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Chapter 3: Is “Chronicity” Inevitable for Psychotic Illness?: Studying Heterogeneity in the Course of Schizophrenia in Yogyakarta, Indonesia
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VVVVVVVVVVV 54 3 Is “Chronicity” Inevitable for Psychotic Illness? Studying Heterogeneity in the Course of Schizophrenia in Yogyakarta, Indonesia BY RON J. GOOD, CAR LA MARCHIR A, NIDA UL HASANAT, MUHANA SOFIATI UTAMI, AND SUBANDI Schizophrenia has long been viewed as an almost inevitably chronic and degenerative form of mental illness. This chapter examines the course of schizophrenia -spectrum mental illness in Yogyakarta in central Java, based on a seven-year longitudinal study that follows a small series of cases of individuals with mental illness and their families. It examines questions about the role of culture in shaping the trajectory of illness over time, as well as the effects of inadequate mental health services on the course of mental illness. The association of the powerful and stigmatizing terms—chronic and degenerative—with schizophrenia is rooted in the history of Western neuropsychiatry . Emil Kraepelin (1913), the early twentieth-century German pioneer of psychiatric diagnosis, still influential today, argued that psychiatric illnesses should be defined in part by their typical longitudinal course (cf. Good, forthcoming). He distinguished manic-depressive or bipolar psychoses from “dementia praecox,” later schizophrenia, not only in terms of symptoms, but in terms of the normal, expected course of the condition. Manic-depressive disorder was seen to fluctuate between periods of mania, produced in part by an excess of “will,” and depression, by a loss of “will.” He conceived schizophrenia as an early onset form of dementia, marked by disorders of thought and reason almost inevitably chronic. Over his lifetime, Kraepelin became increasingly pessimistic about the potential for recovery from dementia praecox, reducing his early “optimistic” estimates of 11 percent recovery downward to 4 percent. A chronic course of psychotic experience was thus identified as a defining characteristic of schizophrenia in Kraepelin’s early, influential writings, with the term chronic, when applied to persons with mental illness, marking the individual for life. IS “CHRONICITY” INEVITABLE FOR PSYCHOTIC ILLNESS? 55 The term degenerative not only signifies that an illness is expected to become increasingly severe with time, but links schizophrenia to nineteenth-century and early twentieth-century thinking about degeneracy—a concept that powerfully influenced Kraepelin but remains largely hidden from awareness today (Good, forthcoming). In a book called Faces of Degeneration: A European Disorder, c. 1848–c. 1918, Daniel Pick (1989) outlines the importance of the theme degeneration and degeneracy in France, Italy, and England. Linked to evolutionary theory, degeneration accounted for the status of some societies encountered by colonialists —degenerate societies—as well as pathological families and individuals, families whose degenerative hereditary processes produced increasing numbers of mentally and morally defective individuals: idiots, criminals, and the mentally ill. These ideas were central to evolutionist theorizing about race, class, and society. They were explicitly articulated in conservative political ideologies, including Kraepelin’s. And they played a special role in efforts to understand serious psychotic illness. For German neuropsychiatrists, including Kraepelin, the question of why some forms of mental illness seemed to produce chronic deterioration, while others were cyclical or allowed recovery, was inevitably caught in the ideology of degeneracy (Roelcke 1997). Kraepelin (quoted in Berrios and Hauser 1988: 817) wrote about “degenerating psychological processes” and “dementia praecox,” commenting: The common feature of those illnesses which we group under the name of degenerating psychological processes is the rapid development of a lasting state of psychological weakness . . . What we call dementia praecox is the sub-acute development of a peculiar, simple condition of mental weakness occurring at a youthful age. Kraepelin says explicitly that hereditary factors seem to be present in about 70 percent of cases of dementia praecox and that the “real nature” of this condition remains “totally obscure” (Kraepelin 1899/1990: 153). Nonetheless, one source of the long-standing idea that schizophrenia is a disease for which there is little or no chance for recovery seems to be the historical linking of dementia praecox to degeneracy (Zubin et al. 1985; Barrett 1996). These ideas of degeneracy and mental illness are at least partially responsible for the long entanglement of schizophrenia in eugenics movements, both in the United States and Europe. It is tempting to suggest that the conviction that psychotic illnesses are a form of degeneracy, linked to social, genetic, and moral degeneracy, is responsible for the hopelessness associated with efforts to treat psychotic illness and the rise of asylums built to house the chronically mad in squalid conditions for their whole lives. This is revisionist history, not true...