Schizophrenia: In Context, Defined and Treated
Anna Bohlinger
University of Wisconsin – Stout

History

Emil Krapelin was the first person to define schizophrenia, which he called “dementia of the young”, during the early 1900s.  Eugene Bleur (1911-1950) coined the word schizophrenia, “to tear the intellect” shortly thereafter.  He described the symptoms of the illness as including: a disturbance of association, a disturbance of affect, apathy, autism, and a change in personality.  (Walker, 2008)   Bleur focused on the negative symptoms of schizophrenia, or the things that get lost from the human experience when one is dealing with the illness.  (Herz, 2002) An example of a negative symptom would be its characteristic blunted affect.  In 1959, Kurt Schnider differentiated “first rank symptoms” which included various perceptual disturbances, such as thought broadcasting, thought intrusion, somatic hallucinations or hallucinations that are felt in the body, and delusional perception.   (Walker, 2008)  Schnider dealt more with the positive symptoms of schizophrenia, or the things that are added to the human experience when one is dealing with the illness.  An example of a positive symptom would be an auditory hallucination. (Herz, 2002)

Although the differentiation of schizophrenia as a discrete mental illness began in the early 1900s (Walker, 2008), delusions, hallucinations, and evidence of the negative symptoms of the current formulation have been noted throughout history.  Isaac Newton appeared to paranoid in many of his letters, Amadeus Mozart thought he was being poisoned while he wrote the Requiem, and

Albert Einstein’s unkempt appearance and odd mannerisms may have been evidence for schizotypal personality disorder.  (Bemak, 2002)

During the 1960s-70s, the diagnosis of schizophrenia was very unreliable.  Clinicians in the United States were diagnosing statistical significant greater numbers of individuals with the illness than their European cohort.  The Diagnostic and Statistical Manual III was partially created to deal with this discrepancy.  (Herz, 2002). 

During the early days of attempting to treat mental illness in general, many thinkers were involved with determining the etiology of schizophrenia in particular.  One of the most common beliefs in the 1940s and 50s especially was the idea that schizophrenia is caused by a rejecting or emotionally unresponsive mother.  Fromm-Reichmann coined the term “schizophrenogenic mother” to describe the rejecting pattern of the mother of a child or adult living with schizophrenia.  (Bemak, 2002)  Sigmund Freud also ascribed to the belief that schizophrenia had a psychosocial origin. (Walker, 2008)

Clinicians who ascribed to these beliefs often focused treatment on removing the “schizophrenic” from their families of origin.  Some went beyond by attempting to teach the families and clients better communication techniques or skills that they hoped would dispel symptoms.  Gregory Bateson, one of the founders of the modern day Marriage and Family Therapy model, focused especially on communication patterns that seemed to cause schizophrenic symptoms.  He noted

the “double-bind” or conflicting pattern of words and actions that leave an individual confused.  Schizophrenia then, was not simply pathology; it was a response to “pathogenic communication” (Nichols, 2008).  Bateson and others who attempted to treat schizophrenia from a purely systemic focus were ultimately unsuccessful.

Early pharmacological treatment for schizophrenia focused on chlorpromazine and other neuroleptics.  These meds were found to be highly effective in treating the positive symptoms of schizophrenia and led to a revolution in their prescription in the 1950s.  However, conventional neuroleptics were found to cause serious side effects, especially extrapyramidal effects like Tardive Dyskensia.  Tardive Dyskensia is especially debilitating in which the individual experiences nearly constant large and small muscle tics.

Current Formulation

Schizophrenia is currently defined by the American Psychiatric Association’s publication of the Diagnostic and Statistical Manual (DSM IV Text Revision) as consisting of at least two characteristic symptoms for at least one month or less, if successfully treated.  The five possible characteristic symptoms are: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behaviors, and negative symptomatology.  There are four subtypes of schizophrenia.  Paranoid type is characterized by a preoccupation with at least one delusion or frequent auditory hallucination (American Psychiatric Association, 2000).  Disorganized type includes prominent disorganized speech, disorganized behaviors, and flat or inappropriate affect.  Catatonic type consists of at least two characteristics of catatonia including: motoric immobility evidenced by catalepsy or stupor, excessive motor activity that is apparently purposeless and not influenced by external stimuli, extreme negativism or mutism, peculiarities of voluntary movement like posturing, stereotyped movements, prominent grimacing, echolalia or echopraxia.  Undifferentiated and Residual are two additional types of schizophrenia (American Psychiatric Association, 2000).  In response to a call for a comprehensive listing of symptoms, (Andreasen, 1991) the most recent conceptualization of schizophrenia includes positive, negative and disorganized symptoms.  It is a group of disorders collated by similar symptomatology. (Herz, 2002)

Schizophrenia manifests in four distinct stages.  First, individuals dealing with schizophrenia experience a prodromal phase.  During this phase, negative symptoms manifest in excess or distortion of normal functions.  Mood swings and appetite changes may occur, as well as changes in sleep patterns (Buttery, 2005).  Depressive symptoms are also common at this stage (Wassink, 1999).  At the height of the prodromal phase, individuals transition to the acute phase of schizophrenia.  During this phase, individuals are experiencing active psychotic symptoms like delusions and/or hallucinations and are generally unable to care for themselves (Herz, 2002).  Most hospitalizations occur during the acute phase (Gerson, 2009).  Following the acute phase, individuals enter a stabilization phase.   During this period there is a gradual decrease in the severity of symptoms.

Individuals are most vulnerable to relapse during the stabilization phase (Herz, 2002).  Following the stabilization phase, individuals dealing with schizophrenia experience a stable phase.  During this time, symptomatology has become more consistent.  Individuals may still deal with both positive and negative symptoms of the illness even in the stable phase (Herz, 2002).

Schizophrenia is typically diagnosed in the late teen or early adult years.  (Buttery, 2005), however it can be diagnosed in children (Asarnow, 2004).  Its onset may be sudden or gradual, often with debilitating effects.  Only 20-30% of individuals dealing the illness are able to lead lives independent from social services (Herz, 2002).  25-50% of individuals dealing with schizophrenia attempt suicide (Walker 2008), with 10-15% of individuals completing suicide (Schwartz, 2001).  1.3% of the population has been estimated to deal with schizophrenia at some point in their lives.  This estimation is consistent with the estimate that approximately 1% of people deal with schizophrenia worldwide (Herz, 2002).

Individuals dealing with schizophrenia often deal with comorbid illnesses.  47% of clients dealing with schizophrenia are diagnosed with a comorbid substance abuse.  Use of substances, especially cocaine and cannabis, can rapidly increase schizophrenic symptomatology (Herz, 2002).  Additionally, substance abuse has been found to increase the risk of suicide (Schwartz, 2001).  Other mental illnesses such as obsessive-compulsive disorder and depression are particularly commonly comorbid with schizophrenia.  Polydipsia, or compulsive water drinking, is seen in approximately 42% of clients dealing with schizophrenia (Herz, 2002).

Although there are no biological markers for schizophrenia, (Herz, 2002) consensus remains that schizophrenia is a brain disease involving genetic, biological and environmental factors in the etiology.  Brain maturation processes also seem to play a role in the development (Walker, 2008).  Biological theories about the development of schizophrenia focus on genetic, prenatal or obstetric factors, abnormalities in the brain structure, or neurotransmitters.  Adoption studies seem to support a genetic component pointing to a diathesis stress model.  A diathesis stress model is one in which an individual is born with a range of likelihood for developing any illness and environmental or stress factors contribute to whether or not the individual develops the disorder.  Generally, however, researchers have abandoned the idea of finding a single gene that causes schizophrenia.  More likely, schizophrenia will be found in a polygene model (Herz, 2002).  Additionally, the effect dopamine levels play in schizophrenia’s symptomatology seem to point to a genetic component (Herz, 2002).

Prenatal and obstetric factors include stressful events during pregnancy, especially in the second trimester (Herz, 2002).  Complications in the labor, especially those related to oxygen deprivation, can have a negative effect on the fetal brain (Walker 2008).  Nutritional deficiencies in pregnancy can also lead to an increase in the diagnosis of schizophrenia (Herz, 2002).  Individuals dealing with schizophrenia often have decreased brain volume, enlarged brain ventricles and smaller lobe volumes.  Additionally, individuals dealing with schizophrenia typically have higher dopamine levels and their levels of Gamma-Aminobutric Acid (GABA) inhibit other transmitters more than they do in typical individuals  (Walker, 2008).  It is important to note that research completed on brain abnormalities for individuals dealing with schizophrenia is primarily correlational.

Once born, there are some signals that have been associated with the development of schizophrenia.  Children at high risk for schizophrenia have been found to have strange gaits, odd postures, strong muscle tone and strange motor function in general.  Before developing schizophrenia, children may demonstrate cognitive deficits, delays in motor function, abnormal gesturing, and subclinical signs of psychotic symptoms (Walker, 2008).  Children may not have a diagnosable mental illness in childhood, but adolescents typically struggle with adjustment issues (Walker, 2008).

Treatment

Successfully treating schizophrenia involves a life-long and contextual approach that considers not only client efficacies, but also severity and course of the illness, family dynamics, and availability of social service and mental health supports.  It also involves a slightly different approach depending on the stage of the illness the individual is currently experiencing.  Most clients dealing with schizophrenia enter the mental health system during times of crisis.  They are often experiencing more of the positive symptoms of psychosis and their families are stressed, describing “common points of entry into the system…as dangerous, traumatic and guilt-inducing” (Buttery, 2005).  Although schizophrenia, like most mental and physical illness, involves a diathesis stress model, the opinion of the author is that criminalizing or blaming families for a result of their offspring’s diagnosis is counterproductive.  The initial evaluation of a client experiencing a psychotic episode should focus on: safety, the ability of the patient to participate in decisions, determining the least restrictive environment, the role of family and others in management and decision making, medical issues, and finally, diagnosis (Herz, 2002).  It is important to first consider the safety of the client, others, and evaluator.  Awareness of the stress surrounding typical points of entry into the system and adapting typical clinical interviewing skills to the environment may prove to be effective.  It is rare to get all of the information a clinician will need in the initial interview, often taking place in a hospital emergency room or triage (Herz, 2002).  The typical diagnostic process consists of ensuring safety for all individuals involved, ruling out a series of conditions that may cause or contribute to psychosis, and finally, diagnosing schizophrenia (Herz, 2002).  When diagnosing, it is important to remember that a disproportionately higher number of African-Americans get diagnosed with schizophrenia than Anglo-Americans (Strakowski, 1996).

During the initial stage of treatment, individuals should be placed in the least restrictive environment possible.  Essentially, if a client is a danger to themselves or others, they should be placed in a hospital inpatient setting, typically a psychiatric unit.  If the client can safely be placed in a community setting, it can be less stigmatizing, maintain family relationships, allow the client to continue to fulfill some social and occupational roles, and allow the client to continue to receive some public benefits (Herz, 2002).  It is important to note that once a client no longer requires the structure and setting of a hospital inpatient unit, they should be seamlessly transitioned to a less restrictive setting; a longer stay in hospital makes no statistical difference than a shorter stay two years later (Herz, 2002).  Hospital environments should be organized, clean and highly structured.  Staff should be clearly delineated with name tags and community meetings should be short and goal-orientated (Herz, 2002).  Psychotropic medications should be evaluated during the initial stage of treatment.  Evaluation should consider the client’s compliance with their current medications, including the blood levels of medications they are currently prescribed, potential side effects of medications they are currently taking and the presence or absence of illicit substance use that may have contributed to the client’s current psychotic state (Herz, 2002).  It is important to note that most completed suicides occur in the first few days of hospitalization.  Keeping this in mind, staff should engage in appropriate precautions and monitor client suicidality throughout their hospitalization (Herz, 2002).  It may also be useful to note that many clients seeking treatment for the first time have been symptomatic for two years or more (Buttery, 2005).

The transition out of the acutely psychotic phase is known as the stabilization phase.  Unfortunately, most research has been done on the acute or stable phase, not the time when clients begin to show some improvement in positive, negative, or disorganized symptomatology.  During this period, clients may transition out of inpatient hospitalization and begin day hospitalization if thoughts of harming themselves or others have disappeared.  Medication consistency is extremely important during this time and the same medications should be continued for a least six months to get a full picture of their efficacy.  Lowering medications rapidly can cause a relapse in symptoms (Herz, 2002).  The only reasonable exception to this rule is that if there is any evidence of tardive dyskensia.  If then, the client should switch medications (Herz, 2002).

When clinical status has plateaued after stabilization, clients enter the stable phase.  During this phase it is especially important to include medication management, psychosocial treatment, and occupational rehabilitation.  Clients who experienced a first and only episode of psychosis require one to two years of management and clients who have experienced multiple episodes require more than five years of management.  Most clients who experience a single psychotic episode will need to remain on medications for the rest of their lives; 40-60% of clients who discontinue medications will relapse (Herz, 2002).  Anecdotal evidence suggest that even after two years of medication compliance, even a small decrease in medications can cause relapse (Flaum, 2003).  However, defining remission continues to be a topic of academic debate (Andreason, 2005).  Medication issues commonly stem from non- or partial- compliance or side effects. Using newer medications like serotonin-dopamine antagonists and second generation antipsychotics can help decrease some of the adverse side effects while maintaining efficacy (Herz, 2002).   Additionally, psychosocial treatment may help treat some of the negative symptoms of schizophrenia (Klingberg, 2009).

When dealing with compliance issues it is important to consider the client’s subjective experience of the medication.  If they perceive that the medication is not effective or causing unwanted side effects, discuss these issues with the client and consider switching medication.  Ultimately, a drug is only as effective as it is taken.  Indicators that someone may not be medication compliant include: denying that they have a mental illness, perceived lack of benefit of treatment, environmental obstacles, embarrassment or shame over having a mental illness, financial obstacles or adverse side effects (Herz, 2002).  If clients struggle to remember to take medications, consider a depot shot, which only has to be administered every two weeks.  Use of talk therapy approaches to deal with some of the shame surrounding a mental health diagnosis can be helpful.  Most clients diagnosed with schizophrenia experience their first psychotic episode as late adolescents or young adults.  They are beginning to formulate their identities and life-long goals, and suddenly, their entire lives change (Gerson, 2009).   Utilize community mental health delivery services and county social services in areas where finances or availability of mental health delivery is suspect.  Program for Assertive Community Treatment (PACT) has been found to be an especially effective community based model for treating schizophrenia.  PACT involves an assertive approach, including finding clients if they do not show up for therapy, individually tailored and tiered programming, ongoing monitoring, milieu services, utilizing on client strengths and 24-hour crisis support (Herz, 2002).

When treating an individual dealing with schizophrenia it is important to consider the individual in context.  When determining the least restrictive setting for treatment, consider the family dynamics.  It is typically families who first notice symptomatology in their members (Gerson, 2009) and via psychoeducational supports, families can be empowered to care for and support their own members to fuller lives.  It is especially important that clinicians refrain from shaming family members of an individual dealing with psychosis or minimizing their experience of the psychosis.  As previously mentioned, it is generally agreed upon by those in the psychiatric community that schizophrenia has some genetic component in its etiology.  That being the case, when individuals and families present with psychotic symptoms, chances are likely that a parent, grandparent or great-grandparent also presented with psychosis in the past.  When that ancestor presented, it is highly likely that their parents were told that it was “their fault” and either cut from the therapeutic healing process or told that if they had done things differently, schizophrenia would have never occurred.  As a clinician, remember this multigenerational approach.  A reactive system needs to move toward becoming proactive, but in order to do so, it needs to be praised for the efforts already being made (Gerson, 2009).

 

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