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Write an assessment for the future publication of DSM-VI on the current status and future of the diagnosis and

treatment of Schizophrenia.

Dionne Angela Donnelly Module Code: PSYC303 Word Count: 2545

In order to understand the current status (and subsequently, the future) of Schizophrenia, we need to consider it in terms of its past (Kyziridis, 2005; see also, Carr, 1990). Furthermore, in todays and, more importantly, the futures multi-cultural, global (and possibly stellar, Ziolo, 2011b) society, our epistemology and more specifically our nosology needs to be one of consilience (Whewell, cited in Ziolo, 2011b), including but not limited to consisting of aspects not only of our own Western culture, but also other cultural traditions (Kupfer & Regier, cited in Yan, 2007; Ziolo, 2011). This is especially so if it is to ensure that patients get proper diagnoses and treatments for their mental health concerns, (Kupfer, head of the DSM-V Task Force, cited in Yan, 2007).

Using the current Diagnostic and Statistical Manual IV, Revised Edition (DSM-IV-TR), Schizophrenia as we understand it today has a prevalence rate of between 0.5 and 1.5 per cent of the population (Camacho, Len, & Uribe, 2005) and therefore has a significant impact on a vast number of people. This assessment will take the form of a psychohistorical analysis of Schizophrenia (which can also be seen as a symbol for Psychology as a discipline) based on the critical realist perspective (as advocated by Moses & Knutsen, 2007). Such psychohistorical analysis allows us to zoom out from our current focal point in society and see things from a wider perspective (in a way similar to fractal imagery), which can then aid our current understandings and drive future change. This is necessary today as Schizophrenia has been in our society now for generations and so the original context and connotations of its categorisation may not be fully realised. Due to the huge scope available to us from this position, the focus here will be on how our current diagnosis and treatments of Schizophrenia are dependent upon its beginnings as a psychological category (or Psychological Kind - PK); how ultimately we should 1

focus on using pluralistic diagnostic criteria and patient-focused treatments; and how we can extend our current knowledge (and methodological pluralism) (Feyerabend, 2002; Moses & Knutsen, 2007) towards progress and interdisciplinarity (concilience) in the future. Which, while it does not seem like a very radical aim, will be a long and difficult task and should suffice until another assessment is called for.

The current diagnosis of Schizophrenia is based on over 100 years of empiricist research into a group of observable and seemingly opposite positive and negative symptoms (Berrios, Luque & Villagrn, 2003; see also, Bentall, 2003). Empiricism requires a complete divorce of subject and object, in order to observe and describe an objective reality (Hume, cited in Moses & Knutsen, 2007) so our current view of Schizophrenia is based on evidence which is abstracted from actual human experience. In the social sciences, and for the diagnosis of mental illness in particular (Hacking, 1997), it is argued that subject and object have a reciprocal relationship (Carr, 1990; Danziger, 1997; Moses & Knutsen, 2007). An appreciation of this is seen in the Psychodynamic Diagnostic Manual (PDM, n.d.; see also, Gordon, 2010). Carr (1990) argues for the critical realist idea that whilst something may take on different shapes from different viewpoints, it still has an objective shape, its just that often we are still too under-developed to conceptualise it accurately (Ziolo, 2011b). So, whilst there are descriptions of individuals suffering hallucinations and delusions dating from antiquity, the PK known as Schizophrenia only came about in the 19th century, and is thought to begin with Kraeplins detailed observations of dementia praecox in 1887 which culminated in Bleulers creation of the category of Schizophrenia (derived from the Greek, split and mind, Moskowitz, 2008) in 1911 (Jeste, Carmen, Lohr & Wyatt, 1985). This is a similar argument to Smiths (2006). He proposed that there was no Psychology before the 2

18th century, despite there being evidence of psychological endeavour. The development of such a psychological science in action was most probably encouraged by competitive individualism and consumerism (Ziolo, 2011a). Due to the changing nature of PKs, and Schizophrenia in particular, the DSM can be viewed like a dictionary of illnesses, documenting things that have already changed, and therefore only giving us reference to the past. Bentall (2003), makes further criticisms of our current diagnostic system, arguing that we should instead work on a symptom based, rather than categorical approach, as in order for the DSM to attempt to account for the diversity of human experience it requires ever increasing numbers of subtypes and comorbid diagnoses. However, this does not mean that the DSM cannot be a useful heuristic tool. It could be used in conjunction with a more patient-based nosology such as the PDM (which is how the PDM is recommended to be used) (PDM, n.d.). Such unification would be the first step towards a pluralistic, foundation-based science. However the next step towards conscilience can only occur if the opposing ideas can be subsumed into a new set of categories from which the previously opposing groups can work and build on, that has a firm foundation; possibly, the shared history and philosophy of the subject (Ziolo, 2011b).

At the present time though, it is still necessary to point out that we are working from the perspective where Schizophrenia is a PK (or an example of Bohms, 2002, implicate order) not a Natural Kind (NK, or explicate order) such as would be studied by the natural sciences (Danziger, 1997; see also, Brown & Stenner, 2009; Hacking, 1997). This does not mean that Schizophrenia is not a real entity, just that it is embedded in layers of cultural meaning, which when they change, act back on the individuals who have been categorised, which then changes the meaning again, in a looping effect (Brinkman, 2005; Hacking, 1997). This needs serious 3

consideration when dealing with the categorisation of something that is so stigmatised as a diagnosis of schizophrenia. When the term was generated it was in within a wider framework of degeneration, with the Schizophrenic as the antithesis of the idealised person (Barrett, 1998a, p. 618), and this association is now being perpetuated again through the lens of neuroscientific degeneration (Barrett, 1998b; see also, Carr, 1990). Wallace and Shapiro (2006) state that we should think of mental health more in terms of a continuum between mental balance and imbalance, as seen in Eastern cultures/religions such as Buddhism. This should guide us into the realisation that the origins and current status of these cultural meanings should always be at the forefront of our research, especially if we are to attempt to fully understand Schizophrenia and thus establish treatments aimed at reducing the suffering of a large group of people. This is all the more important as the American Psychological Association (APA, 2010) is an institution with great power and influence in our society. Due to this influence its output is more likely to be incorporated into general societys conceptions of Schizophrenia. (Danziger, 1997).

The propagation of such changes in how a concept is received can be clearly seen following the Renaissance and Reformation. Before the scientific method was applied to areas of psychological interest, signs that would be now interpreted as Schizophrenic were seen as religious or supernatural phenomena (Kyziridis, 2005; see also, Jeste et al., 2005, Kendall, 2001). In fact, many schizophrenics still have religious delusions (Jeste et al., 1985). From this it can be argued that the categorisation of such signs as mental illness only came about after the Great Transformation, i.e. the change from the theological to a scientific-rational viewpoint that led to the search for absolute certainty (MacIntyre, 2007). This leads to the question of whether we can ever find absolute certainty, as today we have many empirical 4

methods but are still uncertain about the correct origins, classifications, and treatments of the majority of diseases of the mind. From this viewpoint, it would seem that we need to consider the importance and relevance of other methodologies, epistemologies and even ontologies beyond the dominant naturalistic paradigm that is currently being perpetuated by the APA within the DSM-IV-TR. We should do this in order to gain a fuller picture of what we are trying to classify and treat. For instance, a consideration of how Schizophrenia is viewed from another cultural or religious standpoint would greatly enrich our knowledge, and help us to understand what aspects of the illness are common or dissimilar across humanity.

Before diagnostic classification was the norm, hallucinations and delusions often were, and sometimes still are, viewed as Divine Madness (Kyziridis, 2005). In the indigenous people of Australia it is thought that such visions are shamanic, marking the individual as a healer (Lukoff, Roberts, 2000; Walter & Neumann Fridman, 2004). During art therapy (which is one current alternative treatment for schizophrenia) some of the art produced has been argued to be similar to the imagery produced by indigenous shamans (Walter & Neumann Fridman, 2004). . Shapiro (cited in Moses & Knutsen, 2007; see also Brown & Stenner, 2009) believes that novels and myth have a legitimate and convincing voice in scientific discourse, but mainstream Psychology chooses not to hear it. Lukoff (1991) himself had a psychotic episode where he believed he could be the next messiah. . He states that most psychiatrists have to confront an abyss of difference (p. 7) between themselves and the patient, one that he did not have to cross in order to understand his patients needs. His knowledge of the past has helped him change his own and others future. Psychology and psychiatry could learn a lesson from such a case.

Another aspect the discipline could learn from is the transformation in the West from a theological to a scientific worldview, in which science has taken on the functional role that religion used to perform (Ziolo, 2011a). Roberts (2000; see also Feyerabend, 2002) states that mainstream psychiatry is the new form of religion, i.e. a new form of social control. Roberts (ibid.) argues that mentally ill people are the heretics of the modern age, with deviation from our conceptions of normality likened to deviating from the Bible. She also postulates that psychiatry has adopted the disguise of medicine and our new totem - Science. Thus it has generated the idea that mental illness can be cured by chemical fixes; the anti-psychotics. Roberts (ibid.) also refers to the materialist Holy Trinity the pharmaceutical companies, the managed care industry and psychiatrists, who have all profited from the existence of Schizophrenia (an example of power that the use of the Trinity still has as a rhetorical tool, Ziolo, 2011a).

The rhetorical nature of the above argument can be validated by surveying sales figures of antipsychotic drugs. Global pharmaceutical sales in 2009 were worth $808b. Globally, antipsychotics were the leading class of psychopharmacological agent sold (worth $23b) (IMS Health, 2010). In 2007 in the UK, 67% of all anti-psychotic prescriptions were for atypical antipsychotics, 4 million prescriptions worth 213.75m. In contrast, there were 1.99 million prescriptions for typical anti-psychotics, worth only 12.66m (National Institute for Health and Clinical Excellence [NICE]), 2008. Also, the UK figures do not include drugs prescribed in hospitals. It has been found that atypical drugs have only a small efficacy advantage (Bentall, 2003), and their fewer side effects (which Keks, 2004 argues are their main selling point) are highly dependent on the dosage administered (Carr, 2004). Furthermore, Bentall (2003) states that the in the trials that compare these two types of drugs, typical psychotics are usually 6

administered in much higher doses than necessary for a therapeutic effect, thus increasing the likelihood of extrapyramidal side effects (EPS), and making it more likely atypical drugs will be bought instead. In the US, the pharmaceutical industry funds two-thirds of medical research (Yan, 2007). This clearly puts pharmacological treatments at an advantage over more evidencebased psychosocial treatments with their foundations in psychodynamic principles (like family psychoeducation, personal therapy and cognitive enhancement therapy) (Eack, Schooler, & Ganguli, 2007). In the US, insurance companies often refuse to pay for their clients to receive such treatments (ibid.) This could mean that anti-psychotics are so widely used because they pushed by the pharmaceutical companies in order to earn money, not due to their therapeutic effects at all (Bentall, 2003). This is especially a problem when the patients themselves do not believe the treatment is right for them, which can be seen in the emergence of anti-medication websites such as New anti-meds vogue coming up! (n.d.) and Successful Schizophrenia (2009) and numerous posts on website forums (search no meds on Google). We need to pay attention to this. As Geoff Bunn (personal communication, 2011) said Psychology needs to attend to experience. This means that the treatment of Schizophrenia is being influenced by those who have their own private agendas and have the money and influence to guide the research process in their desired direction. Lakatos would argue this is one of the signs of a degenerative group (Ziolo, 2011b).

There is still time for the DSM-V Task Force to show that it can be a progressive group and make a significant change to our current multi-paradigmatic structure (although this is unlikely as it has been a functioning group for approximately 12 years and has not reached its original goal yet). So it would seem that it for the next group of DSM compilers to try and truly advance 7

our knowledge of both Schizophrenia and Psychology. Some would argue that the only way to do this is to make the huge shift from studying the pathology of deviance to studying that of the normal, as it is this what defines what is deviant in the first place (as posited by Freud) (Ziolo, 2011b). However, such a situation is highly unlikely to occur within such a large group as a DSM Task Force, which, at this time involves the contributions of over 1000 researchers. The task of keeping the group together is likely to take up most of the groups efforts, as opposed to the original task at hand (Ziolo, 2011b). Futhermore, group dynamics, and the societies they are embedded within are complex (Moses & Knutsen, 2007), and our actions can often have completely unintended consequences (Butterfield, cited in Carr 1990; see also, Elias, 2000) from our intentions and actions can arise something more complex than ever imagined (Moses & Knutsen, 2007), an emergent order that we do not yet fully understand, but that we could possibly hope to if consilience were to ever occur within our discipline.

To conclude, I have to agree with Danziger, when he states this is not the end of history... the categories of Psychology will continue to change. In this process, old categories will acquire new meaning and some will be discarded altogether. New categories... may represent traditions that were in eclipse for much of the twentieth century. Moreover, changes in psychological categories will... be heavily dependent on changes in the societies within which they have a role. Their meaning will continue to be negotiated and contested among the groups to whom they matter. As the identity of these groups changes, both nationally and globally, the kinds that seem so natural today will become tomorrows legends. (Danziger, 1997, p. 193). It is up to both us and the DSM Task Force to ensure that these categories change for the better.

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Carr, V. (2004). Are atypical antipsychotics advantageous? - The case against. Australian Prescriber, 27, 149-151. Danziger, K., (1997). Naming the Mind. London: SAGE. Eack, S. M., Schooler, N. R., & Ganguli, R. (2007). Gerard E. Hogarty (19352006): Combining Science and Humanism to improve the care of persons with Schizophrenia. Schizophrenia Bulletin, 33(5), 10561062. Elias, N. (2000). The Civilizing Process (Revised ed.). Oxford: Blackwell. Feyerabend, P. K. (2002). Against method (3rd ed.). London: Verso. Gordon, R.M. (2010). The Psychodynamic Diagnostic Manual (PDM). In I. Weiner and E. Craighead, (Eds.) Corsinis Encyclopedia of Psychology (4th ed., volume 3, 1312-1315), Hoboken, NJ: John Wiley and Sons. Hacking, I. (1997). Kinds of people: Moving targets. Proceedings of the British Academy, 151, 285-318. IMS Health (2010). Top-line market data. Retrieved from http://www.imshealth.com/portal/site/ imshealth/menuitem.a46c6d4df3db4b3d88f611019418c22a/?vgnextoid=e599410b6c718210Vgn VCM100000ed152ca2RCRD&cpsextcurrchannel=1 Jeste, D. V., del Carmen, R.,Lohr, J. B., & Wyatt, R. J. (1985). Did schizophrenia exist before the eighteenth century? Comprehensive Psychiatry, Vol. 26(6), 493-503. Keks, N. A. (2004). Are atypical antipsychotics advantageous? - The case for. Australian Prescriber, 27, 146-149.

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Kendall, R. E. (2001). The distinction between mental and physical illness. British Journal of Psychiatry, 178, 490-493. Kyziridis, T. C. (2005). Notes on the history of Schizophrenia. German Journal of Psychiatry, 8, 42-48. Lukoff, D. (1991). Divine madness: Shamanistic initiatory crisis and psychosis. Shaman's Drum, 22, 24-29. MacIntyre, A. (2007). After virtue: A study in moral theory (3rd ed.) London: Duckworth. Moskowitz, A. (2008) Association and Dissociation in the Historical Concept of Schizophrenia, in Psychosis, Trauma and Dissociation: Emerging Perspectives on Severe Psychopathology (eds A. Moskowitz, I. Schfer and M. J. Dorahy). Chichester: John Wiley & Sons. Moses, J. W. & Knutsen, T. L. (2007). Ways of knowing : Competing methodologies in social and political research. Basingstoke: Palgrave Macmillan. National Institute for Health and Clinical Excellence (2008). NICE implementation uptake report: Atypical antipsychotic drugs for the treatment of schizophrenia. Retrieved from http://www.nice.org.uk/usingguidance/evaluationandreviewofniceimplementationevidenceernie/ niceimplementationuptakecommissionedreports/nice_implementation_uptake__commissioned_r eports.jsp?domedia=1&mid=410D1905-19B9-E0B5-D4D59339390BBB35 New anti-meds vogue coming up! (n.d.). Retrieved from http://www.masterjules.net/nomeds.htm Psychodynamic Diagnostic Manual (PDM) (n.d.). Retrieved from http://www.pdm1.org/ intro.htm

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Roberts, M. B. (2000). Australia's invisible religion: A parable about Divine Madness, Schizophrenia & Psychiatry's loss of soul. Retrieved from http://www.jungcircle.com/ Australia.html Smith, R. (2006). The history of psychological categories. Studies in History and Philosophy of Biological and Biomedical Sciences, 36, 55-94. Successful Schizophrenia (2009). Retrieved from http://www.successfulschizophrenia. org/index.shtml Wallace, B. A., & Shapiro, S. L. (2006). Mental balance and well-being. Building bridges between Buddhism and Western Psychology. American Psychologist, 61(7), 690-701. Walter, M. N., & Neumann Fridman, E. J. (Eds.) (2004). Shamanism: An encyclopedia of world beliefs, practices and culture. California: ABC-CLIO. Yan, J. (2007). APA announces DSM-V task force members. Psychiatric News, 42(16), 10-22. Ziolo, P. (2011a). Lecture 2: The psychohistorical origins of Western science. [Lecture Slides]. Retrieved from https://vital.liv.ac.uk/ webapps/portal/frameset.jsp Ziolo, P. (2011b). Lecture 10: The Future. [Lecture Slides]. Retrieved from https://vital.liv.ac.uk/ webapps/portal/frameset.jsp

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