Schizophrenia and the Evolution of Psychiatric Thought

Farrukh H Hashmi, MD

Introduction

• We will briefly discuss schizophrenia• We will then briefly explore a few of the

many questions it raises• Therefore, I do not claim to know the

answers! • “Why can’t psychiatry be more black and

white like the rest of medicine”?

Schizophrenia

• Severe, persistent psychiatric disorder characterized by psychosis, thought disorder and other symptoms

• Onset typically late adolescence or young adulthood, but variable

• Several subtypes of unclear significance• Paranoid, undifferentiated, catatonic,

disorganized

Schizophrenia

• Positive symptoms: hallucinations and delusions (psychosis)

• Hallucinations: sensory experiences without basis in reality

• Schizophrenic hallucinations typically auditory• Delusions: fixed false beliefs• Delusions and/or hallucinations: psychosis

Schizophrenia

• Positive and negative symptoms• Positive: psychosis• Negative: illogical thinking (thought disorder),

executive dysfunction, disturbed affect, loss of function, cognitive disturbance

• Phases: prodromal, active, residual

Schizophrenia• Affects both sexes equally• All known cultures and groups• Roughly 1—2% prevalence• Genetic component but no controlling gene(s)

identified• Involves dysfunction of dopamine circuits-

regarded by most psychiatrists as a brain disease• Typically chronic course with exacerbations;

more negative symptoms, cognitive loss with aging

Schizophrenia

• Often described as incurable, but various levels of recovery possible

• Outcomes may vary among cultures• Treatment typically involves antipsychotic

medications (dopamine blockers) which tend to affect positive symptoms but do little for negative symptoms

Treatment

• Antipsychotic drugs: many categories often grouped into “typical” and “atypical”

• Atypicals are the current class—arguably cause less parkinsonism than older drugs

• However, atypicals associated with weight gain, glucose intolerance and DM, metabolic syndrome, increased cardiovascular risk profile

• Current reexamination of their merits relative to older (and far cheaper) drugs

Medical Co-morbidity

• High incidence of obesity, hyperlipidemia, DM II, heart disease

• How much are atypicals responsible?• High rates of smoking as well as drug and alcohol

abuse• Low medical adherence rates• Adverse diets and lifestyles • USA: Dramatic reduction in life expectancy—by

15-20 years

Schizophrenia

• Schizophrenia is probably the most serious and disabling psychiatric disorder

• It is also the among the most controversial• Exploration of the history of schizophrenia

gives insight into the evolution of psychiatric thought

Statistics• 25% of all psychiatric beds are occupied by

persons with schizophrenia. • Roughly 1/3 of U.S $ is spent on the treatment

and medical needs of schizophrenics• The largest indirect cost associated with

schizophrenia is the loss of productivity over the lifetime.

• Suicide risk is between 4%-5.6%; higher with substances abuse.

• Schizophrenics have a higher chance of noncompliance due to lack of insight, distrust and paranoia.

Social Issues• Schizophrenics tend to have poor grooming and

hygiene• Between 25% - 60% schizophrenics live with

relatives and higher percentage rely on relatives for caregiving

• Those who don’t have relatives to care for them or have some sort of caregivers end up homeless and/or in jail. (10% - 20%)

• There is now abundant evidence to support combined pharmacological and psychosocial interventions that can improve social functioning.

Therapies • Rehabilitation – learn new skills and interpersonal skills for work• Patient and Family support system

– Educates entire family and gives them support in supporting the family member with schizophrenia

• Staying healthy which means eating right, exercising, staying clean and sober, taking medications as directed

• Individual therapy– Learn about their illness, what to expect and how to treat it and

deal with it, talk out past and present issues • Cognitive therapy

– Developing skills for attention, memory, planning and organization

Images of Schizophrenia (clockwise, from top left: John Nash, Jack Kerouac, Peter Green, Syd Barrett

Questions raised by Schizophrenia

• Are psychiatric disorders biological, psychological, or social in origin?

• Should they be regarded as medical problems?• Nature vs nurture• How about free will?• Mind/brain dualism• Have psychiatric disorders always existed in humanity?

• Have they changed or evolved as society has changed?• Politics and schizophrenia: “sluggish” schizophrenia

Questions

• Should society intervene in the lives of those labeled mentally ill, even against their will?

• Does mental illness lead to violence?• Do psychiatric disorders occur in discrete

categories (as implied by DSM-IV TR) or as a variety of symptoms each occurring as points on a spectrum from normal to abnormal?

• Does labeling patients lead to stigma?• Can schizophrenia be adaptive?

When did Schizophrenia Emerge?

• No consensus • Psychosis is described in many ancient texts,

but not clearly equivalent to modern concept of schizophrenia

• Middle ages: demonic possession, witchcraft, persecution (especially of women)

• Beginnings of asylums (“Bedlam”)

18th Century

• First case descriptions equivalent to modern concept of schizophrenia

• Enlightenment ideals applied sporadically to mentally ill (e.g., Pinel)

• Later authors (Foucault) claimed Enlightenment ideals actually marginalized, pathologized, or even “created” mentally ill

Kraeplin

• Emil Kraeplin (Germany) was the first great nosologist in psychiatry

• Kept records of symptoms and course of large numbers of chronically hospitalized patients and separated them into categories

• Popularized the term “dementia praecox” (1897) for early life onset psychosis and cognitive decline; to be distinguished from senile dementia

• Focused on mental deterioration, psychosis

Emil Kraeplin

Bleuler

• Eugen Bleuler (Switzerland) coined term “schizophrenia” (1911)

• He did not see severe cognitive decline in all patients and disliked the term dementia

• Regarded schizophrenia as a split between various aspects of the mind

• “Schiz”: split• “Phrene”: mind

Bleuler

• The “A’s”: associations, affect, ambivalence, autism

• “Loose” associations• Blunted/flat/inappropriate affect• Ambivalence: inability to make decisions• Autism: self-involvement, fantasy world• Deemphasized critical importance of psychosis

Eugen Bleuler

Dissociative disorder

• Note: schizophrenia is not to be confused with “split personality”

• Split personality: multiple personality or dissociative identity disorder

Schneider

• Kurt Schneider added another element to the definition (1920s): “first rank symptoms”

• FRS: thought insertion, thought withdrawal, delusions of control, ideas of reference

• “bizarre or patently absurd” delusions which are impossible, as opposed to paranoia or other delusions which could theoretically be reality based

Kurt Schneider

Asylum Era

• In the USA, the most seriously ill were grouped in asylums

• Kentucky had a number, of which 3 were most important still exist

• Central State, Eastern State, Western State• Every state has one or more• Over 500,000 by about 1950• Warehousing

Central State Hospital“Lakeland”

US Diagnoses-20th Century

• Americans adopted a very broad concept of schizophrenia, incorporating all the previous ideas; schizophrenia much more commonly diagnosed in US

• Virtually any chronically mentally ill person might have been diagnosed as schizophrenic

• DSM-I and DSM-II very broad, loosely described categories; psychoanalytic concepts

Lobotomy

• Prefrontal leucotomy (“lobotomy”) popularized by Moniz (Portugal) and Freeman (US) in 1930s-1950s.

• Largely used for agitated schizophrenics• Cautionary tale

Walter Freeman and Egas Moniz

Deinstitutionalization

• 1950s-1960s• Advent of first antipsychotic drugs• Chlorpromazine (“Thorazine”)• Patients rights and liberation movements• Community mental health movement• Backlash against medical model• Antipsychiatry movement• Dangerousness criteria and due process in

commitment laws

1950s-1960s-Psychosis as Personal Struggle

• RD Laing: schizophrenia as a search for meaning: “Being sane in an insane world”

• Bateson: The “double-bind hypothesis”; the “schizophrenogenic” mother

• Thomas Szasz: “The Myth of Mental Illness”• Foucault : “Madness and Civilization”• Pirsig: “Zen and the Art of Motorcycle

Maintenance” • Denber and others: LSD experiments

R.D. Laing and Thomas Szasz

Robert and Chris Pirsig

DSM-III (1980)• Biological research in schizophrenia• Development of criterion based diagnosis• Narrowing of diagnosis• Advent of lithium---backing in to diagnosis • Dissatisfaction with DSM-II• Reaction to antipsychiatry movement• DSM-III was a revolution in psychiatric practice• Introduced diagnostic criteria, multi-axial diagnosis;

considered validity and reliability, ended reliance on analytic concepts

• Assumed categorical diagnoses• Did not end controversy—think Scientology!

DSM IV TR

• Is a disorder that lasts for at least 6 months and includes at least 1 month of active-phase symptoms

• delusions, • hallucinations, • disorganized or catatonic behavior, negative

symptoms• Subtypes: paranoid, disorganized, catatonic,

undifferentiated and residual

• Two or more of the following, each present for significant portion of time during a 1 month period of time (or less if successfully treated).

1. Delusions2. Hallucinations3. Disorganized speech (frequent derailment or incoherence) 4. Grossly disorganized or catatonic behavior5. Negative symptoms (diminished emotional expression or

avolition).

DSM 5

Atypical Antipsychotics (1990s-current)

• “Atypical” refers to lack of parkinsonism• Thought to be breakthrough• Zyprexa, Risperdal, Seroquel, Geodon, Abilify,

Invega• Growing concerns about effectiveness, cost,

side-effects• Heavily promoted--contributes to concerns

about role of Pharma in psychiatry

Genetics

• Search for “gene for schizophrenia” proved fruitless

• No longer considered to be a simple genetic disorder

• Probably a number of genetic influences on a variety of cellular processes

• Controller genes which switch on/off during development, or with environment may be involved

Genetics

• Bipolar and other mood disorders probably share some common genetics

• Schizophrenia probably not a unitary disorder from a genetic viewpoint

• Leading to reexamination of assumptions about boundaries of disorders

Critics of Psychiatry

• Today’s critics focus on overuse of medications, over-involvement of Pharma

• Patients’ groups seek autonomy and normalization: “voice hearers” associations, “Morgellon’s” support groups

• UK-move away from categorical diagnosis to dimensional approach, seeing symptoms in context of patients’ life, paying attention to content of delusions

Emerging Thoughts

• Brain as a plastic instrument—synthesizing genetic and experiential inputs into its anatomy, physiology, and psychology

• False dichotomies: nature/nurture; mind/brain, etc.

• Limits of pharmacotherapies• Search for new integrative paradigm to better

understand dimensions of schizophrenia• Patient as partner rather than object