CHAPTER 9

Schizophrenia

IN THE NEXT PART of the book we move into the past, settling, for a while, in the period 1874–1886. That was when a wave of multiplicity swept over France, when the sciences of memory firmed up, and when the idea of trauma, previously used only for a bodily wound or lesion, came also to apply to psychic hurt. My aim will be to understand the underlying configuration of knowledge that simultaneously brought into being the sciences of memory, psychic trauma, and multiple personality. It will ease the transition to mention a few aspects of the period between then and now, a period when multiple personality languished, psychoanalysis flourished, and schizophrenia was the most baffling psychosis.

The prototype of multiple personality, as it matured in the time frame 1874–1886, was very different from the recent one that I have described. Here is a brilliant précis by Eugen Bleuler (1857–1939), best known as the man who, in the first decade of the twentieth century, created schizophrenia as a diagnostic category. He used early names for multiple personality, one English (double consciousness) and one French (alternating personality).

A special type of disturbance of personality is the alternating personality, also known as double consciousness. Let us consider a hysterical woman who until now has lived a mediocre existence. For some known or unknown reason she falls into a hysterical sleep, and on awakening she has forgotten her entire previous existence; she does not know who she is, where she has lived until now, and who the persons are whom she sees around her. Notwithstanding this change, the ordinary faculties of walking, speaking, eating, the use of clothes and other things are usually transferred to the new state (état second). Whatever the patient needs for her intercourse with other people, she learns very quickly. Her character, too, undergoes a change; formerly a serious-minded girl, she now becomes frivolous and pleasure-seeking. After some time, she again merges into a state of sleep, and on awakening the patient is back in her first state. She has no realization of the intervening time; all that she remembers is that she went to sleep, and has now awakened as usual. Such changed states may appear alternately for years. While in the first state the patient only remembers the former states and when in the second she always recalls only those of the second series. More frequently, however, it seems that in the second state the patient can recall the first (normal) series, but while in the first state she cannot recall the second (morbid) series. It may also happen that eventually the second state will become permanent and this way cause a transformation of the personality. In quite rare cases there may be an alternation of many such states, each with its very definite character and special memory group (personality); as many as twelve have been observed. As a matter of fact cases of pure dual personalities are very rare. Yet their theoretical significance is very great, for they show what marked changes can be brought about by a systematic elimination or intercalation of association paths.1

État second was Eugène Azam’s name for the alter state of his patient Félida, the first of the French multiples to be studied after 1876. The phrase was standard; Breuer and Freud used it in more than half a dozen different places in Studies in Hysteria.²

During the 1980s, both Bleuler and Freud were seen by many members of the multiple movement as enemies. I will return to the question of why Freud is so loathed, but I begin with Bleuler. It has become an accepted fact that a thriving multiple movement in Boston, led by Morton Prince (1854–1929), was destroyed by a pincer attack mounted 1908–1926. On the left, the psychoanalysts practiced a type of dynamic psychology that had no place for the theories of Janet or Prince. And on the right, the more neurologically and biologically minded psychiatrists treated multiples as if they were schizophrenics. There is a wonderfully mythic quality to this account. Two forces of legendary evil, Freud and Bleuler, overpowered that precious and innocent stripling, multiple personality and dissociation. They won the battle, but perhaps not the war. Some multiple personality activists are now trying to reclaim lost territory from schizophrenia. I shall end by describing this irredentism, but first let us examine the historical story that, as in the case of every irredentism, is essential to legitimating the project.

The foundation for the official history is a single historical note published by Rosenbaum in 1980.³ He observed that after 1926 the Index Medicus listed far more papers about schizophrenia than about multiple personality; between 1914 and 1926 the reverse had been the case. So schizophrenia overwhelmed multiplicity. Why? Putnam writes, “Rosenbaum notes that Bleuler included multiple personality in his category of schizophrenia.”⁴ Using the same source Greaves asserts that Bleuler “included at least some instances of [multiple personality disorder] in his global diagnosis of schizophrenia. Those remaining cases, which he deemed hysterical, he relegated (at least by implication) to the realm of hypnotic artifacts.”5 These statements are based on a misreading of three consecutive sentences of Bleuler’s, which have been extracted, truncated without notice, and actually misquoted from a paragraph whose context is ignored. A libel against a scrupulous author by writers of another caliber is of no moment. But relations between multiplicity and schizophrenia may be hot in the future, so the record should be set straight.

Ellenberger offers an excellent brief summary of Bleuler’s theory and practice, which, as he says, “has often been misunderstood.”⁶ Bleuler was director of the Burghölzli mental hospital, the university psychiatric clinic of Zurich. The crucial division among psychoses had been established by Emil Kraepelin (1856–1926). On the one hand there were manic-depressive illnesses. On the other was dementia praecox, so-called because of its frequent onset in adolescence—it was premature senility. In 1908 Bleuler published what he had been teaching to his assistants for some years. Kraepelin had been wrong to focus on early onset.⁷ No existing label suited this baffling disease. Bleuler settled on split-brain-disease, in Greek: schizophrenia. He did not mean a splitting into personalities that would alternate in control of an individual, as in the prototype for double consciousness. He meant to indicate “the ‘splitting’ of psychic functions.”⁸ To oversimplify enormously, one kind of cleavage was between that part of a person who knew what was going on, and another who felt what was going on—a split between sense and sensibility.

Bleuler had little interest in alternating personality, but he insisted on differential diagnosis. In the literature he knew, one alter succeeds another in taking control, as in the prototype I quoted above. He was not acquainted with what Morton Prince was to call co-consciousness, in which two alters may be aware of each other—that was part of a later prototype of the disorder. Thus schizophrenia and alternating personality both involve splitting, but splitting of very different sorts. The schizophrenic simultaneously has irreconcilable attitudes, emotions, and behaviors, as well as terrible distortions of logic and sense of reality. The multiple has no logical or reality problems but fractures into successive fragments:

Systematic splitting, with respect to personality, for example, may be found in many other psychotic conditions [in addition to the group of schizophrenias]; in hysteria (multiple personality) they are even more marked than in schizophrenia. Definite splitting, however, in the sense that various personality fragments exist side by side in a state of clear orientation as to environment, will only be found in our disease [viz. schizophrenia].9

Had Bleuler known about co-consciousness he would have had to revise this discussion. But he did not. I have quoted his prototype of double consciousness. The three sentences that follow my previous quotation are these:

It is not alone in hysteria that one finds an arrangement of different personalities one succeeding the other; through similar mechanisms schizophrenia produces different personalities existing side by side. As a matter of fact, there is no need of delving into these rare though most demonstrable hysterical cases; we can produce the very same phenomena, experimentally, through hypnotic suggestion, and we also know that in the ordinary hysterical twilight states the memory of former attacks, concerning which the patient shows an amnesia in her normal state, can be retained or can be aroused by suggestion.

The emphases are Bleuler’s in the original German, and are preserved in the faithful English translation. Now, these very sentences are the basis of the claim by Rosenbaum and all subsequent movement writers that Bleuler included multiple personality under schizophrenia. These very sentences? Well, not exactly. Rosenbaum left out Bleuler’s two emphases, “succeeding” and “side by side”; the emphasis was essential, for that was the basis of Bleuler’s differential diagnosis. Instead Rosenbaum italicized quite different words. He also changed the punctuation and omitted the end of the last sentence. He did not mention the impeccable description of multiple personality that came earlier in the very same paragraph.

Bleuler has been so maligned that I should summarize his actual positions. In his view, (1) multiples—alternating personalities—are rare; (2) they are “demonstrably existent”; and (3) they are to be understood in terms of dissociation—“systematic elimination or intercalation of association paths.” Further, (4) dissociation (“similar mechanisms”) also occurs in schizophrenia; there, however, it results not in alternation but in side-by-side fragmentation, which is not known in nineteenth-century reports of multiple personality. And, finally, (5) we can study the important phenomenon of dissociation experimentally, through hypnotic suggestion, rather than seeking out rare spontaneous alternating personalities. In every respect Bleuler is faithful to the literature of multiple personality, and in particular to Pierre Janet. For example, it was above all Janet who taught that multiple personality could be studied experimentally through hypnotism.

Bleuler did not, as Greaves puts it, imply that some alternating personalities were schizophrenic while the rest were hypnotic artifacts. There is a sad irony here. Greaves wonders why Bleuler was so effective at “conscripting” multiple personality into schizophrenia. He explains it by what he calls “inoculation theory: … Whoever relates information first—‘whoever gets there firstest with the mostest’—is in a highly advantaged position.”10 How untrue! Bleuler, who is not read, got there first and is highly disadvantaged. It was Rosenbaum who inoculated people against reading Bleuler by misquoting three truncated sentences out of context.

After its gross misrepresentation of Bleuler, the official history of multiple personality goes as follows. Morton Prince learned of multiplicity from French doctors and diagnosed it in his Boston practice. His two famous cases, Sally Beauchamp and B.C.A., were landmarks.¹¹ A Boston school of psychiatry flourished in the first decade of this century, with a heavy emphasis on dissociation. In 1906, as he was finishing his treatment of Miss Beauchamp, Prince founded the Journal of Abnormal Psychology, which runs to this day, and which featured a good many cases of multiplicity. But within a few years, the diagnosis virtually disappeared. It was savaged by the two demons, psychoanalysis and schizophrenia. Since the multiple movement is American, its official history is American, and its problem is American, the movement asks why multiple personality disappeared in America. The more interesting question concerns France, the begetter of so many patients after 1876, and homeland of the legendary theorist Pierre Janet. The next few chapters will describe that French scene in some detail. No one (to my knowledge) has ever asked why multiple personality disappeared in France.

Psychoanalysis is not the answer. Psychoanalysis has had its own career in France. The work of Jacques Lacan has become famous outside his homeland, but previous events are less well known. Freud’s French evangelist was the redoubtable Marie Bonaparte (1882–1962). She bankrolled the French wing of psychoanalysis; it was she for whom Lacan had the greatest contempt. She seems not to have even thought about Freud before she read the Introductory Lectures on Psychoanalysis in 1924—rather too late to have caused the suppression of multiple personality in France.¹² In fact the French wave of multiples had almost completely subsided by 1910.¹³ There is a very easy explanation for this. French multiple personality was born under the sign of hysteria. All multiples were hysterics, usually with the extraordinary symptoms that Jean-Martin Charcot had made famous. In the period 1895–1910, hysteria ceased to be central to French psychiatry. A simple syllogism follows. Out went hysteria; all multiples were hysterics; so out went multiples.

Mark Micale has shown how the symptoms of hysteria, insofar as they persisted, dissipated into other diagnoses. Hysteria, Micale writes, “vanished into a hundred places in the medical textbooks.” And, as he says, “the large majority of these changes took place during 1895–1910.”14 Freud’s anxiety neurosis collected some bits of hysteria; so did Kraepelin’s dementia praecox, the predecessor of schizophrenia; likewise Janet’s diagnosis of psychasthenia—and many more that are today remembered chiefly by historians of medicine. The result? There was no medical space in which multiple personality could thrive.

Consider Janet himself, who in his first psychological papers, 1886–1887, was so fascinated by double personality. It is a major topic for his philosophy dissertation of 1889, Psychological Automatism. In 1894, in the second volume of The Mental State of Hystericals, a short but significant section was devoted to it. There is substantial attention to the phenomenon in his 1906 Harvard lectures, The Major Symptoms of Hysteria, addressed to an audience that, thanks to Morton Prince, could say it lived in the world capital of multiple personality. But in 1909 his book The Neuroses was rather dismissive of doubling.¹⁵ Note the date: it coincides with Micale’s dating of the demise of French hysteria. Janet was no more true to his youthful enthusiasm than anyone else. In his three-volume Psychological Healing of 1919, in many ways the accumulation of a life’s experience, exactly one page out of 1,147 is dedicated to multiple personality, or rather double personality. There he discusses “a series of periodic transformations of activity and memory, which as I have shown elsewhere [Les Névroses] enable us to interpret in a simpler fashion the phenomena of double personality, which were so mysterious in the early days of pathological psychology.”¹⁶

Skeptics about multiple personality will be astonished and delighted at what Janet wrote in the next paragraph. Double personality should be assimilated to a much more familiar condition of which it is a special and rare case. That is, patients with alternating periods of depression, mania, and stability: “les circulaires, as the early French alienists called them.” In 1854 J.-P. Falret had coined the name folie circulaire, which is roughly coextensive with Kraepelin’s manic-depression or the bipolar disorders of DSM-IV. Notice that Janet did not, in the end, file multiple personality with schizophrenia. Insofar as he used German classification (which on patriotic grounds he detested), he filed the condition with what for Kraepelin was the very opposite of dementia praecox, namely, manic-depressive illness. Janet concluded that multiple personality was a special case of bipolar disorder.

The disappearance of multiple personality in France is completely explicable within a medical history of hysteria. The fact that Janet himself gave it up is of merely anecdotal interest; by 1919, he was no longer influential. What of the United States? Morton Prince’s Boston school did strongly advocate the diagnosis of multiple personality and the use of the concept of dissociation. It lost. Psychoanalysis was irrelevant to the disappearance of multiple personality in France, but it really did matter in America. There was a celebrated congress at Clark University in 1907, to which most of the world’s luminaries in psychology were invited. Freud seems to have dominated the occasion. A gradual groundswell of support for analysis appeared, and for many years psychoanalysis was dominant in American medical schools of psychiatry. In private practice, the American versions of psychoanalysis boomed. There was no place for Prince. Freud’s repression swamped Prince’s dissociation as a cardinal tool of the trade. Nowadays there may be a casual and unreflective interlacing of the two, but once they were two models in confrontation, a situation best described in its own day by the British psychiatrist Bernard Hart (1879–1966).17 The attitude of the analysts to Prince himself verged on contempt. Ernest Jones describes Prince “as a very thorough gentleman, a man of the world, and a very pleasant colleague…. But he had one serious failing. He was rather stupid, which to Freud was always the unpardonable sin.”¹⁸

Thus psychoanalysis—one-half of the multiple movement’s official explanation for the disappearance of multiple personality—is correct for the United States, although irrelevant for France. What of the other half of the explanation, the claim that the diagnosis of schizophrenia engulfed multiple personality? I have shown that Bleuler himself carefully distinguished the two diagnoses. Yet he did contribute indirectly to the disappearance of multiple personality, because he had a major hand in the dissipation of hysteria and hence helped destroy the home base of multiplicity. No one will dispute the increase in diagnosis, reporting, and discussion of schizophrenia during the 1920s. Rosenbaum looked at Index Medicus; we are now able to consult the bibliography collected by George Greaves and his colleagues.¹⁹ We find that the incidence of papers on multiple personality published in English is remarkably flat for five-year periods between 1910 and 1970. Schizophrenia is going up and up, unmistakably, but reports of multiplicity do not vary significantly. What is true is that aside from the flurry of interest in “Eve” in the late 1950s, no one took the subject seriously. No longer was there a Morton Prince to fascinate the world. The number of published papers is a mere epiphenomenon. Since multiple personality was, for the French and for Prince, an unusual kind of hysteria, we should, if we are to count papers, count the publication rate for papers on hysteria. The results are summarized in a note.20 Both hysteria and neurasthenia decline steadily from a high around 1905. In fact by 1917, hysteria without multiple personality has become no more common than multiple personality itself. These statistics should not, however, be taken to prove anything, because the types and volume of psychiatric publication themselves change so much during these years. They merely illustrate what we know on more theoretical ground: that hysteria was being phased out, and with it, multiple personality.

Even if psychoanalysis was the main direct threat, Prince knew full well that the decline of hysteria would be a disaster for multiple personality. One of the major figures in the termination of hysteria was Charcot’s former favorite student, Joseph Babinski. In magnificent Oedipal fashion, Babinski “dynamited hysteria,” to use the apt phrase of a French encyclopedia article. “There has developed,” Prince wrote in 1919, “amongst French neurologists, under the teachings of Babinski, a reaction against the classical conception of hysteria of Charcot and his school.”²¹ Then followed a polite but heartfelt denunciation of Babinski. It came too late in the day to have any effect, and it was too out of touch with the demise of hysteria in Europe. Today’s advocates of multiple personality want to explain the virtual disappearance of the diagnosis of multiple personality. They are asking the wrong question. A better one is: why did it hang on so long in the United States?

One element in the American and English fascination with multiplicity—one that encouraged a more enduring interest in the early years of this century than was found in France—has been underplayed. The disorder always needs a host, much in the way that a parasite needs hosts. In our day, as we have seen, the host has been child abuse. In France the hosts were Charcotian hysteria, hypnotism, and positivism. In New England in particular, and in both America and Britain more generally, an additional host was psychic research linked with spiritualism. One idea was that alters were departed spirits; mediumship and multiple personality grew close. This thought had occurred early in France. Charles Richet (who won the 1909 Nobel Prize for medicine) was the first investigator to apply statistical inference to extrasensory perception. After trying pure randomization, he turned to stellar performers such as Janet’s very first multiple, Léonie, who had originally attracted Janet’s interest because of her ability to be hypnotized at a distance. When Richet did his work on telepathy in 1884, he was virtually the first person to use randomized experimental design in any field of inquiry whatsoever.22 It was, however, in England and the United States that the scientific pursuit of psychical research flourished, starting in 1882. The most careful summaries of the entire nineteenth-century multiple literature are to be found in the writings of F.W.H. Myers, a cofounder of the Society for Psychical Research in London—especially his magnum opus, subtitled Survival of Bodily Death, a work published in 1903 and still one of the richest collections of early reports of multiple personality.²³ The longest single case report of a multiple, or of any other case of apparent mental illness, is the 1,396-page study of Doris Fisher, by Walter Franklin Prince (no relation to Morton Prince). It was published in 1915–1916 in a magazine for psychical research.²⁴ Stephen Braude, whose philosophical views are discussed in chapter 16, remains true to these roots, having published books favorable to psychical research and to multiple personality disorder, and connecting the two in the trance states of mediums.²⁵ These themata will of course go on being updated. A 1994 paper confirms that belief in psychical phenomena—spooks, aliens, and the like—is well correlated with a history of childhood trauma.²⁶ But after thirty-odd years of high times around the turn of the century, mediumship, spiritism, and psychical research went into radical decline. Once again, a zone of deviancy that was hospitable to multiple personality severely contracted.

We have now said everything necessary to explain the virtual disappearance of multiple personality, as a diagnosis or as a serious research topic, in the years 1921–1970. But the relationships among multiple personality, schizophrenia, and psychoanalysis are not over yet. I should say a few words about the multiple movement and Freud, and then turn back to schizophrenia.

The loathing of the multiple movement for Freud is best expressed by Colin Ross: “Freud did to the unconscious mind with his theories what New York does to the ocean with its garbage.”²⁷ Between 1971 and 1990 acknowledgments of Freud by advocates of multiplicity were stunningly brief, even in Cornelia Wilbur, the maverick psychoanalyst. Here is an almost unique example that alludes to Freud: “Freud (1938) contributed to the concept of the unconscious mind as potentially holding the entirety of memories of the life experience.” The citation, “Freud (1938),” is to a generic pocket-book Basic Writings of Freud, to which the author gives no page references.28 The index to Putnam’s textbook refers us only once to Freud: “Even Sigmund Freud reported personal experiences with feelings of depersonalization.”²⁹

The fear and loathing of Freud is easy to understand. The feminist wing of the child abuse movement despised Freud; that wing was hospitable to multiple personality. Jeffrey Masson’s brilliant attack on Freud for abandoning the so-called seduction theory made Freud the villain for anyone who cared about sexual abuse of children. There is the additional feeling of betrayal, in that Breuer’s case of Anna O. is so easily read as a case of multiplicity: Breuer and Freud themselves said she had double consciousness.³⁰ Why did they not keep faith? Then there is a slightly guilty feeling of debt. The etiology of multiple personality is remarkably akin to early Freud, at the time of his collaboration with Breuer. The suffering from memories, the effect of trauma: everyone learned that from Freud, even if in fact Janet was saying much the same thing around 1890.

Perhaps there is even a nagging doubt on the part of a few reflective clinicians: How come we are stuck with the very earliest, simplest, kindergarten Freud, the stock-in-trade of those prewar black-and-white psychodramas shown on late-night television? How come we have not even gone so far as Freud had gone by 1899—how come we have not thought seriously about what Freud called screen memories? Why have we been so literalist, so mechanical, and imagined that an illness produced by trauma is produced at the time of the trauma, in early childhood? Why can’t we at least discuss the idea that the experience of the original event, apparently kept in memory, is not what causes distress and dysfunction; why can’t we ask whether the problem comes from the possibly repressed memory itself, much later in life, and the way in which the mind has worked on and recomposed that memory? But times are changing. The crises of recovered memory have made clinicians go back to Freud. Conversely, students of psychoanalysis have increasingly thought about multiple personality. Sometimes they use traditional Freudian concepts. Otto Rank, one of Freud’s inner circle, wrote about the double as a type of narcissism,³¹ an idea that has been revived by Sheldon Bach.32 The Menninger Clinic, long an important American center of psychoanalytic research, has just devoted a whole issue of its journal to multiple personality.

The relations between schizophrenia and multiple personality are also in flux, although all the action comes from the multiple side. It is urged that many patients now called schizophrenic should be recognized as multiples, and not just because of misdiagnosis, but because many of the classic symptoms of schizophrenia are actually symptoms of multiple personality instead. How can this be? In chapter 1, I urged that we keep multiple personality and schizophrenia completely apart. At the beginning I had to guard against semantic confusion through the misleading but natural equation: multiple personality = split personality = schizophrenia. To make sense of current speculation I now have to lower the barriers a bit. But not too far. There is a lot of good sense in the folksy distinction implied in the book Sibyl: “Dr. Wilbur had seen schizophrenics—psychotics—who had not been as ill as Sibyl. One might say they were running a psychotic temperature of 99 degrees, whereas Sibyl was running a psychoneurotic temperature of 105.”³³ And Wilbur insisted that she had never encountered multiples with the flat affect or disordered thought patterns of schizophrenics.

I mentioned other differences between the two illnesses, but not what really matters. Schizophrenia is an absolutely dreadful condition. There are those who urge that it is the worst illness that is now rampant in the Western industrial world. You can think of schizophrenia, rather than cancer, say, as the worst disease of prosperity because it so often strikes at young people just as they are about to enter adult life. The impact on families is horrible. One of the worst things about severe episodes in the life of schizophrenics is that other people are terrified as they see good sense and order turned upside down, chains of ideas turned into threatening parodies of ordinary life. The withdrawal, the indifference, the fascinations; speech awry, glances blocked, feelings inverted—above all, strangeness. And then the opposite, now much alleviated by drugs for many patients, the catatonic state once so characteristic of insane asylums: people, or former people, who don’t move, don’t respond, who have gone. One of the important ideas in the antipsychiatry movement inspired by R. D. Laing was that the nonschizophrenics were a serious part of the problem.³⁴ One important residue of that movement has been the formation of Friends of Schizophrenics and similar support groups.

The outlook for schizophrenics is not entirely bleak. Bleuler thought schizophrenia could be helped by careful treatment, but that despite spontaneous remissions, patients never truly recover from it. However, the symptom profile and history have been evolving. A few have argued that “the disorder itself has undergone a benign metamorphosis such as has occurred with some infectious diseases.”35 The advent of antipsychotic drugs about 1957 has had an immense effect on the lives of many schizophrenics. These drugs are constantly under development, and one hopes that the undesirable effects on many patients will gradually be modulated.³⁶ For most dedicated psychiatrists the psychotropic drugs are a means, not the final treatment. They make it possible to do long-term therapeutic work, and to reintegrate a patient into the world of friends, family, and employment. It is true that desperate shortage of funds for psychiatric care often results in “warehousing” of patients not further helped by family or action groups to act as their advocates. But responsible medicine does not end treatment for schizophrenics with a package of tablets.

There is no agreement on the extent to which schizophrenia is genetic. There are regional variations in its incidence and manifestations. There is a series of claims for genes associated with schizophrenia, and a barrage of clues to specific biochemical causation. We know precious little about the underlying causes and nature of schizophrenia. The most frequently used word in clinical descriptions of schizophrenia is that it is a “heterogeneous” illness. There are three main approaches to the disease.³⁷ Possibly a majority of scientists think there is one fundamental cause, which has many manifestations. Some suggest that there are two fundamental types, one of which is genetic and associated with the traditional onset in late adolescence, and the other of which is biochemical.³⁸ Others think we are still further away from understanding, and that what we are faced with amounts only to several groups of symptom clusters. And finally, there is an iconoclastic group who deny that schizophrenia is a legitimate grouping at all.³⁹

There has always been a tension between those who strive for an etiological definition of schizophrenia and those who, because of our ignorance, want a purely phenomenological set of diagnostic criteria. The behavior of schizophrenics changes over time. How can the clinician pick out a schizophrenic on interview? There was a search for what were called “prognomic” indicators. (That’s prog-nomic, not pro-gnomic; prognomic indicators are behaviors that justify an expectation that other, more fundamental and lawlike, symptoms will reveal themselves.)

The diagnosis of schizophrenia has never been easy. In 1939 the psychiatrist Kurt Schneider proposed a list of eleven “first-rank” symptoms of the illness.40 A patient showing any sizable number of these symptoms could be confidently diagnosed as schizophrenic. The patient

(1) hears voices speaking the patient’s own thoughts out loud; (2) or is the subject about which voices are arguing; (3) or is the subject of a commentary by the voices, who comment on what the patient is doing or has done; (4) has normal perceptions followed by delusional versions of them; (5) is the passive recipient of body sensations coming from outside; (6) feels thoughts being extracted from the mind by external forces; (7) believes thoughts are broadcast to others; (8) or complains of thoughts being inserted into the mind from outside. Or has the sense that (9) feelings and affects, or (10) sudden impulses, or (11) motor activities, are controlled from outside the patient’s own body.

Schneider thought that any one of these features could be used for a diagnosis of schizophrenia, but it is now generally agreed that Schneiderian first-rank symptoms are no guarantees of schizophrenia. It is here that multiple personality enters. These symptoms, or behaviors very reminiscent of them, are manifested by a great many patients now diagnosed as multiples. In a series of 30 patients whom he had diagnosed as multiples, Richard Kluft found an average of 4.4 Schneiderian first-order symptoms per patient.⁴¹ In a larger series of 236 people diagnosed as multiples, Colin Ross and his associates found that the average number of Schneiderian symptoms per patient was 4.5. Ninety-six out of the 236 patients surveyed had a previous diagnosis of schizophrenia.⁴² Ross infers that the symptoms proposed by Schneider well over fifty years ago as justifying a schizophrenia diagnosis actually are at least as likely to indicate multiple personality. Multiples can have “schizophreniform episodes.” That means acting like a schizophrenic, but not for too long a time. DSM-IV insists that one should not diagnose schizophrenia definitively until the symptoms have been seen for at least six months. The World Health Organization guide, ICD-10, is satisfied with one month; DSM-IV leaves a door open for dissociative identity disorder diagnosis that would be shut by ICD-10. There is now a quite common distinction between positive and negative diagnostic criteria for schizophrenia. The Schneiderian first-rank symptoms are all positive; they are unusual things that schizophrenics and some others do, things that, in their strangeness, often seem scary and threatening to healthy people. Multiples can display many of the positive symptoms of hallucinations and the like. But they do not have the negative symptoms, the sheer absences, the profoundly flat affect, that are so often, in daily practice, the grounds for a diagnosis of schizophrenia. The traditional distinctions between schizophrenia and multiple personality, already insisted upon by Bleuler, still remain intact. But advocates of multiplicity do not limit themselves to claiming back patients diagnosed as schizophrenics because of first-rank symptoms; they want to claim as much of the field of psychiatric research as they can. Ross writes: “MPD is the most important and interesting disorder in psychiatry, which is why I study it. I believe it to be the key diagnosis in an impending paradigm shift in psychiatry…. Biological psychiatry might obtain more clinically meaningful results if it focused on the psychobiology of trauma and abandoned the search for causality in genes and endogenous chemical derangements.”43

Fortunately the paradigm shift that Ross envisages will not take place. When T. S. Kuhn published The Structure of Scientific Revolutions in 1962, he truly knew not what he had wrought. “Paradigm shift” has become a war chant. I finish this chapter at the end of the year 1994. February 1995 will see an aggressive conference titled The First Annual Conference on Trauma, Loss, and Dissociation: The Foundations of Twenty-First Century Traumatology. Psychobiology will figure, to be sure, but one aim of the organizers is to move treatment of trauma away from multiple personality models. The preconference publicity quotes one of the speakers: “Advances in the field of traumatic stress research have led to exciting new paradigm shifts. The conference will break new ground for the 21st century.”⁴⁴ Perhaps I may be allowed a dour Canadian joke. In 1900 the prime minister of Canada announced, “The Twentieth Century Belongs to Canada.”