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Overview of Schizophrenia
WHAT IS SCHIZOPHRENIA?
Schizophrenia is a form of severe mental illness that affects approximately 1 percent of the population of the world (Robins and Regier, 1991), regardless of gender, age, economic status, or ethnic or racial characteristics. The American Psychiatric Association (2000) defines it as “a disorder that lasts for at least six months and includes at least one month of active-phase symptoms (i.e., two [or more] of the following: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms)” (p. 298).
The common symptoms of schizophrenia are usually classified as either positive or negative. Positive symptoms are hallucinations and delusions, and negative symptoms include social withdrawal, anhedonia apathy, and a general inability to interact with others in a socially appropriate way. Cognitive symptoms, which include confused thinking and confused speech, may be a separate category. Individuals with schizophrenia may have some or many of these symptoms. For many, the illness is chronic and severe and they will experience these frightening symptoms periodically for most of their lives. It is not surprising, then, to discover that the suicide rate for people with schizophrenia is higher than among those who suffer from other types of mental illness. Schizophrenia is considered by many mental health professionals to be one of the most disabling mental illnesses (Grinspoon, 1998).
The average age of onset for schizophrenia is the late teens through young adult years. Although rare, it is possible to find children and younger adolescents with this diagnosis. It is even rarer for someone in middle-to-late adulthood to suddenly develop the full syndrome of schizophrenia. Women may be more prone than men for late-onset schizophrenia. Such occurrences have raised concerns about changes in women's physiological functioning following menopause. Research data suggest men develop the disorder earlier in life and may develop a more severe type of schizophrenia. This illness is believed to run in families. Studies examining the rates of occurrence in identical twins versus fraternal twins show a higher incidence among identical twins. However, the concurrence is not exact and lends support to the idea that other factors, besides strict genetic inheritance, play a part in developing the disorder.
In general, schizophrenia can follow a number of courses, depending on the age of onset, severity of the illness, and treatment received. The original term used to define schizophrenia, dementia praecox, implies a chronic and deteriorating course for the ill individual, something akin to Alzheimer's disease. Some who develop schizophrenia experience such a course regardless of treatment received. Others, however, may experience a significant decline in functioning during the active phase of the illness, and then the recovery of some or most of their functioning once they receive adequate treatment. These individuals may experience some residual loss of functioning and require ongoing support and services to help them adapt to life following active occurrences of the illness. Still others may experience a sudden onset of acute schizophrenia, receive adequate treatment, and return to their full level of functioning. These individuals may be prone to future bouts of the illness, but can function very well. The variety of courses and symptoms schizophrenia can take has led to the theory that it may actually be a series of related syndromes as opposed to a single disease.
WHAT CAUSES SCHIZOPHRENIA?
Schizophrenia, or the schizophrenia syndrome, is conceptualized as a neurological illness (or related illnesses) whose etiology resides in some still unspecified genetic or physiological anomaly that leads to its characteristic symptoms. Much of the research on the etiology of schizophrenia has focused on the structure and functioning of specific parts of the brain.
The structure of the brain can be analyzed through the use of computed tomography (CT) scans and magnetic resonance imaging (MRI). Research on the structure of brains in people with schizophrenia has not identified anything specific to the disorder but has identified several anomalies (Miller, 2001). In general, individuals with schizophrenia have larger brain ventricles. Ventricles are cavities in the brain filled with spinal fluid. Also, the average size of the brains of people with schizophrenia is somewhat smaller than the average person. Areas that have been found to be smaller include the cerebral cortex, temporal lobes, and the limbic region. Some of the brain's functioning can be analyzed using positron emission tomography (PET) and functional MRI. Some of the research conducted on people with schizophrenia has indicated problematic blood flow to the prefrontal cortex of the brain (Miller, 2001), the area of the brain associated with planning, judgment, and decision making.
Two chemicals in the brain have also been studied to better understand the etiology of schizophrenia. Dopamine and glutamate are neurotransmitters that pass signals between nerve cells. Dopamine has been studied for many years and many of the antipsychotic medications used in treating schizophrenia try to affect the amount of dopamine in the brain. Glutamate is a chemical produced in the cerebral cortex and is necessary in the management of communication between the cortex and other regions of the brain. Changes in the production and transmission of these chemicals indicate they are probably involved in the development of schizophrenia.
Miller (2001) sums up the current view of the etiology of schizophrenia:
The picture … that emerges is a disturbance of processing and coordination in circuits that connect the cerebral cortex and the limbic system, with some involvement of the cerebellum and thalamus. Mutual responsiveness in these pathways is inadequate, communications are mistimed, and associations are misplaced. It becomes difficult to monitor correct language, thought, and behavior; to distinguish external from internal stimuli and significant from trivial information. (pp. 2–3)
Miller indicates much is still unknown about the etiology of schizophrenia. The interactions between genes, neurochemical processes, and the environment are very complex and in need of extensive further study.
HOW IS SCHIZOPHRENIA DIAGNOSED?
The American Psychiatric Association (2000) outlines the salient features required to make the diagnosis of schizophrenia. Included in the diagnosis are
1. the characteristic symptoms of schizophrenia (delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, and negative symptoms);
2. the presence of social/occupational dysfunction;
3. duration of symptoms for at least six months;
4. the ability to exclude the diagnoses of schizoaffective disorder and mood disorder; and
5. the ability to exclude the influence of a substance or medical condition as the cause of the symptoms.
The five subtypes of schizophrenia are: (1) paranoid type, (2) disorganized type, (3) catatonic type, (4) undifferentiated type, and (5) residual type. Each subtype is differentiated by the predominant symptoms present at the time of the evaluation.
Several tools are available to the clinician to aid in the accurate diagnosis of schizophrenia. The Structured Clinical Interview for the DSM-IV Axis-I Disorders, Clinical Version (SCID-I), is a structured interview schedule (First et al., 1997). The structured interview allows a clinician to walk through a specific interview schedule and obtain information relevant to the presence or absence of the diagnostic behaviors and thoughts indicative of the illness. Training is required to be able to appropriately use SCID-I in either a clinical or research setting. Another tool available is the Brief Psychiatric Rating Scale (Lukoff, Nuechterlein, and Ventura, 1986). Developed through research on people with schizophrenia, it allows a trained clinician to obtain information about the presence and severity of specific behaviors and thoughts related to the diagnosis of schizophrenia. Although not as structured as the SCID-I, it can be a useful tool for clinicians who need a format to more readily identify those individuals who may have schizophrenia or some form of psychosis.
THE IMPACT OF SCHIZOPHRENIA
The impact of schizophrenia can be considered from several different points: personal, social, and economic. Each point focuses on a different aspect of the illness and indicates the far-reaching effect this illness has on families, mental health professionals, and society as a whole.
The personal impact of schizophrenia is the greatest. Each day thousands of families must contend with the stress and strain associated with caring for someone with schizophrenia. Likewise, these ill individuals must contend with the social isolation, disrupted life development, and fear and anxiety brought on by the troubling symptoms and their aftermath. The influence and power of stigma, both for individuals with the illness and their families, can lead them to experience a powerlessness and isolation that directly affects their ability to cope with the illness. Families can experience grief, guilt, anger, humiliation, fear, and anxiety over the illness and over ill family members.
The social impact of schizophrenia can best be seen by the prevalence of homelessness and its associated problems in many communities around the country. Torrey (1997) indicates that, based on several large research studies, the number of homeless individuals in the United States was approximately 125,000 in 1980 and 402,000 in 1988. More recent estimates from the Urban Institute (2000) indicate approximately 3.5 million people will likely experience homelessness in a given year. This is a 300 percent increase over a span of eight years. The total population of the United States only increased 7.6 percent during the same time frame. A number of studies (e.g., Goering et al., 2002; Lehman and Cordray, 1993) indicate that nearly 75 percent of homeless individuals are mentally ill, and approximately 35 percent could be considered severely mentally ill. Many homeless individuals engage in illegal activity to obtain money for food, drugs, shelter, and clothing. Although the homeless mentally ill may commit crimes against other people, they are also prone to be victimized by others. Marley and Buila (1999, 2001) found people with severe mental illness to have much higher rates of victimization than the general population.
The economic impact of schizophrenia is often little appreciated by many mental health professionals and the general public. The major costs of schizophrenia can be figured from two perspectives: (1) the cost in dollars to care for these ill individuals, and (2) the cost in dollars of lost employment and productivity brought on by this devastating illness. The first cost has been well documented. In the United States, approximately one million people suffer from schizophrenia (about 1 percent of the population [Robins and Regier, 1991]). Yet these individuals account for approximately 75 percent of the total mental health services expenditures. Weiden and Olfson (1995) found the cost for inpatient treatment for people with schizophrenia in the United States in 1986 was about 2.3 billion dollars. The cost for read-mission following relapse was about 2 billion dollars. Due to the chronic and severe nature of the illness, many individuals rely on public aid or other government assistance to pay for their frequent hospitalizations and outpatient services. Many of these government assistance programs do not cover the true cost of providing intensive, high quality, long-term care for people with severe schizophrenia. As a result, many of these individuals receive inadequate care. In some cases, the families of people with schizophrenia must pay out of pocket for adequate care. This puts an additional burden on families whose coping skills are already stretched thin by trying to manage the day-to-day reality of caring for someone with schizophrenia.
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Families and Schizophrenia
HISTORICAL RELATIONSHIP BETWEEN THE ILLNESS AND THE FAMILY
The relationship between schizophrenia and the family has been long and contentious. Over the course of the past century in particular, families have had to endure numerous theories that have labeled them the cause of the illness. This was not always the case, and the emergence of such theories speaks to the growing frustration professionals face in understanding the illness and the need to exert power on the often-powerless families devastated by the illness.
In its original, or at least early, conceptualization, schizophrenia was understood as a biological illness. No mention was made of the family or its possible role in the development or course of the illness. In fact, throughout the eighteenth and nineteenth centuries, the focus of treatment for the bizarre symptoms of the illness (the term “schizophrenia” did not emerge until the twentieth century) was on the individual.
With the advent of psychoanalysis in the early twentieth century, and its adoption by American medical professionals, the focus shifted to early life events and the role of family on the development of psychopathology. Family, however, was essentially narrowed down to mean the mother and the mothering the ill individual received. As schizophrenia was considered a sign of severe regression to infantile or pre-oedipal functioning, the traumatic experiences thought to cause schizophrenia were believed to have happened in the earliest stages of life. Because mothers were considered the primary caregivers, failure to develop normally was seen as indicative of poor mothering. The term “schizophrenigenic mother,” coined by Frieda Fromm-Reichmann, has, unfortunately, continued to be an underlying assumption still found among some mental health professionals. The term implied that a particular type of mothering was the cause of schizophrenia. Although psychoanalysis continued to hold sway over the field through the 1950s, a new line of research raised some concerns about the relevance of psychoanalysis in understanding the etiology of schizophrenia.
The advent of medication to treat schizophrenia began somewhat by accident in the 1950s. These early medications were primarily considered major tranquilizers and simply sedated the individual with schizophrenia, thus making him or her easier to manage. As new medications were developed, more practitioners were again asking if schizophrenia really had its etiological roots in some biological process. Throughout the 1970s and up until the present, more research has focused on identifyi...
