Understanding and Treating Schizophrenia

Contemporary Research, Theory, and Practice

Terry S Trepper, Glenn D Shean

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781317825401
• Topic: Psicología
• Subtopic: Salud mental en psicología

Get a fair and balanced perspective on schizophrenia!

Understanding and Treating Schizophrenia: Contemporary Research, Theory, and Practice is a comprehensive overview of schizophrenia and its treatment from a variety of approaches. The book presents a balanced look at the most influential theoretical perspectives based on empirical research, clinical descriptions, and narrative histories. Dr. Glenn Shean, author of Schizophrenia: An Introduction to Research and Theory, examines neurocognitive and neurodevelopmental models of brain dysfunction, psychodynamic and family factors, up-to-date pharmacological advances, and successful community programs for discharged patients suffering from this debilitating disorder.

Understanding and Treating Schizophrenia: Contemporary Research, Theory, and Practice presents a comprehensive review of evidence concerning the epidemiology and course and outcome of schizophrenia based on theoretical groupings and levels of analysis. The book examines the evolution of diagnostic criteria and guidelines, as well as stress-vulnerability and diathesis-stress models, providing critical reviews of biological, genetic, cognitive-behavioral, and phenomenological, approach to understanding and treating schizophrenia.

Topics addressed in Understanding and Treating Schizophrenia: Contemporary Research, Theory, and Practice include:

• the history of the concept of schizophrenia
• the writings of Emil Kraepelin and Eugene Bleuler
• changes in diagnostic guidelines in the last 50 years
• General System Theory Perspective
• diagnostic and statistical manuals
• Schneider's first rank symptoms
• and much more!

Understanding and Treating Schizophrenia: Contemporary Research, Theory, and Practice is an essential resource for undergraduate and graduate students working in psychology, psychiatry, nursing, social work, and social policy.

SECTION I:

THE DEVELOPMENT, EVOLUTION, EPIDEMIOLOGY, AND SUBSYNDROMES OF SCHIZOPHRENIA

The four chapters included in this section cover a wide range of topics. Chapter 1 provides a detailed historical account of Kraepelin’s development of the concept of schizophrenia and Bleuler’s revisions. Chapter 2 traces the different diagnostic definitions and criteria that have been introduced since the first attempt at standardization of American usage in DSM-I. Chapter 3 summarizes a great deal of research on epidemiology, course of symptoms, and outcome of schizophrenia, and Chapter 4 provides extensive illustrations of three syndromal patterns that hold promise for improved descriptions of symptoms. Reading this summary of a large and often confusing body of literature can at times be tedious, but it is a necessary first step if the reader is to understand the basis for the many controversies and opinions described later in the book.

Chapter 1

History of the Concept of Schizophrenia

A review of the terms used to refer to people who speak strangely or act out of control gives some indication of the level of cultural preoccupation associated with such actions. Common terms that are applied, such as insanity, unsoundness of mind, abnormality, and derangement, have prefixes (in-, un-, ab-, de-) that indicate negative contrasts: not, without, away from, absence of, removal from. Insanity, a legal term, is derived from the Latin insanitas which literally means not (in) healthy (sanitas).

The colloquial terms that are commonly used to refer to insanity are also revealing. The term crazy, for example, is a derivative of the middle English word crazen which meant “to break into pieces.” The implication is that madness is associated with thought that is broken and derailed (Wrobel, 1990). Other colloquial terms imply derisive meanings, such as bats in the belfry, cracked, unhinged, gone off the rocker, run off the trolley tracks, loose bolts in the head, and nutty as a fruitcake. The diversity of this language suggests that madness is and has been a matter of considerable concern and interest to English speakers for a long time. People do not develop so many descriptors for phenomena that are of marginal interest.

We sometimes hear people speak of someone having a complete “nervous breakdown,” a generic term that refers to nearly all serious mental problems. Insanity and mental incompetence are terms that have legal implications. The term psychosis is a clinical rather than a legal term that refers to the most serious forms of mental and behavioral disturbances. Psychosis implies something about both the level of seriousness of the mental disturbance and the fact that the disturbance is global, involving cognitive, behavioral, emotional, and interpersonal disturbances. Emotional disturbances may involve a mixture of anxieties and depression or substance abuse, as well as problems with anger and affect modulation. Psychotic individuals fail to meet most criteria for normality: they lack adequate emotional control and capacity for self-direction, and they typically evidence persistent patterns of maladaptive behaviors. In addition, the term psychosis implies that the patient has lost reality contact. That is, there is some form of disturbance or peculiarity in cognitive processes having to do with how the individual views reality. This aspect of cognition has nothing directly to do with intelligence or objective knowledge. Psychotic patients may be very intelligent or mentally retarded; intelligence and objective knowledge are not necessarily related to loss of reality contact.

Psychotic individuals are by definition no longer in touch with the reality of people and situations around them, or with the reality of who they are, in a way that is believable or “makes sense.” Delusions and hallucinations, feelings of being unreal, disorganized speech, bizarre ideas, and tangentiality are examples of the cognitive aspects of psychological functioning that distinguish psychosis from other groupings. Extremes of emotionality and bizarre and eccentric behaviors may also be associated with these cognitive characteristics. Psychotic conditions can result from a wide variety of causes, including infections, vitamin and nutritional deficiencies, head injuries, arsenic or lead poisoning, hyperinsulinism, Alzheimer’s disease, the interactions of prescribed medications, and the effects of vulnerabilities and life stresses.

The degree range of disturbance or loss of reality contact in psychosis is quite broad. The majority of acutely disturbed psychotics benefit from an interval of institutionalization, for their protection and the protection of others. Other “subacute” psychotics may not require hospitalization, and many “residual” psychotics who have been discharged as “improved” can function with varying degrees of independence outside of an institution, although they may continue to evidence mild or moderate symptoms.

The term functional psychosis implies that the disorder is not currently known to be caused by any lesion in the nervous system or specific biochemical or endocrine disturbances of the body. Functional does not necessarily mean that the disorder is caused by psychological or social factors; it simply means “etiology unknown.” The functional psychoses are divided into two broad groups: (1) affective psychoses in which the emotional disturbance is primary and the cognitive disturbance is derivative and (2) schizophrenic disorders in which the cognitive disturbance is primary and the emotional and behavioral disturbances appear to be derivative. Affective psychoses include bipolar disorder, with psychotic features, and major depressive disorder, with psychotic features. Functional psychoses characterized by primary cognitive dysfunction are called schizophrenic disorders.

THE PREMODERN PERIOD

Mental disorders have afflicted humanity throughout history. Written accounts of systematic attempts to classify and understand several mental disorders extend back several thousand years. Hippocrates (ca 460–377 B.C.) was among the first to provide systematic descriptions of the characteristics of disorders such as mania, melancholia, hysteria, and delirium. He viewed systematic description as a necessary first step in the development of a naturalistic understanding of these problems. Hippocrates believed that brain function was affected by the balance of hypothetical body humors (blood, phlegm, black bile, and yellow bile).

Five hundred years later the Greek physician Galen (129-ca 216) integrated Hippocratic medicine with the belief that a spiritual force united mind and body. Galen made observations on the cranial nerves, provided detailed descriptions of disorders such as mania and melancholia, and argued that these disorders were the result of disturbances in the brain. Although similarities exist between ancient and modern descriptions of mania and melancholia, no descriptions of a separate mental disorder that resembles modern definitions of schizophrenia are available prior to the nineteenth century (Gottesman, 1991).

The rational-empiricist orientation of the Greek philosophers was eventually replaced by religious dogma in Western Europe. After the fourth century A.D., when Christianity was established as the official religion of the Roman Empire, the study of the Greek philosophers and attempts at naturalistic understanding of human problems were suppressed. For the next 1,000-plus years superstition and religious doctrine determined how events were to be understood. Fortunately, Islamic philosopher-physicians, such as Avicenna (980–1037), preserved and continued the rationalist traditions of the Greek philosophers. Avicenna helped to create asylums for the mentally disturbed based on humanitarian ideology and rationalist assumptions about physical causes derived from Greek thought (Palha and Esteves, 1997). Some monasteries in Europe also provided shelter and humanitarian care for mentally disturbed individuals during the Middle Ages, but most individuals were simply driven from the towns and left to wander the countryside. There were, however, some exceptions to the neglect of the mentally ill that prevailed in the Middle Ages, such as the colony based in Gheel, Belgium, the asylums in southern Spain that were under Arab influence, and the asylum established in London by Saint Mary of Bethlem in 1247.

With the reintroduction of Greek thought during the early Renaissance in the thirteenth century it became acceptable to attempt to understand the universe through empirical and deductive methods. Gradually, new scientific discoveries and technological advances improved people’s lives, and with time even the taboo against the scientific study of the human body and mind was overcome. During the seventeenth and eighteenth centuries attempts at scientific understanding of mental disorders truly took hold. The Copernican revolution, as extended by Harvey with his research on the circulation of blood, Galvani’s study of nerve impulses, and Descartes in philosophy, contributed to a climate that was increasingly receptive to naturalistic explanations of mental phenomena. Nevertheless, incarceration, neglect, and punishment were the predominant ways of dealing with madness well into the eighteenth century. Psychotics were generally viewed as subhuman animallike degenerates, the objects of fear and loathing, well beyond the period of the French Revolution.

Political and social reforms of the eighteenth century coincided with an increased focus on the provision of asylums for the insane and eventually a renewed interest in the classification of mental disorders. Of those who contributed to the acceptance of rational and empirical approaches to classification and understanding of mental disorders during this period, Phillipe Pinel (1745–1826) is among the most prominent. Pinel was instrumental in reintroducing the notion that mental disorders were the result of natural causes, and he provided detailed descriptions of cases of melancholia, manias with and without delirium, and dementia. Pinel attempted to improve the treatment of mental patients and is renowned for his courage in requesting that the feared Robespierre allow him to unchain the insane. He asserted that the insane were not subhuman animals but men and women who were suffering from a combination of moral failures and brain disorders. Pinel emphasized the importance of providing healthy diet, hygienic conditions, kindness, understanding, and moral rehabilitation; advocated the segregation of the insane from other prisoners; and was among the first to use the term asylum to refer to places designated to house only the insane.

THE NINETEENTH CENTURY

The first half of the nineteenth century was characterized by an increased emphasis on the role of emotions in human life. This emphasis was in part a reaction against what was perceived to be an overemphasis on the primacy of reason by eighteenth-century philosophers. John Etienne Esquirol (1772–1840) emphasized the dominance of emotions over reason and studied the role of precipitating life events in the origins of symptoms such as hallucinations. Johann Christian August Heinroth (1773–1843) argued that mental disorders were caused by demoralization and emphasized the role of immorality as a cause of emotional distress and conflict.

Pasteur’s subsequent discoveries regarding the role of bacteria in illness and infection and Darwin’s publication of On the Origin of Species profoundly affected mid-nineteenth-century thought and fostered a renewed emphasis on biological explanations. The revolutionary ideas associated with Darwin’s theory of evolution and scientific successes in the understanding of infectious diseases provided a foundation for the establishment of asylums as places of medical treatment and placed a renewed emphasis on the importance of the delineation of disorders based on standardized diagnosis.

As understanding of human anatomy increased it became more plausible to assume that genetic inheritance and/or infections of the brain caused mental disorders. The delineation of the asylum as a place of confinement solely for the mentally disturbed and the successes of internal medicine in identifying the causes of several infectious diseases during the nineteenth century contributed to the adoption of policies that madness is a brain-based illness; therefore, only medically trained individuals should be appointed to be asylum directors. These individuals naturally assumed that the first step in developing a scientific understanding of the disorders was to formulate a comprehensive diagnostic system. Pinel’s student Esquirol continued his emphasis on precise descriptions of syndromes and symptoms. This descriptive work laid the foundation for attempts by German psychiatrists during the latter half of the nineteenth century to develop a more complete diagnostic system (Spitzer, Williams, and Skodel, 1983).

Wilhelm Griesinger (1817–1868) was an influential German physician who wrote about psychotic mental disorders during the first half of the nineteenth century. He assumed all mental disorders were the result of brain diseases and denied the role of psychological concepts in the treatment or understanding of these disorders. Griesinger moved away from an emphasis on defining separate symptom syndromes and emphasized the unitary nature of all major mental disorders. He maintained that there is only one fundamental disease process. Melancholia, mania, delusional insanity, and dementia were assumed to be successive stages of the same underlying psychotic process. Griesinger argued that differences in symptoms of patients could be attributed to the particular stage of the underlying unitary process of psychotic disintegration that was observed. In 1868 Griesinger reemphasized his belief that all of the “functional” psychoses were expressions of a single disease referred to as Einheitspsychose. He grouped persistent psychotic states together with transient psychotic episodes and did not emphasize differences in either course or symptoms as the basis for separating out different disease categories.

Despite Griesinger’s dominance during the mid-nineteenth century, many asylum directors continued to strive to develop a diagnostic system that established separate syndromes or categories of psychotic disorders. At the same time neurologists were developing a taxonomy of clinical neurological syndromes based on symptom comparisons.

ORIGINS OF THE CONCEPT OF SCHIZOPHRENIA

In 1852 the Belgian physician Benedict Morel (1809–1873) described the case of a young adolescent boy who had been a cheerful, outgoing individual and good student, but who gradually became melancholy and withdrawn and appeared to progressively lose his cognitive abilities. Morel believed that the deterioration was the result of an arrest in brain development which he attributed to hereditary causes. He considered such cases to be irremediable and named the disorder demence precoce to refer to his observations that the degenerative processes began early in life and progressed rapidly to dementia.

Morel wrote in French; however, most French-speaking physicians in the late nineteenth century were influenced by Jean Martin Charcot (1825–1893) and Pierre Janet (1859–1947). Consequently, the French were more interested in hypnosis and the study and classification of hysteria than in psychotic disorders. German psychiatrists were the primary contributors to the development of systems for the classification of psychotic disorders during the latter part of the nineteenth century. Griesinger’s view of a unitary psychotic process was challenged as physicians increasingly emphasized the importance of separate symptom syndromes.

Karl Ludwig Kahlbaum (1828–1899) was among the first to study the course of psychoses over time and categorize the symptoms. He published descriptions of two patterns of psychotic symptoms: “hebetic paraphrenia,” marked by hallucinations, delusions, and bizarre behavior that began in adolescence and progressed to severe deterioration, and “katatonia,” marked by extreme disturbances in motility and dementia. Kahlbaum used the term catatonia (katatonia) to describe the characteristics of patients who developed an impairment in “self-will,” sat or stood physically immobile, and displayed no reactivity to external stimuli. Hecker independently confirmed Kahlbaum’s observations and proposed the diagnostic term hebephrenia to replace Kahlbaum’s term hebetic paraphrenia. Ewald Hecker also elaborated on Kahlbaum’s work and described hebephrenia as a disorder that began in adolescence with a succession of erratic mood states followed by a rapid and irreversible decline in all mental functions. Catatonia and hebephrenia were viewed as separate disorders by both Kahlbaum and Hecker. During the same period Jean Pierre Falret (1794–1870) revived the tradition of separating mania from other psychotic disorders (Kringlen, 1994).

EMIL KRAEPELIN

Emil Kraepelin (1856–1926) studied under the psychologist Wilhelm Wundt at Leipzig and was trained in the methods of experimental psychology. He applied his scientific training in psychology to his work as a diagnostician and systematically recorded hundreds of case observations of patients. Kraepelin believed there were important underlying similarities in the many variations he observed among patients. He synthesized the works of Morel, Kahlbaum, Hecker, and others and organized his own integrative diagnostic system.

In 1896 Kraepelin published the fifth edition of his textbook on ...

Table of contents

• Cover Page
• Half Title page
• Series Page
• Title Page
• Copyright Page
• Dedication
• About The Author
• Contents
• Preface
• Section I:The Development, Evolution, Epidemiology, and Subsyndromes of Schizophrenia
• Section II:Integrative Models and Levels of Analysis
• Section III:Biological Perspectives
• Section IV:Cognitive-Behavioral, Neurocognitive, and Neurodevelopmental Research
• Section V:Psychodynamic, Phenomenological, and Family-Based Theories
• Section VI:Life in the Community
• References
• Index