Schizophrenia

For psychoanalysis, as for medical research and the entire field of mental health, schizophrenia is a complex, baffling, and frustrating disorder. It is not particularly rare, affecting about 1 percent of the population; its distribution is worldwide. A century after Emil Kraepelin created the diagnosis of dementia praecox and its extensive symptomology—renamed schizophrenia by Eugen Bleuler—it remains poorly understood. In spite of revolutionary advances in biology and neuroscience, no treatment or combination of therapies offers a reliable cure.

Like all the psychotic disorders, schizophrenia was thought from the start to have an organic basis, but Kraepelin was forced describe it as a "functional disorder." Early age of onset and absence of brain lesions such as might be found in epilepsy or tertiary syphilis, for example, encouraged early analysts to attempt treatment, especially in light of the limitations of other therapeutic modalities. It became plausible to suggest, at least tentatively, that schizophrenia was a psychological disorder that originated, like neurotic conflicts, in infancy and early childhood. The fact that some small but significant percentage of patients experienced full or partial recovery made it a target for therapies of all kinds, including psychoanalysis.

Although Freud himself was skeptical about prospects for successfully treating schizophrenia, the disorder was central to the activity of many early analysts, who often were associated with hospitals for the insane. Karl Abraham's first letters to Freud concerned psychosis; like Carl Jung, he worked at the Burgholzi Central Asylum and University Clinic in Zurich, which Bleuler directed. In the United States, where psychiatry only gradually became a primarily office practice beginning about 1920, psychiatrists influenced by Freud also worked in asylums. Adolf Meyer and William Alanson White were both hospital-based psychiatrists, as was Harry Stack Sullivan, who reported impressive results with his analytically oriented treatment beginning in the 1920s. Particularly influential, Sullivan's work led to the creation of a psychoanalytic enclave at Chestnut Lodge in Rockville, Maryland, devoted to the treatment of patients with schizophrenia and related disorders.

The rapid growth of psychoanalysis as a medical specialty in the United States after World War II affected the way that schizophrenia was perceived, understood, and treated. The broad theoretical reach of psychoanalysis, with its ambitious aims to provide a general psychology, extended to schizophrenia both as an explanatory tool and treatment modality. In retrospect it is clear that as a treatment it was not successful and that the early-childhood environmental deficit model that analysts proposed could not be sustained. At the time, however, without benefit of drugs or a significant knowledge base in neurochemistry, and in the wake of a period during which biological explanations of mental disease had favored eugenics, psychoanalysts appeared to be modern and forward-looking professionals who were making an earnest and humane effort to understand severe psychopathology in terms of developmental deficits.

Psychoanalysis was not seriously affected by the introduction of phenothiazine in the mid-1950s. But the narcoleptics and their successor drugs set the stage for the de-institutionalization of the mentally ill that began a decade later and also opened the way for the dopamine hypothesis, the first of various neurochemical pathways to be implicated in schizophrenia. By the late 1960s the authority of psychoanalysis was eroding, both as therapy and theory, and it had to compete with a diversified marketplace of competing treatments. As psychoanalysis in the United States entered a period of steep decline in the 1980s, its efforts on both a theoretical and clinical level were often held to be of no account. However, one positive outcome of analytic interest in the severe mental disorders, in fact, was a sophisticated and durable typology of what became known as the borderline and narcissistic disorders (Kernberg 1975), which developed along separate lines and found a respected place in clinical psychiatry and mental health practice more generally.

The list of analysts who studied and wrote about schizophrenia is long and includes interpersonalists, ego psychologists, Kleinians and their successors, together with any number who might be described as individualistic or idiosyncratic. Key texts included papers by Paul Federn, Melanie Klein, Harold Searles, and many others. Some analysts published books on schizophrenia that remained in print for decades, such as Frieda Fromm-Reichman's Principles of Intensive Psychotherapy (1950) and Silvano Arieti's The Interpretation of Schizophrenia (1955). Arieti served for years as editor of the voluminous American Handbook of Psychiatry.

Today, psychoanalysts view schizophrenia through a diversity of lenses. Many if not most would acknowledge the medical consensus that it is essentially a biological disorder and would not recommend the kind of intensive therapeutic efforts employed in the past. Analysts seeking an in media res would hold that analytic therapy can be beneficial while giving up earlier etiological views. A minority of analysts, post-Kleinians and others, continue to view schizophrenia as amenable in a global sense to therapeutic intervention and theoretical elaboration. Although the classic psychoanalytic model of the etiology of schizophrenia is definitively obsolete, all these currents can coexist and develop alongside the diathesis-stress model of the disorder, currently dominant in psychiatry and medicine.

See Also

See also: Ambivalence; Anti-Oedipus: Capitalism and Schizophrenia; As if personality; Basic Problems of Ethnopsychiatry; Blank/nondelusional psychoses; Character Analysis; "Claims of Psycho-Analysis to Scientific Interest"; Collected Papers on Schizophrenia and Related Subjects; Dementia; Disintegration, feelings of, (anxieties); Ego Psychology and Psychosis; Foreclosure; Infantile schizophrenia; ; Language and disturbances of language; "Metapsychological Supplement to the Theory of Dreams"; Narcissism, secondary; Numinous (analytical psychology); "On the Origin of the 'Influencing Machine' in Schizophrenia"; Organic psychoses; Paranoia; Paranoid psychosis; Paranoid-schizoid position; Paraphrenia; Persecution; Psychological types (analytical psychology); Psychology of Dementia præcox; Psychology of the Unconscious, The;Psychoses, chronic and delusional; Psychotic/neurotic; Psychotic transference; Splitting of the ego; Symbolic equation; Symbolic realization; Thought-thinking apparatus; "Unconscious, The"; Violence of Interpretation, The: From Pictogram to Statement; Word-presentation.