Schizophrenia and! Civilization

Citation preview

Scinizoplarenia

anol Civilization

Torrey, E. Fuller. Schizophrenia and Civilization. E-book, New York: Jason Aronson, 1980, https://hdl.handle.net/2027/heb02208.0001.001. Downloaded on behalf of The University of Chicago

Upon this gifted age, in its dark hour, Rains from the sky a meteoric shower Of facts .. . they lie unquestioned, uncombined, Wisdom enough to leech us of our ill [s daily spun, but there exists no loom

To weave it into fabric.

—Edna St. Vincent Millay, Sonnet 137

Torrey, E. Fuller. Schizophrenia and Civilization. E-book, New York: Jason Aronson, 1980, https://hdl.handle.net/2027/heb02208.0001.001. Downloaded on behalf of The University of Chicago

Schizophrenia and! Civilization

E. Fuller Torrey, M. D.

pay

Jason

Aronson

New York @ London

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Copyright © 1980 by Jason Aronson, Inc. All rights reserved. Printed in Canada. No part of this book may be used or reproduced in any manner whatsoever without written permission from Jason Aronson, Inc. except in the case of brief quotations in reviews for inclusion in a magazine, newspaper or broadcast. ISBN: 0-87668-80-4 Library of Congress Catalog Number: 79-5193) Manufactured

in Canada.

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for Rhoda and her friends, who must suffer through our ignorance

Torrey, E. Fuller. Schizophrenia and Civilization. E-book, New York: Jason Aronson, 1980, https://hdl.handle.net/2027/heb02208.0001.001. Downloaded on behalf of The University of Chicago

Acknowledgments Portions of chapter 3 are taken from E. F. Torrey, B. B. Torrey, and

B. G. Burton-Bradley, ““The Epidemiology of Schizophrenia in Papua

New Guinea,” American Journal of Psychiatry 131:567-573, 1974. A

brief portion of chapter 8 is also found in E. F. Torrey, “Epidemiology, in The Disorders of the Schizophrenic Syndrome, edited by L. Bellak, New

York, Basic Books, 1979. Ms. Barbara Torrey and Dr. Dermot

Walsh provided valuable criticism, and excellent job of typing the manuscript.

Ms.

Torrey, E. Fuller. Schizophrenia and Civilization. E-book, New York: Jason Aronson, 1980, https://hdl.handle.net/2027/heb02208.0001.001. Downloaded on behalf of The University of Chicago

Mary

Adams

did an

Contents Chapter 1 Introduction What Is Schizophrenia? On Incidence and Prevalence What Causes Schizophrenia?

l

Cultural Studies of Schizophrenia Schizophrenia as a Badge of Civilization What

Is Civilization?

Summary

Chapter 2. Is Schizophrenia of Recent Origin? Ancient Texts Rx: One Roasted Mouse Enter Schizophrenia Was Schizophrenia Increasing? The Curious Case of the Missing Disease Summary

19

Chapter 3. Is Schizophrenia a Disease of Civilization? Early Impressions and Some Myths Dispelled From Cherokees to Kalmucks and the Achinese Studies in Africa The South Pacific The Making of “Sheer Folklore” Studies since 1960 Schizophrenia That May Not Be Schizophrenia Summary

A3

Chapter 4

The Distribution of Schizophrenia in the Americas

Schizophrenia among Minority Groups and Lower Socioeconomic Classes

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77

vill

Schizophrenia and Civilization

Prevalence Rates of Schizophrenia in the United States

Prevalence Rates of Schizophrenia in Canada and South America Summary

Chapter 5

The Prevalence of Schizophrenia in Europe and Israel Northern Europe Schizophrenia among European Emigrants Western and Southern Europe Eastern Europe Israel Summary

Chapter 6 Croatia

Croatia and Western Ireland: Two Special Cases

97

15

Western Ireland: The Early Story

Studies of Irish Immigrants Recent Irish Findings What Are the Causes? Summary Chapter 7 Japan Taiwan

Schizophrenia in Asia, Australia, and Africa

137

India, Ceylon, and Iran

Australia Africa

Summary Chapter 8

Clinical Similarities and Differences of Schizophrenia Across Cultures Symptoms and Subtypes Onset, Sex, and Course

Month of Birth Treatment Summary

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149

Contents

Chapter 9 Synthesis Psychosocial Theories

1X

169

Biological Theories

Conclusion References

189

Index

223

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BLANK PAGE

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Introduction

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We are the hollow men

We are the stuffed men

Leaning together

Headpiece filled with straw. Alas! Our dried voices, when

We whisper together

Are quiet and meaningless

As wind in dry grass

Or rats’ feet over broken glass In our dry cellar

Shape without form, shade without colour,

Paralysed force, gesture without motion; Those who have crossed

With direct eyes, to death’s other Kingdom

Remember us—if at all—not as lost

Violent souls, but only

As the hollow men

The stuffed men.

—T.S. Eliot, “The Hollow Men”

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(1925)

Schizophrenia is the cruelest disease of the Western world. It afflicts young adults, often beginning insidiously and progressing until the ambitions, potentials, and hopes of early years are discarded in disarray. In their place lie broken thoughts, inappropriate or stunted emotions, and internal voices or other misperce’ tions that can make existance a living hell. Cancer at least has the decency to kill the body after it has devastated it; schizophrenia rarely does so. Schizophrenia is a common disease. One out of every 100 Americans will be diagnosed as having it during their lifetime. In other countries the incidence can be much higher; in parts of Western Ireland | out of

29 people will be afflicted. The cost of schizophrenia is incalculable,

and includes the expenses of mental hospitals, boarding and halfway houses, educations never used, lost wages, and compensatory welfare payments for those who cannot support themselves. To this must be added the anguish of relatives and friends, helpless to change the situation or make the person well. It is indeed a disease worthy of Dante’s Inferno. This book will explore the relationship between schizophrenia and civilization. Although many people have assumed that schizophrenia has always been with us and exists universally at about the same prevalence rate, the evidence is to the contrary. In all ages and countries a few cases of schizophrenia have existed. These cases can be viewed as the baseline prevalence of the disease, and probably consist largely of organic diseases such as pellagra, trypanosomiasis, temporal lobe epilepsy, and brain tumors masquerading as the disease. In developing nations the few cases of schizophrenia which do exist are probably of this type; the fact that most such cases have a rapid onset (chapter 3) and a good prognosis (chapter 8) supports this view. Beyond this baseline prevalence, however, there appear to be wide differences in the distribution of schizophrenia. The disease was apparently rare before 1800, then increased rapidly during the nineteenth century in both Europe and the United States (chapter 2). It

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Schizophrenia and Civilization

continues to be rare in most developing countries although as such countries move toward development a sharp increase in schizophrenia is sometimes seen (chapters 3 and 7). Because of this schizophrenia has become a badge of civilization for some, and its existance pointed to as proof that the country is indeed “civilized” (chapter 1).

In developed countries there is at least an eightfold difference in the

prevalence of schizophrenia. Areas with the highest rates include Ireland, Scandinavia (especially an area in northern Sweden), and astern Europe (especially part of Croatia)

(chapters 5 and 6). Areas

with an intermediate prevalence are England, Germany, the United

States, and Japan (chapters 4, 5, and 7). Southern European countries

appear to have a low prevalence rate (chapter 5), and developing countries the lowest of all (chapter 3). Schizophrenia occurs more commonly among lower socioeconomic groups in the United States, England, Japan, Norway, Ireland, and Iceland; in India and possibly Italy the opposite is true (chapters 4-7). The disease is also more prevalent among urban dwellers and among blacks in the United States; northeastern states in particular have been noted to have a high rate of schizophrenia (chapter 4). In many countries there is also known to bea definite seasonality to the births of people who become schizophrenic, with many more of them born in the

winter and spring months than in summer and fall (chapter 8).

The most likely explanations for the epidemiological patterns of schizophrenia are biological, not psychosocial (chapter 9). This coincides with other emerging clinical and laboratory data strongly suggesting that schizophrenia is a collection of brain diseases. Within the biological realm viruses combined with familial or genetic factors explain the data best, although dietary factors and environmental contaminants must be kept in mind. Schizophrenia and civilization, then, are correlated, and the relationship is probably controlled by

biological factors. Such is the thesis of this book.

What is Schizophrenia? It is most unfortunate that in the phrenia is used so broadly —often imprecision that surrounds the term disease clearly and thereby probably

United States the term schizocompletely erroneously. The impairs our ability to see the hinders research on it. Schizo-

phrenia is not, for example, a “split personality” in the sense of “Sybil”

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Introduction

5

or “The Three Faces of Eve,” even though the vast majority of Americans believe this to be so. These “split personalities,” a very rare psychiatric occurrence, are properly called dissociative reactions, and they usually occur in people who do not have schizophrenia. Rather, schizophrenia is a symptom complex of abnormal brain function consisting of some combination of the following: Disorders of the thinking process. The person may pick up a rubber band and tell you that it is a musical instrument because it is a “band” and that reminds him of the instruments used in the hospital emergency room where the FBI implanted electrodes in his brain. This thinking pattern demonstrates both loose associations and delusions. Disorders of emotions. The person may have blunted or flattened emotions or may respond with very inappropriate emotions. For example, he or she may laugh when told something most people would find sad. Disorders of perception and sensory stimuli. The person hears nonexistant voices. These auditory hallucinations are a hallmark of schizophrenia, although they are not found in every patient and are occasionally found in other diseases. Because of these disorders, the person with schizophrenia may behave in very strange ways or may say very strange things. (For example, he may take off his clothes in public because of a belief that it will stop the sun from melting.) Thus, the schizophrenic is labeled “crazy.” The disease usually begins in early adulthood and progresses either steadily or intermittently until middle age, when it becomes quieter. By then, however, the person manifests residual brain damage from the disease. Asasymptom complex of disordered thinking, emotions, and perception, there is much

agreement

worldwide

on who

should be labeled

schizophrenic. A World Health Organization study of schizophrenia found that psychiatrists in participating centers in nine separate

countries could agree on a “concordant” group with schizophrenic

symptoms (World Health Organization 1973). This symptom complex is also referred to as “‘process”’ schizophrenia by many (Garmezy 1968) and coincides with the usual use of the term schizophrenia in Western European nations, especially Scandinavia. It is also closely allied with “poor prognosis” schizophrenia as described in studies in Sweden, Norway, England, and the United States (Robins and Guze 1970). It is in this narrow sense of the term that schizophrenia will be used in this book.

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Schizophrenia and Civilization

It would be nice if all the studies to be described in this book utilized a similarly narrow definition of schizophrenia. The truth, of course, is that many of the studies do not specify what they mean by the term. Others appear to adopt a broader definition which includes some combination of pseudoneurotic, borderline, latent, atypical, and schizo-affective varieties. Many others apparently include, under the schizophrenia label, acute transient psychotic states that resemble schizophrenia. The latter condition is often called “reactive” (as opposed to “process’’) schizophrenia (Garmezy 1968) or “good prognosis” (as opposed to “‘poor prognosis’’) schizophrenia (Robins and Guze 1970). These acute transient psychoses appear to be especially common in the developing countries of the world and will be discussed in more detail in chapter 3. Such lack of precision in defining schizophrenia has been a major impediment to epidemiologic research and has compromised the most virtuous cross-cultural intentions. Another source of confusion in defining schizophrenia is its separation from manic-depressive psychosis. In the latter disease, the affect is disordered, with either periodic manic episodes or depressive episodes or both. Manic-depressive psychosis is much less common than schizophrenia, and the person having it often is quite normal between attacks. In its early stages, manic-depressive psychosis may be misdiagnosed as schizophrenia, although as time progresses the correct diagnosis usually becomes evident. A small intermediate group of patients who have symptoms of both diseases, usually called schizo-affectives, compounds diagnostic confusion. This confusion often may result in chaos when diagnosis is considered in a cross-cultural context: separating a schizophrenic from an early manic-depressive patient in one’s own culture may be difficult, but attempting to do so in another culture or in another language may be impossible. In most Western countries, three schizophrenic patients are admit-

ted to mental hospitals for every one manic-depressive. What can be said about studies in India (Rao 1966a)

or Japan

(Seligman 1930)

showing ratios of 5:1 or studies in China (Woods 1929) showing a ratio

of 6:1? Are there genuinely more schizophrenic patients or fewer manic-depressive patients, or are these simply differences in diagnosis?

Alternatively, do these differences coincide with claims that schizo-

phrenia is more common in lower socioeconomic populations and manic-depressive psychosis more common in higher socioeconomic

classes (Tietz, Lemkau, and Cooper 1941, Odegaard 1956)? What are we

to make of a ratio of 8:1 in Nigeria (Lambo 1960) or even 17:1 in South

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Introduction

7

Africa (Lamont and Blignault 1953)? At least some of these are due to differences in diagnosis. In the case of South Africa, for instance, we

can analyze the relevant studies and find that “schizophrenic” patients who were noisy and excited had a better prognosis (Moffson 1954); we may therefore tentatively conclude that many manic-depressive patients were being categorized as schizophrenic, thus leading to the high ratio reported for that country. Another apparent example of this mislabeling of manic-depressive patients as schizophrenics is seen when Malays are described as having a high percentage of atypical schizophrenics and schizo-affectives “with a marked depressive or, more often, hypomanic coloring’ (Schmidt 196l1b). The manic-depressive picture becomes even more confusing when studies showing a reversed ratio are considered—that is, more manicdepressive patients than schizophrenic patients. There have been claims that such a pattern is the case in Mediterranean countries such as Morocco, Tunisia, Portugal (Gold 1951) and parts of Italy (Rose 1964). It has also been described for a group of Formosan aborigines (Rin and Lin 1962), among

the Maoris of New

Zealand

(Beaglehole

1950), and most prominently in the Hutterite study in the United States (Eaton and Weil 1955) which will be discussed in detail in chapter 4. If these ratios are really accurate, they may offer important clues about causative factors in manic-depressive psychosis and schizophrenia. This book will not include an analysis of manic-depressive psychosis in different cultures, as the task of sorting through the literature on schizophrenia appeared sufficiently overwhelming. A discussion of manic-depressive psychosis will be included whenever it will throw light on the true prevalence of schizophrenia—especially in those cases where schizophrenia appears to be either very sparse or very abundant, giving rise to the question of whether cases of schizophrenia have been erroneously called manic-depressive psychosis or vice versa. In a few studies, the authors fail to separate these two major psychoses and simply lump them together; such instances will be so indicated. On

the

Incidence and

Prevalence

Most diseases known to mankind are distributed unevenly around world.

Some,

like

cholera

and

typhoid

fever,

are

distributed

unevenly because of differences in sanitation. Others—dental caries, for instance—vary according to such dietary factors as the use of

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8

Schizophrenia and Civilization

refined sugars in candy and soft drinks. And still others, such as multiple sclerosis and many cancers, vary for unknown reasons; if we knew the reasons we would probably understand what causes them. Schizophrenia falls into the latter group. The measurement of the distribution of a disease is done by measuring either its incidence or its prevalence. Incidence is the number of new cases occurring within a specified time period, whereas prevalence is the total number of cases in a given population at any one time (Kramer 1957). Both are expressed as a rate per total population, and for the sake of uniformity, most rates in this book have been converted to rates per thousand population. Attempting to ascertain the distribution of schizophrenia is fraught with difficulties, not the least of which is the definition of the disease.

As discussed previously, this book uses the term schizophrenia in the narrower sense. However, many of the studies to be discussed use the term more broadly, and, even more regrettably, some fail to say how they are using it. Another problem is finding all the cases. Mental hospitals are of course the most logical place to look, and admissions (especially first

admissions) to mental hospitals have been used in many studies of schizophrenia in the United States. The problem is that hospitalization rates are partly determined by the availability of hospital beds; as the beds increase so do the number of patients (Page and Landis 1943). The discharge rate and the death rate of patients in the hospital also affects

the hospitalized rate. And some schizophrenic patients can be found in

other community institutions, such as prisons and alcohol treatment facilities. Some schizophrenic patients are never hospitalized at all. Different cultures and subcultures define the limits of deviancy differently, anda patient that one group may tolerate and humor the next may insist on hospitalizing. These limits may vary even within subcultures in the

United

States. For example,

one recent study showed

that Irish

Americans have a high tolerance for thought disorder but will readily hospitalize a person with overt emotional disturbance. Jews in the United States, on the other hand, are said to tolerate emotionally disturbed individuals but to be more likely to hospitalize a person witha thought disorder (Wylan and Mintz 1976).

Varying amounts of stigma are attached to mental disorders in different cultures, leading some groups to hospitalize patients more quickly, others to hide affected members in the hall closet when

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Introduction

9

company comes to visit, and still others to simply tolerate the deviant member with gentle good humor. A good example of the last situation was cited by H. B. M. Murphy when he was trying to identify all the schizophrenic patients in a Canadian village: One of our other informants

learnt first of another

case in a fashion

which still less suggests shame or embarrassment. To use his own words, it happened that my wife had been making a social visit to them and she noticed a blanket over the parlour sofa as if some stuff had been covered up there. After a time, while they were having tea, it moved. She must have seemed a little startled, for they said: “Oh, that’s just Hector. He

always hides himself like that.”” Then they went on with tea! [1964, p. 169]

The age distribution of the population may also be a source of error. Since schizophrenia is an age-specific disease, usually beginning after the age of 15, and prevalence rates are expressed as arate per thousand population, populations with greater numbers of children will appear to have lower schizophrenia prevalence rates than in fact they have. For this reason, it is desirable to correct schizophrenia rates for the age

distribution of the population, and this will be done wherever possible

by citing the rate for the age-susceptible group. The advantage of using incidence rates over prevalence rates is that age factors are less important. However, the use of incidence presupposes that it is possible to determine, with some certainty, when in each case the disease began. For cholera or typhoid fever, ascertaining the ‘date of origin may be possible, but for schizophrenia it is notoriously difficult. Did the schizophrenia begin when the patient first had to be hospitalized? When the high school teacher noticed that the person was different from the other children? Or when the mother noticed that the child never wanted to play with other children? Because of this problem, incidence studies have not been used very much to study schizophrenia. The exceptions to this statement are a series of three lifetime incidence studies that took a group of people born during certain years and followed them for life to ascertain how many developed schizophrenia. Klemperer’s 1933 study in Munich was the first, and he found that 1.4 percent of the population ultimately developed the disease. Fremming (1947) followed up all persons born on Bornholm Island

(Denmark) between 1883 and 1887 and found that just under | percent ultimately were affected. And Helgason (1964) replicated Fremming’s

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Schizophrenia and Civilization

study in Iceland, following up all persons born from 1895 to 1897 and

finding an incidence of schizophrenia only slightly less than what Fremming found. Parenthetically, it is interesting that Helgason found in Iceland an incidence of manic-depressive psychosis twice that of schizophrenia; in most places in the world, schizophrenia is more

common by a

ratio of approximately 3:1.

As nice as the three studies just discussed are methodologically, they stand alone in the field of schizophrenia epidemiology and cannot be compared with others. As the vast majority of studies are prevalence

studies, it is to them we must turn for clues. Despite their limitations, they provide the best information available. Because of the many

problems with prevalence studies, however, we should not expect to be able to make precise conclusions regarding the distribution of schizophrenia.

What Causes Schizophrenia? Until the last decade little was known about the causes of schizophrenia. The leading theories of twenty and thirty years ago have led nowhere. For example, it was once said that stress can cause schizo-

phrenia (and many laymen still hold that assumption). This belief arose

because a person can be made to appear transiently schizophrenic if he

or she is subjected to overwhelming stress. This syndrome is seen in military personnel under fire, in immigrants cut off from their native

language, and occasionally in others under extreme personal stress. It

is usually called acute reactive psychosis, and its hallmark is that the

person gets better very rapidly when the stress is removed. Research on true schizophrenia has not uncovered any evidence that it is caused by

stress, and in fact the person who gets the disease cannot be dis-

tinguished in any significant way from other people in terms of previous life experience. Similarly, research attempting to show that schizophrenia is caused by pathological interactions between parent and child in the early

years, or by faulty intrafamily communications, has borne little fruit. Both theories have been abandoned by many contemporary schizo-

phrenia researchers, though they linger on in the public image of the

disease.

Within the last decade, however, there has been an outpouring of promising biological research on the causes of schizophrenia. A familial

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Introduction

11

or genetic factor has been further clarified, biochemical abnormalities have been described, and neurological, physiological, pathological,

radiological, and immunological abnormalities in schizophrenic pa-

tients have been established; these will be briefly reviewed in chapter 9.

The biological bases of this disease are beginning to emerge, making it a particularly auspicious time to review the epidemiology of the disease. There is one fact about schizophrenia that has become virtually certain in recent years: It is not a single disease. Schizophrenia is probably no more precise a term than is cancer or mental retardation; we now know that in all three cases there are many different subtypes

and causes. Some people have therefore suggested that schizophrenia

be referred to as “the schizophrenias’’; although the plural is undoubtedly more semantically correct, in this volume schizophrenia will be used in the singular in conformity with common usage. It should be

understood, however, that schizophrenia used in the singular, just like cancer and mental retardation, refers to a group of diseases with clinical similarities and not to a single disease.

Because there is still so little known about the causes of schizophrenia, it is important to use all available clues. Studies of the distribution and prevalence of diseases have yielded invaluable clues to causation in most diseases known to mankind. To use the two diseases

mentioned above, for example, the prevalence of lung cancers among smokers and the prevalence of mental retardation in children of

mothers exposed to the rubella virus during pregnancy both pointed strongly to one of the causes of these diseases. Whereas epidemiologic

studies can rarely prove cause and effect, they can lay the groundwork for laboratory studies which may do so. They also, of course, often open up the road to prevention of the disease. It is the main thesis of this book that epidemiologic and cross-cultural studies will yield similarly valuable clues to the causes of schizophrenia.

Cultural Studies of Schizophrenia The history of cross-cultural approaches to schizophrenia is a curi-

ous one, beset with premature convictions and prematurely closed

minds. As will become apparent in chapters to come, this is a field with a paucity of methodologically sound studies, yet with a plethora of firm conclusions drawn from the inadequate studies which exist. “One of the striking characteristics of the field is the fact of a small amount of

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Schizophrenia and Civilization

inadequate research combined with a large amount of adequate criticism,” according to one review of it (Mishler and Scotch 1963). Cross-cultural studies of schizophrenia began in earnest with Kraepelin. Shortly after the turn of the century, Kraepelin traveled to Singapore and Indonesia and subsequently corresponded with physicians in many parts of the world. He found patients who appeared to

have schizophrenia in his travels, and concluded that

it has been shown that in all civilized nations it comes under observations in approximately the same forms and everywhere accounts for the greatest number of the permanent inhabitants of institutions. [Kraepelin

1919]

Kraepelin’s conclusions, frequently quoted in textbooks of psychiatry, appear to have put a damper on further research in this area. Scandinavian researchers pursued epidemiologic studies of incidence and prevalence, but only a handful of others (for example, Lin 1953 and Eaton

and Weil 1955) made serious attempts to determine whether schizophrenia really did exist in different proportions in different cultures. The lack of development of cross-cultural approaches to schizophrenia reflected the difficulty of the methodological problems in this field—language, definition of schizophrenia, and accuracy of census

data needed for such studies. Another reason was the ‘‘politicization”’

of schizophrenia, which will be discussed later. Still another reason was

the dominance of psychoanalytic concepts in psychiatry until recent

years. These concepts stressed the in-depth analysis of a few cases of

the disease rather than a broad analysis of many cases. Since the causes of the disease were thought to be rooted in the early experiences of the individual, there was little incentive to look at epidemiologic or crosscultural data on large populations. This led to a paucity of psychiatrists going into the field to study its incidence and prevalence and also toa psychoanalytic orientation in many anthropologists who did related

fieldwork (for example, Spiro 1950 and Roheim 1939) who might otherwise have looked at the prevalence of the disease. The consequence of these problems has been a benign neglect of epidemiologic and cultural approaches to schizophrenia which has continued to the present. When contemporary textbooks of psychiatry deal with the question at all, it is usually in a tone of brief dismissal: Sociocultural studies have demonstrated that schizophrenia occurs in both primitive and civilized societies and that incidence rates, when properly evaluated, do not vary significantly. [Knox and Tourney 1965]

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Introduction

13

Schizophrenia is said to “occur in all known cultures” (Crocetti and

Lemkau 1967) and “‘to have a world-wide distribution” (Henderson and Batchelor 1969). Such ideas develop a life of their own, enshrined and

sanctified as truth by the printing press and passed on from textbook to

textbook. Notice, for example, the following statement from a 1963 text:

The schizophrenic psychoses are recognized in all cultures in which mental disorders have been subjected to thorough study. [Noyes and Kolb 1963]

This view was passed on eleven years later virtually intact: Schizophrenia reactions have been observed in all parts of the world and in all societies subjected to careful study. [Solomon and Patch 1974]

As shall become clear in succeeding chapters, many qualifications of

such a statement had developed during those eleven intervening years.

In retrospect, it is curious that there has not been more interest in epidemiologic and cross-cultural studies of schizophrenia. Virtually all current theories of the disease would lead one to expect moderate or even marked differences in prevalence in different population groups through differences in rates of inbreeding, exposure to psychosocial stress, child-rearing patterns, and theoretical environmental agents. Furthermore, nearly all the important diseases known to man show major differences in prevalence in different population groups. The current situation is summarized by Stewart Wolf in a volume on the

biology of schizophrenia: We

are accustomed

to such variability

in the case of many

diseases,

cancer of the stomach for example and many others. So it is very startling and striking, that the incidence and prevalence of schizophrenia appears to be monotonously uniform from geographical area to geographical area, and from time to time through turbulent differences in social structure.

[1976]

Schizophrenia as a Badge of Civilization There is another generic problem that winds among the studies of this book like a thread, weaving in and out but only occasionally

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Schizophrenia and Civilization

becoming visible. As the association of schizophrenia with civilization became increasingly clear over the years, schizophrenia became known as a badge of civilization. The presence of the disease was put forth by some people as proof that their particular culture was no longer uncivilized. Psychiatrists from developing countries occasionally claimed a high prevalence rate and were indignant when it was sug-

gested that theirs might be lower than that of England or the United

States. Conversely, psychiatrists from developed countries occasionally went to developing countries and said that there was little schizophrenia because the inhabitants were not “‘civilized” enough for it. Like lung cancer and auto fatalities, which are also associated with developed countries, the claiming of a disease like schizophrenia as a badge of civilization seems irrational. The important point, however, is that it did indeed become such a badge, and this fact must be kept in mind when evaluating field studies. The motives of the researcher must be considered. Schizophrenia was not always considered a badge of civilization. For example in 1850, Groddeck submitted a thesis, “On the Democratic Disease, a New Form of Insanity,” to the University of Berlin in which

he attempted to prove that the apparent increase in insanity in the United States was a consequence of independence. He argued that

democracy was bad because it produced insanity (Rosen 1959). Two

decades later, another view of insanity in America was put forward by W. A. F. Browne, the superintendent of the Montrose Asylum in

England:

By the calculations of Sir A. Halliday, . . . which, although perhaps

merely approximations to the truth, have the merit of being the only data we possess, it appears that the proportion of the insane to the sane population of Europe, is 1 to 1,000. In Wales, the proportion is | to 800, in

Scotland | to 574. The Americans, so closely allied to us by descent, language, national character, and customs, it is computed

by Dr. Brig-

ham, present | lunatic in every 262 inhabitants. This disparity probably depends on the rapid acquisition of wealth, and the luxurious social

habits to which the good fortune of our transatlantic brethren has

exposed them. With luxury, indeed, insanity appears to keep equal pace. [Rosen 1959]

The Sir A. Halliday referred to in the Browne quotation was Andrew Halliday, a physician who in 1828 had also claimed that insanity was caused by increasing technology in civilization and “over-exertion of

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Introduction

15

the bodily powers”’ (1828). George Rosen, in his fascinating overview of this development, summarizes it as follows: Ackerknecht has made the provocative progressive increase of insanity during the belief in progress, that the belief was no firm basis in fact because the greater

suggestion that the belief in a the 19th century is an aspect of firmly held even when there was prevalence of mental illness was

evidence of more advanced civilization, since civilization was considered

a basic element in its causation. As Jarvis put it, insanity was paid for the high level of civilization attained by the 19th Western European culture as a consequence of the Industrial tion. In this sense, the problem of mental illness was no different contemporary problems of physical disease. [Rosen 1959]

the price century Revoluthan the

Once the link had been made it was solid. Although Groddeck and Browne would probably have liked to see the United States fall on its collective ear, it did not, and democracy and technology became envied. Insanity was a small price to pay for such things, and a certain amount of insanity proved that people were on the right track and were becoming civilized. The argument sharpened as more and more explorers opened up “primitive” lands for the use of European nations. Did the natives have insanity, or were they free from it? Rousseauean romantics, many of whom opposed the Industrial Revolution, found that the “natives” were free of insanity, thus further indicting advances in technology. Conversely, the small educated elites of the “primitive” lands often claimed that they did indeed have insanity, realizing the implication that they were therefore somehow advancing. Mixed with these ideas was a fundamental racism prevalent among some cross-cultural researchers. For example, Carothers (1948) attempted to show that the brains of Africans were inferior to those of Europeans, specifically that the frontal lobes of the former were underdeveloped. The very low prevalence of schizophrenia which Carothers recorded in Kenya at the time was implicitly attributed to the Kenyan brain not being developed enough to acquire such advanced diseases. Smartt found a low prevalence of schizophrenia in what is now Tanzania, and partly explained this by postulating that Africans were inferior: “The African seems, in some way, to be lacking the higher moral sense which is the heritage of more advanced civilizations’ (1956). On the other side of the African continent, a young African psychiatrist, Thomas Lambo, correctly labeled Carothers a racist and proceeded to demonstrate that his

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Schizophrenia and Civilization

Nigerian countrymen did indeed present some classical cases of para-

noid schizophrenia and that therefore they were civilized (Lambo 1955).

The important point to note in all the preceding discussion is not who

was aracist or who was ethnocentric, but rather that many of the people

who have undertaken epidemiologic and cross-cultural studies on schizophrenia had preconceived ideas about what they wanted to find. Schizophrenia is not a neutral disease, but rather one intimately caught up in history and national self-esteem. This factor makes evaluation of the research done to date doubly difficult. What

is Civilization?

Up until this point we have been using “‘civilized”’ and “developed”’ interchangeably. without examining their meaning. What is civilization? The dictionary defines it as a state of human society characterized

by a high level of intellectual, social, and cultural development. Today

this would imply widespread systems of formal education, social groupings determined by economic advancement, and a broad distribution of technology and manufactured goods. As societies proceed from “uncivilized’”’

to

“‘civilized’’

conditions

in

the

modern

world,

the

following changes usually occur: breakdown in the extended family, increased individual mobility, breakdown of traditional roles and values, changes in child-rearing patterns, industrialization, urbanization, job specialization, changes from a barter to a money economy, and the increasingly wider distribution of new music, art, clothing, values,

and technology which is adopted from “‘civilized”’ societies. It may be philosophically questioned whether the abandonment of breast feeding and adoption of transistor radios is good or not, but that is not the purpose of this book. The issue here is that schizophrenia is associated with civilization, and we therefore must

examine

all facets of what

civilization is in order to learn why schizophrenia is a handmaiden of the civilized state. In concluding this overview, it might be legitimately argued, given the methodological problems referred to in this chapter, that the crosscultural studies of schizophrenia done to date are collectively worthless. The alternative view is that although many of the studies are methodologically poor, not all of them are. And given the state of the

art in schizophrenia research, it is important that we utilize all the clues

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Introduction

17

we have for whatever we can get out of them. purse out of a sow’s ear it is true. But you can out of it, and if you are spilling your money sow s-ear purse may do quite nicely until you

You cannot make a silk make a sow’s-ear purse all over the ground the can find a piece of silk.

Summary l. Schizophrenia is defined as a disease affecting the person’s thinking pattern, emotions, and perceptions. It usually begins in early adulthood and progresses either steadily or intermittently for a period of several years. 2. Until recently little was known about the causes of schizophrenia. It is now virtually certain, however, that the disease has a biological basis. 3. Schizophrenia is almost certainly not a single disease but is rather a symptom complex caused by several different agents. Thus, the term schizophrenia is similar to the terms mental retardation and cancer. 4. Epidemiologic and cross-cultural studies of schizophrenia have been lacking. Such studies may provide important clues to the causes of this disease. d. Epidemiologic and cross-cultural studies are difficult to interpret for several reasons, one being that the presence of schizophrenia in a

culture has come to be associated with the state of being civilized. It is

often taken as a badge of civilization.

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BLANK PAGE

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Is Schizophrenia of Recent Origin?

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Of the uncertainties of our present state, the most dread-

ful and alarming is the uncertain continuance of reason. —Dr.

Samuel Johnson, Rasselas (1759)

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It is generally assumed that schizophrenia is an ancient disease, probably as old as mankind. Kraepelin himself believed that it was: ‘Only so much may be said, that the disease is probably extremely old,

as indeed the descriptions of the old physicians often unmistakably

point to the clinical pictures familiar to us’ (1919, p. 232). Since Kraepelin, nobody has seriously challenged the assumption of the antiquity of schizophrenia, and it has been incorporated into psychiatric textbooks as fact. Suppose that Kraepelin was wrong and that schizophrenia is not an ancient disease but is instead of more recent origin. Since we are assuming that schizophrenia is a heterogenous condition, some (or most) of the biological conditions that cause it would be of more recent origin. Thus schizophrenia would be like cancer, with multiple causes—some of which have been present for centuries but others (such as industrial carcinogens) being of more recent origin. What would we expect to find in looking at the history of schizophrenia if many or most of its causes were of more recent origin? We would expect to find some cases that sounded like schizophrenia, since many diseases of the brain known to mimic schizophrenia have presumably been around for a long time—for example, viral encephalitis, brain tumors, temporal lobe epilepsy, pellagra, trypanosomiasis, myxedema, and metabolic encephalopathy. These diseases by themselves should produce a sprinkling of clinical conditions with historical description similar to what we call schizophrenia. In addition, we would expect some additional cases from those biological conditions currently causing schizophrenia that also existed in the more distant past. So what do we actually find when we turn back the history pages and look for schizophrenia in previous centuries? First, we find a confusion of words and psychiatric categories that makes the job enormously difficult. Not only is there the problem of whether the ‘“mania”’ of

Celsus is the same condition as the “mania” of Soranus or that of

Hippocrates, but also it is doubtful whether “mania” as any of them

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Schizophrenia and Civilization

used the term then is similar to the way it is used today. Furthermore,

as we are dealing with words in translation, we must take account of the translators’ biases in choosing a word with which to convey the Greek or Latin meaning. To adequately answer the question posed, it would be

necessary to analyze the texts in the original languages in which they were written. Since that task is well beyond the purview or ability of the present author, we must settle for less precise impressions. Ancient Texts

_ Madness in the generic sense is definitely found in ancient texts. As

stated by Alexander in the opening line of his history of psychiatry,

“the mentally ill have always been with us...” (1966). Early Indian texts on Ayurvedic medicine, the most ancient system of medicine in the world, prescribe strong purgatives and emetics as a treatment for

madness (Whitewell 1936), and Deuteronomy in the Old Testament warns that “the Lord will smite you with madness and blindness and confusion of mind”’ if you disobey his commandments (Deuteronomy 28:28). Claims have been made that Saul was manic-depressive (Whit-

well 1936), and Karl Jaspers attempted to show that Ezekiel was a schizophrenic. According to medical historian George Rosen, however, “jt cannot be said that the attempt was successful” (1968).

The New Testament contains multiple references to madness, and

also to seeing visions and hearing voices, although these are usually both attributed to the intervention of God. The most serious attempt to find schizophrenia per se in the New Testament was a series of four books published early in this century purporting to prove that Jesus was a paranoid schizophrenic. These books were subsequently analyzed and dissected by physician-theologian Albert Schweitzer in The Psychi-

atric Study of Jesus (1948); he found them to be of doubtful merit or scientific validity.

Turning to ancient Greece and Rome, we find Horace describing a

well-known man in Argos who sat daily in an empty theater claiming he could hear actors talking on the empty stage and applauding the nonexistent theatrical performances (Meier 1970). The man, who was apparently experiencing auditory and perhaps visual hallucinations, was subsequently said to have been cured. He then complained of having had his private productions taken away from him: ‘‘By Pollus! You’ve not done me a good turn. You’d far better have killed me than

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Is Schizophrenia of Recent Origin?

23

take away the exquisite pleasure given me by my delusion [sic]”’ (Whitwell 1936). Another interesting ancient Greek case study was that of Alexarchos. On the basis of a single tetter Alexarchos is alleged to have written, he was said by Weinreich to have been schizophrenic. However, George Rosen (1968) disputes this conclusion by maintaining

that Weinreich’s have even been It is probable ancient Greece ‘““mania, a term

evidence was inadequate and that Alexarchos may not mentally ill. that clinical pictures ressembling schizophrenia in and Rome were subsumed under the category of used more broadly then than it is today. Aretaeus in

the first century A.D. differentiated mania from ‘stupid, absent, mus-

ing,” which may describe either mental retardation or organic brain

disease (Lehmann 1967). Shortly thereafter, Celsus divided mania into

those cases with hallucinations and those without (Menninger 1963). In the second century, Soranus differentiated mania from delerium attributable to fevers and also described delusions of grandeur in those ‘““who believe themselves to be God’? (Lehmann 1967). The more one peruses these ancient sources, however, the more striking it becomes that nobody clearly described a case of schizophrenia with the initial break in late adolescence or early adulthood, the constellation of symptoms, and the chronic course. It may be that the syndrome was simply subsumed under mania, or it may be that it was far less common than it is today. Its absence stands in sharp contrast to good clinical descriptions of many other psychiatric syndromes. Depression, subsumed under the broader category of melancholia, was differentiated into several subtypes, and senile dementia, acute brain syndrome, hysteria, hypochondriasis, and alcoholism were all clearly described (Menninger 1963). Even the astute eye of Hippocrates apparently missed schizophrenia if it existed, although he did describe such syndromes as postpartum psychosis, epilepsy with psychiatric symptoms, and transvestism (“the Scythian disease’’)—all of which are much rarer than schizophrenia (Menninger 1963). And by the sixth century, Alexander Trallianus had provided the “earliest description of what later came to be called circular insanity’ (Whitwell 1936), now known as manic-depressive psychosis and only approximately one-third as common as the schizophrenic syndrome is in most countries. The Middle Ages contributed little of substance to psychiatric nosology or clinical description, the preoccupation of the observers being taken up with which incubi or succubi were afflicting which poor

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Schizophrenia and Civilization

soul. Referrals were for ecclesiastical rather than medical care. The

only real advances during this period were Maimonides’

detailed

descriptions of depression and the careful clinical observations of Rhazes and Avicenna among the Arab physicians. The latter, for example, described a young man with “melancholia” and delusions of being a cow: Every day he would low like a cow, causing annoyance to everyone, crying, ‘‘Kill me so that a good stew may be made of my flesh,” until he

finally would eat nothing. Avicenna was called in. First of all he sent a

message to the patient bidding him be of good cheer because the butcher was coming to slaughter him, whereat the sick man rejoiced. Some time afterwards Avicenna, holding a knife in-his hand, entered the sickroom

saying, Where is this cow that I may kill it?” The patient lowed like a cow to indicate where he was. By Avienna’s orders he was laid on the ground, bound hand and foot. Avicenna felt him all over and said, “He is too lean, and not ready to be killed; he must be fattened.”’ The patient

then took food eagerly, gradually gained strength, got rid of his delusion, and was completely cured. [Whitwell 1936, pp. 96-97, quoting E. G. Brown, Arabian Medicine|

Rx: One Roasted Mouse It was not until the Renaissance was fully under way that physicians returned to the task of describing and classifying mental disorders. Bethlem Hospital, the first mental hospital in England, began taking in mad people at the end of the fourteenth century, thereby providing the possibility of observing groups of mad people together and theoretically multiplying the opportunities for a single observer to make clinical comparisons and describe syndromes

(such as schizophrenia) that had

not yet been described. In the four hundred years following the opening of Bethlem, some excellent clinical observations emerged, but not one provided a clear description of the schizophrenia syndrome as we know it. In the early sixteenth century, Bartholomaeus divided mental illness into melancholy (apparently including depression, anxiety, hypochondriasis, and some delusional states), mania or raving madness, forgetfulness or staring spells, delerium resulting from brain diseases, and delerium resulting from systemic diseases (Hunter and Macalpine 1963). Johann Weyer, a remarkably astute physician of this period, even attempted to

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Is Schizophrenia of Recent Origin?

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treat “witches” with psychotherapy rather than burning them at the stake, yet he did not describe schizophrenia (Galdston 1967). This era also witnessed experimental

new therapies for the insane, including

such gourmet specialties as “a roasted mouse eaten doth heal frantic [psychotic] persons” (Hunter and Macalpine 1963). Good descriptions of delusions and hallucinations were published in 1570 by Ludwig Lavater in Zurich. Translated into English as “Of Ghosts” two years later, the author referred to previous historical descriptions of the same phenomena such as the man from Argos clapping in the empty theater (Hunter and Macalpine 1963). By the turn of the century, William Shakespeare was incorporating descriptions of delusions and hallucinations into his plays; for example, Macbeth and Hamlet experienced visual hallucinations. Madness is a prominent theme in Shakespeare, from the feigned lunacy of Hamlet to the senile ravings of King Lear to the acute reactive psychosis of

Ophelia when she discovered that her father had been killed by the man

she loved (Anonymous 1844); but nowhere in Shakespeare’s works is schizophrenia to be found. In 1621 Robert Burton published his classic The Anatomy of Melancholy. Reprinted five separate times during his lifetime, Burton’s book covered a broad range of mental disorders, including paranoid states, but not schizophrenia per se. Shortly thereafter, Thomas Sydenham published an excellent description of hysteria, and in 1656 Felix Plater in Switzerland described a case of madness later shown to have been caused by a brain tumor (Whitwell 1936). Also in 1656, an English minister named George Trosse published a self-account of his mental breakdown, with delusions and auditory hallucinations, at age 25. Some of his behavior appears catatonic: “for several days... I would neither open my eyes nor my lips’ (Hunter and Macalpine 1963). Hospitalized for several months in a private asylum, Trosse subsequently recovered. This account may have been the first actual description in literature of what we now call schizophrenia. Thomas Willis was another major contributor to psychiatric thinking in the seventeenth century. His work on cerebral anatomy isa classic (Willis 1683), and he was the first to describe the syndrome of general paresis, although its actual cause was not to be discovered for another two hundred years (Hunter and Macalpine 1963). He also differentiated mental deficiency from “deteriorating illnesses’; the latter may have been a reference to schizophrenia. One passage is of particular interest to historians of schizophrenia:

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Schizophrenia and Civilization . . apprehend simple things well enough, dextrously and swiftly, and retain them firm in their memory, but by reason of a defect of judgment, they compose or divide their notions evilly, and very badly inferr one

thing from another; moreover, by their folly, and acting ackwardly and

ridiculously, they move laughter in the bystanders. [Willis 1683]

One historian has claimed that Willis was describing loose associations and that this description was the first of schizophrenia that can be identified in psychiatric literature (Cranefield 1961). However, it is also possible that Willis was describing thought processes in a person with mental retardation,

a chronic

brain syndrome,

or manic-depressive

psychosis. In the eighteenth century, there continued to be much interest in classifying diseases, yet schizophrenia is not to be found. Perhaps the closest approximation of schizophrenia was contained in a letter from Dr. David Kinneir of Edinburgh, published in 1727: A Gentlewoman of Nineteen Years of Age, from an obstinate Fasting for Two Days, and Aversion to see Company, in a religious Turn before Easter, fell into a deep Melancholy, would not talk, nor answer any Questions for some Time, but moan’d and sigh’d continually; slept very

little for Ten Days. This happen’d in the Decline of the Moon. The Night

before the Change she spoke, and call’d for some Water to drink, which being given her, she immediately fell a starting and laughing, and her Eyes got a Briskness in them somewhat uncommon, (as her Relations told me) then began to talk wildly, and continu’d so all that Night, She

became next Morning very furious; whereupon a Physician was call’d, who bled her Four Times a Week the first Fourteen Days, vomited her, purg’d her, us’d the Cold Bath, and many other Methods common in such Cases,

all to no Purpose.

In this

Condition

she

continu’d

for Nine

Months; then I was apply’d to. [Hunter and Macalpine 1963, p. 333]

Kinneir went on to relate how he cured her with a camphor compound

over a three-week period: “and tho’ nine years ago, at this time [she] is ina very good state of health, having no extraordinary ailing ever since

... (Hunter and Macalpine 1963, p. 333). Thus it would appear to qualify as a single episode of a schizophrenia-like psychosis without recurrence over nine years. Dr. Samuel Johnson was a keen observer of the mid-eighteenth-

century

London

scene,

from

whom

we

have

learned

much

about

contemporary philosophy and politics. Johnson apparently had a spe-

cial interest in madness and, as shown in the epigraph for this chapter,

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Is Schizophrenia of Recent Origin? described its occurrence as ‘“‘dreadful and alarming”

27 (1759). In 1763

Johnson told Boswell that insanity was increasing in frequency, which he attributed to a decrease in smoking, which was apparently becoming

less fashionable. Smoking, reasoned Johnson, tranquilizes the mind,

and as smoking becomes less common insanity becomes more so (Anonymous 1847a). This reference is the first mention that I have found of the idea of a contemporary increase in insanity, a view that

became widespread a hundred years later.

In the literature of the eighteenth century, there are, of course, many other references to madness, but none appear to be to schizo-

phrenia. William Cowper, a British poet who had recurrent depressions and fequired hospitalization for as much as a year at a time, immortalized psychotic ravings in his poem ‘“‘Crazy Kate” (Anonymous 1844). No longer were such people thought to be afflicted with devils; rather,

the concept of brain disease was becoming more prevalent. Thus, at the

end of the eighteenth century, when a woman killed her infant as a result of a postpartum psychosis and was brought to trial, “the jury very justly found her not guilty of the murder” (Hunter and Macalpine 1963, p. 557). Interest in madness was also greatly stimulated at that time by the psychosis of King George III in England, whose mental illness is now thought by some to have been secondary to porphyria (Macalpine and Hunter 1966), though others disagree strongly with this position (Dean 1971).

Enter Schizophrenia It was as if somebody

rang a bell precisely at the turn of the

nineteenth century to herald the official entrance of schizophrenia.

Whereas up to that point there appear to have been at best a few

scattered cases in the literature, classical schizophrenia was suddenly being described by different people in different places all at about the same time. Such an entrance for a disease is rather dramatic. The honors for the first clinical descriptions of schizophrenia belong

to both Phillippe Pinel at Hospital Salpetriere in Paris and John Haslam at Bethlem Hospital in London; within the same year, in 1809, they

both described classical examples of the disease with onset in early

adulthood and progressive deterioration. Haslam’s 1809 publication was a second edition of his 1798 book, Observations on Insanity. In the earlier book he analyzed all admissions

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Schizophrenia and Civilization

to Bethlem Hospital from 1748 to 1794 and provided the following breakdown of age of admission: Age 10-20 20-30 30-40 40-50 90-60 60-70

Patients 113 488 927 362 143 31

The bulk of admissions were thus concentrated in the 20-40 age group,

suggesting that many of these patients may have been schizophrenic. Haslam’s definition of insanity was similar to that of schizophrenia: an incorrect association of familiar ideas, which is independent of the prejudices of education and is always accompanied by implicit belief, and generally with either violent or depressing passions. [Haslam 1798, p. 10]

Haslam gave a good example of a delusion, stating that if a peasant says he is going to ride his horse to America he may just be ignorant, but if an experienced seaman says the same thing he is insane. Haslam also seemed to describe the thought blocking commonly seen in schizophrenia: When patients of this description are asked a question, they appear as if awakened from a profound sleep; they are searching, they know not where, for the proper materials for an answer, and in the painful and

fruitless efforts of recollection generally lose sight of the question itself.

[1798, pp. 19-20]

In other parts of the book, Haslem gave good descriptions of paranoid

delusions and auditory hallucinations. The bulk of Haslam’s 1798 book, however, was devoted to descrip-

tions of autopsy findings of the psychiatric patients who died and an

attempt

to relate those

findings to the patients’

previous

clinical

symptoms. Of special interest is the case of a 27-year-old woman who

was hospitalized for ‘‘religious enthusiasm,” delusions, tactile halluci-

nations, suicidal thoughts, and periods of hyperactivity. Following an

intermittent course over nine months, she suddenly died, and an autopsy showed findings in the brain that sound like encephalitis: “The

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[s Schizophrenia of Recent Origin?

29

medullary substance when cut into was full of bloody points” (Haslam 1798). Thus Haslam appears to have been the first researcher to recognize that brain diseases such as subacute encephalitis (presumably viral) may produce the clinical picture that we now call schizophrenia. In terms of causation of insanity, Haslam included repeated intoxication, trauma,

mercury

ingestion

(later to be immortalized

by Lewis

Carroll in the figure of the Mad Hatter, mercury being commonly used in the hat-making industry), and hereditary predisposition. Regarding the latter factor, Haslam noted that insane persons with a positive

family history were most likely to be admitted to the hospital between the ages of 30 and 40. He also made observations on the prognosis of different kinds of insanity—for example, that postpartum psychosis had a high recovery rate of 63 percent. Finally, he recommended ‘gentleness of manner and kindness of treatment”’ in the management of these patients. Overall, Haslam’s 1798 study is a remarkable book, which has not been given adequate recognition by historians of psychiatry.

It was in the second himself over to clinical looking at schizophrenia edition that case studies

edition of his book that Haslam fully gave description. Although he was undoubtedly in the earlier edition, it was not until the 1809 such as the following were presented:

there is a form of insanity which occurs in young persons; and, as far as these cases have been the subject of my observation, they have been more frequently noticed in females. Those whom I have seen, have been distinguished by prompt capacity and lively disposition: and in general have become the favorites of parents and tutors, by their facility in acquiring knowledge, and by a prematurity of attainment. This disorder

commences, about or shortly after, the period of menstruation, and in

many instances has been unconnected with hereditary taint; as far as could be ascertained by minute enquiry. The attack is almost imperceptible; some months usually elapse before it becomes the subject of particular notice; and fond relatives are frequently deceived by the hope that it is only an abatement of excessive vivacity, conducing to a prudent reserve, and steadiness of character. A degree of apparent thoughtfulness and inactivity precede, together with a diminution of the ordinary curiosity, concerning that which is passing before them; and they therefore neglect those objects and pursuits which formerly proved sources of delight and instruction. The sensibility appears to be considerably blunted; they do not bear the same affection towards their parents and

relations;

they

become

unfeeling

to

kindness,

and

careless

of

reproof. To their companions they shew a cold civility, but take no

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Schizophrenia and Civilization interest whatever in their concerns. If they read a book, they are unable . to give any account of its contents: sometimes, with steadfast eyes, they will dwell for an hour on one page, and then turn over a number ina few minutes. Itis very difficult to persuade them to write, which most readily develops their state of mind: much time is consumed and little produced. The subject is repeatedly begun, but they seldom advance beyond a sentence or two: the orthography becomes puzzling, and by endeavouring to adjust the spelling the subject vanishes. As their apathy increases they are negligent of their dress, and inattentive to personal cleanliness. Frequently they seem to experience transient impulses of passion, but these have no source in sentiment; the tears, which trickle down at one

time, are as unmeaning as the loud laugh which succeeds them; and it often happens that a momentary gust of anger, with its attendant invectives, ceases before the threat can be concluded. As the disorder increases, the urine and feces are passed without restraint, and from the

indolence which accompanies it, they generally become corpulent. Thus in the interval between puberty and manhood, I have painfully witnessed this hopeless and degrading change, which in a short time has transformed the most promising and vigorous intellect into a slavering and bloated idiot. [Haslam 1809, pp. 64-67]

Here for the first time was true schizophrenia: a good premorbid personality, insidious onset in adolescence, classical signs and symptoms, and a chronic deteriorating course. At the same time as John Haslam was performing his autopsies in London, Phillipe Pinel in Paris was apparently examining a group of patients with the same symptoms. In 180] Pinel described patients with inappropriate or flattened affect, looseness of associations, and ‘‘diminished sensibility to external impressions” (Altschule 1967). Pinel called this condition démence, a term destined to stick to the syndrome for more than a hundred years. He believed that the syndrome was primarily a disorder of thinking, and he distinguished it from melancholia and mania. Eight years later, in 1809, Pinel published more

complete clinical descriptions of the démence syndrome in his Traite

Medico-Philosophique sur L’Alientation Mentale

(Altschule 1976). Be-

cause of the joint and almost simultaneous initial description of schizophrenia by Haslam and Pinel, it has been proposed that the term

schizophrenia be dropped altogether and replaced with the “‘PinelHaslam syndrome”’

(Altschule 1967).

Pinel’s démence caught on quickly in Europe. In Germany in 1822, Neumann noted that when recovery from the syndrome did occur, it

was often incomplete.

And

in England

in 1828, Burrows further

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elaborated on the clinical manifestations of démence (Altschule 1967).

In the United States Benjamin Rush published descriptions of “manalgia” in 1812, noting that it was a subgroup of general insanity in which patients had “‘taciturnity, downcast looks, a total neglect of dress and person... indifference to surrounding objects . . . and sometimes a fixed position of the body” (Hunter and Macalpine 1963, p. 663). It is not certain whether Rush had read either Haslam or Pinel at the time he reported his findings. In the early years of the nineteenth century, schizophrenia also began appearing in general literature. Madness in general still played a

prominent role, as in Sir Walter Scott’s depiction of manic episodes in Madge Wildfire or of depression in Clara Mowbray (Anonymous 1844). But now classical schizophrenia appeared specifically, as in Balzac’s short story “Louis Lambert,” published in 1832. Not only did Balzac

provide an accurate description of a catatonic schizophrenic, but he

even had his character go to Paris for treatment by Pinel’s famous pupil, Monsieur Esquirol. Unfortunately, Esquirol declared his patient incurable and sent him home to his chronic deteriorating fate. At the same time as Louis Lambert was undergoing his fictional schizophrenic psychosis, John Percivalin England was experiencing the same thing in real life, and in 1838 and 1840 he published a two-part autobiographical account of his psychosis (Bateson 1961). His illness, which began at age 27, sounds very much like schizophrenia; however, as little is known of his later life, it is not possible to ascertain the ultimate outcome. From midcentury onward, the démence of Pinel was refined and expanded. In Belgium 1860, Morel emphasized that the onset occurred in later adolescence, calling it démence précoce. Hecker described ‘“hebephrenia” in 1871, and Kahlbaum added “‘catatonia”’ in 1874. By 1896 it merely remained for Kraepelin to relate the work of Morel,

Hecker, and Kahlbaum to the symptoms of paranoia and to call the whole dementia praecox (Altschule 1967). Fifteen years later, Bleuler,

apparently impressed by the splitting in thought processes and inappropriate affect, renamed it schizophrenia, a label the Pinel-Haslam syndrome has retained to this day.

Was Schizophrenia Increasing? Almost from the first historical suggestions of schizophrenia, an accompanying theme can be heard in the background: Insanity (and

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Schizophrenia and Civilization

schizophrenia) were rapidly increasing. The persistence of this idea throughout the nineteenth century and into the twentieth is one of the

most striking facets of the short history of schizophrenia. As mentioned previously, Samuel Johnson introduced this idea as

early as 1763, believing that the increase in insanity was the result of a decrease in the habit of smoking (Anonymous 1847a). John Haslam’s

choice of Johnson for the epigraph of his 1798 book (the same quotation

that appears as the epigraph for this chapter) suggests that Haslam too considered insanity to be on the rise, a suggestion he confirms in the preface to the 1809 edition: The alarming increase of insanity, as might naturally be expected, has

incited many persons to an investigation of this disease. [Haslam 1809]

In England the newfound interest in insanity resulted in the County

Asylums Act, which was passed by the House of Commons in 1808 and

established asylums in many of the counties. As noted by one observer, ‘The period 1805-1817 saw a rapidly rising tide of interest in lunacy reform in the British Isles’’ (Williamson 1969). Statistics were brought forth “which not only show that insanity, in all its forms, prevails to a most alarming extent in England, but that the numbers of the afflicted

have become more than tripled during the last twenty years!” (Halliday

1829). In 1835 J. C. Prichard’s A Treatise on Insanity also recorded a strong impression of an increase in insanity: Yet the apparent increase is everywhere so striking that it leaves on the mind a strong suspicion that cases of insanity are far more numerous than formerly. .. . [Prichard 1835, p. 350]

In Scotland W.A.F. Browne, writing in 1837, thought that insanity had

also increased and that it was twice as common as it was in the rest of Europe. He admitted, however, that it was not an established fact and that “more careful examination is, without doubt, required to establish

the proposition” (Rosen 1968, p. 185).

In France Pinel asserted early in the century that insanity was increasing, and he thought this was due to the stresses which followed the French Revolution (Rosen 1968). Prichard (1835) also believed

that an increase in insanity had taken place in France between 1801 and 1823. By 1856 Renaudin had published an extensive analysis of the question, and cited figures indicating a rapid increase between 1835 and 1854 (Renaudin 1862). More important, the increase had been most

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marked in the younger age groups, those in which schizophrenia is most prevalent: “Formerly insanity of early age was a very rare exception; now, on the contrary, we observea marked precocity. ... [t happens in all ranks of society, and seems to be on the increase.” Renaudin said the increase “ought to give rise to the most serious reflection”; he personally suspected that it was a consequence of the French Revolution but was unclear about the mechanism. Renaudin made another observation which is of interest. He showed that the incidence of insanity differed from one geographical region to another, and that it was higher in urban areas than in rural: “this inequality is in proportion to the degree of agglomeration of the population, establishing a fundamental distinction between town and country.’ He showed that the incidence of insanity was three times as great for urban areas as for rural areas. We will return to a discussion of this phenomenon in chapter 4.

Meanwhile in England the debate was also continuing. By 1855 the

question of an increase in insanity had become politicized and intertwined with debate over the merits of advancing technology and such things as smallpox vaccination. As a report to the House of Commons noted: It may be in place to notice the increase of another scourge—insanity— of which the [d/lustrated London News of 17th February 1855 says, “In the city of London, without any increase of population the number of lunatic poor has doubled within the memory of some of the guardians, and the cause has baffled their inquiries. Some are inclined to attribute this dreadful visitation to excess of eagerness and strife in commercial pursuits, or in mental exertions; others to diet, and some partially to the effects of railway travelling. Why not to vaccination?” [Gibbs 1855]

Two years later John Hawkes wrote a paper, ‘On the Increase of

Insanity,” in which he said: “I doubt if ever the history of the world, or the experience of past ages, could showa larger amount of insanity than that of the present day” (Hawkes 1857). In 1859 the American Journal of Insanity noted that the rapid rise in insane persons in England required the continuous building of new asylums: To meet the continual increase in the number of insane in England, the existing public asylums have recently been enlarged to an additional capacity of 2,481 patients. Besides this, eight new asylums [are] in course of erection. .. . [Anonymous 1859]

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Schizophrenia and Civilization Toward the end of the nineteenth century the debate became more

sophisticated as reasons for the apparent increase were sought. D. H.

Tuke showed that the number of insane rose in England between 1857 and 1877, and that part of the increase could be accounted for by an increased number of mental hospital beds available. “At the same time,” he concludes, ‘‘we think that it is quite probable that there has

been some real increase” (Tuke 1877). The 1892 edition of Tuke’s Dictionary of Psychological Medicine, on the other hand, analyzed

specific admission figures for England and Wales for the years 1859 to

1885; the conclusion was that there had been an apparent increase but that it was an artifact. Elsewhere on the Continent the story was much the same. In 1861

Wilheim Griesinger said that insanity had increased in Germany, and six years later T. B. Belgrave asserted that in Denmark there had been

‘‘an increase in the proportion of lunatics to the general population’”’ (Rosen 1968, p. 178). In France it was claimed that the Franco-Prussian

War and the civil war that followed in 1871 had increased the number of insane (Rosen 1968, 1978). In Greece in 1893, it was noted that insanity was increasing (Sanborn 1893), and in Russia, Mierzejewsky made this observation: “cases of insanity and nervous diseases increase enormously in our days; they pertain mostly to a serious chronic and protracted character” (1888). The prize for the most extensive analysis of this question, however,

must be awarded to Dr. G. A. Tucker, an Australian physician who

undertook a three-year, 140,000-mile survey of more than 400 asylums from 1882 to 1885. Covering most of the United States and Europe, as

well as scattered other countries, Tucker was a man whose zeal was only

outstripped by his obsessive attention to detail; his trip report, Lunacy in Many Lands (1887), covered 1,564 large pages with small print. At

each asylum, Tucker asked the superintendent whether he believed

that insanity was increasing Tucker than the general population. The superintendents replied that part of the apparent increase could be

accounted for by a greater number of asylums and a greater readiness on the part of the population to use them. Tucker concluded, ‘Making

every allowance on this score, however, it does not sufficiently account for the recorded increase in the number of the insane”’ (1887). The vast majority of superintendents believed that the increase in insanity was real, and this “must be accepted as a fact’”’ (Tucker 1887).

Turning to the United States, there appears to have been considera-

bly less interest than there was in Europe regarding the question of

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whether insanity was increasing in the nineteenth century. Nevertheless, statistical data indicate that an increase was quite possible. For example, the first asylum for the insane in the United States opened in Williamsburg, Virginia in 1773. No other asylum opened until 1816, when suddenly there was an explosion of them: Baltimore in 1816;

Philadelphia in 1817; McLean, Massachusetts, in 1818; Bloomingdale, New York, in 1821; Hartford and Lexington in 1824; South Carolina in 1827; and another in Virginia in 1828. Fourteen more asylums were

opened by 1846; by that time, the superintendents of the asylums had organized themselves into what later became known as the American

Psychiatric Association, and they had begun publishing the American

Journal of Insanity (later renamed the American Journal of Psychiatry).

Thus, the openings of asylums and the organization of the psychiatric

profession took place in the United States during a period of only thirty

years.

What statistical data are available suggest a concurrent rapid increase in numbers of insane patients. The first United States census that identified the “insane and idiotic” was that of 1840; ten years later,

these two categories were separated and were reported individually. By the 1880 census, the identification of insane persons had become quite

elaborate, and their numbers were even solicited by inquiries to private physicians. Dr. Kurt Gorwitz insane to be as follows: 1840 1850 1860 1870

1880

90.7 67.3 76.6 97.1

(1966)

per per per per

has calculated the rise in the

100,000 100,000 100,000 100,000

population population population population

183.3 per 100,000 population

Thus there appears to have been a more than threefold increase in insanity over a forty-year period (Gorwitz 1966). During this same

period the number of insane persons in asylums increased to 38,047 from 2,561 (Gorwitz 1966), and by 1904 this figure had skyrocketed to 150,151 (Pollock and Malzberg 1937). Despite the dramatic statistical increases in the numbers of the

insane there appears to have been much less public debate about them

than there was in Britain. A few leaders, such as Dorothea Dix and Isaac

Ray, said that insanity was on the increase in the United States, and nobody argued the contrary (Rothman 1971). The Report of the United States Commissioner of Education for 187] included the following statement:

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Schizophrenia and Civilization The successive reports, upon whatever source or means of information procured, all tend to show an increasing number of the insane. In the United States, Great Britain, Ireland and other civilised nations, so far as

known there has been a great increase of provision for the insane within forty years and a very rapid increase within twenty years. Hospitals have been built seemingly sufficient to accommodate all the lunatics within

their respective States, counties, or districts. These have been filled, and

then crowded and pressed to admit still more. They have been successively enlarged, and then other institutions created, and filled and crowded as the earlier houses were. [Corbet 1893]

Perhaps the massive increases and shifts in population in the United States during the years 1840-1880 were so great that the full effect of the increasing insanity was not noticed. There was also a strong tendency to simply blame the increase on new immigrants, who were flooding in from Europe by the later years of the nineteenth century (Grob 1973).

The Curious Case of the Missing Disease The history of schizophrenia is, at best, an unusual one for a disease.

Prior to 1800, there were scattered bits and pieces of evidence but nothing to sink one’s teeth into and say that this was schizophrenia as we know it. Virtually every other psychiatric syndrome was well described in ancient texts. Then, Haslam and Pinel independently provided clear and unequivocal descriptions in 1809. Simultaneously in

both Europe and the United States, everyone began building asylums to house the insane, who appeared to increase faster than buildings could

be built for them. In Europe, the increase was the subject of much

concern and speculation, which continued unabated for the entire nineteenth century. By the twentieth century, | out of every 100 people was being diagnosed with the disease. What are we to make of this history? Where was schizophrenia prior

to 1800? Did it really increase during the nineteenth century, or is this

rise some kind of artifact? These questions are important, and the answers to them may provide clues to the disease’s causation. Some possible answers include the following: Schizophrenia was hiding behind mania. The most widespread explanation for schizophrenia’s apparent absence in history is that it was there but just not described as such. We know that both “mania” and

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‘melancholia’ as they were used in the past were very broad terms, much broader than we now know them. They could easily have subsumed the different varieties of schizophrenia, with the quieter forms being grouped with melancholia and the more agitated forms with mania. A correlative explanation is that the schizophrenia syndrome, as an entity, consists of both clinical symptoms and its classical history: onset in early adulthood and chronic, often remitting and relapsing, course. Its full recognition, then, requires continuous observation over time, and it may be argued that ancient observers did not make such long-term connections.

Thought disorders are more difficult to recognize. Schizophrenia is, first

and foremost, a disorder of thinking. Dr. Mark D. Altschule of Harvard, one of the few researchers who has focused on the peculiar history of schizophrenia, believes that this fact explains its apparent absence in history. He argues that mood disorders with marked elation and depression are recognizable in all cultures and in all eras. Thought disorders, on the other hand, are much more relative to time and place

and “much harder to recognize unless extreme’

(Altschule 1976).

Thus, manic-depressive psychosis was clearly described by the sixth century, whereas the recognition of schizophrenia was not forthcoming for another fourteen hundred years. Recognition of the syndrome required the bringing together of a critical mass of people. Prior to the nineteenth century, urbanization had been

minimal. Life was still predominantly rural, and in such circumstances

a delusional person here and there could go pretty much unnoticed. For schizophrenia to be recognized as a syndrome, it was necessary for large numbers of people afflicted with the disease to be seen by an observer within a reasonably short period of time. According to Cooper and Sartorius, this factor explains why schizophrenia was not recognized in

earlier centuries and why there was an apparent increase in the nineteenth century:

During industrialization and rapid population increase, the increase in size of communities brings together schizophrenia in increasing numbers, resulting in their rejection by their community and a tendency to be

gathered together in institutions. This happened on a large scale for the first time in Europe in the nineteenth century and resulted in psychia-

trists having to deal with substantial numbers of patients. This made it much easier for common features to be recognized. The small towns and villages of non-industrial cultures will not generate sufficient numbers of

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Schizophrenia and Civilization schizophrenic patients for them to become a very serious problem, since a few mentally ill persons can be managed on an individual basis. When non-industrial communities become large, those with chronic mental

illness tend to gather in small groups, recognized as odd by their peers and

living in a social limbo, but yet half accepted. But with the much greater increase in community size which accompanies industrialization the limits of local tolerance and support are exceeded, and the reaction of the community is to attempt to provide a special environment in the form of large institutions. Psychiatrists can then achieve an identity, and have to

deal with large numbers of patients over a long period of time to be able to

recognize common

symptoms and develop

new ideas about the sub-

division of mental illness. [Cooper and Sartorius 1977]

Industrialization and rapid social change created the need for asylums. The crux of the argument based on industrialization and social change is that the rapidly changing technological, social, and familial structures which accompanied industrialization in the nineteenth century created more insane (and presumably schizophrenic) patients because of psychological-social-family stress and that asylums were built to accommodate this need. This view is especially popular with those who see schizophrenia as a psychosocial response rather than a biological disease. As explained by one proponent of this view: To summarize these points in terms of contrasting cultural stereotypes, an individual in a non-industrial culture who survives the hazards of a comparatively harsh physical environment, then experiences an interpersonal environment that is characterized by many relationships that are potentially supportive and flexible. There is a comparatively low level of pressure towards differentiation and specialization in work, and social roles are more flexible. There is no intense expectation of social and

financial advancement. For a person developing schizophrenia, this environment is more likely to be supportive and tolerant, and there will

be little risk of prolonged rejection, isolation, segregation and institu-

tionalization. [Cooper and Sartorius 1977]

D. J. Rothman brought this view to full fruition in The Discovery of

the Asylum

asylums was orphanages, said that all loose in the

(1971). Arguing that the rapid proliferation of insane

simply part of a generalized proliferation of penitentiaries, and almshouses for the poor in the nineteenth century, he of these were an attempt to control “the frantic spirit at community” (p. 121) and “an effort to insure the cohesion

of the community in newand changing circumstances” (p. xviii). ‘““The

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Is Schizophrenia of Recent Origin?

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epidemic of insanity, like the prevalence of crime, pointed to the most fundamental defects of the system, from mistaken economic, political, and intellectual practices to grave errors in school and family training” (Rothman

1971, p. 125).

The rapid rise in the nineteenth century was just a consequence of adding hospital beds and the insane coming out of the closet. The medieval rule of

the Blue Cross was that patients would expand to fill whatever beds were built for them. The problem with this explanation is a confusion about cause and effect. Did the building of asylums occur independent

of need, with the insane then emerging from their closets to fill them, or

was it the other way around? The hidden-in-the-closet theory is also flawed by the unsupported assumption that a great many people were probably living in closets for two thousand years or so. There really was no increase in insanity in the nineteenth century; it is Just an artifact. This viewpoint was put forth by Goldhamer and Marshall in their Psychosis and Civilization (1949), a book widely cited by textbooks of psychiatry as having proven that “there has been no increase in the frequency of the psychoses during the past one hundred years” (p. 11). The authors compared first admissions to Massachusetts mental hospitals for five-year periods from 1840 to 1885 and then compared these figures with the rates for 1940. Interested readers are referred to the voluminous tables and footnotes to form their own

conclusion, but it is difficult to understand how the authors arrived at

their conclusions from the data they used. The first-admission rate per

100,000 population shows a progressive increase from 39.4 in 1840-1844 to 62.2 in 1885 (p. 28). The authors caution that such rates

must be corrected for age of admission, and when they do this the rates for the 20-29 age of admission still climb progressively to 84.6 per 100,000 in 1885 from 50.1 in 1840-1844 (p. 49). Comparisons between 1885 and 1940 show a less dramatic rise, but it nonetheless appears to be real. For males in the 20-29 age group, the rise is to 124 from 96 and for females to 91 from 75. Goldhamer and Marshall appended a series of qualifiers to these figures, attempting to

explain the differences as artifacts, and then concluded that “there has

been no long-term increase during the last century in the incidence of the psychoses of early and middle life’”’ (1949). This conclusion, they add, is compatible with psychoanalytic theories of the psychoses: Theories that view the functional psychoses as resulting from repressions of basic human drives and as the consequence of trauma developing

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Schizophrenia and Civilization in early intimate personal and familial relationships, may possibly be thought of as being more especially consistent with our findings. [Goldhamer and Marshall 1949, p. 96]

The late appearance of schizophrenia in history, and tts rapid increase in the nineteenth century, are real. In view of the historical data cited in this chapter, this contention must be considered at least as seriously as the other explanations. When cases resembling schizophrenia from whatever cause (such as brain tumors) occurred in centuries past, as they inevitably must have, they were almost certainly subsumed under

mania or melancholia. Thought disorders are more difficult to recog-

nize, and recognition of a syndrome increases when a critical number of patients are brought together. Industrialization made it more difficult for families to care for their schizophrenic members at home, and there was probably less of a tendency to hide them in closets than there had been previously. And when comparing the rates for the different periods age factors must be taken into account. But these factors by themselves probably do not account satisfactorily for the relative absence of schizophrenia. It seems quite likely that this disease was far less common prior to the nineteenth century, and that it increased rapidly during that century. Schizophrenia as we know it is probably of recent origin, and the reasons for this have to do with the spread of civilization and its concomitants.

Summary 1. Schizophrenia appears to be of recent origin. While there were undoubtedly occasional cases of the disease in past centuries (as would be expected from the baseline prevalence due to organic diseases

mimicking schizophrenia), its widespread distribution appears to date

to the beginning of the nineteenth century. 2. Descriptions of madness, including delusions and hallucinations, date to ancient times. However, none of them appears to describe schizophrenia as we know it, with an onset in early adulthood and

progressive deterioration.

3. The first probable description of schizophrenia in literature appeared in 1656. 4. The first clinical descriptions of schizophrenia were made by Haslam in London and Pinel in Paris, both in 1809.

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Is Schizophrenia of Recent Origin?

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3. Throughout the nineteenth century, there was evidence in Europe that insanity (presumably including schizophrenia) was rapidly increasing. Evidence suggests that there was also a dramatic increase in insanity in the United States.

6. Several possible explanations for the late appearance of schizo-

phrenia and its apparent nineteenth-century increase have been offered. The explanation that the late appearance and increase are real phenomena is at least as persuasive as other explanations.

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ls Schizophrenia a Disease of Civilization?

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... Insanity belongs almost exclusively to civilized races

of man: it scarcely exists among savages, and is rare in barbarous countries. —J.C. Prichard, A Treatise on Insanity (1835)

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Vilhjalmur Stefansson was an explorer of Alaska and the Arctic who, shortly before his death, published a book entitled Cancer: Disease of Civilization? (1960). In it, he enumerated all of the explorers of Alaska

who had had the impression that cancer had been rare among the Alaskan natives before they had begun adopting the white man’s ways. The idea that cancer was a disease of civilization was not new, dating back to at least the time of Napoleon, but Stefansson gave it new emphasis. By and large, his theory was dismissed in polite medical company because he had no hard data, only impressions. Since publication of Stefansson’s book less than two decades ago, there has been a dramatic shift in our understanding of cancer. We now

assume that some cancers are indeed diseases of civilization, and red

dye number two, asbestos, and various chemical carcinogens have become household phrases if not pariahs. Statistical data are now available to substantiate Stefansson’s impressions that many cancers were rare among Alaskan natives prior to the influx of civilization and that the prevalance and distribution of cancers began to change dramatically as the Eskimos traded in the sled team for the family snowmobile (Torrey 1962, Fortuine 1969, Schaefer et al. 1975). More-

over, the study of the prevalance of cancers in various areas of the world and among specific groups of workers has yielded important clues

to causation of the disease.

Schizophrenia is, in many ways, like cancer. Both are singular terms for what we now suspect are multiple conditions. Both appear to have genetic and environmental components. Both are among the most common serious diseases of Western civilization. And both diseases have been said to be rare among people who have not been exposed to Western

civilization.

In the case of cancer,

this observation

led to

important clues about the causation of the disease. In contemporary psychiatric textbooks, the idea that schizophrenia may be a disease of civilization receives virtually no mention whatsoever. Just as the idea that schizophrenia might have shown a dramatic

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increase in the nineteenth century is said to have been disproved by the work of Goldhamer and Marshall (1949), so the idea that schizophrenia might be rare among people not exposed to Western technology is said to have been disproved. Dunham (1976) asserted that “schizophrenia is found in every culture of the world,” and Victor Sauna (1969), in an otherwise excellent review of the literature, concluded: One generalization which can be made is that schizophrenia is to be found in all cultures... . The contention of Van Loon and Seligman that psychosis is almost nonexistent among primitives no longer has adherents today. [p. 291]

There is good reason for questioning Sauna’s conclusion. A careful examination of the literature suggests that schizophrenia is rare among people with minimal contact with Western civilization, and the conclusion to the contrary is based on inadequate data.

Early Impressions and Some Myths Dispelled As the epigraph for this chapter indicates, the idea that “insanity belongs almost exclusively to civilized races of men”’ is an idea with a long history. The earliest reference to this idea is probably that of Sir Andrew Halliday in 1828: ““We seldom meet with insanity among the savage tribes of men; not one of our African travelers remark having seen a single madman” (Halliday 1828). Halliday’s statement was made shortly after Haslam and Pinel first clearly described cases of schizophrenia and during the period when a rapid rise in insanity was being

noted in Europe.

Anecdotal accounts throughout the nineteenth century supported

Halliday’s view. The commander of a United States expedition exploring South Pacific islands reported in 1846 that he had seen no cases of

insanity and further concluded: “I am satisfied that insanity is a disease incidental to civilized life’ (Anonymous 1846a). Two years later a missionary who had lived in China and Tibet for twelve years said that he had seen cases of mental retardation and epilepsy but virtually no cases of insanity: ‘there is no assignable reason why insanity should not also have come to the notice of the physicians in charge if cases had existed.” (Anonymous 1847c). In Australia it was noted that insanity

had been rare among aborigines: “It appears that insanity, if we may

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credit the accounts of early colonists, was very rare among the Aborigines of Australia” (Manning 1890). And in South Africa, Greenlees studied all admissions to the mental hospital from 1875 to 1894 and concluded that the majority of cases came from those tribes with the greatest and longest contact with Europeans

(Greenlees 1895).

Already, however, it was being said that insanity was less common among less civilized groups because the insane were killed or simply left to starve. Thus, when D. H. Tuke in 1877 published an account of the rarity of insanity among the natives of Madagascar, he felt compelled to ‘add that they do not destroy the few insane and idiots which they have” (Tuke 1877). His conclusion was unequivocally that “we have no

doubt that in a civilized community there will always be found by far the larger number of insane persons...” (Tuke 1877). There is no evidence that insane persons were systematically killed or left to starve in these cultures. No doubt some have been, especially if they became destructive or homicidal or if food was in short supply. But to postulate mistreatment of the insane as the primary reason that they are less common in less civilized cultures is contrary to known facts. Insane persons in most technologically undeveloped cultures are treated relatively humanely if they are harmless, usually being given food by the extended family or allowed to forage in other people’s gardens without sanctions. If they are belligerent or destructive, they are usually chained to a log or confined in huts or, as civilization makes inroads, jails.

The other myth that must be dispelled is that insane persons in less

developed cultures are esteemed, rewarded, and given special roles, so

that they no longer appear as insane to the outside observer. As put

forth by one proponent, ‘What is regarded as insane in our civilization

may be considered highly desirable in another culture” (Katz and Schanck 1938). The role most commonly thought to be assigned to insane persons in other cultures is that of shaman or medicine man. For example, an early twentieth-century study of Siberian shamans claimed that “not a few of them were half crazy” (Bogoras 1907). Anthropologist A. L. Kroeber even claimed that one of the points differentiating a

“primitive” from a “developed”’ society is that the former rewards its

psychotics with a socially sanctioned role as healer (Kroeber 1952).

This view has persisted up to the present, as illustrated by a 1967 article in the American Anthropologist entitled “Shamans and Acute Schizophrenia’’ (Silverman 1967). I have elsewhere examined the history and ramifications of this idea in more detail (Torrey 1972a,b).

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The theory that the insane become shamans in other cultures is, ina word, nonsense. For us to sit comfortably in our ivory towers and say

that insane persons in less developed cultures are rewarded and

sanctioned as healers indicates an extraordinary lack of contact with these cultures. This myth has been refuted by several people, but perhaps most effectively by Ralph Linton: However, I am certain that there is no society in which the genuine

psychotic occupies a favored social position. In order to exploit the advantages of abnormal behavior one must be capable of appraising

situations in realistic terms and of devising behavior which would be advantageous to one. The inability to do this, to my mind, is the real test

of psychosis. The medicine men, prophets and the like, who gain prestige

and acquire wealth and power through their abnormal behavior, are

hysterics or neurotics, and not true psychotics. It is precisely this fact

which enables them to exploit their own abnormality for purposes of

gain, and to make it, so to speak, “pay dividends.”’ This is an ability which, to my mind, the psychotic does not possess. [Linton 1956]

An Eskimo summarizes the distinction between an insane person and a shaman very nicely: “When the Shaman is healing he is out of his

mind, but he is not crazy” (J. M. Murphy 1976).

What can we say, then, about the role of insane people in less developed cultures? First, there is no evidence that such people are systematically killed or left to die. Second, the syndrome of insanity is

indeed recognized in all known cultures, and it is distinguished from

mental retardation and hysterical behavior. And, finally, there is no evidence that insane persons are socially sanctioned or given roles as healers. There are occasional shamans who are insane, to be sure, but

the same thing can be said about psychiatrists and other shaman-

equivalents in our own culture (Torrey 1972a,b). The important point

is that we must not invoke such a mythical social role to explain why many have failed to find insane persons in less developed cultures.

From Cherokees to Kalmucks and the Achinese Following the turn of the twentieth century, reports of the infrequency of insanity among “‘primitive’’ people became more numerous. American Indians were one such group. As far back as 1887 it was noted

that “the small percentage of insane among the aborigines .. . is fully in

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accord with the observations of writers upon the causes productive of mental disease’ (Rosen 1968, p. 191). In 1903 it was noted that “insanity is of rare occurrence among U.S. Indians’ (White 1903). H.

M. Hurd (1916) collected many of these impressions. For example:

Dr. Lillybridge of Virginia, who was employed by the government to superintend the removal of the Cherokee Indians in 1827-8-9, and who saw more than 20,000 Indians and inquired much about their diseases,

informs us he never saw or heard of a case of insanity among them. Dr. Butler, who has been a devoted missionary and physician among the Cherokees for about a quarter of a century, informs us in a recent letter that he has as yet seen them delirious when sick of other diseases; and adds that an intelligent chief, a man now 80 years old, told him that ‘“he had never known a case of insanity among his people, such as he had seen in the hospital at Philadelphia.” [p. 381]

It was not claimed that insanity did not exist at all among primitive

people, but rather that it occurred less commonly.

Hurd (1916) offered the following example of insanity, which is very similar to what we now call schizophrenia: The story of Mark Jack, an insane Indian of the Tuscarora tribe, who was under treatment at the Utica State Hospital from 185] to 1874.and at the Willard State Hospital from 1874 until his death there eight years later, is of interest, because it seems to show that insanity among Indians follows much the same course as among white persons. He was a farmer of common school education, but considered one of

the most intelligent men of his tribe, of temperate habits and a church member. A maternal uncle was an imbecile and a maternal aunt was “singular” and a half-brother by his mother’s former husband was

insane. He first showed insanity at the age of 22 years, at a time when he

was attempting to learn English and to study mathematics in 1843, and for two years he had periods of excitement, followed by intervals of quiet in which he was able to do farm work. About the third year he became so violent and incoherent in his talk as to require to be kept in close confinement in a log hut, and remained there for six years. His excitement was called by his Indian associates “‘conreaya bonos,”’ or madness. Being a ward of the state, he was admitted on the order of Governor Washington Hunt. At the time of his admission his brother stated that two other members

of the same tribe had been insane, one of whom

recovered and the other died. His condition during the 31 years of institutional treatment was one mostly of quiet dementia, with rare

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Schizophrenia and Civilization intervals of noisy excitement. His habits became untidy and eventually convulsive seizures developed. He was probably in a stage of terminal dementia at the time of his admission to the hospital at Utica. It is evident that he had a strong hereditary tendency to insanity which was developed

by his efforts to enter upon studies for which he was not fitted. [p. 383]

The impression of relative infrequency of this disorder among American Indians received some statistical validation in 1922 in U.S. government reports of all hospitalized mental patients. The first-

admission rate for Indians for dementia praecox was less than half that for white Americans (Rosenthal 1933). This difference may have partly

reflected the more limited access of Indians to mental hospitals, but it is also possible that it was real. Similar reports were filed from many different corners of the world. In China it was noted that “insanity of puberty and adolescence is

seldom if ever met, and that ‘mania’ appeared to be more common’”’

(Jeffreys and Maxwell 1910). This impression was substantiated in 1926

when an analysis of all hospitalized insane persons in China showed that 28 percent were diagnosed with manic-depressive psychosis, and only 1] percent with dementia praecox (McCartney 1926). Such reports

fail, of course,

to reveal

whether

manic-depressive

psychosis

was

overdiagnosed, schizophrenia underdiagnosed, or both. A 1929 report in German from the Astrachow district of the USSR noted that schizophrenia was rare among the ethnic Kalmucks and

Kirghiz compared with the Russians and Armenians, and that it had

been virtually nonexistent prior to “contact with civilization” about 1850 (Ackerknecht 1943). Another report said that Lopez in 1932 found no schizophrenia among “‘true primitives” in the interior of Brazil but that it did occur occasionaly among the urbanized ‘‘natives” on the coast (Demerath 1942). The vast majority of schizophrenic patients observed by Lopez were either whites or mulattoes (Roheim 1939).

Twenty-five years later, this distribution of schizophrenia in confirmed by Bastide (Sauna 1969). An especially interesting report citing a high prevalence phrenia among the Achinese was Van Loon’s work in 1920, published in German but was extensively summarized by Murphy

(1968b, 1972). The Achinese

Brazil was

of schizowhich was H. B. M.

live in northern Sumatra in

Indonesia. These people were visited by a Dutch physician with an interest in anthropology, who noted that serious mental disorders were rare among them. According to Murphy:

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[s Schizophrenia a Disease of Civilization? Twenty

years later, after a period

of continuous

ol war and attrition, a

psychiatrist was commissioned to do a survey of mental illness in the same people, the reason for his commission being that the local governor had been struck by the unusual frequency with which he encountered insane people during his local travels. The psychiatrist, Van Loon, found that in a neighboring, non-Achinese people that had taken little part in the war the prevalence of mental illness was very low, namely five cases in a population of twenty-six thousand, but that in the Achinese it was very high, reaching twenty cases per thousand in places. Most of the mental illness which he found was schizophrenia of many years’ duration, and it affected men much

more than women. When

we ask what

changes had occurred between these two visits one answer is that venereal disease had become widespread thanks to the misuse of the Achinese women by the conquering soldiery, but the other thing is that the Achinese warriors had been defeated and now had little role in their own land, the women running most of the communal affairs. If the Achinese had had roughly the same level of schizophrenia as other Malaysian peoples in Sumatra before this war, as seems likely from the earlier report and from other clues, then one must think of at least a fivefold increase in the disease over the period. .. . [Murphy 1972]

Murphy explains the apparent rise in schizophrenia among the

Achinese in terms of psychosocial factors. Whatever the cause, the case of the Achinese is an example of a group of people who had

experienced a low prevalence of schizophrenia, with a rapidly rising rate following twenty years of continuous warfare. Studies in Africa Beginning in the 1930s, there was a steady stream of studies from African countries noting the relative infrequency of schizophrenia.

Elisworth Faris, on an expedition in the Congo (now Zaire) in 1932-1933, reported no cases of schizophrenia, although there were some cases of “mania due to infectious disease”’ (Faris 1937). He even

visited four large hospitals looking for cases of schizophrenia:

No records of any such cases existed, nor was there any memory on the

part of those of the staff of any such cases. In the villages attempts were made to describe the symptoms to the natives, but no comprehension of such disorders was found. [Faris 1937, p. 28]

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Schizophrenia and Civilization

Twenty years later Vyncke reported that schizophrenia was more frequent among Westernized Congolese than among those not Westernized (Sauna 1969, quoting Vyncke 1957). Across the African continent in Nyasaland (now Malawi), H. M.

Shelley and W. H. Watson were undertaking the first of many studies

of psychiatrically hospitalized Africans. Out of 84 inmates in the country’s only asylum, 30 were diagnosed as having schizophrenia. The most striking finding in the analysis of these cases was the close correlation between the diagnosis and degree of Europeanization: “‘The tribal incidence indicated a definite predominance of the condition in natives who had been in close contact with European civilizing influence” (Shelley and Watson 1936). Eight of the 30 schizophrenics had been educated, and 6 had even traveled to other countries; the number

of educated schizophrenics is high compared with the total number of educated for the indigenous population of Nyasaland at that time

(Shelley and Watson 1936).

In Kenya, H. L. Gordon studied 120 consecutive admissions to the mental hospital. Nineteen cases were diagnosed with “‘simple adolescent psychosis,” and the outstanding finding was that all 19 had been

educated. Less than half of the admissions for other diagnoses had been educated. Gordon concluded that education caused the psychosis, a view which probably set education back in that country for several

years (Gordon 1936).

Gordon was followed in Kenya by J. C. Carothers (1948, 1951, 1953),

who noted that a large percentage of hospitalized psychiatric patients

were ‘detribalized” and had had more contact with Europeans. To clarify the question

of prevalence

in less Europeanized

areas

he

initiated a ‘“‘field study,’ which unfortunately consisted merely of

asking the tribal chiefs to take a census of all their insane and mentally defective persons. Not surprisingly, the lists were short. Carothers

(1951) concluded that “there was probably a very low general incidence

of insanity among Africans living in their natural environment,” although it is not clear what he bases his conclusion on. It is unfortunate that Carothers did not spend more time on research methodology and less time trying to prove that the brains of Africans were inferior.

Two other East African studies found virtually the same paucity of schizophrenic patients in areas with minimal contact with Europeans. C. P. Donnison was a medical officer in rural Kenya for over two years

in an area which “‘had only been under systematic government administration for less than twenty years at the time of my observations.” In

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the population of 200,000 people, he recalled seeing no cases of schizophrenia (Donnison 1937). And Smartt in Tanganyika (now Tanzania) studied hospitalized schizophrenic patients and found that a highly disproportionate percentage of them were from the towns and not from the rural areas (Smartt 1956).

The only African study which contradicts the several reported above was that conducted in South Africa by Laubscher (1938), who reported schizophrenia to be abundant among the ‘‘natives”’ there. This study has been

severely

criticized,

however,

on

several grounds.

Lambo

stated that Laubscher did not understand the culture and that he regarded sorcery as a phase of schizophrenia (Lambo 1955). Devereux (1939)

called Laubscher’s

schizophrenic diagnoses

“debatable,”

and

Ackerknecht (1943) claimed that “Laubscher’s whole study [was] the result of a gigantic misunderstanding produced by his bias towards an exclusive hereditary theory of schizophrenia.” The South

Pacific

The South Pacific islands have also been fertile ground for studies of schizophrenia. Margaret Mead initiated these studies when she appended to Coming of Age in Samoa (1928) a series of clinical descriptions of all mentally ill persons she observed among the 2,000 people with whom she was working. She recorded two people whom she said were clearly mentally deficient, one man with delusions of grandeur, and one 14-year-old boy whose “relatives insisted had always been stupid but only recently became demented”’ (Mead 1928). Mead stated that the boy gave the “external picture of catatonic dementia praecox.”’ She supplied no further information to allow us to differentiate this diagnosis from congenital or organic brain disease. Furthermore, this group of Samoans had undergone missionization for almost a century and, according to Mead, its members were exposed to both Western medicine and goods at the dispensary; thus they were not without

exposure to Western technology. Mead’s Samoan study was a major part of the argument in Winston's 1934 paper, “The Alleged Lack of Mental Diseases among Primitive Groups.” Winston sought to show not only that functional psychosis

existed among “‘primitive’’ people but also that its prevalence did not

differ appreciably from that of the United States. Winston assumed that both Mead’s man with delusions of grandeur and the 14-year-old

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Schizophrenia and Civilization

‘recently demented”’ boy qualified as functionally psychotic and then calculated the rate for Samoa as | per thousand. This rate was about the same as that of admission to mental hospitals for rural Americans, thereby proving, in Winston’s view, that there was just as much psychosis in Samoa as in the United States. A prevalence study in a community, of course, cannot be compared with hospital admissions. The proper comparison would be with other prevalence studies, as are described in chapters 4-7; these studies show

a prevalence rate in the United States and Europe of approximately

2-10 per thousand. Furthermore, Winston’s assumption that Mead’s two cases qualify as functional psychosis is, at least for the 14-year-old boy, highly questionable. It is important to analyze Winston’s study in

detail, since it has been quoted frequently. And as is often the case, only

the conclusions have passed from psychiatric textbook to textbook, with no reference to the quality of the data base or to its assumptions. Ten years after Mead was on Samoa, Cora DuBois studied five villages on the island of Alor, just north of Timor. Out of the total population of 600 people, she cited two women she called “insane.” One was a woman who would frequently run off into the fields, stay for days at a time, and then return. The other woman married and then left her husband and returned to her village, where she eventually became the village prostitute. DuBois stresses how both contravened the established social mores

of the Alorese,

but it cannot

be said that

there was sufficient evidence to diagnose either one as schizophrenic (DuBois 1944). Ernest Beaglehole, who is widely quoted by psychiatric epidemiolo-

gists, began studies of psychosis in both New Zealand and Hawaii in the 1930s. In New from the other population had the rate for the

Zealand, he did not attempt to separate schizophrenia psychoses, and he reported that the indigenous Maori a hospital-admission rate for psychosis only one-third non-Maori (mostly European) population. The admis-

sion rate for non-Maoris was approximately the same as that for England. Beaglehole himself believed that the differences reflected the

greater cohesiveness of Maori society and its ability to support psychotic patients in the community without having to hospitalize them

(Beaglehole 1950). More recently, there have been indications that the

hospitalization rate for Maoris has risen as they have become more fully integrated into New Zealand society (Beaglehole 1969). Beaglehole’s data for Hawaii is very difficult to decipher (Beaglehole 1937). He reported the total resident cases of “insanity” by ethnic

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Is Schizophrenia a Disease of Civilization?

DO

population group in the state hospital from 1920 to 1936. However, he failed to take into account differences in age distribution, which varied considerably among the ethnic groups. Beaglehole concluded that Puerto

Ricans

twentieth

(who

century)

had

and

come

to Hawaii

persons

whose

around

the turn

ancestry

of the

was part native

Hawaiian showed a disproportionately high number of cases of schizophrenia; native Hawaiians of unmixed ancestry, who typically lived in more rural settings than most other Hawaiians, had less than their share (Beaglehole 1937, 1969).

Shortly after World

War

II, three additional

studies of schizo-

phrenia were conducted on Pacific islands. McCartney (1947) found no

cases of the disease among 10,000 people in a survey of the Marshall

Islands, while on Ifaluck atoll in Micronesia Spiro (1950) found 2 cases

which he called schizophrenia among 250 people. He did not give us enough information about the cases to confirm the diagnosis, but does add, however,

that both cases were men

who

had worked

in forced

Japanese labor gangs during the war. He notes that “the natives know of no instance of this kind [of illness] prior to the Japanese occupation.”

On Saipan, Joseph and Murray (1951) identified 4 people who they

said had schizophrenia out of a total population of 4,796, for a rate of 0.8 per thousand. One of the 4 experienced the onset of symptoms following a fever. Two other “possible” cases were discussed by the authors. One had regular “shaking spells”; the other was an old man who had come from outside (possibly Russia), and it is not possible to

tell from the data given whether he had schizophrenia or an organic brain syndrome. Most recently, Murphy (1979) conducted a survey of approximately

12,800 people on Truk, Tonga, the Solomons, the Cooks, and Niue in

the South Pacific, utilizing the same methodology as in his Quebec village study. Preliminary results revealed a prevalence of major mental disorder (including schizophrenia) on the Pacific islands of less

than one-third that found in the villages in Quebec.

The Making of “Sheer Folklore” By 1950, then, there had accumulated a hundred years of impressions from all over the globe. The striking feature of these impressions is the remarkable consensus that insanity (in the early literature) and schizophrenia (in later studies) were comparatively uncommon prior to

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Schizophrenia and Civilization

contact with European-American imous (for example, Laubscher’s so. Few observers claimed that more “‘primitive’’ societies, but

civilization. The opinion is not unan1938 study) but is very close to being there was no schizophrenia in these rather that it simply was far less

common, even rare. But around 1950 an interesting thing happened. At the same time as Goldhamer and Marshall (1949) were publishing their “proof” that psychoses had not increased in incidence over the previous hundred years, the idea became

current in psychiatric literature that schizo-

phrenia occurs in about the same prevalence in all cultures and is nota disease of civilization. As Knox and Tourney (1965) put it, “‘schizophrenia occurs in both primitive and civilized societies and. . . incidence rates, when properly evaluated, do not vary significantly.” Most people today would accept the fact that a low prevalence of schizophrenia is to be found in all cultures. This is because, as mentioned previously, there are a number of organic diseases (such as temporal lobe epilepsy, pellagra, trypanosomiasis, and brain tumors) which mimic schizophrenia. Thus a baseline prevalence of a disease appearing to be schizophrenia will be found virtually everywhere. This baseline existance of schizophrenia in all cultures got translated in psychiatric literature into a statement that schizophrenia was not a

disease of civilization. To understand how this could have happened it

is important to remember that schizophrenia was widely believed to bea single disease around 1950. And if it was a single disease, then its occurrence at all in a culture was the important fact. Differences in prevalence were less important. And if it occurred at all in a culture with little contact with civilization, then schizophrenia obviously could not be a disease of civilization.

Now, three decades later, most people accept the fact that schizo-

phrenia is probably a heterogeneous collection of several diseases. The

mistake made in 1950 would not likely occur today. However, once an idea is printed in a textbook it tends to be transmitted from text to text

without being reevaluated. Three papers are commonly cited in psychiatric texts as proof that

schizophrenia is not a disease of civilization. Winston’s 1934 article,

“The Alleged Lack of Mental Diseases among Primitive Groups,” has

already been discussed and has been found wanting. The second is Demereth’s “Schizophrenia among Primitives” (1942), in which he reviews many of the studies previously mentioned in this chapter. The

third and most influential paper, ‘Mental Illness in Primitive So-

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cieties,’ was published by Benedict and Jacks in 1954. The authors cited the studies by Beaglehole in New Zealand and Hawaii, Laubscher’s study in South Africa, Carothers’s work in Kenya, and Tooth’s study in Ghana (which will be discussed in detail later in this chapter) and stated

that they collectively “prove” that schizophrenia exists in “primitive” societies: It has been amply demonstrated by trained observers that the mental disorders known to Western psychiatry do occur among primitive peoples throughout the world despite the differences in incidence and symptomatology discussed above. [Benedict and Jacks 1954]

It should be noted that Benedict and Jacks realized that the incidence of these mental disorders may vary significantly between ‘‘primitive’’ and “elvilized” cultures. However, this part of their conclusion was subse-

quently lost to view, and by 1963 it was said that Benedict and Jacks had proved that the belief “‘that schizophrenia is a disease of civilization is sheer folklore’ (Mishler and Scotch 1963). Since that time, virtually no writer in the psychiatric literature has put forth the proposition that schizophrenia is a disease of civilization. Studies Since 1960 “Sheer

folklore”

or not,

evidence

has continued

to accumulate

suggesting that schizophrenia is indeed a disease of civilization. No single piece of work has “‘proved”’ it once and for all, and it would be difficult to conceive of such a project. But several additional studies

conducted in Taiwan, India, Ghana, and Papua New Guinea point in the same direction: the comparative rarity of the disease in societies with

minimal contact with Western civilization and its increased prevalence as such contact increases. Taiwan

The Taiwanese study of Rin and Lin (1962) is perhaps the best known of schizophrenic studies since 1960. It consisted of a survey of four tribes of Formosan

aborigines who

lived by themselves

in remote

mountain villages and who, compared with the Chinese on Taiwan, had been much less influenced by Western technology. In all, 11,442

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Schizophrenia and Civilization

aborigines were surveyed. Case finding was accomplished by means of preliminary visits to local officials, headmen, elders, police, schoolteachers, and health officers; this work was followed by a house-to-

house survey in which two members of the trained survey team were

accompanied by a local community leader. Mishler and Scotch (1963) cited this study as having had the best case finding methodology of any cross-cultural epidemiologic study (1963). Diagnosis of schizophrenia was based on the patient’s history, premorbid personality, and the presence of such symptoms as dissociation of thinking, withdrawal, inappropriate emotional reactions, delusions, hallucinations, and hy-

perkinesis. Apparently, the long-term course was not considered part of the diagnostic criteria. Forty-five cases of past and present psychoses were found among this group; of these, 10 were diagnosed with schizophrenia, 10 with manicdepressive psychosis, 3 with senile psychosis, and 22 with other psychoses (mostly of an acute transient variety). The 10 cases of schizophrenia produced a lifetime prevalence rate of 0.9 per thousand.

Of the 10 cases, 7 came on acutely, and only 3 insidiously. Further-

more, 2 of the cases had lasted less than three months, and only 2 of the

10 were chronic. Thus it may be questioned whether some of these cases would have been considered schizophrenic had the long-term course been included in the diagnostic criteria.

Most important, however, is the fact that this study of aborigines was an exact replication of one conducted a decade earlier by the same research team on 19,931 Chinese emigrants to Taiwan (Lin 1953). This study group was a random sample of inhabitants of a city of 120,000, a

town of 20,000, and five villages which were a few miles outside of the capital city of Taipei; thus, these Chinese emigrants were much more strongly influenced by Western technology and civilization than were the Formosan aborigines. Using the same criteria for schizophrenia, 43

cases were found, yielding a lifetime prevalence of 2.2 per thousand. There are, then, two studies using identical methodology and diagnostic criteria that were conducted

on two groups of people with

different degrees of exposure to Western technology and civilization.

The high-exposure group has a schizophrenia prevalence rate of 2.2 per

thousand, whereas the low-exposure group has a rate of 0.9 per

thousand. The researchers calculated that the difference is significant at a level of p < .OL. Rin and Lin’s explanation for this difference is an assumption that

World War II contributed to the deaths of some aborigine schizo-

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phrenic patients “owing to their limited capacity for adjustment to the

stresses and deprivation of war.’ Specifically, they said that malaria and malnutrition were prevalent. However, since the Chinese survey and the aborigine surveys were both done after the war, their explana-

tion of the difference requires an assumption that the war decimated

more schizophrenic patients among the aborigines than among the Chinese on Taiwan. As no evidence is given to support the latter assumption, the authors’ own explanation of their findings remains merely an hypothesis. An equally plausible hypothesis is that the

different prevalence rates represent real differences. India Unique

and fascinating

findings in the epidemiology

of schizo-

phrenia have been generated in India. Since 1966, several separate studies have been published verifying earlier reports by Dhunjibhoy (1930)

and

Shaw

prevalence among

(1930)

that

schizophrenia

was

found

in greater

the more highly educated and/or Westernized

castes. J. E. Dhunyibhoy, a British-trained Indian psychiatrist who ran

a mental hospital in Ranchi

(Bihar State), noted that schizophrenia

could be found in both sexes and among both educated and uneducated Indians, but

that “those

Indian

communities

highly

advanced

in

Western civilization and culture, such as the Anglo-Indians, Parsees,

the educated section of the Bengalis etc. are more prone to this form of psychosis” (Dhunyjibhoy 1930). He noted that paranoid and catatonic subtypes were especially common among the educated, whereas hebephrenic and simple subtypes predominated among uneducated schizophrenic patients. In the same year that Dhunjibhoy published his papers, W. 5. J.

Shaw independently reported the identical phenomenon at the mental

hospital in Poona (Maharashtra State). Schizophrenia was noted to be prevalent among the Parsees, a comparatively wealthy group with much inbreeding and cross-cousin marriages (Shaw 1930). Among the

Hindus, schizophrenia was said to be ‘rare’ and among the Moslems “rarer still”; for both groups Shaw reported, ‘I have seen the disease mainly among the more educated classes.”’

These early impressions were not confirmed for another thirty-six years. A study suggesting the same findings from Bangalore (Mysore

State) was published in 1960 but must be discarded because no breakdown in diagnostic categories was given (Hoenig and Sreenivasan 1960).

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In 1966 a study by Rao in Ranchi (Bihar State) provided a breakdown

of first-admission schizophrenia patients by caste. Out of ten castes, the

highest numbers of schizophrenic patients came from the Brahmins (aristocracy), the Bania (traders), the Rajputs (landowners), and the Kayasthas (civil servants). The Brahmins and Kayasthas are the castes with the highest literacy, and the Banias have the highest socloeconomic status and are the most urbanized (Rao 1966a,b). Rao’s work was confirmed by Saxena, Bhaskaran, and Anath in the same

hospital in 1972 with the Brahmins and Kayasthas again found to be

overrepresented among schizophrenic patients. In 1971, Rao participated in a psychiatric survey of a village in West Bengal State. Six cases of schizophrenia were found, all of which were from the two highest castes. By contrast, other forms of mental disorders were found more prevalent among the lower castes. The

authors concluded that “itis noteworthy that the highest prevalence of schizophrenia is in the socially and economically advanced groups”’

(Elnagar, Maitra, and Rao 197). Two other village surveys generated similar findings. Dube in Agra (Uttar Pradesh State) found 64 persons with schizophrenia ina survey of 29,468 Indians (Dube 1970, Dube and Kumar 1972). The highest prevalence rates by caste were among the Vaish (business or trade) and the Brahmins (aristocracy and priests). This caste distribution for schizophrenia was not found for ‘“‘other psychoses,” however; the Brahmins ranked fifth out of seven castes for this diagnosis. Thus, “‘the

distribution of schizophrenia according to caste is different from the distribution of other psychoses”

(Dube and Kumar 1972). Another

interesting finding is that although the schizophrenic patients as a

group tend to come from castes that are more highly educated, the schizophrenics themselves are not. This trend contradicts the findings

of Dhunjibhoy, but it may be explained by postulating that early symptoms of the disease may force the preschizophrenic person to drop out of the educational system.

A final village survey is the work of Ravi Kapur, a British-trained psychiatrist and epidemiologist, in Kota (Karnataka State) in South India. Using an Indian Psychiatric Survey Schedule as an interview instrument, he sampled

1,233 villagers and found 9 chronic

schizo-

phrenic patients, one other with chronic persecutory delusions, and no manic-depressives. In terms of the distribution of cases by caste, he noted:

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Even more peculiar was the fact that while the Brahmin males showed the lowest “‘case’’ rate, no fewer than six out of the seven male functional

psychotics were Brahmins! Those numbers are too small for a satisfactory statistical analysis but there is no doubt that the male Brahmins

showed a psychosis rate much higher than could be expected. This excess

was not associated with an excess of consanguineous marriages, which occurred with similar frequency in the three castes. [Kapur 1975,

Carstairs and Kapur 1976]

Kapur,

now

head of the Department

of Psychiatry

at the Indian

National Institute of Mental Health and Neurosciences of Bangalore, added, “From my clinical work I am becoming more and more convinced of the thesis regarding a relationship between cultural sophistication and schizophrenia’

(Kapur 1977).

What do all these findings in India mean? Why should schizophrenic patients be concentrated in more highly educated and/or wealthier castes? If only hospitalized schizophrenic patients were included in these studies, it would be reasonable to dismiss the results as a biased

sample of those who utilize the limited hospital facilities in India. However, with field studies of nonhospitalized schizophrenic patients finding the same thing—for example, Elnagar et al., Dube and Kapur—

the findings cannot be so lightly dismissed. And the unanimity of them over almost forty years is impressive. Finally, it should be noted that India is not the only country in which schizophrenic patients are said to come disproportionately from the educated classes. In 1939, Kao, Ting, and Hsu studied parergastic (schizophrenic) patients in China, comparing them with manic-depressive patients and those seen for general medical illnesses. They reported that “only one result came out clearly positive, namely, that educated and non-conservative families contributed significantly more to the parergastic group than to the (controls)”’ (Kao, Ting, and Hsu 1939). And in East Pakistan (now Bangaladesh), both Chowdhury (1966) and

Rahman

(1972) found a disproportionate number of literate persons

among hospitalized schizophrenics; field studies are needed, however,

to confirm that these findings are not merely a function of access to the

hospital. In the United States, it is generally thought that schizo-

phrenic patients are disproportionately drawn from the lower socioeconomic classes, based on the work of Hollingshead and Redlich (1958); this conclusion is contrary to the findings in India and will be

discussed in chapter 4.

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Ghana

Ghana (formerly the Gold Coast) has attracted three separate teams of psychiatric researchers who have produced data on the prevalence of

schizophrenia in that country. In 1948, Dr. Geoffrey Tooth undertook a ‘census’ of patients by asking for lists of all “lunatics” in the different areas (Tooth 1950). His returns were very uneven, and the methodol-

ogy of his study has been severely criticized (Mishler and Scotch 1963). The most interesting finding of Tooth’s study was a paucity of schizophrenic patients from the Northern Territories—the least missionized, least urbanized, and least developed part of the country—even though he judged his case-finding techniques to have been most complete there. Schizophrenic patients were much more common in the south-

ern part of the country, which had many more missions, schools, and towns.

It was into this southern part of Ghana that Dr. Margaret Field came

in 1955 to study the healing shrines. Trained in both anthropology and medicine with some experience in clinical psychiatry, Field initially concentrated on the Ashanti area, studying their functions and the people (including schizophrenic patients) who were attracted to them. Eventually she began to realize that there were a large number of psychotic persons in the district in which she was working: “‘It was clear that madness was common—commoner, most people thought, than in other districts” (Field 1960). Although it was not part of her original plan to concern herself with chronic schizophrenia, she decided to undertake a survey of the twelve surrounding villages in an

attempt to ascertain the prevalence.

The method of Field’s survey was to use key informants and then

interview all suspected cases. Field identified 41 cases of schizophrenia

out ofa population of 4,283. Some of these cases would clearly not have been labeled as schizophrenia by other observers, however; 7 had an onset at the involution, | had an onset at age 60, and 8 were postpartum. Furthermore, at least 1 may have been organic (onset following a high fever), and some may have been manic-depressive psychosis— ‘among the women the illness is most often schizo-affective and strongly

depressive...”

(Field 1960). It does appear, however, that Field

identified an area in southern Ghana with a larger number of schizophrenic patients than surrounding areas: “How far this applies to other parts of Ashanti I do not know. As for non-Ashanti parts of Ghana, it 1s likely that the situation is much less gloomy. | think I could count on

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one hand the number of madmen I have met over the years elsewhere ... (Field 1960).

Field’s own explanation for this apparent pocket of schizophrenia is

genetic. parents percent phrenic One percent

She notes that the incidence of first-cousin marriage in the of schizophrenic patients was 40 percent, whereas it is only 10 in the general population. Furthermore, 13 of the 41 schizopatients had schizophrenic siblings, parents, or first cousins. other finding of Field’s study is significant: Although only 10 of the population of Ghana was literate, 40 percent of the

schizophrenic patients who came to the shrines were literate. She

suspected that it was because the literate ones were more likely to be able to afford to come to the shrines. However, in view of the previously discussed findings in India, it is also possible that there is some relationship between higher levels of education and predisposition to

schizophrenia in developing countries.

The third study from Ghana is perhaps the most interesting. From 1934 to 1937, anthropologist Meyer Fortes, who had also been trained in psychology, studied the Tallensi villages of northern Ghana. During that period he observed only one psychotic individual, a 22-year-old man who had become ill in adolescence, in the population of approximately 5,000. When talking to him, his attention “frequently wandered and a vacuous look spread over his face’ (Fortes and Mayer 1969). In 1963 Fortes returned to the Tallensi villages for two and a half months, this time accompanied by his wife, Doris Mayer, a boardcertified psychiatrist. In the same villages where twenty-seven years

earlier there had been a single psychotic, there now were 17! Of these,

Dr. Mayer diagnosed 13 as having schizophrenia, and | each as having manic-depressive psychosis, acute reactive psychosis, postpartum psychosis, and involutional depression. Borderline or doubtful cases were excluded, a history

was

obtained

from

a family

member,

and

each

patient was interviewed in his own home. Of the 13 patients with schizophrenia, 9 were from the same Tallensi villages and 4 were Gorensi from nearby areas. The symptoms of the 9 Tallensi schizo-

phrenic patients included thought disorder, flat or inappropriate affect,

bizarre behavior, delusions, and hallucinations (present in all 9). Ages of onset

for

the 9 were

14,

21, 22,

23,

27,

28,

31,

33,

and

45.

Trypanosomiasis (which may mimic schizophrenia) and neurological diseases were specifically examined: ‘and so far as | could tell by crude clinical methods it was not a factor in any of these cases” (Fortes and

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Schizophrenia and Civilization

Mayer 1969). Two cases had predominantly paranoid symptoms and

another was catatonic. Thus it seems likely that these patients did indeed have schizophrenia.

Mayer and Fortes were themselves convinced that the dramatic rise

in schizophrenia in the twenty-seven-year period was real, and that it could not be explained by population growth:

What was quite startling, from my point of view, is that several of these cases occurred in families which were specially well known to me in 1934-37 and which were basically the same in structure in 1963 as in the early period. I knew some of the patients as young wives or youths or children. These were the families of my best friends and informants,

some of whom are still living. Had such cases occurred among them in 1934-37 I could not have missed them. [Fortes and Mayer 1969]

Tallensi elders were also convinced that there had been a sharp rise in insanity. The authors rejected the possibility that cases of schizophrenia had simply been missed in the earlier study: “I doubt this, since sufferers are never hidden from public knowledge’’ (Fortes and Mayer 1969). Similarly, they rejected the explanation that schizophrenic patients in the earlier period had simply been allowed to starve: “This view is not

tenable, for then, as now, food and shelter were always available to a

madman even if he was so violent as to require putting ‘in log’”’ (putting his foot through a log so that he could not run around and be destructive). The villages under study had, of course, become much more de-

veloped and exposed to technology in the twenty-seven-year interim. Schools, missions, bicycles, radios, canned goods, and gin had all become prevalent. In addition to this influx of technology into the

Tallensi area, the authors noted that an unusual number of those who

became psychiatrically ill had traveled to southern Ghana (the more urbanized and technologically advanced area) prior to the onset of their illness. Ten of the 17 who traveled “had become ill during or soon after

a trip to southern Ghana for work.” H. B. M. Murphy, in discussing this

study, believes that the psychosocial stresses encountered in this trip is

the key to understanding the rapid increase in schizophrenia among

these people:

On that trip they might have met new foods or new infections, but the

one thing we know them to have met was a new social orientation which

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severely challenged Tallensi traditional values. It seems likely that this trip to the coast was relevant to the development of the schizophrenia and that of the various environmental changes experienced there the social one was the most stressful. At the earlier period the Tallensi travelled less and met less challenging conditions when they did so. [1972]

Possible biological explanations for the increase in schizophrenia will

be considered in chapter 9. One final observation by Mayer and Fortes is of interest. Despite the large number of schizophrenic patients observed among the Tallensi people in 1963, it was their impression that they were even more

numerous among the neighboring Gorensi. This group, according to

the authors, had become even more Westernized than had the Tallensi.

Papua New Guinea

Interest in Papua New Guinea was initiated by C. G. Seligman, a

physician and anthropologist, who in 1929 reported no psychosis “‘in the villages among natives leading their own normal life.”” However, he did see 6 cases of psychosis among ‘‘natives” who were living along the coast in close contact with European settlers (Seligman 1929). General paresis and neurosyphilis were also noted to be absent at that time.

B. G. Burton-Bradley is a psychiatrist who has been in Papua New Guinea for over two decades, often as the only one to serve the nation’s

2.1 million people. In 1969 he published an analysis of the first 1,000 psychiatric patients who had been referred to him. Of the 1,000, 343 were said to have schizophrenia. Virtually all of them, however, were said to be individuals who had been living in the larger towns or who had recently migrated to the towns: “The person of limited cultural contact, the so-called bush individual, very rarely presents with the symptoms of schizophrenia’? (Burton-Bradley 1969). Those cases of “schizophrenia” who did come from “the bush”’ do not sound like true schizophrenia but rather like acute reactive psychosis: Not uncommon is the acute schizophrenia of sudden onset coming on usually within three months of the patient’s leaving the village and working for the first time in a large town. Such patients readily recover and are returned to their village, at which level they can function without disturbance. [Burton-Bradley 1963]

Burton-Bradley also noted the rarity of general paresis of the insane

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and the relative infrequency of psychosis among mixed-blood Papua New Guineans (1967). With these observations in mind, I undertook in 1973 a collaborative

research project with Dr. Burton-Bradley and Barbara Boyle Torrey (Torrey, Torrey, and Burton-Bradley 1974). Papua New Guinea is an

unusually good country in which to do epidemiologic research because

census records for even the most remote villages are remarkably good and the system of patrol officers, who visit all villages regularly, improves case finding. All psychiatric records for mainland Papua New Guinea were exam-

ined for the period January 1970 through May 1973, a total of 1,450 records. Only cases in which overtly psychotic signs and symptoms were present were selected. Psychoses with fever or organic disease, postpartum psychoses, and mixed diagnoses (for example, schizo-

phrenia with mental retardation, schizophrenia with epilepsy) were not included. Mixed-race individuals were excluded. The result was 478

individuals who had been admitted at least once during the study period. They were then divided into three groups: acute psychosis, schizophrenia, and manic-depressive psychosis. Acute psychosis (332 cases). One or two admissions, each lasting less than three months, with rapid and apparently complete recovery. A large percentage (one-third to one-half) of these cases of acute psycho-

sis were in contract laborers brought from one part of the country to another to work on plantations or in mines. The syndrome was so common that one psychologist simply diagnosed “plantation syndrome” for such cases. Another unknown percentage of these cases undoubtedly included patients with brief organic psychosis for which

the organic etiology was not detected. Some of these cases were culture-

bound syndromes like amok. Finally, some of these patients were true

schizophrenics who would have been so had diagnosed their hospital-

ization been longer or had more information been available. Schizophrenia (121 cases). Hospitalization for longer than three months, or more than two hospitalizations with signs and symptoms of schizophrenia (thought disorder, delusions and/or hallucinations, flat

affect). The vast majority of these patients had had multiple admissions

and classical signs and symptoms of schizophrenia. If there was any

substantial doubt about the diagnosis, the case was put in the acute psychosis group.

Manic-depressive psychosis (25 cases). Multiple admissions for mania.

Depressed periods had also been recorded for some patients, but there

were no cases in which only multiple psychotic depressions occurred.

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The 121 cases of schizophrenia were then grouped into their district of birth. The birthplace information was available on the records and was considered accurate, since it was the person’s primary identifica-

tion. Mainland Papua New Guinea is divided into thirteen mainland

districts of which the nine coastal districts have had intermittent contact with Western influence and technology for approximately seventy-five years, and the four highland districts for only half that time. There are some areas of the highlands where the first contact between the inhabitants and Europeans has occurred only in the last

ten years. The results of the divisions of schizophrenic patients by district revealed a greater-than-expected concentration of them in four coastal districts (Gulf, Central, Morobe, and Milne Bay), and approximately

the expected number

in two other coastal districts

Northern). Three other coastal districts (Madang,

Sepik) and the four highland schizophrenic patients. In all phrenics compared with what reached statistical significance

(Western

and

East Sepik, West

districts all had a striking of the seven the deficiency was expected on the basis of (in four districts at a level of

paucity of of schizopopulation p< .Ol and

in three districts at a level of p