Schizophrenia and the Evolution of Psychiatric Thought

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Schizophrenia and the Evolution of Psychiatric
Thought

• Farrukh H Hashmi, MD

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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 cant psychiatry be more black and white
  like the rest of medicine?

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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

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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

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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

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Schizophrenia

• Affects both sexes equally
• All known cultures and groups
• Roughly 12 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

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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

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Treatment

• Antipsychotic drugs many categories often
  grouped into typical and atypical
• Atypicals are the current classarguably 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

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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 expectancyby
  15-20 years

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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

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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.

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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 dont 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.

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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

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Images of Schizophrenia

• (clockwise, from top left John Nash,
  Jack Kerouac, Peter Green, Syd Barrett

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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

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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?

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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)

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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

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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

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• Emil Kraeplin

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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

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Bleuler

• The As 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

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Eugen Bleuler
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Dissociative disorder

• Note schizophrenia is not to be confused with
  split personality
• Split personality multiple personality or
  dissociative identity disorder

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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

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Kurt Schneider
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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

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Central State HospitalLakeland
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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

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Lobotomy

• Prefrontal leucotomy (lobotomy) popularized by
  Moniz (Portugal) and Freeman (US) in 1930s-1950s.
• Largely used for agitated schizophrenics
• Cautionary tale

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Walter Freeman and Egas Moniz
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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

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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

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R.D. Laing and Thomas Szasz
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Robert and Chris Pirsig
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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 controversythink Scientology!

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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

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DSM 5

• 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).
  
• Delusions
• Hallucinations
• Disorganized speech (frequent derailment or
  incoherence)
• Grossly disorganized or catatonic behavior
• Negative symptoms (diminished emotional
  expression or avolition).

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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

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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

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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

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Critics of Psychiatry

• Todays critics focus on overuse of medications,
  over-involvement of Pharma
• Patients groups seek autonomy and normalization
  voice hearers associations, Morgellons
  support groups
• UK-move away from categorical diagnosis to
  dimensional approach, seeing symptoms in context
  of patients life, paying attention to content of
  delusions

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Emerging Thoughts

• Brain as a plastic instrumentsynthesizing
  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