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what Richard Noll described as psychiatrists’ increasing realization that “pouring muddy water from one jug into another” would not make it clearer. An alternative and, in their eyes, better “solution” would be “to break the jugs” instead.³⁵

      Another example of a dimensional system of evaluation is the “Hierarchical Taxonomy of Psychopathology” (HiTOP).³⁶ The HiTOP was developed by a group of psychologists and psychiatrists from several research centers, with the explicit purpose of offering an alternative to the neurobiologically oriented RDoC. The HiTOP regards mental health as a spectrum. It places mental health problems on a continuum between pathology and normality, in much the same way that we measure body weight or blood pressure. Just as human weight is measured on a numerical scale (from 1 to 250 kg) and blood pressure on a different scale (from, say, 40/70 to 100/190), according to the HiTOP, we can also find a spectrum ranging from normal to abnormal when it comes to memory, perception, attention, social communication, and the ability to regulate fear, loss, or rewards.

The old classification system of the DSM used a top-down approach, defining mental disorders on the basis of their symptoms and presuming underlying natural causes with their corresponding effects. In contrast, these recent models begin by defining the normal distribution of a given trait or characteristic. Only then do they consider what might cause a gradual dysregulation or dysfunction in these systems that might result in symptoms in need of eventual diagnosis and treatment. Instead of looking for delusions, hallucinations, thought disorders, disorganized speech or behavior (or any other symptom that supposedly “make up” schizophrenia as a given entity), they search for domains that span this continuum ranging from the normal to the pathological. In these domains, we find a host of phenomena, mental states, and episodes, which include fear, frustration, learning, perception, memory, language, attachment, communication, understanding of self and others. The aim is thus to avoid setting arbitrary boundaries between health and pathology, normal and abnormal, which in current systems run the risk of being taken as natural kinds. These alternative diagnostic models begin by looking for the basic building blocks of the psychopathological structure, and then work their way upwards to its highest level of generality (HiTOP). In sum, they presuppose that psychopathology is dimensional in nature, while still allowing for categorical diagnoses where these are useful for pragmatic treatment purposes – and, more specifically, to help patients secure disability benefits.

      Suggestions for revising existing diagnostic practices have also been proposed by scholars outside of the mental health professions. For example, Nikolas Rose, a British sociologist, spent decades questioning the psychiatric enterprise and defending a move from “diagnosis” to “formulation.” According to Rose’s distinction, a complex story (one that includes the causes of the person’s distress and that follows how their experiences might have penetrated “under their skin”) would be just as appropriate in clinical practice as using a “name” to label a categorical diagnosis. Moreover, assessing the person’s capabilities and impairments would be much more useful when planning their needs for receiving mental health services. The move from labels like “schizophrenia” to a story told about the person’s overall situation and station in life, the biological, psychological, and social factors that have caused and shaped their ailment and suffering, and the identification of their required current care, would demand more listening on the part of everyone involved. Such listening, Rose argues “would be all to the good.”³⁷

      Other voices in this larger conversation want to bring the diagnosis of schizophrenia to an end for very different reasons. Some psychiatrists, psychologists, social activists, survivors, ex-patients, and others have argued that the label “schizophrenic” is stigmatizing, due to the connotations of hopelessness, chronicity, and even dangerousness, that it carries. In response to this and to patients’ suffering, they seek alternative, less discriminatory, and more appealing, diagnoses. “Extreme mental states,” “voice-hearing,” “non-ordinary states,” or “diverse identities” are but a few of these suggested alternative designations.

Madness from Antiquity to the Present Day

This book proposes to tell the story of the possible end of schizophrenia as a diagnosis by shedding light on the early history and recent usage of this controversial term. While other medical or psychiatric terms that define abnormal mental states and behaviors – such as melancholia, mania, or “insanity” – date back to antiquity, schizophrenia is a relatively new technical term. That said, the perennial difficulty in characterizing abnormal mentalities and behaviors (either as discrete forms of human existence, or as part of a continuum between the normal and abnormal) goes all the way back to the Hebrew Bible and the New Testament, as the first chapter of this book explains.

      As Hacking observed, the idea that it is impossible to retroactively diagnose individuals is a product of the “academically correct official history-of-medicine or philosophy-of-science teaching.”³⁸ Nevertheless, if we set aside academic propriety and the potential self-righteousness it implies, we can follow Hacking and still carefully draw inferences from the way past cases were viewed by contemporary experts. The first chapter in this book thus uses foundational texts in Western culture, ranging from the Bible all the way up to Eugen Bleuler, to reconstruct the origins of the dispute on the relations between the normal and the abnormal (distinctness vs. continuity) when diagnosing individuals who suffer from a severe break in their perception of reality and withdraw from engagement with their social groups.

      In Chapter 2, “The Birth of ‘the Schizophrenias,’” we introduce the two major modern authorities on schizophrenia of the late nineteenth and early twentieth centuries, Emil Kraepelin and Eugen Bleuler. In their paradigmatic texts – Kraepelin’s Psychiatry: A Textbook for Students and Physicians (1896) and Bleuler’s Dementia Praecox or the Group of Schizophrenias (1911) – we will locate the crucial terminological change that appeared in the emergence of modern psychiatry’s dispute over the nature of mental disorders, when the older category of dementia praecox was replaced with the new term, schizophrenia. As we will see, Kraepelin’s and Bleuler’s works can be considered as condensed forms of the two competing – categorical vs. dimensional – paradigms, which remain at the very heart of current debates on schizophrenia.

Chapter 3 then discusses these paradigms in the work of Sigmund Freud, the founding father of psychoanalysis. In his early works, Freud proposes that schizophrenic behavior lies on a continuum, running from neurosis to psychosis. In his later writing, however, Freud argues that schizophrenic behavior is different in kind from more typical behavior, even though he concedes it occurs concurrently with behaviors that are viewed as normal. As we will see, Freud’s legacy of oscillating between these two structurally distinct paradigms continues to shape the discourse of psychoanalysis on schizophrenia and psychosis to this day.

      Chapter 4, “A Moving Target,” examines how the diagnosis of schizophrenia has changed over time. Tracing the definition of schizophrenia in the DSM from 1952 to 2013, this chapter analyzes the critiques and commentaries that professional task forces, activists, journalists, patients, and families have extended to every definition of schizophrenia proposed in the manual’s seven different editions. It concludes with the DSM-5’s declaration that it will systematically consider ethical questions and pragmatic matters in its efforts to revise the classification of psychiatric disorders.

      In light of these ethical considerations, Chapter 5, “Hearing Voices,” then discusses a relatively new form of protest against the diagnosis of schizophrenia. It discusses the example of the Hearing Voices Movement (HVM), which challenges the pathologization of voice-hearing and its systematic association with the diagnosis of schizophrenia. Indeed, while hearing voices was historically considered as one of the central symptoms of schizophrenia, the Hearing Voices Movement depicts it as a natural part of human experience, one that should

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