| Defining Trends
and Definitions for Schizophrenia
Schizophrenia was once considered untreatable
and patients suffering from this antipsychotic
condition were largely sent to mental institutions
to be locked up, at times for life. However, with
the advancements in medicine, medical technology
and various modes of treatment, the same disorder
is today not only treatable, it is no more considered
a condition where the patient has to be locked
up.
In fact such has been the advancement in this
particular field of medicine, that an entirely
separate discipline emerged in the decade of the
50s, namely psychiatry which not only correctly
diagnosed the illness, it also comprehensively
offered various modes of treatment with respect
to the patient's physical condition and severity
of his or her mental state. In addition, it was
also found that this anomaly comprising of disturbances
between the thoughts of an individual and his
emotions largely depended, and in most cases suffered
from the wrong definitions of the illness. It
was thus truly essential a correct set of definitions
be awarded and due modes of treatment offered,
so that the patient community would not have to
suffer, as was perhaps the case some half a century
ago. The result of new definitions awarded to
schizophrenia was an increase in the overall conditions
of the patients suffering from schizophrenia,
a factor that was greater than the mode of treatments
sought (Bower, 1992).
According to the definitions as provided by the
Surgeon General Health of The United States of
America, mental illness is defined as the collective
mental disorders and conditions which are characterized
by alterations in thinking, mood or behavior,
or may even be associated with distress and/or
impaired functioning. At this juncture, it would
also be imperative to define the opposite of mental
illness, mental health which according to the
same source of Surgeon General refers to as the
successful performance of mental function, resulting
in productive, fulfilling relationship with other
people, and the ability to adapt to change and
to cope with diversity; from early childhood till
old age. Furthermore, mental health is attributed
"to thinking and communication skills, learning,
emotional growth, resilience and self-esteem."
The Surgeon General's Report further emphasizes
a number of salient features, all of which also
serve as scope on the findings, and equally numerous
researches carried out over the last more than
a quarter of a century. Primarily, these findings
conclude that the importance of mental health
treatment has been well documented; and that the
extent and range of these treatments have been
found for most, if not all, the mental disorders.
In other words, it is advised that if and when
a mental problem exists, or one perceives that
he or she has symptoms of a mental disorder, it
is essential that the respective individual duly
seek appropriate help.
In addition, the Surgeon General's findings also
state that there have been tremendous developments
in scientific research on both the human behavior
as well as the human brain. The categorization
of different mental disorders and illnesses such
as that under discussion, Schizophrenia, and its
varied forms of treatments then follow this. It
has also been found that there has been a significant
change of attitudes and approaches toward mental
disorders, in turn inviting substantial financing
to treat and set up mental health care institutions
specifically for the treatment of schizophrenia.
From the family's perspective as well, there has
been a gradual shift in attitudes, compared to
the age old practices of locking up patients suffering
from any kind of mental disorder.
On the subject of children, studies on mental
health reveal that since childhood is a crucial
period of transition, it is of vital importance
that correct assessment of children as well as
adolescents be carried in the context of their
"familial, social, and cultural expectations,
emotions and their behaviors". For example
statistics on the number of young individuals
suffering from signs and symptoms of Schizophrenia
was found to in the range of some 20 percent,
however the percentage of occurrence was only
5 percent, the latter of who were graded in the
category of "extreme functional impairment".
A comparison of children suffering from mental
disorder with that of adults revealed that children
were at a greater risk as compared to their adult
counterparts. Included in the list of causes faced
by children which resulted in various mental disorders
included intellectual disabilities, low birth
weight, family history of mental and addictive
disorders, multigenerational poverty, abuse, neglect
and acts of separation on the part of either parent
or caregiver (Preboth, 2000).
History of Schizophrenia
Though the term 'Schizophrenia' has only been
used since the last nearly a century, yet the
illness or illnesses associated have perhaps been
present as long as the history of mankind. An
overview of the human history reveals that Schizophrenia
as we know it today can be traced back to the
ancient Pharaonic era of the Egyptians which dates
back to the 2nde millennium of Jesus Christ. However,
in that period, Schizophrenia encompassed a number
of ailments of the both the body and the mind,
including but not limited to depression and dementia.
One of the best evidences to this respect are
found in the 'Book of Hearts" written by
a German Egyptologist, George Ebers during his
studies on Egypt, written in the early part of
the 19th century. Ebers comments that the heart
and the mind both in their healthy state as well
as in illness appear to be treated in somewhat
similar fashion, thus the mental illness such
as Schizophrenia was looked upon by majority of
the Egyptians as a physical illness, and treated
as such.
Another famous book of the same Pharaonic era,
the Smith papyrus authored by Edwin Smith in 1700
BC introduced the word brain for the first time,
and though its researches are based on findings
of 3000 BC, yet this book is considered the first
medical document in the history of human beings.
Some of the salient aspects of the Smith Papyrus
include brief introductions on the human brain,
the bone marrow, cerebrospinal fluid of the brain
as well as that of the bone marrow. The Smith
Papyrus also documents more than 48 cases of patients
suffering from various forms of mental illness,
including Schizophrenia, as we know it today.
A brief on each of the patients studies is also
mentioned in the said book, according to which
most of the patients suffered brain injuries from
accidental falls or battles. One of the most important
findings of the book reveal that brain was indeed
responsible for the movement of the various parts
of the body, as also evidenced in a patient who
had suffered a brain injury, and as a result he
could not speak. Thus the particular brain injury,
aphasia as we know it today had already been discovered
thousands of years ago, and contradicts the findings
of one Paul Broca who presumably claimed responsibility
for its find in 1861. In addition, most of the
written text found in the Smith papyrus practically
excludes any link to magic or superstitions and
relies its findings on a rational and purely scientific
approach.
Yet another remarkable finding even prior to the
findings of the Egyptians was that of the Greek
philosophers, who had rightly defined the workings
of the brain as being the center thoughts and
perceptions. One such finding was that of physicist
Alcmaion who live in the 5th century era, and
who duly supported the findings of the Greek philosophers.
In the later era, some two centuries after, two
physicians named Herophilus and Erasistratus carried
out one of the first dissections. The findings
of these two Greek philosophers resulted in the
revelations of the internal workings of the brain
such as the nerves and the structure. Perhaps
the most important findings of these Greeks physicians
was that the brain served as the epitome of all
intellectual activity of the human being, in turn
paving the way for a totally new discipline, that
of neuroscience to be pursued by
physicians and surgeons of the later era.
Perhaps the strongest evidence found was a medical
handbook written by the Physician named Aretaios
in 2nd century A.D., which had duly categorized
the varied forms of mental illnesses. Some of
the salient findings which are equally considered
even today include were 'Phrenitis' which corresponds
to an acute and temporary state of febrile confusion;
'hysterical suffocation', corresponding to the
anxiety and various states of depression and schizophrenia.
Then there was the different mania, which corresponded
with the present day illnesses of schizophrenia
having bouts or fits of excitement and agitation.
Such was the importance of these findings that
the later scientists, physicians and surgeons
of Europe and the Middle East benefited greatly
and this influence perhaps continued till the
earlier part of the 19th century (Carlsson, 2002).
Schizophrenia Today
As also reiterated in the above lines, thought
the history of schizophrenia can be traced back
to thousands of human history, possibly to the
beginning of human history, yet it is only a hundred
years or so that the form and status of schizophrenia
as we know it today has been studied and documented
respectively. These findings and researches which
continue even today have however summarized them
to deduce that though studies into this peculiar
mental illness may prove beneficial to the millions
affected by this dreaded disease, yet it understanding
will certainly provide approaches in analyzing
the various difficult and equally critical process
of the human mind, the manner in which human mind
functions and at the same time, how this extraordinary
human organ processes waves of information from
the internal, social as well as the environmental
surroundings.
Some of the famous names that researched and made
remarkable progresses into the study of schizophrenia
include Falvet (1851), Hecker (1871) and Emil
Kraepelin (1878), all of who first coined the
various types of schizophrenia patients. These
included 'cyclical madness' researched by Falvet;
'Hebephrenia' or undisciplined mind followed by
findings on the illness of paranoia and catatonic
states of schizophrenia; dementia of early onset
discovered by Kraeplin with a further break up
into four subtypes.
These were namely:
Simple schizophrenia: this type is marked by a
slow decline accompanied with apathy and symptoms
of withdrawal;
Paranoid state; this is emphasized by attendant
fear on the part of the patient followed by the
'persecutory' delusions;
Hebephrenic and Catatonic: this type is characterized
by a lack of body movements, and expression. Yet
one Eugen Bleuler perhaps provided the strongest
set of definitions in 1908 who suggested the four
'A's model of his definition on schizophrenia.
The first 'A' referred to 'Affect', implying a
diminished emotional response to stimuli;
The second 'A' referred to 'Association', implying
a somewhat disordered pattern of thoughts, which
inferred with cognitive deficit;
The third 'A' referred to the 'Ambivalence', implying
the obvious inability to make or take a decision,
once again referring to the lack of cohesion in
the acceptance and due processing of relevant
information;
The fourth 'A' referred to the 'Autism', made
clear distinctions in the lack of awareness of
external events and people, together with the
'preoccupation' of the patient in his or her own
world of thoughts.
Though most if not all the studies carried out
on the subject of schizophrenia provided immense
insights, yet there were those to, which provided
reasoning to the contrary, and the amazing part
of these researches was that they too were excepted
by physicians and surgeons alike for number of
years, until modern researches proved them to
be completed void of any substance and studies.
One such famous case is that of the famous psychologist
Sigmund Freud, who was responsible for most of
the present controversies in the field of psychiatry
as well as psychology. Though Freud was able to
provide significant data from his researches into
the study of human anatomy of both the human vertebrate
as well as the nervous system, such as the findings
of neurons as being responsible for the various
humanly functions inside the brain. Yet, Freud's
theories on hysteria and dreams perhaps invited
the attention of the entire world, even though
these were later proved to be void of concrete
scientific data only to be replaced with modern
system of diagnosing schizophrenia.
Modern Classification and Diagnosis of Schizophrenia
As one enters the middle of the 20th century,
so do the advancements in the study of schizophrenia.
Thus, by 1959, proper diagnostic classifications
had been made, namely the ICD-10 and the Diagnostic
and Statistical Manual also commonly known as
DSM. According the DSM (IV), schizophrenia is
termed as the set of two or more symptoms to be
present in a given patient and may continue for
a period of no less than a month. Similarly, the
number of symptoms may only be one, if the conditions
of the patient are said to be suffering from 'auditory
hallucinations'.
In addition the DSM (IV) also states that diagnosis
may only be carried out if the symptoms persists,
and signs of disturbances continues for a period
of not less than 6 months. These symptoms and
disturbances should occur while all possibilities
of any other medical condition or substance abuse
have been totally rule out for the respective
patient. In spite of these findings, there also
exists positive as well as negative symptoms,
with each inviting further classification of schizophrenia.
The first is termed as Psychotic Episode, which
is said to make the patients incapable of distinguishing
real life experiences from those that are unreal.
These may include for example delusions such as
false judgements and beliefs, hallucinations where
the individual perceives that an object, event
or an individual is affecting that individual,
whereas no such object, event or individual may
even be present. Then there other irregular humanly
functions including 'disorganized speech' or behavior,
cognitive dysfunction, social and occupation dysfunction,
thought disorder, lack of motivation, withdrawal
symptoms, loss of concentration, loss of emotional
tone or reaction, and the inability to make regular
movements of the arms and limbs.
Schizophrenia - Subtype Characteristics
Schizophrenia is further divided into a number
of subtype characteristics, including the paranoid
state and catatonic state.
The first, paranoid state is given to the condition
where the patient suffers from a preoccupation
with one or more than one delusion or 'frequent
auditory hallucinations', blurred speech, and
behavior problems, which may range from being
simple to those of prominent character.
The catatonic state of schizophrenia, on the other
hand is a term given to the condition where any
two or more of the characteristics such as lack
of motor response to a stimulus, excessive motor
activity, absence of speech, odd movements of
the arms and limbs, repetitions of the words,
and copying the movement of other people.
In addition, there also exist uniform set of symptoms
yet with the exception of three types which include
residual absence of prominent delusions, hallucinations,
disorganized speech, and more than disorganized
and catatonic behavior despite continuing evidence
of a disturbance.
The schizophrenia disorder is further divided
into five principle subtypes, which bring out
additional details on the characteristics of this
illness. These include severe extortion of sensory
processing with attendant problems, in turn highlighting
some of the unwanted sensory stimuli which leads
to delusions and hallucinations implying a decreased
capacity to process
information.
Once there is evidence of a disorganized thought
process and display of behaviors, which do not
match with the social expectations, the result
is the development of poor memory accompanied
with a limited time period in which the patient
can focus his attention.
The disorganized thought process, or disturbed
cognitive processing is also evident in the blurred
speech, additionally proving the lack of processing
information.
A decrease in emotional tone and of reaction to
social and other external stimuli may parallel
a decline in social functioning, emphasizing the
importance of the integrity of higher cortical
circuits in mediating receptive, productive and
appropriate social interaction, or 'successful'
human social 'behavior'.
This reductionism and generalization leading to
the definition of 'schizophrenia' as one or more
related disorders resulting in a disruption of
cortical processing and filtering, permits us
to correlate these human behaviors with those
of animal models from which the putative existence
of a biochemical basis for schizophrenia might
be tested.
Violent Crimes and Schizophrenia - Relationship
Studies Citing Schizophrenic Patients as Being
More Responsible for Crime
Numerous studies on the relationship of crime
with the illness of schizophrenia reveals equally
varied set of information, yet they remain within
the confines of past history of the patient and
substance abuse such as alcohol or drug. Aside
from these findings, it has also been revealed
that patients suffering from schizophrenia and
not taking any medication are more than likely
to inhibit characteristics of being predictors
of violent behavior including crime.
In this respect, a study carried out by MacArthur
Foundation on the relationship between violence
and mental illness revealed that patients who
had been recently discharged from psychiatric
institutions after having been treated of a mental
illness such as schizophrenia were equally likely
to get involved in violent behavior and crimes
as compared to other normal and healthy individuals
residing in the same neighborhoods (Steadman et
al, 1998).
Another study carried out by the psychiatrist
Sosowky comprising some 300 patients carried out
over a period of 6 years between 1972 and 1975
revealed totally opposite findings. This study
revealed that during the said period those arrested
for violent crimes were 10 times greater than
the general population of the same neighborhood
(Sosowsky, 1980).
A study carried out by Gruberg et al on the state
of New York, particularly focusing homicides committed
by mentally ill patients during the two eras of
1963-1969 and 1970-1975 revealed that the latter
period showed a marked increase in the commission
of homicides by schizophrenic population. It was
thus suggested that a comprehensive treatment
plan for the schizophrenic patients would indeed
serve to bring about a safer community, as well
as assist the patient community in the long run
(Grunberg et al, 1978).
The survey carried out by Epidemiological Catchment
Area (ECA) during the period of 1980-83 revealed
that individuals suffering from schizophrenia
were likely to commit or be involved in an increased
number of violent crimes and behaviors as compared
with individuals residing in the same area. A
particular emphasis on the commission of crime
or getting involved in violent behavior by schizophrenic
patients revealed that they were more than likely
to use a weapon as compared to other individuals
with the statistics of 21 times higher on the
part of schizophrenic patients as compared with
the general populations (Swanson et al, 1990).
In a follow-up study carried out by ECA, it was
found that patients who had suffered from bouts
of schizophrenia and had been treated successfully,
except for the last 6 months showed a higher percentage
of commission of crimes, moderate levels of agitation
and increased levels of psychotism. This then
called for an increased set of intervention measures
for the treatment of, and monitoring of patients
who had suffered from schizophrenia, and were
on medication (Swanson et al, 1997).
Similar studies carried out in England on the
relationship of crime and violent behavior with
that of psychotic patients also confirmed previous
findings. In this statistics to this effect revealed
that more than 80 percent of the psychotic patients,
in particular males committed violent crimes,
which were directly related to their illness and
state of health. For example, psychotic patients
studied showed higher occurrences of violent crimes
and behavior, perhaps driven by their delusions
and inability to continue their medications (Taylor,
1985).
Another study carried on the families of members
of the National Alliance for the Mentally Ill
(NAMI) organization comprising of some 1400 members
revealed that some 11 percent of them were responsible
for physically harming another individual (Steinwachs
et al, 1992).
Commenting on the above researches on schizophrenic
patients and the relationship with crimes, Dr.
Rabkin notes that in practically every study comprising
of schizophrenic patients and their involvement
in violent crimes, it was found that their numbers
increased as compared to the general populations
(Rabkin, 1979).
Another example on the relationship of crime and
violence with that of schizophrenia can be found
in a study of individuals arrested by the Secret
Service of the United States of America. In this
study, the number of individuals comprised of
some 192 men and a period expanding from 9 years
to 12 years. All these individuals had been detained
when they presented themselves at the White House
with delusional demands, and the study found that
their involvement in crimes ranged from 1.6 to
4.8 times higher than the general population within
the same period (Shore et al, 1990).
Studies Citing Schizophrenic As having Little
Relationship With Violent Crimes
Though the above section of the paper more than
convincingly that there exists a strong relationship
between violent crime and schizophrenia, there
are equally strong evidences and studies which
suggest that there is little to prove that schizophrenic
patients are involved in violent crimes. A survey
carried out by the British Health Education Authority
revealed that there was little evidence that patients
diagnosed as mentally ill were involved in either
homicide and violent acts, with statistics reaching
a staggering 95 percent to prove that people diagnosed
as mentally ill were involved in the commission
of crimes no more than normal and healthy individuals.
The same studies by the British authorities also
reveals that though they may be little evidence
to suggest the relationship of violence crimes
with schizophrenia, there may be cases such as
'command hallucinations' and 'delusions with hostile
content' with the context of schizophrenia which
somewhat force schizophrenic patients to commit
violent crimes. Command hallucinations refer to
so called voices which the schizophrenic patients
to harm other individuals, which in turn has a
commanding affect on the patients. On the other
hand, 'a delusion with hostile content' implies
and refers to a set of beliefs, which instill
ideas and notions in the patients to commit harm
to other individuals.
The above studies and researches thus prove wrong
the general perception and belief that schizophrenic
patients are largely responsible for the commission
of violent crimes. Yet another important aspect
which needs to be mentioned is the fact that more
than 46 percent of the press coverage of mental
health issues concentrated on crime, harm to other
and self-harm. Furthermore, it is also a fact,
duly proven by the researches by the British Health
Authority, that both tabloids and broadsheet present
a very strong relationship between mental health,
and criminal activity as well as violence in the
society. Stories about schizophrenic patients,
thus strive to present most if not all the negative
aspects of this ailing community, as compared
to the positive points or health aspects (Szmukler,
2000).
Another study carried out in Scandinavia from
both the public health perspective as well as
the psychiatric view also more or less follows
the findings of the above-cited study by the British
Education Authorities. Thus, in the Scandinavian
study, it was found that though there existed
a slight relationship between schizophrenia and
violent crimes, yet the proportion in which violent
crimes were committed at the hands of schizophrenic
patients was of negligible or very little significance.
Furthermore, it was also found that percentage
of strangers being attacked by schizophrenic patients
were significantly lower as compared to those
who were mentally healthy, all proving that the
ration of schizophrenic patients committing crime
was no more than healthy individuals (Matthias,
2000).
The above studies thus clearly show that most
violent crimes are not committed by persons with
schizophrenia, and most persons with schizophrenia
do not commit violent crimes. Substance abuse
significantly raises the rate of violence in people
with schizophrenia but also in people who do not
have any mental illness. People with paranoid
and psychotic symptoms, which can become worse
if antipsychotic medications are discontinued,
may also be at higher risk for violent behavior.
When violence does occur, it is most frequently
targeted at family members and friends, and more
often takes place at home.
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