« ПредыдущаяПродолжить »
ets were condemned. At the time, he was accusing the American CIA of abusing psychiatry by administering LSD.
Next slide please.
What I want to focus on this morning is the diagnosis of schizophrenia in the Soviet Union, specifically the approach to that diagnosis that Dr. Snezhnevsky has developed. This slide shows that there have been many approaches to the diagnosis of schizophrenia in the world. It is a very difficult condition to describe and to define, but, traditionally, there have been two main categories of schizophrenia that have been described. One category has consisted of syndromes and symptoms that are chronic and that amount to a severe condition-"real" schizophrenia. And another category has consisted of syndromes and symptoms that are less chronic in nature, and that amount a schizophrenia that is less severe-and therefore less "real.”
More recently, another category of psychiatric illness has been suggested by various psychiatrists around the world. But that category has not been defined as being necessarily, a part of schizophrenia itself, though it has been said to resemble schizophrenia in some ways. In general, it has been assumed that a diagnostic borderline can be drawn between, on the one hand, the schizophrenias, both the “real” and the "less real," and on the other hand, this other category of psychiatric illness, sometimes called “borderline." However, though this “borderline" condition has been considered to be similar in some of its clinical characteristics, to schizophrenia, it has not been considered, by most theoreticians, to be a part of the schizophrenia category itself, primarily because, while schizophrenia is characterized by plychosis-the inability to accurately assess reality-the borderline condition is not.
What is important in the Soviet approach to schizophrenia is that this borderline condition has become part of the schizophrenia category; the line between them has been erased.
And now that the nonpsychotic borderline category is merged with schizophrenia, it is possible to diagnose schizophrenia in a patient without having to show that that patient is out of touch with reality.
Next slide please.
This is Dr. Snezhnevsky's own rendition of his theories. I present it in order to show its wonderful aesthetic symmetry. [Laughter.] Next slide please (same as figure 1 in prepared statement).
This is my rendition of his theories. He believes that schizophrenia has three course-forms, a course-form being the clinical form that the illness takes during the course of the patient's life. He believes that there is a "continuous" form, a "periodic” form, and a "shift-like” form
If you consider the lines on this figure to represent the state of the patient's health from birth through old age, you can see that what happens in the "continuous course-form is that, at some point, usually in adolescence or early adulthood, the patient is said to become ill, suffers a continuing form of the illness, and stays ill through the rest of his life.
In the "periodic' course form, the patient is said to suffer attacks of illness, but when he improves, he is more or less as well as he was before the attack took place.
In the “shift-like” course-form, there are also attacks of illness, but after each attack the patient is less healthy than he was before, with the result is that, over the course of his life, he becomes increasingly sick.
What is important about this categorization is that, in two of the course-forms, the "continuous” and the "shift-like," there are three subtypes—mild, moderate and severe. In the “continuous” courseform the mild subtype is called "sluggish” or “slowly developing” schizophrenia.
The moderate and severe subtypes of each of these two courseforms would be considered schizophrenia anywhere. The mild subtypes of each of these two course-forms, however, would not be considered schizophrenia in most countries. According to Snezhnevsky's teachings, these subtypes are characterized by neurotic symptoms. In the "sluggish” subtype of the "continuous” courseform, these include self-conscienciousness, introspectiveness, obsessive doubts, conflicts with parental and other authorities, and something called reformism-that is, the wish to reform society.
Similarly, in the mild subtype of the "shift-like" course-form, the symptoms are also often neurotic, though with an affective coloring—that is, they tend to be associated with prominent mood changes. That subtype is said to be characterized by social contentiousness, philosophical concerns and self-absorption. There are, of course, other symptoms as well that are described, but these, I think, are of particular importance with respect to the issue of the use of this classification scheme for the diagnosis of schizophrenia.
It has been these two mild categories that have been most often applied to dissidents, particularly the sluggish.
Next slide please (same as Table 1 in prepared statement].
In fact, if you review the case records of these dissidents that have been purloined and sent to the West, you find descriptions of these dissidents that match the descriptions of schizophrenia in the various psychiatric textbooks that are put out by Dr. Snezhnevsky and his Moscow school of psychiatry-descriptions such as “originality,” which is to say, the dissident in question is different from other people. Another description involves the "tendency toward ideological formulations.” Also, “fear and suspiciousness," which of course tend to develop if you are a dissident. Similarly “religiosity” and “depression,” which can certainly overcome you if everyone is after you.
Other characteristics that have been attributed to dissidents, and that are actually part of the picture of schizophrenia found in Soviet texts include ambivolence, guilt, and internal conflicts, behavioral disorganization, an excessive belief in ideals, and an obsessive attention to detail-for example, the tendency to focus on the details of the Soviet Constitution, which happens to protect certain rights, such as the right of free speech.
In addition, dissidents have been said to be ill because they are unable to adapt to the social environment; but such maladaptation is surely another way of describing dissent. Also considered a sign of illness is a sudden shift of interest from, let's say, physics to world peace; and, again, “reformism.”
That was the last slide.
I want to stress that I am focusing this morning on the ways in which diagnosis is made in the Soviet Union, the ways in which Soviet dissidents have been diagnosed, and the diagnostic categories that have been used.
There are, of course, many questions that remain about the degree to which the diagnoses are actually believed by Soviet psychiatrists; the degree to which Dr. Snezhnevsky, who has been involved in some of the dissident cases, developed his diagnostic system in order to devise a method that would make it possible to hospitalize dissidents; and the degree to which Soviet psychiatrists, other than the prominent ones, using Snezhnevsky's system, have issued diagnoses of illness while knowing that these dissidents were not, in fact, ill.
These are all important and complex questions, and I would be happy to deal with them if they are of interest to the committee. Thank you.
[Dr. Reich's prepared statement and appendixes follow:]
PREPARED STATEMENT OF WALTER REICH, M.D.
Mr. Chairman and members of the Subcommittee on Human Rights and
I am grateful for the opportunity you have given me today to provide this statement. Allow me to note, at the outset, that I am an employee of the National Institute of Mental Health, but that in speaking before this Subcommittee I am expressing my personal views, which are not necessarily those of the National Institute of Mental Health.
For more than a dozen years, we in the West have heard that Soviet political dissidents have been sent to psychiatrists, found mentally 111, and incarcerated in hospitals for the criminally insane.. Though these reports were at first greeted with some incredulity, it soon became clear that they were not without foundation, and that many of the hospitalized dissidents, probably the great majority, were not, and had never been, mentally 111--certainly not in ways that warranted the diagnoses they received.
Others here today will describe these reports at some length and provide this Subcommittee with information regarding the ways in which Westerners, particularly psychiatrists, have responded to them. In my own presentation I will focus on the ways in which Soviet psychiatric theories have made these diagnoses posssible.
For the purpose of bringing those theories to a certain semblance of life, I have arranged to present some slides that will both explain their main features and show the ways in which they have been applied to dissidents. Two of these slides, however, are particularly apt, and are included here.
Figure 1 provides an overview of the concept of schizophrenia that has been developed by Dr. Andrei V. Snezhnevsky, the most influential Soviet psychiatrist. This concept is important because it is schizophrenia which has been the diagnosis used most often in dissident cases, in particular schizophrenia as defined by Dr. Snezhnevsky.
Snezhnevsky believes that there are three forms of the illness, the "continuous," the "periodic," and the "shift-like." These three forms differ from each other in the course that the illness takes during the lifetime of the patient. In the "continuous" form, the patient becomes ill early in life, usually in late adolescence, and grows continuously worse. In the "periodic" form, the patient has attacks of illness but recovers after each attack; and, when he is recovered, he is as well as he had been before the attack. And, finally, in the "shift-like" form, the patient also suffers acute attacks; but, after recovering from such an attack, he is left clinically more impaired than he had been before it came on. In short, the "shift-like" form possesses characteristics that are a combination of the first two forms: a continuous progression in the severity of the illness, but a progression characterized by acute attacks.
What is important about these Snezhnevskyan forms of schizophrenia is that, in two of them, the "continuous" and the "shift-like," there are subtypes--mild, moderate, and severe. The moderate and severe subtypes of each of these course forms would be considered true schizophrenia by psychiatrists almost anywhere in the world: persons suffering from symptoms described in Soviet textbooks as typical of those subtypes would probably be diagnosed as schizophrenic whether the diagnostician were a
Soviet psychiatrist or, say, an American one. This is not the case,
however, with the mild subtypes. The clinical characteristics described by Snezhnevsky as typical of the mild subtypes do not include the one