thmedicati keet uncontrol-- ok.as to where i don'become suical or homicidal. 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 additionastressth they h, and so it's not surprising th being exposed to comt tuations and atcities of various kinds in vieam led many peoe with the vulnerabityto schia to break down and ha the first . 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 ionaort,ly 2os may corite tohe onset of schiphrenia.

all of these may act as triggers for the init schizophrec episode. all of these may act as triggers 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 psychologil faors that may contribute to the onset of schizophrenia. chdhood experiences, unconscious conflicts, the natur some time,mily-- al, e usal factors. one itional the if conoveral viewily-- al, is the concept of the schizophrenogenic family in which overprotectiv or rejecting qualities the parents, especially theother, are thght to be associated schizophrenia in the child. the first theory was advanced by some of the earlier psychoanalytic theorists, and al about thschizophrenia as a result of certain famildynamics. it'shat we refer to asthe sch,

e schizophrenogenic mother, or schizophrenogenic father, referring to schizophrenia caused by mother, father, family. to indicate that there is some vality, again,ce in this theory, in some cases. this idea, that the family constellation and its dynamics is the major cause has cently been mofied. a broader approach to the roles has been developed. imptant question that'she roles 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 that 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 than blaming the other is looking at the effect that the schizophreniindividual 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 inating 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 tngs kind ofall apart, so there's a terble resonating as the psofallapt, place the effe othat on the other family members--

the grief, t glt, the prension, the desperation--i think, really, that, uh, then evolves in the trage of this illness. 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, thfamilyituation can be affected, this is chronic, disabling,and . by this kind of an illness. it's difficultor the pient. it difficult forhe fily, especially when the young person invold has had very promising rlier life ansuddenly is afflted anbecomes disabled. the family eeriences great amounts of stress. ansuddenly is afflted i would y so. disabled. i think th he was more or ls separated from the famy

and wanting to be secretive about what he was in jeff's parents discuss the diuption in their family when they firsrealized their son had schizophrenia. inhe vy rly age,of crs we were entirely, i mean, the whole experience s so new to us, and we certainly 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 illns 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 poi. like, i forget exactly what he did, but he acted crazy. that's thenly way to describe it. psychotic outbreaks. and weook m to-- the doctor sd he should be hospitalized, but gradually we realized that it was a full-blown cas of schophren and we realized at we d have to deal with the illness. dung the 12 yes jeff's been camillo stated hospital, his parents have visited him every saturday, ging him support at seems crucial

ring t courseof this di so, too, did famy and friends of david a former chestnut lodge patient who lives and works in boston. ousupport, the's no way a patient can make i u can't pullf upby your ris. e thing s always aware of ousuwas my inten gratitude for people around me. i couldn't expresst, but i'd go to bed thinking, "wt would i do if i was on the streets?" the most agonizing part of my illness s en i wasnformed that icouldn'. it didt occur to me that i'd have so much support. as it became me apparent that there would be people there for me, i became more optimistic aboumy future. there i just thoughtestion thati'd lose the fight.

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 treatmentof . until this point, up until the point when drugs we introduced in the 196, '7os, and '8os, the treatment of choice was electroconvulsive therapy, what is colloquially referred to as shock treatment. shock treatment's almostever edn schizophrenia anymore. it's used in other disorders more frequently. umdrug treatment has racally redud the length of hospitalizations. for example,n the 195os, the average schizophrenic would ay 353 days in a hospital-- in a pchiatric hospital. in 196o, after the beginning of drug treatments, the average schizophrenic would stay in a hospital 113 days. tremendous change. and in the 198os,

thaverage hospitalization foschizophreniis 18 days. you can see how enormous those differenceare. ug treatments ret the episode of schizophria thin weeks for about 9o% of schizophrenics. w, that doesn't mean cure schizophrenia. it means that it remits the symptom, the episode, and it also has been shown that relapse rates are about half when someone is treated with drugs when you comre with somebody who is not treed with drugs. the spect an offers a valuable opportunity to see how drugsfft the prefrontal cortex in acute schizophrenics. this spect scan showthe acvity in a normal individual's b when carrying out a cognitive task. the ominent red spot in the right frontal 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 thgh the medication doesn't remove the sptoms completely, as you'll see, it can make possle a amat change in thought process and behavior. haveou hadanfeelgs that pe were against you no. nothinlike that? pe were against you i don't like my eyes comi apart, thou. yos... what about yourair, tom?

, one time, i t the ea th the funs were tryinto drive me insane. read them, anthen i'd get all hyrtensed abouthat. i dn't necessarily knowanything, but th'd upsete greatly. theye pulling ur guts and insides-- mm-hmm and suckg you dry. who is they? do you know? my ste and. adon't know wd i't gets up there anes it, but i know thamy sters done some bad thgs. u actual feel adon't kyour inses gets up therbeing ll o?

ye. yeah. it scares me.ainful? um, at the mall, was nuts then. i was, uh, kneelg and praying. inublic? righoutsidthis restaurant athe mall. one the cfs came out stood there and look at anturn around and went back in. ere s a time where they we king me kneel and pray a lot. [dennis schulman the ma effects of the drug are significt, but like eve drug, whether talk about aspirin or antihypertensive medication, drugs have side effes. the side effects in the case of the antipsyotic medication typically are the dryness of the mth, the stiffening of the muscles, the tremors of the hands and the legs,

and the wot one by far is a conditi calledtardivdy. and the legs, what tardive dyskinesia is is disfiguring dturbance of motor control, rticularly in the face winvsmacking othe lips, chewing that goeon-- and somes people 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 dyskines 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 overt behavior. anit increases their ability theito communite.cess but again, i cannot emphasize enough

that drugs do not cure schizophrenia. ey treat theom that make it possible for the person to function at a much higher level than they would without the drugs, it's like the chare brown inhe charactesense. 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 th it doesn't do any good. it's not stopping the voices. it'sot that the voices come all the te, metimei hear friends, whersomemes family.m. 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 in the community aso level. in addition to medication, there are a variety of psychosocial intervens that can help ease this transitio from in- to outpatient. they include family erapy, which focuses on improving faulty communications ancan reduce relapse rates. group therapy, in which several pele wschizorenia meet wh a leader and work on soal interactions and relationship skis, and milieu therapy, an inpatient program that provides a therapeutic mmunity in whichatients share responsibilities andecision-making with a professional staff, preparing them for life outside the hospital sting. at the los angeles veteran's administration medical center, the skilraing progm alsoddresses issues of independent living, such as managing medication and its side effects. what are some things youhi you might looking for

to tell you the efct of the medicine? hypeension. hypertension. think about the medine u' taking. 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 youere havi? one ofhe things you'll be monitoring is the side effects of it, right? would you be monitoring, randy about youredicine? 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, drowsiness, 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 drugs ty take, skills training helps them learn to talk tooctors, besides helping patients manage tmake social nversation,take, ando suceveray tasks as plan and 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 learn w to cop ma of em have cognitiv difficulties whe they c always proc informion effectivel they may getart a message. they get the messagestord.

they may n it all how tand e developsoroiate rpon. anhelp theorgazeiece, it imporntt tonk of a pn as being permanently suffering from schizophrenia or being schizophrenic. a person can go for hours or days or weeks or months and not have 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 theboth how to improve the w in which they communicate and alsoow to enfy thkindof inftion that people need to help tm.

for instan, wi a doctor, if they're not fee well, they can say, "doctor, i'm shang a lot for "i can't writeoctor, i can'hold a cup of coffee, and it really bothers me a lot, "ani'd like you to fix it." that kind response is far more kely torovide the phycian with some real conc imaon about the exnt of the prob that kind response isholong is laed, and what wait's disablingorisc. and mecation, 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 ntrol ov both their thghts and behavior.

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 psychothepists believe thatnsig is possible, but it's through the therapist-patient relationship that progressis most oftene drsilver'sork es what she calls "rebuilding bridges," teaminupita 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 prty much immersed in uninkabldefeat, and the work that i do iso meet with them and um, areas of--of, um,ce maybe mutual interest a gradual develment of intest t of fragments of contact. , and, uh, with the understanding that wmay be working togethe t for a very long time,ct. and that if the going gets rough, that i'm here to go the distance thatwith them.eason 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, vy often, there's a rekindling of hope, and as the relationship with the doctor gbecomes something that they trelyeel they can depend on,, that, then, geralizes, d ey'll more reachable to other people in theommuni d enill start reaching outothers i ubt that at any point research will ever find a single cause of schizophrenia. when we talk about schizophrenia, wee talking about a complex, muitheoretical ideological system that in some cases, certain types of ideological factors are prary.

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.niaacan v you can entify peoplewith piatrs in most any city, onhetreetbecae of the, because of howhey 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 cwd inpite of their illness. what we pe f with sizophrenia

in the current state of the art inpiteis 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 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 ying--working-- i'm at an age where a n is--

when he's pastge 3o, he's a conrmed bachelor, and ve been tryingg-- i'm to get married. a n is-- th help talk to ladies. i'm a paranoid schizophrenic progress, and i'm getting better each and every day. the point i make with my father when we talk about this is that he says, "you're doing so well and trying so hard," and i always tell him,"i was . "i was always doing better than anyone expected "i was always doing tter than i expected of myself when we say,"hey, i'm, because was always fighting." nd i'm tryinto deal th something, and it ruining my life, or i don't know how to relate," y, it's ppening, d 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 beeve me. my parents and i my new experiment,d theye ar and, uh, my neprogram. we mt eversaay, at least, anon the 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 mean to leave them so 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 tr manage in brding care home setting until i can ma it on my own, if ever, again. ptioning performed by the national captiong institute, inc. captions copyrig 1991 alvin h. perlmutter

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