Schizophrenia and the Evolution of Psychiatric Thought

Schizophrenia and the Evolution
of Psychiatric Thought
David A. Casey, M.D.
• We will briefly discuss schizophrenia
• We will then briefly explore a few of the many
questions it raises
• Fair warning: this talk is a work in progress-for
me and for the profession of psychiatry
• Therefore, I do not claim to know the
• “Why can’t psychiatry be more black and
white like the rest of medicine”?
• Severe, persistent psychiatric disorder
characterized by psychosis, thought disorder
and other symptoms
• Onset typically late adolescence or young
adulthood, but variable
• Several subtypes of unclear significance
• Paranoid, undifferentiated, catatonic,
• Positive symptoms: hallucinations and
delusions (psychosis)
• Hallucinations: sensory experiences without
basis in reality
• Schizophrenic hallucinations typically auditory
• Delusions: fixed false beliefs
• Delusions and/or hallucinations: psychosis
• Positive and negative symptoms
• Positive: psychosis
• Negative: illogical thinking (thought disorder),
executive dysfunction, disturbed affect, loss of
function, cognitive disturbance
• Phases: prodromal, active, residual
Affects both sexes equally
All known cultures and groups
Roughly 1—2% prevalence
Genetic component but no controlling gene(s)
• Involves dysfunction of dopamine circuitsregarded by most psychiatrists as a brain disease
• Typically chronic course with exacerbations; more
negative symptoms, cognitive loss with aging
• Often described as incurable, but various
levels of recovery possible
• Outcomes may vary among cultures
• Treatment typically involves antipsychotic
medications (dopamine blockers) which tend
to affect positive symptoms but do little for
negative symptoms
• Antipsychotic drugs: many categories often
grouped into “typical” and “atypical”
• Atypicals are the current class—arguably cause
less parkinsonism than older drugs
• However, atypicals associated with weight gain,
glucose intolerance and DM, metabolic
syndrome, increased cardiovascular risk profile
• Current reexamination of their merits relative to
older (and far cheaper) drugs
Medical Co-morbidity
• High incidence of obesity, hyperlipidemia, DM II,
heart disease
• How much are atypicals responsible?
• High rates of smoking as well as drug and alcohol
• Low medical adherence rates
• Adverse diets and lifestyles
• USA: Dramatic reduction in life expectancy—by
15-20 years
• Schizophrenia is probably the most serious
and disabling psychiatric disorder
• It is also the among the most controversial
• Exploration of the history of schizophrenia
gives insight into the evolution of psychiatric
Images of Schizophrenia
(clockwise, from top left: John Nash, Jack Kerouac, Peter Green, Syd
Questions raised by Schizophrenia
• Are psychiatric disorders biological, psychological, or
social in origin?
• Should they be regarded as medical problems?
• Nature vs nurture
• How about free will?
• Mind/brain dualism
• Have psychiatric disorders always existed in humanity?
• Have they changed or evolved as society has changed?
• Politics and schizophrenia: “sluggish” schizophrenia
• Should society intervene in the lives of those
labeled mentally ill, even against their will?
• Does mental illness lead to violence?
• Do psychiatric disorders occur in discrete
categories (as implied by DSM-IV TR) or as a
variety of symptoms each occurring as points
on a spectrum from normal to abnormal?
• Does labeling patients lead to stigma?
• Can schizophrenia be adaptive?
When did Schizophrenia Emerge?
• No consensus
• Psychosis is described in many ancient texts,
but not clearly equivalent to modern concept
of schizophrenia
• Middle ages: demonic possession, witchcraft,
persecution (especially of women)
• Beginnings of asylums (“Bedlam”)
18th Century
• First case descriptions equivalent to modern
concept of schizophrenia
• Enlightenment ideals applied sporadically to
mentally ill (e.g., Pinel)
• Later authors (Foucault) claimed
Enlightenment ideals actually marginalized,
pathologized, or even “created” mentally ill
• Emil Kraeplin (Germany) was the first great
nosologist in psychiatry
• Kept records of symptoms and course of large
numbers of chronically hospitalized patients and
separated them into categories
• Popularized the term “dementia praecox” (1897)
for early life onset psychosis and cognitive
decline; to be distinguished from senile dementia
• Focused on mental deterioration, psychosis
Emil Kraeplin
• Eugen Bleuler (Switzerland) coined term
“schizophrenia” (1911)
• He did not see severe cognitive decline in all
patients and disliked the term dementia
• Regarded schizophrenia as a split between
various aspects of the mind
• “Schiz”: split
• “Phrene”: mind
• The “A’s”: associations, affect, ambivalence,
• “Loose” associations
• Blunted/flat/inappropriate affect
• Ambivalence: inability to make decisions
• Autism: self-involvement, fantasy world
• Deemphasized critical importance of psychosis
Eugen Bleuler
Dissociative disorder
• Note: schizophrenia is not to be confused
with “split personality”
• Split personality: multiple personality or
dissociative identity disorder
• Kurt Schneider added another element to the
definition (1920s): “first rank symptoms”
• FRS: thought insertion, thought withdrawal,
delusions of control, ideas of reference
• “bizarre or patently absurd” delusions which
are impossible, as opposed to paranoia or
other delusions which could theoretically be
reality based
Kurt Schneider
Asylum Era
• In the USA, the most seriously ill were
grouped in asylums
• Kentucky had a number, of which 3 were most
important still exist
• Central State, Eastern State, Western State
• Every state has one or more
• Over 500,000 by about 1950
• Warehousing
Central State Hospital
US Diagnoses-20th Century
• Americans adopted a very broad concept of
schizophrenia, incorporating all the previous
ideas; schizophrenia much more commonly
diagnosed in US
• Virtually any chronically mentally ill person
might have been diagnosed as schizophrenic
• DSM-I and DSM-II very broad, loosely
described categories; psychoanalytic concepts
• Prefrontal leucotomy (“lobotomy”)
popularized by Moniz (Portugal) and Freeman
(US) in 1930s-1950s.
• Largely used for agitated schizophrenics
• Cautionary tale
Walter Freeman and Egas Moniz
Advent of first antipsychotic drugs
Chlorpromazine (“Thorazine”)
Patients rights and liberation movements
Community mental health movement
Backlash against medical model
Antipsychiatry movement
Dangerousness criteria and due process in
commitment laws
1950s-1960s-Psychosis as Personal
• RD Laing: schizophrenia as a search for meaning:
“Being sane in an insane world”
• Bateson: The “double-bind hypothesis”; the
“schizophrenogenic” mother
• Thomas Szasz: “The Myth of Mental Illness”
• Foucault : “Madness and Civilization”
• Pirsig: “Zen and the Art of Motorcycle
• Denber and others: LSD experiments
R.D. Laing and Thomas Szasz
Robert and Chris Pirsig
DSM-III (1980)
Biological research in schizophrenia
Development of criterion based diagnosis
Narrowing of diagnosis
Advent of lithium---backing in to diagnosis
Dissatisfaction with DSM-II
Reaction to antipsychiatry movement
DSM-III was a revolution in psychiatric practice
Introduced diagnostic criteria, multi-axial diagnosis;
considered validity and reliability, ended reliance on
analytic concepts
• Assumed categorical diagnoses
• Did not end controversy—think Scientology!
Atypical Antipsychotics (1990s-current)
• “Atypical” refers to lack of parkinsonism
• Thought to be breakthrough
• Zyprexa, Risperdal, Seroquel, Geodon, Abilify,
• Growing concerns about effectiveness, cost,
• Heavily promoted--contributes to concerns
about role of Pharma in psychiatry
• Search for “gene for schizophrenia” proved
• No longer considered to be a simple genetic
• Probably a number of genetic influences on a
variety of cellular processes
• Controller genes which switch on/off during
development, or with environment may be
• Bipolar and other mood disorders probably
share some common genetics
• Schizophrenia probably not a unitary disorder
from a genetic viewpoint
• Leading to reexamination of assumptions
about boundaries of disorders
Critics of Psychiatry
• Today’s critics focus on overuse of
medications, over-involvement of Pharma
• Patients’ groups seek autonomy and
normalization: “voice hearers” associations,
“Morgellon’s” support groups
• UK-move away from categorical diagnosis to
dimensional approach, seeing symptoms in
context of patients’ life, paying attention to
content of delusions
Emerging Thoughts
• Brain as a plastic instrument—synthesizing
genetic and experiential inputs into its
anatomy, physiology, and psychology
• False dichotomies: nature/nurture;
mind/brain, etc.
• Limits of pharmacotherapies
• Search for new integrative paradigm to better
understand dimensions of schizophrenia
• Patient as partner rather than object