Elyn R. Saks

Recovery From Schizophrenia: With Views of Psychiatrists, Psychologists, and Others Diagnosed With This Disorder

As the concept of schizophrenia began to develop over a century ago, it was accompanied by little hope of recovery. As the second half of the 20th century began, new treatments and changing social conditions resulted in most long-term patients being discharged into the community. Many of these expatients showed more improvement than had been expected. Treatment approaches evolved to help these persons live better lives in the community. In the recent past, psychosocial and psychiatric rehabilitation approaches to treatment have increasingly incorporated perspectives of persons in recovery. These perspectives are explored with emphasis on how they have helped drive federal government and other perspectives on recovery. Particular attention is given to the varying views of psychiatrists, psychologists, and other highly trained persons who have themselves been diagnosed and treated for schizophrenia.

Ethical, Legal, and Clinical Considerations When Disclosing a High‐Risk Syndrome for Psychosis

There are complex considerations when planning to disclose an attenuated psychosis syndrome (APS) diagnosis. In this review, we evaluate ethical, legal, and clinical perspectives as well as caveats related to full, non- and partial disclosure strategies, discuss societal implications, and provide clinical suggestions. Each of the disclosure strategies is associated with benefits as well as costs/considerations. Full disclosure promotes autonomy, allows for the clearest psychoeducation about additional risk factors, helps to clarify and/or correct previous diagnoses/treatments, facilitates early intervention and bolsters communication between providers but there are important considerations involving heritability, comorbidity, culture, and stigma. Non-disclosure advances nonmaleficence by limiting stigma and stress (which may inadvertently exacerbate the condition), and confusion (related to the rapidly evolving diagnosis) in a sensitive developmental period but is complicated by varying patient preferences and the possibility that, as new treatments without adverse effects become available, the risk with false positives no longer justifies the accompanying loss of autonomy. Partial disclosure balances ethical considerations by focusing on symptoms instead of labels, but evidence that laypersons may interpret this information as a pseudo-diagnosis and that symptoms alone also contribute to stigma limits the efficacy of this approach. In addition, there are notable societal considerations relating to disclosure involving conservatorship, the reach of insurance companies, and discrimination. We advocate a hybrid approach to disclosure and recommend future research aimed at understanding the effects of stigma on clinical course and a renewed focus on those help-seeking cases that do not transition but remain clinically relevant.

Ethical issues in psychosocial interventions research involving controls.

Psychiatric research is of critical importance in improving the care of persons with mental illness. Yet it may also raise difficult ethical issues. This article explores those issues in the context of a particular kind of research: psychosocial intervention research with control groups. We discuss 4 broad categories of ethical issues: consent, confidentiality, boundary violations, and risk-benefit issues. We believe that, despite the potential difficulties, psychosocial intervention research is vital and can be accomplished in an ethical manner. Further discussion and research into these issues are warranted.

Improving classification of psychoses

Psychosis has been recognised as an abnormal state in need of care throughout history and by diverse cultures. Present classifications of psychotic disorder remain based on the presence of specific psychotic symptoms, relative to affective and other symptoms, and their sequence and duration. Although extant diagnostic classifications have restricted validity, they have proven reliability and most clinicians and some patients find them useful. Moreover, these classifications have yet to be replaced by anything better. We propose that an expansion of the subgrouping approach inherent to classification will provide incremental improvement to present diagnostic constructs-as has worked in the rest of medicine. We also propose that subgroups could be created both within and across present diagnostic classifications, taking into consideration the potential value of continuous measures (eg, duration of psychotic symptoms and intelligence quotient). Health-care workers also need to work with service users and carers to develop and adapt approaches to diagnosis that are seen as helpful.

How Occupationally High-Achieving Individuals With a Diagnosis of Schizophrenia Manage Their Symptoms

OBJECTIVE The study objective was to elucidate coping strategies utilized by individuals recovered from schizophrenia. METHODS This qualitative study enrolled individuals with schizophrenia who had reached a level of recovery defined by their occupational status. Diagnosis of schizophrenia was confirmed with the Structured Clinical Interview for DSM-IV. Current symptoms were objectively rated by a clinician. Surveys gathered information on demographic characteristics, occupation, salary, psychiatric history, treatment, and functioning. Audio-recorded person-centered qualitative interviews gathered accounts of coping strategies. Transcripts were summarized and coded with a hybrid deductive-inductive approach. RESULTS Twenty individuals were interviewed, including ten men. The average age was 40 years. Sixty percent of participants were either currently in a masters-level program or had completed a masters or doctoral degree. Eight categories of coping strategies were identified: avoidance behavior, utilizing supportive others, taking medications, enacting cognitive strategies, controlling the environment, engaging spirituality, focus on well-being, and being employed or continuing their education. Some strategies were used preventively to keep symptoms from occurring; others were used to lessen the impact of symptoms. Strategies were flexibly utilized and combined depending on the context. CONCLUSIONS Use of strategies in a preventive fashion, the effectiveness of the identified strategies, and the comfort individuals expressed with using several different strategies supported these individuals in achieving their occupational goals. The findings contribute to an overall shift in attitudes about recovery from schizophrenia and highlight the importance of learning from people with lived experience about how to support recovery.

Retributive constraints on the concept of competency: the Required Role of “Patently False Beliefs” in Understanding Competency to be Executed†

Scott Panetti understands that the state says it intends to execute him for the murder of his wife’s parents, but believes that the real reason that the state is acting—in league with the devil—is to prevent him from preaching the gospel. This case starkly poses the issue of what it is to be competent to be executed, a question that has received little attention in the courts and commentary. Is it enough to understand what the state says, or must one also form relatively correct beliefs about the matters bearing on one’s execution? The first I call the ‘‘magic words’’ test: if you can say ‘‘the state says it will execute me because I was convicted of murder,’’ this is enough for competency. The Supreme Court recently in the Panetti case itself denied this as the reason for execution: one must have a rational understanding of why one is to be executed that goes beyond recognizing what the state says. This article extends the Panetti analysis. First, it further explores and rationalizes the retributive basis for requiring more than the ‘‘magic words.’’ Second, it extends the analysis to other issues involved in competency to be executed—namely, beliefs about the crime and the execution no less than the reason for the execution. It proposes to use the concept of a ‘‘patently false belief’’ (PFB)—a concept with a robust history, both theoretically and empirically, in the context of medical and research decisionmaking—to evaluate how ‘‘good’’ one’s beliefs about the relevant matters must be. In short, the inmate must form no patently false beliefs about the crime, the punishment, or the connection between the two. Finally, the article proposes another basis for its competency standard—the ‘‘too much suffering’’ rationale. Behavioral Sciences and the Law Behav. Sci. Law 27: 1–27 (2009) Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/bsl.852

Why We Need Positive Psychiatry for Schizophrenia and Other Psychotic Disorders

That negative view persisted well into the late 20th century despite growing empirical evidence, especially from Europe, that this syndrome was associated with heterogeneity in course, including a favorable outcome in many persons. The bias was so ingrained that in the International Pilot Study of Schizophrenia, initiated in 1968, only the Washington center used developmental, prognostic, and follow-up outcome scales with multiple dimensions to capture the heterogeneity of course of illness; it demonstrated that the outcome was mainly predicted by developmental factors rather than by psychotic symptoms. A 1988 issue of Schizophrenia Bulletin (14:4) that contained reviews of several long-term follow-up investigations from Europe and North America, illustrated a wide range of courses including good outcomes. In a study in Vermont, Harding and colleagues2 followed a longitudinal cohort of individuals with schizophrenia for decades after initial hospitalization and found that one-half to two-thirds of them had substantial improvement.

Psychoanalysis and the psychoses: commentary on Kafka.

J ohn Kafka’s article is an extremely interesting musing upon the psychoanalytic treatment of patients with psychosis in the context of a psychoanalytic hospitalization, namely, at Chestnut Lodge. A hotbed of therapeutic and research activity, the Lodge provided therapists both a nurturing and a stimulating group process around treating patients with psychosis, a process that helped not only the individual patients but also the analysts and the field itself. Many interesting ideas arose in the context of work in this institution. Some of the prime questions raised remain with us today. Rather than address Kafka’s article point by point, I intend to discuss my own take on some of the issues he raises. I note also that I speak not as a researcher into the psychoanalytic treatment of people with psychosis, nor as a reader and purveyor of theories in articles by others on psychoanalysis of the psychoses. Rather, I speak as a patient with psychosis who has benefited enormously from psychoanalytic treatment, four or five times a week for over three decades (Saks 2007). I do this recognizing that I am an n of only one, so that my experience may not generalize to that of others; and that I may be wrong when I speculate even about my own case.

Approaches to neuromodulation for schizophrenia

Based on the success of deep brain stimulation (DBS) for treating movement disorders, there is growing interest in using DBS to treat schizophrenia (SZ). We review the unmet needs of patients with SZ and the scientific rationale behind the DBS targets proposed in the literature in order to guide future development of DBS to treat this vulnerable patient population. SZ remains a devastating disorder despite treatment. Relapse, untreated psychosis, intolerable side effects and the lack of effective treatment for negative and cognitive symptoms contribute to poor outcome. Novel therapeutic interventions are needed to treat SZ and DBS is emerging as a potential intervention. Convergent genetic, pharmacological and neuroimaging evidence implicating neuropathology associated with psychosis is consistent with SZ being a circuit disorder amenable to striatal modulation with DBS. Many of the DBS targets proposed in the literature may modulate striatal dysregulation. Additional targets are considered for treating tardive dyskinesia and negative and cognitive symptoms. A need is identified for the concurrent development of neurophysiological biomarkers relevant to SZ pathology in order to inform DBS targeting. Finally, we discuss the current clinical trials of DBS for SZ, and their ethical considerations. We conclude that patients with severe symptoms despite treatment must have the capacity to consent for a DBS clinical trial in which risks can be estimated, but benefit is not known. In addition, psychiatric populations should have access to the potential benefits of neurosurgical advances.

Avoidance of accelerated aging in schizophrenia?: Clinical and biological characterization of an exceptionally high functioning individual

OBJECTIVE To determine the clinical and biological characteristics of an exceptionally high functioning index person (IP) with schizophrenia in her mid-50s, which may represent compensatory mechanisms, and potentially, avoidance of the accelerated aging typically associated with schizophrenia. METHOD IP, 11 other women with schizophrenia, and 11 non-psychiatric comparison (NC) women were assessed with standard ratings of psychopathology, neurocognitive function, decisional capacity, and functional brain imaging. IP was also compared to a sample of demographically similar NCs (N=45) and persons with schizophrenia (N=42) on a set of blood-based biomarkers of aging related to metabolic function, oxidative stress, and inflammation. RESULTS IPs scores on working memory, and levels of brain activation during an affective face matching task in the left fusiform, right lingual, and left precentral gyri, exceeded NCs. IP was similar to NCs in severity of negative symptoms, most neurocognitive functions, decisional capacity, and brain activation in the left inferior occipital gyrus during a selective stopping task. IPs levels on 11 of 14 metabolic and inflammatory biomarkers of aging were better than NCs and the schizophrenia group. CONCLUSION Although speculative, results suggest a possible model in which superior working memory permits a person to be aware of the potentially psychotic nature of a thought or perception, and adjust response accordingly. Compensatory overactivity of brain regions during affective processing may also reflect heightened meta-awareness in emotional situations. Biomarker levels raise the possibility that IP partially avoided the accelerated biological aging associated with schizophrenia.