Class, Family, and Schizophrenia: A Reformulation

The proposed formulation attempts to bring genetics, stress, and the conditions of life attendant on social-class position into one coherent interpretation of schizophrenia. The thrust of the argument is that the conditions of life experienced by people of lower social-class position tend to impair their ability to deal resourcefully with the problematic and the stressful. Such impairment would probably result in schizophrenia only for people who are both genetically vulnerable and exposed to considerable stressbut these conditions, too, may impinge with special severity on people in the lowest social classes. A multitude of studies carried out in several countries consistently suggests that schizophrenia1 occurs most frequently at the lowest socialclass levels of urban society. Reviews and assessments of this research literature by the Dohrenwends (1969), Kohn (1968), Mishler and Scotch (1963), and Roman and Trice (1967), all come to the same conclusion: despite serious shortcomings in the research, the weight of evidence clearly points to an especially high rate of schizophrenia at the bottom of the social-class hierarchy.2 What is not clear is why class is related to schizophrenia. Discussions of the class-schizophrenia relationship have generally focused on interpretations that, in effect, explain away its theoretical significance. Some argue that the statistical relationship between social class and rates of schizophrenia is only artifactual, the result of methodological error.3 Others accept the statistical relationship as real, but assert that schizophrenics are found disproportionately in lower social classes (or in declining occupations or in central city areas) because of the impairment they have suffered or because of some charac* Revised version of a paper presented at the Seventh World Congress of Sociology, Varna, Bulgaria, September 1970. 1 The classic definition of schizophrenia (Bleuler, 1950:14) considers it to be a group of disorders whose "fundamental symptoms consist of disturbances of association and affectivity, the predilection for fantasy as against reality, and the inclination to divorce oneself from reality." In common with most American investigators, I use the term broadly, to refer to those severe functional disorders marked by disturbances in reality relationships and concept formation (cf. Rosenbaum, 1970: 3-16). Unfortunately, available research evidence does not enable me to differentiate clinical subtypes of schizophrenia or to make such important distinctions as that between "process" and "reactive" forms of disturbance (cf. Garmezy, 1965). 2 The cited works provide references to virtually all studies of class and schizophrenia published through 1968. The evidence comes from research conducted in Canada, Denmark, Finland, Great Britain, Norway, Sweden, Taiwan, and the United States-an unusually large number of countries and cultures for establishing the generality of any relationship in social science. Moreover, the exceptions are few and partial: they occur in small cities and rural areas or in special subpopulations of larger cities; none contradicts the larger generalization of an especially high rate of schizophrenia at the lowest social-class levels of urban populations. Judging from data about patients newly admitted to psychiatric treatment (e.g., Hollingshead and Redlich, 1958:236), the incidence of schizophrenia is approximately three or four times as great at the bottom of the class hierarchy as at the top. One unresolved issue is whether the relationship of class to schizophrenia is linear or is discontinuous, with an especially high rate in the lowest social class but little variation above that level (cf. Kohn, 1968:157; Rushing, 1969). I have attempted to make my formulation consistent with either possibility. 3 The principal issues are the adequacy of indices, the completeness of the search procedures used, and the relative merits and defects of incidence and prevalence as statistical measures. I (1968) have discussed these issues in an earlier paper.