The APA defines schizophrenia by the presence of two or more of the following, each present for a significant portion of time during a one-month period:
(3) disorganized speech
(4) grossly disorganized or catatonic behavior
(5) negative symptoms i.e. affective flattening, alogia or avolition
Signs of the disturbance must have been present for at least six months and there must be significant deficits in one or more areas of functioning such as work, interpersonal relations or self-care.
The “two or more” concept constitutes a substantial flaw in the so-called diagnosis. An individual who is displaying hallucinations and delusions (criteria 1 and 2) will be assigned a diagnosis of schizophrenia. But a person whose behavior is grossly disorganized and whose affect is flat (criteria 4 and 5) can be assigned the same diagnosis. Superficially these presentations are very different, and the only reason for assigning the same diagnosis is that the APA say so. This state of affairs is found throughout DSM. Elliot S. Valenstein, Professor Emeritus of Psychology and Neuroscience at University of Michigan has this to say:
“Although those who directed the DSM-IV project claim that “there has been a stronger emphasis on research data than with previous revisions,” scientific considerations do not play a significant role in the manual. Instead, the psychiatric tradition and sociopolitical considerations seem to have played the major roles in shaping this document. Dr. Allen Frances, who directed the DSM-IV project, stated that “we didn’t want to disrupt clinical practice by eliminating diagnoses in wide use.” Very different symptoms are included under the rubric of “schizophrenia” mainly because they have always been grouped together, rather than because of any new scientific evidence that they share a common etiology.” (Blaming the Brain, 1998, p 161)
This contrasts markedly with general medicine. For instance, there is a disease called Wegener’s granulomatosis which is caused by inflammation of the blood vessels. In the large vessels the inflammation does relatively little harm, but the small vessels can become completely occluded, leading to significant damage in kidneys, lungs, nerve endings, etc.. People with this disease may present very different clinical pictures, but the underlying disease process is essentially the same and the same antibody will be found in their blood stream.
It is widely assumed among the general public that some kind of similar commonality is present in schizophrenia, and that psychiatrists and other mental health professionals are aware of this pathological link. This is simply not the case. Selecting two “symptoms” out of five leads to ten different presentations. Selecting two or more out of five yields 25 different permutations. Whilst one can acknowledge that a measure of overlap and commonality might exist in these various presentations, there is no evidence that all of these people have the same underlying pathology. They are assigned the same diagnosis and deemed to have the same “mental illness,” simply because the APA says so.
The central point of this blog is that the concept of mental illness is essentially spurious, and that the vast majority of the problems set out in DSM are problems of daily living and learned behavior. The so-called diagnoses are routinely presented as explanations of abnormal or unusual behavior, when in fact they are nothing more than labels.
Let’s examine the schizophrenia “symptoms” one by one.
A delusion is a false belief. Now the only way you can discern a person’s belief is through his speech, writing, or other overt indication. All of these indicators are behaviors. Speech is behavior, and our patterns of speech are subject to the same behavioral influences as any other behaviors. So when people express nonsensical ideas (or more accurately, when they speak nonsense) we need to ask why. Under the DSM system, we don’t ask why. The delusional speech is simply a “symptom” of the “illness” called schizophrenia, and nothing remains except the prescription of major tranquilizers. In fact, it is widely believed, and promulgated to students, that nothing can be done to ameliorate delusional speech.
The reality is quite different. For decades numerous researchers have demonstrated that delusional speech can be reduced and eliminated through appropriately designed behavioral interventions. Ayllon and Haughton (Modification of symptomatic verbal behavior of mental patients in Behavior Research and Therapy, 1964, 2, 87-97), for instance, achieved a 60% reduction in a hospital patient’s delusional speech by training the staff to ignore these kinds of remarks over a period of 6 months. The individual in question routinely referred to herself as “the Queen,” and would question staff as to why she was not being afforded treatment befitting this exalted position. This had been going on for fourteen years. The staff were trained to simply not respond, to look away, to appear bored, to shift their attention elsewhere, etc., whenever she made these kinds of delusional statements, but to respond normally to non-delusional speech.
The essential point is that delusional speech is behavior and follows the same general principles as any other behavior. In particular, speech which attracts positive attention and approval is more likely to increase in frequency, while speech which attracts no attention or disapproval tends to be eliminated. This is as true of everyday conversations as it is of the delusional speech of mental health clients.
In the same article mentioned above, Ayllon and Haughton describe two mental hospital clients, one with a diagnosis of schizophrenia, the other depression. Both were females and both spent a good deal of time complaining about their health, even though no physical problems had been detected. This had been going on for years. Here again, the hospital staff were trained to ignore the somatic complaints, and to respond positively and attentively to normal speech. The incidence of delusional speech declined rapidly, and by 18 months had been reduced to virtually zero. This research was done 45 years ago! More recent examples can be found at Wilder et al (Journal of Applied Behavior Analysis, 2001, V 34, No 1, 65-68) and Mace and Lalli (Journal of Applied Behavior Analysis, 1991, V 24, No 3, 553-562)
What’s particularly noteworthy here is that mental health staff unwittingly but routinely reinforce delusional speech. Under the DSM system, this kind of behavior is considered a symptom, and the staff tend to “prick up their ears,” so to speak, when clients emit this kind of speech. The staff member may even take notes. Mental health clients are as adroit as anybody else at reading signs of attention and approval, and staff become the unwitting coaches for delusional behavior. This kind of interaction is a direct consequence of the DSM system, under which schizophrenia is conceptualized as an incurable disease, one of whose symptoms is the presence of delusions. If one focuses instead on delusional speech as a dysfunctional behavior which is learned, then the appropriate response becomes clear: ignore the delusional speech and encourage normal speech. Note that this is not the same as trying to talk the individual out of his delusions – trying to persuade him that he is mistaken. These kinds of attempts are generally unsuccessful, because they provide attention and therefore reinforcement.
In Western culture the three great challenges of early adulthood are: emancipation from parents; launching a career; and finding a life partner. At the risk of stating the obvious, some individuals are more successful in these endeavors than others. Most young people, however, manage to stumble through these difficult times and to emerge into adulthood with a reasonable measure of success in these three areas.
Some hapless individuals, however, fail miserably in one or more of these challenges, and a small number of people fail in all three. Whenever we fail – whenever we don’t succeed in meeting an objective – whether the matter is large or small – we always have two options. We can recognize the failure and take corrective action, or we can reorganize our thinking so that the failure gets relabeled as something else. This fundamental truth is expressed nicely in the old adage: A bad carpenter blames his tools. If I decide, for example, to make a window box and the project is a disaster, I can acknowledge that I need to improve my carpentry skills, perhaps even attend some classes, or I can complain that the tools were no good or the lumber was defective, or that my wife is a nag for asking me to do the project in the first place, etc.. In other words, I can change my behavior (in this case my carpentry skills) or I can change my thinking. In general the latter is usually easier than the former.
In the case of the window box, the outcome is relatively trivial. In the case of major failures, however, the outcome is very significant, and the cognitive distortion can be considerable.
Consider the example of a young man who leaves home after graduating from high school, and finds a job in another town. He is filled with hope and a sense of independence, but after a couple of months he is fired. He is so dispirited that he doesn’t seek another job, and a month of two later is evicted from his apartment. Finally, in desperation, he calls “home” and his parents wire him the bus fare and pick him up at the bus station. For good measure, let’s also say that his girl friend has dumped him
Now if he’s an exceptional young man, he might say something like this:
“Thank you mother and father for rescuing me. I really didn’t have the discipline, stamina, or interpersonal skills necessary to succeed in the adult world. If it’s all right with you, I’d like to stay here with you for another year and work on my skill deficits. I’ll get a job and pay you rent, and I’ll join Toastmasters to help me develop some confidence in my dealings with other people, and I would greatly appreciate any feedback or coaching that you could give me.”
Unfortunately a more likely scenario is that he sulks in his room, neglects his personal hygiene, and persuades himself that he would have been ok if people hadn’t had it in for him. In a context of significant failure, these kinds of paranoid thoughts feed on themselves, and in extreme cases reach a level that would be described as delusional. A good measure of family tension usually ensues. Sometimes this degenerates into overt hostility, which further feeds and confirms the young person’s paranoia.
At this stage, he (or she) discovers that delusional speech has a significant pay-off. It reduces expectations. He is no longer expected to find a job, set up home for himself, or find a life partner. He is referred to the mental health system, where he is given a diagnosis and a prescription for a major tranquilizer. He may also be awarded disability status with financial and medical benefits. By this stage the chances of emancipation and functional independence are slim. (The major tranquilizer, of course, dampens down the problem behavior. But real improvements in functioning are rare, and the side effects of the drugs can be truly devastating.) If the parents ask why their son is so paranoid and withdrawn and unmotivated, they will receive the reply: “because he has schizophrenia.” This looks like an explanation, but if the parents were to press the matter and ask: “how do you know he has schizophrenia?” the only possible reply is: “because he is so paranoid, withdrawn, and unmotivated.” The “diagnosis” of schizophrenia is nothing more than a label describing the very behaviors it purports to explain. And a destructive label at that, in that it stifles and suppresses genuine exploration into the true cause(s) of the problem, and genuine remediation of the original skill deficits.
It needs to be stressed that I’m not suggesting that our hypothetical individual is deliberately and consciously faking his “craziness.” It is simply the case that behavior that is reinforced tends to increase in frequency whilst behavior that is not reinforced or which attracts negative consequences becomes less frequent. In the case in question, the behavior of launching out on one’s own, finding a job, and a partner, etc., all ended disastrously. But the behavior of sulking in his room expressing angry paranoid thoughts was rewarded with attention, solicitous concern, home-cooked meals, and an extraordinary measure of power and control over his parents. The outcome is not surprising. An essential point here is that delusional speech and normal speech are on a continuum. People express mildly delusional ideas all the time. Listen to any talk radio show. Listen to politicians railing against their opponents. Listen to religious zealots. Listen to racial stereotypes. Listen to people who insist that the Earth is only 6000 years old. Listen to golfers after they’ve played a bad stroke. Listen to people who get passed over for promotion, etc., etc., etc.. The processes that promote this kind of mildly delusional speech can lead to severe delusions if the conditions are ripe.
It is noteworthy that our young person’s real problem – i.e. a marked lack of general coping skills – never gets addressed. The skills we’re talking about here include:
– critical self-appraisal
– bringing tasks to completion
– not procrastinating
– making good dietary decisions
– managing money; budgeting
– interacting appropriately with supervisors and other authority figures
– interacting with peers; resisting negative peer pressure
– managing a checking account
– getting to bed at a reasonable hour
– “chatting up” prospective sexual/relational partners
– personal hygiene
– buying and maintaining a car
– house-cleaning and general management of personal space
– choosing friends
– good management of time
– etc., etc., etc.
Our culture is generally unsympathetic to individuals who are in trouble because of basic skill deficits. We have helpful programs for vocational skill deficits, but not for the more fundamental skills, such as those listed in the previous paragraph. Individuals with these kinds of deficits are usually subjected to censure and negative labeling (e.g. lazy, dirty, slovenly, prodigal, brash, stupid, klutzy, etc.)
The point here is that the three great challenges: emancipation from parents, launching a career, and finding a life partner – are just that: great challenges. They are not easy. But this fact is seldom acknowledged. The cultural expectation is that young people should be able to do all this without difficulty. And the fact is that most of us do manage to muddle through these years with at least some measure of competency. Others, however, don’t, and some of this latter group crash disastrously and become mental health clients for life. In this regard it is noteworthy that the majority of people who are assigned a “diagnosis” of schizophrenia are “diagnosed” in their late teens and early adulthood – precisely when the basic skills demands are greatest.
Of course the bio-psychiatric school would contend that these individuals were already “sick” before they started their emancipation endeavors – that they had a brain disease which impacted their ability to function effectively. This position may be correct. But the APA’s definition of schizophrenia includes the criterion that “the disturbance is not due to … a general medical condition.” So delusional behavior that is caused by a brain malfunction is not (by definition) schizophrenia. If indeed it could be established that there are individuals with compromised brains and that this neurological damage was truly the cause of problems in living, then the disease needs to be recognized as such, given an appropriate name (e.g. Smith’s neuropathy or whatever), diagnosed neurologically, and treated appropriately. Meanwhile, assuming a neurological deficit on the basis of unusual or abnormal behavior is intrinsically unsafe. When we are considering people’s behavior, there are always multiple paths to the same place. Consider eleven people on a soccer team playing a game on a Saturday afternoon. They are all engaged in the same activity (playing soccer), but the sequence of events that led them to this point will be extremely diverse. One player, for instance, might be motivated largely by a desire to please his father, while another might be there primarily to annoy his father. A third might be simply trying to lose weight. A fourth is showing off for his girlfriend. A fifth may be trying to dissipate feelings of anxiety and tension, etc., etc., etc..
Similarly, it is clear that genes and physiology have an impact on people’s actions, and it is possible that one person’s delusional speech is the direct result of a brain malfunction. Another person, however, could be emitting very similar behavior without any neurological problem; the delusional speech in the latter case being the outcome of the kind of failure-ridden psychosocial history described earlier. The brain is a pattern-seeking apparatus. It looks for regularities and patterns in the data it receives and stores these patterns for later use. When it can’t discern a pattern (for whatever reason), it makes one up. In the case of our hypothetical young person mentioned above, the correct pattern was his significant lack of skills in a wide range of areas. This is a difficult thing to accept, so his brain invented the notion that other people were out to get him – were sabotaging his efforts. From his point of view this is a perfectly valid explanation for his failures. Of course, it’s not the true reason, and other people see him as paranoid and delusional, and if he is referred to the mental health system, he is given a diagnosis of schizophrenia.
The problem areas which the APA label as schizophrenia constitute an extremely complex topic, and inevitably this blog post has become very lengthy. I have more to say on this matter, but I thought I’d post this and continue with more thoughts on schizophrenia in the next post. Meanwhile, your comments – as always – are welcome.
Next post: Schizophrenia is not an illness (Part 2)