Schizophrenia, a most devastating mental illness, is as well the most over diagnosed entity in medicine, at least by North American physicians. It is a disturbance of mind and personality appearing in clear consciousness and characterized by several distinctive alterations in mental experiences, thinking capacity, and mood that are seldom completely resolved. The most characteristic features occur during the active phases of the disturbance, and take the form of hallucinations, delusions, and altered behavior toward others. Specific intellectual and affective disabilities varying from minimal to severe can develop insidiously or remain after an attack. A crucial element of the definition is that all these symptoms occur in a patient free of any relevant and discernible pathologic change in his nervous system.
Clinical Manifestations of Schizophrenia.
The symptoms of schizophrenia can begin at almost any stage in life, but most commonly occur during adolescence and early adulthood and then either insidiously or as an acute attack followed by a series of attacks, each leaving behind personality defects of increasing severity.
In some patients it is possible to recognize a particular premorbid personality. They may have seemed more timid, shy, or seclusive than others. They may have, been bookish, unsociable, and preoccupied with philosophic and religious ideas to the exclusion of friendships and community experiences. But this so-called schizoid personality is not found in most patients who develop schizophrenia. At least half of schizophrenic patients had premorbid personalities indistinguishable from normal.
Among the mental changes that mark the onset of a schizophrenic illness, only some are specific to this disorder. Emotional unrest, uncertainty, perplexity, and confusion can be found in many disorders other than schizophrenia, and therefore a diagnosis of schizophrenia cannot rest on them. There are, however, a number of mental changes that are more or less diagnostic. These can be usefully divided into abnormal mental experiences and disturbed modes of expression. The abnormal mental experiences are somewhat more reliable evidence of the illness simply because they are easier to elicit with confidence and less dependent upon interpretation than disturbances in expression.
Hallucinations, and delusions are the outstanding schizophrenic mental experiences. Although hallucinations can arise in any sensory system, auditory hallucinations are the most common, and certain forms of auditory hallucinations are almost diagnostic. Thus, hearing one’s own thoughts, hearing voices commenting about one’s every action, or several voices engaged in a conversation about one in which derogatory and praising remarks are passed with the patient discussed in the third person are the most typical schizophrenic experiences.
Although delusions, i.e., false beliefs that are incorrigible, idiosyncratic, and preoccupying, can be found in many disorders other than schizophrenia, in this illness delusional experiences are dramatic and well-developed. They can begin as vague, fearful interpretations and “half-beliefs” and develop into firm incorrigible convictions. A delusion coming on suddenly, not prompted by any hallucination or previous delusion, nor related in any obvious way to the patient’s mood, is called a “primary delusion” and is highly suggestive of schizophrenia. Many other schizophrenic experiences are of delusional form, but have such individual characteristics that they have been named for themselves.
Common schizophrenic symptoms are the so-called passivity experiences or delusions of bodily control. The patient feels as though he were under the control of some outside force or power making him behave as an automaton without a will of his own. He may feel hypnotized and feel forced to make particular movements, speak with a special voice, or walk to certain areas. The patient may. believe these feelings come to him as penetrating waves from electronic or telephonic equipment.
The schizophrenic patient may experience changes in his thinking. Particularly he may feel that his thoughts are disrupted by some outside agency, that his thoughts are withdrawn from his mind, or that other thoughts are inserted into it. He may believe that people can hear his thoughts, which are leaving his mind as waves broadcast to others.
In contrast to these abnormalities of experience are the disturbances in the patient’s mode of expression. Particularly noticeable is his abnormal language. Characteristically, he is difficult to understand. His thinking is expressed in a vague and awkward fashion with words poorly chosen and ideas poorly related to one another. Strikingly, the patient makes no effort to correct the vagueness of his thinking or to improve the clarity of his talk. Often, asking a question of the patient, the examiner receives a reply that is off the point and that goes into unnecessary details.
Although the questions of the interview seem to start the patient toward a particular answer, it is never reached, but the patient takes up abstract and unnecessary ideas and must be redirected toward his goal. The examiner, laying” the responsibility for the confusion on himself, may work to express himself more clearly, and only after considerable effort recognize that the difficulty in communication rests with the odd replies from the patient.
Another prominent disturbance is emotional expression of these patients. They seem distant, unresponsive, and cold. On some occasions the patient’s emotional attitude seems incongruous, particularly for the thoughts he is expressing. Thus, he may laugh while saying that he is in mortal danger. This cold or incongruous attitude and manner give the schizophrenic patient his most striking features, and even when at their mildest can be baffling and distressing symptoms to his family.
Other abnormal modes of expression of the schizophrenic patient are disturbances in stance and mobility called catatonic symptoms. Gestures may seem stiff, slow, and mannered. Some schizophrenic patients make repetitive movements or facial grimaces. Others may become totally immobile and mute. Still others may assume unnatural postures and hold them for long periods.
During the active phases of the schizophrenic illness the flamboyant subjective experiences are most prominent. During the chronic phase of schizophrenic illness expressive disturbances in thought and emotion are more evident, varying from mild to severe. Although at times some patients seem free of residual symptoms, usually a careful examination will reveal mild disturbances in thinking and emotional responsiveness.
Diagnosis of Schizophrenia.
The diagnosis of schizophrenia rests on recognition of the distinctive clinical symptoms of this disorder and the exclusion of other conditions which may produce similar symptoms.
Many disorders of brain function can imitate schizophrenic symptoms; but with the exception of the three schizophrenia-like disorders to be discussed, the other brain disturbances also manifest disturbed consciousness, disorientation, and disruption of cognitive abilities, particularly recent memory function, that are not found in schizophrenia.
Mania or depression can be confused with schizophrenia (to the considerable embarrassment of the diagnostician when the patient recovers completely on receiving the treatment appropriate for these conditions). A source of difficulty is the occurrence of delusions, which are common enough but usually spring directly from the attitudes of self-confidence or self-blame that are so prominent in mania or depression.
In schizophrenia disturbances in experience, including the auditory hallucinations and delusions just described, form the most secure basis for diagnosis. Thus, in a person free of brain disease or drug intoxication, recognition of formed auditory hallucinations, primary delusional experiences, passivity experiences, or disturbances in “thought control” permit the diagnosis of schizophrenia to be made with some confidence.
If these symptoms cannot be found, then diagnosis must rest upon recognition of manifest disturbances in thought and emotional expression. It should be pointed out, however, that opinion holding a person; thought to be illogical and vague, or his affective responses to be inadequate or incongruous, is an evaluative judgment and must be held with somewhat ‘less confidence than opinion resting on recognition of delusions and hallucinations.
Catatonic symptoms of immobility, posturing, and grimacing, along with the disturbances in behavior described as negativism :r reluctance to cooperate, must be carefully interpreted Only in those patients in whom no evidence of a prominent mood change can be found should a diagnosis schizophrenia be made. Motility changes is the direction of psychomotor retardation are prominent features of depressive disorder, a condition as common as schizophrenia and more common than the catatonic variety of schizophrenia. As a rule of thumb, it can be stated that four of five patients who have psychomotor retardation as a prominent symptom suffer from depression.
Symptoms of emotional unrest, anxiety, withdrawal, hostility, and hyperactivity can be found in schizophrenic patients, but these are common to many other psychiatric disorders, and therefore can never form the basis for a secure diagnosis of schizophrenia. However, that diagnosis is rendered more likely if it can be established that the patient was developing normally without an apparently vulnerable personality, and if these symptoms appeared without a change in the patient’s mood or the pattern of his life.
Karl Jaspers made this important point first when he pointed out the distinction between a paranoid illness disrupting a life course without obvious predispositions and the development of jealousy and auspiciousness in an individual who had always been insecure, sensitive, and irritable. Since these more general symptoms can be found in both schizophrenia and many other psychiatric disturbances, it is important to search carefully for the more basic symptoms of hallucinations and delusions from which emotional unrest and unpredictable behavior may stem. Often repeated efforts are required to gain cooperation of the patient so that he will divulge the existence of those basic symptoms that make a diagnosis of schizophrenia certain.
Causes And Requisite Elements In Schizophrenia
The genetic constitution has been decisively demonstrated to be one of the “causes proper” in schizophrenia. The risk of schizophrenia increases with the closeness of blood relationship to a schizophrenic patient. Thus only 1 per cent of very distant relatives of a schizophrenic patient will themselves suffer from the disorder. This is no higher than the risk in the general population. But 5 to 6 per cent of siblings and 40 to 50 per cent of monozygotic twins of schizophrenic patients will have schizophrenia.
The possible objection that these data merely reflect the increasingly common environment of progressively closer relatives has been refuted by observations on monozygotic twins brought up apart who continue to show an identical high risk. Heston made the same point in a different fashion by studying a group of offspring of schizophrenic mothers. These particular children were raised from earliest infancy in foster homes by normal, non schizophrenic mothers and fathers. The incidence of schizophrenia in these children was exactly the same as that reported for children raised by a schizophrenic parent. They thus resembled their biologic mother although reared apart from her.
It has nevertheless been impossible to fit schizophrenia into a clear Mendelian pattern of dominant or recessive inheritance. Some students of the disease would describe the hereditary contribution to schizophrenia as polygenic, i.e., the sum of a number of contributions from the genes no one of which is solely responsible. The polygenic concept might permit environmental factors to play a larger role in causation. Thus a mild genetic vulnerability might express itself in a schizophrenic phenotype only in those who face stressful environments, whereas those carrying a more severe genetic vulnerability might show the disorder in any environment. It is difficult at the moment to propose a test that would exclude a polygenic hypothesis as a possibility.
Some studies that have established a genetic contribution to the etiology of schizophrenia have also given evidence of the inadequacy of genetics as a sufficient cause for the disorder. That 50 per cent of monozygotic twins of schizophrenic patients are free of this illness means one of the following: (1) Although the genetic constitution is necessary and sufficient to produce schizophrenia, the symptoms employed to define a case fail to provide an adequate means of recognizing all examples of the disorder, and 50 per cent are mistakenly called normal. (2) The defining symptoms encompass a mixed group of disorders, and in only 50 per cent of these disorders are genetic features necessary and sufficient causes for the symptoms. (3) A genetic vulnerability for schizophrenia is necessary but not sufficient. It must be combined with certain life experiences that need not be common for genetically identical individuals.
The present inadequacy of the genetic hypothesis to provide a complete description of the “causes proper” for schizophrenia reinforces a search for environmental and experiential causes. It has proved just as difficult to determine an environmental contribution as to define the genetic contribution! Thus the experiences of being raised by a cold and distant mother, or of receiving insistent, simultaneous, but incompatible directions from the parents, or of simply living in a disharmonious family incapable of providing a healthy environment for psychologic growth have all been considered causes of schizophrenia.
Such disturbed experiences have been found in the lives of schizophrenic patients when viewed retrospectively after the onset of the illness. But none has proved to be a common experience in all schizophrenic people. Nor has it been possible to predict an increased incidence of schizophrenia among other individuals living in comparably disturbed situations. Presently the most economical view of the role of life experiences in the “causes proper” of schizophrenia holds that any adversity, be it a psychological shock, abnormality in critical relationships, or physical injury, may provide a partial contribution to the causes of schizophrenia, but that any given adversity must be acting upon a genetically vulnerable individual.
Mediation of the Schizophrenic Syndrome.
This is the other aspect of etiology. Given that some combination of genetic and environmental attributes may be needed to produce this illness, how does this mediate its development? Does it do so by altering some psychological capacity or by producing some particular change in the nervous system, or still more remotely by altering some vital chemistry of the body that itself can act on the brain? There have been proposals for each of these mediations.
Many distinguished psychiatric studies have proposed that the mediation of the disturbance has been through the production of a particular psychologic change fundamental to the whole syndrome and from which all the symptoms can be explained. Thus Federn has proposed a “loosening of ego boundaries” as the essential feature mediating this illness, whereas Bleuler proposed a basic disturbance in associational thinking. A crisis of identity has been proposed by exponents of existential psychiatry. These views have a ring of plausibility perhaps derived from their resemblance to experiences common to all men, part of which can seem to be reflected in the behavior of schizophrenic patients. But they depend on concepts that are difficult to define except in terms of what they purport to explain.
Other psychiatric studies have attempted to demonstrate the possibility that the mediation of the causal formula is through some change in the central nervous system. The main problem for this approach lies in our ignorance of the physiology of that part of the nervous system related to emotional life.
The treatment for any schizophrenic patient is complex and should not be attempted by the inexperienced. A period of hospitalization will usually be required. There a program to include drug therapy, psychologic treatment, and social evaluation can be planned.
The sheet anchor of treatment now for schizophrenia is the phenothiazine drugs, discovered in the 1950’s almost by accident. To date there is no good explanation for their effectiveness. Clearly they are not simply acting by virtue of their sedative effect, since their remarkable action is not mimicked by other sedatives. They can remove the symptoms of schizophrenia, including the delusions, hallucinations, and disordered thought, and are not restricted to relieving excitement or anxiety as the term tranquilizer might imply.
The most versatile phenothiazine preparation is the original, chlorpromazine. effective in amounts from 200 to 1000 mg. per day. Usually 300 to 400 mg. is an effective range, although at first larger amounts may be needed. A maintenance dosage of 200 to 300 mg. per day should be continued indefinitely for every patient who has had a diagnosis of schizophrenia, since cessation of treatment results in the reappearance of symptoms in 60 to 70 per cent of patients within six months.
The psychotherapy suitable for the schizophrenic patient has been a subject of intense controversy. The more radical approaches based on psychologic and particularly psychoanalytic views of the genesis of schizophrenia have not achieved their optimistic goals of curing the patient by relieving some basic psychologic conflict. More modest psychotherapy is indispensable when it is intended to help the patient in his everyday affairs, taking advantage of those personal assets that persist despite his illness, and establishing a relationship of friendly rapport in order to guide him in his management of personal and social issues, which, if mishandled, can lead to distress and further illness. A particularly pressing issue for the schizophrenic patient is the social situation into which he is placed after hospitalization.
His psychiatrist, usually at first with the help of a psychiatric social worker, must strive to find a job that is regular and well within the patient’s power but not excessively challenging, a domestic arrangement that is calm and supportive but not to emotionally demanding, and a daily routine that combats the tendency to withdraw from all social contacts into an isolated and perhaps fantasy ridden existence.
To accomplish these goals is one of the most challenging exercises in medical treatment. The growth of “halfway houses” as residences for previously hospitalized schizophrenic patients has been prompted by recognition of the need for stable and structured social environments for schizophrenic patients once they have improved enough to leave the hospital.
Prognosis for any patient diagnosed as schizophrenic is always guarded. Before the advent of pharmacologic treatment only 20 to 25 per cent of patients could be expected to recover completely from an attack of schizophrenia, and such patients were always vulnerable to further difficulties later. The other 75 per cent did not recover completely, 50 per cent showing residual signs from mild to severe, and 25 per cent becoming severely and chronically deteriorated in thought and mood. The phenothiazines have considerably reduced the morbidity in schizophrenic patients, but the exact degree is not clear.
Certain features carry a rather good prognosis. Thus, if a patient had an apparently normal personality prior to the illness, his prognosis is better than one with a schizoid personality. If the illness came on acutely and dramatically, prognosis is better than if the illness began insidiously. If catatonic features are prominent, the prognosis is better than if disturbances in thinking and affect are the more prominent symptoms. Finally, if the patient has a family history not of schizophrenic illness but of a manic-depressive illness, or if his particular attack has prominent depressive or manic symptoms, his prognosis is better than that for individuals without these features.