When people think about “crazy” people and people in mental institutions, they are often thinking of people with schizophrenia. Schizophrenia is the primary example of what psychologists and psychiatrists used to call a psychosis. The general characteristic of people with a psychosis is that they seem to be out of touch with reality. Mood disorders, especially mania, used to be considered psychoses as well.
Someone with a neurosis appears to be more emotionally troubled, perhaps even excesssively responsive to reality rather than out of touch with reality. The anxiety disorders are the primary examples. Although we don’t use these terms as much today, psychology students should keep them in mind!
The following quotations on schizophrenia (in italics) are from Mental Health: A Report of the Surgeon General, U.S. Public Health Services (1999), available at http://www.surgeongeneral.gov/library/mentalhealth/home.html
Our understanding of schizophrenia has evolved since its symptoms were first catalogued by German psychiatrist Emil Kraepelin in the late 19th century (Andreasen, 1997a). Even though the cause of this disorder remains elusive, its frightening symptoms and biological correlates have come to be quite well defined. Yet misconceptions abound about symptoms: schizophrenia is neither “split personality” nor “multiple personality.” Furthermore, people with schizophrenia are not perpetually incoherent or psychotic (DSM-IV; Mason et al., 1997) (Table 4-6).
Schizophrenia is characterized by profound disruption in cognition and emotion, affecting the most fundamental human attributes: language, thought, perception, affect, and sense of self. The array of symptoms, while wide ranging, frequently includes psychotic manifestations, such as hearing internal voices or experiencing other sensations not connected to an obvious source (hallucinations) and assigning unusual significance or meaning to normal events or holding fixed false personal beliefs (delusions). No single symptom is definitive for diagnosis; rather, the diagnosis encompasses a pattern of signs and symptoms, in conjunction with impaired occupational or social functioning (DSM-IV).
“Positive” Symptoms of Schizophrenia
Delusions are firmly held erroneous beliefs due to distortions or exaggerations of reasoning and/or misinterpretations of perceptions or experiences. Delusions of being followed or watched are common, as are beliefs that comments, radio or TV programs, etc., are directing special messages directly to him/her.
Hallucinations are distortions or exaggerations of perception in any of the senses, although auditory hallucinations (“hearing voices” within, distinct from one’s own thoughts) are the most common, followed by visual hallucinations.
Disorganized speech/thinking, also described as “thought disorder” or “loosening of associations,” is a key aspect of schizophrenia. Disorganized thinking is usually assessed primarily based on the person’s speech. Therefore, tangential, loosely associated, or incoherent speech severe enough to substantially impair effective communication is used as an indicator of thought disorder by the DSM-IV.
Grossly disorganized behavior includes difficulty in goal-directed behavior (leading to difficulties in activities in daily living), unpredictable agitation or silliness, social disinhibition [loss of normal inhibitions], or behaviors that are bizarre to onlookers. Their purposelessness distinguishes them from unusual behavior prompted by delusional beliefs.
Catatonic behaviors are characterized by a marked decrease in reaction to the immediate surrounding environment, sometimes taking the form of motionless and apparent unawareness, rigid or bizarre postures, or aimless excess motor activity.
“Negative” Symptoms of Schizophrenia
Affective flattening is the reduction in the range and intensity of emotional expression, including facial expression, voice tone, eye contact, and body language.
Alogia, or poverty of speech, is the lessening of speech fluency and productivity, thought to reflect slowing or blocked thoughts, and often manifested as laconic [using few words], empty replies to questions.
Avolition is the reduction, difficulty, or inability to initiate and persist in goal-directed behavior; it is often mistaken for apparent disinterest.
Course of the disorder
Onset generally occurs during young adulthood (mid-20s for men, late-20s for women), although earlier and later onset do occur. It may be abrupt or gradual, but most people experience some early signs, such as increasing social withdrawal, loss of interests, unusual behavior, or decreases in functioning prior to the beginning of active positive symptoms. These are often the first behaviors to worry family members and friends.
Most individuals experience periods of symptom exacerbation [worsening] and remission [improvement], while others maintain a steady level of symptoms and disability which can range from moderate to severe (Wiersma et al., 1998).
A small percentage (10 percent or so) of patients seem to remain severely ill over long periods of time (Jablensky et al., 1992; Gerbaldo et al., 1995). Most do not return to their prior state of mental function. Yet several long-term studies reveal that about one-half to two-thirds of people with schizophrenia significantly improve or recover, some completely (for a review see Harding et al., 1992).
On first consideration, symptoms like hallucinations, delusions, and bizarre behavior seem easily defined and clearly pathological. However, increased attention to cultural variation has made it very clear that what is considered delusional in one culture may be accepted as normal in another (Lu et al., 1995). For example, among members of some cultural groups, “visions” or “voices” of religious figures are part of normal religious experience. In many communities, “seeing” or being “visited” by a recently deceased person are not unusual among family members. Therefore, labeling an experience as pathological or a psychiatric symptom can be a subtle process for the clinician with a different cultural or ethnic background from the patient; indeed, cultural variations and nuances may occur within the diverse subpopulations of a single racial, ethnic, or cultural group. Often, however, clinicians’ training, skills, and views tend to reflect their own social and cultural influences.
Schizophrenia is more common in egocentric, as opposed to sociocentric, cultures. In egocentric societies, each person is seen as more or less responsible for him- or herself, and others may withdraw from the sufferer and allow him or her to fall into isolation. Families may feel free to express criticism and even hostility when a member does not live up to expectations. Sociocentric societies, even when they have other, very negative, qualities, nevertheless provide support in the form of extended families. And, since individual success is not as important as the family’s welfare, individuals are not judged as harshly.
Cultural psychologist Richard Castillo suggests that city living, wage labor, and capitalist society places a lot of demands on people, some of whom are not up to the task. Independence is expected, so people who are not capable of independence are seen as inadequate. You are expected to be productive, unless you are disabled. So if you can’t work, you must therefore be disabled, and so again inadequate.
Here’s another interesting observation about less developed countries and some non-western societies: Recovery from schizophrenia is common. In some of these societies, the voices are interpreted as the voices of the ancestors. Sometimes, the voices are positive, and they give the hearer and his or her family needed advice. When the advice is acted upon, the ancestor withdraws. Even if the voices and impulses are negative, they are seen as the effects of demons or witchcraft, and appropriate rituals will bring that person back to him- or herself. In western society, on the other hand, schizophrenia is defined as an incurable “brain disease.” No wonder people don’t usually get better!