Sluggishly progressing schizophrenia or sluggish schizophrenia (Russian: вялотекущая шизофрения; vyalotekushchaya shizofreniya) was a category of schizophrenia diagnosed by psychiatrists in the Soviet Union. At the time, Western psychiatry recognized only four types of schizophrenia: catatonic, hebephrenic, paranoid, and simple.
The diagnostic criteria for this fifth category were so vague that it could be applied to virtually any person not suffering from mental function impairment and having interests beyond survival needs. The diagnosis was sometimes applied to dissidents who were not in fact mentally ill, so that they could be forcibly hospitalized in mental institutions and subjected to treatments including powerful antipsychotics and electroconvulsive therapy.
Sluggish schizophrenia is not included in the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10)[1] but its Russian version is adapted by adding sluggish schizophrenia to schizotypal disorder in F21 of chapter V.[2]
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Psychiatric diagnoses such as the diagnosis of ‘sluggish schizophrenia’ in political dissidents in the USSR were used for political purposes.[3]:77 It was the diagnosis of ‘sluggish schizophrenia’ that was most prominently used in cases of dissidents.[4] The leading critics implied that Snezhnevsky had designed the Soviet model of schizophrenia and this diagnosis to make political dissent into a mental disease.[5]
According Robert van Voren, the political abuse of psychiatry in the USSR arose from the conception that people who opposed the Soviet regime were mentally sick since there was no other logical rationale why one would oppose the sociopolitical system considered the best in the world.[6] The diagnosis ‘sluggish schizophrenia,’ a longstanding concept further developed by the Moscow School of Psychiatry and particularly by its chief Andrei Snezhnevsky, furnished a very handy framework for explaining this behavior.[6]
Although majority of experts agree that the basic group of psychiatrists that developed this concept did so on the instructions of the Soviet secret service KGB and the party and understood very well what they were doing, this seemed to many Soviet psychiatrists to be a very logical explanation as they were not able to explain to themselves otherwise why someone would be willing to abandon his happiness, family, and career for a conviction or idea which was so different from what most individuals believed or made themselves believe.[6]
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.[7]
The Soviet model of schizophrenia is based on the hypothesis that a single fundamental characteristic, by which schizophrenia spectrum disorders are distinguished clinically, is their longitudinal course.[8]:543 The hypothesis implies that there are three main types of schizophrenia:
This systematization of schizophrenia types attributed to Snezhnevsky[9]:278 is still used in Russia[10]:371 and refers sluggish schizophrenia to the continuous type.[11]: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.[7] Symptoms referred to as 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 scanty symptoms.’[7]
According to Snezhnevsky, patients with sluggish schizophrenia could present as quasi sane yet manifest minimal but clinically relevant personality changes which could remain unnoticed to the untrained eye.[7] Thereby patients with non-psychotic mental disorders, or even persons who were not mentally sick, could be easily labelled with the diagnosis of sluggish schizophrenia.[7] Along with paranoia, sluggish schizophrenia was the diagnosis most frequently used for the psychiatric incarceration of dissenters.[7]
As per the theories of Snezhnevsky and his colleagues, schizophrenia was much more prevalent than previously considered since the illness could be presented with comparatively slight symptoms and only progress afterwards.[6] As a consequence, schizophrenia was diagnosed much more often in Moscow than in other countries, as the World Health Organization Pilot Study on Schizophrenia reported in 1973.[6]
In particular, the scope was widened by sluggish schizophrenia because according to Snezhnevsky and his colleagues, patients with this diagnosis were capable of functioning almost normally in the social sense.[6] Their symptoms could be like those of a neurosis or could assume a paranoid character.[6] The patients with paranoid symptoms retained some insight into their condition but overestimated their own significance and could manifest grandiose ideas of reforming society.[6] Thereby, sluggish schizophrenia could have such symptoms as ‘reform delusions,’ ‘perseverance,’ and ‘struggle for the truth.’[6]
As V.D. Stayzhkin reported, Snezhnevsky diagnosticated a reformation delusion for every case when a patient ‘developes a new principle of human knowledge, drafts an academy of human happiness, and many other projects for the benefit of mankind.’[12]:66
In the 1960s and 1970s, theories, which contained ideas about reforming society and struggling for truth, and religious convictions were not referred to delusional paranoid disorders in practically all foreign classifications, but Soviet psychiatry, proceeding from ideological conceptions, referred critique of political system and proposals to reform this system to delusional construct.[13]:19 Diagnostic approaches of conception of sluggish schizophrenia and paranoiac states with delusion of reformism were used only in the Soviet Union and several Eastern European countries.[13]:18
Someone of those present at a lecture by Georgi Morozov on forensic psychiatry in the Serbsky Institute once asked him a rather provocative question: “Tell us, Georgi Vasilevich, what is actually the diagnosis of sluggish schizophrenia?”[14] Since the question was asked with ironical smile, in the debate, Morozov replied, smiling ironically as well, “You know, dear colleagues, this is a very peculiar disease: there are not delusional disorders, there are not hallucinations, but there is schizophrenia!”[14]
American psychiatrist Alan A. Stone stated that Western criticism of Soviet psychiatry aimed at Sneznevsky personally, because he was essentially responsible for the Soviet concept of schizophrenia with a ‘sluggish type’ manifestation by ‘reformerism’ including other symptoms.[15]:8 One can readily apply this diagnostic scheme to dissenters.[15]:8
Snezhnevsky was long attacked in the West as an exemplar of psychiatric abuse in the USSR.[4] He was charged with cynically developing a system of diagnosis which could be bent for political purposes, and he himself diagnosed or was involved in a series of famous dissident cases, including those of the biologist Zhores Medvedev, the mathematician Leonid Plyushch,[4] and Vladimir Bukovsky whom Snezhnevsky diagnosed as schizophrenic on 5 July 1962.[16]:70
According to Moscow psychiatrist Alexander Danilin, the so-called ‘nosological’ approach in the Moscow psychiatric school established by A.V. Snezhnevsky boiles down to the ability to make an only diagnosis, schizophrenia; psychiatry is not science but such a system of opinions and people by the thousands are falling victims to these opinions—millions of lives were crippled by virtue of the concept ‘sluggish schizophrenia’ introduced some time once by Andrei Vladimirovich Snezhnevsky, academician, whom Danilin called a political offender.[17]
St Petersburg academic psychiatrist professor Yuri Nuller notes that the concept of Snezhnevsky’s school allows, for example, to consider schizoid psychopathy or schizoidism as the early, sluggishly progressing stages of an inevitable progredient process rather than the personality characteristics of an individual, which may not develop along the path of schizophrenic process at all.[18][19] That results in the extreme expansion of diagnosing sluggish schizophrenia and the harm it has done.[18][19] Nuller adds that within the scope of the sluggish schizophrenia concept, any deviation from the norm evaluated by a doctor can be regarded as schizophrenia, with all the ensuing consequences for an examinee.[18][19] That creates ample opportunity for voluntary and involuntary abuses of psychiatry.[18][19] However, neither A.V. Snezhnevsky nor his followers, according to Nuller, found civil and scientific courage to review their concept that clearly reached a deadlock.[18][19]