Schizophrenia

= Schizophrenia =

Overview
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Schizophrenia affects an estimated 24 million people around the world (WHO, 2011). While there is no clear definition of schizophrenia, it is often characterized by a broad array of symptoms such as delusions, hallucinations and catatonia. Schizophrenia can be seen as both a brain disease and a mental illness, with impacts ranging from altered brain functioning to disruptive subjective experiences and cultural explanations for altered mental states. Scholars have not reached a consensus on the causes the disease, though they suspect genetic predisposition or environmental stressors that can alter brain chemistry play crucial roles. There is no cure for schizophrenia. The disease is often treated with anti-psychotic drugs and psychosocial therapy.

Health Impact
Schizophrenia affects people worldwide. It is often hard to diagnose schizophrenia as there are no definitive lab tests for it. Clinicians rely on the deduction of other conditions, such as seizure, brain and thyroid disorders, to derive the diagnosis. The disease afflicts people within a wide age range, from early teens to late adulthood.

Schizophrenia is characterized by three classes of symptoms: positive, negative and cognitive (National Institute of Mental Health, 2011). Positive symptoms, or psychotic behavior, include hallucinations, delusions, thought disorders or a disorganized way of thinking, and movement disorders such as catatonia. Negative symptoms include the “flat effect,” or the lack of facial movement or voice pitch during speech, the lack of pleasure in everyday life, and the inability to participate in every day activities and hold conversations. Cognitive symptoms include poor executive function, impaired memory and attention difficulty.

The Diagnostic and Statistical Manual of Mental Disorders IV (2000, p. 298), a tool for diagnosing mental disorders, defines schizophrenia as “a disorder that lasts for at least 6 months and includes at least 1 month of active-phase symptoms (i.e.: two [or more] of the following: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms).” There are six diagnostic criteria for schizophrenia. The first criterion is based whether a person exhibits two or more of the symptoms listed earlier within a month or less. The second criterion deals with the level of a person’s social and occupational dysfunction. The third is on the duration of the “disturbance” which includes the length of time symptoms are expressed. The fourth and fifth criteria helps physicians rule out other disorders and substance and medical conditions. The last criterion assesses a person’s condition in relations to developmental disorders.

There are several subtypes of schizophrenia, each with its own spectrum of symptoms: paranoid schizophrenia, disorganized or hebephrenic schizophrenia, catatonic schizophrenia, residual schizophrenia, schizoaffective disorder and undifferentiated schizophrenia (DSM-IV, 2000; WHO, 2011). According to the National Institute of Mental Health, there is a wide variation on the course of schizophrenia. Some would go through fluctuations in symptoms, and some would experience a consistent intensity of symptoms. As of now, there is no cure for schizophrenia. Those who are diagnosed with schizophrenia are often treated with anti-psychotic drugs and psychiatric therapy.

Research has shown that multiple factors contribute to schizophrenia. A predominant explanation is that schizophrenia is strongly linked to genetics. Though studies have shown that those with afflicted family members have higher risks of developing the disease, the exact genes or genetic mechanisms are still unknown (NIMH, 2011; Sullivan, Allen, and Nero, 2007). Research also suggests that the form of the brain, including its size, differs in people with schizophrenia versus those who do not. So far, several hypotheses have been offered to explain the discrepancy, and these include environmental factors such as exposure to certain agents that impair or impede brain development at a young age, or genetic mutations that alters brain chemistry (NIMH, 2011).

Schizophrenia exacts a heavy toll on diagnosed individuals, who often have to deal with its symptoms while navigating complicated health care systems and a host of medication. In the United States, the overall cost of schizophrenia was estimated to be $62.7 billion in 2002, and that included direct and indirect health care costs (Wu, Birnbaum, Shi, Ball, Kessler, Moulis, and Aggarwal, 2005). It is also a severe psychiatric disorder that affects both the afflicted person and their caregivers (Barrett and Jenkins, 2004). The personal struggles of these individuals have been captured in numerous documentaries and books, including Susan Smiley’s bracing documentary called //out of the shadow//.

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Anthropology and Schizophrenia
Schizophrenia presents an interesting territory for anthropologists to explore on several levels. In //Schizophrenia, Culture and Subjectivity//, Barrett and Jenkins (2004) invited anthropologists researching schizophrenia around the world to write about the intersection of schizophrenia and culture. The editors noted that predominant research on schizophrenia has fallen within the realms of psychiatry, but little had been done on examining the cultural aspects of the disorder. So they invited authors to write about subjective experience of the disorder and how manifestations of the disorder are socially constructed and dealt with through a cultural approach.

Comparative research also suggests that the less medicalized, and more socially integrated schizophrenic symptoms are, the more afflicted people retain their functioning. Gananath Obeyesekere explores this in his book //Medusa’s Hair// (1981). Obeyesekere’s ethnography on the ascetics in Sri Lanka examines a personal symbol – the matted hair of these ascetics – and how individuals and society internalize it. Employing a psychoanalytic perspective, Obeyesekere explores how these ascetics’ symptoms are transformed into divine gifts and how they retained their agency through their pursuit of a spiritual life path. Their choice and status are expressed through their matted locks, a personal symbol that is socially understood. In a way, matted hair is understood to be a symbol of holiness, as opposed to pathology.

Applied Work
Anthropologists have studied schizophrenia from several angles. On an evolutionary level, physical anthropologists have suggested that the growth in the size of human brains over time spurred brain metabolic adaptations (Khaitovicj, et al, 2008). This joint study by the Max Planck Institute for Evolutionary Biology and other organizations suggests that the growth outpaced the brain’s metabolic rate. In another research, a scientist posits that schizophrenia may be a result of humans’ capacity for language (Crow, 2000). This may be a result of a genetic change that influences the uneven development of certain parts of the brain that affects speech input and output. Crow notes that the inherent capacity for this specific change among //Homo sapiens//, which may have occurred during the species’ split from the great apes, may explain the central paradox of the disorder: the universality of the symptoms and the persistence of the disorder despite poor reproductive chances of afflicted individuals.

Cultural and medical anthropologists have also studied how the symptoms of schizophrenia express themselves in various regions and among different ethnic groups, and how they are dealt with. These factors affect the outcome of the disease, such as the degree of institutionalization of those diagnosed with schizophrenia (Myers, 2010). There is also research on whether the exportation of biomedical approaches to dealing with schizophrenia, i.e.: medication, institutionalization, and agency resulting from a positive diagnosis, is beneficial or harmful.

Some anthropologists have also studied the biosocial and cultural aspects of schizophrenia, such as Scheper-Hughes’ (1979) ethnographic work in Ireland. Jenkins’ and Barrett’s (2005) volume explores the intersection of schizophrenia and culture by looking at the disorder through subjective experiences of the disease, subjectivity and emotion as well as the different methodology anthropologists have used to analyze how culture shapes experiences and contents of a biological phenomenon. Authors in the volume attempt to understand this connection by researching the lived experiences of those suffering from schizophrenia and how their symptoms are constructed and perceived in a “social reality.”

A major study in Palau, which has the world’s highest incidence of schizophrenia per population, deals with the questions of whether there can be universal symptomatic expressions of mental illness and the use of “objective” diagnostic tools (Sullivan, Allen, and Nero, 2007). It is also important to note that anthropologists have also been consulted in the drafting of the DSM-IV to provide the cross-cultural perspective on certain mental disorders such as schizophrenia (Barrett and Jenkins, 2004).

Online Resources

 * This is part of a series of lecture Robert Sapolsky, a biological anthropologist and neurologist, gave at Stanford University. (His talk on schizophrenia starts at 23:07)

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 * This is a panel discussion on cultural and biological contexts of schizophrenia at the University of California Los Angeles.

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 * Schizophrenia.com is a Tides Center project and a member of the Internet Mental Health Initiative. Started in 2005, the site contains information ranging from the economic burden, symptoms, research and tips on how to support those diagnosed with schizophrenia.
 * The National Institute of Mental Health has a comprehensive website on schizophrenia.
 * The World Health Organization provides a global look at schizophrenia, replete with a classification guide.