schizophrenia case study quizlet

15.8 Schizophrenia

Learning objectives.

By the end of this section, you will be able to:

• Recognize the essential nature of schizophrenia, avoiding the misconception that it involves a split personality
• Categorize and describe the major symptoms of schizophrenia
• Understand the interplay between genetic, biological, and environmental factors that are associated with the development of schizophrenia
• Discuss the importance of research examining prodromal symptoms of schizophrenia

Schizophrenia is a psychological disorder that is characterized by major disturbances in thought, perception, emotion, and behavior. About 1% of the population experiences schizophrenia in their lifetime, and usually the disorder is first diagnosed during early adulthood (early to mid-20s). Most people with schizophrenia experience significant difficulties in many day-to-day activities, such as holding a job, paying bills, caring for oneself (grooming and hygiene), and maintaining relationships with others. Frequent hospitalizations are more often the rule rather than the exception with schizophrenia. Even when they receive the best treatments available, many with schizophrenia will continue to experience serious social and occupational impairment throughout their lives.

What is schizophrenia? First, schizophrenia is not a condition involving a split personality; that is, schizophrenia is not the same thing as dissociative identity disorder (better known as multiple personality disorder). These disorders are sometimes confused because the word schizophrenia , first coined by the Swiss psychiatrist Eugen Bleuler in 1911, derives from Greek words that refer to a “splitting” (schizo) of psychic functions (phrene) (Green, 2001).

Schizophrenia is considered a psychotic disorder, or one in which the person’s thoughts, perceptions, and behaviors are impaired to the point where they are not able to function normally in life. In informal terms, one who suffers from a psychotic disorder (that is, has a psychosis) is disconnected from the world in which most of us live.

Symptoms of Schizophrenia

The main symptoms of schizophrenia include hallucinations, delusions, disorganized thinking, disorganized or abnormal motor behavior, and negative symptoms (APA, 2013). A hallucination is a perceptual experience that occurs in the absence of external stimulation. Auditory hallucinations (hearing voices) occur in roughly two-thirds of patients with schizophrenia and are by far the most common form of hallucination (Andreasen, 1987). The voices may be familiar or unfamiliar, they may have a conversation or argue, or the voices may provide a running commentary on the person’s behavior (Tsuang, Farone, & Green, 1999).

Less common are visual hallucinations (seeing things that are not there) and olfactory hallucinations (smelling odors that are not actually present).

Delusions are beliefs that are contrary to reality and are firmly held even in the face of contradictory evidence. Many of us hold beliefs that some would consider odd, but a delusion is easily identified because it is clearly absurd. A person with schizophrenia may believe that their mother is plotting with the FBI to poison their coffee, or that their neighbor is an enemy spy who wants to kill them. These kinds of delusions are known as paranoid delusions , which involve the (false) belief that other people or agencies are plotting to harm the person. People with schizophrenia also may hold grandiose delusions , beliefs that one holds special power, unique knowledge, or is extremely important. For example, the person who claims to be Jesus Christ, or who claims to have knowledge going back 5,000 years, or who claims to be a great philosopher is experiencing grandiose delusions. Other delusions include the belief that one’s thoughts are being removed (thought withdrawal) or thoughts have been placed inside one’s head (thought insertion). Another type of delusion is somatic delusion , which is the belief that something highly abnormal is happening to one’s body (e.g., that one’s kidneys are being eaten by cockroaches).

Disorganized thinking refers to disjointed and incoherent thought processes—usually detected by what a person says. The person might ramble, exhibit loose associations (jump from topic to topic), or talk in a way that is so disorganized and incomprehensible that it seems as though the person is randomly combining words. Disorganized thinking is also exhibited by blatantly illogical remarks (e.g., “Fenway Park is in Boston. I live in Boston. Therefore, I live at Fenway Park.”) and by tangentiality: responding to others’ statements or questions by remarks that are either barely related or unrelated to what was said or asked. For example, if a person diagnosed with schizophrenia is asked if they are interested in receiving special job training, they might state that they once rode on a train somewhere. To a person with schizophrenia, the tangential (slightly related) connection between job training and riding a train are sufficient enough to cause such a response.

Disorganized or abnormal motor behavior refers to unusual behaviors and movements: becoming unusually active, exhibiting silly child-like behaviors (giggling and self-absorbed smiling), engaging in repeated and purposeless movements, or displaying odd facial expressions and gestures. In some cases, the person will exhibit catatonic behaviors , which show decreased reactivity to the environment, such as posturing, in which the person maintains a rigid and bizarre posture for long periods of time, or catatonic stupor, a complete lack of movement and verbal behavior.

Negative symptoms are those that reflect noticeable decreases and absences in certain behaviors, emotions, or drives (Green, 2001). A person who exhibits diminished emotional expression shows no emotion in their facial expressions, speech, or movements, even when such expressions are normal or expected. Avolition is characterized by a lack of motivation to engage in self-initiated and meaningful activity, including the most basic of tasks, such as bathing and grooming. Alogia refers to reduced speech output; in simple terms, patients do not say much. Another negative symptom is asociality, or social withdrawal and lack of interest in engaging in social interactions with others. A final negative symptom, anhedonia, refers to an inability to experience pleasure. One who exhibits anhedonia expresses little interest in what most people consider to be pleasurable activities, such as hobbies, recreation, or sexual activity.

Link to Learning

Watch this video of schizophrenia case studies and try to identify which classic symptoms of schizophrenia are shown.

Causes of Schizophrenia

There is considerable evidence suggesting that schizophrenia has a genetic basis. The risk of developing schizophrenia is nearly 6 times greater if one has a parent with schizophrenia than if one does not (Goldstein, Buka, Seidman, & Tsuang, 2010). Additionally, one’s risk of developing schizophrenia increases as genetic relatedness to family members diagnosed with schizophrenia increases (Gottesman, 2001).

When considering the role of genetics in schizophrenia, as in any disorder, conclusions based on family and twin studies are subject to criticism. This is because family members who are closely related (such as siblings) are more likely to share similar environments than are family members who are less closely related (such as cousins); further, identical twins may be more likely to be treated similarly by others than might fraternal twins. Thus, family and twin studies cannot completely rule out the possible effects of shared environments and experiences. Such problems can be corrected by using adoption studies, in which children are separated from their parents at an early age. One of the first adoption studies of schizophrenia conducted by Heston (1966) followed 97 adoptees, including 47 who were born to mothers with schizophrenia, over a 36-year period. Five of the 47 adoptees (11%) whose mothers had schizophrenia were later diagnosed with schizophrenia, compared to none of the 50 control adoptees. Other adoption studies have consistently reported that for adoptees who are later diagnosed with schizophrenia, their biological relatives have a higher risk of schizophrenia than do adoptive relatives (Shih, Belmonte, & Zandi, 2004).

Although adoption studies have supported the hypothesis that genetic factors contribute to schizophrenia, they have also demonstrated that the disorder most likely arises from a combination of genetic and environmental factors, rather than just genes themselves. For example, investigators in one study examined the rates of schizophrenia among 303 adoptees (Tienari et al., 2004). A total of 145 of the adoptees had biological mothers with schizophrenia; these adoptees constituted the high genetic risk group. The other 158 adoptees had mothers with no psychiatric history; these adoptees composed the low genetic risk group. The researchers managed to determine whether the adoptees’ families were either healthy or disturbed. For example, the adoptees were considered to be raised in a disturbed family environment if the family exhibited a lot of criticism, conflict, and a lack of problem-solving skills. The findings revealed that adoptees whose biological mothers had schizophrenia (high genetic risk) and who had been raised in a disturbed family environment were much more likely to develop schizophrenia or another psychotic disorder (36.8%) than were adoptees whose biological mothers had schizophrenia but who had been raised in a healthy environment (5.8%), or than adoptees with a low genetic risk who were raised in either a disturbed (5.3%) or healthy (4.8%) environment. Because the adoptees who were at high genetic risk were likely to develop schizophrenia only if they were raised in a disturbed home environment, this study supports a diathesis-stress interpretation of schizophrenia—both genetic vulnerability and environmental stress are necessary for schizophrenia to develop, genes alone do not show the complete picture.

Neurotransmitters

If we accept that schizophrenia is at least partly genetic in origin, as it seems to be, it makes sense that the next step should be to identify biological abnormalities commonly found in people with the disorder. Perhaps not surprisingly, a number of neurobiological factors have indeed been found to be related to schizophrenia. One such factor that has received considerable attention for many years is the neurotransmitter dopamine. Interest in the role of dopamine in schizophrenia was stimulated by two sets of findings: drugs that increase dopamine levels can produce schizophrenia-like symptoms, and medications that block dopamine activity reduce the symptoms (Howes & Kapur, 2009). The dopamine hypothesis of schizophrenia proposed that an overabundance of dopamine or too many dopamine receptors are responsible for the onset and maintenance of schizophrenia (Snyder, 1976). More recent work in this area suggests that abnormalities in dopamine vary by brain region and thus contribute to symptoms in unique ways. In general, this research has suggested that an overabundance of dopamine in the limbic system may be responsible for some symptoms, such as hallucinations and delusions, whereas low levels of dopamine in the prefrontal cortex might be responsible primarily for the negative symptoms (avolition, alogia, asociality, and anhedonia) (Davis, Kahn, Ko, & Davidson, 1991). In recent years, serotonin has received attention, and newer antipsychotic medications used to treat the disorder work by blocking serotonin receptors (Baumeister & Hawkins, 2004).

Brain Anatomy

Brain imaging studies reveal that people with schizophrenia have enlarged ventricles , the cavities within the brain that contain cerebral spinal fluid (Green, 2001). This finding is important because larger than normal ventricles suggests that various brain regions are reduced in size, thus implying that schizophrenia is associated with a loss of brain tissue. In addition, many people with schizophrenia display a reduction in gray matter (cell bodies of neurons) in the frontal lobes (Lawrie & Abukmeil, 1998), and many show less frontal lobe activity when performing cognitive tasks (Buchsbaum et al., 1990). The frontal lobes are important in a variety of complex cognitive functions, such as planning and executing behavior, attention, speech, movement, and problem solving. Hence, abnormalities in this region provide merit in explaining why people with schizophrenia experience deficits in these areas.

Events During Pregnancy

Why do people with schizophrenia have these brain abnormalities? A number of environmental factors that could impact normal brain development might be at fault. High rates of obstetric complications in the births of children who later developed schizophrenia have been reported (Cannon, Jones, & Murray, 2002). In addition, people are at an increased risk for developing schizophrenia if their mother was exposed to influenza during the first trimester of pregnancy (Brown et al., 2004). Research has also suggested that a person’s emotional stress during pregnancy may increase the risk of schizophrenia in offspring. One study reported that the risk of schizophrenia is elevated substantially in offspring whose mothers experienced the death of a relative during the first trimester of pregnancy (Khashan et al., 2008).

Another variable that is linked to schizophrenia is marijuana use. Although a number of reports have shown that individuals with schizophrenia are more likely to use marijuana than are individuals without schizophrenia (Thornicroft, 1990), such investigations cannot determine if marijuana use leads to schizophrenia, or vice versa. However, a number of longitudinal studies have suggested that marijuana use is, in fact, a risk factor for schizophrenia. A classic investigation of over 45,000 Swedish military personnel who were followed up after 15 years found that those individuals who had reported using marijuana at least once by the time they were conscripted (drafted) into the military were more than 2 times as likely to develop schizophrenia during the ensuing 15 years than were those who reported never using marijuana; those who had indicated using marijuana 50 or more times were 6 times as likely to develop schizophrenia (Andréasson, Allbeck, Engström, & Rydberg, 1987). More recently, a review of 35 longitudinal studies found a substantially increased risk of schizophrenia and other psychotic disorders in people who had used marijuana, with the greatest risk in the most frequent users (Moore et al., 2007). Other work has found that marijuana use is associated with an onset of psychotic disorders at an earlier age (Large, Sharma, Compton, Slade, & Nielssen, 2011). Overall, the available evidence seems to indicate that marijuana use plays a causal role in the development of schizophrenia, although it is important to point out that marijuana use is not an essential or sufficient risk factor as not all people with schizophrenia have used marijuana and the majority of marijuana users do not develop schizophrenia (Casadio, Fernandes, Murray, & Di Forti, 2011). One plausible interpretation of the data is that early marijuana use may disrupt normal brain development during important early maturation periods in adolescence (Trezza, Cuomo, & Vanderschuren, 2008). Thus, early marijuana use may set the stage for the development of schizophrenia and other psychotic disorders, especially among individuals with an established vulnerability (Casadio et al., 2011).

Schizophrenia: Early Warning Signs

Early detection and treatment of conditions such as heart disease and cancer have improved survival rates and quality of life for people who suffer from these conditions. A new approach involves identifying people who show minor symptoms of psychosis, such as unusual thought content, paranoia, odd communication, delusions, problems at school or work, and a decline in social functioning—which are coined prodromal symptoms —and following these individuals over time to determine which of them develop a psychotic disorder and which factors best predict such a disorder. A number of factors have been identified that predict a greater likelihood that prodromal individuals will develop a psychotic disorder: genetic risk (a family history of psychosis), recent deterioration in functioning, high levels of unusual thought content, high levels of suspicion or paranoia, poor social functioning, and a history of substance abuse (Fusar-Poli et al., 2013). Further research will enable a more accurate prediction of those at greatest risk for developing schizophrenia, and thus to whom early intervention efforts should be directed.

Forensic Psychology

In August 2013, 17-year-old Cody Metzker-Madsen attacked 5-year-old Dominic Elkins on his foster parents’ property. Believing that he was fighting goblins and that Dominic was the goblin commander, Metzker-Madsen beat Dominic with a brick and then held him face down in a creek. Dr. Alan Goldstein, a clinical and forensic psychologist, testified that Metzker-Madsen believed that the goblins he saw were real and was not aware that it was Dominic at the time. He was found not guilty by reason of insanity and was not held legally responsible for Dominic's death (Nelson, 2014). Cody was also found to be a danger to himself or others. He will be held in a psychiatric facility until he is judged to be no longer dangerous. This does not mean that he "got away with" anything. In fact, according to the American Psychiatric Association, individuals who are found not guilty by reason of insanity are often confined to psychiatric hospitals for as long or longer than they would have spent in prison for a conviction.

Most people with mental illness are not violent. Only 3–5% of violent acts are committed by individuals diagnosed with severe mental illness, whereas individuals with severe mental illnesses are more than ten times as likely to be victims of crime (MentalHealth.gov, 2017). The psychologists who work with individuals such as Metzker-Madsen are part of the subdiscipline of forensic psychology. Forensic psychologists are involved in psychological assessment and treatment of individuals involved with the legal system. They use their knowledge of human behavior and mental illness to assist the judicial and legal system in making decisions in cases involving such issues as personal injury suits, workers' compensation, competency to stand trial, and pleas of not guilty by reason of insanity.

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Patient case quiz: screening patients with schizophrenia in practice.

For educational purposes only. Hypothetical patient case. Not an actual patient. Image is for illustrative use only.

Patient Profile:

Simon is a 26-year-old man who works as a children’s book illustrator. He presents with hallucinations, disorganized speech, and flat affect. His sister Sarah accompanies him.

When visiting her brother from the UK, Sarah found that Simon’s usually neat apartment was covered in trash and there were drawings all over the walls. When she asked him about it, Simon tried to explain that the characters he was drawing started leaping off the paper and he had to sleep outside sometimes to get away from them. He also seemed very depressed. Sarah could not convince him that his visions were not real.

Prior to this incident, Sarah explained that Simon sometimes felt down but had not exhibited these behaviors in his past. He attended art school and had been at the same job for several years. When asked about his visions, Simon noted that they started about 6 months ago. He stopped going into work 2 months ago and hasn’t been showering regularly.

Simon also reports that he heard voices that told him he was a failure and a terrible artist. At first the voices were faint and he could ignore them, but over time they grew louder and invaded his mind all the time. He denies any drug or alcohol use but started smoking cigarettes when the visions started. Simon also said that he hadn’t seen his friends in a while because he was afraid that they hate him.

A review of Simon’s medical history revealed that he is being treated for obesity and diabetes, but he has not been taking his diabetes medication regularly. His diet is also poor, and he is not eating regular meals. Simon doesn’t believe that he is sick and doesn’t want to take any medications.

Sarah noted that no one in her family had a history of mental illness to her knowledge. She is very concerned about Simon’s health and safety and is planning to take a leave of absence from her job to take care of her brother.

After careful evaluation of Simon’s symptoms and medical history and exclusion of other possible disorders, he was diagnosed with schizophrenia.

Based on the information provided in this case study, test your knowledge about screening Simon for schizophrenia and other mental health conditions by taking the quiz below:

Patient Case Quiz:  Screening Patients with Schizophrenia in Practice

Does your patient have schizophrenia or another condition? Review this patient case to test your knowledge.

Question 1: Which of Simon’s symptoms, including their duration, meet the required DSM-5 criteria for schizophrenia?

This resource is intended for educational purposes only and is intended for US healthcare professionals. Healthcare professionals should use independent medical judgment. All decisions regarding patient care must be handled by a healthcare professional and be made based on the unique needs of each patient.

ABBV-US-00869-MC, Version 2.0 Approved 02/2024 AbbVie Medical Affairs 

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Module 11: Schizophrenia Spectrum and Other Psychotic Disorders

Schizophrenia, learning objectives.

• Identify and describe the diagnostic criteria and major symptoms of schizophrenia
• Differentiate between the positive and negative symptoms of schizophrenia

Schizophrenia  is a complex and significant psychological disorder characterized by major disturbances in thought, perception, emotion, and behavior. About 1% of the population experiences schizophrenia in their lifetime (i.e., over three million people in the United States alone), and usually, the disorder is first diagnosed during early adulthood (early to mid-20s). Most people with schizophrenia experience significant difficulties in many day-to-day activities, such as holding a job, paying bills, caring for oneself (grooming and hygiene), and maintaining relationships with others. However, contrary to common assumptions, a recent review of studies on schizophrenia (Vita & Barlati, 2018 [1] ) found a wide range of outcomes for persons who have schizophrenia, ranging from persons with severe symptoms and repeated episodes of remission and subsequent hospitalization to persons who experience a single episode that meets criteria followed by complete remission (although they usually continue to participate in treatment). Vita and Barlati (2018) also found that possibly up to half of the individuals diagnosed with schizophrenia either recovered or demonstrated significant improvement over time. They recommended that clinicians and society focus on two outcomes of consideration for persons with schizophrenia: clinical remission (significant reduction of symptoms and severity) and social functioning (e.g., ability to work, to function as a family member or in relationships, enjoy recreation, and dwell in independent living) in thinking about recovery.

Unlike other conditions such as depression or anxiety that almost all people can relate to in some ways, it is more difficult for most people to see the symptoms of schizophrenia and other psychotic disorders as part of the normal continuum of human experiences. However, the types of psychotic symptoms that characterize disorders like schizophrenia are on a continuum with normal mental experiences. For example, work by Jim van Os in the Netherlands has shown that a surprisingly large percentage of the general population (10%+) experience psychotic-like symptoms, though many fewer have multiple experiences and most will not continue to experience these symptoms in the long run (Verdoux & van Os, 2002). Similarly, work in a general population of adolescents and young adults in Kenya has also shown that a relatively high percentage of individuals experience one or more psychotic-like experiences (~19%) at some point in their lives (Mamah et al., 2012; Ndetei et al., 2012), though again most will not go on to develop a full-blown psychotic disorder.

So, what is schizophrenia? It is important to realize that schizophrenia is not a condition involving a split personality; that is, schizophrenia is not the same as dissociative identity disorder (previously known as multiple personality disorder). These disorders are sometimes confused because the word schizophrenia first coined by the Swiss psychiatrist Eugen Bleuler in 1911, derives from Greek words that refer to a “splitting” (schizo) of the mind (phrene) (Green, 2001). In the case of schizophrenia, the “split” is usually interpreted as between cognition (thinking and communicating) and emotions (see the discussion of flat affect below). Schizophrenia is considered a psychotic disorder (while dissociative disorders are not), which impairs a person’s thoughts, perceptions, and behaviors to the point where that individual is not able to function normally in life. Individuals who suffer from psychotic disorders experience a major disconnection with the world around them and do not share in the normal perception of the external environment. In other words, terms like psychosis  or psychotic  do not have anything to do with violence, serial killers, or other common misunderstandings; psychosis refers specifically to the presence of hallucinations (sensory distortions), delusions (unusual beliefs), or disorganized thought processes and can also occur during severe instances with other disorders.

Schizophrenia was once classified into distinct subtypes, such as paranoid, catatonic, disorganized, residual, or undifferentiated, but that method has since been replaced by approaching schizophrenia as a spectrum of disorders with varying degrees of severity and displaying several aspects of the subtypes. Now, schizophrenia subtypes are not listed in the DSM-5, as the subtypes would often change or coexist, but clinicians still sometimes specify a dominant type of subtype, such as “schizophrenia with paranoia.” The spectrum of psychotic disorders includes schizophrenia, schizoaffective disorder, delusional disorder, schizotypal personality disorder, schizophreniform disorder, brief psychotic disorder, and psychosis associated with substance use or medical conditions. These are all disorders of psychosis, with schizophrenia and schizoaffective disorder (schizophrenia combined with a mood disorder) being the most severe and personality disorders being less severe.

Symptoms of Schizophrenia

The main symptoms of schizophrenia can be categorized as either positive symptoms or negative symptoms. Positive symptoms are symptoms of addition, meaning they add something atypical or unusual to what other individuals experience, do, or think. Examples include hallucinations, delusions, and disorganized thinking and behaviors. Negative symptoms are those that result in noticeable decreases or absences in common behaviors, emotions, or drives (APA, 2013; Green, 2001). Examples include flattened emotional expression, lack of motivation for self-care, or significant social withdrawal.

Positive Symptoms

A hallucination is a perceptual experience that occurs in the absence of external stimulation. Auditory hallucinations (hearing voices) occur in roughly two-thirds of patients with schizophrenia and are by far the most common form of hallucination (Andreasen, 1987). The auditory voices may be familiar or unfamiliar, they may have a conversation or argue, or the voices may provide a running commentary on the person’s behavior (Tsuang, Farone, & Green, 1999).   

Figure 1 . Tactile hallucinations, like that of imaginary spiders crawling on the skin, are another type of hallucination.

Less common are visual hallucinations (seeing things that are not there) and olfactory hallucinations (smelling odors that are not actually present). In interacting with persons with psychotic symptoms, it is helpful to remember that although you may not hear what they are hearing nor see what they are seeing or experiencing, they are having those sensory experiences. To them, these experiences seem as real as you seeing a car drive by on the street or hearing a neighbor’s dog barking. Telling them they are wrong or that those things are not happening does not improve your ability to relate to them or help them reconnect to the world around them. Instead, try to understand what they are experiencing and demonstrate empathy and understanding.

Delusions are beliefs that are contrary to reality and are firmly held even in the face of contradictory evidence. Many of us hold beliefs that some would consider odd, but a delusion is easily identified because it is absurd according to normal social and cultural standards. A person with schizophrenia may believe that his mother is plotting with the FBI to poison his coffee or that his neighbor is an enemy spy who wants to kill him. These kinds of delusions are known as paranoid delusions , which involve the false belief that other people or agencies are plotting against the person. People with schizophrenia also may hold grandiose delusions , which are beliefs that one holds special power, unique knowledge, or is extremely important. For example, the person who claims to be Jesus Christ, or who claims to have knowledge going back 5,000 years, or who claims to be a great philosopher is experiencing grandiose delusions. Other delusions include the belief that one’s thoughts are being removed from their head (thought withdrawal) or thoughts have been placed inside one’s head (thought insertion). Another type of delusion is a  somatic delusion , which is the belief that something highly abnormal and improbable is happening to one’s body (e.g., that one’s kidneys are being eaten by cockroaches).

Disorganized thinking refers to disjointed and incoherent thought processes—usually detected by what a person says. Individuals might ramble, exhibit loose associations (jump from topic to topic), or talk in a way that is so disorganized and incomprehensible that it seems as though the person is randomly combining words. Disorganized thinking is also exhibited by blatantly illogical remarks (e.g., “Fenway Park is in Boston. I live in Boston. I live at Fenway Park.”) and by tangentiality: responding to others’ statements or questions by remarks that are either barely related or unrelated to what was said or asked. For example, if a person diagnosed with schizophrenia is asked if she is interested in receiving special job training, she might state that she once rode on a train somewhere. To a person with schizophrenia, the tangential (slightly related) connection between job training and riding a train are sufficient enough to cause such a response.

As another example, at the beginning of an interview, a clinician remarked in passing that he forgot to bring his pen to take notes. The patient begins to talk about living on a farm as a child and taking care of pigs which was tangential to the focus of the conversation. However, there is a linguistic association between “pen” (writing tool) and an animal enclosure (pen) on a farm. In persons without thought disorder or disorganized thinking, the brain would light up with these language associations, but would quickly sort through them and prioritize those that match the context. For someone with schizophrenia, these filters and the ability to determine the appropriate context are usually impaired.

Disorganized or abnormal motor behavior refers to unusual behaviors and movements: becoming unusually active, exhibiting silly child-like behaviors (giggling and self-absorbed smiling), engaging in repeated and purposeless movements, or displaying odd facial expressions and gestures. In some cases, the person will exhibit catatonic behaviors that show decreased reactivity to the external environment, such as posturing, in which the person maintains a rigid and bizarre posture for long periods of time, or catatonic stupor, a complete lack of movement and verbal behavior. Another way catatonia is displayed is through  waxy  flexibility , which occurs when another person places an individual with schizophrenia in an unusual or uncomfortable position and they remain in that position, sometimes for hours.

Negative Symptoms

Unlike positive symptoms, negative symptoms are symptoms where ordinary and expected behaviors may be reduced or absent. A person who exhibits diminished emotional expression displays little emotion in his facial expressions, speech, or movements, even when such expressions are normal or expected (also known as flat affect where affect  is a noun meaning the display of emotion). It is important to recognize, however, that although the person may have difficulty expressing their emotions the way most people do, they still experience the full range of normal human emotions [2] . Avolition (lack of volition) is characterized by a lack of motivation to engage in self-initiated and meaningful activity, including the most basic of daily living tasks such as bathing and grooming. Alogia (lack of speech; from the Greek logos  meaning word or speech) refers to reduced speech output; in simple terms, patients do not speak or respond much in interactions with others. Another negative symptom is asociality, or social withdrawal and lack of interest in engaging in social interactions with others (this is differentiated from antisocial activity such as that of persons with antisocial personality disorder who are “against” or “anti” society). A final negative symptom, anhedonia, refers to an inability to experience pleasure. One who exhibits anhedonia expresses little interest in what most people consider to be pleasurable activities, such as hobbies, recreation, or sexual activity.

In their review of schizophrenia research, Vita and Barlati (2018) note that positive symptoms receive much attention, but negative and cognitive symptoms are often not treated effectively, leading persons to not achieve “functional” (or daily living) levels of remission. In addition to the use of some of the newer antipsychotics that may help with negative symptoms, psychosocial treatments are important in reducing negative symptoms and improving the person’s ability to function well in their life.

Diagnostic Criteria

The diagnostic criteria for schizophrenia are listed below:

A. Two (or more) of the following must each present for a significant portion of time during a one-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):

• hallucinations
• disorganized speech (e.g., frequent derailment or incoherence)
• grossly disorganized or catatonic behavior
• negative symptoms (i.e., diminished emotional expression or avolition)

B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning).

C. Duration: continuous signs of the disturbance persist for at least six months. This six-month period must include at least one month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs or unusual perceptual experiences). [3]

D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.

E. The disturbance is not attributable to the physiological effect of a substance (e.g., drug abuse or a medication) or other medical condition.

F. If there is a history of autism spectrum disorder or communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least one month (or less if successfully treated). [4]

Link to Learning

Watch this video and try to identify which classic symptoms of schizophrenia are shown . See if you can describe the positive and negative symptoms that this individual exhibits.

Watch this video for an overview of schizophrenia, including the causes and symptoms you’ve learned about thus far.

You can view the transcript for “Schizophrenia – causes, symptoms, diagnosis, treatment & pathology” here (opens in new window) .

Risk Factors for Developing Schizophrenia

Consistent with the biopsychosocial model, several factors contribute to the risk of developing schizophrenia:

• Genetics:  It is clear that there are important genetic contributions to the likelihood that someone will develop schizophrenia, with consistent evidence from family, twin, and adoption studies. (Sullivan, Kendler, & Neale, 2003). However, there is no “schizophrenia gene” and it is likely that the genetic risk for schizophrenia reflects the summation of many different genes that each contribute something to the likelihood of developing psychosis (Gottesman & Shields, 1967; Owen, Craddock, & O’Donovan, 2010). Further, schizophrenia is a very heterogeneous disorder, which means that two different people with schizophrenia may each have very different symptoms (e.g., one has hallucinations and delusions, the other has disorganized speech and negative symptoms). This makes it even more challenging to identify specific genes associated with risk for psychosis. Importantly, many studies also now suggest that at least some of the genes potentially associated with schizophrenia are also associated with other mental health conditions, including bipolar disorder, depression, and autism (Gejman, Sanders, & Kendler, 2011; Y. Kim, Zerwas, Trace, & Sullivan, 2011; Owen et al., 2010; Rutter, Kim-Cohen, & Maughan, 2006).
• Environment: There are also a number of environmental factors that are associated with an increased risk of developing schizophrenia. For example, problems during pregnancy such as increased stress, infection, malnutrition, and/or diabetes have been associated with increased risk of schizophrenia. In addition, complications that occur at the time of birth and which cause hypoxia (lack of oxygen) are also associated with an increased risk for developing schizophrenia (M. Cannon, Jones, & Murray, 2002; Miller et al., 2011). Children born to older fathers are also at a somewhat increased risk of developing schizophrenia. Further, using cannabis increases risk for developing psychosis, especially if you have other risk factors (Casadio, Fernandes, Murray, & Di Forti, 2011; Luzi, Morrison, Powell, di Forti, & Murray, 2008). The likelihood of developing schizophrenia is also higher for kids who grow up in urban settings (March et al., 2008) and for some marginalized ethnic groups (Bourque, van der Ven, & Malla, 2011). Both of these factors may reflect higher social and environmental stress in these settings. Unfortunately, none of these risk factors is specific enough to be particularly useful in a clinical setting, and most people with these risk factors do not develop schizophrenia. However, together they are beginning to give us clues as the neurodevelopmental factors that may lead someone to be at an increased risk for developing this disease.
• Brain structure and function:  Scientists think that differences in brain structure, function, and interactions among neurotransmitters may contribute to the development of schizophrenia. For example, differences in the volumes of specific components of the brain, in the way regions of the brain are connected and work together, and in neurotransmitters, such as dopamine, are found in people with schizophrenia. Differences in brain connections and brain circuits seen in people with schizophrenia may begin developing before birth. Changes to the brain that occur during puberty may trigger psychotic episodes in people who are vulnerable due to genetics, environmental exposures, or the types of brain differences mentioned above.

An important research area on risk for psychosis has been work with individuals who may be at clinical high risk. These are individuals who are showing attenuated (milder) symptoms of psychosis that have developed recently and who are experiencing some distress or disability associated with these symptoms. When people with these types of symptoms are followed over time, about 35% of them develop a psychotic disorder (T. D. Cannon et al., 2008), most frequently schizophrenia (Fusar-Poli, McGuire, & Borgwardt, 2012). In order to identify these individuals, a new category of diagnosis, called “Attenuated Psychotic Syndrome,” was added to Section III (the section for disorders in need of further study) of the DSM-5 (APA, 2013). However, adding this diagnostic category to the DSM-5 created a good deal of controversy (Batstra & Frances, 2012; Fusar-Poli & Yung, 2012). Many scientists and clinicians have been worried that including risk states in the DSM-5 would create mental disorders where none exist, that these individuals are often already seeking treatment for other problems, and that it is not clear that we have good treatments to stop these individuals from developing to psychosis. However, the counterarguments have been that there is evidence that individuals with high-risk symptoms develop psychosis at a much higher rate than individuals with other types of psychiatric symptoms, and that the inclusion of Attenuated Psychotic Syndrome in Section III will spur important research that might have clinical benefits. Further, there is some evidence that non-invasive treatments such as omega-3 fatty acids and intensive family intervention may help reduce the development of full-blown psychosis (Preti & Cella, 2010) in people who have high-risk symptoms.

Treatments and Therapies

The causes of schizophrenia are complex and are not fully understood, so current treatments focus on managing symptoms and solving problems related to day-to-day functioning.

Antipsychotic Medications

Antipsychotic medications can help reduce the intensity and frequency of psychotic symptoms. The medications are usually taken daily in pill or liquid forms. Some antipsychotic medications are given as injections once or twice a month, which some individuals find to be more convenient than daily oral doses. Patients whose symptoms do not improve with standard antipsychotic medication typically receive clozapine. People treated with clozapine must undergo routine blood testing to detect a potentially dangerous side effect that occurs in 1%-2% of patients.

Many people taking antipsychotic medications have side effects such as weight gain, dry mouth, restlessness, and drowsiness when they start taking these medications. Some of these side effects subside over time, but others may persist, which may cause some people to consider stopping their antipsychotic medication. Suddenly stopping medication can be dangerous and it can make schizophrenia symptoms worse. People should not stop taking antipsychotic medication without talking to a health care provider first.

Psychosocial Treatments

Cognitive behavioral therapy (CBT), behavioral skills training, supported employment, and cognitive remediation interventions may help address the negative and cognitive symptoms of schizophrenia. A combination of these therapies and antipsychotic medication is common. Psychosocial treatments can be helpful for teaching and improving coping skills to address the everyday challenges of schizophrenia. These treatments may help people pursue their life goals, such as attending school, working, or forming relationships. Individuals who participate in regular psychosocial treatment are less likely to relapse or be hospitalized.

Family Education and Support

Educational programs for family members, significant others, and friends offer instruction about schizophrenia symptoms and treatments, and strategies for assisting the person with the illness. Increasing key supporters’ understanding of psychotic symptoms, treatment options, and the course of recovery can lessen their distress, bolster coping and empowerment, and strengthen their capacity to offer effective assistance. Family-based services may be provided on an individual basis or through multi-family workshops and support groups.

Coordinated Specialty Care

Coordinated specialty care (CSC) is a general term used to describe recovery-oriented treatment programs for people with first-episode psychosis, an early stage of schizophrenia. A team of health professionals and specialists deliver coordinated specialty care (CSC), which includes psychotherapy, medication management, case management, employment and education support, and family education and support. The person with early psychosis and the team work together to make treatment decisions, involving family members as much as possible. Compared to typical care for early psychosis, coordinated specialty care (CSC) is more effective at reducing symptoms, improving quality of life, and increasing involvement in work or school.

Assertive Community Treatment

Assertive community treatment (ACT) is designed especially for individuals with schizophrenia who are at risk for repeated hospitalizations or homelessness. The key elements of assertive community treatment (ACT) include a multidisciplinary team, a clinician who prescribes medication, a shared caseload among team members, direct service provision by team members, a high frequency of patient contact, low patient-to-staff ratios, and outreach to patients in the community. Assertive community treatment (ACT) reduces hospitalizations and homelessness among individuals with schizophrenia.

Key Takeaways: Schizophrenia

Forensic psychology.

In August 2013, 17-year-old Cody Metzker-Madsen attacked five-year-old Dominic Elkins on his foster parents’ property. Believing that he was fighting goblins and that Dominic was the goblin commander, Metzker-Madsen beat Dominic with a brick and then held him face down in a creek. Dr. Alan Goldstein, a clinical and forensic psychologist, testified that Metzker-Madsen believed that the goblins he saw were real and was not aware that it was Dominic at the time. He was found not guilty by reason of insanity and was not held legally responsible for Dominic’s death (Nelson, 2014). Cody was also found to be a danger to himself or others. He will be held in a psychiatric facility until he is judged to be no longer dangerous. This does not mean that he “got away with” anything. In fact, according to the American Psychiatric Association, individuals who are found not guilty by reason of insanity are often confined to psychiatric hospitals for as long or longer than they would have spent in prison for a conviction.

Hollywood depictions and news reports to the contrary, most people with schizophrenia are not violent. Only 3%-5% of violent acts are committed by individuals diagnosed with severe mental illness, whereas individuals with severe mental illnesses are more than 10 times as likely to be victims of crime (MentalHealth.gov, 2017). The most common conditions linked to violence are psychopathic personality (severe antisocial personality disorder), bipolar disorder, and persons who are abusing drugs (especially alcohol). The psychologists who work with individuals such as Metzker-Madsen are part of the subdiscipline of forensic psychology. Forensic psychologists are involved in psychological assessment and treatment of individuals involved with the legal system. They use their knowledge of human behavior and mental illness to assist the judicial and legal system in making decisions in cases involving such issues as personal injury suits, workers’ compensation, competency to stand trial, and pleas of not guilty by reason of insanity.

catatonic behavior:  decreased reactivity to the environment; includes posturing and catatonic stupor

delusion:  belief that is contrary to reality and is firmly held, despite contradictory evidence

disorganized/abnormal motor behavior:  highly unusual behaviors and movements (such as child-like behaviors), repeated and purposeless movements, and displaying odd facial expressions and gestures

disorganized thinking:  disjointed and incoherent thought processes, usually detected by what a person says

dopamine hypothesis:  theory of schizophrenia that proposes that an overabundance of dopamine or dopamine receptors is responsible for the onset and maintenance of schizophrenia

grandiose delusion:  characterized by beliefs that one holds special power, unique knowledge, or is extremely important

hallucination: a perceptual experience that occurs in the absence of external stimulation, such as the auditory hallucinations (hearing voices) common to schizophrenia

negative symptom: characterized by decreases and absences in certain normal behaviors, emotions, or drives, such as an expressionless face, lack of motivation to engage in activities, reduced speech, lack of social engagement, and inability to experience pleasure

paranoid delusion:  characterized by beliefs that others are out to harm them

prodromal symptom:  in schizophrenia, one of the early minor symptoms of psychosis

schizophrenia: a severe disorder characterized by major disturbances in thought, perception, emotion, and behavior with symptoms that include hallucinations, delusions, disorganized thinking and behavior, and negative symptoms

somatic delusion:  belief that something highly unusual is happening to one’s body or internal organs

• Vita, A. & Barlati, S. (2018). Recovery from Schizophrenia: Is it possible? Current Opinion Psychiatry , 31(3), 246-255. DOI: 10.1097/YCO.0000000000000407 ↵
• Publishing, Harvard Health. “The Negative Symptoms of Schizophrenia.” Harvard Health . Accessed December 31, 2020. https://www.health.harvard.edu/mental-health/the-negative-symptoms-of-schizophrenia . ↵
• Substance Abuse and Mental Health Services Administration. Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2016 Jun. Table 3.22, DSM-IV to DSM-5 Schizophrenia Comparison . Available from: https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t22 ↵
• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Publisher. ↵
• Modification, adaptation, and original content. Authored by : Anton Tolman for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• Modification, adaptation, and original content. Authored by : Wallis Back for Lumen Learning. Provided by : Lumen Learning. License : CC BY-SA: Attribution-ShareAlike
• Schizophrenia. Authored by : OpenStax College. Located at : http://cnx.org/contents/[email protected]:gGD_wNTe@5/Schizophrenia . License : CC BY: Attribution . License Terms : Download for free at http://cnx.org/content/col11629/latest/.
• Information on positive symptoms of schizophrenia. Provided by : Boundless. Located at : https://www.boundless.com/psychology/textbooks/boundless-psychology-textbook/psychological-disorders-18/schizophrenia-spectrum-and-other-psychotic-disorders-94/introduction-to-schizophrenia-and-psychosis-360-12895/ . Project : Boundless Psychology. License : CC BY-SA: Attribution-ShareAlike
• Tactile hallucination image. Authored by : Angela Mariam Thomas. Located at : https://commons.wikimedia.org/wiki/File:Tactile_hallucination.jpg . License : CC BY-SA: Attribution-ShareAlike
• Schizophrenia lobes picture. Authored by : BruceBlaus. Located at : https://commons.wikimedia.org/wiki/File:Schizophrenia_(Brain).png . License : CC BY-SA: Attribution-ShareAlike
• Schizophrenia. Provided by : Wikipedia. Located at : https://en.wikipedia.org/wiki/Schizophrenia . License : CC BY-SA: Attribution-ShareAlike
• Schizophrenia Spectrum Disorders . Authored by : Deanna M. Barch . Provided by : Washington University in St. Louis. Located at : https://nobaproject.com/modules/schizophrenia-spectrum-disorders . Project : The Noba Project. License : CC BY-NC-SA: Attribution-NonCommercial-ShareAlike
• Schizophrenia causes, symptoms, diagnosis, treatment & pathology. Provided by : Osmosis. Located at : https://www.youtube.com/watch?v=PURvJV2SMso . License : Other . License Terms : Standard YouTube License
• Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health. Provided by : Substance Abuse and Mental Health Services Administration. Located at : https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t22/ . Project : SAMHSA. License : Public Domain: No Known Copyright
• Schizophrenia. Provided by : NIMH. Located at : https://www.nimh.nih.gov/health/topics/schizophrenia/index.shtml . License : Public Domain: No Known Copyright

Quality and Safety Education for Nurses

Strategy submission, schizophrenia unfolding case study.

Amanda Eymard, Co-Author: Linda Manfrin-Ledet

Associate Professor

Institution:

Nicholls State University College of Nursing and Allied Health

[email protected]

Competency Categories:

Evidence-Based Practice, Informatics, Patient-Centered Care, Quality Improvement, Safety, Teamwork and Collaboration

Learner Level(s):

Pre-Licensure BSN

Learner Setting(s):

Strategy Type:

Independent Study

Learning Objectives:

Strategy Overview:

Submitted Materials:

Schizophrenia-Unfolding-Case-Study_2.ppt - https://drive.google.com/open?id=1-xNAUmNfVJmD3Zwv7nZ44oXcYhd53i0i&usp=drive_copy

Atypical-Antipsychotics-and-Metabolic-article.pdf - https://drive.google.com/open?id=1tshbJ4ljXk9TdySiRsw2xlqb-O3Tx5Oo&usp=drive_copy

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• v.39(9); 2014 Sep

Schizophrenia: Overview and Treatment Options

Schizophrenia is a complex disorder characterized by an array of symptoms. This heterogeneity has resulted in a lack of consensus regarding diagnostic criteria, etiology, and pathophysiology, and has complicated efforts to devise effective treatments.

INTRODUCTION

Schizophrenia is a complex, chronic mental health disorder characterized by an array of symptoms, including delusions, hallucinations, disorganized speech or behavior, and impaired cognitive ability. The early onset of the disease, along with its chronic course, make it a disabling disorder for many patients and their families. 1 Disability often results from both negative symptoms (characterized by loss or deficits) and cognitive symptoms, such as impairments in attention, working memory, or executive function. 2 In addition, relapse may occur because of positive symptoms, such as suspiciousness, delusions, and hallucinations. 1 , 2 The inherent heterogeneity of schizophrenia has resulted in a lack of consensus regarding the disorder’s diagnostic criteria, etiology, and pathophysiology. 1 , 3

This article provides a concise review of schizophrenia and discusses the available treatment options.

PATHOPHYSIOLOGY

Abnormalities in neurotransmission have provided the basis for theories on the pathophysiology of schizophrenia. Most of these theories center on either an excess or a deficiency of neurotransmitters, including dopamine, serotonin, and glutamate. Other theories implicate aspartate, glycine, and gamma-aminobutyric acid (GABA) as part of the neurochemical imbalance of schizophrenia. 1

Abnormal activity at dopamine receptor sites (specifically D 2 ) is thought to be associated with many of the symptoms of schizophrenia. Four dopaminergic pathways have been implicated ( Figure 1 ). 4 , 5 The nigrostriatal pathway originates in the substantia nigra and ends in the caudate nucleus. Low dopamine levels within this pathway are thought to affect the extrapyramidal system, leading to motor symptoms. 1 The mesolimbic pathway, extending from the ventral tegmental area (VTA) to limbic areas, may play a role in the positive symptoms of schizophrenia in the presence of excess dopamine. 1 The mesocortical pathway extends from the VTA to the cortex. Negative symptoms and cognitive deficits in schizophrenia are thought to be caused by low mesocortical dopamine levels. The tuberoinfundibular pathway projects from the hypothalamus to the pituitary gland. A decrease or blockade of tuberoinfundibular dopamine results in elevated prolactin levels and, as a result, galactorrhea, ammenorrhea, and reduced libido.

Pathophysiology of Schizophrenia 4 , 5

The serotonin hypothesis for the development of schizophrenia emerged as a result of the discovery that lysergic acid diethylamide (LSD) enhanced the effects of serotonin in the brain. 1 Subsequent research led to the development of drug compounds that blocked both dopamine and serotonin receptors, in contrast to older medications, which affected only dopamine receptors. The newer compounds were found to be effective in alleviating both the positive and negative symptoms of schizophrenia. 1

Another theory for the symptoms of schizophrenia involves the activity of glutamate, the major excitatory neurotransmitter in the brain. This theory arose in response to the finding that phenylciclidine and ketamine, two noncompetitive NMDA/glutamate antagonists, induce schizophrenia-like symptoms. 6 This, in turn, suggested that NMDA receptors are inactive in the normal regulation of mesocortical dopamine neurons, and pointed to a possible explanation for why patients with schizophrenia exhibit negative, affective, and cognitive symptoms. 7

The brain tissue itself appears to undergo detectable physical changes in patients with schizophrenia. For example, in addition to an increase in the size of the third and lateral ventricles, individuals at high risk of a schizophrenic episode have a smaller medial temporal lobe. 2

Despite more than a century of research, the precise cause of schizophrenia continues to elude investigators. It is widely accepted, however, that the various phenotypes of the illness arise from multiple factors, including genetic susceptibility and environmental influences. 2 , 8

One explanation for the development of schizophrenia is that the disorder begins in utero. 6 Obstetric complications, including bleeding during pregnancy, gestational diabetes, emergency cesarean section, asphyxia, and low birth weight, have been associated with schizophrenia later in life. 2 Fetal disturbances during the second trimester—a key stage in fetal neurodevelopment—have been of particular interest to researchers. 3 Infections and excess stress levels during this period have been linked to a doubling of the risk of offspring developing schizophrenia. 3

Scientific evidence supports the idea that genetic factors play an important role in the causation of schizophrenia; 2 studies have shown that the risk of illness is approximately 10% for a first-degree relative and 3% for a second-degree relative. 9 In the case of monozygotic twins, the risk of one twin having schizophrenia is 48% if the other has the disorder, whereas the risk is 12% to 14% in dizygotic twins. 9 If both parents have schizophrenia, the risk that they will produce a child with schizophrenia is approximately 40%. 9

Studies of adopted children have been conducted to determine whether the risk of schizophrenia comes from the biological parents or from the environment in which the child is raised. These investigations have tended to show that changes in the environment do not affect the risk of developing schizophrenia in children born to biological parents with the illness. 3 , 6 A genetic basis for schizophrenia is further supported by findings that siblings with schizophrenia often experience onset of the disorder at the same age. 2

Environmental and social factors may also play a role in the development of schizophrenia, especially in individuals who are vulnerable to the disorder. 1 Environmental stressors linked to schizophrenia include childhood trauma, minority ethnicity, residence in an urban area, and social isolation. 1 In addition, social stressors, such as discrimination or economic adversity, may predispose individuals toward delusional or paranoid thinking. 1

EPIDEMIOLOGY

The prevalence of schizophrenia is between 0.6% and 1.9% in the U.S. population. 10 Moreover, a claims analysis has estimated that the annual prevalence of diagnosed schizophrenia in the U.S. is 5.1 per 1,000 lives. 11 The prevalence of the disorder seems to be equal in males and females, although the onset of symptoms occurs at an earlier age in males than in females. 2 Males tend to experience their first episode of schizophrenia in their early 20s, whereas women typically experience their first episode in their late 20s or early 30s. 12

Research into a possible link between the geography of birth and the development of schizophrenia has provided inconclusive results. A collaborative study by the World Health Organization in 10 countries found that schizophrenia occurred with comparable frequencies across the various geographically defined populations. 13 On the other hand, a more recent review, which included data from 33 countries, concluded that the incidence of schizophrenia varied by geographic location. 14

CLINICAL PRESENTATION

Schizophrenia is the most common functional psychotic disorder, and (as noted previously) individuals with the disorder can present with a variety of manifestations. Contrary to portrayals of the illness in the media, schizophrenia does not involve a “split personality.” Rather, it is a chronic psychotic disorder that disrupts the patient’s thoughts and affect. The illness commonly interferes with a patient’s ability to participate in social events and to foster meaningful relationships. 2

Social withdrawal, among other abnormal (schizoid) behaviors, typically precedes a person’s first psychotic episode; however, some individuals may exhibit no symptoms at all. 2 A psychotic episode is characterized by patient-specific signs and symptoms (psychotic features) that reflect the “false reality” created in the patient’s mind. 2 , 15

As noted earlier, the symptoms of schizophrenia are categorized as positive, negative, or cognitive. Each symptom is vitally important as the clinician attempts to distinguish schizophrenia from other psychotic disorders, such as schizoaffective disorder, depressive disorder with psychotic features, and bipolar disorder with psychotic features. 12

Positive symptoms are the most easily identified and can be classified simply as “psychotic behaviors not seen in healthy people.” 15 Such symptoms include delusions, hallucinations, and abnormal motor behavior in varying degrees of severity. 12

Negative symptoms are more difficult to diagnose but are associated with high morbidity as they disturb the patient’s emotions and behavior. 12 , 15 The most common negative symptoms are diminished emotional expression and avolition (decreased initiation of goal-directed behavior). Patients may also experience alogia and anhedonia. It is important to understand that negative symptoms may be either primary to a diagnosis of schizophrenia or secondary to a concomitant psychotic diagnosis, medication, or environmental factor. 12 , 16

Cognitive symptoms are the newest classification in schizophrenia. These symptoms are nonspecific; therefore, they must be severe enough for another individual to notice them. Cognitive symptoms include disorganized speech, thought, and/or attention, ultimately impairing the individual’s ability to communicate. 12 , 16

Patients with symptoms of schizophrenia may experience additional limitations and negative conditions. Substance-abuse disorders occur most often among these patients; these disorders can involve a variety of substances, including alcohol, tobacco, and prescription medications. 12 , 16 Anxiety, depression, panic, and obsessive-compulsive disorder are also prominent in patients with schizophrenia and can exacerbate the symptoms of their disorder. 12 , 16 These patients also have a general lack of awareness of their illness. This mindset has been linked to high rates of nonadherence, relapse, poor psychosocial function, poor hygiene, and worse disease outcomes. 2 , 12

The primary symptoms and comorbid conditions associated with schizophrenia may ultimately lead to social and occupational dysfunction. 12 Functional consequences include an inadequate or incomplete education, which may affect the patient’s ability to obtain and hold a stable job. Patients with schizophrenia typically cultivate few social relationships and need daily support to manage relapses and recurring symptoms. 12 , 16

The prognosis for patients with schizophrenia is generally unpredictable. 2 Only 20% of patients report favorable treatment outcomes. 12 The remaining patients experience numerous psychotic episodes, chronic symptoms, and a poor response to antipsychotics. 2

As described earlier, schizophrenia is a chronic disorder with numerous symptoms, where no single symptom is pathogenic. A diagnosis of schizophrenia is reached through an assessment of patient-specific signs and symptoms, as described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). 12 The DSM-5 states that “the diagnostic criteria [for schizophrenia] include the persistence of two or more of the following active-phase symptoms, each lasting for a significant portion of at least a one-month period: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms.” 12 At least one of the qualifying symptoms must be delusions, hallucinations, or disorganized speech. 12

Moreover, the DSM-5 states that, to warrant a diagnosis of schizophrenia, the patient must also exhibit a decreased level of functioning regarding work, interpersonal relationships, or self-care. 12 There must also be continuous signs of schizophrenia for at least six months, including the one-month period of active-phase symptoms noted above. 12

A comprehensive differential diagnosis of schizophrenia is necessary to distinguish the disorder from other mental conditions, such as major depressive disorder with psychotic or catatonic features; schizoaffective disorder; schizophreniform disorder; obsessive-compulsive disorder; body dysmorphic disorder; and post-traumatic stress disorder. Schizophrenia can be differentiated from these similar conditions through a careful examination of the duration of the illness, the timing of delusions or hallucinations, and the severity of depressive or manic symptoms. 12 In addition, the clinician must confirm that the presenting symptoms are not a result of substance abuse or another medical condition. 12

TREATMENT OPTIONS

Nonpharmacological therapy.

The goals in treating schizophrenia include targeting symptoms, preventing relapse, and increasing adaptive functioning so that the patient can be integrated back into the community. 2 Since patients rarely return to their baseline level of adaptive functioning, both nonpharmacological and pharmacological treatments must be used to optimize long-term outcomes. 2 Pharmacotherapy is the mainstay of schizophrenia management, but residual symptoms may persist. For that reason, nonpharmacological treatments, such psychotherapy, are also important. 17

Psychotherapeutic approaches may be divided into three categories: individual, group, and cognitive behavioral ( Figure 2 ). 2 Psychotherapy is a constantly evolving therapeutic area. Emerging psychotherapies include meta-cognitive training, narrative therapies, and mindfulness therapy. 17 Nonpharmacological treatments should be used as an addition to medications, not as a substitute for them. 2

Psychotherapeutic Approaches 2

Not only do nonpharmacological therapies fill in gaps in pharmacological treatments; they can help to ensure that patients remain adherent to their medications. 18 Nonadherence rates in schizophrenia range from 37% to 74%, depending on the report. 19 Individuals with mental disorders tend to be less adherent for several reasons. They may deny their illness; they may experience adverse effects that dissuade them from taking more medication; they may not perceive their need for medication; or they may have grandiose symptoms or paranoia. 2

Patients with schizophrenia who stop taking their medication are at increased risk of relapse, which can lead to hospitalization. 18 Therefore, it is important to keep patients informed about their illness and about the risks and effectiveness of treatment. 20 Some psychotherapies can help educate patients about the importance of taking their medications. These initiatives include cognitive behavioral therapy (CBT), personal therapy, and compliance therapy. 17

In addition to focusing on the patient, treatment programs that encourage family support have been shown to decrease rehospitalization and to improve social functioning. 2 Family members can be taught how to monitor the patient and when to report adverse effects of treatment to the clinician. 20 Most psychotherapies promote family involvement. 17

Pharmacological Therapy

In most schizophrenia patients, it is difficult to implement effective rehabilitation programs without antipsychotic agents. 16 Prompt initiation of drug treatment is vital, especially within five years after the first acute episode, as this is when most illness-related changes in the brain occur. 16 , 21 Predictors of a poor prognosis include the illicit use of amphetamines and other central nervous system stimulants, 22 as well as alcohol and drug abuse. 2 Alcohol, caffeine, and nicotine also have the potential to cause drug interactions. 2

In the event of an acute psychotic episode, drug therapy should be administered immediately. During the first seven days of treatment, the goal is to decrease hostility and to attempt to return the patient to normal functioning (e.g., sleeping and eating). 2 At the start of treatment, appropriate dosing should be titrated based on the patient’s response. 2

Treatment during the acute phase of schizophrenia is followed by maintenance therapy, which should be aimed at increasing socialization and at improving self-care and mood. 2 Maintenance treatment is necessary to help prevent relapse. The incidence of relapse among patients receiving maintenance therapy, compared with those not receiving such therapy, is 18% to 32% versus 60% to 80%, respectively. 16 , 23 Drug therapy should be continued for at least 12 months after the remission of the first psychotic episode. 16 , 24

According to the American Psychiatric Association, second-generation (atypical) antipsychotics (SGAs)—with the exception of clozapine—are the agents of choice for first-line treatment of schizophrenia. 16 , 25 Clozapine is not recommended because of its risk of agranulocytosis. 2 SGAs are usually preferred over first-generation (typical) antipsychotics (FGAs) because they are associated with fewer extrapyramidal symptoms. 2 However, SGAs tend to have metabolic side effects, such as weight gain, hyperlipidemia, and diabetes mellitus. 26 These adverse effects can contribute to the increased risk of cardiovascular mortality observed in schizophrenia patients. 26

The Texas Medication Algorithm Project (TMAP) has provided a six-stage pharmacotherapeutic algorithm for the treatment of schizophrenia. Stage 1 is first-line monotherapy with an SGA. If the patient shows little or no response, he or she should proceed to stage 2, which consists of monotherapy with either another SGA or an FGA. If there is still no response, the patient should move to stage 3, which consists of clozapine monotherapy with monitoring of the white blood cell (WBC) count. 24 If agranulocytosis occurs, clozapine should be discontinued. If stage-3 therapy fails to elicit a response, the patient should proceed to stage 4, which combines clozapine with an FGA, an SGA, or electroconvulsive therapy (ECT). 24 If the patient still shows no response to treatment, stage 5 calls for monotherapy with an FGA or an SGA that has not been tried. 24 Finally, if stage 5 treatment is unsuccessful, stage 6 consists of combination therapy with an SGA, an FGA, ECT, and/or a mood stabilizer. 24

Combination therapy is recommended only in the later stages of the treatment algorithm. 27 The routine prescription of two or more antipsychotics is not recommended because it may increase the risk of drug interactions, nonadherence, and medication errors. 27

Before a new antipsychotic agent is initiated, the patient’s complete medication history should be obtained. Whether the patient has shown a favorable or unfavorable response to previous antipsychotic treatment will help guide the selection of a new medication. 2

Long-Acting Injectable Antipsychotic Agents

Long-acting injectable (LAI) antipsychotic medications offer a viable option for patients who are nonadherent to an oral medication. 2 Clinicians should determine whether the patient’s nonadherence is due to the adverse effects of treatment. If so, then the clinician should consider an oral medication with a more favorable side-effect profile. 2 Before moving to LAI therapy, a short trial should be conducted with the oral counterpart of the LAI to determine tolerability. 2

A recent meta-analysis of randomized controlled trials (RCTs) concluded that outcomes with LAIs are similar to those with oral antipsychotics. 28 The authors suspected, however, that RCTs might not reflect the “real world” efficacy and safety of LAIs. 29 Therefore, they conducted a meta-analysis of 25 mirror-image studies, in which a total of 5,940 subjects served as their own controls in naturalistic settings. 29 This analysis demonstrated the superiority of LAIs over oral antipsychotics in preventing hospitalizations (risk ratio [RR] = 0.43) and in reducing the number of hospitalizations (RR = 0.38). 29

Treatment-Resistant Schizophrenia

Between 10% and 30% of patients with schizophrenia show little symptomatic improvement after multiple trials of FGAs, and an additional 30% to 60% experience partial or inadequate improvement or unacceptable side effects during antipsychotic therapy. 16

Clozapine is the most effective antipsychotic in terms of managing treatment-resistant schizophrenia. This drug is approximately 30% effective in controlling schizophrenic episodes in treatment-resistant patients, compared with a 4% efficacy rate with the combination of chlorpromazine and benztropine. 30 Clozapine has also been shown to increase serum sodium concentrations in patients with polydipsia and hyponatremia. 31

However, as indicated earlier, clozapine has a problematic safety profile. For example, patients treated with this drug are at increased risk of developing orthostatic hypotension, which can require close monitoring. 2 Moreover, high-dose clozapine has been associated with serious adverse effects, such as seizures. 2

Augmentation and Combination Therapy

Both augmentation therapy (with ECT or a mood stabilizer) and combination therapy (with antipsychotics) may be considered for patients who fail to show an adequate response to clozapine. Clinicians should observe the following guidelines when administering augmentation therapy: 24

• The treatment should be used only in patients with an inadequate response to prior therapy.
• Augmentation agents are rarely effective for schizophrenia symptoms when given alone.
• Patients responding to augmentation treatment usually improve rapidly.
• If an augmentation strategy does not improve the patient’s symptoms, then the agent should be discontinued.

Mood stabilizers are common augmentation agents. Lithium, for example, improves mood and behavior in some patients but does not have an antipsychotic effect. 23

In combination therapy, two antipsychotic drugs—such as an FGA and an SGA, or two different SGAs—are administered concurrently. 2 However, exposure to multiple antipsychotics at the same time may increase the risk of serious side effects. 24 , 25 , 32

Mechanism of Action

The precise mechanism of action of antipsychotic drugs is unknown, although it has been suggested that these drugs comprise three main categories: 1) typical, or traditional, antipsychotics, which are associated with high dopamine (D 2 ) antagonism and low serotonin (5-HT 2A ) antagonism; 2) atypical antipsychotics that have moderate-to-high D 2 antagonism and high 5-HT 2A antagonism; and 3) atypical antipsychotics that demonstrate low D 2 antagonism and high 5-HT2A antagonism. 2 , 33 , 34

At least 60% to 65% of D 2 receptors must be occupied to decrease the positive symptoms of schizophrenia, whereas a D 2 blockade rate of 77% or more has been associated with extrapyramidal symptoms. 33 , 35

The improvement of negative symptoms and cognition with atypical antipsychotics may be due to 5-HT 2A antagonism in combination with D 2 blockade, resulting in the release of dopamine into the prefrontal cortex (the area of the brain in which dopaminergic receptors are hypoactive in untreated individuals with schizophrenia). 2 Although atypical antipsychotics appear to improve negative symptoms, no approved treatment options are specifically indicated for these symptoms.

Adverse Effects

Typical vs. atypical antipsychotics.

The adverse effects of schizophrenia medications can involve several organ systems, as discussed below.

Table 1 illustrates the risk of two key adverse effects of anti-psychotic agents: weight gain and extrapyramidal symptoms. 2 SGAs are associated with a greater risk of weight gain, whereas FGAs are associated with a greater risk of extrapyramidal side effects. SGAs with the lowest risk of extrapyramidal symptoms include aripiprazole, quetiapine, and clozapine. 18 , 36 , 37 , 38

Comparative Risks of Weight Gain and Extrapyramidal Symptoms With Typical and Atypical Antipsychotic Agents 2

± = negligible risk; + = low risk; ++ = moderate risk; +++ = moderately high risk; ++++ = high risk

Endocrine System

Hyperprolactinemia can occur in up to 87% of patients treated with risperidone or paliperidone, possibly leading to sexual dysfunction, decreased libido, menstrual irregularities, or gynecomastia. 2 Aripiprazole or ziprasidone is a potential treatment option for patients with increased prolactin levels. 39

Weight gain is another important side effect in patients receiving antipsychotic drugs. 39 , 40 It can occur in patients treated for their first psychotic episode 2 and may eventually lead to nonadherence. 41

Along with hyperprolactinemia and weight gain, antipsychotic drugs also can increase the risks of diabetes mellitus and cardiovascular-related mortality. 39 , 42 Olanzapine has the greatest risk of diabetes, followed by risperidone and quetiapine. The latter two agents cause minimal weight gain, however. 2

Cardiovascular System

Orthostatic hypotension can occur in up to 75% of patients treated with an antipsychotic agent. 43 Patients with diabetes, pre-existing cardiovascular disease, or advanced age appear to have the greatest risk, but all patients receiving antipsychotic medications should be counseled to rise slowly from a sitting position to avoid a hypotensive episode. 2

Electrocardiographic changes, especially QTc prolongation, can occur in some patients treated with antipsychotics, including thioridazine, clozapine, iloperidone, and ziprasidone. QTc prolongation should be monitored during therapy, and treatment should be discontinued if this interval consistently exceeds 500 msec. 2 Antipsychotic medications should be chosen carefully in patients with pre-existing cardiac or cerebrovascular disease, and in those taking diuretics or medications that prolong the QTc interval. 43

Although some studies have shown that the risk of sudden cardiac death in patients treated with FGAs or SGAs is nearly twice that in individuals who do not use antipsychotic medications, more recent findings suggest that both types of drugs have similar cardiac mortality risks. 43 , 44

Lipid Changes

Patients treated with SGAs or phenothiazines tend to show increased concentrations of serum triglycerides and cholesterol. 2 SGAs with a lower risk in this regard include risperidone, ziprasidone, and aripiprazole. 41 , 42 In the CATIE trial, olanzapine was shown to have negative effects on cholesterol levels and lipids. 45

Central Nervous System

Dystonia is another common side effect of antipsychotic medications. This disorder often results in nonadherence and can be life-threatening. 2 Dystonic reactions typically accompany treatment with FGAs and are most common in younger male patients. 2 Dystonia may be minimized by using SGAs or by initiating FGAs at lower doses. 2

Akathisia (often accompanied by dysphoria) occurs in 20% to 40% of patients treated with high-potency FGAs, such as haloperidol and fluphenazine. 36 , 46 Quetiapine and clozapine appear to have the lowest risk for this side effect. 36 , 37

Pseudoparkinsonism has occurred in patients receiving antipsychotic therapy. The incidence of this disorder has ranged from 15% to 36% in patients treated with FGAs. It occurs more often in females and in older patients. 2 The risk of pseudoparkinsonism during treatment with SGAs is generally low, although an increased risk is associated with higher doses of risperidone. 2

The risk of tardive dyskinesia has ranged from as low as 0.5% to as high as 62% during treatment with FGAs and is increased in elderly patients. 2 , 37 , 46 The overall prevalence of the disorder ranges from 20% to 25% among patients receiving long-term FGA therapy. 2 , 37 The risk of tardive dyskinesia is significantly lower with SGAs, and no cases have been reported in patients receiving clozapine monotherapy. 2 , 37

Chlorpromazine, thioridazine, mesoridazine, clozapine, olanzapine, and quetiapine have the highest sedation potential. 2 Studies have shown that SGAs offer superior cognitive benefits compared with FGAs, although the CATIE trial found no differences in cognitive improvement among patients treated with SGAs compared with the FGA perphenazine. 2 , 47

All patients treated with antipsychotic agents are at increased risk of seizures. The antipsychotics with the greatest seizure risk are clozapine and chlorpromazine. 2 Those with the lowest risk include risperidone, molindone, thioridazine, haloperidol, pimozide, trifluoperazine, and fluphenazine. 36

Poikilothermia (the inability to maintain a constant internal body temperature independent of external temperatures) can be a serious side effect of antipsychotic medications. 48 In addition, patients may be at increased risk of heat stroke during exercise because of an impaired ability to dissipate excess body heat. 2 These side effects most commonly occur during treatment with low-potency FGAs, such as chlorpromazine, but they have also been associated with the SGAs that have more anticholinergic effects, such as clozapine. 2

Neuroleptic malignant syndrome (NMS) is a rare but life-threatening side effect of antipsychotic drug therapy, occurring in 0.5% to 1.0% of patients treated with FGAs. 2 Since the introduction and increased use of SGAs, however, the treatment-related occurrence of this disorder has diminished. 2

Psychiatric side effects, such as delirium and psychosis, can occur with higher doses of FGAs or with combination treatments involving anticholinergics. 2 Elderly patients, in particular, are at increased risk of chronic confusion and disorientation during treatment with antipsychotic drugs. 2

Miscellaneous Adverse Effects

Schizophrenia medications can cause a variety of other adverse effects, including the following:

• Antipsychotic medications with anticholinergic effects have been shown to worsen narrow-angle glaucoma, and patients should be appropriately monitored. 49 Chlorpromazine is most commonly associated with opaque deposits in the cornea and lens. 2 Because of the risk of cataracts, eye examinations are recommended for patients treated with quetiapine. 50 Those using thioridazine at doses exceeding 800 mg daily are at risk of developing retinitis pigmentosa. 2
• Low-potency FGAs and clozapine have been associated with urinary hesitancy and retention. 2 The incidence of urinary incontinence among patients taking clozapine can be as high as 44% and can be persistent in 25% of patients. 2 , 51
• FGAs and risperidone have a greater tendency to cause sexual dysfunction compared with SGAs. 2 , 52
• Treatment with antipsychotics can cause transient leukopenia. 2 , 53
• The three antipsychotics with the greatest risk for hematological complications are clozapine, chlorpromazine, and olanzapine. 54 Clozapine is associated with an especially high risk for the development of neutropenia or agranulocytosis. 54
• On rare occasions, dermatological allergic reactions have occurred at approximately eight weeks after the initiation of antipsychotic therapy. 2
• Both FGAs and SGAS can cause photosensitivity, leading to severe sunburn. 2
• Clozapine has been reported to cause sialorrhea in approximately 54% of patients with schizophrenia. 2 The mechanism of this effect is unknown. 2

The varying safety profiles of antipsychotic medications may be due to their effects on various neuroreceptor systems. 33 , 34 , 55

Progress Evaluation

As in other medical specialties, recovery during the treatment of schizophrenia is defined both objectively and subjectively. 56

Objective dimensions of recovery include the remission of symptoms and the patient’s return to full-time work or enrollment in college. 56 Several tools are available for rating the progress of patients with schizophrenia. The Brief Psychiatric Rating Scale (BPRS) and the Positive and Negative Syndrome Scale (PANSS), for example, were developed as numerical indicators of improvement. 57 Clinicians also use quicker four-item instruments such as the Positive Symptom Rating Scale and the Brief Negative Symptom Assessment. 24 , 58

Subjective dimensions of recovery are measured by the patient in terms of his or her life satisfaction, hope, knowledge about his or her mental illness, and empowerment. 56

Despite continued therapeutic advances, the life expectancy of patients with schizophrenia is reduced by approximately 10 to 25 years compared with that of healthy individuals. 59 The increased mortality among patients with schizophrenia has been attributed to unhealthy lifestyles common among this population (i.e., lack of exercise, unhealthy diet, and excessive smoking and alcohol intake), treatment-related adverse events, the suboptimal treatment of concomitant physical illnesses, and suicide. 59

Schizophrenia is a complex disorder that requires prompt treatment at the first signs of a psychotic episode. Clinicians must consider the potential for nonadherence and treatment-related adverse effects when developing a comprehensive treatment plan. Although patients can increase adaptive functioning through available pharmacological and nonpharmacological treatment options, it is hoped that future research will address gaps in treatment and potentially a cure for schizophrenia.

ORIGINAL RESEARCH article

Intersubjectivity in schizophrenia: life story analysis of three cases.

• 1 Centro de Estudios de Fenomenología y Psiquiatría, Facultad de Medicina, Universidad Diego Portales, Santiago, Chile
• 2 Escuela de Psicología, Facultad de Ciencias Sociales, Pontificia Universidad Católica de Chile, Santiago, Chile

The processes involved in schizophrenia are approached from a viewpoint of understanding, revealing those social elements susceptible to integration for psychotherapeutic purposes, as a complement to the predominant medical-psychiatric focus. Firstly, the paper describes the patients’ disturbances of self-experience and body alienations manifested in acute phases of schizophrenia. Secondly, the paper examines the patients’ personal biographical milestones and consequently the acute episode is contextualized within the intersubjective scenario in which it manifested itself in each case. Thirdly, the patients’ life stories are analyzed from a clinical psychological perspective, meaningfully connecting symptoms and life-world. Finally, it will be argued that the intersubjective dimension of the patients’ life stories shed light not only on the interpersonal processes involved in schizophrenia but also upon the psychotherapeutic treatment best suited to each individual case.

Introduction

Pathological experiences are usually described as phenomena that are divorced from the life context in which they are manifested. Nevertheless, in the field of phenomenological psychopathology, symptoms have traditionally been considered from a more comprehensive perspective: they are embedded in the person’s life thus their contents and meanings can only be understood within the context of that life. In themselves “unhistorical,” symptoms become connected meaningfully only within the comprehensive picture of the patient’s life as a whole ( Jaspers, 1997 ).

An even stronger argument could be made to the effect that “no mental illness can be diagnosed, described, or explained without taking account of the patients’ subjectivity and their interpersonal relationships” ( Fuchs, 2012 , p. 342). It is clear that psychopathological manifestations cannot simply be reduced to the workings of the nervous system ( Fuchs, 2011 ). For that reason, the recommendation here would be not to establish linear or “cause/effect” relationships, but to approach mental illnesses with the notion of a “circular” mode of causality, regarding their emergence from subjective, neural, social, and environmental influences continuously interacting with each other ( Fuchs, 2012 ).

Contemporary psychopathological phenomenology regards schizophrenia as a paradigmatic disturbance of embodiment and intersubjectivity ( Dörr, 1970 , 1997 , 2005 , 2011 ; Blankenburg, 2001 , 2012 ; Fuchs, 2001 , 2005 , 2010a ; Sass and Parnas, 2003 ; Stanghellini, 2004 , 2009 , 2011 ). From this approach, it seems appropriate to use methods that attempt to characterize not only the patients’ symptomatic disturbances but also the interpersonal processes involved, broadening the scope of exploration to areas not taken into account in the criteriological manuals of diagnostic systems Diagnostic Statistical Manual of Mental Disorders (DSM) and International Classification of Deseases (ICD) ( Fuchs, 2010b ).

This paper presents the life story analysis of three cases that form part of the corresponding author’s doctoral dissertation entitled “Study of disorders of the pre-reflexive self and of the narratives of first admitted patients with schizophrenia” (unpublished), covering a total of 15 patients with schizophrenia during their first psychiatric hospitalization.

Here, “life-world” refers to the person’s subjectively experienced world, which emerges in the process of conceiving one’s self and the others through a history of social interactions ( Husserl, 1970 ; Schutz and Luckmann, 1973 ; Varela, 1990 ; Varela et al., 1991 ; Maturana and Varela, 1996 ).

Materials and Methods

Study design.

The study was developed within the qualitative paradigm, it being an explorative–descriptive type of study. This type of studies proceeds with inductive logic: in other words, both hypotheses and analysis categories are developed as the study progresses, and emerge from the data itself (Danhke, 1989 quoted in Hernández et al., 2003 ).

The so-called “critical case sampling” criteria was used, where the interest in an in-depth approach to the phenomena means working with few cases, with representativeness not being of key importance for these purposes. Thus, the significance and understanding emerged by qualitative inquiry have more to do with the richness of the cases chosen and also with the observational and analytical abilities of the researcher, rather than with size of the sample ( Patton, 1990 ; Schwartz and Jacobs, 1996 ; Creswell, 1998 ).

Participants

The broad research covered a total of 15 patients with schizophrenia during their first psychiatric hospitalization. All of them were males, aged between 18 and 25. Additional inclusion criteria were the following: (1) accessibility to the sample, (2) homogenous sample ( Halbreich and Kahn, 2003 ), and (3) earlier first onset and higher risk of developing schizophrenia in men ( Aleman et al., 2003 ).

The three cases were selected due to the variety of subtypes to illustrate the interpersonal processes involved in schizophrenia, taking the intersubjective dimension of the patients’ life stories into consideration. Cases 1, 2, and 3, as they appear in the paper, correspond to patients with diagnoses of disorganized-type, paranoid-type, and catatonic-type schizophrenia, respectively.

Instruments

In-depth interviews.

In-depth interviews were used to gather qualitative data from the first encounter with the patients and from their life stories. These interviews had open questions aimed at allowing for a natural manifestation of the patients’ accounts. For the first encounter, the recommendations on interviews for the phenomenological diagnosis of schizophrenia were taken into account ( Dörr, 2002 ), and clinical biographical focus criteria were used to perform the life story interviews ( Sharim, 2005 ).

Positive and Negative Syndrome Scale

The Positive and Negative Syndrome Scale (PANSS; Kay et al., 1987 ) is a rating scale used for measuring symptom severity of patients with schizophrenia. The name refers to the two types of symptoms: positive, which refers to an excess or distortion of normal functions (e.g., hallucinations and delusions), and negative, which represents a diminution or loss of normal functions.

The Examination of Anomalous Self-Experience

The Examination of Anomalous Self-Experience (EASE; Parnas et al., 2005 ) is a semi-structured interview for the phenomenological examination of disorders of the pre-reflexive self, postulated as early markers or basic phenotype of the schizophrenic spectrum ( Raballo et al., 2011 ). The EASE explores a variety of anomalous self-experiences, which typically precede the onset of positive symptoms and which also often underlie negative and disorganized symptoms ( Parnas and Handest, 2003 ).

Data gathering was performed by means of semi-structured interviews, which are characterized by the use of eminently “open” research questions. Less structured methods allow for the emergence of ideographic descriptions, personal beliefs and meanings, focusing on “how” the psychological processes occur ( Barbour, 2000 ).

Five encounters with the patients were carried out. These encounters were coordinated throughout the three following phases:

Phase I: A first encounter to record the patients’ accounts of the disturbances of self-experience and body alienations manifested in the acute episode (30–45 min interview carried out 1–2 weeks after hospitalization), following the confirmation of the diagnosis of schizophrenia in accordance with expert judgment and the standard diagnostic criteria of DSM-IV-R ( American Psychiatric Association, 2003 ) and ICD-10 ( OrganizaciónMundial de la Salud, 2003 ).

Phase II: Two subsequent encounters to carry out the EASE ( Parnas et al., 2005 ; 30–45 min per interview carried out 1 month after hospitalization), when patients did not score with “positive” symptomatology on the PANSS ( Kay et al., 1987 ).

Note: The results of Phase II of the broad research have not been included in this paper. The results from the EASE exploration will be published in a complementary paper focused on basic self-disorders entitled “The lived body in schizophrenia” (in preparation).

Phase III: Finally, two further encounters were held to perform the life story interviews (30–45 min per interview carried out 1–2 months after hospitalization). The first encounter started with the open instruction “tell me about your self,” “tell me about your life,” while the second one was focused mainly on the patients’ significant social interactions and personal meanings, also including their first image in life, their early dreams (hopes), their self-definition, and their expectations about the future.

All the interviews were recorded on video and fully transcribed for subsequent analysis. Extracts of the patients’ accounts were kept literally in quotes.

First Encounter (Phase I)

The patients’ accounts of the disturbances of self-experience and body alienations manifested in the acute episodes were summarized in corresponding descriptions containing the essential structure of the transcripts, which were obtained with the “Descriptive Phenomenological Method in Psychology” ( Giorgi, 2009 ), by following five steps: (1) the researcher reads the entire transcript in order to gain an overall sense, (2) the same transcript is then read more slowly, and underlined every time a transition in meaning is perceived, providing a series of units constituting meaning, (3) the researcher then eliminates redundancies and clarifies the meaning of the units, connecting them together to obtain a sense of the whole, (4) the arising units are expressed essentially in the language of the subject, revealing the essence of the situation for him, and finally, (5) there is the summarizing and integrating of the achieved understanding in a description with the essential structure of the transcript.

Life Story Interviews (Phase III)

The criteria of the clinical biographical focus were considered in the life story analysis, which are part of the so-called “clinical human sciences” paradigm ( Legrand, 1993 ; Sharim, 2005 , 2011 ). This approach stresses the life story method, in which the clinical dimension is constantly present, working primordially on singularity: case-by-case, story-by-story.

At the same time, the examination of singularity and heterogeneity of individual situations allows the progressive appearance of common processes that structure behavior and organize these situations ( Sharim, 2005 , 2011 ; Cornejo et al., 2008 ). This method highlights the role of the subject in recounting his life story, giving the possibility to analyze the reciprocal relationship between the subject’s determination by his history and his potential to create his own existence ( De Gaulejac, 1999 ; De Gaulejac et al., 2005 ).

The in-depth analysis of the life stories was developed under a course guided by the co-author of this paper. The course was called “Hermeneutic analysis of biographical material for the study of patients with schizophrenia” and took place during one academic semester at the Catholic University of Chile. The analysis focused on the personal meanings ( Fuchs and De Jaegher, 2009 ) by following the patients’ history of significant social interactions.

Therefore, the transcripts were analyzed by peer researchers (corresponding author and co-author of this paper) both clinical psychologists with a specialty in psychotherapy. To avoid bias each researcher previously made a separate analysis and then met for the co-analysis, ensuring with this procedure the validity of the qualitative research ( Maxwell, 1996 ; Morrow, 2005 ; Fischer, 2009 ).

Firstly, an individual (case-by-case) in-depth analysis of each narration using a hermeneutic approach was carried out. In this analysis each life story was re-constructed, carrying out a thematic and chronological ordering, which enabled the identification of “biographical milestones,” as well as the analytical axes in each life story. Second, a cross-sectional analysis was carried out contemplating the stories all together, revealing the differences, similarities, and shared structural dimensions.

Ethical Issues

The broad research, covering 15 patients with schizophrenia during their first psychiatric hospitalization, was regarded as entailing no physical, psychological, or social risks for the subjects involved, based on the Declaration of Helsinki principles, the Council for International Organizations of Medical Sciences (CIOMS) 1992 International Ethical Guidelines for Biomedical Research Involving Human Subjects, and the 1996 International Conference on Harmonisation (ICH) Good Clinical Practice guidelines, by the following Ethics Committees: (1) Research into Human Beings Ethics Committee of the University of Chile’s Medical Faculty, dated January 19, 2011. (2) Ethics Committee Research of the Psychiatric Hospital, dated August 2, 2012. (3) Ethics Committee Research of the North Metropolitan Health Service (Santiago, Chile), dated August 16, 2012.

The Ethics Committees also approved the patients’ and their tutors’ (legal representatives) consent documents. In this regard, the following ethical aspects were taken into account: (1) consent was informed and obtained from the patients’ tutors by the attending doctor at Phase I of the study, considering that as a patient affected by an acute episode of schizophrenia, his competence or capacity is diminished and he must be authorized to participate. (2) Consent was obtained directly from the patients at Phase II of the study. (3) Pseudonyms were employed to protect the identity of the patients and ensure confidentiality (internal codes were used for each patient to replace their original names).

Note: Careful attention was paid in this paper to the protection of the patients’ anonymity. Identifying information such as dates, locations, hospital numbers, etc., was avoided.

Individual Analysis (Case by Case)

Santiago (Santi) is an 18-year-old patient, diagnosed with disorganized-type schizophrenia. He has completed 8 years of basic school education. His father died of cancer 1 month before his hospitalization: until then, he lived with him and his two brothers. He is the middle brother. The patient’s mother left home when he was 12 years old.

First encounter . A first interview was carried out after 2 weeks of hospitalization. In this encounter, the patient indicates that although he considers himself to be a “normal” person, begins to recognize a “ repetitive failure .” It is primarily the mediating process of thinking that has become the main impediment in this case.

The patient indicates that he hears voices, which are as if his own thoughts were repeated inside his head, like an echo, “ as if I was reading them aloud but with my mouth closed .” Most of the voices repeat meaningless things that he does not understand. He also hears voices on the radio, repeating what he is thinking: these are voices of unknown people who seem to be talking to him. Additionally, it sometimes seems to him that some television personalities repeatedly say things to him, all sorts of non-sense. He does not know how or why they do.

There are periods in which the “repetitive failure” intensifies, to the extent that it prevents him leaving home, and that only by going to bed to sleep is he able to take a break from these thoughts. This has made it difficult for him to progress with his studies or concentrate. He feels that this situation is annoying for him and is harmful because he cannot live a normal life.

At first, the patient figured it was sort of a game, playing with the voices and thoughts, but he could not control it, he could not stop it, he kept on playing. This was sometimes unbearable for him, and has even made him want to hang himself.

Biographical milestones . The life story interviews were carried out after 2 months of hospitalization. The patient was receiving the usual pharmacological treatment and had recently completed 12 electroconvulsive therapy sessions.

“My mum left me when I was 12”

Santi begins his account by indicating that he has had a hard life. He refers to his parents’ divorce, and particularly to when his mother left him alone with his brothers when he was 12. His mother moved away from the city and got married again. “ It was very hard, when she wasn’t there and we lacked a mother’s love .”

In addition to being angry with his mother when she left home, Santi also points out that he did not get on with her as a child. He remembers that she used to get very annoyed with him when he and his father sometimes made fun of her.

The mother returned after 2 years for her children. Santi’s brothers agreed to go with her, but he preferred to remain with his father. At the age of 14, he was living alone with his father. However, the brothers returned 2 years later, when he was 16, due to the serious situation with the mother’s new husband, who beat them.

Santi states that he got on well with his brothers; they had an affectionate relationship, one of friends, between them. They helped each other out and shared the housework between them.

“I died in high school”

Santi acknowledges that a significant change took place in his life at school. As a young child, he was a very good pupil and wanted to study medicine, but at the age of 12 he lost interest in his studies, skipped school, and began taking drugs. He had to repeat the last school year twice due to absenteeism. He liked the typical tools of the medical trade and wanted to have a stethoscope. “ Now that I have them here (at the psychiatric hospital), I ask myself, why can’t I, if everyone else can? ”

He stopped taking drugs at the beginning of this year and returned to his studies. He wanted to study accountancy to earn money. He had recently started the first year of high school when he was hospitalized.

“My dad passed away recently”

Santi states that his first memory is one of being with his family, when he was 7. It is a memory of the time when they were still living with their mother. He recalls it was his father who took them to a pretty square at the center of the city. “ Nice memories, everything was nice with my dad. ”

The father worked in the public sector and had taken early retirement, the reason for which is unknown. He did not remarry or have a relationship with another woman. Santi has a very positive image of him. He describes him as hard worker, a good father and who liked to go out and play ball with him and his brothers.

Santi displays an empathetic attitude toward his father, even a certain loyalty, which is made clear when he recounts the time when his mother left home, and later when his brothers left. In fact, he decided to stay alone with his father, despite the pain caused by the separation from his mother and brothers. “ My dad went through an extremely painful time, to put it one way, he didn’t show it but, inside, he was feeling bad .”

The father passed away 3 months ago, from cancer, at the age of 65. He became ill a month before dying, and had immediately told his sons of his disease, so they were aware of how much longer the doctor had given him. The father was hospitalized at the time of his death.

Santi recognizes that he was very attached to his father, he states that “ even too much .” He realizes that he still has not gotten over the death of his father, “ because of my illness, I still have not gotten over it. I haven’t realized what it all really means .”

“ I see the future as nothing ”

Since the last 4 years, Santi has been becoming more and more distanced from the world, to the point where he is extremely isolated. He has no friends, does not study or work, takes no part in social activities and has not embarked on any romantic relationship.

During the week, he helped with some household chores, such as making lunch. Nor did he do anything special during the weekend, except go out to the square with his brother. He spent a lot of time in his room playing on his PlayStation. “ I see the future as nothing, the way I’m going. Not doing anything, not studying, because where will I get like this? It’s looking bad, isn’t it? I’m worried .”

Life story analysis . The patient took part in the interviews without any problems. He appeared interested in obtaining more information on his state of health and motivated to seek help to secure a speedy discharge. He interrupted the interviews on a number of occasions to ask what his illness was, if it was very serious and when his attending doctor would discharge him. Generally, he appeared constantly concerned about his state and anxious to put an end to his confinement.

His life story contains a series of events that could be regarded as stressful. It is certainly possible to establish a connection between the death of his father (i.e., the patient’s state of grief) and the emergence of the first acute episode, and also to identify his mother’s leaving home as the crucial biographical milestone in the development of the prodromal stage of schizophrenia. Somehow, the sense of abandonment in the world has come to dominate the patient’s life.

The scale of the emotional impact of the recent loss of a father is obvious: nevertheless, the patient at no time displays any signs of sadness and does not cry. Instead of a spontaneous emotional expression, he rationally discerns the seriousness of the situation and like a “witness” he testifies the tremendous impact this must have on his life.

He manifested an initial perplexity, conveyed with a degree of humor, in light of the apparent oddness and incomprehensibility of the account of his anomalous experiences (“the repetitive failure”). Nevertheless, although he recounts sad events in his life, any actual sadness can only be assumed. To put it one way, it is possible to “intuit” the patient’s suffering, through the loneliness, abandonment and lack of support in his life, rather than by means of an explicitly emotional manifestation on his part.

The patient notices the paradoxical situation involved (of being hospitalized) when he states that he regards himself as a “normal” person, except for his “repetitive failure.” Far from merely being a game, as he previously regarded it, it is now given the name of schizophrenia, a diagnosis that defines him as a seriously ill patient and justifies his compulsory commitment to a hospital. This has led him to realize that what is happening to him is not socially acceptable, and is thus regarded as more serious in his own judgment.

Angel is a 22-year-old patient, diagnosed with paranoid-type schizophrenia. He has 11 years of basic school education and lives with his parents and the eldest of his three sisters. He is the youngest of the siblings and the only brother. His family are evangelical Christians.

First encounter . A first encounter was carried out a week into his hospitalization. The patient has not been able to find a convincing explanation for the fear he feels, which he recognizes as his major impediment. He thinks he could be delivered over to the Tribulation – the Tribulation is a biblical time of pain.

About 3 months ago he began to feel persecuted by people. His house was the only place he felt safe, but for a few weeks now he has even begun to feel unsafe at home. The idea that somebody can hurt him comes from the fear he feels and he thinks that the worst thing would be that somebody kills him somehow, like stabbing him, for example. This fear is a distressing feeling, of wishing to escape, when he suddenly feels that something bad is going to happen to him.

He is quite concerned about his problem, and thinks a lot about it, and how to solve it. He wants to find a way to overcome the fear. He would like to find a “ clear and precise ” answer to what he should do, how he should live and how to face up to his fear. He wishes that the bible could tell him what to do in the Tribulation, “ if I was in that time, that it told me in light of this fear to do this or that, to face up to it, don’t be afraid, I’ll be with you .”

Biographical milestones . The life story interviews were carried out 1 month into the patient’s hospitalization. He was receiving usual pharmacological treatment and his suitability for electroconvulsive therapy was being assessed.

“ When I was a kid I went to school ”

Angel woke up one night and found himself alone at home: it was very dark and he started crying. This is the earliest image that he recalls from his childhood. He also remembers that he would sometimes run up the stairs because he thought that someone, “ perhaps the bogeyman ,” was after him.

He remarks that his grades were not great but things went well for him at school. During his childhood, he felt good because he went out to play and climb trees. He also liked to fix televisions and take apart toy cars. He stresses the fact that he was more outgoing and playful as a child.

His family was always good to him, and he notes that he had a happy childhood. He was closest to his mother, as she stayed at home and was very attentive and loving toward him. His mother was of good character, and only punished him on a couple of occasions, “ because once I hit my sister with a hammer, when I was playing, and my mum punished me, she gave me a slap on the behind .”

“My sisters were very critical of me”

Angel has three older sisters. He has had a difficult relationship with them, and particularly with the eldest. He points out that his sisters criticized him a great deal and made fun of him. Therefore, even as a child, he took great care to say the right thing, so as not to make a fool of himself and feel embarrassed.

He was not only concerned to ensure that he said the right thing, but also with his personal appearance. He was very sensitive about the comments his sisters made about him. He states that he was very shy as a child, and when he was embarrassed by something he would run away and did not want to come back.

“Then I went to high school”

At high school, Angel was unable to make friends. He notes that he changed, became less playful, less “chatty” and more reclusive. He did not play ball so much or join in with classmates as often.

He also comments that he found it difficult to appear in front of his classmates, and skipped school when he had to give a talk to the class on a subject. This got worse when he started to suffer from acne, which made him feel that people were looking at him too much and a little persecuted.

It was because of the acne that Angel began to skip school, until he stopped going completely and became totally isolated. “ By this point, the acne wasn’t as bad, but it was the fact I missed school, I skipped class a lot, I was embarrassed that I skipped school so much, and that’s why I stopped studying .”

“ Then I went out to work. That’s when it all went wrong ”

Angel does not think that his acne is any better, but somehow he learned to come to terms with this concern. He has spent a lot of time at home, in his room playing on his PlayStation. This is what he has mostly done over the last 4 years, as he admits. “ I didn’t see anyone except for my family, not friends, because it’s a bit solitary on the PlayStation, you get closed in on yourself when you’re on it .”

After 4 years, Angel went out to work. He notes that it is when everything went wrong. He had spent a lot of time at home, without going out. He notes that he was perhaps unprepared to go out and experience life like that all of a sudden. It was then that he began to feel that people were after him.

“ Now, as a person ”

In adolescence, Angel wanted to be an air force pilot but he could not apply because he did not finish his studies and was under the required height – “ it came as quite a blow, but I was still interested in mechanics .”

Angel does not have a clear vision of what the future holds, principally because he has not overcome the fear of being harmed and the thought that “somebody” will kill him, which is his most serious affliction. Nevertheless, he indicates that, if he can overcome his fear, he would like to work and study mechanics and electronics, which have been interests of his since childhood.

Life story analysis . The patient was very willing to take part in the interviews, although he generally appeared tired and dispirited. He seemed not to have much to say, or not to be ready to recount his story. He is of a religious disposition and a frequent reader of the Bible where, above all, he hoped to find an explanation for the problem affecting him: his fear.

His account is mainly based around the fear of being harmed, which is the subject of his delusion. He even appears, in a way, excited when talking about the problem of his fear and about the different explanations he uses to understand what is happening to him. Aside from this core problem afflicting him, his account barely touched on other aspects of his life, and he appeared to become dispirited, tired, and uninterested when moving away from the subject of his delusion.

He seems concerned that he is unable to find certainty in things, above all with regard to explaining his fear. He feels prey to a fear that is completely restrictive, and is unable to find a satisfactory explanation that would allow him to understand what is happening to him or to give a completely convincing response to overcome the situation. He is aware of the extent of the fear and the significant limitations it causes in his life, and of the lack of any clear orientation as to how to overcome it.

The patient conveys a feeling of “ontological” uncertainty or insecurity. From an early age in his life, the world (and others) acquired a sense of unreliability or threat. Shame and fear of ridicule are the predominant emotional aspects of his experience in childhood. Somehow, later on in adolescence these emotions led to the fear of persecution. Persecution progressively became a fear of being hurt until it reached the extreme point of a fear that he would be killed, which manifested itself in the first acute episode.

Salvador (Salva) is a 25-year-old patient, diagnosed with catatonic-type schizophrenia. He has completed 12 years of compulsory school education and lives with his father and older brother. His parents divorced 2 years ago.

First encounter . The first interview was carried out when the patient had been hospitalized for close to 2 weeks. He explains that 2 years ago started with an episode of mental illness: “ I was getting cramps in the back of my brain .” It was because of the confusion these cramps caused in his brain that he went to the psychiatrist. Then, he was diagnosed with depression and treated with medication for a year but the problem persisted.

He feels mental pressures, and indicates it is as if they squeeze his brain. His thoughts are jumbled up, all messed up with ideas. Reality gets distorted for him as well, as if he were in a constant dream. In addition, he has felt someone possessing his body and explains it as “demonic possession.” He thinks that spirits get in when someone is depressed. It is something he cannot control, something unpredictable, imminent.

The patient is worried about the state of his mental health. It worries him to “live like this,” and he feels a deep-seated desperation. He does not want to do anything and feels depressed, downcast, dispirited, and powerless. Before he was hospitalized, he wanted to committed suicide by jumping off a hill due to the desperation.

Biographical milestones . When the life story interviews were carried out, the patient had been hospitalized for a month and a half. He was receiving the usual pharmacological treatment.

“ My interest in religion began at the age of 8 ”

Salva completed his primary education at a Christian school. He liked the religious part of school because religion was taught in a fun way. When he was a child, he used to go to church with his family. “ I liked the teachings about love, love for one another, love for one’s neighbor .”

He points out that he was a very good student and got very good grades. He wanted to be a vet when he was a child, because he liked animals. He describes himself as a gentle, playful, brotherly, sweet boy.

“ They moved me to a worldly high school ”

The change of school had a negative impact on Salva. His performance suffered, and he went from being an outstanding student to being just an average one. He notes that students at the new school were treated more coldly.

He had wanted to be a vet since childhood but he could not go to university, as he did not pass the entrance exams. He therefore chose to study architectural drawing at a college, but did not manage to complete his first year there.

“ My mum was sweet to me when she was Evangelical ”

Salva had a good relationship with his mother as a child. He points out that his mother was very loving toward him whilst she was Evangelical. Later, however, for reasons unknown to him, she distanced herself from church. Their relationship deteriorated when he was a teenager.

He got on badly with his mother because, he explains, of their very different characters. His mother ill-treated him and frequently insulted him. This made him feel powerless. “ She was really aggressive, and punished and hit me for anything. She used to insult me in all kinds of ways, she called me mentally ill .”

His mother also fought with his father and brother. She drank, and when she did so she became more violent.

“ I went through a lot in 2010 ”

Salva states that he had his first episode of “mental illness” 2 years ago, and has not been able to work or study since then. “ I did nothing at home, just playing games on the computer; I’d play on it, football games and PlayStation. I spent a load of time doing that .”

It was in this same year that his mother left home and his father fell ill with diabetes. His brother had had a heart attack at the end of the previous year.

His mother left home to live with a new partner, saying she wanted her independence. At first he missed her, but was also angry. He did not want to see her or be with her after she left.

Salva continued to live with his father and brother. He feels very attached to them, and is concerned about their health. He feels he has a really great father, because he has had to play a double role. He gets on well with his brother too, who he regards as a second father.

“ It’s great at church, they treat me really well ”

Salva’s current friends are evangelicals and he joins them at church. He likes going to the church because there he got to know beautiful people and had a much closer relationship with God. “ I like being in communion with God, praying, singing, that’s how I look for protection .”

He has had four episodes of “demonic possessions,” all of which happened at church. It was at church where he was told that his bodily experiences were “possessions” and that they are somehow “normal.” However, the treatment he was given there was unsuccessful. They carried out “deliverances,” which are a way of getting the devil out the body with prayer.

At the moment, Salva does not know why these episodes have happened to him, or whether they are due to an illness, and has not even talked much about the matter with his attending doctor.

“ In the future, I want to study massage therapy ”

Over the course of the last 7 years, Salva worked on and off in a number of fields. He took jobs as a shelf stacker in a supermarket, a cleaner at a cinema and a shop assistant. His last job was 2 years ago selling fragrances in a street market.

He has remained socially isolated over the last 2 years, only keeping in touch with his evangelical friends at church sporadically. “ I’ve found it difficult to relate to people in recent years. I haven’t worked much or had much of a social life. I’ve been isolated .”

In the future he would like to have children, a wife and work giving massages, although he realizes that he remains scared about his mental state, that he feels vulnerable.

Life story analysis . The patient took part in the interviews willingly, although he did appear very tired and sleepy (he was constantly yawning). The disordered thoughts persist, as do his low spirits, mental pressures and the uncertainty in the face of possible new “possessions.” He talks about himself and his life quite candidly and seems naïve, as if recounted by a small child. He speaks calmly, slowly, with little verve. It is a story with few elements told at a basic level of articulation.

He is very religious, a habitual reader of the Bible and a regular churchgoer. Now, although the episodes were “demonic possessions,” fear does not appear to be the predominant or explicit emotion: it is rather the loss of control of his bodily experiences and the unpredictable nature of these episodes that make the patient desperate. In other words, his desperation is due to his inability to once again feel normal or healthy.

He left school 7 years ago and has not developed a specific plan to carry out his life. Although he wishes to have a “normal” life, his life project faces a vacuum. However, the lack of a plan does not seem to concern him at all. Instead, what most worries the patient at present is the state of his mental health, that is, the anomalous bodily experiences he is not able to control.

It is possible to make a connection between the emergence of the first acute episode and a series of stressful events that occurred in the patient’s life at that time: his mother left home, his father fell ill with diabetes and his brother had heart problems, all in the same year. Although, the negative impact of the change in high school and the deterioration of the relationship with his mother in his adolescence are the crucial biographical milestones identified in the development prodromal stage of schizophrenia.

Besides, what the patient explains as “spirits getting into” does not seem to correspond to a typically clinical depression (as it was diagnosed initially), but rather to a severe “passivity” of his own existence, which finds concrete form in his disembodied experiences.

Cross-Sectional Analysis

The cross-sectional analysis shows that a severe disorder of intersubjectivity starts developing in early adolescence. Beginning at an early stage, the patients progressively distance themselves from the social world. This distancing becomes a structural element, a key part in the prodromal stage of schizophrenia.

It is not an active deliberate distancing, but rather an overall difficulty that hampers the living of a normal life. It implies a progressive “passiveness” of the patients’ own existence, which manifests itself not only in the disturbances of self-experience and body alienations of the acute phases, but also in the patients’ radical withdrawal from the social world.

For several years, the patients have not worked or studied, have had no social life, and have stayed shut in at home watching television or playing on their PlayStation for hours at a time. Here, it is important to notice that the acute episode occurred at a time when they were planning to return to their studies or the world of work after a number of years of extreme isolation.

It is possible to make a connection between the prodromal stages of schizophrenia and several stressful events that occurred in the patients’ lives. It is also possible to follow a continuity in the experience of vulnerability regarding the main personal meaning configured early in life: the feeling of abandonment, the fear of ridicule and the feeling of powerlessness, corresponding to Cases 1, 2, and 3, respectively.

Nevertheless, the patients’ withdrawal from the social world is what eventually leads to the manifestation of their psychosis. Somehow, in their attempts to returning to intersubjectivity, all of a sudden the patients confront themselves with their own “vulnerability” of being in the world.

Although they have some ideas about what to do in the future, the patients are insufficiently prepared, and lack a specific plan to implement them properly. Their life project faces a vacuum. This is what makes their condition so severe: there is an interruption in the patients’ normal unfolding of life.

The patients do have a concept of what a “normal life” should be (basically, to study, to have a job, to marry, and to have a family), but they do not seem to possess the factual grounding needed to deal with the world, as if they were lacking the implicit “know how” to carry out the normal life they wish to live.

It should be noted that the patients’ life stories feature a series of healthy elements or personal qualities that reflect a certain nobility of character: sensitivity, authenticity, naivety, empathy, and innocence. There does not appear to be any secondary gain associated with the symptoms.

Key Findings

In acute phases of schizophrenia, patients’ accounts concentrate on (or are limited to) the disturbances of self-experience or body alienations. In other words, patients’ accounts lie outside the time-space dimension of the social context and exclude personal history. Body alienation appears to be the way in which the de-subjectivized accounts find concrete form (or are materialized).

The assessment of the life stories complements the symptomatic descriptions embedding them in the patients’ life-worlds, thus incorporating a social horizon. In this way, the dimension of intersubjectivity is illustrated in the patients’ history of significant social interactions, discovering the interpersonal elements to integrate in psychotherapeutic and prevention models.

The articulation of the patients’ life stories allow to follow the patients’ progressive withdrawals from the social world, and also to identify the interpersonal conditions involved at the time of the acute episode’s emergence. Thus, the spatiotemporal dimension of the personal history allows the understandability of the interpersonal processes involved in schizophrenia from a broader perspective.

From the individual analysis of the life stories, it is possible to identify the patients’ biographical milestones, the personal meanings involved in their significant social interactions, and also continuity in their experience of vulnerability of being in the world, which are useful elements to consider for psychotherapeutic treatment.

The cross-sectional analysis of the life stories shows that a severe disorder of intersubjectivity starts in early adolescence, which should be a useful element to consider for the early detection and on the prevention. Beginning at an early stage, the patients progressively distance themselves from the social world, ending in a radical withdrawal. This distancing becomes a structural element, a key part of the prodromal stage of schizophrenia, as it was found in every case of the broader sample covering 15 patients with schizophrenia.

Social interactions are interrupted prior to the emergence of acute symptoms, possibly due to the threatening or anxiety provoking encounters with others. Nevertheless, the underlying anguish was not measured in this study. Instead, the study shows the personal vulnerability that leads to a psychotic break (or to the culmination of the intersubjective interruption).

Clinical Implications

Psychotherapeutic interventions for patients with schizophrenia have been widely neglected in general. Current treatments are primarily with medication, including elctroconvulsive treatments in acute phases, thus following a medical-biological model that has not been questioned sufficiently. In this context, the intersubjective dimension seems extremely relevant for both the development of psychological treatments and the understanding of the interpersonal processes involved in schizophrenia (as an interruption in intersubjectivity).

From the very start of hospitalization, psychotherapeutic support would appear of fundamental importance. The patients should be accompanied on their return to intersubjectivity, whereas efforts should be made to provide proper emotional support for the realization of the overall problem affecting them. Prior to interventions focused on tasks (for example, successfully performing a social role, such as studying or working), the patients need to experience being in the world with another person, in a synchronous accompaniment of affective reciprocity.

In other words, the intersubjective dimension should be integrated in psychotherapeutic models focusing on the patients’ social interactions. These models should be oriented to developing a collaborative encounter between the patient and the therapist, as well as enhancing metacognitive capacities, as it has been shown to be helpful especially for the recovery of patients with schizophrenia in several case studies ( Dimaggio et al., 2008 ; Harder and Folke, 2012 ; Lysaker et al., 2013 ).

The process of recovering understandability would be a key aspect in overcoming the patients’ alienation. Therefore, special consideration should be given to psychotherapeutic approaches that focus upon encouraging patients’ self-understanding and the establishment of a common communicative base between patient and psychotherapist ( Holma and Aaltonen, 1997 , 2004a , b ; Seikkula and Olson, 2003 ; Seikkula et al., 2006 ). The idea is that the patient’s experience can be explicitly shared on the basis of a common meaning by a dialog process that takes into account the other’s point of view (or second person-perspective; Stanghellini and Lysaker, 2007 ).

Patients’ narrativity should improve along different levels of articulation, by the recognition of beliefs, the incorporation of emotions and the reconstruction of different meaningful life events. However, during acute phases delusional beliefs constitute the patients’ only available form of cognitive and interpersonal organization, so instead of confronting them, the focus should be placed on the difficulty in pragmatically comprehending others and on the experience of vulnerability ( Lysaker et al., 2011a , b , c ; Salvatore et al., 2012a , b ; Henriksen and Parnas, 2013 ; Škodlar et al., 2013 ).

Besides, acute psychosis in schizophrenia manifests itself with a collapse of the temporal dimension of the narrative plot, which leads to a de-contextualization of self-experience ( Holma and Aaltonen, 1997 , 2004a ; France and Uhlin, 2006 ). From the so called “literacy hypothesis” ( Havelock, 1980 , 1991 ), which belongs to studies that follow the transition from orality to literacy in the development of the thematic consciousness, it could be noted that in the acute phase the patients lose the modality of ordering their experience in consensual logical sequences, displaying a narrativity with epic or poetic characteristics ( Guidano, 1999 ).

The re-establishment of the consensual ordering given by the locational/situational aspects of the life story (by articulating the self-experience in thematic/chronological sequences; Havelock, 1980 , 1991 ; Bruner and Weisser, 1991 ; Narasimhan, 1991 ; Guidano, 1999 ; Irarrázaval, 2003 ; Bruner, 2004 ; Holma and Aaltonen, 2004a ) allows to follow the patients’ progressive withdrawals from the social world, and also to identify the interpersonal conditions involved at the time of the acute episode’s emergence.

In this sense, the articulation of the patients’ life stories, expressed as narrative creations of their own subjectivity (and meanings), allows for the spatiotemporal dimension “re-ordering,” as well as for the understanding of the interpersonal processes involved in schizophrenia from a broader perspective. This psychological understanding reveals the intersubjective dimension that connects the emergence of the acute episode with the patients’ biographies, taking into account the personal meaning at play in each case.

In the case of Santi, there appears to be a need for emotional support aimed at accompanying him in becoming aware of the magnitude of the loss caused by the recent death of his father and, subsequently, to help him to develop strategies to deal with his feeling of abandonment in the world.

With Angel, his fear of ridicule is a structural emotional trait that dominates his life and is becoming a fundamental part of his worldview. Here, it is most important to deal with his sense of embarrassment and help him to accept himself. The aim is to provide a new, positive meaning to the sense of himself, overcoming his fear of ridicule in his encounters with others, or in other words, recovering the legitimacy of the sense of himself.

Salva requires an intervention in terms of developing a more basic sense of self-embodiment, which would be aimed at reflecting the feelings of “the other,” to re-establish primordial reciprocity. Additionally, space needs to be created in which the patient can recover a feeling of protection in the world, overcoming the feeling of powerlessness.

From this viewpoint, taking into consideration the story the patient tells of himself improves the articulation of self-narrative, which should gradually be extended toward diverse areas of his life whose elaboration appears important for him to make his way back to daily life. It would be important to articulate the present considering the experience that takes place in the actual interpersonal context, and from here to articulate the future as a horizon of possibilities.

Therefore, reconstructing the intersubjective dimension of the patients’ life stories shed light not only on the interpersonal processes involved in schizophrenia, but also on the psychotherapeutic intervention best suited to each individual case. Moreover, when intervention in acute phases of schizophrenia focuses mainly on reducing “positive” symptomatology, without assessing the psychological and social elements that are part of the overall situation affecting the patient, relapse seems highly likely.

Limitations of the Study

Regarding the limitations of the study, mainstream scientific research in mental health has been dominated by quantitative methodologies and statistical analyses of big samples (representativeness), while the value of in-depth psychological analyses has been underestimated.

There is a predominant excessive confidence in the accuracy of numbers, as if they could not be easily manipulated in data analyses. This tendency has been supported by the illusion that numbers represent exactly (as a mathematical formula) the experience of the subject, rather than the patients’ own stories.

While qualitative methodology has been the tradition for research in humanities and social sciences, psychotherapy research has been developed using the methodologies of the medical sciences, which are mostly quantitative, being the randomized controlled trials being the favored design.

Nevertheless, research in psychotherapy should be guided by questions that are relevant to clinical practice. It should not be forgotten that methodologies are only means to carry out scientific research, but should not be the ultimate aim in themselves. Thus in this field of research it seems necessary to incorporate the questions psychotherapists need to answer to improve the practice of psychotherapy (to help patients), and then to choose the most appropriate methodologies.

However, one of the main advantages of qualitative studies is the open, mindful and detailed assessment of the subjective experience, enabling the emergence of the patients’ worldview and their personal meanings, which cannot be obtained by means of superficial assessments. Therefore, psychotherapists should also have a voice on the debate of which methodology is best suited to improving the practice of psychotherapy.

Future Directions

Certainly, it would be important to systematize the results of this study in a model of psychotherapeutic treatment for persons with schizophrenia, which should include the intersubjective dimension, starting from the hermeneutic analysis of the patients’ life-worlds toward a meaning-based psychotherapeutic practice. This model would eventually require evidence of effectiveness.

Moreover, it would be interesting to explore gender differences in the processes involved in schizophrenia, investigating prodromal and acute stages, as well as life stories of women with schizophrenia. In addition, improvement is needed regarding the differential diagnosis between acute phases of schizophrenia and acute phases of other severe mental disorders, such as major depression and bipolar disorder.

Finally, the future challenge in the field of phenomenological psychopathology would be to develop a comprehensive/unified philosophical framework for an embodied science of intersubjectivity. And, consistently, to continue developing coherent methodologies for empirical research, since this is the closest we can get to the patients’ life-worlds.

Author Contributions

Co-author Dariela Sharim made substantial contributions to the analysis and interpretation of data to include in the paper; she revised the paper critically for important intellectual content; she made a final approval of the actual version of the paper to be published; she agreed upon the accuracy and coherence of the development of the sections for the paper.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

We would like to thank Thomas Fuchs from Heidelberg University, the Reviewers and the Editor for their helpful comments to improve the manuscript. Leonor Irarrázaval would like to thank Comisión Nacional de Investigación Científica y Tecnológica (CONICYT) for the grant “Beca Doctorado Nacional” (Doctorado en Psicoterapia UCH/PUC) and German Academic Exchange Service DAAD for the grant “Short duration research scholarships for doctoral students and young researchers.”

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Keywords : schizophrenia, phenomenology, hermeneutic, intersubjectivity, life stories, clinical psychology

Citation: Irarrázaval L and Sharim D (2014) Intersubjectivity in schizophrenia: life story analysis of three cases. Front. Psychol . 5 :100. doi: 10.3389/fpsyg.2014.00100

Received: 03 December 2013; Accepted: 24 January 2014; Published online: 12 February 2014.

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*Correspondence: Leonor Irarrázaval, Centro de Estudios de Fenomenología y Psiquiatría, Facultad de Medicina, Universidad Diego Portales, Av. Manuel Rodríguez Sur 253, Oficina 206, Santiago CP 8370057, Santiago de Chile, Chile e-mail: [email protected]

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