Diagnostic discussion
There are a variety of diagnostic definitions of schizophrenia. Jansson, et. al., identify “at least 15” from from the 1970’s to the early 2000’s (Jansson, et. al. 2002). While there is mostly overlap -- especially for key symptoms such as delusions, hallucinations, and disordered thoughts -- there is sufficient disagreement in the details of the criteria to vary the diagnostic outcomes. Jansson and company used eight different systems, including the ICD-9, 10, and DSM-IV, to compare diagnoses for 155 first-admitted patients suffering from psychotic symptoms. After they dropped the ICD-10 “simplex” definition for being too broad, 108 patients were diagnosed with schizophrenia by at least one of the systems; however, only 14 of the cases were diagnosed by all the systems (Jansson, et. al. 2002). The ICD-9 criteria diagnosed the most (89), while the ICD-10 diagnosed the least (35). The ICD-10 and the DSM-IV were the most in-synch with each other, with a kappa interrater agreement of 0.823 (Janson, et. al. 2002).
I was not able to find a more recent, similar test comparison of the various diagnostic criteria, but Ruben Valle in a 2020 article neatly compares the ICD-11 with the ICD-10 and DSM-5. He finds the ICD-11 and DSM-5 very similar, with two notable variations: 1) the DSM-5 includes functional disability as a criterion, while the ICD-11 does not specifically discuss functionality; 2) while both the DSM-5 and the ICD-11 require the psychotic symptoms to persist for at least one month, the DSM-5 additionally requires that some symptoms of the disorder persist for at least six months (Valle 2020). One key difference in both the DSM-5 and ICD-10 from their respective predecessors is the lack of subtypes (e.g., paranoid, hebephrenic, catatonic, etc.). Valle explains that the subtypes had “little clinical utility, low diagnostic stability, no heritability and no influence on treatment” (Valle 2020).
Working in America I will need to be most familiar with the DSM diagnostic system. In the DSM-5 schizophrenia is in the category “schizophrenia spectrum and other psychotic disorders” (APA 2013), which, as Valle notes, is a nod toward a dimensional view of mental health conditions, even though the DSM and ICD are still mostly in the categorical camp (Valle 2020). The DSM-5 notes five key features of the disorders in this group, including schizophrenia: 1) delusions, 2) hallucinations, 3) disorganized speech, 4) grossly disorganized or catatonic behavior, 5) negative symptoms (APA 2013). For a schizophrenia diagnosis, the person must display two out of the five persistently over at least one month, with at least one of those two coming from 1, 2, or 3. The person must be functionally impaired to some degree in one or more major areas of life. “Continuous signs of the disturbance” must occur over a six month period (APA 2013). Other diagnoses or causes of the symptoms -- such as bipolar disorder with psychotic features, “organic” causes, substance use, medication side effects, etc. -- must be ruled out. And finally the DSM notes that if the person has been diagnosed with autism spectrum disorder or another communication disorder in the past, then the person must show “prominent delusions or hallucinations” over a one month period (APA 2013).
David Castle and Peter Buckley, in their introduction to schizophrenia for the Oxford Psychiatry Library, categorize the key features and symptoms of schizophrenia as positive, negative, and disorganizational (Castle, Buckley 2015). Positive symptoms consist of delusions and hallucinations. Negative symptoms are depressed or flat affect, apathy, and social withdrawal. Castle and Buckley note that depression often goes untreated in people with schizophrenia because depressive symptoms can be assumed part of the negative features of schizophrenia (Castle, Buckley 2015). Disorganizational symptoms are disordered actions, disordered thoughts, or inappropriate affect. Castle and Buckley also include other cognitive symptoms beyond thought disorder - such as memory problems, motor functioning problems, executive functioning problems, and communication problems. While these cognitive issues are not as central to the diagnosis as delusions and hallucinations, they can do quite a bit to impair the daily and vocational functioning of people with schizophrenia (Castle, Buckley 2015).
Many of the authors on schizophrenia I have perused mention the wide diagnostic overlap between schizophrenia and other disorders. Depression, obsessive-compulsive, bipolar, and post-traumatic stress disorders can all come with delusions or hallucinations. Alcohol and drug use -- both licit and illicit -- can also cause psychotic symptoms, as can “organic” problems like brain tumors and traumatic brain injuries. People with symptoms of schizophrenia that do not last a full six months may be diagnosed with schizophreniform disorder. Or, if the symptoms, when they are highly active, are accompanied by a major depressive or manic episode then the person may be diagnosed with schizoaffective disorder. A “brief psychotic disorder” includes the same active symptoms as schizophrenia but lasts less than a month and does not recur regularly (APA 2013). Schizotypal personality disorder includes schizophrenic-like symptoms that are less intense but consistently associated with a person’s personality (APA 2013). Castle and Buckley stress that it may be hard to give a definitive diagnosis when people first seek treatment for psychotic symptoms. Doctors may need to use a “working diagnosis” to start treating what they can while continuing to investigate diagnostic possibilities (Castle, Buckley 2015).
Historical discussion
The tap-root of current definitions of schizophrenia is Emil Kraepelin’s “dementia praecox,” which he characterized as a condition predominantly male, with young-adult onset of delusions, hallucinations, and disordered thinking which typically did not improve over time (Hewitt 2007). Eugen Bleuler first introduced the term ‘schizophrenia’ in a 1908 lecture and 1911 book, in which he proposed renaming Kraepelin’s dementia praecox to “the group of schizophrenias (Maatz 2015). Bleuler thought that a “splitting” up (schizein-phrenos, split-mind) of mental functions or associations was a key symptom of the group of schizophrenias (Maatz 2015).
The term stuck, and at about the same time understandings of the disorder took a psychodynamic turn. In the middle of the 20th century doctors and clinicians tended to view schizophrenia as the consequence of an intense, inner emotional conflict (Luhrmann, Marrow 2016). Much of the blame was placed on the “schizophrenogenic mother” (Luhrmann, Marrow 2016). Many children and adults with what today would be called “autism spectrum disorder” were diagnosed with schizophrenia. In the 80’s and 90’s the biomedical perspective took hold and returned in part to Kraepelin’s understanding of the disorder as a brain disease.
Current views of schizophrenia stress strong genetic influence, neurodevelopmental abnormalities, neurochemical processes, and socioeconomic risk factors. However, schizophrenia as a concept has not been externally validated and is very much a clinical diagnosis based on signs and symptoms (Castle, Buckley 2015). There are no physical or behavioral “tests” that can prove a person has schizophrenia, and there are no “pathognomic” signs or symptoms, that is -- symptoms specific only to schizophrenia (Castle, Buckly 2015). Geneticists have identified vulnerabilities and genetic associations with schizophrenia but no single genetic cause or set of causes. The “dopamine hypothesis” helps to explain a lot about the mechanics of the disorder, but it does not account for everything (Castle, Buckley 2015).
Prevalence
The DSM-5 says the lifetime prevalence of schizophrenia is about 0.3%-0.7% (APA 2013). Other sources place the prevalence rate at about 1% (Castle, Buckley 2015), about 0.14-0.46% (Seeman 2016), or about 0.5-0.7% (Asarnow, Forsyth 2017). Prevalence rates seem to be slightly higher in “western” countries than non-western, and higher in socioeconomically disadvantaged communities within those western countries. The prevalence rate of childhood onset schizophrenia -- which diagnostically is basically the same -- is unclear but estimated to be much lower, probably less than .01% (Asarnow, Forsyth 2017).
Risk factors
Although there are no clear cut “causes” of schizophrenia, there are a variety of predictive “risk factors.” Genetics is the primary one. If both a person’s parents have schizophrenia, the person has a 46% chance of also developing the condition; with one parent the chance is 13%; with a sibling the chance is 10%; and with a grandparent the chance is 4% (Castle, Buckley 2015). If one monozygotic twin has schizophrenia, there is a 50% chance the other twin has or will have it as well (Castle, Buckley 2015). Another way of describing the genetic influence is to say that about 80% of the variance between developing schizophrenia or not is due to genetics (Seeman 2016). On the other hand, this is not to say that people develop schizophrenia only if it runs in their family. The DSM-5 notes that “most individuals who have been diagnosed with schizophrenia have no family history of psychosis” (ADA 2013). Also, much of the genetic material associated with schizophrenia is also associated with other neurodevelopmental disorders, such as autism spectrum disorder (Castle, Buckley 2015).
An “excess of de novo copy number variants” -- sometimes associated with older fathers -- is another genetic risk factor, increasing risk up to 14% (Castle, Buckley 2015). The male chromosome is traditionally a risk factor, although the DSM-5 notes that depending on how schizophrenia is defined the male/female prevalence rates may be more male or more even.
Castle and Buckley point to important research into the higher rates of schizophrenia among Afro-Carribean migrants in the U.K., even though the prevalence rates of schizophrenia in their countries of origin are the same or lower than the U.K.’s (Castle, Buckley 2015). Similar studies have identified other socioeconomic disadvantages as risk factors, small compared to genetics but significant nonetheless (Luhrmann, Marrow 2016). T.H. Luhrmann and Jocelyn Marrow, in a cross-cultural analysis of schizophrenia, suggest the term “social defeat” as a way to understand how psycho-social-economic experiences of being ‘put down’ and demeaned can slightly increase the risk of developing schizophrenia and greatly impact the course and outcome of the disorder. Experiencing childhood trauma, specifically sexual and physical abuse, appears to be another small risk factor for developing schizophrenia (Coughlan, Cannon 2017).
Two very weak risk factors, potentially related, are the season of birth (late winter/early spring) and the mother’s exposure to the flu while pregnant (Castle, Buckley 2015). Maternal anaemia, starvation, and vitamin D deficiency are also very slight risk factors (Castle, Buckley 2015). An interesting risk factor Castle and Buckley discuss is the use of cannabis. For people with certain rare genetic vulnerabilities, THC seems to induce the onset of schizophrenia (Castle, Buckley 2015).
The dopamine hypothesis
According to many of my introductory sources, the “dopamine hypothesis” is the strongest explanation of how schizophrenia exists in the brain. This research took off after certain drugs were discovered to help decrease psychotic symptoms. Many of these drugs are hypothesized to work by binding to dopamine receptors and antagonizing dopaminergic pathways. Other drugs, like amphetamines, have the opposite effect, increasing the release of dopamine, and sometimes cause psychotic symptoms (Castle, Buckley 2015). In other words, too much dopamine, especially in the mesolimbic pathway, is strongly correlated with psychotic symptoms. However, other neurochemicals have been implicated, such as glutamate and serotonin, in the mechanics of schizophrenia, as have other aspects of the brain - such as inflammation, enlarged third and lateral ventricles, decrease in grey matter, abnormal myelination of nerve tracts, and white matter changes in the front and temporal lobes (Seeman 2016).
The development and course
Schizophrenia typically develops in young adulthood, between the late teens and mid-30’s, with onset for males generally earlier than for females (APA 2013). Onset rates for men and women both dip after early adulthood, but for women they pick back up a little bit after menopause (Castle, Buckley 2015). The DSM-III stated that schizophrenia should not be diagnosed in people over 45, but more recent versions have dropped this criterion (Castle, Buckley 2015). There seems to be some continued disagreement about whether or not late-onset schizophrenia is a separate disorder.
Onset is defined by the first psychotic episode, or “frank psychosis,” but some research suggests that certain cognitive symptoms of schizophrenia can be observed from childhood, which would fit with the neurodevelopmental view of schizophrenia (Castle, Buckley 2015). Psychotic symptoms can begin in childhood, of course, but schizophrenia cannot be reliably diagnosed until after age seven (Asarnow, Forsyth 2017). The onset of symptoms may be more or less rapid and dramatic, but typically symptoms gradually appear during a “prodromal” phase until the “first episode psychosis” (APA 2013).
Traditionally the “course” of this disorder has been described as chronic with a poor outcome and very little chance at recovery. Kraepelin estimated chances of recovery at 2.6-5.5%, but more recent data is much more optimistic (Hewitt 2007). Roz Hewitt in her guide to schizophrenia reports data that about 16% will recover and never suffer from schizophrenic symptoms again (Hewitt 2007). Jaaskelainen, et. al, report a similar recovery rate, above 14% (Jaaskelainen 2013). The estimated recovery rate from a “first episode psychosis,” which includes more than those initially diagnosed with schizophrenia, is even higher, at 38% (Lally, et. al., 2017). The DSM-5 states that, while only a small number of people diagnosed with schizophrenia will recover completely, the “course appears to be favorable for about 20%” (APA 2013). Castle and Buckley write that about one quarter of patients will recover to premorbid functioning levels, about one third will have recurrent bouts of psychosis but will function well during the intermorbid periods, and about 40% will have a “poor outcome” (Castle, Buckley 2015). [what about the leftover%?] Typically symptoms are most intense during the first 5-10 years of the condition, and abate somewhat with age (Seeman 2016).
Some cross-cultural data suggests that intermorbid functioning tends to be better outside of western contexts (Luhrmann, Marrow 2016). In addition to slightly lower prevalence rates in the “developing world” (specifically India) than in the west, the NARP version of schizophrenia (non-affective acute remitting psychosis) is more common in non-western contexts (Luhrmann, Marrow 2016). With this condition psychotic symptoms occur sporadically but they remit quickly and completely.
Treatment
Antipsychotic medications are the core treatment for schizophrenia. These drugs are often classified into two groups: the first generation, or “typical” antipsychotics, and the second generation, or “atypical” (although Castle and Buckley point out that the atypicals are not really a ‘class,’ as they do not all target the same neurochemical processes) (Castle, Buckley 2015). Typical antipsychotics, beginning with chlorpromazine in the 1950’s, reduce psychotic symptoms with a “dopamine blockade,” binding to D2 dopamine receptors (Castle, Buckley 2015). However, these drugs do not usually provide much relief from negative or cognitive symptoms, and in fact sometimes make the negative symptoms worse. Additionally, long-term use of these drugs can produce extra-pyramidal side effects: Parkinsonism, distonias, dyskinesias, and akathisias (Castle, Buckley 2015). Atypical antipsychotics are generally about as effective as typicals for psychotic symptoms, but do not tend to produce the disabling extra-pyramidal side effects. Some of these drugs may also help with negative and cognitive symptoms, or at least they do not tend to make negative symptoms worse (Castle, Buckley 2015).
The most effective antipsychotic is clozapine, but it has a particularly risky side effect profile, including serious cardiovascular problems. Castle and Buckley suggest that clozapine should not be administered unless at least two other drugs have been tried first (Castle, Buckley 2015). Antipsychotics are not usually combined, but this is sometimes safe and effective when no single drug is effective for all symptoms (Castle, Buckley 2015).
Electroconvulsive therapy is not common for treating schizophrenia, but may be used for those who are also suffering from severe, treatment resistant depression. Transcranial magnetic stimulation has also been tested, but results are mixed (Castle, Buckley 2015).
Psychotherapy treatments, such as cognitive behavioral therapy and acceptance and commitment therapy, while not directly ameliorating psychotic symptoms, can help with all the stress and functional impairment caused by psychosis. CBT or motivational interviewing may be employed to help with medication adherence and guard against relapse (Seeman 2016). Cognitive enhancement therapy or cognitive remediation therapy may also help counteract some of the cognitive symptoms of schizophrenia. For treatment resistant delusions or hallucinations, psychotherapies have had mixed results (Castle, Buckley 2015). Some therapeutic approaches, like the Hearing Voices Network or Avatar therapy, attempt to help people with schizophrenia find a more positive relationship with their hallucinations (Luhrmann, Marrow 2016).
Individual psychotherapy and group therapy may be most critical in combating comorbid conditions. People with schizophrenia have very high rates of depression, anxiety disorders, and substance use disorders (Castle, Buckley 2015). An estimated 20-50% of people with schizophrenia attempt suicide, and approximately 10% die by suicide (Seeman 2016). Castle and Buckley stress the fact that people with schizophrenia are way undertreated for comorbid mental and physical conditions (Castle, Buckley 2015).
Social and Vocational Effects
Not only do people with schizophrenia have to deal with the symptoms they experience, but the stigma of the condition is particularly harsh. The stigma of the diagnosis is so strong that several campaigns have been launched to rename the disorder (Lasalvia, et. al. 2019). National psychiatric bodies in Japan, South Korea, and Taiwan have already done this, and some evidence suggests the name change has improved client-doctor communications and public attitudes towards those with the condition (Lasalvia, et. al. 2019). Doctors in India, as opposed to the U.S., tend to exercise more “diagnostic neutrality” when talking to patients and their families; they tend to focus more on the treatment and possibilities for improvement (Luhrmann, Marrow 2016). Luhrmann and Marrow speculate that this more diagnostically neutral stance may contribute to the better outcomes for people with schizophrenia in India as compared with the U.S. (Luhrmann, Marrow 2016).
Social isolation is a major challenge for people with schizophrenia, espcially in western cultures. Most people with schizophrenia do not marry (Seeman 2016). Castle and Buckley list several reasons why people with schizophrenia may experience social impairment: depression, anxiety, persecutory delusions, cognitive impairments, among others (Castle, Buckley 2015). These mostly have to do with the person, but we could make a similar list of reasons why western societies are not actively inclusive of people with schizophrenia: discomfort with ‘unusual’ behavior, the stereotype of a violent psychopath (people with schizophrenia are much more likely to be the victim of violence), fear of saying the wrong thing or triggering the person, and so forth. Luhrmann and Marrow point out that in the United States people with mental illness are constantly faced with opportunities for “social defeat,” and many people with schizophrenia end up on the “institutional circuit” of hospital, prison, shelter, transitional housing, etc. (Luhrmann, Marrow 2016).
Connected to social challenges are employment challenges. A 2013 study in Denmark found people with schizophrenia only have a 18% employment rate in that country, despite the fact that “a significant number of people with schizophrenia consider employment and education the most important factors in their recovery process” (Greve, Nielsen 2013). Interestingly, Greve and Nielsen found this drop in employment beginning six years before people received their first inpatient treatment. There has been some conflicting evidence about how or whether the “duration of untreated psychosis” (DUP) affects the long-term course of schizophrenia (Castle, Buckley 2015). This study would suggest that, regardless of whether beginning drug therapy earlier or later affects long-term outcomes, beginning psychosocial and vocational therapies as early as possible could improve people’s short-term and long-term quality of life.
With the development of supported employment programs, particularly the Individual Placement and Support model, Robert Drake writes in the Schizophrenia Bulletin, “Employment is now a realistic goal for the majority of people with schizophrenia and other severe disorders, not just a future goal for a small minority” (Drake 2017). Metcalfe, et. al., found that people who received IPS were more than twice as likely to achieve competitive employment than those who received other types of vocational rehabilitation support (Metcalf,e et. al. 2017). The Job Accommodation Network website, askjan.org, provides a wealth of accommodation possibilities for the workplace and the home, most of which I would say fall into two categories: in-person psychosocial support -- like mentors, counselors, job coaches, group therapy -- and very simple cognitive support technology -- like reminders, noise or stress reducing measures, checklists, flexible breaks or flexible work schedules (askjan.org).
The potential ripple effects of schizophrenia on a person’s life are wide ranging. People with schizophrenia have higher rates of cardiovascular problems, diabetes, obesity, cigarette smoking, mortality due to cancer, homelessness, imprisonment, violence and victimization, and as I mentioned earlier - depression, anxiety, substance use disorder, and suicide (Castle, Buckley 2015). These effects are produced by a bewildering combination of factors: the disorder itself, personal reactions to the disorder, societal reactions to the disorder, medication side effects, and so on. As one might imagine, this condition and its effects have a big impact on family and friends of the person with schizophrenia. Castle and Buckley stress the importance of providing psychoeducation and support services to the family as much as possible (Castle, Buckley 2015). Luhrmann and Marrow theorize that one major reason people with schizophrenia in India have better long-term outcomes -- as compared to the U.S. and the U.K. -- is that extended families tend to live together and provide more mutual social support (Luhrmann, Marrow 2016). In the U.S. and U.K. adults are expected to live very independently, on their own or with a single partner and children; so, people with schizophrenia in the U.S. are more likely to be on their own and/or relying on support from one or two relatives as opposed to a larger family network.
Since religion is important to the person I interviewed as well as to me, I was curious to learn about any effects of religiosity on people with schizophrenia. Grover, Davuluri, and Chakrabarti review a handful of studies on this topic (Grover, et. al, 2014). There is no consensus that religious participation or beliefs tend to improve or worsen a person’s schizophrenia, but religion and culture do have an effect on the thematic content of people’s psychotic symptoms. Religious coping strategies can be very beneficial to people with all kinds of mental and physical illnesses, but on the other hand there is some evidence that higher religiosity correlates with more reluctance to seek psychiatric treatment. There is conflicting evidence on the relationship between religiosity and treatment adherence. Overall, Grover, et. al., stress that religion can be an important factor, often overlooked by researchers and clinicians, in the experience and treatment of schizophrenia (Grover, et. al., 2014).
To conclude, informally, schizophrenia is a big deal, a potentially life-long condition with lots of difficult symptoms, stigma, and biopsychosocial effects. Or, as Seeman writes, “Schizophrenia is considered to be one of the most serious mental illnesses in terms of the patient, the patient’s family, and the patient’s community” (Seeman 2016). Nonetheless there are reasons for optimism: medication can help ameliorate positive symptoms, and some of the newer drugs have better side effect profiles; psychotherapy can also improve negative symptoms, cognitive issues, and quality of life; and supported employment programs have proven effective. If we in the U.S. can consistently provide mental health access, housing, decriminalization, and supported employment programs -- we can go a long way in decreasing the amount of disability caused by schizophrenia.
Interview
Prior to phone-interviewing Mr. N. last week, I had met him several times. He is the brother of a friend of mine, Mr. J.. I met him once with Mr.J. at a religious service, once at their family home in Tidewater after the funeral of their younger brother, and once I gave him a ride home from a substance use disorder day program here in Richmond while he was staying with Mr. J.. All three times I had very positive interactions with him; he is a very friendly person. He did seem somewhat sedated or absent and somewhat nervous, but if J. had not told me that N. had been diagnosed with schizophrenia, I would not have guessed anything of that nature. Because of these previous interactions, I felt okay in calling him to ask him if I could interview him, but even so, I was very hesitant and felt a little guilty. Is that the effect of stigma and fear? Or is it respect for his privacy? Both, and more, probably. I didn’t want him to feel alienated or objectified, but he was happy to talk and very willing to share.
At first N. said that he was “hanging in there,” but he quickly retracted that, saying “I’m not hanging in there, I want to be upfront.” At the moment, depression is really weighing on him, as is knee pain. His overall physical health isn’t great, he isn’t sleeping well, and he is very worried about dying soon and what will come after death. He has had a very emotionally difficult several years - beginning with the death of his mother, living in several different places, an alcoholic relapse, the death of his younger brother, moving to Richmond, a global pandemic, and moving to Florida.
On the positive side of things, he is glad to have stable housing. He is living in a mobile home behind a friend’s house, in Florida. They used to live together in Connecticut, but N. moved to Virginia when his parents moved. He loves his dogs and enjoys playing with them outside. His current antipsychotic medication regimen certainly helps, and it doesn’t cause the tardive dyskinesia, facial muscle twitching, that his previous medication did. His depression medication, Trazodone, helps him sleep as well as treat his depressive symptoms, however it sounds like depression is perhaps his biggest challenge right now.
N. was born in New York, and raised in Connecticut. His parents were born in Italy, but mostly raised in the states -- if I remember correctly; in any case Italian culture is very strong in their family, as is Roman Catholicism. Belief in God, Jesus, mercy, forgiveness, heaven, and hell featured strongly in our conversation. N. said that religion has provided a lot of comfort and support in his life, however the possibility of hell, that God may not accept him, is a major concern for him. I asked him if he is currently receiving any support from a local parish or church, but his answer was a little vague and he seemed like he wanted to move on from that question. He seems to have close relationships with all his siblings, and talking to his siblings is one of his favorite things to do. He believes that mental illness runs in his family, and he is particularly worried about his youngest brother, who he says needs treatment but doesn’t want it.
N. first got treatment for symptoms of schizophrenia at the age of 19, at an inpatient facility in Danbury, Connecticut. However, he said symptoms started earlier, even as a freshman in high school. The main symptoms he mentioned were auditory hallucinations, depression, and anxiety. He said these were and are worse at night. He received a lot of inpatient treatment as a young man in Danbury. He also became addicted to alcohol, but eventually joined AA and achieved sobriety. He received some group psychotherapy and vocational support during his time as an adult in Connecticut. He said that, when he worked, he enjoyed it and did well, but he hasn’t had work or pursued work for a while. The two antipsychotic medications he mentioned were Invega Sustenna -- a monthly injection -- and Olazapine. I thought he said that he was taking both, but I may be mistaken. He has a case manager and has consistent healthcare access, but it doesn’t sound like he is currently receiving any psychotherapeutic or vocational services. N.’s biggest hopes for the future are spiritual in nature, hoping for union and wholeness in heaven.
I really appreciated talking with N.; he was very open and honest about his experience. I intend to call him again soon and thank him again for his time, and I hope to see him the next time he visits his brother here in Richmond. Perhaps the biggest clinical implication from my interview with N. is something Castle and Buckley mention in their introduction to schizophrenia: while the positive symptoms get most of the diagnostic attention, it is the negative and cognitive symptoms and comorbid conditions -- like depression in N’s case -- that “carry” much of the “burden of disability” in schizophrenia (Castle, Buckley 2015). Thankfully medications are able to help ameliorate many of the positive symptoms, but our society needs to do a better job attending to other aspects of this condition.
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