Schizophrenia: A Controversial Diagnosis

Almost all psychiatrists see schizophrenia as a biological mental illness. Their empirical proof is its successful treatment with anti-psychotic medication; and that, when patients don’t take the medicine, the results can be tragic. As a practicing psychiatrist for more than thirty years, I agreed with that point of view.

However, since anti-psychotic medication does not cure schizophrenia, and is often only partially effective, its proof of the nature of schizophrenia is, at best, partial.

Moreover, conceptually, schizophrenia is a very problematic diagnosis. It does not have even one symptom that is unique to it (pathognomonic). For example, auditory hallucinations are just as common in the nonpsychotic, dissociative disorder, dissociative identity disorder (multiple personality disorder), and voices are heard by many people who are well.

One dissenting view as to the nature of at least some cases of schizophrenia comes from psychiatrists and psychologists who see symptoms like auditory hallucinations as evidence that some people diagnosed with schizophrenia have a posttraumatic, dissociative disorder related to multiple personality (1).

1. Andrew Moskowitz PhD, Martin J. Dorahy PhD, Ingo Schäfer MD, MPH (Editors). Psychosis, Trauma and Dissociation: Evolving Perspectives on Severe Psychopathology, Second Edition. Hoboken NJ, Wiley Blackwell, 2019.

Added April 3, 2020: The new April issue of The American Journal of Psychiatry addresses the fact that psychiatric treatment of schizophrenia does reasonably well in reducing its psychotic symptoms, but cognitive impairment, not psychosis, is the basic problem:  https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2020.20020147
My question: Are many patients diagnosed with schizophrenia who do not have its basic cognitive impairment, and who are diagnosed only on the basis of psychotic symptoms, misdiagnosed? And if they do not really have schizophrenia, what do they have?

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What have you discussed with others? What have you related to your own ideas? Do you see any practical applications?

“Amy and Isabelle” by Elizabeth Strout (post 2): How are novels written? How was this novel written? Who wrote it?

Isabelle, 33, is the mother of Amy, 16. They live together in a small town of the far northeastern USA, the part of the country where Strout was born (with Boston to the south and Canada to the north). They are the central characters of this “novel of shining integrity and humor, about bravery and hard choices of what is called ordinary life” (back-cover blurb by Canadian Nobel Prize winner, Alice Munro).

“Isabelle sighed deeply. It surprised her sometimes how absorbed she could become in something that was not happening. (What was happening? Nothing. She was sitting in a chair in a silent house and had been sitting there for quite some time)” (1, p. 205), which would appear to be the character’s reflection on the author’s writing process.

The narrator says that Amy “had become desperate, crazy, somebody else” (1, p. 68). The conventional interpretation here is that this teenage girl has become infatuated with an older man. But it wasn’t necessary for the author to phrase it in multiple personality terms—as Amy’s becoming “somebody else”—unless that reflected the author’s psychology.

One of Amy’s friends says, “Roses are red, violets are blue, I’m schizophrenic [she meant multiple personality] and so am I…My father [a psychologist] thinks that’s funny” (1, p. 106). Why was this old multiple personality joke thrown in. It is gratuitous, and is present only as something on the author’s mind.

Isabelle “wished she could stop the part of her mind where the hidden pieces about Amy lay. She wished she could stop picturing certain things. Sometimes sitting at her typewriter she would squeeze her eyes closed and pray” (1, p. 152).

“The part of her mind where the pieces…lay” is a way of saying that a “part” (common euphemism for alternate personality) has its own separate memory bank. The typewriter (Isabelle is a secretary) reinforces the idea that any implicit reference to multiple personality is an implicit reference to the author (who uses a typewriter). “She wished she could stop picturing things” suggests that the story is coming to the author, not from the author (author in the sense of her regular personality).

“…who was Isabelle Goodrow?…She didn’t know herself. She didn’t think this was Isabelle Goodrow” (1, p. 180). This was after the scene (see below) in which Isabelle had violently cut Amy’s hair. Who, then, was it, who committed that violent act, an alternate personality?

Six-minute Video Interview (2)

The author says the writing of this novel started with an unexplained image. She doesn’t say which scene, but it may be the one in which Isabelle, after discovering Amy’s sexual involvement with a teacher, violently cuts off much of her daughter’s golden hair. Then the process of the rest of the writing of this novel was “spending time with these characters,” finding out about them, and understanding what that initial image had been all about. She often worried that she wouldn’t learn enough about Isabelle.

In other words, as I commented above, the creative process did not start with an idea for a story about characters she had manufactured, at least that is not how she experienced it. Yet that initial image had to come from somewhere in her mind. And those coherent characters had to have been created by some kind of intelligent process in her mind.

But to the author’s regular personality, the story and characters were—to borrow a phrase from Stephen King about his own creative process—“found objects.” I would say they were produced by the author’s alternate personalities for her regular personality to find (subject, of course, to editing and revision).

1. Elizabeth Strout. Amy and Isabelle. New York, Random House, 1998.

2. Charlie Rose (interviewer). “A conversation with author Elizabeth Strout about her novel, “Amy and Isabelle” https://charlierose.com/videos/2289

Search “Strout” to see a brief previous post in which she is quoted about her writing process.

Interviewing Voices: Should you try to interview the voices of everyone diagnosed with schizophrenia? I never did, but a study should be done.

I would attempt to interview a patient’s voices only when I suspected multiple personality, as when:

1. Patients have conversations with their voices.

2. Patients relate to their voices as though they are people or rational beings of some sort.

3. Patients have a history of memory gaps (you have to ask).

4. Voices converse with each other.

5. Voices give the patient relevant advice.

6. Patients have gotten different diagnoses at different hospitalizations or from different mental health professionals.

7. Patients are more socially engaging than is typical for a person with textbook schizophrenia.

8. Patients act or dress differently at different times.

9. Patients have arguments with themselves.

10. Patient’s family or friends think that the patient has multiple personality, but hadn’t told the doctors, because they thought it was obvious, or thought that the diagnosis of schizophrenia encompassed multiple personality.

Most people have either schizophrenia or multiple personality, not both. Part of the concept of schizophrenia is cognitive impairment; whereas, in contrast, multiple personality is a cognitive feat (to be able to juggle multiple personalities and memory banks). But there could be exceptions.

“Hearing Voices, Living Fully” (a memoir) by Claire Bien (post 3): Diagnosis and Interviewing Voices

Bien says that she first became ill with voices and schizophrenia at age 31. After several hospitalizations, plus outpatient psychotherapy, and with minimal antipsychotic medication, she was able to negotiate with, and stand up to, her voices, so that they mostly stopped. She assures the reader that she did not hear voices before age 31, and had not been traumatized in childhood. But neither assurance is true.

Telling a Voice to Shut Up in College

“Once, when I was alone in my dorm room, I broke my study board over the post of my bed, saying as I slammed it over the post, ‘You won’t talk to me!’…I had no idea who I was ‘talking’ to…I continued to be depressed and angry throughout my twenties,” but “I graduated…with honors…” (1, pp. 36-37).

Voices Since Childhood

“The inner voices I grew up with were benign, often helpful, sometimes curious, and…sometimes inexplicably knowing…” (1, p. 244). “Until 1983 [age 31]…They had been for me as I imagine they are for most people: quiet thoughts not entirely my own” (1, p. 248).

Most people don’t have “inner voices” with “thoughts not entirely my own.” But people who do have them may assume that everyone else does, too.

Three Childhood Traumas

First, in early childhood, when Claire’s family emigrated from China to the United States, she was separated from the woman who had been her nursemaid, and was then “terrified” of losing her mother, too (1, p. 31).

Second, “I had severely crossed eyes” (1. p. 32), for which she had eye surgery at age nine.

Third, “I fell often, hitting my forehead on the ground so hard a lump would form because, for some reason, I never put my arms out to break the fall. I got so many ‘goose eggs’ that I have permanent, bony bumps on my forehead” (1, p 31).

I don’t know what to make of the third one. I am hesitant to speculate that an alternate personality, perhaps a precursor of the malicious alternate personalities that came out at age 31, was making her fall while restraining her arms. But something must have been going on.

Comment

Claire Bien says, “I was trained as a Hearing Voices Network facilitator in the summer of 2014 and in November 2014 began co-facilitating a Hearing Voices Support Group at Yale-New Haven Hospital. It is the first support group in a psychiatric inpatient facility in Connecticut” (1, p. 271).

My impression is that the Hearing Voices Movement and Hearing Voices Network (2) are against the “medical model” for treating people with voices, by which they mean that just giving a person medication to control voices is inadequate.

Part of their approach is to negotiate with voices. I see voices [with which you can negotiate] as alternate personalities, but they do not. Since negotiation with alternate personalities is a standard aspect of psychotherapy for multiple personality, I agree with them in regard to negotiation. But since they have little if any interest in multiple personality, I think their approach is not as good as it could be.

So what is the best diagnosis in this instance? It depends on what you want to do. Schizophrenia may be best for choosing medication. Deemphasizing diagnosis may be best to minimize stigma. Multiple personality may be best for psychological understanding.

Interviewing Voices

If I had been treating her based on the realization that she had multiple personality, I would have interviewed her voices. First, I would use her regular personality as an intermediary, asking her to relay my questions to a voice and tell me what the voice answers. After a while, the voice would get tired of going through her regular personality as an intermediary, and would come out and speak for itself (confirming the diagnosis).

To some extent, Claire Bien, herself, did the above: “I imagined that I was ‘talking’ with some of the new voices who seemed friendly…and who said they would help me when necessary. I thanked them and asked if they could tell me their names, as I wished to know who my friends were…‘Okay, call me Gary Putka.’ When I responded that I thought Putka was a silly name, the exasperated spirit said, ‘Then call me Gary Slutka!’ And we all laughed…In the weeks following my introduction to Gary Putka and his fellow guardian angels, I was encouraged…Believing that I had allies who were kind and mostly good helped me feel better” (1, pp. 183-184).

In the treatment of multiple personality, you need to meet and interview all (or at least the most important) alternate personalities. A few will really have their own names. Others, as in the above example, will suggest something to call them. Others, without names and who don’t see a reason to have one, will be addressed by their main characteristic, such as “the angry one.”

In my clinical experience, when I have tried to anticipate how alternate personalities will explain what they do and what has been going on, my guesses are usually wrong. I have found that you can’t really understand things until you meet and interview the personalities, themselves. Of course, you have to corroborate what alternate personalities say, to make sure they are not just making it up.

And when you interview an alternate personality with whom the regular personality is not co-conscious, then when the person switches back to their regular personality, they will have amnesia, a memory gap, for the conversation you just had.

1. Claire Bien. Hearing Voices, Living Fully: Living With The Voices in My Head. London and Philadelphia, Jessica Kingsley Publishers, 2016.

2. Wikipedia. Hearing Voices Network. https://en.wikipedia.org/wiki/Hearing_Voices_Network

“Hearing Voices, Living Fully” by Claire Bien (post 2): Bien says others with schizophrenia who defied poor prognosis are Elyn Saks and Joanne Greenberg

Elyn Saks is a professor of law, psychology, and psychiatry. Joanne Greenberg is the author of I Never Promised You a Rose Garden.

from October 29, 2015

Elyn R. Saks The Center Cannot Hold: “The most lucid and hopeful memoir of living with schizophrenia I have ever read” (Oliver Sacks). But is it schizophrenia?

As stated on the front flap, “Elyn Saks is a success by any measure: She’s an endowed professor at the prestigious University of Southern California Gould School of Law. She has managed to achieve this in spite of being diagnosed as schizophrenic and given a ‘grave’ prognosis—and suffering the effects of her illness throughout her life.” The back flap adds that she is also an adjunct professor of psychiatry, a research clinical associate in psychoanalysis, and married. The flaps and back cover also include praise of the book from five eminent psychiatrists.

With all that consensus, if I question the diagnosis, I’ve probably misread the book, don’t you think? However, I’m interested in the distinction between schizophrenia and multiple personality, so here I go again.

The strong case in favor of her diagnosis of schizophrenia is that, for many years, she has had major episodes of, and continual tendencies toward, delusions (e.g., that she has killed many people with her thoughts), plus a lot of crazy, disjointed, nonsensical talk. Moreover, when she finally started taking antipsychotic medication (including Navane, then Zyprexa, and eventually clozapine) her psychotic symptoms were much less—often gone or minimal—but would relapse when she went off the medication.

Both Psychotic and Cogent

My first quibble with the diagnosis is that I don’t see how a person with schizophrenia can be flagrantly illogical and delusional during the same period of time in her life that she produces an excellent, fifty page, legal article (unless Hyde was the crazy one, and Jekyll wrote the article):

“In one [psychotherapy] session with [a psychologist-psychoanalyst], I was frantically pacing from one side of his office to the other, growing more agitated as my thoughts became more violent. ‘I’ve killed people and I will kill again,’ I announced. I was almost growling at him. ‘Who else is in the office with us? Are you human?’ “ (1, p. 134).

Meanwhile, “In [law school], I was assigned to prepare my first legal memo. Its purpose was to explain a very specific area of law, in a succinct, cogent manner…the length was to be no more than fifteen pages…I worked on the memo day and night…And when I was finished, my paper was nearly fifty pages in length. I later learned that the person in charge of grading papers thought that it was one of the two best pieces of work turned in by anyone that year…something inside me pushed me farther than I was supposed to go…” (1, pp. 134-135).

Diagnostic Controversy

Over the years, Saks’s doctors have not always diagnosed schizophrenia. Some had previously said that she had depression or schizoaffective disorder or atypical psychosis. A history of disagreement about diagnosis and of changing a patient’s diagnosis is much more common in cases that are eventually revealed to be multiple personality than in cases of schizophrenia.

Clinically Atypical

In the psychotherapy session quoted above, Saks’s disconnected thoughts could be called “loose associations,” a supposedly classic symptom of schizophrenia, but they strike me as inauthentic; not faked—there is no reason for her to fake—but not the way I have ever heard any of my own schizophrenic patients talk.

(However, if Saks was not quoting therapy transcripts, but only recreating what had been said, perhaps what I find inauthentic is only her retrospective version of what she had said.)

Suggestive of Multiple Personality

Saks occasionally says and does things that people unfamiliar with multiple personalty might take as evidence of schizophrenia, but which might not be. For example, she says, “I started to sense that the others—the beings who never seemed far off when I got sick—were in the office with me. An evil presence, and growing stronger. Why are they here? Are they trying to take over my mind? Why do they want to hurt me?” (1, p. 249). This could be schizophrenic delusion, but it could also be the host personality’s experience of rival alternate personalities who want to get her out of the way by getting her hospitalized.

That is how Dostoevsky’s The Double ended, with the regular personality carted off to the mental hospital while the alternate personality took his place in everyday life. Alternate personalities have such a sense of their separate existence that they sometimes even think that they can kill the host personality while they themselves remain alive.

“Another command (or thought, or message) I continually received was to hurt myself…So I burned myself—with cigarettes, lighters (easily come by…) electric heaters, boiling water. I burned my flesh in places on my body that I thought people would never see…” (1, p. 85). I previously discussed self-mutilation caused by persecutor personalities (search posts) in my post on Gillian Flynn’s novel Sharp Objects.

Saks says that one of her doctors “didn’t want me to cover my face with my hands during our sessions, something I’d done with all my analysts to help me feel safe and contained” (1, p. 322). As I discussed in a previous post about Charlotte Brontë—who was described as repeatedly seen to turn her face away from the person she was speaking to at school before she suddenly changed from reticent to talkative—people with multiple personality may want to hide the switch from one personality to another, which they think will be detected if their face is seen at the moment of the switch. It sounds to me like Saks was hiding her personality switches during therapy sessions.

Schizophrenia or Multiple Personality

Saks, who once wrote a book on the law and multiple personality, is familiar with it, and in interviews, she always emphasizes that she has schizophrenia, not multiple personality. And since her memoir has nothing definitive in regard to multiple personality, she may be right.

Her positive response to medication does not necessarily prove that she has schizophrenia. The medicine may help by shifting the balance of power among her personalities, making it harder for problematic alternate personalities to take over. I learned about this possibility when the host personality of a patient of mine with multiple personality would “misplace” her antidepressant medicine from time to time. Her alternate personality later admitted to me that she would hide the medicine, because when the host took it, it would be harder for the alternate personality to come out.

So is Saks a very high-achieving person with schizophrenia or a very high-achieving person with undiagnosed multiple personality? I am undecided.

1. Elyn R. Saks. The Center Cannot Hold: My Journey Through Madness. New York, Hyperion, 2007.

Search “Joanne Greenberg,” author of I Never Promised You a Rose Garden, to see several past posts.

“How to Be Calm About Anxiety” by Laura Turner: Is her approach “Acceptance and Commitment Therapy” or multiple personality?

“Anxiety has been my constant companion for as long as I can remember…”

And Laura had always fought her fear and anxiety.

“…but it turns out that befriending my fear has actually caused its voice to soften.

“I’ve started to call my anxiety Susan. She goes pretty much everywhere with me, and while she means very well, she’s simply too loud and too concerned about everything. So I tell her thanks for looking out for me, and then try to go about my day knowing that she’ll continue to pop up, and that I don’t need to walk her out of my cubicle anymore. She can stay…

“Now, whenever Susan knocks at my door, I let her in and invite her to sit down. I tell her to stay a while. She’s welcome here” (1).

1. Laura Turner. “How to Be Calm About Anxiety.” The New York Times, Sunday Review, March 15, 2020.  https://www.nytimes.com/2020/03/12/opinion/sunday/anxiety-treatment-therapy.html

Controversy: Are schizophrenia and multiple personality mutually exclusive? Can a person have both? Claire Bien’s memoir raises the issue.

DSM-5, the psychiatric diagnostic manual, assumes that schizophrenia and multiple personality (dissociative identity) are completely different and mutually exclusive.

But the person whose memoir I am reading (1) seems to have had symptoms of both schizophrenia (a psychosis) and multiple personality (not a psychosis).

For example, there is an episode in which she is studying a textbook on editing. In the passages she is reading, she is supposed to recognize editing mistakes. Suddenly, she hears a voice commenting on what she is reading.

She is frightened. How could the voice know what she is reading? There must be cameras in the room! She can’t find any cameras, but suspects they must be hidden in the lighting fixtures. So she smashes all the light bulbs in the room. Her behavior seems blatantly psychotic.

However, her study of editing makes sense. She is a nonfiction writer who gets employment at magazines. And what does the voice say to her? It tells her to look back two paragraphs in what she is reading, because she had missed a mistake in editing. She does look back, and finds that the voice was right.

The problem is that schizophrenic voices do not have a reputation for helpfully guiding a person to correctly perceive objective reality (in this case, the editing mistake). But an alternate personality might do just that.

So did the author have schizophrenia, multiple personality, neither, or both? As I continue to read the memoir, I am trying to decide.

1. Claire Bien. Hearing Voices, Living Fully: Living With The Voices in My Head. Foreword by Larry Davidson, PhD. London and Philadelphia, Jessica Kingsley Publishers, 2016.

DSM-5’s index misleads psychiatrists, other mental health professionals, and the general public about auditory hallucinations (hearing voices)

from November 25, 2015

American Psychiatric Association, in DSM-5, indexes auditory hallucinations as psychosis, but many nonpsychotic people hear voices

DSM-5

If you look up “hallucinations, auditory” in the index of DSM-5 (1, p. 929), all the pages referenced are in the chapter, Schizophrenia Spectrum and Other Psychotic Disorders.

However, DSM-5, itself, in the chapter, Dissociative Disorders [which are not psychoses], contradicts the view that voices are necessarily psychotic: 

“Dissociative identity disorder [aka multiple personality disorder] may be confused with schizophrenia or other psychotic disorders. The personified, internally communicative inner voices of dissociative identity disorder…may be mistaken for psychotic hallucinations…Persecutory and derogatory internal voices in dissociative identity disorder associated with depressive symptoms may be misdiagnosed as major depression with psychotic features” (1, pp. 296-297).

The General Public

Most successful novelists hear voices (2).

Many normal people in the general public hear voices:

https://en.wikipedia.org/wiki/Hearing_Voices_Movement

http://www.hearing-voices.org/voices-visions/

http://www.abc.net.au/news/2015-05-28/hearing-voices-in-your-head-more-common-than-thought-study/6504704

Do any, or perhaps many, of the nonpsychotic people who hear voices have a normal version of dissociative identity (multiple personality)? I think so.

1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013.

2. Thaisa Frank, Dorothy Wall. Finding Your Writer’s Voice: A Guide to Creative Fiction. New York, St. Martin’s Press, 1994.

“This Is the Story of a Happy Marriage” by Ann Patchett (post 4): Are Novels Autobiographical?

Rose—the protagonist of Patchett’s first novel, The Patron Saint of Liars, discussed in previous posts—is never happily married. She abandons her first husband, and later abandons her second husband and daughter, all without explanation.

The title of the title essay of Patchett’s collection of autobiographical essays, “This is the Story of a Happy Marriage” (1), suggests that Rose’s story is not Patchett’s own. But the essay itself reveals that the issue is complicated.

“I know that a minimum of four generations of my family have failed at marriage. On my father’s side, six out of the seven Patchett children, my aunts and uncles, married, and five of them divorced. My sister and I have both divorced. Our parents divorced when I was four” (1, pp. 239-240).

The man, sixteen years older than Patchett, to whom she became happily married, had wanted to marry her for years. She agreed to marry him only when doctors said he had developed a serious heart disease. After they were married, it turned out the doctors had been wrong, or, at least, that he had completely recovered.

In another essay, “Dog without End,” Patchett recalls her sixteen-year loving relationship with her dog named Rose (1, p. 276).

1. Ann Patchett. This Is the Story of a Happy Marriage. New York, HarperCollins, 2013.

Authorial Intent in “Beloved” by Toni Morrison (post 18)

Are novels written primarily to promote ideas? If you think so, you may assume that Morrison wrote Beloved to raise consciousness about the horrors of slavery. And Morrison probably did want to raise consciousness about the horrors of slavery.

But if promoting the credibility of the horrors of slavery had been her primary motivation, she would not have written her novel as a ghost story, especially one with this ending: Sethe is judged mentally ill—“That woman is crazy. Crazy.” (1, p. 305)—and Beloved may have been imaginary.

I think that novels are written (apart from money) to express the author’s psychological issues (through stories co-written by alternate personalities).

1. Toni Morrison. Beloved [1987]. New York, Everyman’s/Knopf, 2006.