Back to Schizophrenia Part III

There is enough current research on the part genetics may play in the etiology of schizophrenia to assume that genetics needs to be a part of a systems understanding of schizophrenia. From a purely genetics stance, Siddhartha Mukherjee includes a section on schizophrenia in his book, “The Gene: An Intimate History” (2017). He States:

“Like many other genetic diseases, schizophrenia also comes in two forms – familial and sporadic. In some families with schizophrenia, the disorder courses through multiple generations. Occasionally some families with schizophrenia also have bipolar disorder. In sporadic or de novo schizophrenia, in contrast, the illness arises as a bolt from the blue: a young man from a family with no prior history might suddenly experience the cognitive collapse, often with little or no warning. Geneticists tried to make sense of these patterns, but could not draw a model of the disorder” (p.442).

Again, from a purely genetic stance, Mukherjee works to navigate through the schizophrenic genetic puzzles: “In some families, perhaps, there are fewer gene variants, but with more potent effects – thereby explaining the recurrence of the disorder across generations. In other families, the genes may have weaker effects and require deeper modifiers and triggers – thereby explaining the infrequent inheritance. In yet other families, a single, highly penetrant gene is accidentally mutated in sperm or egg cells before conception, leading to the observed cases of sporadic schizophrenia” (p.446).

I propose that a purely genetic explanation of the etiology of schizophrenia is insufficient, but that some aspect of what Mukherjee suggests likely plays a role – in combination with other factors. I would add the diathesis-stress model, which is a psychological theory that attempts to explain a disorder or its trajectory, as a result of an interaction between a predisposition vulnerability and stress caused by life experiences. A diathesis can take the form of genetic, psychological, biological, or situational factors. This is also, what Christine C. Gispen-de Wind and Lucres MC Jansen explain in their article, “The Stress-Vulnerability Hypothesis in Psychotic Disorders: Focus on the Stress Response Systems” (2002):

“The vulnerability-stress model is an intriguing concept to look into the etiology of psychotic disorders, and in particular, into the ‘nature-nurture’ principle. That stress affects a vulnerable nature may be obvious, but its mechanism is not well understood, and many questions remain to be answered, let alone how to define ‘vulnerability'”. Their article covers the biologic stress response systems, the autonomic nervous system (ANS), the hypothalamic pituitary adrenal (HPA) system, and the immune system and highlights the plasticity of the HPA system as the mediator of adaptation.

An aspect of vulnerability might also include impairments in sensory gating. Sensory gating is the ability of the central nervous system to adapt to sensory stimuli upon their repeated presentation. It is commonly impaired in schizophrenia patients, and may relate to the inability to concentrate, and to the overload of attended stimuli and a reduced ability to suppress processing of irrelevant and uninformative sensory input.

It is possible that six of the Galvin family children had varying degrees of predispositional vulnerability for possible schizophrenia and combined with familial and other social stresses, schizophrenic symptoms became manifest, while such vulnerabilities were either not at all a factor or were minimal enough that the other six children did not succumb to schizophrenia. Since genetics alone cannot explain the expression of schizophrenia in the Galvin family, I believe the diathesis-stress model is likely and the stresses within the family seem quite obvious. Perhaps the dynamics of early interpersonal relationships between the Galvin parents and their first two boys played a role in the environmental stresses. This would uphold at least some of the interpretations of the Interpersonal Psychiatrists, such as Freida Fromm- Reichmann, Harry Stack Sullivan, and Otto Will. The older two boys who did have symptoms of schizophrenia had then affected the other most vulnerable siblings. There were ongoing serious battles between and among some of the boys, and as illness impacted all family members – those with schizophrenia and those without, the pressure on the non-schizophrenic parents became increasingly challenging. Their need to keep as much of this a secret as possible must also have had an effect on those most affected with symptoms.

Since we know there is no known cure for schizophrenia and that medications alone may have as many deleterious affects as ameliorating ones, I suggest as part of a systems approach to treatment for schizophrenia, combining therapeutic work on communications and relationships, along with the best available symptom management medication (this will change over time and will need to be calibrated to each specific person). Bateson’s papers on schizophrenia in “Steps to an Ecology of Mind”(1972) suggest the ways that people with schizophrenia communicate and characterize the types of double binds created by parents as possible clues to understanding and treating patients. While the Interpersonal Psychotherapists subscribed to an early mother-infant relationship contributing to schizophrenia, they approached the treatment of people who were seriously ill much as psychotherapists might approach helping non-psychotic people with their personal relationships.

It is well known that Freud did not believe that psychoanalysis was appropriate with people suffering from psychosis, yet Freida Fromm-Reichmann, in “Psychoanalysis and Psychotherapy” (1960) said that Freud did not close off the possibility: “He (Freud) expressed the hope for future modifications of psychoanalytic techniques which would make it possible to do intensive psychoanalytically oriented psychotherapy with schizophrenics” (p.176). And this is what she and other Interpersonal Psychotherapists believed they were able to do at Chestnut Lodge, Austen Riggs, and other psychiatric hospitals which treated people with schizophrenia.

Elyn Saks, in her memoir (reviewed in an earlier post), made a convincing argument for combining psychoanalytic treatment along with medication for her to manage her ongoing struggles with schizophrenia, even while she has developed a very successful life and career. She did not write about the specific psychoanalytic approach she has been involved with, but it may be somewhat similar to what Christopher Bollas discloses in his book, “When the Sun Bursts: The Enigma of Schizophrenia”(2015). Bollas has practiced psychoanalysis with people suffering from schizophrenic for well over thirty years. Based on his experience, he writes about how to approach de-coding the language of someone with schizophrenia. His position has been, along with that of Bateson and the Interpersonal Psychotherapists, that there is a logic to the language of schizophrenia, and that the schizophrenic patient wants someone, such as a clinician, to recognize this and be able to communicate with them. Most people with schizophrenia have been institutionalized or otherwise isolated, with no one to communicate with them. Bollas has this to say about his understanding of the condition of people with schizophrenia:

“We shall never know whether schizophrenia is the outcome of phylogenetic, genetic, intra-uterine, early infantile, infant-mother, linguistic, sex shock, family, or accident-in-the-real causes. Clearly it is yet another form of being human.

However, we do know something about how schizophrenics perceive reality, how they think, how they behave, and how they relate. We know a great deal about why they resist many forms of treatment, but we also know how, why, and when they seem prepared to work with a clinician.

Whatever the genesis of schizophrenia, the first distinct outcome is a split in the self in which one part functions in an ordinary manner and another part develops a radically different way of perceiving, thinking, and relating”(p.181).

Bollas summarizes my own position regarding the importance of psychotherapy along with medication in the treatment of schizophrenia:

“Although medications may prove valuable in the course of psychotherapy, nothing helps schizophrenics more than a single one-on-one commitment by a fellow human being who has taken the time and endured the training to know how to read them, be with them, understand them, and talk to them.”(p.187).

I hope that my systems approach to the etiology and treatment of schizophrenia is helpful for those touched in one way or another by this devastating illness. I will revisit this topic as any new and relevant information becomes available.