The Concept of Schizophrenia
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Other routes to "schizophrenia" are also being identified. Around 1 percent of cases appear to stem from the deletion of a small stretch of DNA on chromosome 22, referred to as 22q It is also possible that a low single digit percentage of people with a schizophrenia diagnosis may have their experiences grounded in inflammation of the brain caused by autoimmune disorders, such as anti-NMDA receptor encephalitis , although this remains controversial.
At a debate on whether the concept of schizophrenia is still useful, both speakers - pro and con -presented strong cases. In the end, the. Since its early days, the disease concept of schizophrenia [1, 2] has undergone several modifications. The aim of the present article is to.
All the factors above could lead to similar experiences, which we in our infancy have put into a bucket called schizophrenia. One person's experiences may result from a brain disorder with a strong genetic basis, potentially driven by an exaggeration of the normal process of pruning connections between brain cells that happens during adolescence.
Another person's experiences may be due to a complex post-traumatic reaction. Such internal and external factors could also work in combination. Either way, it turns out that the two extreme camps in the schizophrenia wars — those who view it as a genetically-based neurodevelopmental disorder and those who view it as a response to psychosocial factors, such as adversity — both had parts of the puzzle.
The idea that schizophrenia was a single thing, reached by a single route, contributed to this conflict. Many medical conditions, such as diabetes and hypertension, can be reached by multiple routes that nevertheless impact the same biological pathways and respond to the same treatment. Schizophrenia could be like this. Indeed, it has been argued that the many different causes of schizophrenia discussed above may all have a common final effect: increased levels of dopamine.
If so, the debate about breaking schizophrenia down by factors that lead to it would be somewhat academic, as it would not guide treatment. However, there is emerging evidence that different routes to experiences currently deemed indicative of schizophrenia may need different treatments. Preliminary evidence suggests that people with a history of childhood trauma who are diagnosed with schizophrenia are less likely to be helped by antipsychotic drugs.
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However, more research into this is needed and, of course, anyone taking antipsychotics should not stop taking them without medical advice. It has also been suggested that if some cases of schizophrenia are actually a form of autoimmune encephalitis, then the most effective treatment could be immunotherapy such as corticosteroids and plasma exchange washing of the blood.
Yet the emerging picture here is unclear. Some new interventions, such as the family-therapy based Open Dialogue approach , show promise for a wide range of people with schizophrenia diagnoses. Both general interventions and specific ones, tailored to someone's personal route to the experiences associated with schizophrenia, may be needed.
This makes it critical to test for and ask people about all potentially relevant causes. This includes childhood abuse, which is still not being routinely asked about and identified.
A study of first-episode patients. Expert Review of Neurotherapeutics. Criminology and Criminal Justice. Family Law. Biol Psychiatry ;
The potential for different treatments to work for different people further explains the schizophrenia wars. The psychiatrist, patient, or family who see dramatic beneficial effects of antipsychotic drugs naturally evangelically advocate for this approach. And Bleuler meant dissociation when he used the term splitting. In every case, we are confronted with a… splitting of the psychic functions. This sounds dramatically like how severe dissociative disorders are understood!
But dissociation also designates more: for example, the constriction of the content of consciousness…[and] may thus give rise to misunderstandings. T here is no difference in principle between a fragmentary personality and a complex The aetiology of their origin is frequently a so-called trauma, an emotional shock or some such thing, that splits off a bit of the psyche pp. So, enigma 1 is that the diagnosis of schizophrenia, at its birth, was deeply intertwined with the concept of dissociation and dissociative disorders.
And with them, the memory of the connection between dissociation and schizophrenia was lost. Schneider, in the s, generated a series of symptoms he considered to be predictive of schizophrenia Schneider, His writings were not translated into English until the s, and did not impact diagnostic approaches until the s, but when they did, the impact was profound.
Such symptoms were strongly emphasized in the redesigned diagnostic criteria for schizophrenia from on Diagnostic and Statistical Manual of Mental Disorders, 3 rd Edition DSM-III ; APA, , to such an extent that only one of them particularly voices commenting or conversing was required for a diagnosis of schizophrenia to be given! While this changed slightly with the most recent American diagnostic system, the DSM-5 APA, , such ideas remain influential in the rest of the world.
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While several studies from dissociative disorders researchers have confirmed these findings, the results have been completely ignored by the schizophrenia field. Indeed, the recent slight de-emphasis of the first rank symptoms in the DSM-5 schizophrenia diagnostic criteria had nothing to do with these studies. Even so, while it has long been recognized that hearing voices commonly occurs in persons given the diagnosis of schizophrenia, they also occur in persons who do not otherwise appear mentally ill. So, the experience of hearing voices is not only not uniquely associated with schizophrenia, it is common in persons who have had no contact with mental health professionals and appear to be functioning reasonably well.
This argument has been strengthened over the past decade, with study after study demonstrating strikingly powerful relationships between measures of dissociation in various populations and voice hearing summarized in Longden et al. This body of research was reviewed in a meta-analysis published a few years ago Pilton et al, , which found very large effect sizes between measures of dissociation and measures of voice hearing in all clinical and non-clinical groups. From the time it was first proposed as a concept and a diagnosis, more than years ago, schizophrenia has been linked with dissociation and dissociative disorders in at least three ways: 1 Bleuler conceived of it as a dissociative disorder, whose symptoms were psychologically-driven, 2 Schneider proposed symptoms of schizophrenia which turn out to be more characteristic of the most severe form of dissociative disorder than schizophrenia and 3 voice hearing, common in schizophrenia but also in the general population, appears to be dissociative in nature.
These are enigmas because schizophrenia is generally conceived — in the public mind and by biomedical psychiatry — as a genetic, biological disorder — the polar opposite of DID which is caused by severe, often sadistic, childhood abuse Moskowitz, But childhood trauma is now recognized to be common in schizophrenia, related to the brain abnormalities seen in this condition, and possibly causative in nature Fosse et al, Does this mean that schizophrenia really is split mind — a dissociative disorder?
It certainly is not the same as DID, as any clinician working with these two disorders can tell you. And that cannot occur until the schizophrenia field starts to recognize the reality of post-traumatic and particularly dissociative disorders and include such groups as comparisons in all studies of schizophrenia, particularly phenomenological and psychotherapy outcome studies.
The dissociation is no longer fluid and changeable… it is more like a mirror broken into splinters. Editor, Psychosis, Trauma and Dissociation, 2 nd Ed. Wiley, American Psychiatric Association Washington, DC: Author. Bleuler, E. The value of all these endeavours ultimately depends on the external validity which means that a relationship has to be established with the etiology, treatment response and outcome. The premises of all these research efforts is, however, the idea that the pathogenic agent of schizophrenia or a subtype will be found.
In this paper an outline of the literature about the ordening of overt and covert symptoms in schizophrenia is presented. It is concluded that the different approaches are essential analogue and that research into the delineation of cognitive deficits and their treatment is at present most promising.
Schizophrenia - Wikipedia
Introduction Although the psychopathological picture of Kraepelins' dementia praecox with a general weakening of mental processes resulting in a defect as cornerstone, has been described more than a century ago, the diagnosis still depends on the subjective experiences of the patient, the history and course of symptoms and the observation of behaviour and is based therefore on observable symptoms. With respect to symptomatology, however, it has to be stressed that symptoms of schizophrenia encompasses the entire spectrum of psychopathology with a substantial interindividual variation and that virtually any combination of symptoms may be present in an individual patient.
Despite the critics on schizophrenia as a disease entity Van Praag, , Kendell , , it is, however, generally accepted that the disorder can be identified in different cultures and nations and has a worldwide prevalence of 1 percent and that the diagnosis is rather stable over time WHO , , Kendell et al. Furthermore a wide variety of outcomes can be observed in patients with similar initial symptom characteristics Jablensky et al. Although symptoms and signs are crucial for the diagnosis of schizophrenia, there is an ongoing debate since Kraepelin about how to group symptoms or to subtype this disorder with the aim of discovering the nature of schizophrenia and its outcome and prognosis Strauss et al.
The search for the ideal phenotype deals with composing 'Idealtypen', relevant subtypes, delineation of symptom clusters by means of statistical procedures, the description of underlying cognitive deficits and the identification of so called endophenotypes. The present paper reviews these different approaches and tries to answer the simple question what approach is the most relevant for outcome and prognosis. Diagnostic typing and subtyping Since the original description by Kraepelin of the dementia praecox with its subtypes and the longitudinal outcome as diagnostic criterion, various attempts have been made to arrange the manifold symptoms and signs of schizophrenia.
In Eugen Bleuler introduced the so called 'fundamental' and 'accessory' symptoms which comprise loosening of associations, ambivalence and autism on the one hand, and hallucinations, delusions and catatonic signs on the other hand. According to Bleuler fundamental symptoms are obligatory for the diagnosis.
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In the fifties, Kurt Schneider , formulated, on an entirely pragmatic base, the so called first rank symptoms of schizophrenia that were believed to have a crucial significance for the diagnosis. They included eleven symptoms such as audible thoughts, third person auditory hallucinations, interference with the thought process or delusional perception.
Schneider himself, however, never referred to these symptoms as pathognomonic for schizophrenia. The emphasis on Schneider-like symptoms was reinforced by the effects of neuroleptics in alleviating them.
Split Minds, Split Personalities, Split Paradigms? The Enigmas of Schizophrenia
Despite the clinical effects of these compounds, a majority of patients was still disabled due to persistent Bleulerian fundamental symptoms. Kraepelins' original distinction of defective and productive symptoms was in the seventies revived by the positive and negative symptom distinction. This dichotomy was described in some form in most theoretical constructs before that time.
According to Berrios this terminology, that stems from observations in epilepsy, was first mentioned by John Russell Reynolds in and elaborated subsequently by John Hughlings-Jackson in the eighties of the nineteenth century. The concept of Jackson is based on the doctrine of the dissolution of higher nervous functions. His theory of a hierarchy of levels of functional organisation in the nervous system implied that positive symptoms such as delusions and hallucinations represented release phenomena, arising when a higher cortical regulator has been lost and the activity from a lower level therefore emerged unchecked.
Negative symptoms were due to 'dissolution', that is they represented a diffuse and generalised loss of higher centres. Until the present day the positive-negative symptom polarity is used in the dissection of schizophrenia and this was given again impetus by Crow a,b who proposed to group the symptoms and signs of schizophrenia as either positive or negative, the so called type I and type II schizophrenia.
According to Crow, type I is characterised by positive symptoms like delusions, hallucinations and formal thought disorder that occurs usually in the setting of an acute illness, while type II is defined by negative symptoms such as blunting of affect and poverty of speech as well as indices of structural cerebral abnormalities which generally shows a chronic course Crow He hypothesized that these types represent two etiological distinct subtypes.
Subsequent factor analytical studies suggested that these types represent the two ends of a continuum Andreasen and Olsen , Lewine et al. It should be stressed, however, that the placement of symptoms in either category is purely descriptive and rather arbitrary. In reviewing the literature, Walker and Levine concluded that only six symptoms were consistently classified as either negative or positive that are included in de widely used scales.
In addition, Carpenter et al. To the non-deficit negative symptoms belong psychomotor slowness, anergia and social withdrawal that depend on mood state and side effects of medication. The ambiguity of the negative-positive dichotomy is best illustrated by symptoms like thought and speech disorder as well as catatonic features which are difficult to place in either group. The difficulties in the appreciation of motor symptoms can be inferred from the specific history of catatonia, originally recognised as a separate disease entity by Karl Ludwig Kahlbaum and later considered to be a subtype of schizophrenia or an accessory symptom in various neuropsychiatric disorders review: Van der Heijden et al.
The two-factor model As elegantly described by Jablensky , grouping of symptoms has been done on the basis of expert clinical impression like the fundamental and accessory symptoms as described by Bleuler or the hierarchical continuum as proposed in later works by Kraepelin, and the frequency profiles of symptoms. By applying statistical procedures to discover latent variables or factors, Liddle a found a three factor structure of symptomatology instead of the previously described positive and negative dimensions.
Symptoms, assessed in a relatively small sample of stable patients with schizophrenia, segregated into three syndromes: psychomotor poverty, disorganisation and reality distortion, of which the first two were associated with social and occupational impairment. Later, Peralta et al. It should be stressed, however, that the results of this kind of studies are highly dependent on the input, in that the number of factors required to explain the variance is greater when a wider range of symptoms is used.
Furthermore, the results are influenced by the patient population investigated, sample size, age, duration, course and outcome of illness, response to treatment and the applied diagnostic criteria. In addition, the stability of factors over time is still questionable Arndt et al. In the first decades of the past century, several subtypes of schizophrenia were described that ultimately resulted in eight categories in the ICD simple, hebephrenic, catatonic, paranoid, schizoaffective, latent and residual and acute, whereas the DSM-III recognised five categories: disorganised, catatonic, paranoid, undifferentiated and residual.
Many other subgroups based on clinical pictures have been proposed of which those of Kleist and Leonhard are examples of clinical ideographic classifications Leonhard , review: Van der Heijden et al. These scales were developed on the assumption that there are two major syndromes that account for schizophrenic phenomena Klimidis et al. In the early eighties Crow as well as Andreasen and co-workers published their data on the positive-negative symptom polarity in schizophrenia.