“Sluggishly progressing schizophrenia”

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Psychiatry in Russia and the USSR

“Sluggishly progressing schizophrenia or sluggish schizophrenia (Russian: вялотеку́щая шизофрени́я, vyalotekushchaya shizofreniya) is an independent diagnostic category that is characterized by a slowly progressive course and included in the systematics of schizophrenia developed by Soviet psychiatrist Andrei Snezhnevsky and his Soviet colleagues.[1] This diagnostic concept was limited to the USSR and some other East European countries.[2][3]

Sluggish schizophrenia is not included in the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) used in western countries;[4] however, its Russian version adds sluggish schizophrenia to schizotypal personality disorder in section F21 of chapter V

Psychiatric diagnoses (such as the diagnosis of “sluggish schizophrenia” in political dissidents) in the USSR were used for political purposes;[7]:77 the diagnosis of sluggish schizophrenia was most frequently used for Soviet dissidents.[8] Critics implied that Andrei Snezhnevsky designed the Soviet model of schizophrenia (and this diagnosis) to make political dissent a mental illness.[9] According to American psychiatrist Peter Breggin, the term “sluggish schizophrenia” was created to justify involuntary treatment of political dissidents with drugs normally used for psychiatric patients.[10]

According to Robert van Voren, the political abuse of psychiatry in the USSR arose from the concept that people who opposed the Soviet regime were mentally ill (since there was no logical reason to oppose the sociopolitical system considered the best in the world).[11] The diagnosis of sluggish schizophrenia (a concept developed by the Moscow School of Psychiatry and its chief, Andrei Snezhnevsky) furnished a framework for explaining this behavior.[11]

Although a majority of experts agree that the psychiatrists who developed this concept did so under instructions from the Soviet secret service KGB and the Communist Party (and understood what they were doing), this seemed to many Soviet psychiatrists a logical explanation why someone would be willing to abandon his happiness, family, and career for a conviction so different from what most individuals believed (or made themselves believe).[11] Professor A. Snezhnevsky, the most prominent theorist of Soviet psychiatry and director of the Institute of Psychiatry of the USSR Academy of Medical Sciences, developed a novel classification of mental disorders postulating an original set of diagnostic criteria.[12]

The Soviet model of schizophrenia is based on the hypothesis that a fundamental characteristic (by which schizophrenia spectrum disorders are distinguished clinically) is its longitudinal course.[13]:543 The hypothesis implies three main types of schizophrenia:

* Continuous: unremitting, proceeding rapidly (“malignant”) or slowly (“sluggish”), with a poor prognosis
* Periodic (or recurrent): characterized by an acute attack, followed by full remission with little or no progression
* Mixed (German: schubweise; in German, schub means “phase” or “attack”): mixture of continuous and periodic types which occurs periodically and is characterized by only partial remission[13]:543

The classification of schizophrenia types attributed to Snezhnevsky[14]:278 is still used in Russia,[15]:371 and considers sluggish schizophrenia an example of the continuous type.[16]:414

A carefully crafted description of sluggish schizophrenia established that psychotic symptoms were non-essential for the diagnosis, but symptoms of psychopathy, hypochondria, depersonalization or anxiety were central to it.[12] Symptoms considered part of the “negative axis” included pessimism, poor social adaptation and conflict with authorities, and were themselves sufficient for a formal diagnosis of “sluggish schizophrenia with few symptoms”.[12] According to Snezhnevsky, patients with sluggish schizophrenia could present as seemingly sane but manifest minimal (and clinically relevant) personality changes which could remain unnoticed by the untrained eye.[12] Patients with non-psychotic mental disorders (or who were not mentally ill) could be diagnosed with sluggish schizophrenia.[12] Along with paranoia, sluggish schizophrenia was the diagnosis most frequently used for the psychiatric incarceration of dissenters.[12]

According to Snezhnevsky and his colleagues schizophrenia was more prevalent than previously thought, since the illness could present with relatively mild symptoms and progress later;[11] schizophrenia was diagnosed more often in Moscow than in other countries, as the World Health Organization Pilot Study on Schizophrenia reported in 1973.[11]

The incidence of sluggish schizophrenia increased because, according to Snezhnevsky and his colleagues, patients with this diagnosis were capable of socially functioning almost normally.[11] Their symptoms could resemble those of a neurosis or paranoia.[11] Patients with paranoid symptoms retained insight into their condition, but overestimated their significance and had grandiose ideas of reforming society.[11] Sluggish schizophrenia could have such symptoms as “reform delusions”, “perseverance” and “struggle for the truth”.[11] As V.D. Stayzhkin reported, Snezhnevsky diagnosed a reform delusion in every case where a patient “develops a new principle of human knowledge, drafts an ideal of human happiness or other projects for the benefit of mankind”.[17]:66

During the 1960s and 1970s, theories which contained ideas about reforming society, struggling for the truth, and religious convictions were not considered delusional paranoid disorders in nearly all foreign classifications; however, Soviet psychiatry (for ideological reasons) considered critiques of the political system and proposals to reform it as delusional behavior.[18]:19 The diagnoses of sluggish schizophrenia and paranoid states with delusions of reform were used only in the Soviet Union and several Eastern European countries.[18]:18

An audience member at a lecture by Georgi Morozov on forensic psychiatry in the Serbsky Institute asked, “Tell us, Georgi Vasilevich, what is actually the diagnosis of sluggish schizophrenia?”[19] Since the question was asked ironically Morozov replied ironically: “You know, dear colleagues, this is a very peculiar disease. There are not delusional disorders, there are not hallucinations, but there is schizophrenia!”[19]

American psychiatrist Alan A. Stone stated that Western criticism of Soviet psychiatry was directed at Snezhnevsky, because he was responsible for the Soviet diagnosis of sluggishly progressing schizophrenia with “reformism” and other symptoms.[20]:8 This diagnosis could be applied to dissenters.[20]:8

Snezhnevsky was attacked in the West as an example of psychiatric abuse in the USSR.[8] He was charged with developing a system of diagnoses which could be used for political purposes, and diagnosed (or was involved with) a series of famous dissident cases (including biologist Zhores Medvedev, mathematician Leonid Plyushch[8] and Vladimir Bukovsky, whom Snezhnevsky diagnosed as schizophrenic on 5 July 1962).[21]:70

According to Moscow psychiatrist Alexander Danilin, the nosological approach in the Moscow psychiatric school established by Andrei Snezhnevsky (whom Danilin considered a political offender) boiled down to the ability to diagnose schizophrenia; psychiatry was not science, but a system of opinions by which millions of lives were affected by a diagnosis of “sluggish schizophrenia”.[22]

St Petersburg professor of psychiatry Yuri Nuller notes that Snezhnevsky’s concept allowed schizoid personality disorder as the early stages of an inevitable process, rather than the personality characteristics of an individual which may not develop into schizophrenia.[23][24] This resulted in an expansion of the diagnosis of sluggish schizophrenia, with subsequent harm.[23][24] Nuller adds that within the scope of sluggish schizophrenia, any deviation from the norm (evaluated by a doctor) can be regarded as schizophrenia.[23][24] This created the opportunity for the voluntary (and involuntary) abuse of psychiatry.[23][24] However, according to Nuller neither Snezhnevsky nor his followers reviewed their theories.[23][24]

According to Ukrainian psychiatrist Semyon Gluzman, there is not just the diagnosis of “sluggish schizophrenia” in Ukraine, Ukrainians are fully adapted to the international classification of mental disorders, but in Russia, as far as he knows, this diagnosis still exists.[25]

According to the warning made in 2010 by the president of the Independent Psychiatric Association of Russia Yuri Savenko, prof. Anatoly Smulevich, author of the monographs Problema Paranoyi (The Problem of Paranoia) (1972) and Maloprogredientnaya Shizofreniya (Continuous Sluggish Schizophrenia) (1987), which had contributed to the hyperdiagnosis of “sluggish schizophrenia”, again began to play the same role he played before. Recently, under his influence therapists began to widely use antidepressants and antipsychotics but often in inadequate cases and in inappropriate doses, without consulting psychiatrists. This situation has opened up a huge new market for pharmaceutical firms, with their unlimited capabilities, and the flow of the mentally ill to internists.[26]

In their joint book Sociodinamicheskaya Psikhiatriya (Sociodynamic Psychiatry), Doctor of Medical Sciences professor of psychiatry Caesar Korolenko and Doctor of Psychological Sciences Nina Dmitrieva note that Smulevich’s clinical description of sluggish schizophrenia is extremely elusive and includes almost all possible changes in mental status and partly conditions that occur in person without psychopathology: euphoria, hyperactivity, unfounded optimism, irritability, explosiveness, sensitivity, inadequacy and emotional deficit, hysterical reactions with conversive and dissociative symptoms, infantilism, obsessive-phobic states, stubbornness.[27]:18 At present, the hyperdiagnosis of schizophrenia becomes especially negative due to a large number of schizophreniform psychoses caused by the increasing popularity of various esoteric sects. They practice meditation, sensory deprivation, special exercises with rhythmic movements which directly stimulate the deep subconscious and, by doing so, lead to the development of psychoses with mainly reversible course.”
“Because of this form of schizophrenia, Russia in the 1980s had three times as many schizophrenic patients per capita as the USA, two times as many schizophrenic patients as West Germany, Austria and Japan. There were not as many schizophrenic patients in any other country (of Western ones)”

“As per your exposure to foreigners we have detected a clear case of sluggishly progressing schizophrenia.”


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