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Concepts of schizophrenia

Each account of the concept of ‘schizophrenia’ reaches into the past from a viewpoint in a contemporary present. Berrios and Hauser (1988) commented that such accounts were unhistorical because we still lived in a Kraepelinian world. That was fair comment at the time and could be applied to many emerging disciplines whose concepts became temporarily stuck.

It is also true that most people who have been concerned with such concepts over a professional lifetime find that the accumulation of new knowledge requires them to take a critical look back along several progressively different sightlines. This section is limited to the past two centuries, but a comment by John Locke over 300 years ago illustrates the confusion arising from terms used to describe severe deviations from mental health.

Locke was ‘astonished at the Obstinacy of a worthy man,
who yields not to the Evidence of reason, though laid before
him as clear as Day-light . . . I shall be pardoned for calling it
by so harsh a name as Madness, when it is considered that
opposition to Reason deserves that Name and is really
Madness; and there is scarce a man so free from it, but that if
he should always on all occasions argue or do as in some
cases he constantly does, would not be thought fitter for
Bedlam, than for Civil Conversation. I do not here mean
when he is under the power of an unruly Passion, but in the
calm steady course of his Life.’ (Locke 1959)

Locke carefully distinguished ‘madness’ in the sense of unreasonableness, which was as common in his time as in ours, and the effects of being overpowered by ‘an unruly passion’, which was rare. His terminology is upside down to current readers but his distinction is clear and surprisingly modern.

Nevertheless,  Michel Foucault would have none of it.  To him, madness was always a form of opposition to ‘established’ reason. He thought that the way people react to it was a function of the historical epoch in which they lived (Foucault 1967).

Such issues have not gone away, but one of the strongest tendencies in modern psychiatry is towards accepting Locke’s basic differentiation between ‘unreasonableness’, which is common, and illness,  which is rare.  The international acceptance of specified definitions for mental disorders, with ‘schizophrenia’ as perhaps the outstanding example,  may,  however,  have created an undue confidence in the durability of the global concepts.  It is less likely that definitions of the constituent ‘symptoms’, about which people understandably complain and which are the most obvious and accessible phenomena,  will change much in the foreseeable future.  However,  there is a gradual acceptance that standardized definitions of symptoms, plus new means of investigating brain functions, might eventually lead to the combination, break-up or abandonment of some current disease concepts,  schizophrenia conceivably among them.

Even to the sceptical eye of the present authors, there has been sufficient advance in knowledge during the past decade to make another retrospective worthwhile, both for its own sake and because of the possible implications for future development.

J.K. Wing and N. Agrawal

Edited by
Steven R. Hirsch
MD FRCP FRCPsych
Professor of Psychiatry Emeritus, Division of Neuroscience and Psychological Medicine Imperial College Faculty of Medicine and Director of Teaching Governance, West London Mental Health NHS Trust London, UK


Daniel R. Weinberger MD
Chief, Clinical Brain Disorders Branch Intramural Research Program National Institute of Mental Health Bethesda MD 20982, USA

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