The

problem of schizophrenia and social class

Research has shown schizophrenia

to be more

at the lower end

of the among people social scale than at the upper. But is lower status the cause or the result of the disease? Dr. Thomas Arie of the London Hospital Medical College reviews the evidence and finds strong support for the view that schizophrenia brings about a downward drift. common

Schizophrenic patients occupy about one-seventh of all National Health Service beds, and it has been estimated that well over half of all the long-stay psychiatric patients suffer from schizophrenia. It is clear that, despite the great benefits which have come from the new drugs and social treatments, the burden of schizophrenia is still massive. In at least two respects, this burden is remarkably constant. One constant feature is that the individual risk of developing the disease (about

one per cent) uniform in different lands and different cultures. Another is that the disease is very unequally distributed between the different social classes, being much more common among members of the lower social classes than among the higher? among unskilled labourers than among professional men. In other words, the lower one looks in the

is

strikingly

socio-economic scale, the more schizophrenia one finds. The unequal distribution of the disease was first described by R. E. L. Faris and H. W. Dunham, whose study in Chicago was reported in 1939. They

investigated the frequency of the disease in different districts, and found that schizophrenia rates were highest in the central 'downtown' areas where the

the vagrant and the solitary lived, often in lodghouses and rented rooms. From these central afeas, the rate followed a diminishing gradient out to the settled, residential suburbs, where it was lowest. This pattern has been found in other American studies, and in this country by Dr. E. H. Hare in

poor,

ing

between the doctor and his working class patients, and because the effect of the diagnosis might be more serious for a man in a skilled occupation. The result would be to underestimate the real amount of disease in the upper social classes. But it has equally been argued that since the effect of schizophrenia is generally less noticeable with unskilled work, the condition is not identified among unskilled workers, so that many cases go undiagnosed in this group. There is some evidence that more rapid recovery and rehabilitation occur in middle-class patients, and this would result in fewer active cases among them at any given time. Such a difference could be due (more in the U.S.A. than in this country) to differences in the type of medical care available, but, if it exists, it is probably much more dependent upon other social, and particularly family factors. Although it is likely that all these considerations play a part, there is plenty of evidence that the gradient between the social classes is real. What is it due to, then? Two main types of explanation have been put forward for the social class distribution of schizophrenia. The first is that social conditions themselves, including social isolation, cause schizophrenia. Whilst the role of social factors in the development of schizophrenia is certainly complex and important, this view has had fewer supporters than the alternative one?that low social status, and often isolation, is the result of the disease. In other words, that schizophrenia either causes patients to drift downwards in the social scale or, at least, to fail in achieving that degree of upward mobility which often results from the normal progress of a man's career. Faris and Dunham did not originally favour this 'drift' hypothesis, though recently, Dunham has published evidence which would support it. A. B. Hollingshead and F. C. Redlich, in an important study in Connecticut, suggested that schizophrenics might even move upwards socially, in relation to their families of origin. But the work of E. M. Goldberg and S. L. Morrison of the M. R. C. Social Media common The The eye is a common symbol in paintings eye is by schizophrenic schizophrenic symbol in paintings by This painting is by 25. (Reproduced patients. patients. This patient aged aged 25. (Reproduced by painting is by aa patient by Netherne Hospital, the Art Art Director, Director, Netherne Coulsdon). courtesy courtesy of of the Hospital, Coulsdon).

Bristol.

Once this striking relationship with environment had

heen discovered,

other workers looked at the disease

in relation to 'social class' (in this country, the Registrar General's index is based on occupation). Here,

t?o,

the findings have generally shown a gradient, which has its peak among the lowest social classes. Various suggestions have been made to explain away the class gradient as due to bias in diagnosis by doctors. It has been suggested that they may be very reluctant to diagnose the disease in professional men, as compared with unskilled labourers, both because ?f cultural barriers to effective communication

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15

The heart of the

matter

cine Research Unit has seemed to settle the matter in favour of the 'drift' hypothesis, at least as far as this country is concerned. Goldberg and Morrison approached the problem at two levels. On the one hand, they investigated consecutive admissions of young men with schizophrenia to two local mental hospitals, enquiring in detail into the history of each patient and his family. Alongside this clinical investigation, they examined the records of a sample of over 500 men, aged 25 to 34, who had been admitted for the first time with schizophrenia to mental hospitals in England and Wales during 1956. (In the case of a disease like schizophrenia, which almost always results in hospital admission at some

stage, first admissions

are a

fair

measure

of its inci-

dence.) They found out the occupation (and thus social class) of the young men at the time that they were admitted, and, using the patients' birth certificates, they established the social class of their fathers at the time that the patients were born. The findings of both studies agreed in showing more patients among the lower social classes, though their fathers were spread throughout the social classes, in a similar way to the general population. Social class of young male schizophrenic patients at first admission compared with that of their fathers at time of patients' birth Social Patients Fathers

Class I and II III IV and V ?

33 178 142 18

56 192 121 2

371

371

The schizophrenic men had evidently moved downwards in the social scale in relation to their families of origin. It was also found that the patients' fathers had themselves had normal careers since their son's birth?a fact which, incidentally, is not easy to reconcile with a hereditary theory of schizophrenia. It seems probable that the difference between these findings and those of Hollingshead and Redlich arises from the fact that the two studies were very differently cast. The American workers were using a different class scale, based, among other things, on education and area of residence. If Goldberg and Morrison had used such a scale, the effect would have been to miss occupational drift in those patients who had been to a grammar school or who continued to live with their middle-class parents. Another important point is that the British study was concerned with current admissions to hospital, whereas the American study included all those who were resident in hospital. If, as has been suggested, schizophrenics who start in the lowest social classes tend to stay longer in hospital, then Hollingshead and Redlich's subjects would have included more of such chronic patients, who couldn't move any further downwards.

All in all, then, there are good grounds for accepting the 'drift' hypothesis. Also, it makes sense, for we know that chronic disease in general (bronchitis, for example) often produces a fall in social class. The Reports of the National Assistance Board show to how great an extent chronic illness is a cause of poverty and of lowly employment today. That schizophrenia should interfere with the natural progress of a man's career is entirely in accord with the way in which the disease, inadequately treated, disrupts the personality and the normal drives and emotions. By contrast with schizophrenia, manic and depressive illnesses leave the personality little, if at all, damaged, and it is not surprising that the sharp association with social class, which schizophrenia shows so regularly,

has, with equal regularity, failed to be found in manic-depressive psychosis. Attempts to prevent schizophrenia have poor promise of success so long as we understand so little of its causes. Preventive medicine in schizophrenia consists in early diagnosis and energetic treatment, aimed at preventing disability and forestalling relapse. Such measures are already showing their power to reduce the grim social consequences of the disease. Footnote: 1 am grateful to Miss E. M. Goldberg, Professor J. N. Morris and Dr. T. W. Meade for helpful discussion.

The Problem of Schizophrenia and Social Class.

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