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After reading this article we will learn about:- 1. Origin of Schizophrenia 2. Definition of Schizophrenia 3. Fundamental Characteristics 4. Specific Characteristics 5. Alternative Classification 6. Process Schizophrenia 7. Theories 8. Aetiology 9. Organic Factors 10. Constitution 11. Explanations 12. Treatment 13. Functional Explanation.
Contents:
- Origin of Schizophrenia
- Definition of Schizophrenia
- Fundamental Characteristics of Schizophrenia
- Specific Characteristics of Schizophrenia
- Alternative Classification of Schizophrenia
- Process Schizophrenia
- Theories of Schizophrenia
- Aetiology of Schizophrenia
- Organic Factors of Schizophrenia
- Constitution of Schizophrenia
- Explanations of Schizophrenia
- Treatment of Schizophrenia
- Functional Explanation of Schizophrenia
1. Origin of Schizophrenia:
Schizophrenia is the most common form of psychotic behaviour, characterised by “breakdown of integrated personality function, withdrawal from reality, emotional blocking, distortion and disturbances of thought and behaviour”. It is in-fact, the most serious, bizarre disabling and widespread of all behavioural disorders. It is otherwise known as Dementia Praecox.
As reported by Babigian, (1975), Mosher and Fein-silver, (1971), it has been estimated that between 180,000 and 200,000 new cases of Schizophrenia are diagnosed each year in the United States. About 2 million Americans suffer from some form of schizophrenia at any time. Finally, it has been estimated that there are about 10 million Schizophrenic people.
The mental symptoms of a 13 year old boy led Morel, the Belgian psychiatrist to describe the case as dementia praecox meaning mental deterioration at an early age. He held that due to hereditary causes the mental, emotional and physical functions of the patient deteriorate.
German psychiatrist Emil Kraepelin later used this term to refer to serious behavioural disorders beginning early in life. Analysis of ancient Indian scriptures and Ayurveda also has a reference to this disorder.
Kraepelin believed that schizophrenia was caused because of the malfunctioning of the sex glands which ultimately produced chemical in-balance affecting the neuroses system. He also believed that it begins in adolescence.
Blueler (1911) later on introduced the term schizophrenia to designate all cases of functional mental disturbances. However, he partly agreed with Kraepelin and partly differed from him. He agreed this disorder as organic, but he was not ready to agree that it begins in adolescence and cannot be cured.
As a matter of fact, schizophrenia is found to begin from the early childhood. Very calm and quiet children, ideal and model with no problem for the parents, sitting, playing and reading by themselves become the victims of schizophrenia. Though it may occur at all ages from childhood to senility, it is essentially a disease of early adulthood.
Thus, Blueler introduced the term Schizophrenia to designate all cases of functional mental disturbances. The abnormality is centred around the emotional behaviour and thinking of the individual. It is called functional psychoses, as up-to date no proper organic cause of this widespread disease has been established.
Schizophrenia is a disease, most often found in the civilized countries. It is called by some as a civilized disease. Having a slow insidious onset, and higher rate of incidence, it lasts for longer, have fewer recoveries and most difficult for the patients and his relatives to understand.
2. Definition of Schizophrenia:
Bleuler (1911) described schizophrenia in a more acceptable and descriptive term. He used the term schizophrenia meaning splitting of personality characterized by lack of coherence in-associative thought processes, emotional blunting, withdrawing to the self away from the reality.
Bleuler pointed out the most important features of this disease to be splitting of the various aspects of personality and so he called this more appropriately schizophrenia.
Schizophrenia, in fact has been defined differently by French, British, American and Russian psychiatrists. Janet included different kinds of schizophrenia under psychosthenia and the French followed Janet by not including acute delusional and acute confusional states under schizophrenia.
As found in DSM II, the American definition of schizophrenia is a thought disorder marked by hallucinations, delusions and mood disorders and disturbed behaviour. Contrary to this the British definition includes disorganisation and disturbances in personality, disturbances in thinking and unpleasant sensations.
According to Coleman (1981) the term schizophrenia includes a group of psychotic reactions in which there are fundamental disturbances in reality.
Shanmugam (1981) opines that “Empirical studies of the American and British diagnostic methods have revealed that it is better than American one. The fact of the existence of different types of diagnostic criteria itself indicates, the general nature of schizophrenic disorder and the difficulty in arriving at a single effective method of diagnosis.”
A historical analysis of various definitions of schizophrenia reveals that while the French orientation continues in Belgium, Argentina and Iran; the U.S.A., the U.K. and India by and large included chronic delusional and acute confusional states under schizophrenia.
In U.S.S.R., though the French orientation privatized for a long time, currently Bleuler’s approach is more often than not followed. Germany and other continental countries according to Kolb (1977) however follow their own definitions and methods of diagnosis.
Four modern Psychiatrists who contributed to schizophrenia were Adolf Meyer, Harry Stack, Sullivan, Gabriel Langeldt and Kurt Schneider. Meyer, the founder of psychobiology believed that schizophrenia and other mental disorders were reactions to a variety of life stresses. Sullivan, the founder of interpersonal Psychoanalytic school stressed on social isolation as both a cause and symptom of schizophrenia.
Langfeldt divided the disorder into true schizophrenia and schizophrenic form Psychoses. The diagnosis of true schizophrenia rests on the findings of depersonalization, autism, emotional blunting, insidious onset and feelings of de-realisation and unreality. True schizophrenia is often referred to as nuclear schizophrenia, process schizophrenia or non-remitting schizophrenia.
Kurt Schnedier described a number of symptoms of schizophrenia that he considered in no way specific for the disease but of great use in making a diagnosis. His first rank symptoms include the hearing of one’s thoughts, spoken aloud, auditory hallucination, somatic hallucination, delusions and the experience of having one’s actions controlled and influenced from the outside.
He further maintained that schizophrenia can be diagnosed exclusively on the basis of second rank symptoms. Second rank symptoms include other forms of hallucination, perplexity, depressive and euphoric disorders of effect and emotional blunting.
3. Fundamental Characteristics of Schizophrenia:
The symptoms and characteristics of schizophrenia are very baffling and varied. This makes diagnosis a difficult job. Moreover, two different types of schizophrenics are not similar in their symptoms.
However, though the symptoms vary from type to type, the different types of schizophrenics share certain common characteristics for all the varieties. Schizophrenia begins with slight dizziness, headache, temporary in attention, momentary irregularities in speech and periods of loss of interest.
As Jung holds, such persons who like solitude are very seclusive, lonely and introverted from the very childhood. They are usually very calm and quiet type and ideal children of the family. They are usually intellectually superior.
But when they proceed to adulthood, they generally become indifferent, withdraw from the environment and being extremely imaginative like to build castles in the air, sink in their own fantasy and day dream.
As the disease progresses, serious symptoms are found. The most prominent symptoms are failure of affect, emotional blocking, apathy, indifference and suggestiveness. The disharmony between mood and thought is another depressive feature of the schizophrenics.
The patient is always clouded with a feeling of failure and he does not seem to appreciate joy or sorrow or fear. His attitude is rather one of indifference and apathy. The schizophrenic lives in a life in which his relatives, friends and physicians can get in touch with him.
Defects in thinking and emotion and disorder in speech is marked. A schizophrenic patient feels that the whole world centres around him. An interesting characteristics of schizophrenia arises due to in attention and lack of concentration.
Bleuler (1930) has emphasised 4 common fundamental characteristics of schizophrenia:
1. Disturbance of affect
2. Disturbance of association
3. Disturbance of activity
4. Presence of behaviour that is autistic (detached from reality).
However, these characteristics known as the 4 ‘—A’ has been of little interest to modern diagnosticians, though, no doubt they have some historical importance.
Current specialists in the area generally consider schizophrenia to be a conglomerate dysfunctions in six important areas, such as in the general, behavioural, perceptual, cognitive, affective and verbal realm of human behaviour.
I. General Dysfunctions:
The general dysfunctions are most common in most schizophrenic people.
According to Lehmann (1975) 5 special characteristics are associated with schizophrenics:
(a) Symbolism, i.e., the increased use of indirectly related patterns in speech, thought and behaviour.
For instance, using Lord Krishna as a symbol for some one important to her, one may worship Lord Krishna instead of worshipping the person itself.
(b) Hypersensitivity to sensory and emotional stimulation lead to schizophrenics to respond strongly to sensory stimulation than normal people.
(c) Withdrawal — More often than not usually the schizophrenic person is separated and alienated from others and frequently cannot establish close relationships.
(d) Loss of ego boundaries:
Commenting on the schizophrenics Duke and et al. (1979) view “they are unable to know where I ends and you begins. Thus, schizophrenics may believe others can read their minds and understand their bizarre speech.” Conversely, some schizophrenics may feel they can read others thoughts. In extreme cases of ego boundary, people may see themselves as being merged or fused with objects such as rocks or T.V. sets.
(e) Variability:
In addition to the above characteristics, the last general characteristic of schizophrenia is variability which refers to the frequent unpredictability and inconsistency of schizophrenic behaviour. In contrast to the normal people, the behaviour and actions of schizophrenics are very unpredictable and one cannot assume what they will do next.”
II. Behavioural Dysfunctions:
Though behavioural dysfunction varies from person to person, they can be divided into 4 general kinds:
(i) Psychotic mannerisms:
Such as eyes may be held in a downward or skyward gaze and he or she may exhibit a wry smile. Such mannerisms may have little importance for one who observes, but they may be very meaningful to the schizophrenic person. Thus, they show strange mannerisms.
(ii) Cehopraxia or the mimicking of behaviour seen in others and they never realize the unfavourable effect of such behaviour on those who are mimicked.
(iii) Stereotyped behaviour. This refers to repetition of self initiated behaviour like pacing back and forth between two doors, counting a particular number through finger for a long time etc.
(iv) Untidy appearances and poor social manners. For days and months together, patients do not take bath or wash themselves. They appear to be very dirty, clothing sometime being soiled with feces and urine; furthermore, they do all these being completely oblivious of the surrounding and people around them. They are least socialized and in fact poor in this respect. They for instance do not respond a smile with a smile.
III. Perceptual Dysfunctions:
Lchmann (1975) has described that schizophrenic people may show distortions in or absence of accurate perceptions of the real world. “Perceptual disturbances include hypersensitivity to light, changes in perception of other people’s faces, misperception of movement; hypersensitivity to sound or smell or taste”.
Among all the perceptual dysfunctions, hallucination is most common. It may be of sound, vision, taste or smell, auditory being the most frequent type of hallucination followed by visual, such as hearing the voices of Gods and Goddesses, talking, screaming, worshipping etc.
IV. Cognitive Dysfunctions:
Otherwise known as cognitive disturbances, it refers to ideas or thoughts that have no basis in reality i.e., false ideas without sound basis. These are called delusions and dysfunctions of thinking. Delusions are wrong or false beliefs which cannot easily be corrected by discussion or logical argument.
The content of delusion can vary widely and their bizarreness is apparent to normal people, even to the other schizophrenics, such as delusion of influence i.e., making one to do certain things against his will.
(a) Delusion of grandeur:
Such as the belief that one is really a great figure of the world or country like king Napoleon, Prime Minister of India or queen of England.
(b) Delusion of persecution:
The belief that one is being actually persecuted or troubled by some individuals or groups
(c) Delusion of reference:
The belief that he is so important that others are talking about him, referring to him in important discussions, news items and T.V. coverage’s etc.
(d) Delusions of bodily change:
A belief that one’s body is changing in some unusual way like male or female or fingers growing bigger and bigger day by day etc.
(e) Delusion of nihilism:
This refers to a belief that nothing really exists, that all things are simply shadows.
These delusions are based on false belief and faulty logic.
Thought disturbances also include the use of special rules and logic called, “Paralogic” like “Ram was a good king. I am good. Therefore, I am Ram.”
Similarly, Made, Blanco (1959) have described what is called the pathological symmetry of schizophrenic like logic such as Jagat is Mohan’s father. So Mohan is Jagat’s father.
In addition to this, thought disturbances have also been ascribed to other factors besides faulty logic.
Payne (1966) has stated that schizophrenics cannot easily discriminate unnecessary stimuli and hence have difficulty in emphasizing on the important aspects of a situation. Shakow (1971) believes that “the schizophrenic person has difficulty in responding to irreverent stimuli and therefore may experience constant interruption in thought processes, for this reason it is characteristic of many schizophrenics to stop in the middle of a thought and change to a new topic.”
V. Affective Dysfunctions:
Emotional blunting or reduced emotional responsiveness is most noteworthy among the affective disturbances. They are very apathetic and flat in responding to situations with normal level of feeling.
According to Venables and Wing (1962) schizophrenic people may be so involved with responding to internally generated stimuli that they cannot respond to anything else. On the contrary, Mednick (1958) stated that schizophrenics actually protect themselves from stimuli with which they cannot cope “by themselves off.”
In appropriate emotional responses also characterize affective dysfunctions specially in advanced state of the disease. For example, while everyone is laughing at a hilarious example one may to the utter surprise of others, cry. Appropriate affective responses and reduction of blunting are signs of recovery of the disease.
VI. Verbal Dysfunctions:
Verbal deficits like a distortion of speech and language are the first signs of schizophrenia showing deviation from normal conversation. Mutism, i.e., complete in capability to produce a sound from a few hours to several years. Echolalia, i.e., repetition of the most of the words of the question such as;
Q. What are you doing?
Ans. I am doing nothing.
Q. Are you alright today?
Ans. Yes, I am alright today.
Incoherent speech:
Creation and coin of new words, etc. Verbigeration-senseless repeating of the same word for hours or even days.
4. Alternative Classification of Schizophrenia:
Schizophrenia at different times is classified to different subtypes and categories representing different specific symptoms. According to Duke and Nowicki (1979) “the diagnostic subtypes of schizophrenia are determined primarily by the content of symptoms and variation in the fundamental characteristics of schizophrenia.”
Schizophrenia was classified into malignant (typical) and benign (atypical) types, which are to-day renamed as Reactive and Process Schizophrenia. These terms were first used by Jasbers to refer psychoses in general but were subsequently applied to schizophrenia also.
The process versus reaction dimensions system suggests that only these 2 sub-groups can be delineated within the population of schizophrenia. These two types are used to refer to schizophrenic types where constitutional reactions seem to play the most dominating role in which environmental, stresses appear of greater importance.
Reactive schizophrenia has a sudden onset, occurs periodically and has a favourable prognosis or good chance of recovery.
5. Specific Characteristics of Schizophrenia:
The common disorders and symptoms of schizophrenia can be classified; under the following two broad divisions such as mental and motor characteristics.
i. Mental Disorder:
Disorder in thinking is the most prominent and significant among all the mental symptoms. The disorder is observed in the form and content of speech, from referring to the organisation of ideas and content to the actual ideas expressed. The following is an example of form disorder in a schizophrenic as given by Davidson and Neale (1978).
The train of thought of the schizophrenic lacks unity, organisation and specificity of object. There is lack of coherence in the thought process. It is most illogical and a sort of jumbling up. The patient lacks the capacity of abstract thinking. In this connection Goldstiene (1969) remarks that thinking in schizophrenics are concrete compared to the abstract thinking of the normal.
Concrete thinking suggests that the schizophrenic interprets the words projecting his own feeling. The words and events of all sorts are interpreted by the schizophrenic not in connection with which they occur, but in connection with their day dreams and fantasy.
The thinking of the schizophrenics is so dis-organised and illogical that they do not mean what they say. The disturbance is so significant that they cannot differentiate between logical and illogical thinking. Dislocation of words and physical trial and error are found in their thought process.
To sum up, the thinking of a schizophrenic is dominated by his complexes and therefore the schizophrenic always thinks in terms of his own day dreams with phantasies.
a. Affective Disorder:
The emotional reaction of a schizophrenic is so unnatural and deviated from the normal reaction that it is extremely difficult on the part of the normal people to establish friendly rapport with them. The distortions of the affective process of the schizophrenic are observed in several forms.
There may be for example, complete lack of emotion, he may show complete indifference to his surroundings and things going on around him and finally, he may demonstrate an emotion which is out of context to the situation.
For example, he may laugh at the death of a near and dear one or may cry at the most happiest occasion of life, like passing an examination or getting a much awaited promotion. Sometimes they are found laughing and smiling without any reason.
In short, the emotional reaction of such patients are flat and amenic or inappropriate to the environment or situation which elicits them. They are at the same time most unpredictable.
Some people are completely untouched by the tear of their relatives, death of parents and success of their children. Love, sympathy and feeling of tenderness have no meaning for them. They become so pale emotionally that they loose affection in themselves and even commit suicide. Their emotion to be more precise, is completely blunted.
Bluer (1911) gave the example of a lady who wept simultaneously in desperation with her eyes and laughed heartily in her mouth. Such unpredictable, incongruous and ambivalent quality of the emotional reaction of schizophrenics puzzle normal people and prevent sympathetic understanding.
b.Volitional Disorder:
A schizophrenic lacks the power of decision. He cannot take a decision neither he can put his thoughts to action quickly. At the same time he shows several negative symptoms. If one asks him to raise his left hand, he would raise his right hand. When asked to sit, he would immediately stand up.
c. Perceptual Disorder:
The world is not the same to the schizophrenics as it is to the normal people. They show several kinds of perceptual disorders such as disorder of perception of size and duration etc. Right perception of speech of others and identification of people is also hampered. Interpretation of speech is made according to their own desire, wishes and perception of the world.
Hallucinations and delusions are commonly experienced by schizophrenics. Sometimes they hear the voice of God, spirit and are found to actually talk with them. Especially common are delusions of influence and persecution and auditory hallucinations in which patient hears voices talking about him.
Experimental evidences and day to day observations show that auditory hallucination is most evident among the schizophrenics and visual hallucination follows it. This is supported by experimental findings of Mintz and Alport (1972).
They noted as reported by Shanmugam (1981) that “the incidence of varied sensory imageries like visual and auditory hallucinations were similar in the case of normal people and schizophrenics. The difference between the two groups therefore lay not in the frequency or form of imageries experienced but in terms of their relevance to reality.”
The imageries of the normal are organised and relevant to the reality. On the contrary, schizophrenics display highly organised and irrelevant imageries. They further experience tremendous difficulty in differentiating the relevant from the irrelevant and also choosing the relevant.
d. Alienation Disorder:
Lack of attention and concentration is usually observed in schizophrenics since they are more often than not engaged in their own fantasies and day dreams. Withdrawing from their immediate environment their attention is narrowed and it is only passive.
Though there is no intellectual impairment, active attention is affected. Due to this they often repeat the words spoken by others. Because of the unimpaired intellectual capacity and contact with reality they are able to meet the practical needs though, these are not sufficient for a socialized adjustment. Thus, they like to be away from the social word withdrawing to their own private chamber of fantasy; day dream etc.
e. Withdrawal From Reality:
Introversion being an important characteristics of a schizophrenic, schizophrenics are said to be terrible escapists. They loose interest in the people and world around them. Though a mild schizophrenic has an unstable and distorted connection with the reality world an acute schizophrenic is found to withdraw from the reality fully. Such persons attempt to retire to their ivory towers and sometimes called “lotus eaters”.
A schizophrenic feels that he does not understand the world, neither the world understands him and so he prefers to withdraw to his own little world which is quite vast to cater his needs and desires. Thus, he becomes self centred, talks to himself and has no relation with external environment.
These withdrawal symptoms in-fact are found from the very childhood. Children sitting, playing, reading by themselves, very quiet, such types may later on show signs of schizophrenia. They like to live alone and usually very shy seeking the company of others. They are completely lost in their phantasy.
Findings of Duke and Mullins (1973) indicate that schizophrenics prefer large interpersonal distances in the actual sense of space between himself and others. According to the reports of Harris (1968) schizophrenics never stare at people and avoid the gaze of others. He becomes so much self centred that he always interprets his external environment in his own terms.
ii. Motor Disorders:
(a) Disorder of speech:
The speech of the schizophrenic is very irregular. He cannot pronounce the sentences correctly but sometimes coins new words and phrases which is called ‘nealogism’ as a result of which no one around his environment is able to understand him.
Sometimes, they mix two words and so what they say becomes absolutely meaningless. But at times, they convey idea very clearly. Some of them become very talkative and some others do not talk at all.
The speech and language of the schizophrenic also indicate a poverty of ideas and associations. They are very poor in using ideas, images and associations in their language. The total disorganization of speech among the schizophrenics is called ‘salard’.
(b) Anomalies of behaviour:
Coleman (1981) states that the schizophrenics show peculiarities of movement, gesture, posture and expression, such as silly giggling, mutism and various repedtive motor acts. Some others someumes assume ridiculous postures and positions, sitting and lying down for a long period of time.
(c) Walking peculiarities:
The walk of the schizophrenic is quite funny and as the disease advances some of them even cannot move. A variety of schizophrenics develop wax like symptoms. They develop mannerism, stereotypes and postures.
(d) Writing peculiarities:
Writing peculiarities are also found in some schizophrenics. Some can never touch a pencil, while others are prolific writers. Their style of writing is usually repetitive. Symbols, lives, drawings are combined in hotch potch fashion. Rules of grammar are ignored. Some words are omitted and strange letters are added.
Disorganization and lowering of inner control:
Lowering of moral standards, deterioration in habits and personal hygiene, inability to peruse a sustained train of thought are by and large some of the typical characteristics of schizophrenics.
Finally, commenting on the most significant characteristic of the schizophrenic, Coleman (1974) concludes, “Perhaps the most striking characteristic of the schizophrenic is his emotional withdrawal and the rupture of the bonds that ordinarily bind on individual to human society.”
6. Process Schizophrenia:
Process schizophrenia on the contrary is coloured by gradual and slow development showing slow insidious onset of symptoms during early life, with social withdrawal, excessive fantasy, lack of interest, seclusiveness and day dreaming etc. It has long history of adjusting problems. However, once the disease occurs, it progresses very rapidly.
Genetic and organic factors seem to be responsible for this category of disease though no clear evidences have been found in support of this view. The prognosis is difficult and the chance of recovery is quite slim.
Many believe that process schizophrenia is biologically caused whereas reactive schizophrenia may be induced by psychological stress and anxiety.
Higgins (1964) reports differences between the two categories in the area of perception, learning, performance and affective responses.
In reactive schizophrenia, the individual is quite socialized in early stage. It has relevant precipitating causes. The chances of recovery are good. According to Shanmugan (1981), “the division is however found to be useful in predicting the length of the patient’s stay in the hospital and therefore this dichotomy concept continues to be used by psychiatrists.”
Duke and Nowicki (1979) sums up the discussion on reactive and process schizophrenia by saying that “In other words, these two types of schizophrenia share similar symptom patterns, but they may have different causes.”
7. Theories of Schizophrenia:
i. Psychoanalytic Theory:
Schizophrenia is a regression to the oral stage when the ego has not emerged from the id. As there is no distinct ego, by regressing to the primary narcissistic stage, schizophrenics lose contact with the world. There is heightening of id impulses specially of sexual nature during adolescence.
As Shanmugam points out, lack of interpersonal relations and libidinal attachment are attributed to their heightened sensitivity to criticism and behaviour.
By trying to adapt with the demands of the id impulses and to have contact with some stimulus, symptoms of delusions, hallucination and thought disorders are found. Bellack, Hunvich and Geidman (1973) have conducted some investigation to prove that in schizophrenia ego impairment is caused by an increase in id impulse.
ii. Social Learning Theory of Schizophrenia:
Schizophrenics according to this theory do not respond appropriately to the social environment like their normal counterparts. Thus deficit in attention to social environment leads to lack of proper association and disturbances in the thought processes of the schizophrenics. Moreover, lack of proper attention to the stimuli coming from the social environment makes the individual appear withdrawn.
According to Ulman and Kreshmer (1965) schizophrenia is primarily a reaction to the reinforcement it receives within the mental hospital. The hospital staff attend to the patients more when their speech is incoherent and behaviour irrational.
Attempts have been made to verify social learning theory by Braginsky, Grosserking (1966) by conducting a study to examine whether hospitalized patients can manipulate to create an impression on others through the administration of M.M.P.I. which has been strongly criticised.
“Cameron and Margaret (1949, 1951) noted that the schizophrenic patients are inflexible in their own social roles and uncomprehending of the role behaviour of others. Hence, they create their own social role to protect themselves from social expectations and demands. However, though a split occurs between their outer and inner selves, their hopes, aspirations etc. in the inner self may still remain intact.
iii. Experimental Theory of Schizophrenia:
This theory of schizophrenia advanced by Ronald Laing, holds schizophrenia not as an illness but as a label for a certain kind of problematic experience and behaviour. According to the experimental theory, it is the family which first stamps a specific behaviour as schizophrenia instead of accepting it as an experience which is potentially meaningful and beneficial to the individual.
He further views that a schizophrenia is like a person on a psychedelic trip who needs guidance and not control. From the schizophrenic point of view an attitude which considers their illness as positive experience may have beneficial effects.
The schizophrenics will continue to be what they are and have a marginal existence after being discharged from the hospital. However, there is not much evidence in support of Laing’s view. Frankly speaking, at present there is no single psychological theory to explain schizophrenic behaviour fully.
8. Aetiology of Schizophrenia:
Being the most complex functional psychoses, the wide range of dysfunctions commonly found in all types of schizophrenia cannot be fully explained by any single theory advanced to explain the causes of schizophrenia.
According to Duke and Nowicki (1979) schizophrenia is so complex, so puzzling phenomenon that theorists from many disciplines have joined in a massive effort to explain it. Research findings on the causes of schizophrenia are more or less controversial.
However, different theories have been advanced to explain the aetiology of schizophrenia. They are organic and functional or biological and psychological. The main purpose of advancing these causes lie in the treatment.
Schizophrenia has been found in all cultures and socio-economic classes. However, in the industrialized nauons schizophrenic patients are found in a disproportionate number in lower socio-economic classes.
This suggests that the affected individuals either move to a lower socio economic class or fail to rise out of a lower socio-economic class because of illness. Immigration, industrialization, urbanization and abrupt change contribute to the aetiology of schizophrenia as it becomes quite difficult to adjust to such abrupt changes.
The re-valence of schizophrenia appears to rise among third world populations as contact with technologically advanced culture increases. It is an accepted fact that schizophrenia is less visible in less developed nations where persons are reintegrated to their community and family more completely than they are in more highly civilized western societies.
This is why schizophrenia has been called a disease of civilized society. It is held that an individual may have a specific vulnerability for the disease and when acted upon by some stressful environmental influence shows the symptom of schizophrenia to develop. The stress can be biological or environmental or both.
9. Organic Factors of Schizophrenia:
(a) Biological Factors:
Kraepelin first classified psychoses and said that schizophrenia is due to metabolic disorder in which the glands play an important role. He said his investigators have proved this by examining the schizophrenic patients. They said that in schizophrenia the ovaries and testis deteriorate. The works of Mott, Gibbs and Lewis support the hypotheses of Kraepelin.
But Moss views that it may be an accompanying factor among the several causes of schizophrenia. In support of her view she found in 3 or 4 schizophrenic the gonads are microscopically normal. Later on, Kallman (1946) advanced the view that schizophrenia is due to some inherent defect in the genes.
(b) Hereditary Factors:
The higher incidence of schizophrenia in the families of schizophrenic patients has stimulated many valuable investigations on the genetic basis of schizophrenia. The data of Kallman (1953, 1958) on identical twins revealed the incidence of schizophrenia in the families of schizophrenic patients to be 86.3 per cent in identical twins and 14.5 per cent in fraternal twins.
The genetic theorists propose that schizophrenia is physically inherited. Approximately 50 to 60 per cent of the schizophrenic patients have a family record of mental illness. A further study by Kringten (1967) using more refined techniques reported the incidence rate to be 38 per cent for identical twins and 10 per cent for fraternal twins.
The disease is most frequently seen in parents and children than in brothers and sisters. Sometimes it is found that a schizophrenic patent has not a schizophrenic father, but a schizophrenic grandfather. Kallman explains this by saying that there may be a recessive genes.
The genetic theorists thus view that schizophrenia occurs frequently among people who are closely related and more so when the genetic similarity is closer.
In other words, in case of identical twins, the concordance rates are found to be greater than in the case of fraternal twins. Experimental findings of Rosenthal (1970), Rosenthal (1971), Cohen, Allen (1972), Fisher (1973), Wender, Rosenthal and Ketz (1974), Kringlen (1976) have provided ample evidences to support the contention that certain kinds of schizophrenia are genetically determined.
Duke and Nowicki (1979) view that when concordance rates for schizophrenia spectrum disorders among twins are calculated, genetic component is even clearer. For example, Shields, Hestow and Gottesman (1975) have been able to show that using spectrum diagnosis concordance rates for dizygotic twins as well as monozygotic twins could be elevated above the 50 per cent level.
Heston (1966) conducted a valuable study which places learning in the role of genetic factors in schizophrenia. Children from schizoid parents but separated and reared by adopted parents were his subject of study.
These children were compared with those who did not have schizophrenic parents. Findings indicated that 16.6 per cent of these children developed schizophrenic symptoms later on while none in the control group had similar symptoms.
Findings of Rosenthal (1970) and Wender, Rosenthal and Ketz (1974) support Heston’s findings. Kety (1968, 1975) and Rosenthal; Wender Kety, Welner and Schulsinger (1971) have made some important studies on adopted children to throw more light on this problem.
Kety (1975) has reported that the percentage of schizophrenia spectrum disorders in biological relatives of schizophrenic adoptees is significantly greater than in non-biological relatives. Kety further reported that half of the schizophrenic adoptees he studied had no biological or adopted relatives with schizophrenic spectrum disorders.
He has conducted that there may be two different types of schizophrenia one with a strong genetic basis and the other with little or no genetic basis. To solve this riddle, Stromgren (1975), the modern geneticist views that there are schizophrenics which are caused genetically and which are caused environmentally.
These studies on adoptees shaked the field of genetic research in schizophrenia. The strong belief that child rearing patterns and practices and other social and psychological factors were most important in the development of schizophrenia changed with the research findings of Ketty, Rosenthal.
Analysis of the studies conducted on adoptees have led Guttesman and Shields to conclude that “the burden of proof has shifted from showing that genes are important to showing that environment is important.”
Some further researches have been conducted which highlight the importance of genetic components in the development of schizophrenia. They have studied populations where the risk of schizophrenia is considered very high due to several genetic factors such as close relatives of schizophrenics showing higher incidence rates than distant relatives.
To add to this, Slater and Cowie (1971) have found that while the risk of schizophrenia in children with one psychotic parent is 13.9, it is 46.3 when both the parents are schizophrenics.
Analysis of these studies on adoptees thus lead one to conclude that the probability of one becoming schizophrenic is more with those having a defective genetic background. But there are also instances where one of the twins are not schizophrenic though both parents or one of them are schizophrenics.
It can therefore be concluded that besides the defective genetic background, environmental factors such as anxiety and stress are also important in the causation of schizophrenia.
Advancing a balanced approach, the Diathesis — stress theorists therefore hold that it is not a specific abnormality that a person inherits, but rather a predisposition to develop schizophrenic disorder, given the proper environmental conditions (stress).
In this connection Meehl’s (1962), Duke and Nowicki’s (1979) theory suggests that an inherited predisposition schizotaxia must interact with a schizophrenogenic environment to produce schizophrenia.
According to Coleman (1974), Kallman and other investigators conclude that schizophrenia must be transmitted by genetic factors in the forms of ‘predisposition’ i.e., having some metabolic disorder which makes the individual liable or predisposed to schizophrenic reaction when placed under stress.
On the other hand, Dohrenwend (1975,1976), the notable environmental theorists hold the view that “we must recognize a standoff between the genetic explanation and the environmental theories.”
Gottesman and Shields (1976) believe that liability to schizophrenia is inherited and not schizophrenia itself and that the development of schizophrenia is dependent upon the existence of severe life stresses and inability to cope with the current social conditions and circumstances.
Many investigators point out that life situation of a person with a family background of schizophrenia is usually coloured by sufficient stress and anxiety; undesirable child rearing practices and pathological child parent relationship and family interaction. These variables are likely to predispose individuals psychologically to schizophrenia.
Research on the hereditary factors has been reviewed by Jackson (1960) and Gregory (1960) and they point out several flaws in these research undertakings. Commenting on his critical analysis on these research findings Gregory has stated that the role of possible genetic factors in the development of schizophrenia and other functional disorders will remain in the realm of speculation.
10. Constitution of Schizophrenia:
Besides being the result of faulty heredity, constitutional differences liable to schizophrenia may be due to early environmental influences. Toxins, viruses and several other stresses during pregnancy of the mother may have strong after effects upon the development of the embryo.
Early postnatal influences similarly arrest the normal development of the child. Such errors of development lead the individual to make faulty responses to life situations.
But what specific part the constitutional defects play in the development of schizophrenia is not very clear due to the paucity of researches in the area. In the meanwhile, investigators are in the process to get specific answer to their haunches in relation to the role of constitution in the development of schizophrenia.
(a) Physique:
The findings of the study by Sheldon (1974) supports Kretschmer’s view that slender people are sensitive to schizophrenia. Sheldon’s findings show that approximately 66 per cent of schizophrenics have slender constitution.
But it would be quite unjustified to draw a positive relationship between slender constitution and schizophrenia on the ground that research findings are not sufficient to corroborate this view of Kretchmer and Sheldon.
(b) A Typical Development:
The notable study of Bender (1953, 1955, 1961) in particular has stressed the role of retarded and arrested growth during childhood being responsible for schizophrenic reactions. She specially emphasized the effect of immaturity and lack of integration of respiratory, autonomic, nervous and other organs upon the normal behaviour of the child.
Due to these typical developments, he is unable to cope with the world around him and show normal sensory and motor responses to various stimuli. His self image is destructed and is unable to develop ego defences necessary to meet anxiety provoking situations. All these consequently, lead to disturbed interpersonal and parent-child relationship.
Escalona has pointed out that disturbed parent-child relationship which is advocated to be one of the core causes of schizophrenia is an outgrowth of these developmental irregularities. However, researches in this area do not lead to any generalized conclusion supporting early atypical developments being the characteristics of individuals who show schizophrenic reactions.
I. Biochemical:
Neurological disease, an imbalance of neurotransmitters, a slow acting viral infection and self generated hallucinogenic chemicals are included under the biochemical explanation of schizophrenia.
(a) Neuromuscular disorder:
Meltzer (1976) has found evidences in support of his view that neuromuscular dysfunctions present in the schizophrenics leading to disorder of nervous system are a typical function of schizophrenia. He noted that in comparison to their normal counterparts abnormal musculator is found in high percentage of schizophrenics.
He further observed that close relatives of schizophrenics showed higher than normal levels of muscle tissue. All these evidences lead one to believe that schizophrenic person may possibly have some physical defect or more specifically neurological disease or nerve disorder.
(b) Viral infection:
There is some evidence to believe that schizophrenia is caused by a long acting virus. This hypotheses states that certain slow viruses may combine with genetic predispositions for the onset of schizophrenia.
Duke and Nowicki (1979) hold that acquisition of the virus prior to birth would account for the higher concordance rates for schizophrenia among monozygotic twins than dizygotic twins in as much as MZ twins share the same placenta and for more likely to be simultaneously affected.
The experimental evidences of Penn, Racy, Laphan, Mandel and Sandt (1972) support the viral hypotheses. In addition to this Torrey and Peterson (1976) conducting an investigation of 4000 schizophrenics found a satisfactory significant occurrence about abnormal finger, foot and palm prints in them.
The viral hypotheses thus argues that infants are infected during the prenatal period, more particularly during late pregnancy or shortly after birth and only manifest symptoms many years later.
(c) Neurophysiological factors and stress:
(i) Excitatory inhibitory process:
Pavlov’s view that schizophrenics have hyper excitable nervous system led to a large number of research work in the area of excitation-inhibition balance in the nervous system. Pavlov believed that schizophrenia was the function of a state of partial inhibition resulting from a weakness of the nervous system.
Consequently, there may be irregularity in the functioning of the autonomic nervous system. Because of inhibition, the brain responds equally to weak and strong stimuli and hence weak stimuli acquire the force of strong stimuli. This creates difficulty in distinguishing necessary from the unnecessary, relevant from the irrelevant and so he confuses reality with fantasy.
The individual finally becomes away from reality being unable to distinguish between reality and fantasy. This ultimately leads to various hallucinatory experiences. Coleman reports that this view has been supported by pharmacological experiments demonstrating that cortical stimulants like caffeine temporarily abolish or diminish hallucinations. While cortical depressants like bromides intensify them.”
However, further brain research in the area is necessary to give strong support to the role of excitation inhibition balance in the aetiology of schizophrenia.
(ii) Endogenous hallucinogens:
Research on the biochemistry of brain metabolism has provided sufficient evidence to believe that significant mental changes can be produced by some amounts of chemical agents. Experiments with drugs such as mescaline or lysergic acid diethylamide (L.S.D.) have been demonstrated and temporarily produced by injecting this drug to a normal individual.
So it is argued that similar chemical substances produced within the body under certain conditions like stress may lead to schizophrenic reactions and other psychic disorders in thought and affective processes which is well known as “Model Psychoses”.
Heath (1957) and his associates (1960) have important findings to his credit supporting the biochemical origin of schizophrenia. They injected taraxein, a substance obtained from the blood of schizophrenic patients, to two convicts.
Out of these two subjects one developed catatonic type of reaction; the other paranoid type. Subsequently similar studies conducted on large number of subjects brought about similar findings.
These subjects developed reactions such as mental blocking with dis-organisation of thought processes. There were also symptoms of delusion of reference, persecution and grandeur, auditory hallucination and subjective complaints of depersonalisation. These findings have, however, not been confirmed by studies in this area. Thus, the theory of endogenous hallucinogens is yet to be established scientifically.
From the available evidences, it is argued that schizophrenics may be biologically different in the sense that they may convert certain chemicals in their body into psychosis producing agencies when they are exposed to stress situation.
This interpretation receives the support of the findings of Mandell, Segal, Kuezenski and Knapp (1972). They have found an enzyme in the human brain which can convert normal neutral transmitter chemicals such as serotin into hallucinogen like compounds.
Keeping in view these experimental reports, biochemical factors may be treated as one of the contributory factors of schizophrenia but nevertheless, it is not “the” factor of schizophrenia. In the Dopamine hypotheses attempts have been made to explain the physical traces for antiseptic drugs such as schizophrenia at a molecular level.
Clorpromazine (Thorazine) and haloparidol (Haldol) supported the importance of dopamine hypotheses. Carlesson and Lindquist (1973) found these drugs reduced psychotic behaviours by reducing dopamine’s effectiveness via a block added of dopamine receptors in the brain.
Similarly, Synder, Banerjee, Yammura and Greenberg (1974) reviewing a number of studies have proved that dopamine levels are reduced by antipsychotic drugs parallel to the remittance of schizophrenic symptoms. However, social withdrawal, blunting of emotion and lack of ability to experience pleasure do not appear to be related to excess of dopamine alone.
(iii) Sleep loss:
Some experts in the area have emphasized the role of prolonged ‘Sleep loss’ in the aetiology of schizophrenia. White (1896) has described the effects of sleep deprivation on people who are already mentally ill.
Contemporary research of investigators like Bliss (1959) indicate the relationship between sleep deprivation and schizophrenic reaction such as irritability, visual hallucinations, dissociative slates and paranoid thinking and lack of contact with reality. The findings of Korayni and Lehman (1960) Luby (1962) provide additional evidence to this.
II. Evaluation:
However, according to Coleman………… “in general the data indicate that various neurophysiological and metabolic processes are altered in schizophrenic, but the etiological significance of these changes remain to be clarified”.
Analysing various other data in this field it would not be probably safe to hold that neurophysiology will provide a complete explanation for schizophrenia.
Coleman thus comments “certain individuals may be constitutionally vulnerable to distortions in neurophysiological processes as a result of stress, but such disturbances in brain function are not likely to explain total clinical picture. The personality make up of the individual, the life stresses with which he is confronted and the socio-cultural context in which he lives all enter into the onset, nature and outcome of the disorder.”
11. Explanations of Schizophrenia:
Social explanation:
Numerous research findings point out the effect of socio-cultural and environmental life stresses on the development of schizophrenic reactions. Although schizophrenia is found in all societies and cultures, it has been observed that paranoid type of schizophrenia is most frequent in U.S.A. but uncommon in Africa.
Similarly, Field (1960) found that people of rural Glance showed typical symptoms of hebephrenic schizophrenia such as showing inappropriate laughs, smiles, standing still and mute, dancing, singing, soiling and smearing etc. and showing delusions and hallucinations.
Rin and Lin (1962) have noted that high incidence of schizophrenia is found among rural Africans in contrary to the aborigines of Formosa. From the reports of W.H.O. (1959) it has been clear that societies undergoing rapid social change experience a disproportionately high rate of schizophrenia.
Holingestead and Redlich (1954) after prolonged research conducted for 10 years in U.S.A. found that the incidence of schizophrenia was 11 times as high in low S.E.S. group than the high S.E.S. group. Further this correlation was high among women of low S.E.S. groups.
Jaco (1960) recorded higher incidence of schizophrenia among women in professional and semi professional occupations in comparison to their male counterparts. Further studies conducted by Kohn (1968) in Denmark, Norway and England have supported the above findings.
Cambbell (1958) found the degree of incidence, type of reaction and the specific nature of symptoms vary with the difference in socio-cultural conditions. According to Dohrenwend (1975), Dohrenwend and Dohrenwend (1974) the social perspective assumes that environmental stress can produce failure to cope which may lead to schizophrenic symptomatology.
The relationship between social class and schizophrenia reactions have been explained by saying that the problems of lower social class are plenty. In fact they apparently grow through social disorganisation, insecurity, poverty, unhealthy living conditions and poor nutrition’s, torture and severe frustration arising out of un-favourable socio economic conditions.
They lack educational opportunities as they are poor. So they cannot afford early treatment neither they develop the consciousness for early treatment. These stresses and strains of life make them prone to schizophrenia and create field for the same. According to Pasamanick (1962) such people are instinctualized.
In the opinion of Myers and Roberts (1959) lower class patients typically come from homes in which they felt rejected and isolated, were often subjected to brutal treatment and lacked adequate parental models for patterning their behaviour. They therefore fail to adjust with the familial and environmental conditions.
The relationship between stress (arising out of familial and social conditions) and symptom development has been emphasised by Gersten, Langener, Eiserberg and Orzek (1947).
Evaluation:
Keeping Dohrenwend’s view in mind, there are evidences that when normal people are exposed to the extreme stresses of war, they develop psychotic symptoms. If one has to conclude in that line of thought, normal life must have to be that stressful like war to produce schizophrenia which is indeed not a fact.
Moreover, it is equally true that many people develop schizophrenia without experiencing significant life stresses probably because of the biological factors even if they are kept away from stress.
Thus, the exact and specific role of social class on the aetiology of schizophrenia is yet to be established and for this purpose more research is necessary to give some generalized conclusion on the relationship between social class and schizophrenic reactions.
12. Treatment of Schizophrenia:
Previously the chances of cure of schizophrenia were very bleak and the rate of discharge from mental hospital after cure was approximately 30 per cent. Further there were chances of the disease being relapsed. However, but currently with advanced research in the area and modern methods of treatment there has been a lot of progress in the treatment of schizophrenia.
But in-spite of that about one third of the schizophrenics are cured by the present techniques; one third become long term chronic patients and the rest one third suffer the same fate. Unfortunately these figures are quite discouraging and hence more refined techniques of treating schizophrenia should be developed.
The treatment of schizophrenia varies with the type of reaction, the patient itself and the nature of patient’s home situation.
The methods of treatment may be divided into:
1. Milieu therapy,
2. Drug therapy and
3.Psychotherapy including operant conditioning methods.
i. Milieu Therapy:
Otherwise known as socio-therapy it is a type of in- hospital treatment in which the individual’s total environment i.e., the ward, doctors, nurses and other staffs and all experiences are planned in such a way so as to create a healthy and refined corrective atmosphere for these patients. The whole climate is so set up to make it a therapeutic one.
Thus, here emphasis is given upon the establishment of a normal homely and meaningful world in which the patients take active part. For many patients such environment serves as a starting point for their return to their community.
It involves the person’s participation in self regulatory activities. This therapeutic procedure includes talk therapy, occupational or vocational rehabilitation, music, dance and art therapies and other types of recreations.
Hospitalization is necessary for diagnostic purposes — stabilization or medication, safety of the parents with suicidal and homicidal tendencies. Hospitalization is even necessary for the inability of the patient to take care of basic need.
The basic goal of hospitalization should be established as an effective link between the patient and the community support system. The stress of a patient is decreased through hospitalization.
Research studies have shown that short hospitalization is as effective as long hospitalization. Active treatment programmes with behavioural approaches are more effective. After care facilities after hospitalization should also be provided.
Day care centres and home visits can sometimes help a patient to improve the quality of his daily life. In short, there is mutual interaction between the staffs and patients and each member is considered to be a part of each person’s treatment programme.
However, the milieu therapy has its limitations and many psychiatrists do not accept it to be universally helpful. Scher (1958), Wilmer (1958), Jackson (1962) etc. have done extensive work on milieu therapy.
According to Van Putten (1973) this technique may be harmful to those patients who cannot perceive, attend to or process social stimuli as it emphasizes the person learning to behave appropriately as a consequence of exposure to the proper environmental conditions.
ii. Drug Therapy:
It includes the use of drug therapy or psycho chemo therapy i.e., the use of tranquilizers, energizers, anti anxiety drugs, and anti depressant drugs to cure schizophrenia. This type of treatment is particularly made to outpatients. Such drugs though do not cure the symptoms of schizophrenia permanently, do reduce the frequent occurrence or intensity of schizophrenic reactions.
Some of the commonly used drugs are:
(a) Phenothiazine’s, such as chlorpromazine, applied to control excitement, agitation and thought disorders, confusion, anxiety and restlessness of acute schizophrenia.
(b) Anti depressants are used to increase alertness and interest and to elevate mood.
(c) Anti anxiety drugs used to decrease apprehensions and tension and to promote sleep.
Along with these drugs electro shock therapy is also used in some cases depending upon the need of the patient.
(d) Phenothiazine’s are usually used in long term treatments while antidepressants and anti anxiety drugs are used for a short duration, more particularly during periods of special stress.
Drugs show a favourable effect in reducing the symptoms within a few weeks of acutely ill patients. However, the effects go slower on chronically ill patients.
In 50 per cent of the cases drugs can be administered in an out-patient clinic and so in such cases hospitalization is not necessary. Allowing the patient to live in one’s own family or society, drug treatment can be done effectively.
Drugs however have a temporary effect and it only treats the symptoms. Even if drugs reduce the hallucinations and delusions of schizophrenic patient, his personality structure remains however schizophrenic and does not change. Drugs have temporary effects and there is likelihood of the disease to relapse.
Adverse Effects:
Treatment through drugs have also some adverse effects. Neurological signs, weight gains, extra pyramidal symptoms are more commonly found to have adverse effects in men and younger people than in women and older people. However, in case of use of moderate dose the side effects may not be very much visible.
The most adverse side effects as reported by psychiatrists are tardive dyskinesia and neuroleptic malignant syndrome. Tardive dyskinesia is reported to have prevalence in 15 to 20 per cent of the patients treated. It is more common in women than in men and in older patients.
It has been found that 40 per cent of the patients improve if the and psychotic is discontinued. Neuroleptic malignant syndrome occurs in approximately 0.5 to 1 per cent of the patients who use these drugs. The syndrome occurs with fever, generalized rigidity, delirium and increased abnormal behaviour.
iii. Psychotherapy:
To treat the actual disease and to change the basic personality structure of the patient, psychotherapy seems to be imperative. It is essential in assisting him to overcome his distorted attitude towards life, self and society, his immaturities, false beliefs and pathological adaptations to the stresses and strains of life.
Psychoanalysis or client centred therapy are difficult to apply on schizophrenic as he has problems in interpersonal communication. Through better socialization procedure the disease can be treated effectively and from this angle, group psychotherapy seems to be useful.
In group psychotherapy technique the patients get enough opportunity to grow in a safe social environment necessary for developing understanding, sense of security, healthy interpersonal relationship and finally appropriate adjustment to life situations. Such atmospheres make him more reality oriented. Other special counselling techniques have been developed to treat schizophrenia in particular.
Direct Analysis:
Devised and applied by John Rosen (1953) who believes that schizophrenia is due to faulty mother child relationship it is a type of psychotherapy in which the patient is forced to accept that he is a schizophrenic patient and the therapist is there to fulfil all his needs just like a loving, affectionate and dedicated parent.
For making or persuading the patient accept this, all sorts of techniques, like to persuade and pressurize him to give up his psychotic behaviour, by rewarding him, or threatening and punishing him etc. etc. are used.
Having the belief that schizophrenia develops because of faulty child parent relationship, Rosen wanted to replace the faulty mal-adoptive parent of the schizophrenic with the therapist who will guide and provide all stimulations to the patient for better adjustment.
a. Behavioural Psychotherapy:
Recently operant conditioning techniques have been widely applied to the treatment of schizophrenics and the results have been quite illuminating particularly in case of chronic and childhood schizophrenics. Demyer’s (1962) report amply support the above view. Based on learning principle, it tries to change or modify behaviour symptoms of the patients through laboratory tested techniques.
“Isaacs, Thomas and Goldiamond (1960) used chewing gum as a reinforce to re-establish verbal communication in a mute withdrawn patient. Each time the patient made an approximation to speech, he was rewarded with a piece of gum. After a time, the patient asked for gum prior to receiving it.”
Similarly, the token economy technique developed by Ayllon and Azrin (1968), a more complex application of learning theory is being currently used to treat schizophrenia. It is a small economic unit within a treatment setting. Appropriate behaviours of the patients are reinforced by staff with tokens of various kinds and with earned tokens patients are able to buy things of their choice, which thus act as reinforces.
Reviewing the effectiveness of token economy, Liberman (1972) has stated, “The token economy has been shown to be effective in increasing the adoptive repertoire of institutionalised schizophrenics. Behavioural interventions are effective even when phenothiazine medication is withdrawn from chronic psychotics.”
However other experts and evaluators of behaviour therapy like Gagnon and Davison (1976), Kazdin and Bootzin (1972) have doubted that the generalisation of change of behaviour from hospital to home may not occur. Moreover, complex behaviours like distorted abstract thought and language dysfunctions cannot be improved by behaviour manipulations.
b. Family Therapy:
Familial maladjustment and pathological behaviour of many members being considered as a major factor of schizophrenia, family therapy has specific importance in the treatment of schizophrenia.
It has been observed in several cases that family therapy used specifically can reduce the relapse rates of some schizophrenic patients. Families with high expressed emotions are likely to have hostile, aggressive, critical, emotionally over involved interactions with the schizophrenic patients.
If these behaviours are modified through family therapy and training the relapse rates can be substantially reduced. In addition to educating the family members in the above line, the counsellor/ therapist should also introduce them to family support groups for parents of schizophrenic patients.
c. Group Therapy:
For schizophrenic patients with feeling of social isolation, lack of cohesiveness and detachment from reality group therapy proves specially effective.
d. Social Skills Training:
It is a highly structural form of group therapy used to identify and reduce deficiencies in social behaviour.
The therapist here utilizes a number of techniques and strategies to achieve the goal required for community survival, independence and to establish supportive and socially rewarding relationship by applying behaviour analysis principles, improvement of social skills and deficiencies in social behaviour is the primary purpose of this therapeutic method.
e. Individual Psychotherapy:
Since traditional and formal Psychoanalysis has no effective place in the treatment of schizophrenia exaggerated worth and over compassion on the part of the clinician towards the patient is not desirable.
Although the schizophrenic patient is very lonely and closeness and thrust and excessive sympathy on the part of the clinician is likely to produce suspicion, hostility and anxiety in the patient it is suggested that flexibility may be essential while dealing with the patient.
Manfred Bleuler stated that the correct therapeutic attitude towards a schizophrenic patient is to accept him as a brother, rather than watch him as a person who has become unintelligible and different from the therapist.
Conclusion:
The National Institute of Mental Health (1974) has noted that unfortunately a treated and discharged schizophrenic patient has only a 50 per cent chance of remaining out of the hospital for about 2 years. Nevertheless, early detection of the disease increases the chances of cure just like cancer.
This hopelessness so far as cure of schizophrenia is concerned has posed a key problem for psychiatrist and experts and it is said to be the nation’s number one mental health problem. Number of studies have shown a correlation between early onset of the disease and less chance of cure.
The percentage of relapse is so high in this bizarre and complex mental disease that one feels utter frustration while contemplating about its cure. Further research in this area would probably bring new hopes and higher percentages of cure; let us expect.
Coleman (1974) after reviewing the treatment aspect of schizophrenia has opined that “other things being equal, the prognosis are better for catatonic, for schizoaffective and undifferentiated types, than for the hebephrenic, simple and childhood types. The paranoid type seems to fall in between.”
According to Duke and Nowicki (1979) “Perhaps schizophrenia cannot be truly cured, perhaps much like the broken bone, which although no longer painful, still is permanently scarred, schizophrenia can merely be repaired, controlled or softened in its efforts.”
13. Functional Explanation of Schizophrenia:
Kraepelin and Bleuler both emphasized the relationship of psychological factors of schizophrenia, in-spite of their organic bias. The role of frustration and conflict was emphasized by Bleuler in particular.
The splitting of the personality according to him is caused by conflict. According to Duke and Nowicki “The psychological approaches share the belief that schizophrenia is caused by or expressed in behavioural, cognitive, perceptual or experiential dysfunction. Early pathological experience of the child such as unusual and disintegrated family relationship, conflicts among the parents, conflicts among the mother and son lead to the development of schizophrenia. Lidz’s (1958) study provides evidences to the above view. Studying several families they marked two important phenomenon’s in the marital adjustment of parents of schizophrenic children. They are ‘Marital Schism’ i.e., the situation where parents remain together, constantly argue and quarrel and Marital Skew which refers to deep parental hatred and lack of respect which mask happiness and harmony in family. This is called ‘skewed home’. Constant conflict and quarrel between husband and wife and lack of understanding between and respect for each other, constant underestimation of the worth and importance of the other contribute to adjustment problems and such children grow under constant maladaptive behaviour of the family members. They find it difficult to develop a feeling of security and sense of self importance.”
Fontana (1966) analysing 100 family studies of schizophrenics reached at the conclusion that:
Conflict between parents of schizophrenics and inadequate communication between the parents of the schizophrenic are important psychological determinants of schizophrenia. The theorists emphasizing the role of unhealthy family life, view that as a result of pathological and disturbed early family life, the interpersonal skills necessary to communicate effectively are not learnt by the schizophrenics.
For instance, Haley (1959) has stressed upon four different communication problems having their basis on early unhealthy family life.
Bateson, Jackson, Haley and Weakland (1956) opine that families of schizophrenics engage in “double bind communications” i.e., conflicting mother child interaction leading to insecurity in the child.
As a result of such interpersonal conflicts, and morbid mother-son relationship, the child cannot possibly communicate with others and hence withdraws into psychoses. Being an immature and anxious youth, he goes through bitter identity crisis and suffers from underlying feelings of inadequacy and helplessness.
Serious emotional disturbances on the part of the mother herself may lead to the development of weak spots in the personality of the child which are later on conducive to schizophrenia. Friedman and Friedman (1972) reported in comparison to parents of normal children, parents of schizophrenic patients showed more pathological behaviour and thought disturbances.
Wynne and Singer got similar evidences. Heilbrun (1974) on the basis of his findings has viewed that schizophrenia is related to the presence of aversive control in the mother child relationship. Severe rejection or over-protection by one of or both parents lead to schizophrenia. Thus, the role of father and role of mother have been emphasized to produce schizophrenic behaviour.
On the basis of several experimental findings other psychological explanations are:
(a) Psychoanalytic explanation such as regression.
(b) Schizophrenia as a learned behaviour.
(c) Schizophrenia as an arousal and attention dysfunction.
(d) Schizophrenia as regression.
Freud views that schizophrenia is a return to the oral stage of Psycho sexual development and regression to a phase of Primary narcissism and ego disintegration. The concept of ego disintegration refers to a return to the time when the ego was not established or had just began to be established. Such a person is unable to develop a mature ego capable of interpreting reality.
Current Psychoanalytic theory suggests that the various symptoms of schizophrenia have symbolic meaning for the individual patient. H.S. Sullivan observed from his clinical investigations that some schizophrenic patients had been made anxious as infants by their anxious mothers which caused the disintegration of the ego function seen in the disorder.
Freud views schizophrenia as a return to the earlier level of functioning. Schizophrenia is viewed as a loss of contact with reality and regression to the oral stage of psychosexual development. Regression according Duke and et al. occurs because of either an uncontrollable increase in id demands or anxiety provided by the superego.
The regressive functions reflect (after the initial break with reality) the return to the infantile level caused by intrapsychic conflict that led to regression in the face of unbearable stress. As a result of regression, he shows various symptoms of schizophrenia like feeling of depersonalization, sense of loss, delusions of grandure and self importance etc. Also hallucinations may be developed to replace reality based beliefs.
This view of Freud has been supported by Silvano Arieti (1955) who also proposed a regression hypotheses and supports that schizophrenic represents regression to an earlier level of functioning.
According to him “schizophrenics regress further and further back until they reach a point at which high mental functions such as logical thought and speech breakdown and the typical symptoms of psychoses are clearly observable.
Schizophrenia as an arousal and attention dysfunction. Motivation theorists consider schizophrenia as an inability “to receive, process or respond to internal or external stimulation.” Mednick (1950) suggests that schizophrenia is coloured by excessive anxiety which is a function of excess arousal, i.e., development of excessive anxiety due to stimulus generalization.
The anxiety spreads so much from one stimulus to another that any stimulus he meets responds with anxiety and when this point is reached, the person suffers from acute schizophrenia. To face with the anxiety situation he withdraws from a number of relevant stimuli from the real world and only attends to a number of irrelevant events and stimuli.
This attentional shift leads to under arousal and unresponsiveness. Zahn (1975) has found evidences for poor arousal in schizophrenics. He found that in comparison to their normal counterparts, schizophrenics are not aroused by important environmental stimuli. Shakow (1962) has obtained similar findings.
Payne (1962) holds that the important problem of schizophrenia is an inability to exclude unimportant stimuli and they thus respond to everything. Recent evidences of attention deficit in schizophrenics have been obtained by Holzman, Prator and Hughes (1973), Holzman, Proctor, Levy et al. (1974), Wohlberg and Kornetsky (1973).
The psychoanalysic theory also holds that a disturbance in ego organisation affects the interpretation of reality and the control of inner drives like sex and aggression leading to the onset of schizophrenia. These disturbances occur as a consequence of distortions in the reciprocal relationship between the infant and the mother.
The close attachment between the child and the mother leading to a feeling of security is absent in a schizophrenic patient. Paul Tedern concludes that the fundamental disturbance in schizophrenia is the patient’s early inability to achieve self object differentiation.
According to others the defect in rudimentary ego functions permits intense hostility and aggression to distort the mother infant relationship leading to a personality organisation that is susceptible to stresses.
The symptoms during adolescence occur at a time when the person requires a strong ego to deal with increased load of external and internal factors like drives, separation and identity crisis, need to function independently and take independent decisions.
Evaluation:
The functional causes of schizophrenia have been advanced by Freud, Maiers, White, Lidz, Tontasa, Friedman and several others. The environmentalists and psychiatrists emphasizing the role of unhappy family background in the development of schizophrenia view in short, that the causes of schizophrenia lie in the faulty adaptation to life situations. This faulty reaction consists in avoidance and withdrawal.
The basic view is that when some individuals meet difficulties, problems, stresses and strains of life, they withdraw or make some sort of maladaptive pathological unsatisfactory compromises without making any effort to face the situation in a healthy manner.
Just as Ostrich digs up a hole and puts its head inside it thinking to get rid of the storm, but ultimately dies, so also the schizophrenic tries to avoid a stressful anxiety provoking situation by withdrawing from the real world or making faulty adjustments.
Once they go back to their imaginary world, they try to solve their reality problems in phantasy and hence fail to adjust. They find real life painful and phantasy giving pleasure. Because of consistent withdrawal, the repressed desires are accumulated and a stage arrives at last when he cannot return back to the real life.
Maiers thus concludes “schizophrenia is the end result of an accumulation of faulty habits of reaction.” The question, however, arises, why some people react to life situations in a faulty way? Why they are not able to overcome difficulties and withdraw under similar circumstances? Why some react normally to stressful situation while others respond in a pathological way?
Some biologically oriented psychologists explain this by saying that constitutionally predisposed persons having some biological, constitutional or neurophysiological disorders react in a maladaptive manner. Others argue that emotional predisposition, sensitive personality, introversion and temperament makes one unfit to solve the problems. But why they are emotionally imbalanced and introverted?
Such questions have not been answered with a scientific bias and hence need further research to explain the aetiology of schizophrenia.
Though there is no specific evidence that a specific family pattern plays an etiological role in the development of schizophrenia, at-least three major theories have been advanced in the past 40 to 50 years.
Gregory Basteson described a family situation called the ‘Double Bind’ in which a child is put into a situation where he has to make a choice between two alternatives, both of which will produce conflict, confusion and are unbearable.
Theodore Lidz described two abnormal patterns of family behaviour:
(i) Where one patient gets overtly very close to the child of the opposite sex.
(ii) Where there is a skewed relationship with one parent, i.e., a power struggle in which one parent is dominant.
Lyman Wynne talked of families where emotional expression is suppressed by the consistent use of a pseudo-mutual verbal communication.
Schizophrenia as a learned behaviour:
Ullmann and Krasner (1969, 1975) have developed a learning theory to account for the causes of schizophrenia.
Ullmann and Krasner (1975) in their socio-psychological explanation of schizophrenia have viewed that schizophrenia results from the ‘extinction of attention, to social stimuli to which normal people respond. In other words, for attending appropriate social stimulus, schizophrenics have not been reinforced by others.
On the contrary, they might have been punished for doing the same. When he is unable to give attention to socially appropriate stimulus, he tries to attend irrelevant stimulus around him and makes inappropriate responses. So he is considered a deviant and later on a schizophrenic.
Conclusion of Schizophrenia:
From these discussions on the aetiology of schizophrenia and evaluations, it has become apparent that the causes of schizophrenia are diverse and it is quite difficult to emphasize on a single etiological factor of schizophrenia.
Schizophrenia undoubtedly is the most complex and baffling of all mental diseases having diverse types and innumerable symptoms. In-fact, there is no one casual sequence of schizophrenia as held by Coleman. The several types of disorders and dysfunctions have multiple causes.
Biological causes in some cases have upper hand, while in other cases psychosocial or psychological factors play an important role in the development of schizophrenia. It is also not possible to give the relative importance of the organic or functional causes.
The relative importance of different causes vary from patient to patient and hence no generalized conclusion on the single aetiology of schizophrenia can be made. This view on the aetiology of schizophrenia has been accepted by the W.H.O. Study group on schizophrenia.
Researches and attempts are still going on to explain the causes of Schizophrenia, but they are more or less controversial and hence further research to unfold and explain the causes of schizophrenic, the most complex functional psychoses should be conducted.