Many psychiatric survivors claim to have had nothing wrong with their minds before encountering psychiatry and that they were originally diagnosed with schizophrenia simply for being a little different to other people; or for being different from the way others expected them to be. These claims are usually made after long struggles to escape from the coercive grip of psychiatry, often lasting many years, sometimes decades, and are impossible to verify on an individual basis. However, it is fairly easy to demonstrate that this type of claim is likely to be true simply by analysing the diagnostic criteria for schizophrenia. If the guidelines direct clinicians to include this type of person, it is fair to assume that a substantial fraction of schizophrenics will be of this type.
DSM-IV specifies the indicators for schizophrenia as being positive symptoms such as delusions, hallucinations, disorganised speech, and disorganised or catatonic behaviour; and/or negative symptoms such as affective flattening, alogia and avolition.[6] These are the Criterion A symptoms.[7] If any single ‘bizarre’ example of these symptoms, or any two examples if they are non-bizarre, correlate with a Criterion B symptom—that is, a social/occupational dysfunction concerning matters such as work, interpersonal relations or self-care—a diagnosis of schizophrenia can be made. It should be pointed out once again that there are no laboratory tests available to confirm a diagnosis, and nothing more needs to be done to make a definitive diagnosis than to follow the DSM-IV (or ICD-10)[8] guidelines.
Let us begin with delusions. In its Glossary of Technical Terms, DSM-IV describes a delusion as:
"A false belief based on incorrect inference about external reality that is firmly sustained despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary. The belief is not one ordinarily accepted by other members of the person’s culture or subculture (for example, it is not an article of religious faith)."[9]
A delusion is said to have the additional pathology of ‘bizarre’ attached to it when it ‘involves a phenomenon that the person’s culture would regard as totally implausible’.[10]
The first thing that is evident here is that there is no hard-and-fast division between bizarre and non-bizarre delusions, and what seems to differentiate a delusion from a false belief is a matter of cultural acceptance. This distinction between a false belief and a delusion, by cross-checking for cultural acceptance, is a special psychiatric interpretation of the word ‘delusion’. In normal lay usage a ‘delusion’ can be any kind of false belief whether it is accepted by the person’s culture or not.
There are two implications that can be drawn from this DSM-IV definition of delusion. Both concern the beliefs of the psychiatrists who have compiled the manual. The first is that culturally based beliefs can be false. The second is that false beliefs only become delusions, and therefore symptoms of schizophrenia, when they are culturally unacceptable.
If normal people and schizophrenics both have false beliefs, with the only difference between them being that the normal peoples’ beliefs are culturally acceptable, while those of schizophrenics are culturally unacceptable, then it is hard to avoid the conclusion that the use of delusions as a symptom can easily lead to the diagnosis of people who are simply cultural outsiders. The requirement to correlate delusions with a disturbance in social functioning (Criterion B) only strengthens this line of thinking.
The DSM-IV Glossary of Technical Terms defines a hallucination as a ‘sensory perception that has the compelling sense of reality of a true perception but that occurs without external stimulation of the relevant sensory organ’.[11] But the manual warns that ‘[t]ransient hallucinatory experiences may occur in people without a mental disorder’. Hallucinations, in themselves, are thus not necessarily indicative of abnormality.
To be an indicator of schizophrenia, a hallucinatory experience should be beyond the range of normal experience. Certainly it should be more unusual than the common experience of a person who is distracted, or who is in a noisy environment, and imagines the voice of an accompanying person and asks, ‘did you say something?’ When this happens there is usually no suspicion that it might be a symptom of mental disorder.
Exactly how different and unusual a hallucinatory experience has to be to qualify as a symptom of schizophrenia is not specified. But it is implied by the diagnostic criteria that the ‘did you say something?’ type of hallucination, although seemingly harmless to lay people, might be close to a schizophrenic marker. DSM-IV makes the point that some clinicians are only interested in hallucinations of external voices, and ignore those perceived as being inside the head, which clearly suggests that the ‘did you say something?’ kind of hallucination, being concerned with an imagined external source, is of the more serious kind.
In its diagnostic overview of schizophrenia, DSM-IV specifies that of all the types of hallucination possible, auditory hallucinations experienced as voices ‘are by far the most common and characteristic of Schizophrenia’.[12] This is repeatedly confirmed in the psychiatric literature. So it seems that imagined external voices are the most positive of the hallucinatory indicators for schizophrenia, even though these are demonstrably common experiences.
This lack of certainty about hallucinations means that the diagnostic emphasis has to be shifted onto the cross-referencing criterion of social/occupational dysfunction. Although hallucinations by themselves might not properly distinguish a schizophrenic from a normal person, if a person is observed to hallucinate, and also to have a disturbance in their social functioning, then the hallucinations might indicate schizophrenia. When the diagnostic criteria are interpreted this way, it would seem that social functioning is exposed as a key determinant of schizophrenia, which gives support to the claim that sometimes schizophrenics are just outsiders.
The third symptom in the DSM-IV Criterion A for schizophrenia is disorganised speech. Examples of disorganised speech are given as being ‘derailment’ or ‘incoherence’. The manual makes it clear that disorganised speech is used as an indicator for an underlying disorganisation in the person’s thinking ‘because in a clinical setting inferences about thought are based primarily on the individual’s speech’.[13] This means that for diagnostic purposes the level of organisation apparent in a person’s speech is assumed to represent their level of mental organisation as well.
However, in a further discussion about varieties of disorganised speech to watch out for, the manual goes on to advise that ‘[b]ecause mildly disorganised speech is common and nonspecific, the symptom must be severe enough to substantially impair effective communication’.[14] This means that the compilers of the manual recognise that normal people can have mildly disorganised thoughts, as is sometimes indicated by their speech, and that, in relation to this symptom, the threshold of mental illness is only crossed when a person’s mind is so disorganised that the ability to communicate through speech is impaired.
In using this particular indicator to identify schizophrenia, it is the inability to communicate effectively with other people that is the key. Yet if a person can be diagnosed with schizophrenia simply because his or her speech has been judged in a diagnostic situation to be too disorganised to communicate effectively, and this has been combined with a perception that the person is also socially or occupationally dysfunctional (Criterion B)—which may be for the same or perhaps some other reason—this would seem to provide particularly strong evidence that schizophrenia can be culturally determined.
A person who is diagnosed with schizophrenia in this way might lack sufficient interest in other people, or perhaps lack the social skills, to make themselves easily understood by others, and as a result have social/occupational difficulties. It is conceivable that the mental functioning of this person might otherwise be normal.
Nor does it follow that an impairment in communication necessarily indicates a short-coming in the person who is doing the speaking. In a clinical setting, the inability of the diagnostician to understand the patient should also be taken into account. The essential feature of this particular diagnostic tool is that the ability of the diagnostician to comprehend the speech of the patient is assumed to be a standard test of sanity. But this begs the question as to whether diagnosticians’ minds are calibrated to make standard measurements in this regard; and, if they are, whether that standard is concerned with the measurement of mind or with cultural adaptation. If the latter is indeed the case, then it offers strong support to the view of schizophrenic-as-outsider.
The fourth group of Criterion A symptoms is ‘grossly disorganised or catatonic behaviour’. The DSM-IV guidelines for recognising these symptoms are the following:
"Grossly disorganised behaviour (Criterion A4) may manifest itself in a variety of ways, ranging from childlike silliness to unpredictable agitation. Problems may be noted in any form of goal-directed behaviour, leading to difficulties in performing activities of daily living such as organising meals or maintaining hygiene. The person may appear markedly dishevelled, may dress in an unusual manner (for example, wearing multiple overcoats, scarves, and gloves on a hot day), or may display clearly inappropriate sexual behaviour (for example, public masturbation) or unpredictable and untriggered agitation (for example, shouting or swearing)."[15]
Whereas the instructions regarding the use of ‘disorganised speech’ specify that the symptom is only an external indicator of internal mental disorganisation, there is no similar instruction concerning ‘grossly disorganised behaviour’. This means that disorganised behaviour is not meant to be read as an indicator of inner mental disorganisation. The types of disorganised behaviours listed above are merely some of the things schizophrenics have been observed doing, and the behaviours do not directly reflect inner mental activity. This means that wearing multiple overcoats, or public masturbation, has the same kind of relationship to schizophrenia as the wearing of a hat has to baldness. Both bald and hirsute people might wear hats. But when a bald person wears one, baldness can serve as a convenient, though not necessarily correct, explanation for why the hat is worn.
Similarly, schizophrenia might serve as a convenient explanation for why a person might ‘dress in an unusual manner’, providing the observer has already been informed that a person is indeed schizophrenic. But to use unusual dress as a diagnostic indicator of mental disorder seems as doubtful as assuming that any person wearing a hat is bald.
This symptom is transparently loaded with cultural bias. Even so, it is worth noting that although private masturbation is no longer considered to be either a cause or a symptom of madness, as it once was, public masturbation is clearly listed as an indicator of schizophrenia. What makes the difference here, apparently, is whether the setting of the behaviour, rather than the behaviour itself, is culturally acceptable.
Some of the examples of this symptom, such as wearing multiple overcoats in hot weather and public masturbation, only appear in the psychiatric literature as anecdotes and have not been subjected to any kind of extensive scientific investigation. It is possible that these forms of behaviour might have more to do with homelessness than with mental disorder.
Next: Negative Symptoms
[6] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, fourth edition, (DSM-IV), p. 274–277.
[7] Ibid., p. 285.
[8] World Health Organisation, The ICD-10 Classification of Mental Disorders and Behavioural Disorders: clinical descriptions and diagnostic guidelines.
[9] American Psychiatric Association, op. cit., p. 765.
[10] Ibid.
[11] Ibid., p. 767.
[12] Ibid., p. 275.
[13] Ibid., p. 276.
[14] Ibid., p. 276.
[15] Ibid., p. 276.