Thesis: Through an exploration and increased understanding of the neurobiological disorder schizophrenia, harmful stereotypes and prejudices against affected individuals may be reduced; insight and evaluation concerning personal perceptions about mental capabilities and spirituality may also be assessed.

II. What is Schizophrenia?
        A.  Symptoms and Diagnosis
        B.  Causes
                1. Genetic factors
                2. Biochemical imbalances and brain dysfunction
                3. Diathesis-stress theory

III.  Treatment
        A.  Historical approaches
        B.  Chemical drugs
                1. Typical neuroleptics
                2. Atypical neuroleptics
        C.  Alternative therapies

IV.  Ethical Issues
        A.  Homelessness
        B.  Crime and violence
        C.  Incarceration
        D.  Economic cost

V.  The Christian Response

Introduction

"Schizophrenia is a cruel disease. The lives of those affected are often chronicles of constricted experiences, muted emotions, missed opportunities, unfulfilled expectations. It leads to a twilight existence, a twentieth-century underground man...It is in fact the single biggest blemish on the face of contemporary American medicine and social services; when the social history of our era is written, the plight of persons with schizophrenia will be recorded as having been a national scandal."

I personally don't know anyone with schizophrenia, or at least I don't think I do. Perhaps I don't realize that my neighbor is walking through life with a secret, like the homosexual who, afraid of society's unfounded prejudice, confusion, and doubts over issues not talked about, remains silent. For this reason, my interest in schizophrenia developed: not because I have been affected by the disorder in a direct (or even indirect) way, but precisely because I haven't. I haven't because mental disorders are not something discussed over coffee. In our society schizophrenia isn't everybody's problem, and so most are content not to think – and consequently not to do – anything about it.

My concern with schizophrenia stemmed from the unknown; thus it was fitting that my search to discover facts about it steadily uncovered more gray areas. What are the causes of schizophrenia? No one knows for certain. The symptoms? They vary. What about treatments? They too have varied throughout history and current treatment differs from case to case. Faced with the frustration of unanswered queries, I began to wonder why I chose this topic. However, that is the nature of science: one question leads to another and while the goal may be to solve a problem or determine the reason behind an observed phenomenon, the process of discovery is at the heart of the discipline.

Ignorance and fear of the unknown lead to oppression. Often forced to the fringes of society in terms of socioeconomic status, medical treatment and insurance coverage, those with schizophrenia have historically been oppressed and continue to be. Many feel very much alone, labeled by society as "crazy," "dangerous," or "violent." As a whole, they are misunderstood. Thus it is time for "an aggressive research campaign to be mounted against the ignorance that has surrounded schizophrenia" (Keefe xii). My focus, then, is to shed light on schizophrenia through an exploration of the possible causes and treatments of the disorder, in an effort to reduce harmful stereotypes and prejudices as well as wrestle with how perceptions of mental functions and capabilities relate to personhood and spirituality.

Schizophrenia is a common neurobiological disorder, striking approximately 1–2% of the world's population, with the average age of onset between 21 and 27 years (Keefe 2). The term schizophrenia refers to an individual split off from the environment, not to be confused with the splitting of an individual's personality into parts (as with multiple or split personality disorder). Clear definitions in psychology, however, are hardly possible; likewise, one for schizophrenia has been difficult to arrive at because of the fact that there is no single symptom or set of symptoms that definitively identifies its presence. Thus the disorder is characterized not as a medical disease where specific symptoms are indicative of a specific disease. Because of the wide variety of symptoms individuals with schizophrenia may have, the disorder encompasses a broad spectrum of differing symptoms, making diagnosis a difficult task.
 
 

Symptoms and Diagnosis
The symptoms of schizophrenia can be categorized as either positive or negative. The term positive refers to behaviors and experiences that individuals with schizophrenia have that others do not have (Holmes 302). These are the symptoms that most people commonly associate with the disorder. They include hallucinations or false perceptions, mostly auditory – or hearing voices. Although less common, other hallucinations may be visual, tactile, or olfactory. Individuals may also experience delusions, or false beliefs. The delusions are of an extremely bizarre quality, not only untrue but often impossible.

Another positive symptom is disorganized speech. An example follows: "The thing is, the people aren't told what the difference is. Why should God care if I'm brown or not? That's why the ozone is going away and the babies are sick! Doesn't matter. You know, everybody's got to die. I just can't see why this bed is so soft all the time" (Keefe 30). Clearly the individual seems to be saying something important, frequently using an urgent voice. However, the words and ideas do not hold together enough to understand the intended meaning. Often the speaker cannot remember how he or she started the sentence or in what direction the thoughts were going.

In contrast to the positive, negative symptoms reflect the absence of normal behavior and functions, referring to characteristics which most people possess that someone with schizophrenia is lacking (Holmes 302). These include social withdrawal and the absence of normal emotional feeling and expression. "Flat affect" is the condition of an unchanging facial expression. Despite assertions on the part of the person with schizophrenia that he or she is enjoying him/herself, there is a lack of emotion, interest and enjoyment in activities that were once pleasurable. This is often coupled with a lack of energy, motivation and sense of purpose in life.

Other negative symptoms appear to be even more severe. Catatonic posturing is the state of the body being contorted, with the affected individual holding a specific position for hours. Extreme paranoia, suspiciousness and unrealistic fear are other negative symptoms. Persons may also suffer impairments in attention and thinking, leading to disorganization in some cases of such degree that they cannot care for themselves. Often accompanied by poor insight, individuals may lack an awareness of their illness altogether and do not understand their difficulties and limitations. Because they may honestly believe that "you're the one with a problem: why should I take any medicine?", they refuse their medication, escape from hospitals, and avoid support from family and friends.

Positive symptoms are more likely to respond to medication and generally less destructive to a person than negative symptoms.

In the past, diagnosis has not been constant. Because mental illnesses vary tremendously and have only relatively recently been recognized as legitimate, persons with schizophrenia were generally considered "crazy", "demon possessed" or somewhere in between. There was no clear diagnosis because there was no clear perception: it was not understood that the symptoms of schizophrenia were indicative of a specific disorder. In the fifties and sixties in North America, a psychoanalytical approach was the norm, and doctors were left to diagnose according to their own criteria. With no specific guidelines, it was common to hear: "well, I can't really explain it to you, but I can feel it in my bones that you have schizophrenia" (Keefe 20). The problems with this methodology are self-evident.

Presently, there is an outlined set of symptoms that must be present before diagnosis is made. Diagnostic criteria are outlined in detail in the DSM-IV, allowing for greater continuity in diagnosis.
 

Causes
Historically schizophrenia was thought to be caused by poor parenting or other types of dysfunction within the home. In this causal scenario, most of the responsibility and consequent blame fell on the mother. She was labeled as schizophrenogenic, a term which referred to her personality and implied that she was "emotionally frozen," detached from her baby, and basically a terrible mother (O'Brien 153). It was believed that these characteristics in relation to the child's development led to a confused child who would eventually develop schizophrenia. Other theories hypothesized causes to be a passive father or parents who said one thing but through their actions modeled another. There has been no scientific support for any of these theories and they have since been discarded.

Although the causes of schizophrenia are still somewhat a mystery, it is generally agreed upon that biology and physiological factors play significant roles in the causation of the disorder, along with environmental factors – though not of the familial sort mentioned above. Schizophrenia is presently classified as a neurobiological disorder, with possible causes including genetic factors, biochemical imbalances and brain dysfunction. Most theories couple these abnormalities with environmental stressors, which in combination produce a schizophrenic condition.

Genetic factors. Experience has shown that schizophrenia is familial; the question that follows, therefore, is whether the shared root is similar genes or common experiences. Scientific research has determined the link to be genetic. As discussed by Mortensen et al. in the New England Journal of Medicine, schizophrenia runs in families, and twin and adoption studies indicate that such familial aggregation is largely accounted for by genetic factors. However, the same studies also indicate that familial genetic transmission can account for only a portion of the cases of schizophrenia; for example, the concordance rate in monozygotic twins is approximately 40 percent, suggesting that nongenetic factors must also have a role (Andreasen www).

Genetically, schizophrenia resembles other complex illnesses, in that it is nonmendelian, probably polygenic, and probably multifactorial (Andreasen www). In 1988 some English researchers reported finding a gene on chromosome 5 which they believed was linked to schizophrenia; however, they were unable to reproduce their results and since then no substantial evidence has been found to support their claim although the search to identify loci continues (Keefe 90). Some theories propose that it is an interaction of two or more genes or that it is a matter of heterogeneity, with different roots for different types of schizophrenia. Still another theory suggests that one gene expresses itself in different ways; thus a defective gene may manifest certain symptoms in one person and other symptoms in another (Keefe 92). The most common hypothesis, though not fully understood, posits that an abnormal gene plus an environmental agent cause schizophrenia. In this situation an individual has a genetic predisposition towards the disorder which may or may not develop in the future.

Biochemical factors and brain dysfunction. Causes of schizophrenia in relation to biochemical imbalances are problems of neurotransmission. Dopamine, a neurotransmitter involved in attention and memory, appears to be central. In the 1960s the drug chlorpromazine, a receptor antagonist of dopamine, seemed to work wonders in reducing symptoms of schizophrenia by decreasing the activity of the dopamine system. Conversely later research has shown that amphetamines which increase dopamine activity alleviate symptoms in some people; however, high doses cause a syndrome that resembles schizophrenia. Thus hormonal homeostasis seems to dictate that the right balance of dopamine is needed, with either too high or too low of levels affecting normal functioning (Keefe 108).

Other neurotransmitters believed to be significant are serotonin and norepinepherine. Serotonin plays a role in depression, eating disorders and impulsivity. Its function is mainly regulatory, controlling the activity of other transmitters. The antidepressant Prozac affects serotonin activity by blocking the reuptake of the transmitter. Treatment with drugs that affect serotonin levels have been shown to improve symptoms like hallucinations, delusions, and blunted affect but have no effect on cognitive impairments (Keefe 110). Norepinepherine is also associated with depression, as well as being responsible for alertness, attention and cardiac reactivity. Drugs that increase activity can alleviate depression; however, extremely high levels are associated with positive symptoms of schizophrenia. Cocaine, for example, increases levels of norepinepherine: the effect associated with syndromes of paranoia (Keefe 111). Again the key seems to be the fine balance of biochemical levels.

Structural brain abnormalities appear to be related to schizophrenia, although it is debatable as to whether or not the dysfunction is the cause or result of the disorder. Either way, MRI and PET scans show areas with decreased brain activity in affected individuals (Chiko www). Brain damage to the frontal lobes results in mental and behavioral abnormalities similar to those found in persons with schizophrenia, most often in reference to negative symptoms. It is thought that damage to the temporal lobes, on the other hand, may affect the individual with regards to positive symptoms. The basal ganglia is another area of the brain that could be related, due to the fact that it is dopamine rich and involved in the connections between the frontal lobes and emotional responses (Keefe 120). However, despite increasing knowledge and understanding with respect to the brain, the neurobiological causes of schizophrenia are still questionable and research in this area is ongoing.

Diathesis-stress theory. The most accepted theory today relates genetic factors and brain dysfunction with environmental stressors that may trigger the development of the disorder. Although these environmental factors have nothing to do with the "schizophrenogenic mother," the mother may be involved. According to a Danish study, prenatal brain disruptions due to infection, influenza, and/or poor maternal nutrition may influence one's chances of developing schizophrenia (Bower 170). The study also reported that risk is higher in individuals born in February or March in urban areas (170). Although these observations show no definite cause, there does seem to be a correlation between maternal health, intrauterine environment, and obstetric complications. It has been reasoned, then, that in winter months the mothers may be more susceptible to influenza, and in urban areas among the lower socioeconomic class, birthing complications are more frequent as healthcare among this class is limited.
 
 

Treatment
Before the 1800s the treatment of individuals with mental disorders often involved chains and other restraints, ostracism from community life, and various forms exorcism including the drilling of holes in the skull to allow escape of evil spirits. After the 1800s society had somewhat progressed: lifetime confinements in huge mental institutions, separated from friends and families, seemed to be the accepted practice. The 1900s saw the onset of biological treatments including lobotomies, insulin coma therapy, and fever therapy. Electroshock convulsion therapy and psychosurgery were in vogue.

It was not until the 1950s, however, that any type of drug treatment was developed, with neuroleptics now being the most widely used method of treatment. In 1952 chlorpromazine, or Thorazine, hit the market with seemingly miraculous results (Keefe 132). By blocking dopamine at its D2 receptor, chlorpromazine worked to completely control symptoms in one-third of the schizophrenic population and reduce symptoms for another third. Other typical antipsychotic medications include Haldol and Mellaril. It is important to note that although these drugs reduce symptoms, they do not cure the disorder, and in fact produce other symptoms. The side effects of typical medications include extrapyramidal symptoms (EPS): rhythmic movements of muscles in the lower extremeties or in the face, rigid masklike facial expressions, anxiety, restlessness, and a stiffened gait (Holmes 359).

In more recent years the development of a new type of chemical treatment has come about, in response to the third of those with schizophrenia for which typical drugs do not work. These atypical medications have different effects, controlling negative symptoms as well as positive, whereas typical drugs seem to work best for only positive symptoms. Another benefit is the lack of EPS or other major side effects. The current drug of choice, in terms of cost and effectiveness is risperidone, or Risperdal. Results from the few studies published so far indicate that this new generation of neuroleptics, in particular risperidone, has a more positive effect on cognitive functions than conventional (typical) neuroleptics (Rund 123).

In addition to drug treatments, alternative therapies are being researched. There has been a recent trend towards identifying early signs of schizophrenia and thus detecting and preventing onset, if possible (Stephenson 1877). Other alternative methods range from the role of a fish oil extract in reducing symptoms to psychotherapy. Integrated skills, life, and communication training approaches also seem to be beneficial (Keefe 167).
 
 

Ethical Issues
As alluded to in the introduction, issues surrounding the misconceptions about, and oppression of, individuals with schizophrenia are far-reaching. They affect not only the individual, but also those in direct contact with the individual as well as society at large. The impact of society on schizophrenia and schizophrenia on society is reciprocal.

Homelessness. One of the largest issues in relation to mental illness is homelessness. Statistics show that as many as one-third to one-half of all homeless in the United States have a severe mental illness, largely schizophrenia (Keefe 44). In the process of deinstitutionalization, many of those discharged from state hospitals found themselves out on the street. With untrained and inept families, there was no one to care for them. Furthermore the rate of occurrence is much higher in the lower class than in the middle or upper class. Clearly there is a downward social drift for the mentally ill: the reduced ability to work leads to unemployment, poverty, inability to pay rent, and finally homelessness. With mental illness as a whole concentrated in the lower class, bias in treatment and diagnosis will undoubtedly continue unless active reparations are pursued.

Crime and violence. Other myths and prejudice center on the idea that individuals with schizophrenia are violent and aggressive. When tabloids splash headings like "Schizo Kills Three in Subway", stereotypes are perpetuated. Violent assaults against famous people by psychotic persons further reinforce this notion, as isolated events stigmatize an entire group in regards to mental disorders and behavior. Examples include the assassination of Robert Kennedy by Sirhan Sirhan, the murder of John Lennon by Mark David Chapman and the attempted assassination of Ronald Reagan by John Hinckley, Jr. Media distortion of such events "exaggerates any genuine relationship that may exist" (Gottesman 191).

Are those with schizophrenia likely to be more violent? This question is highly debatable. According to Pamela Taylor, a forensic psychiatrist at the Institute of Psychiatry in London, "There is no doubt that schizophrenics are capable of violent behavior, and, there, any certainty about the relationship between schizophrenia and violence ends" (Gottesman 190). Other studies have shown that people with schizophrenia may be six times more likely to be violent than those without a neurobiological disorder (Keefe 146). However, the correlation possibly lies with those who refuse their medication; those taking medication are no more violent than the rest of the population, thus underscoring the importance of treatment, with respect to the individual's safety as well as the safety of the community.

The question needs to be evaluated within the larger picture of crime and society. Poverty, racial factors, undereducation, easy access to weapons, and endemic urban drug trafficking impact problems in the United States and must be taken into consideration. With widespread crime and violence in our society, it appears that the seriously mentally ill have made only a trivial contribution: one is safer "on the ward of a mental hospital than on the streets of any major city after dark" (Gottesman 192). Age, gender and socioeconomic status seem to be more significant when considering aptitude for violence (Gottesman 193).

Incarceration. Although the evidence that those with schizophrenia are any more violent than the general population is controversial, their incarceration is common. In a recent report published by the National Alliance for Mentally Ill, Criminalizing the Seriously Mentally Ill: The Abuse of Jails as Mental Hospitals, Dr. Fuller Torrey describes how affected individuals are held in jails while awaiting transportation to mental hospitals, even though there are no charges against them (Keefe 48). Although jailing is completely inappropriate (for in their condition individuals are highly vulnerable to abuse), the process is legal in seventeen states and occurs in many more. In spite of what is clearly unjust, there has been little legislative change. In fact 70% of jails recently investigated in regards to the incarceration of the mentally ill reported that the problem has increased in the last ten years (Keefe 48).

Economic cost. A final issue with regards to the social biology of schizophrenia involves pecuniary matters. The direct cost of care for those with schizophrenia and other related disorders coupled with the indirect costs of lack of occupational productivity and income lost to others that must care for them is high. According to the National Advisory Mental Health Council in Washington, DC, an estimated $33 billion is spent each year (Keefe 59). Of that, however, only $1.7 billion is given towards research and training. In comparison, more than five times as much is spent on cancer research. Because of the economic burden of schizophrenia on society (as evidenced by the fact that 15% of all Medicaid goes towards affected individuals), there needs to be more research on the causes, treatments and prevention so that resources can be more appropriately distributed.

Despite the large financial sums consumed in relation to schizophrenia, there is still a significant bias against affected individuals. President Clinton's health care reform proposals delivered to the nation in September 1993 do not provide full coverage for severe mental illnesses until the year 2001; until then, an individual with mental illness must pay 100% of the expenses for time spent in the hospital beyond 60 days (Keefe 60). There are no such limits on any other illness or trauma. According to the National Alliance for the Mentally Ill, this lack of equality is "federally mandated discrimination against persons with severe mental illness" (Keefe 60). Clearly there is room for improvement with regards to legislative mandates and appropriated funds for dealing with schizophrenia.
 
 

The Christian Response
As Christians I believe it is not only a responsibility but also a duty to become informed about these issues. Whereas ignorance can lead to oppression, knowledge in turn can lead to liberation. We should not only recognize the ethical issues surrounding schizophrenia and other mental illnesses but also actively seek change.

One response by the Mennonite Church in particular is found in the Mennonite Disabilities Committee, which strives to uphold the welfare of those who are mentally ill as well as those with other disabilities. The Merimna Homes in Goshen, for example, provide group living situations for mentally ill individuals, capitalizing on the truth that for those individuals in which group homes are a possibility symptoms of illness are generally decreased and quality of life increased. Another joint project of Merimna Homes and Goshen College is Vita House, a living situation at Goshen College where students reside with one or two people who are mentally disabled, maintaining the house and assisting with day to day tasks. According to Phil Swartzendruber, a former resident, "My decision to live in Vita House was an attempt to 'get off my idealistic duff.' It was an opportunity to practice accepting and appreciating people whom I had categorically ignored" (Swartzendruber www). Sadly such a program of integration is not the norm, attesting to GC's "uncommon-ness".

However, there are many other types of programs and organizations that are advocates for those with schizophrenia and other mental illnesses. Seek them out and get involved; volunteer; offer to buy groceries, balance a checkbook or clean house. Be a support to individuals and their families and friends. In learning more about those who are different from you, you will undoubtedly discover new things about yourself. Model Christ's response to the oppressed in everyday life.

I went to a dance the other night at Vita House. I was unaware of any individuals with schizophrenia present but those with other mental disorders danced energetically, freely mingling with others who had their own differences and struggles. As I sipped my hot cider, the blare of country music was drowned out by my own thoughts and the impact this scene and my research have had on me. Can we have a society where each is valued for his or her own contributions to life? The topic is much more on my mind these days and has increasing significance and relevance to my life. I am presently considering working at a L'Arche community next year, where all residents are seen as unique with something to offer, despite differing levels of mental capacity. I am hoping to transform ideas into practice, aware that in my search for discovery I have only come a short way. The cycle continues, as new insight brings more questions: How do neurobiological changes affect spirituality, relationships with God and with others? Who decides the quality of life? If bodies are just chemical matter and upsetting the balance of these chemicals changes emotion and personality, what is the essence of the soul? Thus I leave you with some questions of my own, to ponder and consider for yourself, in hopes that together our journeys will lead to real change.
 
 

Works Cited

Andreasen, Nancy. "Understanding the Causes of Schizophrenia." The New England Journal of Medicine 340.8 (Feb 25, 1999). http://www.nejm.org/content/1999/0340/0008/0645.asp.

Bower, Bruce. "Schizophrenia's places and seasons." Science News 155.11 (03/13/99): 170.

Chiko, Brian. The Schizophrenia Homepage. Summer 1996, rev. Jan 1999. http://www.schizophrenia.com

Gottesman, Irving. Schizophrenia Genesis. New York: W.H. Freeman & Co, 1991.

Holmes, David S. & Marion B. Castellucci. Abnormal Psychology, 3^rd ed. New York: Longman Publishers USA, 1997.

Keefe, Richard & Philip Harvey. Understanding Schizophrenia. New York: The Free Press, 1994.

Mortensen PB, Pedersen CB, Westergaard T, et al. "Effects of family history and place and season of birth on the risk of schizophrenia." New England Journal of Medicine 340 (1999): 603-8.

O'Brien, Patrick. The Disordered Mind. New Jersey: Prentice-Hall, Inc., 1978.

Rund, Bjorn Rishovd. How do neuroleptics affect cognitive dysfunctions in schizophrenia? Nordic Journal of Psychiatry 53.2 (1999): 121-125.

Stephenson, Joan. "Schizophrenia researchers striving for early detection and intervention." Journal of the American Medical Association 281.20 (05/26/99): 1877.

Swartzendruber, Phil. "Mainstreaming the marginalized." Printed in The Record (April 2, 1998). https://www.goshen.edu/record/1997-98/April2-1998/mainstream.html.