Lecture 13
      
                               Schizophrenia: Etiology
                                Psychosocial Factors
      
      
      Lecture Outline
      
      I.  Introduction
      II. Vulnerability
           A. Developmental Dysfunction
           B. Social Factors
           C. Summary
      III.Psychosocial Stress Factors
           A. Communication
                1. Double Binds
                2. General Communication Patterns
           B. Expressed Emotion
      IV.  Conclusion
      
                     -------------------------------------------
      
      I.  Introduction
      
           In today's lecture we will look at some of the psychosocial factors
      that play important roles in the onset, course and treatment of
      schizophrenia.  Most researchers today see these factors as part of an
      overarching diathesis-stress model - that is, there is an interaction
      between genetic/biological predispositions and environmental stresses. 
      Today, we will focus on those psychological factors that have been
      identified as important in the development of schizophrenia.
      
      II. Vulnerability
      
           To identify psycho-social vulnerability factors (ie: personal
      attributes of the person and social/environmental conditions which
      predispose the person to schizophrenia), it is necessary to examine the
      person and his/her environment prior to the development of the disorder. 
      Typically, identification of such "high-risk" people is accomplished by
      finding children with one or more schizophrenic blood relatives (usually
      a parent).  It is hypothesized that such individuals are at higher risk
      than those without disturbed relatives (Goldstein, 1987).  There is
      evidence that indicates this is in fact the case (eg: Erlenmeyer-
      Kimling, 1968):
           Lifetime risk of developing Schizophrenia
      Both parents normal:        1-2%
      One parent Schizophrenic:   12%
      Both parents Schizophrenic: 35-46%
      (As we shall see next lecture, there is evidence of a genetic component
      as well).
           The lives of these high-risk children are then followed, and those
      that go on to develop schizophrenia are compared to those who do not and
      to those children who are not at risk.  
           Problems:  Around 90% of schizophrenic persons do not have a
      schizophrenic parent (Goldstein, 1987).  In addition, only about 10 -
      16% of the high risk children develop schizophrenia (Goldstein, 1987). 
      And finally, high risk children do not necessarily develop
      schizophrenia, many children develop other types of psychological
      disorders instead (Goldstein, 1987).  
           Questions (unanswered to date):  To what extent can we actually
      generalize from high risk studies to schizophrenia in general?  To what
      extent have we identified people at risk for schizophrenia as opposed to
      people merely at risk for psychopathology in general?  More research is
      necessary before we can answer these questions.
      
      A. Developmental Dysfunction
           A number of cognitive and behavioral abnormalities have been
      identified in children who later develop schizophrenia (Goldstein,
      1987, for a review).  These include:
      -periods of disorganized or delayed motor, visual, physical
      development
      -impaired balance, motor coordination, perception, attention
      -passive, unenergetic, short attention span
      -cognitive impairment on complex tasks
      
      These abnormalities, however, are not consistently found across
      studies.  Results are often contradictory.  Currently, these
      findings are suggestive at best.
      
      B. Social Factors
           Perhaps one of the most consistent social factors associated
      with later onset of schizophrenia is marked social withdrawal and
      generally poor interpersonal relationships (Goldstein, 1987,
      Parnas, Schulsinger, Schulsinger, et al., 1982).  These social
      difficulties become particularly noticeable during later childhood
      and adolescence.  
           Problem: Such social problems are seen with children who
      develop other psychological disorders as well.  
      
      C. Summary
           Only a subset of schizophrenic adults manifest these early
      signs during their childhoods.  Those children who do, however, may
      be at the greatest risk for schizophrenia.  Nevertheless, the
      nonspecificity of these vulnerability factors (ie: schizophrenic
      persons are not the only ones to experience them) makes it
      impossible to use these factors to reliably identify those children
      who are "at risk", at least at our present level of knowledge.
      
      III. Psychosocial Stress Factors
      
           The difficulties associated with identifying high risk individuals
      and interpreting the findings of the vulnerability research apply here
      as well.  Thus, we should approach the following findings as suggestive:
      as hypotheses regarding possible "provoking" or stress factors.
           The family environment as a source of chronic stress has been
      hypothesized to be a critical provoking factor in schizophrenic
      disorders.
      
      A. Communication
      
           During the 1950's there was a growing interest in the role
      disturbed family interactions might play in the development of
      schizophrenia in a family member.  Of particular interest were
      disturbed patterns of communication.  
      
      1. Double binds:  Bateson and his colleagues (eg: Bateson,
      Jackson, Haley & Weakland, 1956) identified a particularly
      insidious communication pattern that they hypothesized could
      play a causal role in schizophrenia.  They first noted that
      communication occurs on multiple levels: verbal, facial, voice
      tone, posture.  In the double bind situation, a parent gives
      the child simultaneous messages on more than one level which
      contradict each other:  he/she says one thing but acts
      differently.  For example:
      
      A schizophrenic patient, glad to see his mother
      "impulsively put his arm around her shoulders, whereupon
      she stiffened.  He withdrew his arm and she asked, "Don't
      you love me anymore?"  He blushed, and she said, "Dear,
      you must not be so easily embarrassed and afraid of your
      feelings." (Bateson, et al., 1956, p.251).
      
      No matter what the child does, he/she loses.  This "crazy"
      type of communication, Bateson hypothesized, leads to "crazy"
      behavior and thought processes.
      
      Once a very popular theory of schizophrenia, there has not
      been a lot of empirical support for the double bind
      hypothesis.  In addition, it has been difficult to explicitly
      define double bind communication.  Thus, even if it does
      occur, it is difficult for researchers to agree on when it has
      occurred (Ringuette & Kennedy, 1966).
      
      2. General Communication Patterns:  Other lines of research
      have looked at general patterns of communication within the
      family as a whole.  Families of schizophrenics tend to have
      deviant communication patterns.  For example, parents are
      unable to establish a focus of attention and instead
      communicate with each other and other family members in an
      incoherent manner (Wynne, Singer, Bartko & Toohey, 1975). 
      Verbal exchanges are often confused, vague, or incomplete. 
      For example (Wynne & Singer, 1963, quoted in Neale & Oltmanns,
      1980, p.315):
      
      Daughter (presenting patient), complainingly:  Nobody     
               will listen to me.  Everybody is trying to       
              still me.
      Mother:   Nobody wants to kill you.
      Father:   If you're going to associate with intellectual  
               people, you're going to have to remember that    
              still is a noun and not a verb.
      
      One hypothesis is that such communication patterns teach the
      child the disturbed thinking associated with schizophrenia. 
      In addition, these communication disturbances are often
      occurring in the context of marital conflicts, thus making the
      home environment even more stressful for the child.  The child
      is caught between his parents (Neale & Oltmanns, 1980), in a
      situation that makes very little sense.
      
      It seems clear that deviant communication occurs in these
      families, but such deviance may not be causally related to
      schizophrenia.  For instance, both the schizophrenia disorder
      and the deviant communication patterns may be due to some
      third variable, such as a family genetic defect (Reis, 1974,
      Goldstein, 1987).  Alternatively, we may just have our causal
      arrows pointing the wrong way:  the presence of a
      schizophrenic person in the family may give rise to the
      disturbed communication.  Perhaps such communication is how
      the family learned to cope with the schizophrenic child.  For
      example, in one study (Liem, 1974), 11 families with
      schizophrenic sons were compared with 11 families with normal
      sons.  Results:
      
      disorder was not observed in the communications of
      parents of schizophrenic sons - there was no
      significant difference between the two sets of
      parents
      
      normal and schizophrenic sons were not
      differentially affected by the communications of
      normal and schizophrenic parents
      
      both sets of parents were adversely affected by the
      communications of schizophrenic sons
      
      Finally, we must ask: Why do not all the children in the
      family develop schizophrenia?
      
      In any event, the communication variables that are
      hypothesized to be stressful and thus provoke a schizophrenic
      episode also appear to contribute to its exacerbation. 
      Interventions that teach family members more adaptive
      communication methods have lead to substantial reductions in
      relapse rates.  Indeed, family based communication skills
      training appears more effective than individual psychotherapy
      or drug treatment in reducing relapse rates over a 1 year
      period (Goldstein, 1987).
      
      B. Expressed Emotion
      
           Another family variable associated with schizophrenia is a
      negative emotional climate, or more generally, a high degree of
      expressed emotion (EE).  Of particular interest are things like
      critical comments, hostility and emotional overinvolvement (high
      levels of tension and emotion).  
           It has been claimed by some that families with high EE seem
      more likely to have a member who develops a schizophrenic disorder
      (Goldstein, 1987).  Nevertheless, the problems with interpreting
      communication deviance discussed above, apply here as well.  
           The most consistent evidence is that EE modulates relapse
      (Falloon, 1988):  A patient returned to a family with high EE is
      much more likely (eg: 76%) to relapse, than a patient whose family
      is low in EE (eg: 28%) (Brown, Monck, Carstairs & Wing, 1962; see
      also Brown, Birley & Wing, 1972).  What seems to then happen is
      that the negative emotional climate (eg: hostility and criticism)
      in these families raises the patient's arousal and stress beyond
      his or her already impaired coping mechanisms.
           An alternative explanation: patients in high EE families are
      initially more disturbed than patients in low EE families - ie:
      severe pathology is the key variable for both the negative
      emotional climate and the increased relapse rate.  The data, do not
      support this, however: neither relapse rate nor level of EE is
      related to the degree of disturbance.  
           Indeed, relapse rates have been found to be related to the
      extent to which the patient is actually exposed to the EE climate: 
      In one study (see Neale & Oltmanns, 1980), relapse rates were
      examined not only for low EE and high EE groups, but also within
      the high EE groups based on the amount of time the patient spent in
      face-to-face contact with family members.  The results (N=128):
      
      Relapse rates
      
      Low EE 13%   (n=71)
      
      High EE 51%  (n=57)
               a)with less than 35 hours per week contact: 28%       
               b)with more than 35 hours per week contact: 69%
      
           Family based therapies, already shown to be particularly
      effective in reducing relapse rates, also typically decrease
      (Doane, Goldstein, Miklowitz & Falloon, 1986).  In fact, whatever
      the therapy method (family based, individual...), when family
      members shift to low EE patterns, relapse rates are as low as 0%;
      if EE stays high, relapse rates stay high (Hogarty, Anderson,
      Reiss, et al., 1986).  
      
      IV.  Conclusion
      
           Today we have looked at a few of the psychosocial factors
      identified as important in the etiology of schizophrenia: developmental
      dysfunctions, social factors, communication deviance, and expressed
      emotion.  The picture is still far from complete, of course.  It is
      difficult to specify the direction of causality in these findings. 
      Nevertheless, family factors appear to play some important role in the
      course of schizophrenic disorders.  [Note: "Cause" vs "Course" - as we
      saw with Expressed Emotion, a variable can have importance in the course
      of a disorder (its duration, severity, prognosis, etc), if not in its
      initial cause].
           The deviant communication patterns and high EE undoubtedly have
      complex origins.  We are talking about individuals, within a family
      context, who are attempting to cope with the many overwhelming demands
      of a relative with schizophrenia (Goldstein, 1987).
           A purely psychosocial explanation of schizophrenia, however, is
      probably unlikely.  In our next lecture we shall examine some of the
      biological factors that are associated with the development and course
      of schizophrenia.