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Some reflections on the psychiatric illness schizophrenia
J. chron. Dis. 1964,
Vol. 17, pp. 641443. PergamonPress Ltd. Printed in Great Britain
LETTER TO THE EDITOR
SOME REFLECTIONS
ON THE PSYCHIATRIC
ILLNESS SCHIZOPHRENIA
IN A general way, duration of illness on hospital admission has always been known to have prognostic significance. This tends to be true of all illnesses irrespective of diagnosis. The patient who has been ill continuously for many years is universally considered a poorer risk for therapy than the patient with disease of fresh onset. Furthermore, illnesses which can become chronic, such as certain diseases of the heart or forms of arthritis, generally are accepted by both the patient and physician as conditions which may necessitate hospitalization from time to time. They are seen as illnesses which can exacerbate and remit. Typically, in many of these chronic illnesses, medical specialists concede that there is no specific or definitive treatment yet available which will yield a cure. Distressing though this may be to those afflicted and to their families as well as to society in general, there has been a tendency for this reality to be universally accepted. In respect of schizophrenia, however, a psychiatric illness which also can become chronic, rarely is there such acceptance. Not only is the schizophrenic patient virtually never told that he suffers from a potentially chronic disease which may recur from time to time necessitating hospitalization, but his family and the general community are similarly left in ignorance. Indeed, despite overwhelming evidence that the illness is qualitatively different from most illnesses, frequently becomes chronic and appears to be essentially unresponsive over the long run to present medical techniques*, the mental hygiene movement in this country continues to suggest mental illness is like any other illness, and the possibility of cure is strongly implied, especially if the patient is sped into therapy at the earliest sign of illness. In marked contrast to the view that mental illness is like any other illness is the observation from the Final Report of the Joint Commission for Mental Health [l] that the psychotic may at times behave in a way antagonistic to our natural sympathetic feelings. When such behaviour has elements of hostility along with a complete lack of insight, empathy on our part becomes difficult. In short, mental illness at times can be distinctly unlike mos& other illnesses. While it seems likely that medically neglected schizophrenia could result in serious consequences (e.g. suicide) which hospitalization might prevent, there is no evidence that present-day treatments shorten the duration of an episode, prevent a subsequent *Several large-scale studies have recently reported comparable readmission rates of the mentally ill throughout the country following hospital discharge (FREEMANand SIMMONSwith 649 patients [2]; SHERMAN,MOSELEY,GING and B~~KNNDER with 590 patients 131; VA Psychiatric Evaluation Project (PEP) with 1142 patients [4]. The PEP and FREEMANand SIMMONSstudies report that approximately 40 per cent of all discharged patients are readmitted one or more times in the fkst year following discharge. The cumulative readmission rates over longer follow-up periods ranging up to a full 3 years following discharge are approximately 67 per cent [3, 41. Clearly, recurrence or exacerbation of the illness can not be considered rare or exceptional. 641
642
Letter to the Editor
relapse, or arrest a chronic schizophrenic condition. Because of the erratic course of the disease, early hospitalization can appear to have a beneficial effect which may be completely spurious. For example, among patients hospitalized close to onset, it is very likely that a greater proportion of episodic types would be found than among a group of chronically ill patients hospitalized after a long period of illness at home. No doubt daily readings from a book of astrology would ‘result’ in more remissions in the former group than in the latter. As reported by LINN [5] and noted in Psychiatric Evaluation Project subsamples [6, 71, duration of illness on hospital admission appears to be predictive of recovery. Symptom recovery, on the other hand, does not seem to be related to treatment received [8-lo]. Early hospitalization per se, therefore, may be totally irrelevant to the rapidity of change in clinical status. Despite statements to the effect that there is no cure for schizophrenia, many mental health specialists operate as though they can materially alter the course of the illness given full cooperation and optimum conditions. Typically, in such cases the schizophrenic patient and his family initially have great hopes that a first episode of the illness will be followed by permanent remission. When this proves not to be the case, as so frequently happens, both patient and family (to say nothing of the professional staff concerned) feel that they have failed in some way. After a subsequent episode, there is renewed conviction that stow a permanent remission lies ahead. Later relapses, however, all too often occur and cause double anguish. In addition to the unavoidable suffering directly related to the illness, there are gratuitous feelings of personal failure and guilt stimulated by our practice of handling each hospitalization as a separate entity rather than as an incident in the course of a chronic disease. Before the patient and the general public can be reasonably well informed about the facts of mental illness, however, there obviously must be better agreement among mental health specialists themselves as to what the facts are. The vastly disparate views held by the experts ranging from the notion that schizophrenia is merely role playing [ 1l] through the belief that it is preferably treated by one who behaves in a psychotic-like fashion himself [12] to a conviction that the illness has unmistakable genetic aspects [ 131suggest that the field is in serious disarray. Hopefully, an accumulation of a number of carefully recorded observations based on sizable samples of patients studied over substantial time periods and reported in a fashion consistent with scientific standards would soon offset the flamboyant and spectacular but ill-supported theories and speculations which have led to the gross dissensions currently found among mental health specialists. When a high-staff, dynamically-oriented federal hospital is contrasted with a lowstaff, custodially-oriented state hospital and similar rehospitalization rates are found [2], it suggests that the time may have arrived for a revolutionary reappraisal of some long cherished clinical hypotheses. The monotonously high rates of hospital return reported in the broadly designed and reasonably well executed surveys previously mentioned may give pause to those who ignore or minimize the biogenetic aspects of mental illness. To paraphrase MEEHL [14], it is somewhat ironic but undeniable that psychologists, along with other non-medically trained mental health specialists, are making major contributions to the point of view that, while its content may be learned, schizophrenia appears to be fundamentally a neurological disease of genetic origin. So long as the detailed etiology of schizophrenia remains obscure, however, perhaps
Letter to
the Editor
643
the best approach to the illness is a conservative one, both from the medical and logical points of view. The least interference with naturally occurring remissions may well be the best medical technique against which to compare experimental approaches. Psychological procedures viewed as ancillary to a medical approach to the illness would certainly not be inappropriate. If only a ‘Hawthorne’ effect were introduced, it could be considered beneficial. Furthermore, quite independently of purely psychiatric or psychological matters, there is merit in treating any human being with dignity and kindness irrespective of his diagnostic label or clinical condition at the moment. However, the assumption that because no gross physical abnormality or processes have been discovered which unequivocally account for schizophrenic symptoms, the deviant behavior must be psychogenic in origin not only is a 12011 sequitur but seems increasingly hard to justify in the light of recent evidence. In any case, because the illness sometimes takes an episodic course with remissions lasting for various periods of time while in other instances runs a more continuous course, appropriate steps have to be taken in studying the illness to avoid misleading findings. For meaningful comparisons of the relative effectiveness of different treatment procedures, the employment of control groups and/or adequate follow-up would seem to be mandatory. ROBERT WALKER, Ph.D.
Research Psychologist, Veterans Administration Hospital, Brockton, Massachusetts.
REFERENCES
I . Joint Commission for Mental Illness and Health, Final Report. Basic Books, New York, 1961. 2. FREEMAN,H. E. and SIMMONS,0. G.: The MentalPatient Comes Home. Wiley, New York, 1963. 3. SHERMAN,L. J., MOSELEY,E. C., GING, R. J. and BOOKBINDER, L. J.: The acute schizophrenic. three years later. Paper read at the Eighth Annual Conference of the VA Cooperative Studies in Psychiatry, Kansas City, Missouri, 26 March 1963. 4. VA PSYCHIATRICEVALUATIONPROJECT: Release and Community Stay Criteria in Evaluating Psychiatric Treatment. Intramural Report 63-3, Washington, D.C., 1963. 5. UNN, E. L. : The relation of chronicity in the functional psychoses to prognosis, J. nerv. mat. Dis. 5, 460, 1962. 6. WALKER,R. G. and KELLEY,F. E. : Predicting the outcome of a schizophrenic episode, Arch. gen. Psychiat. 2,492,1960. 7. WALKER,R. G., WILLIAMS,R. A. and KELLEY,F. E.: An evaluation of maintenance medication in the post-hospital adjustment of 66 schizophrenic patients, J. clin. exp. Psychopath. 21, 304, 1960. 8. ELLSWORTH,R. B. and CLAYTON,W. H. : The effects of chemotherapy on length of stay and rate of return for psychiatrically hospitalized patients, J. consult. PsychoL 24,50,1960. 9. JENKINS,R. L. and GURJZ, L. : Predictive factors in early release, Ment. Hosp. 10,11, 1959. 10. WALKER, R. G. and KELLEY, F. E.: Shortterm psychotherapy with schizophrenic patients evaluated over a three-year follow-up period, J. nerv. ment. Dis. 137, 349, 1963. 11. SZASZ, T. S. : The myth of mental illness, Amer. Psychol. 15,113, 1960. 12. ROSEN,J. N.: Direct Analysis. Grune & Stratton, New York, 1953. 13. KALLMANN,F. J.: Expanding Goals of Genetics in Psychiatry. Grune & Stratton, New York. 1962. 14. MEEHL, P. : Schizotaxia, schizotypy, schizophrenia, Amer. Psychol. 17, 827, 1962.
Vol. 17, pp. 641443. PergamonPress Ltd. Printed in Great Britain
LETTER TO THE EDITOR
SOME REFLECTIONS
ON THE PSYCHIATRIC
ILLNESS SCHIZOPHRENIA
IN A general way, duration of illness on hospital admission has always been known to have prognostic significance. This tends to be true of all illnesses irrespective of diagnosis. The patient who has been ill continuously for many years is universally considered a poorer risk for therapy than the patient with disease of fresh onset. Furthermore, illnesses which can become chronic, such as certain diseases of the heart or forms of arthritis, generally are accepted by both the patient and physician as conditions which may necessitate hospitalization from time to time. They are seen as illnesses which can exacerbate and remit. Typically, in many of these chronic illnesses, medical specialists concede that there is no specific or definitive treatment yet available which will yield a cure. Distressing though this may be to those afflicted and to their families as well as to society in general, there has been a tendency for this reality to be universally accepted. In respect of schizophrenia, however, a psychiatric illness which also can become chronic, rarely is there such acceptance. Not only is the schizophrenic patient virtually never told that he suffers from a potentially chronic disease which may recur from time to time necessitating hospitalization, but his family and the general community are similarly left in ignorance. Indeed, despite overwhelming evidence that the illness is qualitatively different from most illnesses, frequently becomes chronic and appears to be essentially unresponsive over the long run to present medical techniques*, the mental hygiene movement in this country continues to suggest mental illness is like any other illness, and the possibility of cure is strongly implied, especially if the patient is sped into therapy at the earliest sign of illness. In marked contrast to the view that mental illness is like any other illness is the observation from the Final Report of the Joint Commission for Mental Health [l] that the psychotic may at times behave in a way antagonistic to our natural sympathetic feelings. When such behaviour has elements of hostility along with a complete lack of insight, empathy on our part becomes difficult. In short, mental illness at times can be distinctly unlike mos& other illnesses. While it seems likely that medically neglected schizophrenia could result in serious consequences (e.g. suicide) which hospitalization might prevent, there is no evidence that present-day treatments shorten the duration of an episode, prevent a subsequent *Several large-scale studies have recently reported comparable readmission rates of the mentally ill throughout the country following hospital discharge (FREEMANand SIMMONSwith 649 patients [2]; SHERMAN,MOSELEY,GING and B~~KNNDER with 590 patients 131; VA Psychiatric Evaluation Project (PEP) with 1142 patients [4]. The PEP and FREEMANand SIMMONSstudies report that approximately 40 per cent of all discharged patients are readmitted one or more times in the fkst year following discharge. The cumulative readmission rates over longer follow-up periods ranging up to a full 3 years following discharge are approximately 67 per cent [3, 41. Clearly, recurrence or exacerbation of the illness can not be considered rare or exceptional. 641
642
Letter to the Editor
relapse, or arrest a chronic schizophrenic condition. Because of the erratic course of the disease, early hospitalization can appear to have a beneficial effect which may be completely spurious. For example, among patients hospitalized close to onset, it is very likely that a greater proportion of episodic types would be found than among a group of chronically ill patients hospitalized after a long period of illness at home. No doubt daily readings from a book of astrology would ‘result’ in more remissions in the former group than in the latter. As reported by LINN [5] and noted in Psychiatric Evaluation Project subsamples [6, 71, duration of illness on hospital admission appears to be predictive of recovery. Symptom recovery, on the other hand, does not seem to be related to treatment received [8-lo]. Early hospitalization per se, therefore, may be totally irrelevant to the rapidity of change in clinical status. Despite statements to the effect that there is no cure for schizophrenia, many mental health specialists operate as though they can materially alter the course of the illness given full cooperation and optimum conditions. Typically, in such cases the schizophrenic patient and his family initially have great hopes that a first episode of the illness will be followed by permanent remission. When this proves not to be the case, as so frequently happens, both patient and family (to say nothing of the professional staff concerned) feel that they have failed in some way. After a subsequent episode, there is renewed conviction that stow a permanent remission lies ahead. Later relapses, however, all too often occur and cause double anguish. In addition to the unavoidable suffering directly related to the illness, there are gratuitous feelings of personal failure and guilt stimulated by our practice of handling each hospitalization as a separate entity rather than as an incident in the course of a chronic disease. Before the patient and the general public can be reasonably well informed about the facts of mental illness, however, there obviously must be better agreement among mental health specialists themselves as to what the facts are. The vastly disparate views held by the experts ranging from the notion that schizophrenia is merely role playing [ 1l] through the belief that it is preferably treated by one who behaves in a psychotic-like fashion himself [12] to a conviction that the illness has unmistakable genetic aspects [ 131suggest that the field is in serious disarray. Hopefully, an accumulation of a number of carefully recorded observations based on sizable samples of patients studied over substantial time periods and reported in a fashion consistent with scientific standards would soon offset the flamboyant and spectacular but ill-supported theories and speculations which have led to the gross dissensions currently found among mental health specialists. When a high-staff, dynamically-oriented federal hospital is contrasted with a lowstaff, custodially-oriented state hospital and similar rehospitalization rates are found [2], it suggests that the time may have arrived for a revolutionary reappraisal of some long cherished clinical hypotheses. The monotonously high rates of hospital return reported in the broadly designed and reasonably well executed surveys previously mentioned may give pause to those who ignore or minimize the biogenetic aspects of mental illness. To paraphrase MEEHL [14], it is somewhat ironic but undeniable that psychologists, along with other non-medically trained mental health specialists, are making major contributions to the point of view that, while its content may be learned, schizophrenia appears to be fundamentally a neurological disease of genetic origin. So long as the detailed etiology of schizophrenia remains obscure, however, perhaps
Letter to
the Editor
643
the best approach to the illness is a conservative one, both from the medical and logical points of view. The least interference with naturally occurring remissions may well be the best medical technique against which to compare experimental approaches. Psychological procedures viewed as ancillary to a medical approach to the illness would certainly not be inappropriate. If only a ‘Hawthorne’ effect were introduced, it could be considered beneficial. Furthermore, quite independently of purely psychiatric or psychological matters, there is merit in treating any human being with dignity and kindness irrespective of his diagnostic label or clinical condition at the moment. However, the assumption that because no gross physical abnormality or processes have been discovered which unequivocally account for schizophrenic symptoms, the deviant behavior must be psychogenic in origin not only is a 12011 sequitur but seems increasingly hard to justify in the light of recent evidence. In any case, because the illness sometimes takes an episodic course with remissions lasting for various periods of time while in other instances runs a more continuous course, appropriate steps have to be taken in studying the illness to avoid misleading findings. For meaningful comparisons of the relative effectiveness of different treatment procedures, the employment of control groups and/or adequate follow-up would seem to be mandatory. ROBERT WALKER, Ph.D.
Research Psychologist, Veterans Administration Hospital, Brockton, Massachusetts.
REFERENCES
I . Joint Commission for Mental Illness and Health, Final Report. Basic Books, New York, 1961. 2. FREEMAN,H. E. and SIMMONS,0. G.: The MentalPatient Comes Home. Wiley, New York, 1963. 3. SHERMAN,L. J., MOSELEY,E. C., GING, R. J. and BOOKBINDER, L. J.: The acute schizophrenic. three years later. Paper read at the Eighth Annual Conference of the VA Cooperative Studies in Psychiatry, Kansas City, Missouri, 26 March 1963. 4. VA PSYCHIATRICEVALUATIONPROJECT: Release and Community Stay Criteria in Evaluating Psychiatric Treatment. Intramural Report 63-3, Washington, D.C., 1963. 5. UNN, E. L. : The relation of chronicity in the functional psychoses to prognosis, J. nerv. mat. Dis. 5, 460, 1962. 6. WALKER,R. G. and KELLEY,F. E. : Predicting the outcome of a schizophrenic episode, Arch. gen. Psychiat. 2,492,1960. 7. WALKER,R. G., WILLIAMS,R. A. and KELLEY,F. E.: An evaluation of maintenance medication in the post-hospital adjustment of 66 schizophrenic patients, J. clin. exp. Psychopath. 21, 304, 1960. 8. ELLSWORTH,R. B. and CLAYTON,W. H. : The effects of chemotherapy on length of stay and rate of return for psychiatrically hospitalized patients, J. consult. PsychoL 24,50,1960. 9. JENKINS,R. L. and GURJZ, L. : Predictive factors in early release, Ment. Hosp. 10,11, 1959. 10. WALKER, R. G. and KELLEY, F. E.: Shortterm psychotherapy with schizophrenic patients evaluated over a three-year follow-up period, J. nerv. ment. Dis. 137, 349, 1963. 11. SZASZ, T. S. : The myth of mental illness, Amer. Psychol. 15,113, 1960. 12. ROSEN,J. N.: Direct Analysis. Grune & Stratton, New York, 1953. 13. KALLMANN,F. J.: Expanding Goals of Genetics in Psychiatry. Grune & Stratton, New York. 1962. 14. MEEHL, P. : Schizotaxia, schizotypy, schizophrenia, Amer. Psychol. 17, 827, 1962.