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Table of contents

General Description

Biological Aspect

Psychological Aspect

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General Description

History
Prehistoric times - 1900
People living in prehistoric periods believed that schizophrenia was caused by evil spirits inside the body. They might also believe that drilling a hole into the person's skull would release the evil spirits, thereby curing them.
About 400 B.C., the Greek physician Hippocrates stated that mental disorders were caused by an imbalance of four body fluids: blood, phlegm, yellow bile, and black bile.
During the Medieval times, especially the Reformation, a belief in witchcraft and a wide persecution of witches spread throughout western Europe. People with mental illness were often considered as witches and were burned. Many mentally ill people were also incarcerated.
Humane treatment of mentally ill people emerged in the late eighteenth century when Philippe Pinel, a French physician strove to ameliorate the conditions of mental institutions in France. Many mental hospitals began to introduce treatment programs that included fresh air.
In 1883, Emil Kraepelin, a German psychiatrist, worked out a systematic diagnosis and classification of schizophrenia. He also accounted causes of schizophrenia to abnormalities in the brains of schizophrenics.
In the dawn of the twentieth century, the famous Austrian psychiatrist Sigmund Freud proposed a theory that forces in the unconscious mind greatly affect an individual's personality and behavior. This theory, along with his other theories, became the basis for psychoanalysis.
During the 1950's, the advent of effectual medical treatments led to a gradual reduction in the number of schizophrenic patients hospitalized. However, many communities lacked enough facilities to help mentally ill people live independently.
In 1963, the Community Mental Health Centers Construction Act was approved. It offered funding for the development of community mental health centers throughout the United States. The National Alliance for the Mentally Ill was established in 1979.
During last two decades, many scientists began to study the living brain of schizophrenic patients with a variety of new techniques, including positron emission tomography (PET) and magnetic resonance imaging (MRI). Using these technologies, scientists have found that schizophrenia entail problems in the development and physical and chemical activities of the brain.

Symptoms
There are a variety of distinctive symptoms associated with schizophrenia. They can be divided into two major groups: positive symptoms and negative symptoms.
Thinking disorder: Thinking disorder is the lack of the ability to think logically and clearly. Sometimes nonsensical language that hinders communication with others signals the presence of the disease.
Delusions: Delusions are false and irrational personal beliefs that are not interpreted by a person's usual concepts. Delusions are common among schizophrenia patients. A patient may believe that he or she is being inveighed or conspired against by others. There exists another type of delusion known as broadcasting, in which the individual with this disease thinks that his or her thoughts can be heard by others.
Delusions of persecution: patients suffering from paranoid-type symptoms often experience delusions of persecution, or other non-exist conceptions that they are being conspired against.
Delusions of grandeur: a person with schizophrenia may believe he is a person of significance. For example, one might believe that someone is controlling his behavior or a star in the night sky is sending him messages about his fate.
Hallucinations and Illusions: Hallucinations occur when a person sense things that do not exist in reality. The most common hallucination in schizophrenia is hearing voices. A schizophrenic may carry on a conversation with voices that no one else can hear, or perceive that voices are telling him what to do. Hallucinations can be heard, seen, or even felt. Illusions, on the contrary, take place when a sensory stimulus is present but is incorrectly interpreted by the brain of the patient.

Negative symptoms represent a reduction in or loss of normal emotions or mental abilities. They may appear early in the disease. Examples of negative symptoms include dulled emotions and social withdrawal.
Dulled emotions People with schizophrenia usually have a severe loss in emotional expressiveness. Schizophrenics may not be able to start or carry on a conversation. The individual may not show the signs of normal emotion.
Social withdrawal: The person may be reserved to avoid social contact. In some severe cases, a schizophrenic can spend entire day doing nothing at all, even ignoring basic hygiene. These problems with social skills are typical characteristics of schizophrenia, not personal flaws.

Subtypes
There are three subtypes of schizophrenia: paranoia, hebephrenia, and catatonia.
Of all the disorders, perhaps paranoia (or paranoid schizophrenia) is the most devastating. Paranoia is a subtype of schizophrenia whose symptoms include delusions of grandeur or persecution. It occurs among older and intelligent individuals. Delusions is so severe that it can dominate life if not treated.
Hebephrenia involves absurd outbursts. In addition, people suffering from hebephrenia also suffer gradual decrease in social contact. Hebephrenic patients seem to be playing like a child. However, they usually do not lost any adult mental functions.
Despite its severe symptoms, catatonia is more treatable with medications than other subtypes.
Catatonia involves extreme muscle tension. People with catatonia usually act in robot-like movements or frenzied motion. Catatonia can be fatal by exhaustion if not treated.

Connections with drugs
Antipsychotic drugs, since its advent in the 1950s, have been the most effective medications to treat schizophrenia. When used, they reduce many of the mentally devastating symptoms such as hallucinations. Nowadays, physicians often give schizophrenic patients antipsychotic medications. Despite their efficacy in reducing the symptoms, antipsychotic drugs do not cure schizophrenia. Nevertheless, antipsychotic medications enable schizophrenic pattients to live outside the hospital.
Antipsychotic drugs reduce many of the symptoms of schizophrenia by blocking the action of dopamine, a neurotransmitter , on certain nerve cells. Although physicians have not yet identified the role of dopamine in schizophrenia, almost all antipsychotic drugs reduce the activity of dopamine in the nerve system.
There always has been a small number of patients who do not respond to any of the antipsychotic medications. Hence they must remain in hospital for other types of treatments.
Psychotherapy and rehabilitation programs can help patients live independently. In the United States, the National Alliance for the Mentally Ill offers help for schizophrenic patients and their families.

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Studies involving adoption offered evidences against the nurture argument of the "nature-nurture" controversy.
FACTS
In the situation where identical twins are raised in two separate households with no awareness of one another, one will become schizophrenic 50% of the time if the other develops schizophrenia.
Therefore, it can be argued that identical twins that are raised together or apart have equal chances to develop schizophrenia, thereby eliminating adoption as a factor affecting in the incidence of the disease.
Adoption studies have cast further light on whether schizophrenia is inherited. According to these studies, adopted children who had a schizophrenic natural parent are at far higher risk of developing the mental disorder than adopted children who did not.
Based on the studies and facts mentioned above, it is very convincing that genetics plays a role in the incidence of schizophrenia. The fact that one of the identical twins is not 100% concordant with the other in developing the disease means that more than genetics is involved in the disease. The biological and environmental influences remain a debated issue.
For more than 200 years, scientists have found various structural abnormalities in the brains of many dead schizophrenics. These abnormalities are clues which offer researchers hints in understanding the disorder. Nowadays, new devices such as computerized axial tomography and magnetic resonance imaging have enabled researchers to study the brains of living schizophrenics. These also revealed a number of abnormalities. Yet their roles in the disorder, if any, still remain as merely a conjecture. The genetic determination of such abnormalities has not been proved.
Structural Difference
between the Left and Right Hemispheres
Both autopsy and living-brain examinations have detected structural differences between the left and right hemispheres in schizophrenics, which were not found in normal individuals.
The brains of schizophrenics are lighter than those of normal people. Certain parts, such as the two key centers of the emotions-hippocampus and the amygdala, are smaller in schizophrenics.
Enlarged Ventricles in the Brain
The ventricles are composed of a chain of connected cavities that the cerebrospinal fluid flows through. This liquid helps to cushion the brain and the spinal cord against injury. Enlarged ventricles indicate some contraction of adjacent brain tissue, usually leading to deterioration of that tissue. However, this difference does not convince everyone because some experts found no significant difference in ventricle size between individuals with the disorder and those without it.
A higher dopamine level in the left hemisphere but a normal dopamine level in the right hemisphere. Dopamine is one of the neurotransmitters that nerve cells use to communicate and transfer messages. Dopamine is considered to play an important role in schizophrenia. A number of differences in the physical structure as well as in the chemical activities of the two hemispheres have been reported in the brains of schizophrenics.

A number of biological theories have been established to explain schizophrenia.
The neurotransmitter dopamine. Evidences: first, high dose of amphetamines can cause severe schizophrenia-like symptoms, and amphetamines increase the dopamine levels in the brain. Second, when the drug L-dopa, which increases the brain's output of dopamine, is given to schizophrenics, their condition gets worse.
Another popular theory blames nutritional deficiencies. Supporters of this theory advocate treatment with large doses of vitamins as well as such minerals as zinc and manganese.
The brains of many schizophrenics contain abnormal structures or anomalous chemical activities. If brain abnormalities are always present, then why is schizophrenia often an episodic disease? These questions remain unanswered.

The brain's chemical messengers. Certain chemicals called neurotransmitters make it possible for a nerve impulse to travel from the axon of one neuron to the dendrite of another.
Researchers have not yet found out the role dopamine plays in schizophrenia. Some believed that a surplus of dopamine was the cause; others believed that schizophrenia was caused by an insufficient supply of monoamine oxidase, an enzyme which breaks down dopamine, thereby accumulating amount of dopamine in the brain.
Since the beginning of the 20th century, researchers have shown interests in the idea that infections might cause schizophrenia. For one thing, 54 percent of schizophrenics are born in the winter and spring, months which infections occur more often. And it is known that viruses can attack the brain and that slow-acting viruses can remain inactive for years before suddenly beginning to multiply and cause illness. One theory suggests that a slow-acting virus infects the fetus in the womb and that this infection causes changes in the brain that lead to schizophrenia in adolescence or early adulthood.
In 1948, Fromm-Reichmann argued that a 'schizophrenogenic' mother, one who is both overprotective and hostile to her children, caused schizophrenia.

Some others suggested that life events are a cause of schizophrenia. This theory is based on the finding that schizophrenics experience substantially more life events in the period prior to the onset of the illness and that life events appear to precipitate deterioration.

The neurodevelopmental hypothesis of schizophrenia proposes that a proportion of schizophrenia is the result of an early brain insult which affects brain development leading to abnormalities which are expressed in the mature brain.
Diagnosis
There is no objective way to diagnose schizophrenia. So psychiatrists must rely on symptoms to decide whether a person suffers from schizophrenia. Unfortunately, a number of diseases may have the same symptoms.
Treatments

In the early 1950s, chlorpromazine, an antipsychotic drug, emerged as an antipsychotic drug. When it was applied to schizophrenic patients, it not only calmed agitated patients but also reduced some of the major symptoms of schizophrenia.
Antipsychotic drugs do not cure schizophrenia. They can only control many of its devastating symptoms and allow schizophrenics to live a normal life. If patients stop taking their medications, it is highly likely their symptoms will return.
Antipsychotics are not equally effectual against all of schizophrenia's symptoms. They work primarily against such symptoms as delusions and bizarre behavior and thoughts. Nevertheless, patients may continue to experience sporadic delusions, hallucinations, and other symptoms even when they take their medications consistently.

Chlorpromazine was followed by the development of other antipsychotic drugs. Despite the differences between their chemical compositions and their mechanisms of action, they share a common end result: They all block the action of dopamine in the brain. No one, however, knows why interfering with dopamine alleviates the symptoms of schizophrenia.

The greatest limitation of treatment with traditional antipsychotic drugs is their side effects. Schizophrenics have to endure disabling side effects such as parkinsonism, akathisia (restlessness in the legs and body), acute dystonia, and tardive dyskinesia (involuntary movements, often of the tongue and face but also of the fingers, hands, legs, and trunk).

Nevertheless, antipsychotics are safe drugs. An overdose does not kill. They are not addictive. And they do not create tolerance-that is people do not have to take larger and larger does to get the same effect. However, as everyone knows, no drug is completely safe.

Patients experiencing their first occurrence of schizophrenia should consider using the new antipsychotic drugs except clozapine. For those patients who do not respond to the new antipsychotics, a treatment with a traditional antipsychotic should be used.
For those patients who have responded to traditional antipsychotics but have consistent side effects should be offered a trial of a new antipsychotic. Patients who have not responded to other antipsychotics should be offered a trial of clozapine.
Before the advent of antipsychotic drugs, the treatment of schizophrenia had been extremely unsuccessful. The next few paragraphs will explain three false therapies of schizophrenia.

Insulin is one of the hormones of the body that regulate the sugar level in the blood. In a normal person, insulin is released to lower the sugar level in the blood if the level is high. It is used to treat diabetics who cannot produce insulin on their own. However, if too much insulin is given, the sugar level in the blood will be so low that coma occurs. This is fatal. In 1930s, the insulin coma therapy was falsely regarded as a method that helps treat schizophrenia. Doctors in Europe and the United States rushed to induce insulin coma in severe schizophrenics. As a result, some patients died, without any evidence that excessive insulin actually bettered the symptoms.

Electroconvulsive therapy (ECT) is another example of a therapy once widely used with little evidence of its efficacy. In ECT, brief pulses of electricity are passed through the brain. ECT has proved very effective in helping some people with severe depression. But it has little or no effect on their illness.

Perhaps the most brutal "therapy" for schizophrenia is the frontal lobotomy. A frontal lobotomy removes parts of the front of the brain. It is proposed that the site of schizophrenic's mental problems lay in the brain's frontal lobes. The surgery did produce a quieter patient, and it was used on tens of thousands of schizophrenics in Europe and the United States. There is no evidence that frontal lobotomy provided any improvement in the disease.

The main goal of the psychological branch in the diagnosis and treatment of schizophrenia is to treat the patient and to reintroduce him into society without the use of drugs or other physical interventions. This comes from decades, and even centuries, of experience of observation and treatment of schizophrenics. Over this time, there have been many theories about the cause of schizophrenia and the most safe and effective treatment. When the condition was first diagnosed, it was done so by Kraeplin, and instead of classifying it under the name Schizophrenia, he called it Dementia Praecox, meaning an early stage of Dementia. This has been disproven over the years, though, and it was finally classified as it's own condition in the
In the early days of battling the condition, there wasn't really an established psychological basis to this condition.
At that time, in the 19th century, many of those who treated schizophrenia experimented with primitive forms of ECT, lobotomies, and harsh punishments for the patient's behavior. There was a minority who thought that the disease, along with dementia, was probably psychologically derived, rather than biologically, but were unsuccessful in yielding results with their methods. It wasn't until the early to mid 20th century, when the field of Psychology was very large and encompassing, when there were serious thoughts of a psychological basis to this condition. As more and more evidence was collected, it was shown that at times of stress the condition appears, and that otherwise it went primarily undetected. From the vast field of psychology rose the application of the psychoanalytic technique, love-centered therapy, and various other forms of treatment. Of all of the forms of psychological basis, many of them obscure, the psychoanalytic technique seemed to be most reasonable, and yielded better results than many of the other techniques.

The reasons behind the psychological basis is really from the 1940s and 50s, when psychologically based theories seemed to solve many problems ranging from mild personality disorders to the severely disturbed. Also, with behaviorism on the rise, there was a great behaviorist influence in television commercials, school curriculi, and it made people thinking about the government and it's social settings that it was pressing upon the people, primarily in B.F. Skinner's "Walden II." If psychologically could be broad and solve so many problems, why not schizophrenia? And so a great divide occurred between the scientists and psychologists, hence leaving us with the Psychological, Biological, and Eclectic perspectives in dealing with this condition.
etiology
Schizophrenia is believed to be caused by overwhelming pressures in life that amount to an ultimate break from reality. This break is often over long courses of time, ranging from weeks to months, and sometimes, years. The break often occurs when the individual encounters a new and powerful stress, such as college. It has been shown that many new college students become ill and must take leave, and in this category lie schizophrenics. This leads many to believe that there have been building pressures and anxieties in the individual's life, and this new stress is the last straw, so to speak. This break is seen to be a self-protective break, as the person is protecting his brain from damage or trauma. In order to do this, the brain filters out more and more reality, creating a haven for the patient. The brain, not being perfect, creates a terrifying world that is an exaggerated model of the real world. This is thought by many to be the origin of schizophrenia. There is also a gene that is thought to be linked to this break, and it basically makes certain people more susceptible to this delusion. Other than somewhat vague notions, nobody REALLY knows how the break occurs, or even if a break occurs. The best the psychological world can do is make educated guesses, based on certain data.
treatments

The psychological treatments are all various methods of therapy, with varying degrees of success. The treatments are nearly always harmless, and the only thing that a patient has to lose is the cost of the treatment, unlike antipsychotic medications, which destroy brain cells and blanket the brain, causing a sedated state of being, and ECT, which destroys tons of brain cells, leaving irreparable damage. The main types of psychological treatments are:
Started by Freud, psychotherapy is a treatment of various mental disorders and complications in which the psychotherapist "talks to the unconscious." In discussing dreams that the patient had, or just talking about life or relationships, the therapist gets a glimpse of what's going on in the unconscious mind. Once this is identified, the therapist then nudges the patient to initiate and respond to conversations that indirectly, or directly, relate to what is REALLY bothering them. This process usually takes anywhere from a year to numerous years to complete, and is often put down for taking so long to fix seemingly simple problems.

While Freud treated the patient directly, Spotnitz established objects that the schizophrenic could relate to. An example would be if the patient seemed to mention his dog a few times during the session. The analyst would then continue talk of the dog, and if the patient was in a glum mood, the analyst would paint the dog as being sad. Once the patient understood the dogs problem, the analyst would treat the dog, always reading the patient, and would ask for patient input, too, on the dog's treatment. The patient would subconsciously recognize a parallel between him and the dog, and would mature through the therapy.
Initially, in the therapy, the model schizophrenic would be withdrawn and not too eager to talk. Instead, he would be quite indifferent about the analyst. "If you die, the hospital will just send another." "Why should I care about YOUR life?" (If too much rage, rather than indifference is immediately felt towards the analyst, then this hinders the therapy, along with too much love towards the therapist.) The Modern Psychoanalytic movement sees this indifference as a repression of rage, and that this rage, instead of being directed outward, is directed to the patient himself. The analyst's first job is to try to get a glimpse of this rage and try to point it out to an object. While the Modern Psychoanalytic movement doesn't necessarily endorse catharsis, this is a good method of initiating a connection between the patient and the analyst.

Freud developed the psychosexual stages of development:
Oral (0-1 yrs)
Anal (1-3)
Phallic (4-7)
Latency (7-12)
Genital 13+
Freud only really worked with patients that were over the age of 5, with the ability to speak coherently. If a 30 year old came to him at 2:00, and started feeling left out by the 1:00, say, that the 1:00 is getting him at a better time or is getting more out of him, then Freud could recognize this as being a projection of her and her older sister. Freud could then treat this feeling of neglect, and throughout the therapy, the patient would become better. Schizophrenia, also known as the Narcissistic Neurosis, is believed to have developed in the preverbal stages of development, when the feelings that the individual had were not conveyed in words. This makes standard psychotherapy difficult, because a direct association between those feelings and speech isn't there. The therapist must then skillfully talk to those emotions and feelings, without actually talking to them. This is by use of transference.

When the analyst makes a "connection" with the patient, this can be done through transference. Transference is basically when the patient takes his/her aggression, or other emotions felt by previous experiences, and directs it at the analyst, being closest persona. This transference has always been key to psychoanalysis, as it is key to the analysis of the schizophrenic patient. There are different stages of transference:
Negative Narcissistic Transference
Positive Narcissistic Transference
Negative Object Transference
Erotic Transference
Positive Transference
Freud dealt only with patients who were at the NOTranference stage, and nothing earlier. It is at this stage where speech is developed, and so the patient can go through a 'talking cure.' Freud's big thing was the Talking Cure. It's basically the patient sitting on the bench, and the analyst talking and directing the patient through his problems. This doesn't work with schizophrenia, because schizophrenia is believed to start in the first stage of transference. Since this is preverbal, it is harder to treat than the average neurotic.

Mirroring is the most widely used method of treating the narcissism. Initially in the therapy, an indifference is felt by the patient towards the analyst. To help that, the analyst will engage in conversation about the what a nice day it is, if he/she likes the colors of the curtains, and so on with trivial nonsense. This will continue until the patient makes some sort of emotional attachment towards the therapist, and we hit our first transference road-block. The patient will no longer feel indifferent towards the analyst, but will feel a contempt towards him. This is a good sign. This is an indication that the aggression that is turned towards the patient's self is now being redirected, to some degree to the analyst. This is the first, and most important, connection between the analyst and the patient. The therapist's job is now to work through the negative narcissistic transference, and this is done by mirroring the patient's mood. If the patient is cautious, the therapist is cautious, if the patient is outgoing, the therapist is more outgoing. This tends to show the patient that he is in the proper atmosphere, and he is understood, to some degree. He/She will most likely become angry about narcissistic situations, like lack of attention, abuse, etc. by the analyst. Once this passes, then the patient will talk about how his life was pretty good, and will usually be in a happy state during the session. The patient usually won't say something like, "Wow, do I love your company!" but will react more like a baby at the heels of his mother, perfectly content. He is standing near his mother and is happy, but he won't say, "Boy, mom, do I love your company." The company is there, and so is the positive feeling that is felt by the analyst. After overcoming this preverbal stage,(entering the erotic level of transference), we are now in Freud's realm of psychoanalysis. Now, the patient can be treated like a neurotic, and can become functional in society, depending on the patient and analyst. This is now the most widely accepted practice, as the Modern Psychoanalytic movement is the largest analytical movement in the US.

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