Everything about Schizophrenic totally explained
Schizophrenia (pronounced /ˌskɪtsəˈfriːniə/), from the
Greek roots schizein (σχίζειν, "to split") and
phrēn,
phren- (φρήν, φρεν-, "
mind"), is a
psychiatric diagnosis that describes a mental illness characterized by impairments in the
perception or expression of
reality, most commonly manifesting as auditory
hallucinations, paranoid or bizarre
delusions or
disorganized speech and thinking in the context of significant social or occupational dysfunction. Onset of symptoms typically occurs in young adulthood, with approximately 0.4–0.6% of the population affected. Diagnosis is based on the patient's self-reported experiences and observed behavior. No laboratory test for schizophrenia currently exists.
The disorder is primarily thought to affect
cognition, but it also usually contributes to chronic problems with
behavior and
emotion. People diagnosed with schizophrenia are likely to be diagnosed with
comorbid conditions, including
clinical depression and
anxiety disorders; the lifetime
prevalence of
substance abuse is typically around 40%. Social problems, such as long-term unemployment, poverty and homelessness, are common and
life expectancy is decreased; the average life expectancy of people with the disorder is 10 to 12 years less than those without, owing to increased physical health problems and a high
suicide rate.
Signs and symptoms
A person experiencing schizophrenia may demonstrate symptoms such as
disorganized thinking, auditory
hallucinations, and
delusions. In severe cases, the person may be largely mute, remain motionless in bizarre postures, or exhibit purposeless agitation; these are
signs of
catatonia. The current classification of psychoses holds that symptoms need to have been present for at least one month in a period of at least six months of disturbed functioning. A schizophrenia-like psychosis of shorter duration is termed a
schizophreniform disorder. No one sign is diagnostic of schizophrenia, and all can occur in other medical and psychiatric conditions.
Late adolescence and early adulthood are peak years for the onset of schizophrenia. These are critical periods in a young adult's social and vocational development, and they can be severely disrupted by disease onset. To minimize the effect of schizophrenia, much work has recently been done to identify and treat the
prodromal (pre-onset) phase of the illness, which has been detected up to 30 months before the onset of symptoms, but may be present longer. Those who go on to develop schizophrenia may experience the non-specific symptoms of social withdrawal, irritability and
dysphoria in the prodromal period, and transient or self-limiting psychotic symptoms in the prodromal phase before psychosis becomes apparent.
Schneiderian classification
The psychiatrist
Kurt Schneider (1887–1967) listed the forms of psychotic symptoms that he thought distinguished schizophrenia from other psychotic disorders. These are called
first-rank symptoms or
Schneider's first-rank symptoms, and they include delusions of being controlled by an external force; the belief that thoughts are being inserted into or withdrawn from one's conscious mind; the belief that one's thoughts are being broadcast to other people; and hearing hallucinatory voices that comment on one's thoughts or actions or that have a conversation with other hallucinated voices. The reliability of first-rank symptoms has been questioned, although they've contributed to the current diagnostic criteria.
Positive and negative symptoms
Schizophrenia is often described in terms of
positive (or productive) and
negative (or deficit) symptoms. Positive symptoms include
delusions,
auditory hallucinations, and
thought disorder, and are typically regarded as manifestations of
psychosis. Negative symptoms are so-named because they're considered to be the loss or absence of normal traits or abilities, and include features such as flat or
blunted affect and
emotion, poverty of
speech (
alogia),
anhedonia, and lack of
motivation (
avolition). Despite the appearance of blunted affect, recent studies indicate that there's often a normal or even heightened level of emotionality in schizophrenia, especially in response to stressful or negative events. A third symptom grouping, the
disorganization syndrome, is commonly described, and includes chaotic speech, thought, and behaviour. There is evidence for a number of other symptom classifications.
Diagnosis
Diagnosis is based on the self-reported experiences of the person as well as abnormalities in behavior reported by family members, friends or co-workers, followed by secondary signs observed by a
psychiatrist,
social worker,
clinical psychologist or other clinician in a clinical assessment. There is a list of criteria that must be met for someone to be so diagnosed. These depend on both the presence and duration of certain signs and symptoms.
borderline personality disorder, drug intoxication, brief drug-induced psychosis, and
schizophreniform disorder.
Investigations are not generally repeated for relapse unless there's a specific
medical indication. These may include serum
blood sugar level (BSL) if
olanzapine has been prescribed previously,
liver function tests if
chlorpromazine, or
creatine phosphokinase (CPK) to exclude
neuroleptic malignant syndrome. Assessment and treatment are usually done on an outpatient basis; admission to an inpatient facility is considered if there's a risk to self or others.
The most widely used criteria for diagnosing schizophrenia are from the
American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, the current version being DSM-IV-TR, and the
World Health Organization's International Statistical Classification of Diseases and Related Health Problems, currently the ICD-10. The latter criteria are typically used in European countries while the DSM criteria are used in the USA or the rest of the world, as well as prevailing in research studies. The ICD-10 criteria put more emphasis on Schneiderian
first rank symptoms although, in practice, agreement between the two systems is high. The
WHO has developed the tool
SCAN (Schedules for Clinical Assessment in Neuropsychiatry) which can be used for diagnosing a number of psychiatric conditions, including schizophrenia.
DSM IV-TR Criteria
To be diagnosed with schizophrenia, a person must display: part of a larger
criticism of the validity of psychiatric diagnoses in general. One alternative suggests that the issues with the diagnosis would be better addressed as individual dimensions along which everyone varies, such that there's a spectrum or continuum rather than a cut-off between normal and ill. This approach appears consistent with research on
schizotypy and of a relatively high prevalence of psychotic experiences and often non-distressing delusional beliefs amongst the general public. this is particularly relevant to the evaluation of
delusions and
thought disorder. More recently, it has been argued that psychotic symptoms are not a good basis for making a diagnosis of schizophrenia as "psychosis is the 'fever' of mental illness — a serious but nonspecific indicator".
Perhaps because of these factors, studies examining the
diagnosis of schizophrenia have typically shown relatively low or inconsistent levels of diagnostic reliability. Most famously,
David Rosenhan's 1972 study, published as
On being sane in insane places, demonstrated that the diagnosis of schizophrenia was (at least at the time) often subjective and unreliable. More recent studies have found agreement between any two psychiatrists when diagnosing schizophrenia tends to reach about 65% at best. This, and the results of earlier studies of diagnostic reliability (which typically reported even lower levels of agreement) have led some critics to argue that the diagnosis of schizophrenia should be abandoned.
In 2004 in Japan, the Japanese term for schizophrenia was changed from
Seishin-Bunretsu-Byo (mind-split-disease) to
Tōgō-shitchō-shō (
integration disorder). In 2006, campaigners in the UK, under the banner of Campaign for Abolition of the Schizophrenia Label, argued for a similar rejection of the diagnosis of schizophrenia and a different approach to the treatment and understanding of the symptoms currently associated with it.
Alternatively, other proponents have put forward using the presence of specific
neurocognitive deficits to make a diagnosis. These take the form of a reduction or impairment in basic psychological functions such as
memory,
attention,
executive function and
problem solving. It is these sorts of difficulties, rather than the psychotic symptoms (which can in many cases be controlled by
antipsychotic medication), which seem to be the cause of most
disability in schizophrenia. However, this argument is relatively new and it's unlikely that the method of diagnosing schizophrenia will change radically in the near future.
The diagnosis of schizophrenia has been used for political rather than therapeutic purposes; in the
Soviet Union an additional sub-classification of
sluggishly progressing schizophrenia was created. Particularly in the
RSFSR (Russian Soviet Federated Socialist Republic), this diagnosis was used for the purpose of silencing political dissidents or forcing them to recant their ideas by the use of forcible confinement and treatment. In 2000 there were similar concerns regarding
detention and 'treatment' of practitioners of the
Falun Gong movement by the Chinese government. This led the
American Psychiatric Association's Committee on the Abuse of Psychiatry and Psychiatrists to pass a resolution to urge the
World Psychiatric Association to investigate the situation in
China.
Epidemiology
Schizophrenia occurs equally in males and females although typically appears earlier in men with the peak ages of onset being 20–28 years for males and 26–32 years for females. and late- (middle age) or very-late-onset (old age) schizophrenia. The
lifetime prevalence of schizophrenia, that is, the proportion of individuals expected to experience the disease at any time in their lives, is commonly given at 1%. A 2002
systematic review of many studies, however, found a lifetime prevalence of 0.55%. within countries, and at the local and neighbourhood level. One particularly stable and replicable finding has been the association between living in an
urban environment and schizophrenia diagnosis, even after factors such as
drug use,
ethnic group and size of
social group have been controlled for. Schizophrenia is known to be a major cause of
disability. In a 1999 study of 14 countries, active
psychosis was ranked the third-most-disabling condition, after
quadriplegia and
dementia and before
paraplegia and
blindness.
Causes
While the reliability of the diagnosis introduces difficulties in measuring the relative effect of genes and environment (for example, symptoms overlap to some extent with severe
bipolar disorder or
major depression), evidence suggests that genetic and
environmental factors can act in combination to result in schizophrenia. Evidence suggests that the diagnosis of schizophrenia has a significant heritable component but that onset is significantly influenced by environmental factors or stressors. The idea of an inherent vulnerability (or
diathesis) in some people, which can be unmasked by biological, psychological or environmental stressors, is known as the stress-diathesis model. The idea that biological, psychological and social factors are all important is known as the "biopsychosocial" model.
Genetic
Estimates of the
heritability of schizophrenia tend to vary owing to the difficulty of separating the effects of genetics and the environment although
twin studies have suggested a high level of heritability. It is likely that schizophrenia is a condition of complex inheritance, with several
genes possibly interacting to generate risk for schizophrenia or the separate components that can co-occur leading to a diagnosis. Genetic studies have suggested that genes that raise the risk for developing schizophrenia are non-specific, and may also raise the risk of developing other psychotic disorders such as
bipolar disorder. Recent research has suggested that rare deletions or duplications of tiny DNA sequences within genes (known as
copy number variants) are also linked to increased risk for schizophrenia.
Prenatal
It is thought that causal factors can initially come together in early
neurodevelopment, including during pregnancy, to increase the risk of later developing schizophrenia. One curious finding is that people diagnosed with schizophrenia are more likely to have been born in winter or spring, (at least in the
northern hemisphere). There is now evidence that
prenatal exposure to infections increases the risk for developing schizophrenia later in life, providing additional evidence for a link between in utero developmental pathology and risk of developing the condition.
Social
Living in an
urban environment has been consistently found to be a risk factor for schizophrenia. and migration related to social adversity, racial discrimination, family dysfunction, unemployment or poor housing conditions. Childhood experiences of abuse or trauma have also been implicated as risk factors for a diagnosis of schizophrenia later in life. Parenting isn't held responsible for schizophrenia but unsupportive dysfunctional relationships may contribute to an increased risk.
Substance use
The relationship between schizophrenia and drug use is complex, meaning that a clear causal connection between drug use and schizophrenia has been difficult to distinguish. There is strong evidence that using certain drugs can trigger either the onset or relapse of schizophrenia in some people. It may also be the case, however, that people with schizophrenia use drugs to overcome negative feelings associated with both the commonly prescribed antipsychotic medication and the condition itself, where negative emotion,
paranoia and
anhedonia are all considered to be core features.
Amphetamines trigger the release of dopamine and excessive dopamine function is believed to be at least partly responsible for the psychotic symptoms of schizophrenia (a theory known as the
dopamine hypothesis of schizophrenia). This is, in part, supported by the fact that amphetamines reliably worsen the symptoms of schizophrenia. Schizophrenia can be triggered by heavy use of
hallucinogenic or stimulant drugs. One study suggests that
cannabis use can contribute to psychosis, though the researchers suspected cannabis use was only a small component in a broad range of factors.
Psychological
A number of psychological mechanisms have been implicated in the development and maintenance of schizophrenia.
Cognitive biases that have been identified in those with a diagnosis or those at risk, especially when under stress or in confusing situations, include excessive attention to potential threats, jumping to conclusions, making external
attributions, impaired reasoning about social situations and
mental states, difficulty distinguishing inner speech from speech from an external source, and difficulties with early visual processing and maintaining concentration. Some cognitive features may reflect global
neurocognitive deficits in
memory,
attention,
problem-solving,
executive function or
social cognition, while others may be related to particular issues and experiences. Despite a common appearance of "blunted affect", recent findings indicate that many individuals diagnosed with schizophrenia are highly emotionally responsive, particularly to stressful or negative stimuli, and that such sensitivity may cause vulnerability to symptoms or to the disorder. Some evidence suggests that the content of delusional beliefs and psychotic experiences can reflect emotional causes of the disorder, and that how a person interprets such experiences can influence symptomology. Further evidence for the role of psychological mechanisms comes from the effects of therapies on symptoms of schizophrenia.
Neural
Studies using
neuropsychological tests and
brain imaging technologies such as
fMRI and
PET to examine functional differences in brain activity have shown that differences seem to most commonly occur in the
frontal lobes,
hippocampus, and
temporal lobes. These differences have been linked to the
neurocognitive deficits often associated with schizophrenia. The role of antipsychotic medication, which nearly all those studied had taken, in causing such abnormalities is also unclear.
Particular focus has been placed upon the function of dopamine in the
mesolimbic pathway of the brain. This focus largely resulted from the accidental finding that a drug group which blocks dopamine function, known as the
phenothiazines, could reduce psychotic symptoms. An influential theory, known as the
Dopamine hypothesis of schizophrenia, proposed that a malfunction involving dopamine pathways was the cause of (the positive symptoms of) schizophrenia. This theory is now thought to be overly simplistic as a complete explanation, partly because newer antipsychotic medication (called
atypical antipsychotic medication) can be equally effective as older medication (called
typical antipsychotic medication), but also affects
serotonin function and may have slightly less of a
dopamine blocking effect.
Interest has also focused on the neurotransmitter
glutamate and the reduced function of the
NMDA glutamate receptor in schizophrenia. This has largely been suggested by abnormally low levels of
glutamate receptors found in postmortem brains of people previously diagnosed with schizophrenia and the discovery that the glutamate blocking drugs such as
phencyclidine and
ketamine can mimic the symptoms and cognitive problems associated with the condition. The fact that reduced glutamate function is linked to poor performance on tests requiring
frontal lobe and
hippocampal function and that glutamate can affect
dopamine function, all of which have been implicated in schizophrenia, have suggested an important mediating (and possibly causal) role of glutamate pathways in schizophrenia. Further support of this theory has come from preliminary trials suggesting the efficacy of coagonists at the NMDA receptor complex in reducing some of the positive symptoms of schizophrenia.
There have also been findings of differences in the size and structure of certain brain areas in schizophrenia, starting with the discovery of
ventricular enlargement in those for whom negative symptoms were most prominent. However, this hasn't proven particularly reliable on the level of the individual person, with considerable variation between patients. More recent studies have shown various differences in brain structure between people with and without diagnoses of schizophrenia. While brain structure changes have been found in people diagnosed with schizophrenia who have never been treated with antipsychotic drugs there's evidence that the medication itself might cause additional changes in the brain's structure. However, as with earlier studies, many of these differences are only reliably detected when comparing groups of people, and are unlikely to predict any differences in brain structure of an individual person with schizophrenia.
Treatment and services
The concept of a cure as such remains controversial, as there's no consensus on the definition, although some criteria for the remission of symptoms have recently been suggested. The effectiveness of schizophrenia treatment is often assessed using standardized methods, one of the most common being the
Positive and Negative Syndrome Scale (PANSS).
Management of symptoms and improving function is thought to be more achievable than a cure. Treatment was revolutionized in the mid 1950s with the development and introduction of
chlorpromazine. A
recovery model is increasingly adopted, emphasizing hope, empowerment and social inclusion.
Hospitalization may occur with severe episodes of schizophrenia. This can be voluntary or (if mental health legislation allows it) involuntary (called civil or
involuntary commitment). Long-term inpatient stays are now less common due to
deinstitutionalization, although can still occur. and patient-led support groups.
In many non-Western societies, schizophrenia may only be treated with more informal, community-led methods. The outcome for people diagnosed with schizophrenia in non-Western countries may actually be better than for people in the West. The reasons for this effect are not clear, although
cross-cultural studies are being conducted.
Medication
The mainstay of psychiatric treatment for schizophrenia is an
antipsychotic medication. These can reduce the "positive" symptoms of psychosis. Most antipsychotics take around 7–14 days to have their main effect.
Though expensive, the newer
atypical antipsychotic drugs are usually preferred for
initial treatment over the older
typical antipsychotics; they're often better tolerated and associated with lower rates of
tardive dyskinesia, although they're more likely to induce weight gain and
obesity-related diseases. Prolactin elevations have been reported in women with schizophrenia taking atypical antipsychotics.It remains unclear whether the newer antipsychotics reduce the chances of developing
neuroleptic malignant syndrome, a rare but serious and potentially fatal neurological disorder most often caused by an adverse reaction to
neuroleptic or antipsychotic drugs.
The two classes of antipsychotics are generally thought equally effective for the treatment of the positive symptoms. Some researchers have suggested that the atypicals offer additional benefit for the negative symptoms and cognitive deficits associated with schizophrenia, although the clinical significance of these effects has yet to be established. Recent reviews have refuted the claim that atypical antipsychotics have fewer extrapyramidal side effects than typical antipsychotics, especially when the latter are used in low doses or when low potency antipsychotics are chosen.
Response of symptoms to medication is variable; "Treatment-resistant schizophrenia" is a term used for the failure of symptoms to respond satisfactorily to at least two different antipsychotics. Patients in this category may be prescribed
clozapine, a medication of superior effectiveness but several potentially lethal side effects including
agranulocytosis and
myocarditis. Clozapine may have the additional benefit of reducing propensity for substance abuse in schizophrenic patients. For other patients who are unwilling or unable to take medication regularly, long-acting
depot preparations of antipsychotics may be given every two weeks to achieve control. The United States of America and Australia are two countries with
laws allowing the forced administration of this type of medication on those who refuse but are otherwise stable and living in the community. Some findings have found that in the longer-term some individuals may do better not taking antipsychotics. Despite the promising results of early pilot trials,
omega-3 fatty acids failed to improve schizophrenic symptoms, according to the most recent
meta-analysis.
Psychological and social interventions
Psychotherapy is also widely recommended and used in the treatment of schizophrenia, although services may often be confined to pharmacotherapy because of reimbursement problems or lack of training.
Cognitive behavioral therapy (CBT) is used to reduce symptoms and improve related issues such as
self-esteem, social functioning, and insight. Although the results of early trials were inconclusive, more recent reviews suggest that CBT can be an effective treatment for the psychotic symptoms of schizophrenia. Another approach is cognitive remediation therapy, a technique aimed at remediating the
neurocognitive deficits sometimes present in schizophrenia. Based on techniques of
neuropsychological rehabilitation, early evidence has shown it to be cognitively effective, with some improvements related to measurable changes in brain activation as measured by
fMRI. A similar approach known as cognitive enhancement therapy, which focuses on social cognition as well as neurocognition, has shown efficacy.
Family Therapy or Education, which addresses the whole family system of an individual with a diagnosis of schizophrenia, has been consistently found to be beneficial, at least if the duration of intervention is longer-term. Aside from therapy, the impact of schizophrenia on families and the burden on carers has been recognized, with the increasing availability of self-help books on the subject. There is also some evidence for benefits from social skills training, although there have also been significant negative findings. Some studies have explored the possible benefits of music therapy and other creative therapies.
The
Soteria model is alternative to inpatient hospital treatment using a minimal medication approach. It is described as a
milieu-therapeutic
recovery method, characterized by its founder as "the 24 hour a day application of interpersonal phenomenologic interventions by a nonprofessional staff, usually without neuroleptic drug treatment, in the context of a small, homelike, quiet, supportive, protective, and tolerant social environment." Although research evidence is limited, a 2008 systematic review found the programme equally as efffective as treatment with medication in people diagnosed with first and second episode schizophrenia.
Other
Electroconvulsive therapy isn't considered a
first line treatment but may be prescribed in cases where other treatments have failed. It is more effective where symptoms of catatonia are present, and is recommended for use under
NICE guidelines in the UK for catatonia if previously effective, though there's no recommendation for use for schizophrenia otherwise.
Psychosurgery has now become a rare procedure and isn't a recommended treatment for schizophrenia.
Service-user led movements have become integral to the recovery process in
Europe and
America; groups such as the
Hearing Voices Network and the
Paranoia Network have developed a self-help approach that aims to provide support and assistance outside the traditional medical model adopted by mainstream psychiatry. By avoiding framing personal experience in terms of criteria for
mental illness or
mental health, they aim to destigmatize the experience and encourage individual responsibility and a positive self-image. Partnerships between hospitals and consumer-run groups are becoming more common, with services working toward remediating social withdrawal, building social skills and reducing rehospitalization.
Prognosis
Numerous international studies have demonstrated favorable long-term outcomes for around half of those diagnosed with schizophrenia, with substantial variation between individuals and regions. One retrospective study found that about a third of people made a full recovery, about a third showed improvement but not a full recovery, and a third remained ill. A clinical study using strict recovery criteria (concurrent remission of positive and negative symptoms and adequate social and vocational functioning continuously for two years) found a recovery rate of 14% within the first five years. A 5-year community study found that 62% showed overall improvement on a composite measure of symptomatic, clinical and functional outcomes. Rates are not always comparable across studies because an exact definition of what constitutes recovery hasn't been widely accepted, although standardized criteria have been suggested. despite the fact antipsychotic drugs are typically not widely available in poorer countries, raising questions about the effectiveness of such drug-based treatments.
Several factors are associated with a better prognosis: Being female, acute (vs. insidious) onset of symptoms, older age of first episode, predominantly positive (rather than negative) symptoms, presence of mood symptoms and good premorbid functioning. Most studies done on this subject, however, are correlational in nature, and a clear cause-and-effect relationship is difficult to establish. Evidence is also consistent that negative attitudes towards individuals with schizophrenia can have a significant adverse impact. In particular, critical comments, hostility, authoritarian and intrusive or controlling attitudes (termed high '
Expressed emotion' or 'EE' by researchers) from family members have been found to correlate with a higher risk of relapse in schizophrenia across cultures.
Mortality
In a study of over 168,000 Swedish citizens undergoing psychiatric treatment, schizophrenia was associated with an average life expectancy of approximately 80–85% of that of the general population. Women with a diagnosis of schizophrenia were found to have a slightly better life expectancy than that of men, and as a whole, a diagnosis of schizophrenia was associated with a better life expectancy than
substance abuse,
personality disorder,
heart attack and
stroke. There is a high
suicide rate associated with schizophrenia; a recent study showed that 30% of patients diagnosed with this condition had attempted suicide at least once during their lifetime. Another study suggested that 10% of persons with schizophrenia die by suicide. Other identified factors include smoking, poor diet, little exercise and the negative health effects of psychiatric drugs. Studies have indicated that 5% to 10% of those charged with murder in Western countries have a schizophrenia spectrum disorder.
The occurrence of
psychosis in schizophrenia has sometimes been linked to a higher risk of violent acts. Findings on the specific role of delusions or hallucinations have been inconsistent, but have focused on delusional jealousy, perception of threat and command hallucinations. It has been proposed that a certain type of individual with schizophrenia may be most likely to offend, characterized by a history of educational difficulties, low IQ, conduct disorder, early-onset substance misuse and offending prior to diagnosis. Another consistent finding is a link to substance misuse, particularly alcohol, among the minority who commit violent acts. Violence by or against individuals with schizophrenia typically occurs in the context of complex social interactions within a family setting, and is also an issue in clinical services and in the wider community.
Screening and prevention
There are no reliable markers for the later development of schizophrenia although research is being conducted into how well a combination of genetic risk plus non-disabling psychosis-like experience predicts later diagnosis. People who fulfil the 'ultra high-risk mental state' criteria, that include a family history of schizophrenia plus the presence of transient or self-limiting psychotic experiences, have a 20–40% chance of being diagnosed with the condition after one year. The use of psychological treatments and medication has been found effective in reducing the chances of people who fulfill the 'high-risk' criteria from developing full-blown schizophrenia. However, the treatment of people who may never develop schizophrenia is controversial, in light of the side-effects of antipsychotic medication; particularly with respect to the potentially disfiguring
tardive dyskinesia and the rare but potentially lethal
neuroleptic malignant syndrome. The most widely used form of preventative health care for schizophrenia takes the form of public education campaigns that provide information on risk factors, early detection and treatment options.
Alternative approaches
An approach broadly known as the
anti-psychiatry movement, most active in the 1960s, opposes the orthodox medical view of schizophrenia as an illness. Psychiatrist
Thomas Szasz argued that psychiatric patients are not ill, but rather individuals with unconventional thoughts and behavior that make society uncomfortable. He argues that society unjustly seeks to control them by classifying their behavior as an illness and forcibly treating them as a method of
social control. According to this view, "schizophrenia" doesn't actually exist but is merely a form of
social construction, created by society's concept of what constitutes normality and abnormality. Szasz has never considered himself to be "anti-psychiatry" in the sense of being against psychiatric treatment, but simply believes that treatment should be conducted between consenting adults, rather than imposed upon anyone against his or her will. Similarly, psychiatrists
R. D. Laing,
Silvano Arieti,
Theodore Lidz and
Colin Ross have argued that the symptoms of what is called mental illness are comprehensible reactions to impossible demands that society and particularly family life places on some sensitive individuals. Laing, Arieti, Lidz and Ross were notable in valuing the
content of
psychotic experience as worthy of interpretation, rather than considering it simply as a secondary but essentially meaningless marker of underlying psychological or neurological distress. Laing described eleven case studies of people diagnosed with schizophrenia and argued that the content of their actions and statements was meaningful and logical in the context of their family and life situations. In 1956,
Palo Alto,
Gregory Bateson and his colleagues
Paul Watzlawick,
Donald Jackson, and
Jay Haley articulated a theory of schizophrenia, related to Laing's work, as stemming from
double bind situations where a person receives different or contradictory messages. Madness was therefore an expression of this distress and should be valued as a
cathartic and trans-formative experience. In the books
Schizophrenia and the Family and
The Origin and Treatment of Schizophrenic Disorders Lidz and his colleagues explain their belief that parental behaviour can result in mental illness in children. Arieti's
Interpretation of Schizophrenia won the 1975 scientific
National Book Award in the United States.
The concept of schizophrenia as a result of civilization has been developed further by psychologist
Julian Jaynes in his 1976 book
The Origin of Consciousness in the Breakdown of the Bicameral Mind; he proposed that until the beginning of historic times, schizophrenia or a similar condition was the normal state of human consciousness. This would take the form of a "
bicameral mind" where a normal state of low affect, suitable for routine activities, would be interrupted in moments of crisis by "mysterious voices" giving instructions, which early people characterized as interventions from the gods. Researchers into
shamanism have speculated that in some cultures schizophrenia or related conditions may predispose an individual to becoming a shaman; the experience of having access to multiple realities isn't uncommon in schizophrenia, and is a core experience in many shamanic traditions. Equally, the shaman may have the skill to bring on and direct some of the
altered states of consciousness psychiatrists label as illness.
Psychohistorians, on the other hand, accept the psychiatric diagnoses. However, unlike the current
medical model of mental disorders they argue that
poor parenting in tribal societies causes the shaman's schizoid personalities. Speculation regarding primary and important religious figures as having schizophrenia abound. Commentators such as
Paul Kurtz and others have endorsed the idea that major religious figures experienced psychosis, heard voices and displayed delusions of grandeur.
Psychiatrist
Tim Crow has argued that schizophrenia may be the evolutionary price we pay for a left brain hemisphere specialization for
language. Since psychosis is associated with greater levels of right brain hemisphere activation and a reduction in the usual left brain hemisphere dominance, our language abilities may have evolved at the cost of causing schizophrenia when this system breaks down.
Alternative medical treatments
A branch of
alternative medicine that deals with schizophrenia is known as
orthomolecular psychiatry. Orthomolecular psychiatry considers the schizophrenias to be a group of disorders; management entails performing the appropriate diagnostic tests and then providing the appropriate therapy. Vitamin B-3 (
Niacin) has been proposed as an effective treatment in some cases. The body's adverse reactions to
gluten are
implicated in some alternative theories; proponents of orthomolecular psychiatric thought claim that an adverse reaction to gluten is involved in the etiology of some cases. This theory—discussed by one author in three British journals in the 1970s—is unproven. A 2006 literature review suggests that gluten may be a factor for patients with celiac disease and for a subset of patients afflicted with schizophrenia, but that further study is needed to conclusively confirm such a link. Some researchers suggest that dietary and nutritional treatments may hold promise in the treatment of schizophrenia.
History
Descriptions of schizophrenia-like symptoms date back to
circa 2000 BC in the
Book of Hearts—part of the
ancient Egyptian Ebers Papyrus. However, study of the
ancient Greek and
Roman literature shows that although the general population probably had an awareness of psychotic disorders, there was no recorded condition that would meet the modern criteria for schizophrenia. Symptoms resembling schizophrenia were, however, reported in
Arabic medical and
psychological literature during the
Middle Ages. In
The Canon of Medicine, for example,
Avicenna described a condition somewhat resembling schizophrenia which he called
Junun Mufrit (severe madness), which he distinguished from other forms of madness (
Junun) such as
mania,
rabies and
manic depressive psychosis.
Although a broad concept of
madness has existed for thousands of years, schizophrenia was only classified as a distinct mental disorder by
Emil Kraepelin in 1893. He was the first to make a distinction in the psychotic disorders between what he called
dementia praecox (literally 'early dementia'—developed from a syndrome first outlined by psychiatrist
Bénédict Morel in 1853 and labelled
démence précoce) and
manic depression. Kraepelin believed that
dementia praecox was primarily a disease of the brain, and particularly a form of
dementia, distinguished from other forms of dementia, such as
Alzheimer's disease, which typically occur later in life.
The word
schizophrenia—which translates roughly as "splitting of the mind" and comes from the Greek roots schizein (σχίζειν, "to split") and phrēn, phren- (φρήν, φρεν-, "mind")—was coined by Eugen Bleuler in 1908 and was intended to describe the separation of function between personality, thinking, memory, and perception. Bleuler described the main symptoms as 4 A's: flattened
Affect,
Autism, impaired
Association of ideas and
Ambivalence. Bleuler realized that the illness wasn't a
dementia as some of his patients improved rather than deteriorated and hence proposed the term schizophrenia instead.
The term
schizophrenia is commonly misunderstood to mean that affected persons have a "split personality". Although some people diagnosed with schizophrenia may hear voices and may experience the voices as distinct personalities, schizophrenia doesn't involve a person changing among distinct multiple personalities. The confusion arises in part due to the meaning of Bleuler's term
schizophrenia (literally "split" or "shattered mind"). The first known misuse of the term to mean "split personality" was in an article by the poet
T. S. Eliot in 1933.
In the first half of the twentieth century schizophrenia was considered to be a hereditary defect, and sufferers were subject to
eugenics in many countries. Hundreds of thousands were
sterilized, with or without consent—the majority in
Nazi Germany, the
United States, and
Scandinavian countries. Along with other people labeled "mentally unfit", many diagnosed with schizophrenia were murdered in the Nazi "
Action T4" program.
The diagnostic description of schizophrenia has changed over time. It became clear after the 1971 US-UK Diagnostic Study that schizophrenia was diagnosed to a far greater extent in America than in Europe. This was partly due to looser diagnostic criteria in the US, which used the
DSM-II manual, contrasting with Europe and its
ICD-9. This was one of the factors in leading to the revision not only of the diagnosis of schizophrenia, but the revision of the whole DSM manual, resulting in the publication of the
DSM-III.
Sociological and cultural aspects
Popular views and misconceptions
Stigma has been identified as a major obstacle in the recovery of patients with schizophrenia. 12.8% of a large, representative sample of Americans in a 1999 study believed that individuals with schizophrenia were "very likely" to do something violent against others, and 48.1% said that they were "somewhat likely" to. Over 74% said that people with schizophrenia were either "not very able" or "not able at all" to make decisions concerning their treatment, and 70.2% said the same of money management decisions. The perception of individuals with psychosis as violent has more than doubled in prevalence since the 1950s, according to one meta-analysis.
As public understanding of mental illness as a
neurobiological disorder is yet developing, patients may be discouraged by friends or family members from taking prescribed medication. Consumers' views on treatment and recovery may differ from those of mental health professionals. later made into a movie.
In
Bulgakov's Master and Margarita the poet Ivan Bezdomnyj is institutionalized and diagnosed with schizophrenia after witnessing the devil (Woland) predict Berlioz's death. The book
The Eden Express by
Mark Vonnegut recounts his struggle with schizophrenia and his recovering journey.
Further Information
Get more info on 'Schizophrenic'.
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