Schizophrenia: A Description
- 41 Downloads
KeywordsAmerican Psychiatric Association 2013a Positive Schizophrenia Schizotypal Personality Disorder Negative Symptoms Blunted Affect
Schizophrenia is a psychological disorder, characterized primarily by thought disturbances, such as delusional thinking, and/or perceptual disturbances, such as hallucinations, as well as social and motivational deficits (i.e., flat or blunted affect, avolition, alogia, and asociality). The thought, perception, and social/motivational disturbances characteristic of schizophrenia often result in comorbid emotional/affective symptoms (e.g., depression or anxiety) and behavioral disturbances (e.g., peculiar, risky, or pointless behaviors).
Schizophrenia is the mental health disorder that has perhaps most intrigued the population, both professional and lay, throughout the years. This interest has led to an influx of movies and television shows that serve to perpetuate a number of negative, and ultimately untrue, stereotypes of those suffering from schizophrenia. Movies such as “The Voices” and “Me, Myself, and Irene” represent individuals suffering from schizophrenia as violent and homicidal. One study demonstrated that in movies and television shows released between 1990 and 2010 which depict a character with schizophrenia, approximately one third of these individuals murdered another character. Given that only 6.8% of individuals who have committed homicide meet criteria for a diagnosis of schizophrenia (Large et al. 2009), the rate at which television characters with schizophrenia commit violent acts is highly exaggerated. Thus, media portrayal of schizophrenia likely plays a large role in the stigma associated with the disorder.
Schizophrenia: A Description
The DSM-5 describes schizophrenia as involving a range of cognitive, behavioral, and emotional dysfunctions associated with impaired occupational or social functioning (American Psychiatric Association 2013a). At least two of the following symptoms must be present: delusions, hallucinations, disorganized speech, grossly disorganized behavior or catatonic behavior, and negative symptoms. Schizophrenia occurs in three phases: the prodromal, active, and residual phases. The prodromal phase precedes the onset of a psychotic episode and, like the disorder itself, looks different across individuals. Individuals may experience sub-diagnostic levels of paranoia, anxiety, magical thinking, etc. (Lieberman et al. 2001). In this phase, individuals may begin to withdraw from society or use substances in an attempt to cope with increasing symptoms. The active phase follows the prodromal phase, and is characterized by the onset of acute psychotic symptoms, including hallucinations, delusions, and grossly disorganized behavior. It is at this stage when an individual may be found to be a danger to self or others and may require institutionalization in order to better manage the disorder. Finally, the residual phase is often defined by the presence of negative symptoms, including avolition (i.e., a reduced drive to pursue goal-directed behavior) and blunted affect (APA 2013).
Schizophrenia is heterogeneous in presentation. Individuals with the disorder can present with a number of constellations of symptoms, from experiencing mainly auditory hallucinations, to predominantly experiencing delusional ideations, to experiencing mostly negative symptoms, or any combination of these presentations. Individuals also vary greatly in the severity of experienced symptoms and response to interventions. Some individuals experience the active phase only once and never require hospitalization, while others experience chronic psychosis and multiple hospitalizations. Given such heterogeneity of presentation, it is surprising that Hollywood focuses primarily on individuals experiencing visual hallucinations in conjunction with auditory hallucinations (i.e., voices) commanding them to do harm unto others.
Our conceptualization of schizophrenia has changed greatly over the years. As recently as 2013 with the release of the DSM-5, two changes in the diagnostic criteria for schizophrenia were introduced (APA 2013b). In the previous edition of the DSM (DSM-IV-TR; APA 2000), an individual was only required to meet one symptom from Criterion A, provided that symptom constituted a “bizarre delusion” or “Schneiderian first-order hallucinations” (e.g., auditory hallucination consisting of two voices holding a conversation). This caveat was removed for the DSM-5 due to the “nonspecificity of Schneiderian symptoms and poor reliability of distinguishing bizarre from non-bizarre delusions” (APA 2013). With this change, two symptoms from Criterion A are now required for a diagnosis of schizophrenia. A second change is that the DSM-5 now requires that at least one of the two or more Criterion A symptoms endorsed must be the experience of hallucinations, delusions, or grossly disorganized speech, in order for the individual to meet criteria for a diagnosis of schizophrenia. Finally, the subtypes of schizophrenia included in the DSM-IV-TR (e.g., paranoid, disorganized, catatonic) have been removed due to “their limited diagnostic stability, limited reliability, and poor validity” (APA 2013).
Researchers have attempted to account for the wide array of presentations of schizophrenia. In 1980, Tim Crow attempted to account for this heterogeneity by subtyping schizophrenia (Andreasen and Olsen 1982). Type I, or, positive schizophrenia, was theorized to be characterized by predominantly positive symptoms of the disorder. Crow proposed that the onset of Positive Schizophrenia was acute, that individuals with this subtype of the disorder would experience “exacerbations and remissions,” and that these individuals would experience relatively normal premorbid- and remission functioning. Type II, or, negative schizophrenia, was theorized to be characterized predominantly by the experience of the negative symptoms of the disorder, including avolition, anhedonia, impoverished speech, and attentional impairments. He hypothesized that the onset of symptoms would be gradual in nature, leading to poorer premorbid functioning and a more chronic prognosis (Andreasen and Olsen 1982). Andreasen and Olsen (1982) elucidated a number of failings of this theory, including nonspecificity of symptoms, the ambiguous nature of some symptoms (e.g., is incongruity of affect a positive or negative symptom?), the categorical vs. dimensional measurement of symptoms, and the ignoring of the fact that many individuals present with both positive and negative symptoms.
Research has also attempted to clarify the etiology of schizophrenia. Some of these etiologies have been at least partially supported (e.g., genetic factors, diathesis-stress models), while others have been largely refuted. In 1948, Frieda Fromme-Reichman coined the term “schizophrenogenic mother” (Neill 1990). She believed that individuals suffering from schizophrenia experienced extreme distrust of others based upon “warp or rejection” they were exposed to during infancy, usually from the mother. This “warp or rejection” was proposed to be a result of either overprotective or rejecting mothering, and the theory was supported by a number of under-controlled case studies. This theory was widely popular in psychiatry between 1940 and 1970; however, in the 1970s, a number of controlled studies discredited the theory, demonstrating that rejection was not isolated to mothers and that rejecting mothers were not overly represented among individuals suffering from schizophrenia (Neill 1990).
Although many etiological theories have been refuted, there is no widely accepted single etiological factor of schizophrenia, but rather it appears that a wide variety of biological, social, and environmental factors are at play in the development of the disorder (Hosak and Hosakova 2015). It has long been accepted that there is a significant genetic component to schizophrenia. Individuals who have a first-degree family member who has been diagnosed with schizophrenia have a much greater likelihood of also developing the disorder; however, many individuals who have been diagnosed with schizophrenia have no family history of the disorder. For these individuals, there is an increased emphasis on the role of environmental influences on the etiology of schizophrenia. Research has demonstrated that the two most influential environmental factors in the etiology of schizophrenia are psychosocial stress and cannabis use, and it is hypothesized that these factors may lead to the development of schizophrenia through their effect on vulnerable neural pathways (Hosak and Hosakova 2015).
Studies of genetic-environment interactions have provided some level of clarity in the development of schizophrenia. One recent study proposed that genetic factors account for up to 80% of the variance in schizophrenia, and that environmental factors are rarely, if ever, sufficient to cause the onset of the disorder alone (Hosak and Hosakova 2015). This lends support to the idea of a diathesis-stress model. A diathesis-stress model states that individuals are born with a level of genetic risk for developing a disorder, that, when combined with a sufficient level of environmental triggering, leads to the development of the disorder. In the case of schizophrenia, this may take form in an individual with a genetic vulnerability to the development of schizophrenia using cannabis, and this acute exposure to cannabis in combination with high levels of psychosocial stress serves as a catalyst for the development of the disorder.
The frontline treatment of schizophrenia involves the use of psychotropic medications referred to as antipsychotics. Antipsychotic medications come in three classes (typical, atypical, and dopamine partial agonist antipsychotics), all of which target the dopaminergic system (Miyamoto et al. 2005). There are a number of psychosocial treatments available for the treatment of schizophrenia, such as cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT); however, these treatments alone are not sufficient in treating acute psychosis and should be utilized as adjunctive treatments. Unfortunately, although newer generations of antipsychotics demonstrate improvements over first-generation antipsychotics in terms of both treatment effects and side effects, they still fail to adequately treat all symptoms of schizophrenia and lead to uncomfortable, and sometimes dangerous, side effects. These side effects include extreme weight gain, facial deformities, and muscular spasms.
Despite the level of effort placed into understanding schizophrenia, it remains one of the most stigmatized mental health disorders. There is a common yet unsupported belief in society that individuals suffering from schizophrenia are often violent and dangerous, though research has shown that they are more likely to be victims of violence than perpetrators. This belief is perpetuated by Hollywood, which has continuously misrepresented the disorder in films and television shows. Further, individuals suffering from schizophrenia are often left with the unenviable choice of forgoing medications and risking a psychotic episode and hospitalization, or taking antipsychotic medications which fail to alleviate a number of symptoms and lead to crippling side effects. Although our understanding of schizophrenia has improved drastically from the time of the schizophrenogenic mother theory, we still have much to learn in order to optimally treat these individuals.