Wednesday, December 17, 2014

Schizophrenia From a Pychological Point of View

Written and Compiled by Dr Ruwan M Jayatunge M.D.   

There is always this element of concealed accusation in neurosis, the patient feeling as though he were deprived of his right-that is, of the center of attention - and wanting to fix the responsibility and blame upon someone.
 -Alfred Adler

 Schizophrenia is a brain disorder that distorts the way a person thinks, acts, expresses emotions, perceives reality and relates to others. Schizophrenia has an altered perception of reality. Research suggests that schizophrenia may be a developmental disorder resulting from alterations in the usual maturing process of the nervous system. Around 1 in 100 people will develop schizophrenia during their lifetime, and this figure is the same all over the world.

Kraepelin and Dementia Praecox
Schizophrenia was originally called the senility of youth by Kraepelin in 1911. Kraepelin originally called schizophrenia Dementia Praecox. He believed that the typical symptoms were due to a form of mental deterioration which began in adolescence. Symptoms are mainly disturbances of thought processes but also extend to disturbances of behavior and emotion. He called the illness schizophrenia, meaning split mind or divided self in which the personality loses its unity. Kraepelin believed that dementia praecox was primarily a disease of the brain.

Types of schizophrenia
There are several types of schizophrenia. In Paranoid schizophrenia the patient has delusions and auditory hallucinations.  The delusions can often be about being persecuted unfairly or being some other person who is famous like Napoleon Bonaparte or Albert Einstein .  They can exhibit anger, unfriendlyness, anxiety, and argumentativeness. Disorganized schizophrenia is characterized by speech and behavior that are disorganized or difficult to understand, and flattening or inappropriate emotions.  Patient’s disorganized behavior may disrupt normal activities. In Catatonic-type schizophrenia  disturbances of movement can be observed. In Undifferentiated-type schizophrenia a mixed picture is often seen.

Schizophrenia  and Cognitive Dysfunctions
People with schizophrenia can have certain type of cognitive dysfunctions. The cognitive  dysfunctions are acurately  detected  by neuropsychological tests. Some patients loss the  ability to absorb and interpret information and make decisions based on that information. They have inability to sustain attention, and problems with working memory or to keep recently learned information.

With schizophrenia the person's inner world and behavior change notably. These bhavioral  changes might include social withdrawal, intense anxiety and a feeling of being unreal (Depersonalization), poor self care , experiencing hallucinations,  sense of being controlled by outside forces ,  delusions, or making up words without a meaning (neologisms). Schizophrenia makes it difficult for a person to tell the difference between real and unreal experiences, to think logically, to have appropriate emotional responses to others and to behave appropriately in social situations.  

Sigmund Freud on Schizophrenia
For schizophrenia Freud sometimes uses the term "dementia praecox. Freud’s early consideration of schizophrenia as a non psychotic continuation of mental disorders, he later concluded that some of its aspects could be comprehended from a psychological point of view. Freud seems to suggest here that narcissism is a later stage in human development than auto-eroticism, the ideas of "ego-libido" (inward-directed libido invested in the ego) and "object-libido" (libido directed outward toward objects, including other people) have value for Freud because they are derived from direct observations of the nature of psychological processes in patients.

Freud's (1911) hypothesis explains the basic disorder in schizophrenia consists in the patient's inability to maintain the libidinal cathexis of objects. The fact that patients suffering from the two principal types of schizophrenia present signs of real and fantasy object relationships has been taken as evidence that the illness cannot be based on a decathexis of object representations. This contradiction is easily dispelled if account is taken of the real likelihood that these object relationships, which are mostly of a pathological kind, represent a spontaneous tendency towards recovery. They are therefore secondary to the primary disorder and a reaction to it.

In the original theory Freud (1911) described the flight of the libidinal cathexis from the love object in schizophrenia as a form of repression. After the introduction of the structural theory (Freud, 1923) he dropped this term.  Freud concludes that the libido theory does not help to explain schizophrenia.  The psychoanalytic sense of "libido," which Freud describes as an energy that can be directed to human beings or, as in the case of the anchorite in the example, sublimated and directed toward non-human objects such as God or nature. The ascetic can sublimate and redirect his or her sexual desires for other human beings, but that does not mean that the libido is directed toward the ego, as in Freud's conceptualization of the etiology of schizophrenia. 

The psychodynamic model is due to a regression to an infantile stage of function. Freud calls this the oral stage. Freud believes that there are three stages of the oral stage, the id, the ego and the superego. The id wants immediate gratification, the ego tries to control the id and apply a reality principle, and the superego which is the conscience which controls guilt and morality uses defense mechanisms when the ego has too much pressure. Freud believes schizophrenia occurs when the ego becomes overwhelmed by demands of id or besieged by unbearable guilt from the superego. The ego cannot cope so it uses defense mechanisms to protect itself which is regression. The schizophrenic’s fantasies become confused with reality which gives rise to hallucinations and delusions.  Freud is suggesting that the schizophrenic is dreaming and the hallucinations are not really happening, but they cannot tell the difference between dreams and reality.

Freud concluded that schizophrenia, like homosexuality was due to nurture. But the contemporary researchers do not support this argument.

Schizophrenogenic families
In the 1950's and 1960's it was thought that schizophrenia was caused by a dysfunction of communication in the family. Fromm Reichman in 1948 used the term schizophrenogenic families to describe families with high expressed emotion. This means families with emotional tension, many secrets, close alliances and conspiracies. Bateson et al in 1956 suggested the double bind situation where children are given conflicting messages from parents who express care but are also critical. He thought that this led to self doubt, confusion and eventually withdrawal. This theory went into decline in the 1970's as there was more convincing evidence for a genetic predisposition in schizophrenia

Treatment of Schizophrenia
Antipsychotic drugs have proven to be crucial in relieving the psychotic symptoms of schizophrenia – hallucinations, delusions, and incoherence   Antipsychotic medications have been available since the mid-1950s. They have greatly improved the outlook for individual patients. These medications reduce the psychotic symptoms of schizophrenia and usually allow the patient to function more effectively and appropriately. Psychotherapy is not a substitute for antipsychotic medication,

Carl Jung and Treatment of Schizophrenia
The psycho analyst Carl Jung deeply studied the schizophrenic patients. Supervised by Bleuler, Jung and a group of therapists originated the idea of symbolic communication to comprehend schizophrenic patients. Their method helped to improve the communication skills of the patients.

Psychotherapy of Direct Confrontation
The Psychotherapy of Direct Confrontation evolved from an eclectic theoretical orientation originated by Rosberg, but the technique suggests basic suppositions that give grounds to the therapy of the chronic schizophrenic.  

According to Rosberg schizophrenia can be treated with psychotherapy as a supportive therapy.   The schizophrenic patients feel rejected, despised, detested in their significant interpersonal relationships. To decrease the suffering therapeutic acceptance is fundamental. In psychological context Rosberg argues that Schizophrenia is a survival mechanism and the symtomatology is a way for the schizophrenic to be distant from others, to decrease suffering and the fear  of rejection.  

In this mode a strong therapeutic alliance between the patient and the psychotherapist is established and the patient is encouraged to engage in positive interpersonal relations.   The psychotherapist must be tolerant with the problems of negative transference and be able to utilize and manage the anger to break the psychotic defenses. In the   Psychotherapy of Direct Confrontation the therapist gets involved in a communicative interaction with the patient. 

The therapist tries to persuade the patient to abandon his negative symptomatology and   learn more effective and more appropriate mechanisms for a positive life.   Rosberg believes that many factors may cause schizophrenia. He does not deny the possibility of it being organically based.  The main task of the therapist is to help the patients to live a reasonable, meaningful and productive life.

For Rosberg, the defense mechanisms in the schizophrenic patients are conscious and unconscious.   Rosberg suggests that the chronicity of schizophrenia is based on the organization and systematization of the delusional system.  Rosberg thinks nobody is totally schizophrenic. In his therapy technique, he constantly seeks a way of finding the healthy basic nucleus. Rosberg says “I believe that there is some healthier life in the internal world of every schizophrenic". (Rosberg 1982).

Integrated psychodynamic Approach
Integrated psychodynamic approach can be used in treating schizophrenia. Professor Yrjo O. Alanen introduced a   therapy based on an integrated psychodynamic approach. For nearly forty years of psychotherapeutic involvement with schizophrenic patients in Finland he created the Turku Schizophrenia Project that helps schizophrenic patients immensely.

Cognitive-behavioral psychotherapy
Schizophrenia results in distorted perceptions of the world, including self, and disordered or disorganized thinking. Cognitive-behavioral psychotherapy is effective in the treatment of schizophrenia. 

The basic premise of cognitive therapy is that beliefs, expectations, and cognitive assessments of self, the world, and the nature of personal problems in the world affect how patients  perceive themselves and others, how they approach problems, and ultimately how successful they are in coping in the world and in achieving their goals.  The misinterpretation of events in the world is common in schizophrenia. The treatment goal, for the cognitive therapist, is not to "cure" schizophrenia, but to improve the client's ability to manage life problems, to function independently, and to be free of extreme distress and other psychological symptoms.

 Individuals with schizophrenia often make incorrect assessments of cause and effect. Also, they often do not learn as well from experience because of their disordered and disorganized thinking. Behavior therapy teaches them the social skills they never learned, and helps them understand when to apply those skills to problems in the world.

Individual psychotherapy
Individual psychotherapy involves regularly scheduled talks between the patient and a mental health professional. The sessions may focus on current or past problems, experiences, thoughts, feelings, or relationships. By sharing experiences with a trained empathic person – talking about their world with someone outside it – individuals with schizophrenia may gradually come to understand more about themselves and their problems. They can also learn to sort out the real from the unreal and distorted. Recent studies indicate that supportive, reality-oriented, individual psychotherapy, and cognitive-behavioral approaches that teach coping and problem-solving skills, can be beneficial for outpatients with schizophrenia.

Social Support for the patients
Adolph Meyer expressed that schizophrenia could be understood as logical reactions to psychiatric disorders, but maladapted to everyday life. A patient's support system may come from several sources, including the family, doctor, counselor or friends. There are numerous situations in which patients with schizophrenia may need help from people in their family or community. In a relapse of the illness the patient should be given a helping hand by this supportive network.  The family, friends, and peer groups can provide support and encourage the person with schizophrenia to regain his abilities and self esteem.  

When patients with schizophrenia are discharged from the hospital into the care of their family the family members should learn the nature schizophrenia and understand the difficulties and problems associated with the illness. It is also helpful for family members to learn ways to minimize the patient's chance of relapse. In supportive family environment patients learn    various coping strategies and problem-solving skills. This social support network contributes to an improved outcome for the patient.

Rehabilitation includes a wide array of non-medical interventions for those with schizophrenia. Rehabilitation programs emphasize social and vocational training to help patients and former patients overcome difficulties in these areas. Programs may include vocational counseling, job training, problem-solving and money management skills, use of public transportation, and social skills training. These approaches are important for the success of the community-centered treatment of schizophrenia, because they provide discharged patients with the skills necessary to lead productive lives outside the sheltered confines of a mental hospital.


A Schizophrenic - Do not Label Us 
(By Dr Ruwan M Jayatunge)

My world is limited
Filled with wired sounds
I see Rocky Marciano
Fighting with Woody Allen

Long time ago
Aliens abducted me
They fixed wires in to my brain
Then sucked out my brain substance

I cannot control my thoughts
Because thoughts control me
Some kind of energy is inside me
Giving continuous commands

I hate to go to the Bush House London
Where the BBC transmits my thoughts
People often express amusement 
When they read my thoughts

A man with a black jacket
Is an agent from the KGB
He is spying and tries to track me down
May be he wants to take me to Moscow

I was in Lubianka
Questioned by Lorenthy Beria
I was released by the NKVD
Then planted in Pennsylvania

When JFK was murdered
I knew the secret plot
No one took it seriously
Not even my psychiatrist

When the Deep Throat revealed his identity
All the president's men pardoned him
I cannot reveal my secrets
It would lead to a catastrophe

I bear top secrets
I know all the classified information
The world cannot survive without my skills

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