- Schizophrenia and the mirror system: an essay - ScienceDirect
- Is schizophrenia disappearing? The rise and fall of the diagnosis of functional psychoses: an essay
In this line, Lin and Kleinman highlight five conditions that can explain the better prognosis for patients in non-industrialized countries, referring to social support, the family environment, the nature of work, stigma, and the differential survival rates of vulnerable individuals. In any case, over and above any lists of characteristic social factors, it would be necessary to carry out anthropological studies revealing everyday ways of life in relation to those who have psychotic access, such as that of Juli McGruder in Zanzibar, Tanzania McGruder, From McGruder's study, which resulted from her living with various families with schizophrenic members, three aspects should be highlighted McGruder, ; Watters, One of these is that the idea that people in traditional cultures have a simpler and less stressful life is just a fantasy in the heads of Western people.
The toughness of life, social conflicts, wars, family problems—they are far from free of such challenges. Another aspect is the social-moral status of the member of the family who is ill, as opposed to a particular-individual status, which precludes criticism and hostility. The third aspect is the normal acceptance and tolerance of the ill person. It is a naturalized tolerance, described by McGruder in terms of acquiescence in the face of adversity and the embracing of difficulties as part of life McGruder, In this context it is understood that mental illness has less stigma attached to it than it would in a medical context.
High rates of schizophrenia have repeatedly been found over the last 20 years among immigrants from various countries in a range of European cities Coid et al. It is now emerging a similar problem with refugees Hollander et al. Quite apart from the public health tragedy involved, this phenomenon represents quite a challenge for psychiatry Morgan and Hutchinson, b.
Its impact for psychiatry concerns the aetiology, pathophysiology and treatment of schizophrenia, and hence its conception and scientific and clinical status. This high rate of schizophrenia, within its variability in the different studies, is between 2 and 8 times that for the indigenous British or Dutch populations.
At the same time, it is high in the same proportion with respect to its incidence in the populations of their countries of origin.
Schizophrenia and the mirror system: an essay - ScienceDirect
The finding is robust and consistent, and is not subject to methodological artifacts, since the studies have been repeated and improved and the reviews are increasingly exacting Coid et al. However, not all immigrants in Europe show high rates of schizophrenia. This phenomenon is notable among migrants from the West Indies, in particular African-Caribbeans, and also among Moroccans, but this does not seem to be the case among migrants from Asia or Turkey.
The incidence of schizophrenia among Asian immigrants in London is lower than that for other groups, and similar to that for the populations of their destination and origin Chang et al. Likewise, the incidence of schizophrenia among Turkish immigrants in Holland is lower than it is among other groups Veling et al. Various explanations are put forward for the findings. The self-selection explanation often proposed, according to which migrants would be those with some predisposition to psychosis, together with explanations based on genetic and neurobiological causes, have been discredited by the data van der Ven et al.
It is the turn of an explanation in environmental terms, be they biological, social or an interaction of the two.
Among the biological factors investigated, no increased prevalence has been found for birth complications or neurobiological abnormalities diagnosed; as far as drug abuse is concerned, rates are not significantly higher among migrants Morgan and Hutchinson, b. There remain the social factors. A number of social factors are involved: urban stress, unemployment, poverty, family separation, racial discrimination, and so on. Two explanations have been proposed: social defeat theory and the sociodevelopmental model, already introduced in our discussion of the juvenile onset of schizophrenia.
The theory of social defeat refers to a particular pattern of social interaction whereby people are the victims of disdain, humiliation, and subordination from others Selten et al. Social defeat theory integrates social, psychological and biological mechanisms in that order to account for the development of psychotic symptoms. The sociodevelopmental model emerges in relation to the abundant and robust evidence showing the link between not only migration, but also a broader range of experiences and social and psychological factors trauma, social adversity , and the onset of psychosis Morgan and Hutchinson, a ; Morgan et al.
And what of the lower incidence of schizophrenia observed among Asian and Turkish immigrants in European cities? These differences in favor of Asians and Turks probably have to do with the fact that their system of emigration incorporates the family and their own customs wherever they go Veling et al. For example, Turks in The Hague perceive less discrimination and show lower incidence of schizophrenia than Moroccans, even though they have similarly low economic status Veling et al. Similar regarding to Asians:.
It has been suggested that the more cohesive cultural, ethnic, and religious structure of Indian, Pakistani, and Bangladeshi communities may confer greater social support than in other groups that may otherwise share similar levels of discrimination. That the excess risk of psychoses for Asian immigrants in our sample appeared to be restricted to women provides anecdotal support for the social defeat hypothesis given the additional pressure of marginal status faced by some women in Indian, Pakistani, and Bangladeshi communities Coid et al.
If we are to take culture seriously—and it is high time we did—it is these types of aspects emigration systems, social integration, etc.
To begin with, the epidemiological, family, twin, and adoption studies on which this myth is based do not adequately support such assertions Leo, , ; Crow, ; Fleming and Martin, ; Joseph, ; James, However, and as these authors stress, the question is not the accuracy of the percentage, but rather the inextricability of genetics and environment, insofar as genetics itself is modulated by the environment even while we are in the womb.
The fact that schizophrenia runs in the family does not mean that it is in the genes; after all, religion and accent, for example, also run in the family. Furthermore, the passing on of schizophrenia via the family would be surprising, seeing as these individuals are by no means the most prolific reproducers Hare, , chap. In , these authors were confident that molecular genetics would confirm the statistical genetics. While the human genome has been described and ground-breaking methods and projects have been developed, the genes for schizophrenia are still nowhere to be seen.
From the most comprehensive genetic association study of genes previously reported to contribute to the susceptibility to schizophrenia, based on reasonable candidate genes, a large, rigorously phenotyped sample and a dense set of single nucleotide polymorphisms SNPs Sanders et al. Although the disappointing study focused on candidate genes may possibly continue, genetic research is adopting the genome-wide association studies GWAS paradigm.
In contrast to gene-specific candidate-driven studies, GWAS investigate the entire genome, in which hundreds of thousands of SNPs are tested for association with a disease in hundreds or thousands of persons. GWAS have revolutionized the search for genetic influences on complex traits, identifying hundreds of genetic variants that contribute to a variety of common traits and illnesses. But even though dozens of genes have been linked to a trait or disease, the individual and cumulative effects are disappointingly small, and far from sufficient for explaining the previously estimated heritability Manolio, Larger and larger samples are showing smaller and smaller effect sizes James, ; Leo, This disappointing finding has turned the issue of personal genomes into the case of the missing heritability, a veritable mystery Zuk et al.
There are several possibilities. A possibility is that the missing heritability consists, partly, in copy-number variations CNVs , emerging de novo , in an individual without family history of mutation Bassett et al.
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In reality, the majority of the genetic variants so far identified Sekar et al. A further possibility is that such or so much heritability simply does not exist, because it is over-estimated. As more is known about the genetics of schizophrenia, environmental factors appear to be the most important Stepniak et al. Epigenetics shows how there is environmental regulation of the genome and its functions, whereby the different genomic, contextual, and environmental components interact non-additively throughout development Gottlied, The behavior of organisms themselves, in this case the phenotype, influences the genome, both through its influence on the environment and directly.
Thus, in relation to schizophrenia, it has been possible to identify epigenetic mechanisms such as DNA methylation, histone modifications, and chromatin remodeling Rutten and Mill, What is important to highlight here is that these epigenetic changes occur in response to life adversities known to be associated with schizophrenia, such as abuse in childhood Read et al. Possible vulnerability to future experiences due to early epigenetic changes should be understood in the context of original and continued life adversities, according to bi-directional causality Gottlied, ; Laland et al.
The linear G-E model should give way to one of reciprocal influences that incorporates the phenotype van Os et al. The environment can shape phenotypes as well as inducing epigenetic changes. Phenotypes, that is, people's psychotic symptoms and adaptive efforts, can build environments which in turn induce and select epigenetic changes.
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Although phenotypes are never separated from the environment, we can conceive of their direct epigenetic influence, as way of life or continued pattern of response. Genetic dispositions can select environments and influence phenotypes, which in turn feedback influence in terms of genetic stability. In any case, what is involved is an ongoing and intricate interplay: environment-behavior-genetics.
However, the treatment of choice for schizophrenia is so-called antipsychotic medication. Notwithstanding the fact that it would be difficult to dispense with it, the truth is that antipsychotic medication presents at least three problems as the treatment of choice: 1 It is merely symptomatic, insofar as it ignores the circumstances that have led to the crisis.
Medication becomes the topic of subsequent visits—whether to maintain it, reduce it, change it, etc. The condition sine qua non in the psychotherapy of schizophrenia is a particular kind of therapeutic relation. This interpersonal encounter would be more focused on an understanding of the person's altered being-in-the-world experience than on repairing the supposed malfunctioning of a mechanical system Nelson et al.
Phenomenology offers a vision that situates patient's disorders not in the hidden circuits of their brains, nor in remote corners of their minds, but in the real word of their lives with others, in the Lebenwelt , which is, after all, the only world in which psychotherapy takes place Fuchs, An empathic bridge between the therapist and the patient is at the basis of possible recovery in schizophrenia. The space necessary for a person to emerge from the illness is opened up by means of the person being perceived by others as more than his or her illness Davidson, , p.
Within this approach, the narrative takes on special importance Roe and Lysaker, More specifically, the narrative can serve as a thread for re-authoring lives. What is behind the symptoms is a tormented, disconnected, disintegrated, diminished self. Narratives do not merely recount experience, but actually form it, insofar as the functions of language and hermeneutics are not only expressive, but also constitutive of one's own experience and personal history Raffard et al.
Acceptance is important in schizophrenia in relation to upsetting experiences, such as voices, the attempt at control of which is often more pernicious than beneficial. Acceptance has much to do with mindfulness, a more common application in cases of psychosis Abba et al. For its part, commitment consists in reorientation toward values significant for one's life, despite the fact that certain experiences persist and disturb.
Commitment is acting in the direction of values in spite of the distress caused by the symptoms. The question is not to wait until one gets better before going out and living, but rather to act and remake one's life so as to feel better, or at least, to be on the way to something, and not just shut up inside oneself. This reorientation of self-experiences toward values begins with the identification and clarification of one's own values.
We have proposed seven reasons, linked together, for a reconsideration of schizophrenia first and foremost as a disorder of the person, not of the brain.
Is schizophrenia disappearing? The rise and fall of the diagnosis of functional psychoses: an essay
The argumentational thread is the role of the self, of the subject or of the person in the disturbance for which schizophrenia is diagnosed. This thread is at the basis of each one of the reasons discussed.
The first reason deals with the actual conception of schizophrenia as a disorder of the experience of oneself and of the world ipseity , in accordance with criteria of a phenomenologically-informed psychopathology Fuchs, ; Stanghellini, Schizophrenia being an alteration of the basic self or center of gravity, it is understood as affecting the person in toto and his or her way of being-in-the-world Sass, ; Stanghellini and Rosfort, The second reason refers to its modern origin.
The third reason concerns the juvenile onset of schizophrenia, which has a dual implication in the perspective taken here. One is that adolescence, the period in which schizophrenia usually has its beginnings Harrop and Trower, , is a critical time in the formation of the self Erikson, Thus, certain normal characteristics of adolescence have aspects in common with the clinical manifestations for which schizophrenia is diagnosed Fonseca-Pedrero et al.
The other implication is that adolescence as a critical age is a historical phenomenon that coincides with the modern origin of schizophrenia, so that it is no coincidence that the name of the disorder avant la lettre —hebephrenia—denoted youth Stanghellini G.
The fourth reason, the better prognosis for schizophrenia in developing countries compared to those of the developed world, may also have to do with the role of modernization in the determination and configuration of schizophrenia Cooper and Sartorius, The fifth reason, referring to the high incidence of schizophrenia observed among migrants from traditional communities such as the former colonies of the West Indies in European cities, at the same time as calling into question the well-rehearsed genetic and neurobiological explanation, demands an alternative one in terms of social causes Morgan and Hutchinson, b.
The exposition of the sixth reason includes a reappraisal of the role of genetics in schizophrenia. Without negating its possible role, but not magnifying it either Joseph, ; Ross, , here genetics is not given primacy, but rather situated in the context of the conditions of life and of development, in accordance with epigenetics, whereby the decisive aspect in genetic terms is what occurs over the whole course of development.
Thus, environmental factors such as abuse as a child, disorganized attachment or the impact of emigration, may bring about epigenetic changes that predispose one to schizophrenia Read et al. Schizophrenia may indeed be hereditary, without being genetic Jablonka and Raz, The seventh reason, which closes the circle, is the possibility of a psychotherapy of schizophrenia, without detriment to its being complemented by drugs where necessary. The sensitivity of schizophrenia to psychological therapy is understood in accordance with the interpersonal context provided, a condition for the recovery of one's sense of self Fuchs, ; Stanghellini and Lysaker, If, as stated in our exposition of the first reason, schizophrenia stems from a crisis of the sense of self, a natural recovery involves the provision of an interpersonal context such as that of psychotherapy Davidson, The possibility of a psychotherapy of schizophrenia is based on the simple but fundamental idea that people diagnosed with schizophrenia are people, and continue to be so.
The reasons considered situate schizophrenia as a human condition—rather that a natural one—of historical-cultural origin and biographical nature, related to vicissitudes and circumstances of life. In any case, the nature of schizophrenia is and will continue to be controversial and for that very reason is worth a proposal such as the present one, which does not lessen the possibility of future improvements. The hypothesis and theory derives from all authors as a research group. MPA drafted the manuscript. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.