The Schizophrenic Syndrome A Warning and a Conjecture

John E. Cooper1

This commentary is limited to two topics: first, how best to avoid some drawbacks of ''diagnostic criteria'', and second, a conjecture that some of

1 Meadow Cottage, 25 Ireton Grove, Attenborough, Nottingham NG9 6BJ, UK

the effects of the schizophrenic syndrome can be usefully interpreted at the conceptual level of a reduction of some of the ordinary social rituals of everyday life.

ICD-10 and DSM-IV share two problems in the way that they present the necessary names and criteria by which the subject matter of this review is identified. They both use the term ''schizophrenia'' as if one illness is being described, and they both give a list of symptoms under the title of ''diagnostic criteria''. But experienced psychiatrists know that even Bleuler described ''the group of schizophrenias'', and they know that the heading ''diagnostic criteria'' should be replaced by ''criteria for identifying the disorder'', since there are no implications about underlying processes or knowledge of causes.

Until these defects are put right in future versions of the classifications, psychiatric teachers and researchers should take care to make it clear that to identify a disorder is not the same as making a diagnosis. Reference should always be to ''the schizophrenic syndrome'' or the ''schizophrenic disorder'', and the single misleading term ''schizophrenia'' should be avoided.

One of the most persistent impressions I have formed about patients with long-standing schizophrenic syndromes can be interpreted as a remarkable indifference to their immediate environment, both social and physical. This is an interpretation, since when asked about the points noted below, the patients themselves seem to be unaware of any problem, and have no specific complaints. This indifference shows as an apparent unawareness of minor discomforts in their immediate physical environment, but it is the indifference to the immediate social environment that I should like to examine, that is, their indifference to other persons. This is manifest as a lack of the normal social rituals, such as greetings, farewells and the general niceties of trivial but polite conversation.

To have a diminished ability to engage in the social rituals of everyday life can be a very serious problem; ''friendship exists through ritual'' is a well-known maxim in some schools of social anthropology. Most social roles cannot be performed satisfactorily in any society without accompanying social rituals, such as greetings, thanks and farewells. These exchanges allow a person to establish and re-affirm an identity and a position in the social group; this in turn facilitates performance of work or family duties.

The successful performance of a social ritual requires the brain and mind to be functioning at the very highest levels. It requires the awareness, monitoring and coordination of internal emotional and motor states, and the perception of and responses to similar states in the other person concerned. A variety of complicated motor and sensory processes are involved, such as the recognition of facial expressions, the appreciation of subtle variations of tone of voice, the performance of gestures, and the adoption of appropriate postures.

All animals have a repertoire of social rituals, by which they express both their own individual identity and the identity of their species. We are being most typically human when these social rituals are performed, and it would not be surprising if the performance of these very human activities requires that part of the brain that is most typically human — in other words, the prefrontal cortex. A comment by Andreasen [1] implies this, although without direct mention of the concept of social rituals, ''the negative symptoms of schizophrenia may represent a loss of functions that are generally thought to reside in the frontal lobes''.

There are some studies on patients with schizophrenic syndromes that can be regarded as underpinning this suggestion. Their authors do not mention the concept of social rituals directly, but often come very close. For instance, Brown [2] reports marked loss of politeness in persons with schizophrenic syndromes, and Davison et al [3] conclude that ''schizophrenics showed a generalised decrease in all facial behaviours measured''. The efforts of Frith, Done and others [4] to establish ''a neuropsychology of schizophrenia'' are also relevant, in that a theme of ''faulty self-monitoring'' runs through the conclusions of several of their studies.

The point of this conjecture is that, if even partially correct, it has implications for social treatments of some of the things lost (or perhaps never present) in persons with long-standing schizophrenic syndromes. Social skills training, as carried out in many centres at present, often includes some aspects of what we are here calling social rituals, but, without doing a systematic survey, my impression is that this is usually an incidental part rather than a main focus. Perhaps what is needed is a purposeful and concentrated programme that first assesses whatever social rituals are appropriate for the individual in question, and then tries to instil or regain any that are missing. Since social rituals are heavily dependent upon culture, there are all kinds of interesting opportunities to compare and contrast across different cultures both the states of ritual defect, and attempts to find remedies.

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