Social construction of schizophrenia

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Social Constructionism, a branch of sociology, queries commonly held views on the nature of reality, touching on themes of normality and abnormality within the context of power and oppression in societal structures. The concept of a social construction of schizophrenia denotes that the label of 'schizophrenia' is one that has been socially constructed through ideological systems, none of which are truly empirical especially as currently there is no definitive evidence as to the cause(s) of schizophrenia.

Introduction[edit]

In 1966, Berger and Luckman coined the term 'social constructionism' in their seminal work 'The Social Construction of Reality'. In summary it examines the basis of fact and truth / knowledge within culture. Whilst some 'truths' such as 'fire is hot' are universally agreed as objective, many others considered 'fact' are the result of a common subjective experience and the subsequent validation of that.

Schizophrenia is one such term that can be viewed as a social construction. Walker has argued that psychiatric diagnoses are nothing but linguistic abstractions. He has criticized the DSM-IV's poor reliability and postulated that terms like 'schizophrenia' and 'mental illness' only exist by consensus and persist by convention. Further he argues that the pathologizing language which persists in the medical model of disability is unuseful in working towards a recovery model. [1]

Other notable practitioners and authors within the humanistic tradition that have viewed schizophrenia as a social construction include psychiatrist Thomas Szasz (1920-2012), Joseph Berke, R.D. Laing and Mary Barnes. Szasz viewed the diagnoses as a fabrication that is borderline abusive in terms of treatment. Szasz has protested against the taxonomic classifications of mental illness and reification of these as 'science' and has long argued against institutionalisation as a fundamental deprivation of liberty. In Joseph Berke's and Mary Barne's book: "two accounts of a journey through madness", Berke explores themes of psychosis as an enriching experience. Berke argues that the invalidation of schizophrenic experiences labelled 'sick or mad' is a uniquely western standpoint insofar as dream states and altered perception are not considered valid modes of interpolation of the truth within westernised culture.[2]

Laing (1964) commented “the mad things done and said by the schizophrenic will remain essentially a closed book if one does not understand their existential context”.[3]

Noll (1983) has explored the links between shamanism and schizophrenia, testing the research evidence on shamanism against the DSM-III diagnostic criterion. Though he draws comparisons between the two states of mind in terms of the phenomenon experienced, he draws out important differences between shamanic and schizophrenic states, notably that many people on the schizophrenic spectrum do not voluntarily enter an altered state of consciousness whereas research into shamanism unilaterally shows that shamanic states are induced and controlled voluntarily by the shaman, who ultimately maintains a healthy world view between a base line level of consciousness and an altered state of consciousness. He concludes that differences between schizophrenic and shamanic states such as 'volition', means that the DSM-III cannot be used to define shamanism as the same state as schizophrenia.[4] Robert Sapolsky has theorized that shamanism is practiced by schizotypal individuals rather than schizophrenics.[5]

Themes[edit]

Philosophy[edit]

Themes in social constructionism draw on various philosophies such as those espoused by Kant and Wittgenstein centred around the differences between objective reality or that which is known or absolute and subjective reality or that which is observed by the knower. In Schizophrenia: A scientific delusion?, Mary Boyle explores 'schizophrenia and its assumptions as truths or knowledges which are socially produced and managed'.[6]

Power and control[edit]

Post Structuralist Jurgen Habermas examines questions of identity in the concept of societal integration and discusses how change occurs when there is a legitimation crisis. It assists the understanding of the social construction of schizophrenia and other illness in also understanding forces that shape power imbalances in aetiologies. Phil Brown in 'Naming and Framing: The social construction of diagnosis and illness' points out how professionals were very slow and unwilling to accept the diagnosis of 'Tardive dyskinesia', despite many research indicated warnings on it, as it was iatrogenic (caused by) prescription drugs that had been plaudited to be successful in treatment of the associated condition of psychoses. Market forces in pharmacology and/or cultural embarrassment can shape the rate at which society adapts to include new frameworks such as those demonstrated in the DSM. [7]

Conrad writes on medicalization and social control. He looks at the process of science and medicalization. Science is heralded as the new religion in terms of ideological power and Conrad describes how medicalization can be used to police morals.[8]

The Self and Identity[edit]

Research directions here are on the importance of experiential narrative within psychiatric dialogue. Some Research is critical of modern psychiatric adoption of an 'empiricist-behavioural approach' within the DSM. Nelson, Yung, Bechdolf and McGorry examine this in context of a phenomenological approach to the understanding of ultra high risk psychiatric disorders. They criticize psychiatric research that addresses subjectivity:

"When attempts have been made to address subjectivity, the psychiatric researcher is left without the requisite conceptual tools. Instead, this form of research has tended to live out Abraham Maslow’s statement ‘‘If the only tool you have is a hammer, you tend to treat everything as if it were a nail.’’ That is, the subjective has been approached in operational terms..." [9]

Movement to reconstruct Schizophrenia[edit]

'Alternative Perception' is one of several names suggested by the schizophrenic user movement to replace the term schizophrenia which is on a spectrum of psychotic disorders[10] and is considered to be outmoded by many consumers of services. Several leading academic authorities, notably Professor Marius Romme founder and principle theorist for the Hearing Voices Movement provide a rationale for the abandonment of this label. A symposium of some of the leading notions in this field from consumers of services and academics concluded:

We are calling for the label of schizophrenia to be abolished as a concept because it is unscientific, stigmatising, and does not address the root causes of serious mental distress. The CASL campaign is driven by two central factors. The concept of schizophrenia is unscientific and has outlived any usefulness it may once have claimed. The label schizophrenia is extremely damaging to those to whom it is applied.[11]

Historical construction of Schizophrenia[edit]

The Terms Schizophrenia and Autism originated from the works of Eugene Bleuler (1857–1939) as different aspects of the same diagnostic condition. Bleuler was a contemporary of Sigmund Freud and Carl Jung. Prior to Bleuler's interventions schizophrenia was referred to as Dementia praecox (early insanity) and perceived as a single disorder. Schizophrenia is sometimes also referred to as hebephrenia, stemming in etymology from the Greek god Hebe who was associated with adolescence and as it was thought the onset of schizophrenia came at adolescence. It is generally acknowledged that Schizophrenia can have early onset and late onset.

"He first advanced the term schizophrenia in 1908 in a paper based on a study of 647 Burghölzli patients. He then expanded on his paper of 1908 in Dementia Praecox oder Gruppe der Schizophrenie…Bleuler is credited with the introduction of two concepts fundamental to the analysis of schizophrenia: autism, denoting the loss of contact with reality, frequently through indulgence in bizarre fantasy; and ambivalence, denoting the coexistence of mutually exclusive contradictions within the psyche." [12]

Charities committed to changing public perception[edit]

Charities that disagree with the notion of the schizophrenia label in the U.K. include Mind (charity) and Rethink. Mind state on their website "Because of differences of opinion about schizophrenia, it's not easy to identify what might cause it." Mind have previously published an explanatory leaflet, prefaced by Michael Palin that gives a definition of schizophrenia as people 'who think outside the normal range of human experience'.[13] The National Alliance on Mental Health say:

"By changing the name, consumers with the symptoms of what actually may be a spectrum of disorders would have a more accurate and descriptive name attached to their diagnosis. Ideally, they would also experience less stigma, as they left behind a name with Greek origins that roughly translates to “shattered mind” and which is often used in popular culture to mean "multiple personality disorder" or "split personality.".[14]

Science of schizophrenia and comorbid conditions[edit]

Whilst the definitive cause(s) of schizophrenia remain unknown, research has indicated links between genetic make-up, social predisposing factors/stressors, and environmental conditions in relation to the development and onset of schizophrenia and other conditions. Geneticists are working towards identifying a gene for schizophrenia, and combined efforts are reported at the SzGene database. In the course of this research geneticists have identified specific genes/copy number variants/alleles that may explain the comorbidity of various conditions.

Chromosome 16
Ideogram of human chromosome 16

Links between autism and schizophrenia have been studied. From clinical observation, both conditions cause a disruption in normative social functioning which may be mild or severe depending on the individual's position within the spectrum. Social cognition is under-developed in autism and highly developed in psychoses. Four genetic loci are diametrically opposed in terms of diagnoses of autism and schizophrenia, with corresponding deletions for one condition or duplications for the other. Researchers examining chromosome 16 (16p11.2) identified a heredity area on the short arm of human chromosome 16 (16p11.2) which contains microduplication and microdeletion of genome variation. Microduplication of hereditary factors in this heredity area increased the individual's risk of schizophrenia more than 8–14-fold and of autism over 20-fold. A corresponding microdeletion instead of microduplication in the area affected the risk of autism only, but not of schizophrenia.[15][16][17][18] A recent study of de novo mutations, ie new mutations in people with both autism and schizophrenia spectrum conditions, concluded that schizophrenia and autism are due to "errors" during early organogenesis.[19][20]

The National Institute of Mental Health reported on 8 December 2009 that in spring 2010, major databases on autism research will be joined up to facilitate further research.[21] One study ascribes links between schizophrenia and bi-polar disorder by studying a total group of 6909 Europeans, both diagnosed and undiagnosed.[22] Another study suggests that genetic markers may be very dissimilar among different lineages of DNA in people of different cultures, making an international commonality in genetics as a precipitating factor in schizophrenia difficult to identify.[23][24]

The onset of the condition has also been ascribed to social factors. Some authors refute the argument that racism may contribute to more diagnoses from psychiatrists of schizophrenia amongst members of the Afro Caribbean community and ascribe more value to deprivation and social isolation as triggering factors in those with a propensity towards schizotype personalities.[25]

Various studies have indicated chemical precipitating factors in the development of autism/schizophrenia and also suggested that environmental factors such as toxins in the air may have precipitated a rise in the number of children born with autism. Prenatally prescribed softenon in the 1960s and 1970s lead to an increase of children born with autism by 4% as opposed to a usual figure of 0.1%.[26][27] Sodium valproate, a drug used as an anti-epileptic and as a mood stabilizer, increased the chance of children being born with autism sevenfold.[28] The active component of cannabis (THC) in its "skunk" preparation was found by one study to increase the chances of psychosis sevenfold.[29] Another study found cannabis to increase chances of a "psychotic-like experience" by 2.6 times, but concluded that "schizophrenia is a relatively rare condition so it's very hard to be sure about its causation."[30] There are many candidates for copy number variants that may predispose a likelihood of developing schizophrenia.[31]

Timothy Crow has long argued that schizophrenia came about as a result of natural selection. He has argued that schizophrenia is a by-product of the development of language, resulting from an evolutionary change approx 150,000 years ago, that persisted due to sexual selection. However, conversely to study in polygenes or multiple allele combinations, he maintains that the answer lies in: "the evolutionary history of the Protocadherin11XY gene pair that characterizes the hominin lineage including the 'sapiens' event that represents the transition to modern Homo sapiens."[32][33] Other medical model of disability research directions corroborate the link between an evolutionary advantage to schizotype personalities. Studies into unfocussed or coarse semantic activation in the right hemisphere of the brain which is associated with creative associations as opposed to left hemisphere language control suggest:

The use of the RH semantic system may constitute a selective evolutionary advantage allowing the genes predisposing to schizophrenia to proliferate despite the obvious disadvantages of this devastating disease.[34]

From a social model of disability perspective, this interlinks with the concept of salience syndrome:

The human mind has the ability to turn its attention to something that is salient, something that jumps out at you. We then focus on it. In some people this function is disturbed, and everything gets an enormous significance. They think, for example, that a television programme is about them, or that people who are just walking along the street are out to harm them. Research shows that this can happen to everybody under the influence of drugs, also to healthy people. The word syndrome indicates that it is about a cluster of symptoms. And not about a clearly defined illness.[35]

Global moves to change the construction of 'Schizophrenia'[edit]

In the Netherlands alternative proposals for the name schizophrenia include 'dysfunctional perception syndrome' [36] and Salience Syndrome:

"The concept of 'salience' has the potential to make the public recognize psychosis as relating to an aspect of human mentation and experience that is universal. It is proposed to introduce, analogous to the functional-descriptive term 'Metabolic syndrome', the diagnosis of 'Salience syndrome' to replace all current diagnostic categories of psychotic disorders. Within Salience syndrome, three subcategories may be identified, based on scientific evidence of relatively valid and specific contrasts, named Salience syndrome with affective expression, Salience syndrome with developmental expression and Salience syndrome not otherwise specified."[37]

In Japan "In order to contribute to reduce the stigma related to schizophrenia and to improve clinical practice in the management of the disorder, the Japanese Society of Psychiatry and Neurology changed in 2002 the old term for the disorder, "Seishin Bunretsu Byo" ("mind-split-disease"), into the new term of "Togo Shitcho Sho" ("integration disorder"). Eighty-six percent of psychiatrists in the Miyagi Prefecture found the new term more suitable to inform patients of the diagnosis as well as to explain the modern concept of the disorder."[38] This model is ascribed as a stress-vulnerability model rather than a kraepelian disease model.[39] The Japanese society of psychiatry and neurology report: "This change is making psychoeducation much easier and is being useful to reduce misunderstandings about the illness and to decrease the stigma related to schizophrenia. The new term has been officially accepted by the Japanese medicine and media and is being adopted in the legislation in 2005."[40]

See also[edit]

Social model of disability

External links[edit]

References[edit]

  1. ^ Walker MT (2006). "The Social Construction of Mental Illness and its Implications for the Recovery Model". International Journal of Psychosocial Rehabilitation 10 (1): 71–87. 
  2. ^ Mary Barnes; Joseph H. Berke (17 March 2002). Mary Barnes: two accounts of a journey through madness. Other Press, LLC. ISBN 978-1-59051-016-2. Retrieved 23 October 2010. 
  3. ^ Roberts GA (2000). "Narrative and severe mental illness:what place do stories have in an evidence-based world?". Advances in Psychiatric Treatment 6 (6): 432–441. doi:10.1192/apt.6.6.432. 
  4. ^ Noll, Richard. (1983). "Shamanism and Schizophrenia.A State-Specific approach to the 'Schizophrenia Metaphor of shamanic states'". American Ethnologist 10 (3): 443–459. doi:10.1525/ae.1983.10.3.02a00030. JSTOR 644263. 
  5. ^ "Dr. Robert Sapolsky's lecture about Biological Underpinnings of Religiosity" [1]
  6. ^ Mary Boyle (2002). Schizophrenia: a scientific delusion?. Psychology Press. ISBN 978-0-415-22718-6. Retrieved 23 October 2010. 
  7. ^ Brown, Phil. (1995). "Naming and Framing: The Social construction of Diagnosis and Illness". Journal of health and social behaviour 35 (extra issue): 34–52. doi:10.2307/2626956. JSTOR 2626956. 
  8. ^ Conrad, Peter. (1992). "Medicalization and social control". Annual review of sociology 18: 209–232. doi:10.1146/annurev.so.18.080192.001233. 
  9. ^ Nelson, Yung, Bechdolf, McGorry., 2008, "The Phenomenological Critique and Self-disturbance: Implications for Ultra-High Risk ‘Prodrome’ Research", Schizophrenia bulletin, 34(2) pp381-392
  10. ^ Daryl Fujii; Iqbal Ahmed (19 March 2007). The spectrum of psychotic disorders: neurobiology, etiology, and pathogenesis. Cambridge University Press. ISBN 978-0-521-85056-8. Retrieved 23 October 2010. 
  11. ^ Campaign for The Abolition of The Schizophrenia Label
  12. ^ Encyclopædia Britannica - Eugene Bleuler
  13. ^ Mind
  14. ^ Changing the 'S' Word Is There a Better Name?
  15. ^ Crespi, B.; Badcock, C. (2008). "Psychosis and autism as diametrical disorders of the social brain". Behavioral and Brain Sciences 31 (3): 241–261; discussion 261–320. doi:10.1017/S0140525X08004214. PMID 18578904.  edit
  16. ^ "Research backs theory on autism, schizophrenia": accessed 9 December 2009
  17. ^ McCarthy SE, Makarov V, Kirov G, et al. (November 2009). "Microduplications of 16p11.2 are associated with schizophrenia". Nature Genetics 41 (11): 1223–7. doi:10.1038/ng.474. PMC 2951180. PMID 19855392. 
  18. ^ Kumar RA, KaraMohamed S, Sudi J, et al. (February 2008). "Recurrent 16p11.2 microdeletions in autism". Human Molecular Genetics 17 (4): 628–38. doi:10.1093/hmg/ddm376. PMID 18156158. 
  19. ^ Awadalla, P.; Gauthier, J.; Myers, R. A.; Casals, F.; Hamdan, F. F.; Griffing, A. R.; Côté, M.; Henrion, E.; Spiegelman, D.; Tarabeux, J.; Piton, A. L.; Yang, Y.; Boyko, A.; Bustamante, C.; Xiong, L.; Rapoport, J. L.; Addington, A. M.; Delisi, J. L. E.; Krebs, M. O.; Joober, R.; Millet, B.; Fombonne, É.; Mottron, L.; Zilversmit, M.; Keebler, J.; Daoud, H.; Marineau, C.; Roy-Gagnon, M. H. L. N.; Dubé, M. P.; Eyre-Walker, A. (2010). "Direct Measure of the De Novo Mutation Rate in Autism and Schizophrenia Cohorts". The American Journal of Human Genetics 87 (3): 316. doi:10.1016/j.ajhg.2010.07.019.  edit Direct Measure of the De Novo Mutation Rate in Autism and Schizophrenia Cohorts
  20. ^ "Ploeger Thesis Summation"
  21. ^ Major Databases Link Up to Advance Autism Research. Accessed 12 December 2009
  22. ^ Purcell SM, Wray NR, Stone JL, et al. (August 2009). "Common polygenic variation contributes to risk of schizophrenia and bipolar disorder". Nature 460 (7256): 748–52. doi:10.1038/nature08185. PMID 19571811. 
  23. ^ McClellan JM, Susser E, King MC (March 2007). "Schizophrenia: a common disease caused by multiple rare alleles". The British Journal of Psychiatry 190 (3): 194–9. doi:10.1192/bjp.bp.106.025585. PMID 17329737. 
  24. ^ "New findings on the hereditary factors of schizophrenia and autism". Accessed 10 December 2009
  25. ^ Lewin, M. (2009) 'Schizophrenia 'epidemic' among African Caribbeans spurs prevention policy change' The Guardian. 9 December:"Schizophrenia 'epidemic' among African Caribbeans spurs prevention policy change". Accessed 12 December 2009
  26. ^ "Autism and schizophrenia share common origin"
  27. ^ "Study shows California's autism increase not due to better counting, diagnosis"
  28. ^ "Epilepsy drug may increase risk of autism in children"
  29. ^ "Skunk users face greater risk of psychosis, researchers warn"
  30. ^ "David Nutt: my views on drugs classification:David Nutt, the government's former chief drugs adviser, on how he formulated his controversial views on drugs"
  31. ^ "CNV 'Double Whammies' May Account for Variable Neuropsychiatric Phenotypes"
  32. ^ Clues to the origin of language?
  33. ^ Schizophrenia Research Forum Comment on Published Paper
  34. ^ Creative, Paranormal, and Delusional Thought: A Consequence of Right Hemisphere Semantic Activation?
  35. ^ Mol., S., 2009, ‘Dysfunctional Perception Syndrome’: The new name for schizophrenia? [2]
  36. ^ Dysfunctional Perception Syndrome
  37. ^ van Os J (November 2009). "'Salience syndrome' replaces 'schizophrenia' in DSM-V and ICD-11: psychiatry's evidence-based entry into the 21st century?". Acta Psychiatrica Scandinavica 120 (5): 363–72. doi:10.1111/j.1600-0447.2009.01456.x. PMID 19807717. 
  38. ^ Sato M (February 2006). "Renaming schizophrenia: a Japanese perspective". World Psychiatry 5 (1): 53–5. PMC 1472254. PMID 16757998. 
  39. ^ Sato, W. (2009). The Japanese Solution, in World Congress on Hearing Voices, September 17th-18th, 2009, Maastricht Holland The Japanese Solution
  40. ^ The Yokohama Declaration: an update. PMC 1414727.