May 2010

Schizophrenia is a fascinating set of phenomena, the study of which has launched a thousand ships including, arguably, my field, family therapy; many of the original family therapists left psychiatry to study schizophrenia (or, as the DSM would have me write it, Schizophrenia–capitalizing words gives them more authority, don’t you think?) as an interactive process. That is, if all behaviors make sense in their context, what context might make schizophrenic behavior necessary?

There was an almost violent backlash against this line of thinking, as it seemed to (and did, in many cases) blame mothers for their schizophrenic children–as in the unfortunate phrase “schizophrenogenic mother.” The conventional wisdom about schizophrenia these days reads like a pharmaceutical company press release, something like, “Schizophrenia is a biological disease of the brain which is at present incurable, but there are drugs which can help manage the symptoms, and if taken regularly can provide a decent quality of life.”

So schizophrenia is assumed to be a biological disease of the brain though it, like every other Mental Disorder, has no laboratory test that can detect its presence. The best we can do is a set of behavioral diagnostic criteria which, frankly, are a bit of a mess. You may notice as you read that different flavors of schizophrenia may have nothing or little in common with each other. Are they really the same “disease”? We don’t know.

We do have good evidence that you can inherit, in some fashion, a tendency for one of these constellations of behaviors. There is good evidence that environmental factors are also important, though they are not a big part of the mainstream discussion. We also have evidence that therapy helps in a lot of cases. There is some (hotly contested, I’m sure) evidence from the World Health Organization that unmedicated schizophrenics can eventually recover while those on medication do not. Here is a trailer for a moving documentary about two recovered women and the public perception of schizophrenia, called Take These Broken Wings. Also, consider checking out the documentary A Brilliant Madness, about John Nash, in which puts the lie to A Brilliant Mind, which showed Nash recovering with the help of psychopharmaceuticals.

The DSM says that schizophrenia may be overdiagnosed (or at least is diagnosed more often) in African- and Asian-American men, that it affects men differently than women (men tend towards the negative symptoms were women tend towards delusions and hallucinations), and that incidence rates are something like .5-1.5% of adults.

Here are a few terms that you’ll need to know to get through the criteria:

affective flattening: does not show emotion. Also, “affect” means “emotion” to scientists and people who like to talk like scientists.

alogia: lack of speech.

avolition: lack of motivation.

prodromal: symptoms coming early on in the course of a disease.

echolalia: repetition of others’ speech sounds.

echopraxia: repetition of others’ movements

And here are the diagnostic criteria, word-for-word, from the DSM-IV-TR, pp. 312-319:

Diagnostic criteria for Schizophrenia

A. Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated):

(1) delusions

(2) hallucinations

(3) disorganized speech (e.g. frequent derailment or incoherence)

(4) grossly disorganized or catatonic behavior

(5) negative symptoms, i.e., affective flattening, alogia, or avolition

Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts, or two or more voices conversing with each other.

B. Social/occupational dysfunction: For a significatn portion of the time since th onset of the distrubance, one or more major areas of functioning such as work, interpersonal relations, or self-care are mardekly below the level achieved prior to the onset (or when the onset is in childhood or adolewscence, faliure to achieve expected level of interpersonal, academic, or occupational achievement).

C. Duration: Continuou signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 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. Doring these prodromal or residual periods, the signs of the ditrubance may be manifested by only negative symptoms or two or more symptoms listen in Criterion A pressent in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

D. Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either (1) no Major Depressive, Manic, or Mixed Episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.

E. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition.

F. Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated).

Classification of longitudinal course (can be applied only after at least 1 year has elapsed since the initial onset of active-phase symptoms):

Episodic With Interepisode Residual Symptoms (episodes are difined by the reemergence of prominent psychotic symptoms); also specify if: With Prominent Negative Symptoms

Episodic With No Interepisode Residual Symptoms

Continuous (prominent psychotic symptoms are present throughout the period of observation); also specify if: With Prominent Negative Symptoms

Single Episode In Partial Remission; also specify if: With Prominent Negative Symptoms

Single Episode In Full Remission

Other or Unspecified Pattern

Diagnostic criteria for 295.30 Paranoid Type

A type of Schizophrenia in which the following criteria are met:

A. Preoccupation with one or more delusions or frequent auditory hallucinations.

B. None of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect.

Diagnostic criteria for 295.10 Disorganized Type

A type of Schizophrenia in which the following criteria are met:

A. All of the following are prominent:

(1) disorganized speech

(2) disorganized behavior

(3) flat or inappropriate affect

B. The criteria are not met for Catatonic Type.

Diagnostic criteria for 295.20 Catatonic Type

A type of Schizophrenia in which the clinical picture is dominated by at least two of the following:

(1) motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor

(2) excessive motor activity (that is apparently purposeless and not influenced by external stimuli

(3) extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism

(4) peculiarities of voluntary movement as evidenced by posturing (voluntary assumptions of inappropriate or bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing

(5) echolalia or echopraxia

Diagnostic criteria for 295.90 Undifferentiated Type

A type of Schizophrenia in which symptoms that meet Criterion A are present, but the criteria are not met for the Paranoid, Disorganized, or Catatonic Type.

Diagnostic criteria for 295.60 Residual Type

A type of Schizophrenia in which the following criteria are met:

A. Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior.

B. There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms or two or more symptoms listed in Criterion A for Schizophrenia, present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

I was surprised that these criteria did not specifically mention pain. I had thought that sadism and masochism were about wanting to hurt and be hurt. Reading these makes me think that it’s more about issues around control and humiliation than enjoying the sensation of pain.

This is word-for-word from the DSM-IV-TR, pages 573 and 574:

Diagnostic criteria for 302.84 Sexual Sadism

A. Over a period of at least 6 months, recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors involving acts (real, not simulated) in which the psychological or physical suffering (including humiliation) of the victim is sexually exciting to the person.

B. The person has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.

Diagnostic criteria for 302.83 Sexual Masochism

A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the act (real, not simulated) of being humiliated, beaten, bound, or otherwise made to suffer.

B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or important areas of functioning.

What is therapeutic about therapy? It seems to have a lot to do with the kind of relationship that the therapist and client create. This is Carl Rogers’ version of what happens in an ideal therapeutic relationship, quoted from Yalom’s Group Psychotherapy (p. 62). If you want to see footage of Rogers trying to create this relationship, I posted clips here.

1) The client is increasingly free in expressing his feelings.

2) He begins to test reality and to become more discriminatory in his feelings and perceptions of his environment, his self, other persons, and his experiences.

3) He increasingly becomes aware of the incongruity between his experiences and his concept of self.

4) He also becomes aware of feelings that have been previously denied or distorted in awareness.

5) His concept of self, which now includes previously distorted or denied aspects, becomes more congruent with his experience.

6) His becomes increasingly able to experience, without threat, the therapist’s unconditional positive regard and to feel an unconditional positive self-regard.

7) He increasingly experiences himself as the focus of evaluation of the nature and worth of an object or experience.

8) He reacts to experience less in terms of his perception of others’ evaluation of him and more in terms of its effectiveness in enhancing his own development.

I know people who happily smoke pot, drink beer, and use other recreational drugs with no apparent concern, but who would not take an Ibuprofen because it’s bad for your liver. This confuses me. Yes, non-steroidal anti-inflammatory drugs are bad for your liver. So are many, many other mainstream drugs, like antidepressants and birth-control pills. (Here’s a list.)

But what is the reasoning that lets hippy-friendly drugs off the hepatotoxicity hook? It seems to be that these drugs are “natural” and so they are trustworthy, as if God wouldn’t make such righteous substances poisonous. This is not rational.

It’s true that there isn’t as much research on the hippy-friendly drugs as there is on medical drugs. The FDA makes pharmaceutical companies do a bunch of expensive research on the drugs trying to go the legitimate route, but they don’t get involved in the illegal stuff. There is some research, though, and we do know that even hippy drugs are made out of chemical compounds that the liver has to metabolize before we can pee them out. It is safe to assume that pot, acid, mushrooms, ecstasy, cocaine, and the rest of your recreational drug list are bad for your liver. (And alcohol, duh.)

I will happily support you in not taking over-the-counter pain meds, but if an Ibuprofin is a drop in the hepatotoxic-lifestyle bucket, your priorities confuse me. If you are willing to ingest any number of chemicals in order to feel good, why not ingest one or two more to feel a little less pain?

My favorite answer to the question, “What is the meaning of life?” came from my friend, Taber Shadburne seven or eight years ago. He said that it’s a misleading question because we think of meaning as existing in language, so we imagine that the meaning of life will have a narrative, a set of values, a statement about the nature of reality. We expect mental games to do something that they just can’t do. The meaning of life, he said, is more like the meaning of skiing. If you ask yourself, “What is the meaning of skiing?” you see that you can’t answer that question with language. Instead, the meaning of skiing is something like this: He jumped up on a nearby bench, crouched into a skier stance with a delighted, slightly terrified look on his face, and shouted “Woohoo!”

The meaning of life is kind of like that.

Here’s Taber playing one of his songs:

I’m learning a lot about child abuse this term. It is no fun. It’s got me feeling sad–depressed, even–pissed off, and creeped out. Did you know that 1 in 20 American men sexually assaults a child? That’s 15,000,000 men! I’m having trouble with that.

I saw a documentary last night called Playground, about child sex traffic in the US. I’m still feeling heavy about it. One of the points it made: If someone broke into a woman’s room and raped her, a video of the crime would not be called “pornography.” It would be called “footage of a crime” or “evidence of sexual assault” or something like that. Footage of a child being raped shouldn’t be called “pornography,” either. That gives it too much legitimacy, like it’s just one of the more repulsive niches of that booming industry, pornography. How about we call it “footage of a child being raped”?

All right. I’ve been pitching the Long Now Foundation and their Seminars on Long Term Thinking for a while now, and no one is taking the bait. That is, some-number-less-than-three of you have clicked through the links I’ve put up. (WordPress only shows me links that hit three clicks in my stats.) You guys are missing out! These lectures are so good. Imagine, super-smart people giving entertaining, informative talks on their area of expertise and how it relates to long-term thinking. What’s better than that?

I just found out that LNF has video of the seminars up on, in full, for free. I prefer the audio versions, so I can simultaneously clean my kitchen, but if you’ve been holding off because you don’t like podcasts, check them out, in color, along with their slides and footage. Here is a list of all of the videos they have up.

And here are a couple of my current favorites:

Saul Griffith’s “Climate Change Recalculated,” in part about how he very rigorously figured out how much power (in Watts) his lifestyle uses, and then scaled back to his share of global energy production. Really, really good.

Steven Johnson’s “The Long Zoom,” about levels of complexity, cholera, television and video games, the evolution of the detective novel, and why bad ideas stick around, among many other things.

Michael Pollan’s “Deep Agriculture,” about the future of food production.

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