Schizophrenia split psychiatry

F E AT U R E How schizophrenia split psychiatry A hundred years after Bleuler coined the term ‘schizophrenia’ in Berlin, Dr Robert Kaplan reflects on the concepts that have divided the profession, and on the unifying potential of a new discovery Insanity… provides us with the proper scale for comprehending the numerous intellectual, moral, religious, and artistic currents and phenomena of our social life. Emil Kraepelin I n what may be the most important psychiatric news of the new century, a large Swedish study has shown that schizophrenia and bipolar affective disorder (manic-depression) share the same genes. This may not be of interest to anyone outside psychiatry, but the implications affect all humankind. Now that all psychoses are shown to have the same genetic origin, it is clear that another cause is responsible for the different symptoms and outcomes that occur. And that cause is laterality – the extent to which the human brain is rotated along the front/back axis to determine the language centre. In order to understand this, a brief account of psychiatry’s first century is required. It effectively started on 24th April 1908, when Swiss psychiatrist Eugen SCOPE Bleuler delivered a lecture describing schizophrenia, a disease “characterised by a specific type of alteration of thinking, feeling and relation to the external world”. Schizophrenia, the most severe psychiatric illness, has been recognised since antiquity and there are credible descriptions in the Mesopotamian Assyrian Codex. However, until the 19th century, psychosis was regarded as merely another form of lunacy. Bleuler’s work, however, was co-opted by Emil Kraepelin, who was to be the most forceful and dominating figure in psychiatry for the next century. Kraepelin (who instead used the term “dementia praecox”) made the distinction that has haunted psychiatric practice ever since. Schizophrenia meant an irretrievable descent into madness, while manic depressive episodes were self-limiting without the accompanying breakdown of personality. Kraepelin’s findings became the leitmotif of 20th century psychiatry, assuming paradigmatic status. Like all psychiatrists of the time, Kraepelin cut his research teeth by studying syphilis. Kraepelin had no doubt an organic cause would be found for psychiatric illnesses, and saw general paresis of the insane (GPI) as a template condition for the other illnesses. Examining mental patients in Java (in the process establishing transcultural psychiatry), he observed that Indonesian GPI patients had identical symptoms to German patients. Kraepelin believed that syphilis caused GPI and stated as much in 1904: “Syphilitic infection is essential for the later appearance of paresis.” Kraepelin had deeply bureaucratic 41 F E AT U R E instincts and established a comprehensive basis for a modern specialty. He developed training programmes, set up a prestigious research institute, lobbied the government for mandatory syphilis testing and constantly planned trips to exotic locations to see how psychiatric illness manifested in other cultural settings. Following in the footsteps of Virchow and Koch, who respectively established pathology and microbiology, Kraepelin was the last of the German medical giants; the delay behind the other two understandable in view of the reluctance with which psychiatric disease yielded up its secrets. The success of Kraepelin’s approach derived from his specific views on the relationship between psychological and social phenomena, and biology. The dichotomy did very well for 20th century psychiatry: schizophrenic patients were psychotic, frequently had a negative outcome and responded to antipsychotic medication; bipolar patients mostly recovered between episodes and responded well to lithium. But over time it became evident that there was a procrustean deal: the available facts were distorted to fit the preconceptions of the dualists. Before long there arose schizo-affective disorder, an unhappy compromise to explain patients who fell between the two conditions. Then there were the genetic data. Neither condition bred true; bipolar families, for example, always had a higher incidence of schizophrenic relatives. The regular announcement by researchers that they had “finally” isolated the genes for one or other condition turned out to be a mere shuffling of the epigenetic pack. Manic depressive patients responded just as well to antipsychotic medication as did schizophrenics. Those attempting to maintain the distinction were forced into increasingly desperate attempts to maintain the sanctity of the dogma, but the emperor, to those who were prepared to look objectively, clearly did not have any clothes. There are two sorts of psychiatrists, those by inclination, and those by chance; those entering psychiatry by chance are sometimes reasonable. Emil Kraepelin By the end of the 20th century, the situation could only be compared with another longer, scientific dispute – the fall of classical Newtonian physics a century ago. After three centuries it was obvious to many 42 Above: Emil Kraepelin popularised, though did not himself introduce, the term dementia praecox (‘premature dementia’) when referring to schizophrenia. German neurologist and psychiatrist Arnold Pick reportedly first used the term in 1891. Eugen Bleuler (oval inset) introduced the term ‘schizophrenia’ in 1908, realising that the condition was not a dementia and did not always occur in young people. Thomas Kuhn’s The Structure of Scientific Revolutions (1962) was a groundbreaking work in the philosophy of science. Kuhn used the term ‘paradigm’ to define a set of basic assumptions within the ruling theory of science physicists that the available data just did not fit Newton’s model; for example, the influence, however slight, of gravity on light. Any dissenters, however, were ruthlessly suppressed as heretics or malcontents. It took Einstein’s stunning relativity papers of 1905 to blow the situation wide open – and dissent persisted for years afterwards, even after the 1919 experiments showed the bending of starlight during a solar eclipse. This is the current state of thinking in psychiatry. Oxford psychiatrist Tim Crow has for several decades pursued a controversial, if not lonely, path to find the cause of schizophrenia. According to Crow, schizophrenia arises from a genetic mutation – protocadherin XY – that determined the extent of lateralisation of the early hominid brain. Humans go into the world with their brain lateralised to a varied degree on the dominant side. The implication of this is that there is only one psychosis which can manifest in various symptoms and outcomes depending on the extent of laterality, not on a genetic distinction breeding two distinct conditions. You are pitiful isolated individuals; you are bankrupts; your role is played out. Go where you belong from now on – into the dustbin of history! Leon Trotsky Thomas Kuhn, who developed the concept of scientific paradigms in The Structure of Scientific Revolutions, showed how reluctant the current establishments were to surrender a concept on which they had staked their careers, whether for reasons of opportunism, personality or simply lack of intellectual ability. These new findings have, as it were, flushed the classicists out of their bunkers and their predictable reaction is to man the ramparts with all the weapons at their disposal for some time. But the end result is already known; it is a new era, requiring a flexible mental approach and, most of all, an understanding of the deeper meaning of these new findings. The laterality gene results in a range of profoundly human capabilities. These include intellectual ability, creativity, emotionality, psychosis and a range of phenomena variously referred to as schizotypal, eccentric or magical traits. Schizophrenia and schizotypy are linked with increased creativity and increased right hemisphere dominance. Those who lie between the extremes of normal and schizophrenic tend to be schizoid, artistic, creative, eccentric or just plain different, but not psychotic, individuals. The neurological components of creativity and spirituality include religiosity, hypergraphia and capacity to develop trance states. Add all of that together and we start to see how there arose the first specialised role among humans: shamanism, the cultural adaptation of hunter-gathering societies to the biological potential for altered states of consciousness. Through such altered states of consciousness the shaman would commune with the spirits to heal tribal groups, divine the weather, follow totemic animals and heal illness. The shaman became the magician, witchdoctor, sage, healer, and tribal seer – the forerunner of the artist, prophet and healer, special individuals in our society. Schizophrenia is more – much more – than a name for the emblematic psychiatric disorder. It will remain the ürword for psychiatry. At long last we can find an honoured place for it in the spectrum of human nature. To quote Tim Crow: “Schizophrenia is not just an illness of humans, it may be THE illness of humanity.” + Dr Robert Kaplan is a forensic psychiatrist, writer and historian at the Graduate School of Medicine, University of Wollongong, New South Wales, Australia SCOPE