Lecture 12
      
                                    Schizophrenia
      
      Lecture Outline
      
      I.  Introduction
      II. The Concept of Schizophrenia
           A. Kraepelin
           B. Bleuler
           C. Schneider
           D. US-UK Cross National Project
           E. A More Conservative US
      III.DSM-III
           A. Duration
           B. Symptoms
           C. Age
           D. Organic Exclusion
           E. Subtyping
                1. Catatonic
                2. Disorganized
                3. Paranoid
                4. Undifferentiated
                5. Residual
      IV. Conclusions
      
                     -------------------------------------------
      
      I. Introduction
      
           We have thus far examined psychological disturbances that, while
      potentially quite debilitating, are typically "ambulatory" in nature:
      the person can usually still function, there is usually no serious loss
      of contact with reality.  Today we turn to Schizophrenia, a class of
      psychological disorders that is perhaps the ultimate in psychological
      breakdown (Carson, et al., 1988).  The individual typically has marked
      breaks with and distortions of reality.  As we shall see, Schizophrenia
      "strikes at the very heart of what we consider the essence of the
      person" (Carpenter, 1987, p.3)  Such a disturbance is often termed
      psychotic to distinguish it from the milder "neurotic" disorders
      (Anxiety and Mood disorders).  Today, we will review some of the issues
      and controversies regarding Schizophrenia, as well as briefly look at
      how the DSM-III-R defines the concept.
      
           Schizophrenia affects all areas of functioning: thought,
      perception, emotion, behavior.   A Schizophrenic individual suffers from
      impairment in multiple areas of functioning.  The following is a list of
      those symptoms identified by the DSM-III-R.
      
      (Note: Your text goes into much more detail for each of these areas, so
      we won't spend a lot of time on them in lecture.  Make sure you review
      them carefully).
      
      A. Content of Thoughts:  delusions (false beliefs).  Eg:  Others
      able to read my thoughts (thought broadcasting), thoughts are being
      placed in my head (thought insertion), other people/beings are
      controlling me
      
      B. Form of Thoughts:  Eg: loose associations (one thought has
      little to do with the previous or forthcoming thoughts), poverty of
      content (talks a lot, but says very little), unique/made-up words
      (neologisms), clanging (speech follows meaningless rhymes.  (See
      Handout 12-1).
      
           [Note: The specificity of thought disturbances is not
           altogether clear (disturbances of thought occur to varying
           degrees in many psychological disorders [Rattenbury,
           Silverstein, DeWolfe, et al., 1983)].
      
      C. Perception:  hallucinations, especially auditory.  Eg: hearing
      voices.
      
      D. Affect:  flat and/or inappropriate emotional responses.  Eg:
      extreme silliness, or an utter lack of emotion.
      
      E. Sense of Self:  no sense of self, of being an individual.  No
      sense of meaning.
      
      F. Volition:  inadequate self-initiated behavior.  Eg: inability to
      meet goals or complete tasks.
      
      G. Interpersonal Relations:  withdrawn, detached (sometimes called
      "autism") or excessive clinging, dependency, and intrusiveness.
      
      H. Psycho-Motor Behavior:  unresponsive or bizarre responses to the
      environment.  Eg: Catatonia (such as extreme rigidity or stupor),
      overexcited activity, strange faces.
      
      The final, overarching diagnostic criterion is that the person's
      functioning has declined markedly below the highest level of functioning
      achieved prior to the disorder.  This criterion is included to
      discriminate between people with Schizophrenia and those with more
      isolated problems (such as someone who, although experiencing some form
      of delusion, shows no reduction in social or work functioning). 
      Schizophrenia typically involves impairment in multiple areas of
      functioning.  Because the impairment is often so pervasive,
      Schizophrenic individuals often require prolonged or repeated
      hospitalization.  
      
      Case Study: (Susan, a young woman, placed by her school in a class for 
      the emotionally disturbed):  She talked at length about her
      interests and occupations.  She said she made a robot in the
      basement that ran amok and was about to cause a great deal
      of damage, but she was able to stop it by remote control. 
      She claims to have built the robot from spare computer
      parts, which she acquired from the local museum.  When
      pressed on details of how this worked, she became
      increasingly vague, and when asked to draw a picture of one
      of her inventions, drew a picture of an overhead railway and
      went into what appeared to be complex mathematical
      calculations to substantiate the structural details, but
      which in fact consisted of meaningless repetitions of
      symbols (eg: plus, minus, divide, multiply).  When the
      interviewer expressed some gentle incredulity, she blandly
      replied that many people did not believe that she was a
      supergenius.  She also talked about her unusual ability to
      hear things other people cannot hear, and said she was in
      communication with some sort of creature.  She thought she
      might be haunted, or perhaps the creature was a being from
      another planet.  She could hear his voice talking to her and
      asking her questions (Spitzer, Skodol, Gibbon & Williams,
      1981, p221-222).
      
      Sex ratio: Schizophrenia is apparently equally common in both sexes
      (APA, 1987).
      
      Prevalence: Lifetime prevalence rates have been reported to be around
      0.2% to almost 1% in Europe and Asia.  Studies in the U.S. (which have
      traditionally used broader definitions - see below) report somewhat
      higher rates (APA, 1987).
      
      II.  The Concept of Schizophrenia (Andreasen, 1987a, 1987b; Neale &
      Oltmanns, 1980)
      
           Schizophrenia occurs in almost all societies - it is a virtually
      universally accepted concept (Andreasen, 1987a).  Nevertheless, there is
      debate over exactly how to define the concept.  Typically, the
      controversy revolves around how to determine the boundaries of the
      disorder:  What are the "rules" for deciding what is and what isn't
      Schizophrenia?
      
      A. Kraepelin:  No discussion of Schizophrenia would be complete
      without recognizing the role played by the German psychiatrist,
      Emil Kraepelin during the late 1800's and early 1900's.  Kraepelin
      was the first to identify and comprehensively describe the disorder
      that we now call Schizophrenia.  Kraepelin used the term "dementia
      praecox", a Latin phrase meaning "mental deterioration at an early
      age".  For Kraepelin, the early age of onset was a defining
      criteria of dementia praecox (ie: Schizophrenia).  An additional
      defining characteristic was a deteriorating course, that is, it is
      only Schizophrenia if the person gets progressively worse.  While
      Kraepelin's definition incorporates observable symptoms as well,
      the emphasis was on early onset/deteriorating course as the
      defining features.  Thus, Kraepelin's approach is fairly narrow.
      
      B. Bleuler:  The Swiss psychiatrist, Eugen Bleuler (a contemporary
      of Kraepelin's) rejected Kraepelin's emphasis on early onset and
      deteriorating course.  He did much to broaden the concept, as well
      as coining a new term: "Schizophrenia".  For Bleuler, Schizophrenia
      was a group of disorders, including mild and severe cases, those
      with a favorable outcome and those with a deteriorating course, and
      those which were acute and those which were chronic.  He attempted
      to identify the core psychological feature unifying this group of
      disorders, and decided it must be the loosening of associations. 
      That is, the associations typically joining thought, communication,
      actions, and emotions become disconnected, giving rise to the often
      times bizarre behaviors.  (Schizophrenia literally means "split
      mind": from the Greek schizien for split, and phren for mind).  The
      ultimate split is seen in the person's disconnection with the
      outside world.
           This approach was the "prevailing wisdom" in the United States
      for much of the 50's and 60's, where Bleuler's definition was
      further broadened to include various other inferred mental process,
      in addition to loosening associations.
      
      C. Schneider:  Meanwhile, back in Europe, there was a push to
      narrow the meaning of Schizophrenia away from the broad Bleulerian
      conceptions of America.  European psychiatrists were worrying that
      the definitions were becoming so broad that Schizophrenia was
      becoming a meaningless term.  Work by people like Kurt Schneider
      was gaining importance.  The emphasis was on identifying observable
      symptoms that would indicate the presence of Schizophrenia ("first
      rank symptoms" in Schneider's terminology) and avoiding inferred
      processes.  
      
      D. US-UK Cross National Project:  This distinction between broad
      (Bleulerian) and narrow (Kraepelinian) conceptions of Schizophrenia
      is dramatically illustrated in the US-UK Cross National Project
      conducted by a team of researchers in the early 1970's.  One part
      of this study compared the frequencies of diagnoses made in London
      hospitals and New York hospitals:
      
                           New York         London   
      Schizophrenia          118 (62%)        59 (34%)
      Mood Disorder           13 (7%)         68 (38%)
      Anxiety Disorder         5 (3%)         10 (6%)
      Personality              2 (1%)          8 (5%)
        Disorder
      Other                   54 (28%)        29 (17%)
                              -------         ------- 
                              192             174
      
      The project researchers made their own diagnoses of the two sets of
      patients and found that the actual characteristics of the
      inpatients in the US hospitals were virtually identical to those of
      the British inpatients:
                           New York         London   
      Schizophrenia          56  (28%)        61 (34%)
      Mood Disorder          62  (31%)        76 (44%)
      Anxiety Disorder        3  (2%)          7 (3%)
      Personality             8  (3%)          5 (3%)
        Disorder
      Other                  63  (33%)        25 (13%)
                             ---------        --------- 
                             192              174                    
        
      As can be seen, the US hospital staff were much more likely to make
      the diagnosis of Schizophrenia than were the British staff.
      
      E. A More Conservative U.S.:  Spurred by studies like the Cross
      National Project, psychologists, psychiatrists and others in the
      mental health field became increasingly critical of the broad
      American definition of Schizophrenia.  
      
      The "Feighner Criteria":  During the 1970's a group of Washington
      University (Saint Louis) researchers (Feighner and his associates)
      developed a more comprehensive set of criteria for defining
      Schizophrenia than was currently in use (for example, and
      especially, the DSM-II) (Feighner, Robins, Guze, et al., 1972).  
      
      The RDC:  The "Feighner criteria" were the bases for the Research
      and Diagnostic Criteria, or RDC (Feighner, Robins, Guze, et al.,
      1972).  These criteria returned to Kraepelin's emphasis on
      observational data - the RDC has notable clarity and precision
      (Neale & Oltmanns, 1980) compared to earlier diagnostic systems. 
      The RDC meant a smaller and more homogeneous (hence, more
      meaningful?) set of patients would be diagnosed as Schizophrenic. 
      This, in turn, meant diagnoses would be more reliably made
      (although this increased reliability did not insure increased
      validity).
      
      III. DSM-III
      
           This work had an important influence on the development of the DSM. 
      The DSM-III moved away from the overly broad definition in the DSM-II to
      create a more narrow definition.  The DSM-III-R has carried on this
      trend toward a narrow conception of Schizophrenia, as illustrated by its
      diagnostic criteria.
      
      A. Duration Criterion:  To be diagnosed as Schizophrenic, the
      individual must have had the symptoms for at least 6 months.  This
      criterion eliminates brief psychotic episodes and Mood Disorders
      such as Major Depression from the diagnostic category of
      Schizophrenia.  (Why 6 months?  6 months seems to discriminate
      between those patients with a good prognosis [less than 6 months]
      and those with poor outcomes [more than 6 months] [Andreasen,
      1987b]).
      
      B. Characteristic Symptoms:  Only those symptoms that are reliably
      identifiable are included.  Problem:  even with a highly reliable
      symptom, if it occurs infrequently it may not be useful as a
      criterion symptom.  The symptoms should be common enough to be
      present in enough patients so that the diagnosis can be made
      accurately.  In addition, the symptoms ideally discriminate between
      Schizophrenia and other disorders (ie: symptoms shouldn't also
      typically occur in other disorders).  There is, however, debate
      over the diagnostic significance of DSM-III-R symptoms.
      
      C. Age Criterion:  DSM-III required onset prior to age 45.  This
      criterion has been broadened a bit in the DSM-III-R: onset can
      occur after 45, but you must specify it as "late onset".  The idea
      is that, after 45, we may be dealing with a different disorder,
      perhaps symptoms due to natural aging processes.
      
      D. Organic Exclusion Criterion:  If there is evidence that the
      symptoms are due to an organic (biological) disorder (eg: mental
      retardation, drug intoxication) then the diagnosis of Schizophrenia
      is not made.  This is a confusing criterion, especially with all
      the evidence that various organic factors may be the cause of
      Schizophrenia.
      
      E. Subtyping:  In recognition that there do seem to be distinct
      types of Schizophrenia, a number of subtypes have been defined in
      the DSM-III-R.  There is, however, much debate over the validity of
      these subtypes.  Typical criticisms: The subtypes don't predict
      outcome; they lack validity; reliability is questionable: patients
      will present with different subtype symptoms during different
      episodes of the disorder; they ignore biological facts.  (See your
      text, pp. 331-340, for extensive detail regarding these subtypes).
      
      1. Catatonic Type:  The essential feature is serious motor
      behavior disturbance.  Such disturbance can take various
      forms:  Stupor (marked decrease in responsiveness to
      environment, reduction in spontaneous movements, mutism);
      Negativism (resistance to all instructions or attempts to be
      moved); Rigidity (maintaining a rigid posture against all
      efforts to be moved); Excitement (purposeless and excited
      activity and movements); Posturing (voluntary assumption of
      inappropriate or bizarre postures, often for extended periods
      of time).
      
      2. Disorganized Type (previously known as hebephrenia):  A
      particularly severe (although also less common) type o f
      Schizophrenia, characterized by incoherent behaviors,
      thoughts,and affect.  There is extreme loosening of
      associations.  The individual seems to become increasingly
      indifferent and infantile.  Giggling, silliness, weeping,
      anger and other reactions inexplicable and inappropriate to
      the situation are common.  In some cases the incoherence
      progresses to the point where the person "makes no sense at
      all".
      
      3. Paranoid Type:  Characterized by delusions that have themes
      of suspiciousness, persecution, or grandeur.  For example, the
      individual may become extremely suspicious that everyone at
      work is trying to kill him, or that he possesses some profound
      or even divine powers.  Hallucinations will often accompany
      these delusions, often reinforcing the false beliefs.
      
      4. Undifferentiated Type:  A "waste basket" category, for
      those individuals who do not fit neatly into the other
      categories, but who do show prominent psychotic symptoms
      (delusions, hallucinations, incoherence, grossly disorganized
      behavior).
      
      5. Residual Type:  A category reserved for those individuals
      who have had at least one episode of Schizophrenia, but where
      there are no prominent psychotic symptoms.  Nevertheless, the
      individual still exhibits signs of disorder (eg: marked social
      isolation or withdrawal, peculiar behavior, inappropriate
      affect, illogical thinking, mild loosening of associations).
      
      6. Alternative Subtyping Schemes:  Most investigators would
      agree that Schizophrenia is probably made up of a
      heterogeneous group of disorders.  However, not all would
      agree with the way the DSM-III-R has cut up the pie.  The DSM-
      III-R is just one of many proposed subtyping systems
      (Andreasen, 1985; Andreasen, 1987; Carson, et al., 1988; Neale
      Oltmanns, 1980):
      
      a) Process vs Reactive
      Some cases of Schizophrenia develop slowly and gradually
      over a period of time, not in response to any obvious
      stressors, and tend to be long-lasting.  Other cases seem
      to arise quite suddenly, marked by intense emotional
      turmoil and confusion.  These cases are often associated
      with an identifiable stressors; the symptoms usually
      fade.  These two subtypes have been termed Process
      Schizophrenia and Reactive Schizophrenia, respectively. 
      Alternative terms that are approximately equivalent have
      been Poor Premorbid or Chronic Schizophrenia for the
      Process type, and Good Premorbid or Acute Schizophrenia
      for Reactive Schizophrenia.
      
      b) Paranoid vs Nonparanoid
      Schizophrenia has also been subdivided based on the
      presence or absence of paranoid symptoms (delusions and
      hallucinations of grandeur, persecution, suspiciousness,
      etc).  Paranoid type: paranoid symptoms are a dominant
      feature.  Nonparanoid type: paranoid symptoms, if present
      at all, tend to be fleeting, rare, and inconsistent.
      Paranoid Schizophrenia tends to be more "reactive" than
      "process" in type, to have a more benign course and
      outcome, and has a less clear genetic link.  [There may
      be, however, a subgroup of paranoid schizophrenics whose
      disorders are quite chronic].  
      
      c) Positive vs Negative
      Currently, there is much interest in the possible
      subtyping of Schizophrenia into positive and negative
      types.  [To some extent, this approach overlaps the
      "process" vs "reactive" approach].  Positive
      Schizophrenia: prominent positive symptoms (delusions,
      hallucinations, emotional turmoil, motor agitation,
      bizarre behavior, and perhaps catatonic features).  In
      addition, there tends to have been good premorbid
      adjustment, a relatively acute onset, and a good
      prognosis.  Negative Schizophrenia: negative symptoms
      (dulled emotions, little movement, impaired or absent
      reactivity to the environment).  In other words, there is
      a deficit or absence of behaviors normally present in a
      person's repertoire.  In addition, there tends to be poor
      premorbid adjustment, suggesting an underlying process
      beginning early in life (perhaps biological); onset is
      slow and subtle, making it difficult to date the precise
      time of onset; and there is a poor prognosis.  
      IV. Conclusions
      
           There is still debate over how to define Schizophrenia.  There is
      concern today that the DSM-III-R criteria are too narrow, that "the
      pendulum has swung too far" to the narrow side of things (Andreasen,
      1987a).  Others have even gone further, arguing that the entire concept
      of Schizophrenia is a myth.  Rather, it is a means of labelling social
      undesirables and norm violators and thereby justifying their
      incarcerations (eg: Szasz, 1976).  The Scottish psychiatrist, R.D. Laing
      (1967) has gone so far as to claim that the so-called Schizophrenia
      symptoms are in fact highly adaptive responses to an extremely disturbed
      environment.  Laing argues that, instead of trying to prevent or
      interfere with the course of Schizophrenia, we should allow the person
      to experience the full course of the disorder.  Like a phoenix from the
      ashes, the person would eventually arise from his or her psychosis,
      reformed and "cured".  By "treating" the person, Laing argues, we
      actually prevent him or her from growing.  
           Needless to say, positions such as Szasz and Laing have been
      challenged by many investigators.  We will have more to say about this
      later in the course.  However, note that such extreme positions are
      important because they force us to confront our assumptions (eg:
      Schizophrenia is real, Schizophrenia is bad, Schizophrenia is a problem
      with the individual and not his or her environment, etc).  As Neale and
      Oltmanns in their book on Schizophrenia warn us: Diagnostic systems are
      often based more on faith than fact.  Instead of blindly accepting the
      reality of Schizophrenia (or any disorder for that matter), we must show
      that it is a meaningful concept.
      
           In close, a quote:
      When we think of schizophrenia, we think of [the destruction
      of] the inner unity of the mind and [the weakening of] the
      volition and drive that constitute our essential character...
      The mind loses the intimate connectedness between thought and
      emotion, and the mental life is often resplendent with
      distorted perception, false ideas, and lack of clarity or
      logic in thought.  Aberrant motor and social behaviors are
      manifest.  The [person's] place in society erodes in an
      interactive process reflecting the incapacity to engage and
      sustain social bonds and society's reaction to the social and
      personal deviancy caused by the [disorder].  This [disorder]
      strikes at the very heart of what we consider the essence of
      the person.  Yet, because its manifestations are so personal
      and social, it elicits fear, misunderstanding, and
      condemnation in society instead of sympathy and concern. 
      Schizophrenia remains unparalleled as a stigmatizing
      [disorder] with all the societal consequences of personal
      shame, family burden, and inadequate support of clinical care,
      research, and rehabilitation.  It is ironic that in a society
      with pride in individual freedom and achievement, the response
      to a person whose personal capacity is being eroded...is the
      withdrawal of opportunity (Carpenter, 1987, p.3).