i have both those tendencies. usually the homicidal. they taught me too well. i've hurt lots of people. for those veterans who see combat, the's additional stress th they ha to deal with, for those veterans and so it's not surprising th being exposed to comt situations and atrocities of varis kinds in vietnam led many peoe with the vulnerabityto schia to break down and have the firs. it isn't only der the stress of war that symptoms of schizophrenia manifest. the challenges of new adulthood, whichand often involvte teens loss of ioort,arly 2os may corite tohe onset of schiphrenia. all of these may act as triggers for the initl schizophrec episode.

interestingly, onset for schizorenia at this age, under 25 uslly apies to men. onset for schizophrenia in women isater, after age 25. there are her psychological faors chdhood experiences, to tunconscious conflicts,nia. the natur se time,family-- al, e usal factors. one itional the if conoveral viewily-- al, is the concept of the schizophrenogenic family in which overprotective or rejecting qualities the parents, especially theother, are thght to be associated of schizophrenia in the child. the first theory was advanced by some of the earlier psychoanalytic theorists, and ital about thschizophrenia as a result of certain famildynamics. it's what we refer to as the schizophrenonic family, the schizophrenogenic mother, or schizophrenogenic father, referring to schizophrenia caused by mother, father, family.

to indicate that there is in this theory, in some cases. this idea, that the family constellation and its dynamics is the major cause has cently been modified. a broader approach to throle os has been developed. important question that's come out of more modern thinking in terms of psychopathology and psychology is whether possibly that an impairnt in a child can cause a family to react in a disturbed fashion, that it's possible that it's not all a one-way street ere the patient is a passive recipient of the family disorder, t th the family is reacting to the disorder already evident in subtle forms in the child. dr. ann silver of chestnut lodge plifies the notion of these complex mily interactions.

what's more alive an blaming the other is looking at the effect tt the schizophrenic individual or t preschizophrenic individual has othe family. denise ford, who's on the medical staff here, did her ph.d. thesis on the subject, d it was realla scinating piece of work, with early and developg who's schizophrenia alters the communication and mood pattern so there's a terble resonating in tthat takes place as things kind ofall apart, so there's a terble resonating as the psofallapt, place the effe othat on the other family members-- the grief, the glt, the apprension, the desperation- think, really, that, uh, then evolves .

whathere is good evidence for is that the family, just as awhere a personwith a sg and often bie and unpredictable lness is living and interacting, thfamily situation can be affecd, can be seriously affected by this kind of an illness. this is a chronic, disabling,an. it's difficultor the pient. it difficult forhe fily, especially when the young person involved has had very promising rlier life ansuddenly is afflted byhis illness anbecomes disabled. the family eeriences great amounts of stress. i think that he was more or ls separated from the famy and wanting to be secretive about what he was doing. jeff's parents discuss the disruption in their faly when thefirsrealized their son had schizophrenia.

inhe vy y stage, of crs we were entirely, i mean, the whole experience s so new to us, and we ctainly did not connect the experience with schizophria that's something thawe lrned about as time went on, and, uh, having no background wain this illness,y. why, we just didn't know how to take it, but as time went on, we realized that there was somg and that there was illness involv... and, uh, we d as much as we cod to learn about the illness, and for months, after we tried one psychiatrist after another, and no one seemed to be able to--be able to help directly.

well, jeff sort of acted up at one point. like, i forget exactly what he did, but he acted crazy. th's thenly way to describe it. psychotic outbreaks. and weook him to-- the doctor said he should be hospitalized, but gradually we realized that it was a full-blown cas of schophren, and we realized that we d have to deal with the illness. dung the 12 years jeff's been camillo stated hospital, his parents have visited him every saturday, giving him support at seems crucial ring t courseof this di so, too, did family and friends of david a former chestnut lodge patient who lives and works in boston.

thousupport,here's no way a patient can make i u can't pullf upby your ris. e thins always aware of thouwas my inten gratitude for people around me. i couldn't express it, but i'd go to bed thinking, "wt would i do if i was on the streets?" was en i was informed that icou. of my illness itidt occur to me ast became more apparentpport. that there would be people thereor me, i became more optimistic aboumy future. there was never a question that i'd stop fighting. i just thoughti'd lose th. there is nothing that happened in the field of abnormal psychology, and particularly in the work with schizophrenia, that has revolutionized the work

more than the drug treatment of schizophrenics. unt this point, up until the point when drugs were introduced in the 196, '7osand '8os, the treatment of choice was elecoconvulsive therapy, what is colloquially referred to as shock treatment. shock treatment's almostever ed in schizophrenia anymore. it's used in other disorders more frequently. umdrug treatment has radically redud the length of hospitalizations. for example,n the 195os, the avage schizophrenic would ay 353 days in a hospital-- in a pchiatric hospital. in 196o, after the beginning of drug treatments, the average schizophrenic woul. tremand in the 198os, thaverage hospitalization foschizophrenia is 18 days. you can see how enormous those differenceare. ug treatmes ret the episode of schizophria

within weeks for about 9o% of schizophrenics. now, that doesn't mean cure schizophrenia. it means that it remits the symptom, the episode, and iare about half whenwn someone is treated with drugs when you comre with somebody who is not treated with drugs. the spect scan offers a valuable opportunit see how drugsfft the prefrontal cortex in acute schizophrenics. this spect sn showthe acvity when carrying out in a cognitive task.al's brain the ominent red spot in the right froal cortex indicates there's activity in this part of the brai that's used for planning and other executive functions. in the unmedicated chronic schizophrenics, there's no red spot in the top right. this means that the prefrontal cortex hasn't been activated in these patients.

once on phenothiazine medication, the scans of chronic schizophrenics show a marked difference. although there's no prominent red spot, as in the normals, it reflects more normal functioning in that brain region. for most medicated patients, symptoms of schizophrenia can be reduced markedly thfollowg patits are presented off d then on although the medication esn't remove the sptoms completely, you'll see, it can make possle a dramat change in thought process and behavior. haveou had anfeelgs that pe were agast you . nothinlike that? pe were agast you i don't like my eyes comi apart, though. yos... whatbout yourair, tom?

, one time, i t the ea th the funs were tryinto drive me insane. ad them, and then i'd get all hyrtensed about that. i dn't necessarily knowanything, they're pulling at your guts and insides-- but th'd upset me greatly. mm-hmm and suckg you dry. who is they? my ste and.you know? and nurses and i't sewho, reay. don't know w gets up there and es it, bui know thamy sters done some bad thgs. u actual feel your ies being ll o? ye. u actual feel your ies yeah. it scares me.ainful?

um, at the mal was nuts then. i was, uh, kneg and praying. inublic? righoutsidthis restaurant athe mall. one the chefs came out stood there and look at anturn around and went back in. ere was a time where they we kinge kneel and pray a lot. [dennis schulman] the main effects of the drug are significant, but like eve drug, whether talk about aspirin or antihypertensive medication, drugs have side effes. the side effects in the case of the antipsyotic medicatio typically e the dryness of t mouth, the stiffening of the muscles, the tremors of the hands and the legs, and the worst one by far is a conditi calledtardivdy. and the legs, what tardive dyskinesia is is disfiguring disturbance

of motor control rticularly in the face winvsmacking othe lips, chewing that goeon-- and somes pele misinterpret tse symoms as part of the schizophrenia when in fact it's a by-product of the drugs that we the treatment for schizophrenia. the horrible problem about taive dyskinesia is that people can develop it even if they're no longer on the drug, and there no way to reverse it. the main effect of t drug, the thing the drug does do, is that in many cases it normalizes the person's overt behavior. anit increases their ability theito communite.ss but again, i cannot emphasize enough that drugs do not cure schizophrenia. they treat the symptom that make it possible that drugs do not cure for the person to function at a much higher level than they would without the drugs,

but it's not a cur inheypical sense. it's like the charlie brown characte has his dust blank-- has his blanket, and it's a security for him. and it's like the medication, when you first get on it, it's like a security for you, but after a while, you notice that it doesn't do any good. it's not stopping the voices. metimei hear friends,s whersometimes family. sometimes my friend paul talks me. leslie's vces are likely to plague him for the rest of hilife, but for many patients with schizophrenia, medications do provide a means for effectively relieving major symptoms, allowing a return to living inhe community asome level. in addition to medication,

there are a variety of psychosocial intervenons that can help ease this transitio from in- to outpatient they include family erapy, which focuses on improving faulty communications and can reduce relapse rates. group therapy, in which several pele witschizophrenia meet wh a leader and work on soal interactions and relationship skills, and milieu therapy, an inpatientrogram that provides a therapeutic mmunity in whichatients share responsibilities andecision-making with a professional staff, praring them for life outside the hospit sting. at the los angeleseteran's administration medical center, the skilraining progm alsoddresses issues of independent living, such as managing medication and its side effects. what are some things you thi you might be looking for to tell you the efct of the medicine? hypertension. hypertension. think about the medine you' ting. what medine doou take?

mellaril. well, i did. so witmellaril, you would be looking for the effect of mellaril onou, right? yes. sleepiness, um, anxiy. at about anxiety? i get it when i tk mellaril. ok. mellaril made you anxious, so iwas side effect that you were havi? one of the things you'll be monitoring is the side effects of it, right? would you about youredicine?dy i happen to take a lot of medicin mainly sinequan. navane for voices, sinequan for depression and schizophrenia. i take cogentin. i take klonopin. i take, uh, uh, clonidine, and with all these different medications, i take them at different time schedules. one of the things that i always look for is how my appetite is,ferent whether or not i slept well, drowsine, if i'm tired or not, if i'm alert or not,

whether i'm constipated or not. all right. besides helping patients manage the panoply of dgs ty take, skills training helps them learn to talk to doctors, make social nversation, ando suceveryday tasks as plan d cook dinner. these are the same executive functions of the prefrontal cortex that the spect scan seen earlier showed to be abnormal in sizizophrenic patients. social skills training is a way of helping the patient arn w cop ma of them have cogniv difficulties whe they c always proc informion fectivel they may getart a message. ey get the messagestord. they may n it all. swe ceam ep bst,insoci skis ni piece by piece,

how tand e developsomepproiaten. and he theorgaze it important t tonk of a person as being permanently suffering from schizophrenia or being schizophrenic. a person can go for hours or days or weeks or months and not ve these disabling symptoms of schizorenia.atment so treatment, to be most helpful and to enable a person to be effective in getting back on tck in life, has toe link t the person's current state. whenhecome to us, we can teach thebo how to improve the way in which they communicat and al how to enfy thkinds of infortion that peoplneed to help them. for instan, wi a doctor, if they're not fee well, they can say, "doctor, i'm shang a lot "i can't write i can'hold a cup of coffee,

they can say, and it really bothers me a l, "ani'd like you to fix it." that kind response is far more kely torovide the phycian wh some real conc infmaon about the exntf the prob holong is laed, and what wait's disablingor di. and medication, various kinds of psychotherapy are used in the treatment of thechizophrens. the goals are to help patients understand their illness, to help them identify and manage their needs, including that of a safe environment, anto help them gain control over both their thghts and behaor. and in the psychodynamic treatmt of schizophrenics, it's different than treatment of anxiety disorders. in anxiety disorde, the focus of the treatment is on insight,

whereas the psychodymic treatment of schizophrenia has to do with developing a new parental relatiohip. it's the nature of the positive relaonship between the patient and the analyst that is curative in this form of treatment. some psychotherapists believe thatnsig is possible, thbut it's through the intherapist-patient relationship that progressis most often. dr. silver'sor what she calls "rebuilding bridges," teaming upita tit by talking, listeng, drand being a constant source of support throughout the illness. by andarge, the patients i've worked with have been sick for many years. they've worked with manyoctors. they've had many expiences of defeat. they've been on many medications, either individually or in combinatio, and, uh, come pretty much immersed in unthinkabldefeat,

and the work that i do iso meet with them and um, areas of--of, um,cewher. maybe mutual interest or a gradual development of intest t of fragments of contact. um, and, uh, with the understanding that we may be working togethe t for a very long time,ct. and thatf the going gets rgh, that i'm here to go the distance thatwithhem. reason touit, david was dr. silver's patient at chestt lodge. my relationship with my doctor was one of distrust, admiration, and gratitude with a slight bit of trust.very. it's getting bigger because i'm still in contact with her.

initially, the patients will hardly ever believe it's that anything goodause i'm sis going to come of it.r. gradually, very often, there's a rekindling of hope, and as the relationsp with the doctor gbecomes something that they treally feel they can depend on, that, then, geralizes, and ey'll more reachable to other people in theommuni d enill start aching outothers i ubt that at any point research will ever find a single cause of schizophrenia. when we talk about schizophrenia, wee taing about a complex, muitheoretical ideological system that in some cases, certain types of ideological factors are primary. in other ces, certain other ideological factors are primary, but th search for the single caus i think by definition,

will end up being fruitls. what we have to do is get better at doing research on combining theory and coining treatmts. no matter what the future brings in terms of at more normal lives.reniaycav in most any city, you can entify peoplewith piatrs because of how theycae of tk conduct themselves, because of how they interact and talk. we try to teh them the kis of skills that will able them to fade into the crowd inpite of their illness. what we pe f with sizophria in the current state of the art is effective control, rehabilitation, and management, and that in this sense, the role of the psychotherapist,

the behavior therapist, e social therapist, the rehab therapist, all the other social a psychological interveners, is important. even if we take the hard view that schizophrenia is exclusively underood as a biological disease caed by biological factors and maintained by biological factors, nevertheless, there is fairly strong evidence that there are psychological and social interventions which can help that schizophrenic patient, usually in conjunction with antipsychotic drugs, can help that schizophrenic patient to maka better adjusent to the world than was made before. there's been some changes. i learned how to slow down my speech when i take my time and speak slowly. i was ng--working-- i'm at an age where a man is-- when he's past age 3o, he's a confirmed bacher, and ve been trying- i'm to get married. a man is-- th help talk to lads.

i'm a paranoid schizophrenic progress, and i'm getting better each and every day. the point i make with my father when wtalk abo this is that he says, "you're doing so well and trying so hard," ani always tell him,"i was al. "i was always doing better than anyone expected "i was always doing better than i expected of myself because was always fighting." when wsay,"hey, i'm a, "and i'm trying to deal th something, and it rng my life, or i don't know how to relate," hey, it's ppening, and you haveo acknowledge that, but science doesn't want to acknowledge that. that's part how they mess up your kids. they called me a cub scoutnt they said i was deluded. he didn't believe me.

they're all fori my new experimentll, and, uh, my neprram. we mt eversaay ateast, anonhe phone during the morning hours, and i like them a t, and i ve them. they'll always do the best for me i didn't mn to leave them early in li. after al 19 years old can be very young to leave home. some people don't leaveunt. all i know is that my parents and i get along very well, to make a long story short. hopefully, if i can't live out there on my own and have my own individual le, then i'll li in a boardincare home where i can build up my self-esteem, my o life, and try manage in brding care home setting until i can ma it on my own, if ever, again.

ptioning performed by the national captiong institut inc. captions copyright 1991 alvin h. perlmutter

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