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Schizophrenia: Emil kraepelin, Adolph Meyer, and beyond
TheJournalof Emergency Medicine,Vol13,No6,pp805-809, 1995 Copyright0 1995ElsevierScience Inc. Printedin theUSA.All rightsreserved 0736-4619/95$9.50
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0736-4679(95)02022-F
Medical Classics
SCHIZOPHRENIA: EMIL KRAEPELIN, ADOLPH MEYER, AND BEYOND Michael J. Tueth,
MD
Department of Psychiatry, University of Florida College of Medicine, Gainesville, Florida Reprint Address: Michael J. Tueth, MD, Assistant Professor in Psychiatry, University of Florida College of Medicine, VA Medical Center, 1601 SW Archer Road, Gainesville, FL 32606
0 Abstract-Prior to 1800, insane persons often lived on the streets or were incarcerated in asylums, jails, or prisons. The 19th century witnessed progression in the anderstanding of psychosis, and the hospital management of psychotic patients began. While Kraepelin in Europe described the symptoms of what would later be called schizophrenia, Meyer developed humanistic treatment for the illnessin the United States. The early 20th century treatments for schizophrenia included insulin coma, metrazol shock, electro-convulsive therapy, and frontal leukotomy. Neuroleptic medications were first used in the early 1950s. Deinstitutionalization, beginning in the 196Os, resulted in medicated, stable schizophrenics being released from state hospitals. However, lack of stable living arrangements, misuse of funds, poor medical follow-up, and drug use resulted in deterioration of a large segment of this outpatient schizophrenic population. The 1990s have seen the development of newer, more effective antipsychotic agents and managed care. Both have impacted the state of health of schizophrenics in our society.
diseasecould explain why descriptions of schizophrenia-like disorders were rare before 1800 (1). While mentally retarded and insane persons were often contained in prisons or asylums prior to 1800, attempts to treat insanity began approximately 200 years ago. Treatment often consisted of twirling the patient on a stool until loss of consciousness occurred, or dropping the person into an icy lake. Humane and compassionate treatment for psychotic patients began in the United States during the middle of the 19th century (2). Efforts to understand the nature of insanity began in the middle of the 18th century, when Morel introduced the term dementia praecox to describe a mental disorder of degeneracy beginning in puberty. Prior to that time, the conditions of congenital insanity, dementia, mania, melancholia, and common madness were not differentiated. Later, in 1871, Hecker published an article on “hebephrenia” and, in 1874, Kahlbaum described a patient suffering from “catatonia.” These conditions described by Morel, Kahlbaum, and Hecker each described a psychotic illness having its onset in puberty and following a course of progressive deterioration (2). In the late 18th century, Emil Kraepelin observed that dementia praecox, previously described by Morel, was identical to the conditions of hebephrenia and catatonia identified by Hecker and Kahlbaum. In 1896, Kraepelin distinguished dementia praecox, which ultimately ends in functional decline, from
0 Keywords- schizophrenia, insan&; psychosis; dementia praecox
HISTORY
1800-1951
Over the past 3000 years, writers have commented about persons showing irrational behavior or seen as insane, but few clear descriptions of behavior resembling modern day schizophrenia were recorded prior to 1800. The hypothesis that schizophrenia is a recent
Medical Classics is coordinated by George Sternbach, MD, of Stanford University Medical Center, Stanford, California RECEIVED: 19 Se tember 1994; FINAL SUBMISSIONRECEIVED: 11 January 1995; ACCEPTED: 8 Fe&ruary 1995
805
M. J. Tueth
manic-depressive psychosis, which does not usually end in any significant decline. In 1898, he unified all primary and secondary “dementias” into one mental disease characterized by the lack of external causes, by occurrence usually in young and previously healthy persons, and most important, by ultimate deterioration (2). In 1919, Kreapelin wrote:
All mental activity must have it’s physiological side and it’s anatomical substratumin the form of nervous mechanisms,especiallyof the cerebralcortex. Schizophreniais a crowding out of normal reactions and a substitution of inferior reactions, some of which determine the cleavagealong distinctly psychobiologicallines incompatible with reintegration (3).
I got the starting point of the line of thought which in 1896lead to dementiapraecoxto be regardedas a distinct disease,on the one hand, from the impression of the states of dementia being quite similar to each other. On the other hand, these particular dementiasseemto stand in relation to the period of youth. The name dementia praecox consistedof a seriesof states,the common characteristicof which is a particular destructionof the internal connections of the psychicpersonality. The effectsof this injury predominatein the emotional and volitional spheres of mental life (4).
Meyer expanded on Bleuler’s optimistic outlook for schizophrenia. He viewed mental illness as a reaction to lifelong habits and conflicts leading to mental breakdown. He felt that schizophrenia was the natural result of a life history that could be clearly traced to various physical, social, and psychological factors in the patient’s past. While Kraepelin viewed schizophrenia as a fixed psychological condition with a progressive degenerative prognosis, Meyer stressed psychological and environmental factors in addition to biological causesand maintained a positive prognosis for the illness. Both approaches, however, shared the identical view that at the root of schizophrenia was a biological illness and that there were hereditary determinates (3). Due partially to the influence of Adolph Meyer, American psychiatrists developed a humanistic treatment approach to psychotic persons that resembles today’s milieu and social therapies. However, with the development of large state mental hospitals, a client-centered personal approach drifted away to be replaced by mechanistic institutional care. The early 20th century ushered in various somatic treatments for schizophrenia. Included among the early treatments were prolonged narcosis using barbiturates, insulin coma, metrazol shock, electro-convulsive therapy, and frontal leukotomy. Prolonged narcosis and insulin coma were largely ineffective treatments for schizophrenia. Seizure induction by using intramuscular camphor in oil and intravenous metrazol developed by Ladislous Meduna in Hungary were more effective. Seizure induction using metrazol won approval as an effective treatment for schizophrenia in 1935. In 1938, however, the induction of seizures using medication was permanently replaced with electricity, termed electro-convulsive therapy, pioneered by Cerletti in 1938 for the treatment of schizophrenia (7). The last experimental therapy for schizophrenia was psychosurgery, frontal leukotomy, developed principally in the 1940s. The technique was quickly popularized in the United States by Walter Freeman and became widely used in the treatment of schizophrenia (3,8). Fortunately, psychosurgery was relatively short-lived due to the development of modern treatment for schizophrenia, pharmacotherapy, in the early 1950s.
Essentially, Kraepelin distinguished mental disorders due to nonorganic causes from the traditional physical causes for insanity, as well as the disease of schizophrenia from manic depressive psychosis. According to data from the Board of Control, the average yearly number of direct admissions to all lunatics asylums in England and Wales for the years 1909-l 3 consisted of 69% functional disorders (1). In 1911, Eugene Bleuler introduced the new term schizophrenia for dementia praecox. Translated literally, schizophrenia means split-mindedness, and Bleuler saw the splitting of the personality as the central feature of the disease. Another of Bleuler’s fundamental contributions was the introduction of a hierarchy of symptoms for schizophrenia (2). However, Bleuler, as opposed to Kraepelin, maintained an optimistic prognostic view for schizophrenia. His support for therapy of this condition reflected his appreciation of the psychological and environmental factors at play in the illness (3,5,6). By the middle of the 19th century, the management of insane persons had progressed from incarceration in prisons and asylums to care in hospitals. Although the treatment was primitive and sometimes abusive, psychotic persons were viewed more as sick than as demon-possessedor evil. While Morel, Hecker, Kraepelin, and Bleuler were European physicians, Adolph Meyer’s views on schizophrenia in the United States proved increasingly influential. Although born and medically educated in Switzerland, Meyer immigrated to the United States in 1892. His influence in this country was enormous and he is generally acknowledged to be the “Dean of American Psychiatry” (2). Meyer maintained that:
History of Schizophrenia
HISTORY, l!MMWESENT AND COMMENTARY Schizophrenia occurs in 1% of the population and is believed to be a genetically transmitted illness with variable penetrance (9). First-degree biologic relatives of individuals with schizophrenia have a risk for the diseasethat is about 10 times greater than that of the general population. However, children adopted by schizophrenic families have no increased risk for schizophrenia. Environmental factors probably play a significant role in the development of schizophrenia since only 50”10of monozygotic twins are concordant for the disease,and environmental factors seemto increasethe risk for developing schizophrenia (10,ll). The clinical features of schizophrenia encompass symptoms in multiple areas including thought content, thought process, behavior, perception, affect, and ego functioning. Characteristically, the thoughtcontent abnormalities are bizarre delusions that include the concept that one’s mind or body is being controlled by a bizarre force from afar. The thought processes of the schizophrenic are usually concrete, loose, and irrational. Abnormalities of behavior consist of verbal idiosyncratic communication, including new words and persistent repetition of words and phrases. Behavioral disturbances range from the mildly eccentric to the bizarre, such as distorted posturing and repetitive patterns of moving. Perceptual abnormalities typically are auditory hallucinations. The schizophrenic affect is generally flat and often inappropriate. The ego function is disturbed in that reality testing is commonly impaired and interpersonal relations are almost always distorted. The course and prognosis of schizophrenia is variable, ranging from relative stability to multiple psychotic episodes with continuing and rapid deterioration in functioning. The development of neuroleptic medications in the early 1950s was a watershed in treatment. Pharmacotherapy enabled schizophrenics to function on a higher level without continually focusing on their internal world of hallucinations and delusions. Neuroleptics such as chlorpromazine and haloperidol were widely utilized during the 196Os, prompting state hospital administrators and psychiatrists to consider the option of discharging to the community schizophrenics who may have been hospitalized for decades. In 1965, the Community Mental Health Centers Act was funded by the Federal Government, and releasing medicated schizophrenics to the community began. During the next 15 years, previously institutionalized schizophrenics were discharged to aftercare fa-
607
cilities including group homes, relatives’ homes, as well as low cost hotels and boarding homes. Community mental health centers opened around the country with the mandated purpose of providing outpatient biopsychosocial management and resocialization services with group day treatment therapy for these deinstitutionalized schizophrenic patients. While neuroleptic medications often do positively impact hallucinations and delusions, they generally have little effect on improving insight or judgment, or on the negative symptoms of schizophrenia such as poor planning, hygiene, and volition. Partially due to poor judgement, planning, and decision-making, these community-dwelling schizophrenics often did not maintain their living arrangements or seek outpatient treatment at the community health centers, despite social workers who actively promoted outreach services in neighborhoods. In addition, they were victims of crime, and acquaintances often misused their monetary resources. An additional factor that led to the relative failure of deinstitutionalization was the availability of illicit drugs in the culture. The combination of these factors, including lack of stable living situations, misuse of funds, lack of medical followup, and drug use, resulted in a situation not unlike that of 200 years ago, when psychotic persons were living on the streets or incarcerated in asylums or jails (12,13). Partly due to the work of Bleuler in Europe and Meyer in the United States, a standard Diagnostic and Statistical Manual (DSM), which classified mental illness, was developed in 1952 as the DSM-I. After four further editions, it evolved into the DSM-IV, published in 1994. The diagnostic criteria for schizophrenia published in these manuals progressed from a rather simple reactive definition in DSM-I to a detailed descriptive disorder in DSM-IV (14). However, the availability of treatment for schizophrenics in the last two decadeshas not paralleled the clear advances in pharmacotherapy as well as day treatment and resocialization therapies. The treatment of schizophrenia has progressed from relatively effective residential care in state hospitals to less effective crisis intervention treatment in emergency departments, inpatient psychiatric units, and community mental health centers. Research data indicate that 20-40% of homeless people suffer from major mental illness, including schizophrenia. A recent governmental report estimates that 1 in 20 of the severely mentally ill experience homelessness ( 15). Empirical studies of state mental hospital constituents found that from 928% have been homeless (16-18). Homeless schizophrenic subjects were found to differ significantly from nonhomeless schizophrenic subjects in severity
M. J. Tueth
of symptoms, illicit substance abuse, and neuroleptic noncompliance ( 12,13). Two recent developments have significantly impacted the current management of schizophrenia. First, two antipsychotic medications were approved for use in schizophrenia: clozapine and respiridone. These agents are generally superior to neuroleptic medications for treatment of schizophrenia because they treat the positive symptoms for a larger percentage of schizophrenics and often decreasethe negative symptoms of schizophrenia, such as poor planning and grooming. While respiridone has a much safer side effect profile than the neuroleptic medications, clozapine can cause fatal reactions such as agranulocytosis and seizures. In addition, while respiridone has few serious side effects and is generally considered safe, clozapine can lead to significant morbidity from postural hypotension, sedation, tachycardia, and anticholinergic complications such as urinary retention and delirium. These newer antipsychotic medications, especially clozapine, require frequent monitoring in an outpatient setting and are quite expensive (19-26). Although these medications treat schizophrenia more successfully, it has been difficult to provide this treatment to many schizophrenic patients because of financial and follow-up obstacles. The second development that has recently impacted the treatment of schizophrenic patients is managed care. Health maintenance organizations (HMOs) in particular and the managed care movement in general have drawn criticism for possibly abandoning social objectives in favor of economic ones (27). Some HMOs have very limited chronic mental health coverage for conditions such as schizophrenia (28,29). Regardless, most managed care systems, in-
chiding HMOs with and without capitation, tend to emphasize cost containment and crisis intervention over expenditures for chronic mental illness (30-32). The reluctance of managed care systems to allocate chronic care funds for persons with schizophrenia may contribute to the over utilization of emergency services by these patients. The two effects of the newer antipsychotic agents on emergency department usage by schizophrenics tend to balance each other. Clozapine and respiridone usage should decrease the need for emergency care for schizophrenics by better stabilizing the condition. However, since the cost of clozapine and respiridone is very high and compliance with outpatient treatment is low, the overall effect on the rate of emergency care utilization may be negligible. Concerning managed care and schizophrenia, while some studies indicate no harmful effects of enrolling chronically mentally ill patients in prepaid care (33), most investigations indicate that the overall impact is fewer services for the chronically mentally ill (2729,31,32). Thus, the demand for emergency services for schizophrenic patients may have increased. The present state of schizophrenia in our society is not unlike conditions in the early 19th century; that is, many persons with schizophrenia are homeless and some are incarcerated in jails. A redirection in the approach to the management of the schizophrenic patient similar to the past contributions of Kraepelin and Meyer may be needed to move beyond the current state. Along with the expanded use of respiridone, possible new directions might be funding community outreach programs to provide intensive case management, and targeting money for each patient’s individual needs.
REFERENCES 1. Hare E. Schizophrenia as a recent disease. Br J Psychiatry. 1988;153:521-31. 2. Freedman AM, Kaplan HI, Sadock BJ. Modern synopsis of comprehensive textbook of psychiatry, 2nd ed. Baltimore: Williams and Wilkins Co.; 1976:418-23. 3. Tomlinson WK. Schizophrenia, history of an illness. Psychiatry Med. 1990;8:1-19. 4. Kraeplin E. Dementia praecox and paraphrenia. In: Robertson GM, Edinburgh ES, Livingstone, eds.; 1919:3-4. 5. Bleuler B. Dementia praecox or the group of schizophrenias. New York: International University Press; 1950. 6. Bleuler E. Primary and secondary symptoms in schizophrenia. Z Gen Neurol Psychiatry. 1930;124:607. 7. Kolb L, Vogel V. The use of shock therapy in 305 mental hospitals. Am J Psychiatry. 1942;99:90-100. 8. Ford ME. A history of lobotomy in the United States. The pharoes of Alpha Omega Alpha. 1987;50:7. 9. Kety SS, Rosenthal D, Wender PH, Schulsinger F. Mental illness in the biological and adoptive families of adoptive schizophrenics. Am J Psychiatry. 1971;128:302-6.
10. Berman KF, Torrey EF, Daniel DG, Weinberger DR. Regional cerebral blood flow in monozygotic twins discordant and concordant for schizophrenia. Arch Gen Psychiatry. 1992;49:92734. 11. Lewis G, David A, Andreasson, S, Allebeck P. Schizophrenia and city life. Lancet. 1992;340:137-40. 12. Caton CL, Scrout PU, Eagle PF, Opler LA, Felix A, Dominquez B. Risk factors for homelessnessamong schizophrenic men: A case-control study. Am J Public Health. 1994;84:26570. 13. Opler LA, Canton CL, Shrout P, Dominquez B, Kass FI. Symptom profiles and homelessnessin schizophrenia. J Nerv Ment Dis. 1994;182:174-8. 14. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC: American Psychiatric Association; 1994. 15. Federal Task Force on Homelessness and Severe Mental Illness. Outcasts on Main Street. Washington, DC: Interagency Council on the homeless; 1992:18. 16. Mowbray CT, Johnson US, Solar A. Homelessnessin a state
History of Schizophrenia hospital population. Hosp Community Psychiatry. 1987;38: 880-Z. 17. Drake RE, Wallach MA, Hoffman JS. Housing instability and homelessnessamong aftercare patients in an urban state hospital. Hosp Commumty Psychiatry. 1989;40:46-51. 18. SusserES, Lin SP. Conover SA. Risk factors for homelessness among patients admitted to a state mental hospital. Am J Psychiatry. 1991;148:1659-64. 19. Alvir JM, Lieberman JA, Safferman AZ, Schwimmer JL, Schaaf JA. Clozapine-induced agranutocytosis: incidence and risk factors in the United States. N Engl J Med. 1993;329:162-7. 20. Pickar D, Woen RR, Litman RE, Konichi PE, Gutierrez R, Rapaport MH. Chnical and biologic responseto clozapine in patients with schiaophrf&a. Arch Gen Psychiatry. 1992;49:345-53. 21. Meltzer HY, Cola P, Way L, et al. Cost effectiveness of clozapine in neuroleptic-resistant schizophrenia. Am J Psychiatry. 1993;150:1630-8. 22. Safferman A, Lieberman JA, Kane JM, Szymanski S, Kinon B. Update on the clinical efficacy and side effects of clozapine. Schizophrenia Bull. 1991;17:247-61. 23. Breier A, Buchanan RW, Kirkpatrick B, et al. Effects of clorapine on positive and negative symptoms in outpatients with schizophrenia. Am J Psychiatry. 1994;151:20-6. 24. Marder SR, Meibach RC. Respiridone in the treatment of schizophrenia. Am J Psychiatry. 1994;151:825-35.
809 25. Schooler NR. Negative symptoms in schizophrenia: assessment of the effect of respiridone. J Clin Psychiatry. 1994; 55(5,Suppl):22-8. 26. McEvoy JP. Efficacy of respiridone on positive features of schizophrenia. J Clin Psychiatry. 1994,55(suppl J):l&21. 27. Dorwart RA. Managed mental heahh care: myths and realities in the 1990s. Hosp Community Psychiatry. 1990;41: 1087-91. 28. Brady J, Krizay J. Utilization and coverage of mental health services and health maintenance organizations. Am J Psychiatry. 1985;142:744-6. 29. Fishel L, Janzen C, Bemak F, Ryan M, McIntyre F. A preliminary study of recidivism under managed mental health care. Hosp Community Psychiatry. 1993;44:919-20. 30. Reed SK, Hennessy K, Brown SW, Fray J. Capitation from a provider’s perspective. Hosp Community Psychiatry. 1992;43: 1173-5. 31. Brady J, Krizay J. Utilization and coverage of mental health services and health maintenance organizations. Am J Psychiatry. 1985;142:744-6. 32. Norquist GS, Wells KB. How do HMOs reduce outpatient mental health care costs? Am J Psychiatry. 1991;148:96-101. 33. Lurie N, Moscovice IS, Finch M, Christianson JB, Popkin MK. Does capitation effect the health of the chronically mentally ill? JAMA. 1992;267:3300-4.
+
.OO
0736-4679(95)02022-F
Medical Classics
SCHIZOPHRENIA: EMIL KRAEPELIN, ADOLPH MEYER, AND BEYOND Michael J. Tueth,
MD
Department of Psychiatry, University of Florida College of Medicine, Gainesville, Florida Reprint Address: Michael J. Tueth, MD, Assistant Professor in Psychiatry, University of Florida College of Medicine, VA Medical Center, 1601 SW Archer Road, Gainesville, FL 32606
0 Abstract-Prior to 1800, insane persons often lived on the streets or were incarcerated in asylums, jails, or prisons. The 19th century witnessed progression in the anderstanding of psychosis, and the hospital management of psychotic patients began. While Kraepelin in Europe described the symptoms of what would later be called schizophrenia, Meyer developed humanistic treatment for the illnessin the United States. The early 20th century treatments for schizophrenia included insulin coma, metrazol shock, electro-convulsive therapy, and frontal leukotomy. Neuroleptic medications were first used in the early 1950s. Deinstitutionalization, beginning in the 196Os, resulted in medicated, stable schizophrenics being released from state hospitals. However, lack of stable living arrangements, misuse of funds, poor medical follow-up, and drug use resulted in deterioration of a large segment of this outpatient schizophrenic population. The 1990s have seen the development of newer, more effective antipsychotic agents and managed care. Both have impacted the state of health of schizophrenics in our society.
diseasecould explain why descriptions of schizophrenia-like disorders were rare before 1800 (1). While mentally retarded and insane persons were often contained in prisons or asylums prior to 1800, attempts to treat insanity began approximately 200 years ago. Treatment often consisted of twirling the patient on a stool until loss of consciousness occurred, or dropping the person into an icy lake. Humane and compassionate treatment for psychotic patients began in the United States during the middle of the 19th century (2). Efforts to understand the nature of insanity began in the middle of the 18th century, when Morel introduced the term dementia praecox to describe a mental disorder of degeneracy beginning in puberty. Prior to that time, the conditions of congenital insanity, dementia, mania, melancholia, and common madness were not differentiated. Later, in 1871, Hecker published an article on “hebephrenia” and, in 1874, Kahlbaum described a patient suffering from “catatonia.” These conditions described by Morel, Kahlbaum, and Hecker each described a psychotic illness having its onset in puberty and following a course of progressive deterioration (2). In the late 18th century, Emil Kraepelin observed that dementia praecox, previously described by Morel, was identical to the conditions of hebephrenia and catatonia identified by Hecker and Kahlbaum. In 1896, Kraepelin distinguished dementia praecox, which ultimately ends in functional decline, from
0 Keywords- schizophrenia, insan&; psychosis; dementia praecox
HISTORY
1800-1951
Over the past 3000 years, writers have commented about persons showing irrational behavior or seen as insane, but few clear descriptions of behavior resembling modern day schizophrenia were recorded prior to 1800. The hypothesis that schizophrenia is a recent
Medical Classics is coordinated by George Sternbach, MD, of Stanford University Medical Center, Stanford, California RECEIVED: 19 Se tember 1994; FINAL SUBMISSIONRECEIVED: 11 January 1995; ACCEPTED: 8 Fe&ruary 1995
805
M. J. Tueth
manic-depressive psychosis, which does not usually end in any significant decline. In 1898, he unified all primary and secondary “dementias” into one mental disease characterized by the lack of external causes, by occurrence usually in young and previously healthy persons, and most important, by ultimate deterioration (2). In 1919, Kreapelin wrote:
All mental activity must have it’s physiological side and it’s anatomical substratumin the form of nervous mechanisms,especiallyof the cerebralcortex. Schizophreniais a crowding out of normal reactions and a substitution of inferior reactions, some of which determine the cleavagealong distinctly psychobiologicallines incompatible with reintegration (3).
I got the starting point of the line of thought which in 1896lead to dementiapraecoxto be regardedas a distinct disease,on the one hand, from the impression of the states of dementia being quite similar to each other. On the other hand, these particular dementiasseemto stand in relation to the period of youth. The name dementia praecox consistedof a seriesof states,the common characteristicof which is a particular destructionof the internal connections of the psychicpersonality. The effectsof this injury predominatein the emotional and volitional spheres of mental life (4).
Meyer expanded on Bleuler’s optimistic outlook for schizophrenia. He viewed mental illness as a reaction to lifelong habits and conflicts leading to mental breakdown. He felt that schizophrenia was the natural result of a life history that could be clearly traced to various physical, social, and psychological factors in the patient’s past. While Kraepelin viewed schizophrenia as a fixed psychological condition with a progressive degenerative prognosis, Meyer stressed psychological and environmental factors in addition to biological causesand maintained a positive prognosis for the illness. Both approaches, however, shared the identical view that at the root of schizophrenia was a biological illness and that there were hereditary determinates (3). Due partially to the influence of Adolph Meyer, American psychiatrists developed a humanistic treatment approach to psychotic persons that resembles today’s milieu and social therapies. However, with the development of large state mental hospitals, a client-centered personal approach drifted away to be replaced by mechanistic institutional care. The early 20th century ushered in various somatic treatments for schizophrenia. Included among the early treatments were prolonged narcosis using barbiturates, insulin coma, metrazol shock, electro-convulsive therapy, and frontal leukotomy. Prolonged narcosis and insulin coma were largely ineffective treatments for schizophrenia. Seizure induction by using intramuscular camphor in oil and intravenous metrazol developed by Ladislous Meduna in Hungary were more effective. Seizure induction using metrazol won approval as an effective treatment for schizophrenia in 1935. In 1938, however, the induction of seizures using medication was permanently replaced with electricity, termed electro-convulsive therapy, pioneered by Cerletti in 1938 for the treatment of schizophrenia (7). The last experimental therapy for schizophrenia was psychosurgery, frontal leukotomy, developed principally in the 1940s. The technique was quickly popularized in the United States by Walter Freeman and became widely used in the treatment of schizophrenia (3,8). Fortunately, psychosurgery was relatively short-lived due to the development of modern treatment for schizophrenia, pharmacotherapy, in the early 1950s.
Essentially, Kraepelin distinguished mental disorders due to nonorganic causes from the traditional physical causes for insanity, as well as the disease of schizophrenia from manic depressive psychosis. According to data from the Board of Control, the average yearly number of direct admissions to all lunatics asylums in England and Wales for the years 1909-l 3 consisted of 69% functional disorders (1). In 1911, Eugene Bleuler introduced the new term schizophrenia for dementia praecox. Translated literally, schizophrenia means split-mindedness, and Bleuler saw the splitting of the personality as the central feature of the disease. Another of Bleuler’s fundamental contributions was the introduction of a hierarchy of symptoms for schizophrenia (2). However, Bleuler, as opposed to Kraepelin, maintained an optimistic prognostic view for schizophrenia. His support for therapy of this condition reflected his appreciation of the psychological and environmental factors at play in the illness (3,5,6). By the middle of the 19th century, the management of insane persons had progressed from incarceration in prisons and asylums to care in hospitals. Although the treatment was primitive and sometimes abusive, psychotic persons were viewed more as sick than as demon-possessedor evil. While Morel, Hecker, Kraepelin, and Bleuler were European physicians, Adolph Meyer’s views on schizophrenia in the United States proved increasingly influential. Although born and medically educated in Switzerland, Meyer immigrated to the United States in 1892. His influence in this country was enormous and he is generally acknowledged to be the “Dean of American Psychiatry” (2). Meyer maintained that:
History of Schizophrenia
HISTORY, l!MMWESENT AND COMMENTARY Schizophrenia occurs in 1% of the population and is believed to be a genetically transmitted illness with variable penetrance (9). First-degree biologic relatives of individuals with schizophrenia have a risk for the diseasethat is about 10 times greater than that of the general population. However, children adopted by schizophrenic families have no increased risk for schizophrenia. Environmental factors probably play a significant role in the development of schizophrenia since only 50”10of monozygotic twins are concordant for the disease,and environmental factors seemto increasethe risk for developing schizophrenia (10,ll). The clinical features of schizophrenia encompass symptoms in multiple areas including thought content, thought process, behavior, perception, affect, and ego functioning. Characteristically, the thoughtcontent abnormalities are bizarre delusions that include the concept that one’s mind or body is being controlled by a bizarre force from afar. The thought processes of the schizophrenic are usually concrete, loose, and irrational. Abnormalities of behavior consist of verbal idiosyncratic communication, including new words and persistent repetition of words and phrases. Behavioral disturbances range from the mildly eccentric to the bizarre, such as distorted posturing and repetitive patterns of moving. Perceptual abnormalities typically are auditory hallucinations. The schizophrenic affect is generally flat and often inappropriate. The ego function is disturbed in that reality testing is commonly impaired and interpersonal relations are almost always distorted. The course and prognosis of schizophrenia is variable, ranging from relative stability to multiple psychotic episodes with continuing and rapid deterioration in functioning. The development of neuroleptic medications in the early 1950s was a watershed in treatment. Pharmacotherapy enabled schizophrenics to function on a higher level without continually focusing on their internal world of hallucinations and delusions. Neuroleptics such as chlorpromazine and haloperidol were widely utilized during the 196Os, prompting state hospital administrators and psychiatrists to consider the option of discharging to the community schizophrenics who may have been hospitalized for decades. In 1965, the Community Mental Health Centers Act was funded by the Federal Government, and releasing medicated schizophrenics to the community began. During the next 15 years, previously institutionalized schizophrenics were discharged to aftercare fa-
607
cilities including group homes, relatives’ homes, as well as low cost hotels and boarding homes. Community mental health centers opened around the country with the mandated purpose of providing outpatient biopsychosocial management and resocialization services with group day treatment therapy for these deinstitutionalized schizophrenic patients. While neuroleptic medications often do positively impact hallucinations and delusions, they generally have little effect on improving insight or judgment, or on the negative symptoms of schizophrenia such as poor planning, hygiene, and volition. Partially due to poor judgement, planning, and decision-making, these community-dwelling schizophrenics often did not maintain their living arrangements or seek outpatient treatment at the community health centers, despite social workers who actively promoted outreach services in neighborhoods. In addition, they were victims of crime, and acquaintances often misused their monetary resources. An additional factor that led to the relative failure of deinstitutionalization was the availability of illicit drugs in the culture. The combination of these factors, including lack of stable living situations, misuse of funds, lack of medical followup, and drug use, resulted in a situation not unlike that of 200 years ago, when psychotic persons were living on the streets or incarcerated in asylums or jails (12,13). Partly due to the work of Bleuler in Europe and Meyer in the United States, a standard Diagnostic and Statistical Manual (DSM), which classified mental illness, was developed in 1952 as the DSM-I. After four further editions, it evolved into the DSM-IV, published in 1994. The diagnostic criteria for schizophrenia published in these manuals progressed from a rather simple reactive definition in DSM-I to a detailed descriptive disorder in DSM-IV (14). However, the availability of treatment for schizophrenics in the last two decadeshas not paralleled the clear advances in pharmacotherapy as well as day treatment and resocialization therapies. The treatment of schizophrenia has progressed from relatively effective residential care in state hospitals to less effective crisis intervention treatment in emergency departments, inpatient psychiatric units, and community mental health centers. Research data indicate that 20-40% of homeless people suffer from major mental illness, including schizophrenia. A recent governmental report estimates that 1 in 20 of the severely mentally ill experience homelessness ( 15). Empirical studies of state mental hospital constituents found that from 928% have been homeless (16-18). Homeless schizophrenic subjects were found to differ significantly from nonhomeless schizophrenic subjects in severity
M. J. Tueth
of symptoms, illicit substance abuse, and neuroleptic noncompliance ( 12,13). Two recent developments have significantly impacted the current management of schizophrenia. First, two antipsychotic medications were approved for use in schizophrenia: clozapine and respiridone. These agents are generally superior to neuroleptic medications for treatment of schizophrenia because they treat the positive symptoms for a larger percentage of schizophrenics and often decreasethe negative symptoms of schizophrenia, such as poor planning and grooming. While respiridone has a much safer side effect profile than the neuroleptic medications, clozapine can cause fatal reactions such as agranulocytosis and seizures. In addition, while respiridone has few serious side effects and is generally considered safe, clozapine can lead to significant morbidity from postural hypotension, sedation, tachycardia, and anticholinergic complications such as urinary retention and delirium. These newer antipsychotic medications, especially clozapine, require frequent monitoring in an outpatient setting and are quite expensive (19-26). Although these medications treat schizophrenia more successfully, it has been difficult to provide this treatment to many schizophrenic patients because of financial and follow-up obstacles. The second development that has recently impacted the treatment of schizophrenic patients is managed care. Health maintenance organizations (HMOs) in particular and the managed care movement in general have drawn criticism for possibly abandoning social objectives in favor of economic ones (27). Some HMOs have very limited chronic mental health coverage for conditions such as schizophrenia (28,29). Regardless, most managed care systems, in-
chiding HMOs with and without capitation, tend to emphasize cost containment and crisis intervention over expenditures for chronic mental illness (30-32). The reluctance of managed care systems to allocate chronic care funds for persons with schizophrenia may contribute to the over utilization of emergency services by these patients. The two effects of the newer antipsychotic agents on emergency department usage by schizophrenics tend to balance each other. Clozapine and respiridone usage should decrease the need for emergency care for schizophrenics by better stabilizing the condition. However, since the cost of clozapine and respiridone is very high and compliance with outpatient treatment is low, the overall effect on the rate of emergency care utilization may be negligible. Concerning managed care and schizophrenia, while some studies indicate no harmful effects of enrolling chronically mentally ill patients in prepaid care (33), most investigations indicate that the overall impact is fewer services for the chronically mentally ill (2729,31,32). Thus, the demand for emergency services for schizophrenic patients may have increased. The present state of schizophrenia in our society is not unlike conditions in the early 19th century; that is, many persons with schizophrenia are homeless and some are incarcerated in jails. A redirection in the approach to the management of the schizophrenic patient similar to the past contributions of Kraepelin and Meyer may be needed to move beyond the current state. Along with the expanded use of respiridone, possible new directions might be funding community outreach programs to provide intensive case management, and targeting money for each patient’s individual needs.
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