Perspectives on Understanding Schizophrenia

The term 'schizophrenia' has a long history and dates back over 100 years. Historically people with a diagnosis of schizophrenia were generally perceived as having a poor outlook, having to live their life in a uniformly downward spiral of persistent and enduring symptoms. Unfortunately there are many myths associated with the term 'schizophrenia' that have led to misunderstandings and myths amongst the general population, the media and even within mental health services. Some of these myths are listed below:

• Nobody recovers from schizophrenia.
• Schizophrenia is an untreatable disease.
• People with schizophrenia are usually violent or dangerous.
• People with schizophrenia are likely to infect others with their madness.
• People with schizophrenia are lazy and unreliable.
• Schizophrenia is the result of a deliberate weakness of will.
• Everything people with schizophrenia say is nonsense.
• People with schizophrenia are completely unable to make rational decisions about their own lives.
• People with schizophrenia are unpredictable.
• People with schizophrenia cannot work.
• Schizophrenia is the parents' fault.

The above statements are untrue. There is no evidence to support them. However, they are sometimes the basis for negative attitudes that lead to poor quality and outdated services and care being offered.

Throughout this NICE Implementation Resource Tool there will be one message that is consistent and that is one of Recovery. People do and will recover from psychosis and schizophrenia. Integral to this is the importance of hope and of people's right to receive positive and optimistic services.

In a review of mental health policy the vision for recovery orientated services was presented as:

'Services of the future will talk as much about recovery as they do about symptoms and illness. We need to create an optimistic, positive approach to all people who use mental health services. The vast majority have real prospects of recovery - if they are supported by appropriate services, driven by the right values and attitudes'. Journey to Recovery (DoH 2001) [79]

The main purpose of this section is to introduce some of the dominant views used to understand schizophrenia, and in so doing provide an overview of helpful and effective approaches (sometimes known as 'interventions') that should be available to individuals and their carers (family and friends) by local services.

This section will provide an overview of the recent advances in understanding schizophrenia and the psychological, social and biological approaches that attempt to alleviate the distress associated with the experience of psychosis.

Background

Severe mental illness refers to a group of psychiatric diagnoses including 'schizophrenia', 'paranoid schizophrenia', 'psychosis', 'manic depression', and 'bipolar affective disorder'. These terms refer to experiences such as hearing voices that other people cannot hear (sometimes called auditory hallucinations), having unusual thoughts and/or believing unusual things that other people do not share (sometimes called delusions), and experiencing extreme moods such as depression or elation.

How Common are these Problems?

Generally about 1% of the population will be diagnosed with schizophrenia during their lifetime. Again estimates of lifetime risk of being diagnosed with bipolar disorder (manic depression) are similar (around 1%).

There is also evidence that a considerable number of people in the general population are said to have what could be termed psychotic experiences but never come into contact with mental health services. Tien (1991) [69] suggested that as many as 10% of the general population hear voices. The amount of distress caused by these experiences appears to be the key factor that brings people to the attention of services (Romme et al., 1993) [69].  

• It is difficult to say how widespread these problems are, partly because of the way research has traditionally been conducted.
• Using medical definitions of the problems, about 1 person in 100 is likely to receive a diagnosis of schizophrenia in their lifetime, and similarly about 1 person in 100 is likely to receive a diagnosis of bipolar disorder (manic depression) in their lifetime.
• 100,000 to 500,000 people in the UK today are likely to have been given a diagnosis of schizophrenia, and about 500,000 are likely to have been given a diagnosis of bipolar disorder (manic depression).
• It is clear that people's circumstances are very important. People from disadvantaged backgrounds, especially young men, seem at greatest risk of receiving a diagnosis of schizophrenia.
• Although the risks might vary, psychotic experiences may happen to anyone in circumstances of extreme stress.

Other Diagnoses

Psychiatrists use a number of other diagnoses that are extremely similar to either schizophrenia or bipolar disorder. In general these refer to very similar problems. People who become severely depressed sometimes have psychotic experiences (usually unusual beliefs - delusions - or hallucinations with very depressive content). Up to 3% of men, and perhaps 4% to 9% of women will be given a diagnosis of depression in its more general form. Psychotic features are however relatively uncommon, probably representing only some 10% to 20% of inpatients with a diagnosis of depression, and most people, even if they attract such a label, are never admitted to hospital.

Models of Understanding Psychotic Experience

Sometimes there are differences between how mental health workers (such as psychiatrists, clinical psychologists, nurses, social workers and occupational therapists) tend to view these experiences. These differences arise from the models or explanations that professionals are given during their training. We have already mentioned that there are different schools of thought about the causes and maintaining factors underlying psychosis, and these that are taught to professionals to varying degrees to help them better help people to better help them help people. Some of these are explained below:

A Biological Explanation

This would assume that the causes of psychosis are as a result of chemical or neurological changes to the brain. People at the extreme end of this explanation would see psychosis and schizophrenia as a disease that traditionally has been viewed as long term and incurable.

However, there is no definite proof that psychosis is a disease. Indeed, it is strongly contested by an increasing number of people (from different professions) that schizophrenia should not be seen as a disease because of the hopeless message this gives to people. Furthermore, unlike other neurological diseases where there is agreement about there cause (such as Parkinson's) people will and have recovered from their psychosis whereas this does not happen with the likes of Parkinson's.

Within a biological explanation medication (usually called antipsychotic medication) would be the main treatment used to correct the chemical imbalance. Medication has been found to be helpful for many people, and crucial for their recovery and wellbeing. However, a significant number of people find that their experiences described as psychosis do not go away, and medication simply dampens down their interest in all areas of life as well as reducing their interest in their experiences.

Antipsychotic medication is almost universally prescribed for people who experience psychosis and come into contact with mental health services. Medication alone does not represent the perfect treatment. It generally makes psychotic experience less distressing and less intense, however, it is not a cure, does not develop life skills, does not help everybody and rarely removes the problems completely.

• Physical causes such as brain tumours or taking street drugs can occasionally cause psychotic experiences. However, for the majority of psychotic experiences, research into genetics, brain chemistry, the physical environment and brain structure has not led to definite conclusions about physical causes.
• Genetics: It is true that psychotic experiences appear to 'run in families'. However research findings are a subject of debate. It is likely that many different genes are associated with a vulnerability to general traits, which may be more distantly related to psychotic experiences.
• Brain chemistry: Drugs that reduce levels of a brain chemical called dopamine can help reduce psychotic experiences. Although interestingly, this does not necessarily mean dopamine abnormalities cause psychosis.
• Brain structure: Particular brain structures i.e. the lateral ventricles, are often larger in people who have psychotic experiences. We do not know if this represents a cause of the psychotic experiences or a result of the drugs that were prescribed.
• The environment: Researchers have also looked at the possible effect of the environment on the biology of the brain. They have examined such things as difficulties during birth or the effect of viruses in the womb. No firm conclusions can be drawn.
• It is clear that psychotic experiences involve brain events, and can be influenced by chemical processes. It is important to remember, however that every single thought we have involves chemical changes in the brain.

Psychological and Social Explanations

A range of psychological interventions has been developed in recent years that have a strong evidence base that support their use. Such interventions include family therapy, social, cognitive and occupational rehabilitation, cognitive behaviour therapy and intervention early in the development of problems.

Psychological and social explanations are sometimes referred to as 'talking treatments' and include cognitive behavioural therapy, a broad range of counselling approaches and practical self-help or problem solving solutions to help people improve the quality of their lives. Psychological interventions are based on a psychological framework of understanding and aim to help people work out their own understanding of the nature of their difficulties and what is likely to help.

• Psychological models of psychotic experiences focus on patterns of thought that are associated with these phenomena.
• Psychological researchers have studied two quite distinct types of problems: deficits (impaired thought processes) and biases, where people's experiences have led them to interpret the world in particular ways. Many psychotic experiences are thought to involve a combination of the two.
• There is evidence that people with a diagnosis of schizophrenia tend to have difficulties with various aspects of attention.
• People who have psychotic experiences sometimes appear to have difficulty understanding what other people might be thinking, at least when they are distressed.
• Unusual beliefs are often associated with an increased tendency to jump to rapid conclusions. Paranoia is associated with the tendency to believe that the bad things that happen are the fault of other people.
• Hearing voices often appears to be the result of difficulties distinguishing one's own, normal, inner speech from the words by other people.
• Incoherent speech ('thought disorder') appears to reflect a general difficulty in adjusting conversations to the needs of the listener. It is often associated with high levels of arousal or agitation.
• Mania is a term used to describe a combination of increased activity or agitation, incoherent speech and, usually, a combination of euphoria, depression and irritability. These experiences are thought to be related to disruptions of the physiological and psychological mechanisms that control our emotions.

A continuum between mental health and mental illness

There is good reason to believe that mental health and 'mental illness' (and different types of mental illness') shade into each other and are not separate categories. There is evidence that psychotic experiences are more extreme expressions of traits present in the general population. There is a wide range of 'psychosis proneness'. Healthy, well functioning individuals sometimes have 'psychotic' experiences. For example, 10 to 15 per cent of the population have heard voices or experienced hallucinations at some point in their life. These are frequently triggered by extreme experiences such as sleep deprivation.

It is probably appropriate to think in terms of 'stress vulnerability' when explaining psychotic experiences. People may have greater or lesser levels of vulnerability to this type of experience, which are triggered by greater or fewer numbers of stressful events experienced. In some cultures hearing voices and seeing visions is seen as a spiritual gift rather than as a symptom of mental illness.

A continuum from normality to psychosis

It has often been assumed that the behaviour and experiences of people who are placed in diagnostic categories such as 'schizophrenia' and 'bipolar disorder' are qualitatively different from 'normal' behaviour and experience. Research suggests that this assumption is false. It is often difficult to discriminate between 'normal' and 'abnormal' or psychotic experiences. The view that there may be a thread of continuity between mental health and ill-health was already voiced at the beginning of the century, but it is somewhat at odds with traditional medical approaches, which view 'mental illnesses' as qualitatively separate from normality.

A continuum from normal to abnormal

A number of clinical psychologists have suggested that psychotic symptoms lie on a continuum with normality, and are the severe expression of traits that are present in the general population. Individuals range from the conventionally 'normal', through various shades of eccentricity, to those who experience severely distressing psychotic experiences. Thus, the distinction between signs of mental illness (i.e. symptoms) and the expression of human individuality (i.e. traits) becomes blurred. The presence of psychotic-like traits in the normal population has been termed 'psychosis-proneness' or 'schizotypy'.

This continuum view is easily understood if one imagines other common experiences such as anxiety. Individuals differ in how anxious they are in general. This is an enduring characteristic of their personality, and is likely to be due to a combination of genetic factors and their upbringing. Only a minority of individuals will ever experience extremes of anxiety such as a series of panic attacks, which are recognised in the diagnostic textbooks as justifying a diagnosis of an anxiety 'disorder'.

Similarly, the state of extreme suspiciousness known as 'paranoia' is on a continuum with the feelings of suspiciousness that we all feel from time to time. People differ in this regard: we all know people with whom we have to be very careful what we do or say lest they interpret it as an insult. Similarly, situations vary in their tendency to provoke suspiciousness. We have all been in situations where it makes sense to be extra vigilant, and in such situations it is easy to be frightened by even the most innocent things.

Continuum of normality

Substantial evidence has accrued in favour of the idea that psychotic experiences are on a continuum with normality. So-called 'schizotypal' traits have been described which are believed to have similarities with thought processes observed in psychotic experiences. These can be measured in 'normal' individuals by the use of questionnaires. Such questionnaire studies have demonstrated that there is a wide range of scores in the normal population, and that schizotypal traits tend to form clusters similar to different sorts of psychotic experiences (for example delusions and hallucinations). Moreover, individuals who score highly on such scales resemble individuals with psychotic experiences on a number of psychological measures, such as measures of attention and reasoning Recent psychiatric research has indicated that a dimensional approach to psychotic experiences can be more useful in terms of understanding and planning care than a categorical system.

So-called 'abnormal' experiences can be seen in healthy, well -functioning individuals. For instance, 10 to 15 per cent of the normal population have had a hallucination at some point in their lives. Recent studies show that 'psychotic-like' experiences are 50 times more prevalent than the narrower, medical concept of 'schizophrenia'. Extreme circumstances, such as sensory or sleep deprivation, have been shown to lead to various disturbances, including paranoia and hallucinations.

There are individuals who have 'strange' experiences (such as visions, auditory hallucinations, or profound spiritual experiences) and are conceptualised as spiritually enriching; there is a huge diversity in what is considered an appropriate expression of distress in different cultures. Indeed, different cultures vary on whether particular experiences are seen as signs of 'mental illness', as normal (religious and spiritual beliefs and beliefs about spirit possession),or even as 'spiritual gifts' which are to be revered to some degree. These findings suggest that although psychotic 'symptoms' can, for some individuals, be extremely distressing and disabling, it is also possible to have unusual experiences that are not necessarily noxious, and may even be adaptive and life enhancing.

Alternatives to diagnosis 

Given the problems of diagnosis outlined above, clinical psychologists have suggested alternative approaches.

Symptom approach

Many researchers have argued that the problems of diagnosis can be overcome by focusing on specific experiences and behaviours (symptoms, in medical terminology). In Britain, in particular, considerable progress has recently been achieved in understanding specific psychological mechanisms that can lead to unusual beliefs, hallucinations and difficulties in communication.

Psychological formulations

In order to understand and explain people's experiences, clinical psychologists have developed the approach termed 'formulation'. Psychological formulations are a way of helping people to make sense of their difficulties in a way that is meaningful to them. They comprise a statement of what the person sees as the problem (or problems), how these might have come about and what is keeping them going. Problems will usually be expressed in terms of what the person experiences (such as unhappiness, hearing voices, not functioning well at work, or fearing that people are trying to harm them) rather than in terms of 'symptoms' observed by others.

Clinical psychologists also attempt to develop, in collaboration with the client, ideas about what things might have led to the development of these problems. For this reason, formulations are very individual, tailored for each person and relevant to their specific problems. Typically, a formulation will examine what events have happened in a person's life, and how they have been interpreted and reacted to these. This can help the person to see that some of their problems have not just come 'out of the blue' but may be an understandable response to their circumstances.

Even when it is not possible to pinpoint one particular cause, worker and client can explore together what might be maintaining the problem. For example, a vicious circle may be going on where the person's fear about what their experiences might mean is keeping them in a highly aroused state, which in turn leads to more psychotic experiences. An example might be the fear that hearing voices means that they are going mad or are possessed by a demon. Formulations tend to change as the psychologists and their clients learn more about the problems. Formulations are designed to be 'best guesses' about the problems, and these guesses are tested out over time. The process of developing a formulation is collaborative. Psychologist and client work together to develop a picture of the problems and a joint theory as to what has caused them and what might help.

Psychological case formulations are complex. Clinical psychologists draw on a large variety of psychological theories, each drawing on scientific research. Although individual case formulation will not draw on all this research, each person may have a range of interrelated psychological difficulties. Training is essential and professional bodies such as the British Psychological Society's Division of Clinical Psychology endeavour to guard the competence of practitioners.

Text taken from: Recent Advances in Understanding Mental Illness and Psychotic Experiences - A report by The British Psychological Society Division of Clinical Psychology, June 2000.