The fifth and final group of symptoms in Criterion A are the negative symptoms such as affective flattening, alogia, and avolition. Positive symptoms are indicated by forms of deviant behavioural activity, and they are meant to disclose a commensurate level of inner mental deviance. Negative symptoms, on the other hand, are descriptions of behavioural inactivity and are supposed to indicate a commensurate level of inner mental inactivity. If a person does not speak, or speaks as little as possible (alogia), it is assumed that there is insufficient thinking going on to generate communication.
The observed presence of both positive and negative symptoms for schizophrenia indicates that it is a mental disorder with an extraordinary variety of complications. A schizophrenic might be a person in a highly active delusional state, conversing incoherently with inner voices, wearing multiple overcoats and masturbating in public; or, alternatively, it could also be a person who says, and feels, and does, and presumably thinks, next to nothing. It is important to note at this point that the negative and positive symptoms have equal status as diagnostic criteria. This means that a person manifesting negative symptoms is not thought to be in remission, or in an inactive phase of the disease, but is at the time a full-blown schizophrenic and diagnosable.
Bearing in mind the diagnostic setting, which from the patient's point of view is a kind of interrogation session in which all power is transferred to the diagnostician,[16] it is worth considering the DSM-IV definition of alogia, which is one of the principle negative symptoms:
alogia An impoverishment in thinking that is inferred from observing speech and language behaviour. There may be brief and concrete replies to questions and restrictions in the amount of spontaneous speech (poverty of speech). Sometimes the speech is adequate in amount but conveys little information because it is overconcrete, over-abstract, repetitive, or stereotyped (poverty of content).[17]
‘Concrete’ is a key term, and it is used here to describe ‘poverty’ in both the quantity and quality of speech. In common usage concrete means solid, firm or serious, and is the opposite of light and airy. In psychiatric literature, concrete is used variously to describe the opposite of metaphorical thinking and speech,[18] as well as to describe the opposite of abstract thinking and speech.[19] The inclusion of both extremes—overconcrete and over-abstract—in the above definition indicates that mentally healthy people stick to the middle ground.
Yet even though concreteness is viewed by psychiatric diagnosticians as indicative of schizophrenia in their patients, strangely it is also viewed as being a quality that therapists should develop in themselves, for working with schizophrenics:
The development of a therapeutic relationship is critically important in work with persons with schizophrenia (Frank & Gunderson, 1990; Lamb, 1982). Core skills of empathic attunement, warmth, genuineness, and concreteness were used to establish a supportive relationship (Anthony, 1980; Elson, 1986; Hepworth & Larsen, 1993).[20]
What can this contrariness mean? Why is concreteness associated with qualities such as ‘empathic attunement, warmth, genuineness’ when it is found in the therapists of schizophrenics, and with a pathological impoverishment of thinking when it is found in the schizophrenics themselves? Can there be anything wrong with concreteness if it is actually recommended as a therapeutic tool? Or, does a therapist who deliberately develops concreteness in speech for therapeutic purposes also run the risk of being diagnosed with schizophrenia?
Perhaps it could be seen as a demonstration of overconcrete thinking to question, in this way, the words used to describe schizophrenic symptoms. But it should be remembered that we are discussing a class of people who are diagnosed when their minds are functioning normally. They become schizophrenics simply because they can be fitted to the symptoms. For them, there is nothing more to schizophrenia than the supposed symptoms themselves. This means that the words which describe the symptoms are all-important, because from this perspective it is only a linguistic consensus amongst psychiatrists that brings this class of schizophrenics into existence.
Quite frequently people are involuntary participants in the clinical procedures that lead to a diagnosis of schizophrenia. Psychiatrists are looked upon as interrogators who have been retained by a third party to ask probing questions about the person’s private thoughts and beliefs, for the transparent purpose of acquiring damaging evidence. Under these circumstances it might not be surprising if a perceptive and wary person seems concrete in their responses, and gives other evidence of DSM-IV negative symptoms such as ‘brief, laconic, empty replies’.[21] In fact, when schizophrenia diagnosis is viewed from the schizophrenic-as-outsider angle, the specification of negative symptoms such as these appear to create a ‘Catch-22’: anything the person says about themselves can be used against them, and if nothing of substance is said, that can be used, too.
Avolition is another of the negative symptoms:
avolition An inability to initiate and persist in goal-directed activities. When severe enough to be considered pathological, avolition is pervasive and prevents the person from completing many different types of activities (for example, work, intellectual pursuits, self care).[22]
Consider a person who does not share with other people an appropriate level of culturally acquired goal-direction for specific activities such as formal education and career. This kind of person is often referred to as a loser, a drop-out, a bum, a hopeless case, or a never-do-well. The specification of avolition as a symptom makes it apparent that ‘schizophrenic’ can also be added to this list of pejoratives.
In discussing the negative symptoms, DSM-IV warns: ‘Although quite ubiquitous in Schizophrenia, negative symptoms are difficult to evaluate because they occur on a continuum with normality’. But this ‘continuum with normality’ is exactly what the schizophrenic-as-outsider case argues. Alogia might be no more than a disinclination for conversation, in situations where such a disinclination is culturally unacceptable. Similarly, avolition might be no more than a disinclination to participate in normal social intercourse. If these disinclinations are indeed on a continuum with normality, then in relation to the negative symptoms at least, the schizophrenic-as-outsider case is very strong.
Criterion B is the second group of diagnostic indicators that are concerned with social or occupational dysfunction in the areas of interpersonal relations, work or education, or self-care. If Criterion A symptoms have been identified, the diagnostician cross-checks to see whether there is any evidence of social or occupational dysfunction:
Typically, functioning is clearly below that which had been achieved before the onset of symptoms. If the disturbance begins in childhood or adolescence, however, there may be failure to achieve what would have been expected for the individual rather than a deterioration in functioning. Comparing the individual with unaffected siblings may be helpful in making this determination. Educational progress is frequently disrupted, and the individual may be unable to finish school. Many individuals are unable to hold a job for sustained periods of time and are employed at a lower level than their parents (‘downward drift’). The majority (60%–70%) of individuals with schizophrenia do not marry, and most have relatively limited social contacts.[23]
There seems to be some overlap here with avolition. A loss of interest in activities of social value, or a loss of interest in climbing the ladder of social status, or even failure to satisfy the status expectations of others, are all deemed to be indications of mental pathology. Ostensibly Criterion B indicators are primarily used as a cross-reference to evaluate the level of disability a person incurs from the presence of one or more Criterion A symptoms. Unemployment, for instance, is only meant to be significant as a measure of the detrimental effect of a Criteria A symptom like delusions.
However, although Criterion B indicators are supposedly only intended to give secondary confirmation of pathology, references can be found in the literature of mental health professionals arguing that ‘[i]mpairment in the ability to work is a defining characteristic of schizophrenia’.[24] Thomas Szasz has written emphatically about the way unemployment in young people can lead directly to a diagnosis of schizophrenia.[25]
It is quite apparent that people can be diagnosed, even though their thinking and behaviour might be on a continuum with that of normal people, simply because a psychiatrist observes personal attributes that are outside the boundary of cultural acceptance. There are numerous case studies in the literature of psychiatric survivors that confirm this contention. A particularly compelling story is told by Leonard Roy Frank. Frank is the author of a number of articles and books which argue against psychiatric coercion.
Frank recounts how he began a promising career in real estate sales in Florida and San Francisco. At a certain point, however, he decided to quit his job and take some time off to read books and follow an interest in philosophy. When his parents heard about his new life-style they went to visit him and, dismayed at his lack of interest in continuing his career in real estate, they advised him to see a psychiatrist. When he refused they signed the necessary papers to have him involuntarily committed to a mental hospital. He was diagnosed with paranoid schizophrenia and given 85 shock treatments. When he finally obtained his psychiatric records twelve years later, he discovered the symptoms that had been identified to justify the diagnosis and treatment included: ‘not working, withdrawal, growing a beard, becoming a vegetarian, “bizarre behaviour”, “negativism”, “strong beliefs”, “piercing eyes”, and “religious preoccupations”. The medical examiner’s initial report said that I was living the “life of a beatnik—to a certain extent”.’[26]
Next: The Schizophrenic-as-Scapegoat
[16] Thomas Szasz, ‘Psychiatric diagnosis, psychiatric power and psychiatric abuse’, pp. 135–8,
[17] American Psychiatric Association, op. cit., p. 764.
[18] M. Spitze et al., ‘Comprehension of metaphoric speech by healthy probands and schizophrenic patients: an experimental psychopathologic contribution to concretism’, pp. 282–92.
[19] P. W. Corrigan et al., ‘Situational familiarity and feature recognition in schizophrenia’, pp. 153–61.
[20] William Bradshaw, ‘Evaluating Cognitive-Behavioural Treatment of Schizophrenia: four single-case studies’, p. 419.
[21] American Psychiatric Association, op. cit., p. 276.
[22] Ibid., p. 764.
[23] Ibid., p. 278.
[24] Paul Lysaker and Morris Bell, ‘Work Performance Over Time for People With Schizophrenia’, pp. 141–6.
[25] Thomas Szasz, Cruel Compassion: psychiatric control of society’s unwanted, p. 145.
[26] Leonard Roy Frank, interview, in Seth Farber, p. 193.