Part one covered the history (click here for part I); part two diagnosis (click here for part II); and part three causes and treatments (click here for part III). The final section reviews literature rarely discussed in medical circles, but research that is just as relevant as medical model notions.
When I was in graduate school we were taught that schizophrenia was a "disease" and medical treatments (drugs) were most effective approach to treatment. As I matured from school and investigated the validity of the medical model as it applies to mental illness I realized how limited this model actually is. This section reviews some of my thoughts and provides empirical support for them.
The “Pitfalls” of Psychological Explanations of Psychopathology
As the understanding of the biological elements involved in schizophrenia evolved, many changes occurred in hospitalization and treatment of these patients. The pharmacological treatments for psychotic illnesses have grown exponentially in the past quarter of a century using antipsychotic medications and mood stabilizers that have enabled many very ill patients to emerge from their psychosis in a relatively short time and reducing their terror and isolation in the process. In recent years, these medications have improved with the use of newer drugs and their side effects are fewer, though still considerable in many cases. Hospital treatment of schizophrenia has become limited to stabilization of the most acute psychotic symptoms, which has led to a limited focus in the current psychiatric textbooks only describing the medications available and helping patients understand the limitations of what can be offered (Cohen, 2003; Sadock & Sadock, 2007).
Thinking of psychotic symptoms as symbols with concrete meaning for patients should not be at odds with a biological model emphasizing medical treatment of the most painful symptoms, but often in hospitals and clinics this scenario has become the norm (Perry, 1999). Medications help many patients feel better, and inpatient hospitals are increasingly limited to crisis stabilization as the criteria for discharge. Psychotherapy with schizophrenics is extremely difficult, it takes time, and can be quite frustrating. For the treatment of schizophrenia once patients’ symptoms are reasonably stable, those that treat them understandably feel the need to then turn to help those patients that are in the most acute crises.
However, a major problem in the management of schizophrenia today is that psychiatry has perhaps thrown out our baby with the bathwater. There are several newer studies that indicate that there is not such a rosy picture for the effects of medications and the outcome for psychiatric patients including the surprising finding that outcomes for schizophrenic patients are often better in countries where medications are not the first line treatments (see Cohen, Patel, Thara, & Gureje, 2008 for a discussion).
Facts You Will Not See Drug Companies Publishing
Here are some well-known facts concerning the treatment for schizophrenia:
First, in the pre-neuroleptic period before these drugs were developed and before there were long-term follow-up studies approximately two-thirds of schizophrenic patients made good social recoveries (Bleuler 1968; Ciompi 1980). Based on a large meta-analysis of patients covering a 100 years from 1895 to 1992 it also appears that outcome for persons with a diagnosis of schizophrenia is worse now than it was before treatment with neuroleptics medications dominated the field (Hegarty, Baldessarin, Tohen, Waternaux, & Oepen, 1994).
About two two-thirds of patients (or more depending on the definition to define “recovery”) of 118 former Vermont State Hospital patients hospitalized for schizophrenia in the mid-1950’s were doing well in their community nearly 30 years after being discharged (Harding, Brooks, Ashikaga, Strauss, & Breier, 1987). The explanation to their recovery looks to have been due to these patients having well-organized and individualized rehabilitation programs. Interestingly, the majority of these patients had stopped taking their neuroleptic (antipsychotic) medications.
The World Health Organization’s (WHO) findings from a nine-country study of schizophrenia indicated that at the five year follow-up period nearly 63% of patients from third world developing countries were doing well compared to 39% of those from developed countries. The most parsimonious explanation that could be offered for this surprising finding is that only 16% of third world country patients were maintained on neuroleptics medications compared with 59% from developed countries (Whitaker 2002).
There are many studies that indicate that newly identified schizophrenic patients who are treated with specialized psycho-social methods and few or no neuroleptic drugs, recover as well as drug-treated patients in the short run (e.g., Mosher and Menn, 1978; 1979). However at two year follow-ups of patients treated in programs without drugs indicates that these patients have better outcomes than patients in similar programs who receive neuroleptic medications (Bola and Mosher 2003). Therefore, consistent with Perry (1999) it appears justified to expect recovery for most persons with early-episode psychosis if the proper conditions can be maintained to foster their recovery.
In a similar vein there is an emergent body of research that indicates that many of the standard treatments in psychiatry (e.g., medications) are no more effective than active placebos (e.g., see Kirsch, 2010). When psychiatry declared psychotherapy no longer the province of hospital treatment, they may have also unwittingly declared meaning and context irrelevant in the understanding and treatment of schizophrenia as well. The famous psychiatrist the late Carl Jung and others would interpret such a move to be colluding with patients’ illness: they have lost the capacity for symbolic thought as their symbols are now facts, and such patients must fight to protect against the assault from frightening ideas which seem to come from outside them.
However it is undoubtedly a lot easier for a mental health professional with patients who have learned the mental patient role and have antipsychotic drug treatments. A number of studies programs have attempted minimize medicalization of certain psychiatric illnesses as well as reduce the labeling as theses are viewed as impediments to the recovery of the patients (Mosher & Menn, 1979; Perry, 1999). There are a number of studies that have indicated that early stages of psychosis can be successfully managed with a no or a low-dose antipsychotic drug approach.
What this means to the patient is that people in these programs will experience few, if any, of the adverse affects of the major drugs used to treat psychosis such as tardive dyskinesia, tardive dementia and neuroleptic-induced deficiency syndrome, which are all serious iatrogenic disorders. Treating people with schizophrenia and avoiding these side effects, that in many cases last throughout the patient’s lifetime, is a tremendous accomplishment. This is why speedy attention to “first break” persons is vital. It can prevent the continued accumulation of persons suffering from irreversible iatrogenically (physician or treatment produced) induced neurological disorders.
Patients who have been hospitalized have been so because their most fundamental defenses have broken down and failed them. In the case of paranoid, psychotic people, it is the capacity to split off good from evil that enables them to function in an insane world. Whether the stance they maintain is that of pure-hearted knight or of supreme sinner, they know still have a sense of what is bad from what is good and this organizes their world (this is not to say that they understand right from wrong). When this separation disappears, so does the grasp and command of the reality around them. When in a schizophrenic patient the “bad” and the “good” merge, infecting one another, there is no safety in the world for them any longer.
Conclusions
As mentioned in the studies of Harry Harlow, the expressed emotion literature, the double bind theory, and many of the aspects of Jungian theory indicate that there is a common theme in schizophrenia that does not reflect a merely organic basis. Modern psychiatry has abandoned these notions in favor of a medical model approach and has suppressed evidence to the contrary of their paradigm in favor of pharmacological treatments. I find this quite disturbing.
I am not advocating for the complete disuse of medications (not yet anyway) but for the incorporation of a more complete understanding and treatment for all mental illness.
References
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Bleuler, M. (1968). A 23 year follow-up study of 208 schizophrenics. In D. Rosenthal and S.
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Bola, J. & Mosher, L. (2003). Treatment of acute psychosis without neuroleptics: Two-year
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Ciompi, L. (1980). Catamnestic long-term study of the life course and aging of schizophrenics.
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Cohen, B. (2003). Theory and practice of psychiatry. New York: Oxford University Press.
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Rudy Hatfield - I am a clinical neuropsychologist with extensive experience in the assessment and treatment of neurological and psychiatric disorders. I ...
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