A DECADE AGO psychologist Ronald Levant, then at Nova Southeastern University, was telling some of his colleagues at a conference about patients with schizophrenia whom he had seen recover. One of them asked rhetorically, “Recovery from schizophrenia? Have you lost your mind, too?”
Until recently, virtually all experts agreed that schizophrenia is always, or almost always, marked by a steady downhill progression. But is this bleak forecast warranted? Certainly schizophrenia is a severe condition. Its victims, who make up about 1 percent of the population, experience a loss of contact with reality that puts them at a heightened risk of suicide, unemployment, relationship problems, physical ailments and even early death. Those who abuse substances are also at risk for committing violent acts against others. Contrary to popular belief, people with schizophrenia do not have multiple personalities, nor are they all essentially alike—or victims of poor parenting.
Nevertheless, research has shown that with proper treatment, many people with schizophrenia can experience significant, albeit rarely complete, recovery from their illness. Many can, for example, live relatively normal lives outside a hospital, holding down a job and socializing periodically with family and friends. As psychiatrist Thomas McGlashan of Yale University concluded in a prescient 1988 publication, “The certainty of negative prognosis in schizophrenia is a myth.”
From Desperation to Hope
Around 1900 the great German psychiatrist Emil Kraepelin wrote that schizophrenia, then called dementia praecox (meaning “early dementia”), was characterized by an inexorable downward slide. In 1912 another doctor, A. Warren Stearns, wrote of the “apparent hopelessness of the disease.” Some treatments of the day, which included vasectomy and inducement of intense fever using infected blood, reflected this sense of desperation. An attitude of gloom pervaded the field of schizophrenia research for decades, with many scholars insisting that improvement was exceedingly rare, if not unheard of.
Yet experts have lately come to understand that the prognosis for patients with schizophrenia is not uniformly dire. Careful studies tracking patients over time—most of whom receive at least some treatment—suggest that about 20 to 30 percent of people recover substantially over years or decades. Although mild symptoms such as social withdrawal or confused thinking may persist, these individuals can hold down jobs and function independently without being institutionalized.
In one study published in 2005 psychologist Martin Harrow of the University of Illinois College of Medicine and his colleagues followed patients over 15 years and found that about 40 percent experienced at least periods of considerable recovery, as measured by the absence of significant symptoms as well as the capacity to work, engage in social activities and live outside a hospital for a year or more. Although most patients do not go into long remissions and may even decline over time, some 20 to 30 percent of this majority experience only moderate symptoms that interfere with—but do not devastate—their ability to perform in the workplace or maintain friendships.
Contributing to this less fatalistic view of schizophrenia are the effective treatments that have become available over the past two decades. Such atypical antipsychotic medications as Clozaril (clozapine), Risperdal (risperidone) and Zyprexa (olanzapine), most of which were introduced in the 1990s, appear to ameliorate schizophrenia symptoms by affecting the function of neurotransmitters such as dopamine and serotonin, which relay chemical messages between neurons.
In addition, certain psychological interventions developed over the past few decades can often attenuate symptoms such as delusions and hallucinations. For example, cognitive-behavior therapy aims to remedy the paranoid ideas or other maladaptive thinking associated with the disorder by helping patients challenge these beliefs. Family therapies focus on educating family members about the disorder and on reducing the criticism and hostility they direct toward patients. Though not panaceas by any means, these and several other remedies have helped many patients with schizophrenia to delay relapse and, in some cases, operate more effectively in everyday life.
Who is most likely to improve? Researchers have linked a number of factors to better outcomes in patients. These include functioning successfully in their lives before the disease emerged; experiencing severe symptoms suddenly, all at once, rather than little by little; being older when the disease appeared; being female; having a higher IQ; and lacking a family history of the disorder. All these traits and features, however, allow at best modest forecasts of schizophrenia’s prognosis.
Clearly, we have made considerable progress in our understanding of schizophrenia’s course and are more optimistic than we have ever been about the future of those afflicted. Nevertheless, we need even more effective remedies if our aim is to bring patients back to the productive, happy lives they enjoyed before their illness struck—and shattered their sense of self.
Although most people have heard of schizophrenia, many misunderstand the disorder. Here we dispel three widespread misconceptions about this troubling mental illness.
Myth #1: People with schizophrenia have multiple personalities.
Fact: This belief reflects a confusion between schizophrenia and dissociative identity disorder—once called multiple-personality disorder—a controversial diagnosis that is supposedly marked by the coexistence of multiple personalities or personality states within individuals. People with schizophrenia possess only one personality, but that personality has beenshattered, with severe impairments in thinking, emotion and motivation.
Myth #2: All people with schizophrenia are essentially alike.
Fact: People with schizophrenia experience a bewildering variety of symptoms. Some suffer primarily from “positive” symptoms, such as delusions, which are fixed false beliefs—the idea, say, that government agents are following them—and hallucinations, such as hearing voices. In contrast, others mainly have “negative” symptoms, such as social withdrawal and diminished emotional and verbal expression. Still another set of patients experiences cognitive deficits—problems with paying attention, remembering and planning. Many patients’ deficits span all three categories.
Myth #3: Schizophrenia is caused by family attitudes and behaviors.
Fact: In 1948 German psychoanalyst Frieda Fromm-Reichmann introduced the notion of the schizophrenia-inducing mother—one who was hostile and hypercritical—an idea that persisted for decades. Yet research has consistently failed to directly link parenting to the onset of schizophrenia, although numerous investigations suggest that intense familial criticism may hasten its relapse.