphasizing an evaluation of both the assessed and the
assessors. What follows is an attempt to take into account the personal, economic, and
political pressures that (on one hand) segregate schizophrenic persons into disease
entities having little or no kinship with the rest of us in terms of our deeply human
emotions, personal relationships, and ways of thinking, and that (on the other hand)
deny the seriousness of these disorders and their substantial commonality.
This book attempts to delineate the sense and nonsense of how schizophrenic
disorders are conceptualized and assessed and how persons labeled schizophrenic are
treated, as well as the sense and nonsense of schizophrenic modes of being.
LEIGHTON C. WmTAKER
Swarthmore, Pennsylvania