The diagnostic criterion for schizophrenia is extensive. The ‘A’ section is the characteristic symptoms in which a person has two or more symptoms of “delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms” (Barlow & Durand, 2009). The ‘B’ section is social and occupational dysfunctions that are “for a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset” (Barlow & Durand, 2009). The duration of disturbances is the ‘C’ section, which states that signs must persist for at least 6 months; the ‘D’ criterion rules out schizoaffective and mood disorders and the ‘E’ section rules out substance abuse and general medical conditions (Barlow & Durand, 2009). The ‘F’ criteria is the relationship to a pervasive developmental disorder, and if there is a history, then “the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month” (Barlow & Durand, 2009). The subtypes of schizophrenia include paranoid type, disorganized type, catatonic type, undifferentiated type, and residual type (Barlow & Durand, 2009). The paranoid type can seem relatively normal upon brief interactions. According to the DSM-IV-TR, the diagnostic criteria for paranoid type are “preoccupation with one or more delusions or frequent auditory hallucinations” and the person does not have “disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect (Barlow & Durand, 2009). Disorganized type, previously known as hebephrenic, has prominent symptoms of “disorganized speech, disorganized behavior, flat or inappropriate affect” and does not meet the criteria to be considered catatonic type. Silvano Arieti (1974) explains that the “content of thought is characterized by many poorly systematized, poorly rationalized, and in many cases completely disorganized delusions” (p. 37). The disorganized type may look at themselves in the mirror, laugh at inappropriate times, or be completely unintelligible before they are treated (Barlow & Durand, 2009). An individual that meets the criteria for catatonic type schizophrenia is ruled by at least two of the following, “motoric immobility, excessive motor activity, extreme negativism, peculiarities of voluntary movement, and echolalia or echopraxia.” (Barlow & Durand, 2009). When a person does not fit clearly into the criteria for the first three types, but still exhibit the major symptoms of schizophrenia, they are considered the undifferentiated type. Lastly, the residual type is characterized by the “absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior” and “there is continuing evidence of the disturbance, as indicated by the presence of negative symptoms or two or more symptoms listed in criterion A for schizophrenia, present in an attenuated form” such as believing weird things or perceiving abnormal occurrences (Barlow & Durand, 2009).

The symptoms of schizophrenia are classified as positive and negative symptoms. The positive symptoms are the obvious “active manifestations of abnormal behavior or an excess or distortion of normal behavior,” such as hallucinations and delusions (Barlow & Durand, 2009). The negative symptoms “involve deficits in normal behavior in such areas as speech and motivation,” including withdrawing from social interactions, being apathetic, and lacking normal thought or speech (Barlow & Durand, 2009). One of the most common delusions associated with schizophrenia is “delusions of persecution,” which is when a person becomes convinced that someone, such as FBI or CIA is out to get them (Barlow & Durand, 2009). When such delusions are combined with some semblance of truth, it becomes difficult for others around the schizophrenic to make a distinction between what is real and what is in the persons head. In the case of one of my clients, who will be referred to as Lucy, was terrified that an ex was out to kill her immediate family to the extent that she put them in a safe place. She told her children that this man had deep connections with the mafia and there were people everywhere trying to hurt them to get retribution for him. The fabricated revenge was for an actual reality of the man going to prison for breaking one of her children’s arms. The indvidiual suffering from schizophrenia drove around aimlessly in search for a safe place to live and was gone from her family for three months. After deciding on a location, she relocated and began counseling. It was a few years later that her children learned of her illness and understood that there was probably no basis for her overwhelming fear. For her children it was likely strange to see her constantly looking over her shoulder, making sure to never sit by windows in public places, and coving her face as though “they” were watching. Another type of delusion that affects a very small percentage of schizophrenics is delusions of grandeur. This type of delusion involves “believing in one’s inflated worth, power, knowledge, identity or special relationship to a deity or famous person” (Barlow & Durand, 2009).

As previously mentioned, Lucy experienced delusions as well as hallucinations, such as monsters that were physically in the house according to her. Hallucinations are “the experience of sensory events without any input from the surrounding environment” and one does not have to be mentally ill to experience such sensations (Barlow & Durand, 2009). Perhaps the most noted way to hallucinate is through the use of hallucinogenic drugs such as mushrooms or LSD. Hallucinations can affect any of the senses. The auditory hallucination is most common and popularized by the media. These hallucinations are hearing voices that tell one to do things that they would not otherwise consider. The most popular example on television is hearing voices to kill others. Several investigative dramas use this idea as a basis for criminal psychotic behavior. Unfortunately this stereotypes schizophrenics and other mentally ill as being violent. In actuality, although auditory hallucinations are most common, “they may comment on what the patient is doing or make mocking and derisive remarks,” but after awhile people get use to them (Andreasen, 1984).

Before mental illness was even an idea, there were mentally ill people. Without knowing what to do with them or how to handle them, people deemed them demonic or having the “evil eye,” concepts that formed “an integral part of primitive culture prior to civilizations” that we are familiar with today (Fischer, 1946). The evil in one’s eyes was seen physically as a discoloration in the pigmentation, which is a physiological response to stress (Fischer, 1946). This concept may not be widely accepted as it once was, however, whenever something unfortunate occurs, people are quick to blame anyone that may have been giving “ojo,” or evil eye. Hispanic culture even considers “ojo” such a dangerous thing that people must touch something they are fond of (such as a cute baby) in order to prevent the occurrence of the ailment. In one of his writings, Roland Fischer (1946) quoted an early fifteen century text, “Malleus Maleficarum,” which illustrated how chemical reactions were believed to be the work of the devil (p. 93). According to the ancient text, one of the “five ways in which [the devil] can delude anyone” is through the “interposition of some substance,” an idea that Fischer (1946) explains as the physiological reactions to stressors we now know as General Adaptation Syndrome (Fischer, 1946). Our ancestors would not have understood the neurotransmitters firing in the brain or the chemical reactions of what we know as drugs. Without the knowledge the world has now of medications and psychotherapy, schizophrenics were basically condemned to what amounted to imprisonment. When mental health facilities did finally become available to the mentally ill, they were not so much for the treatment of individuals, as the restraining of them. Schizophrenics would have been chained to a wall and left to thrash about as they fell “precipitously, catastrophically, from one level of functioning into another, into an abyss,” fighting in such a way “that many of his symptoms manifest his struggle to awaken from a nightmare in which he feels trapped,” without any medication to help facilitate awareness of reality (Edelson, 1971). Blood letting was an early attempt to treat many ailments, including schizophrenia. Physicians attempted to remove the “toxic factor in the blood of schizophrenics,” and although some claimed success, further investigation was unable to find statistically significant results (Fischer, 1946). In the twentieth century, health care professionals began to question the diagnosis of schizophrenia being one that would put a patient in a “hospital until he died” and a study was conducted that followed “339 schizophrenic patients during the five years after they were admitted to three mental hospitals in 1956” (Brown, Bone, & Wing, 1996). About one-third of the patients remained as ‘transient’ patients, while 315 were discharged, a third “left by themselves and one-third with their families” (Brown et al., 1996). The patients were admitted based on various criteria with “three mutually exclusive patient groups” which included being a danger to self or others, grossly abnormal behavior, and “other” behavior (Brown et al., 1996). Nowadays involuntary admission to hospitals has been restricted to being a danger to oneself or others. Allowing schizophrenics to function in society and be treated on an outpatient basis is the most cost effective method of treatment, as well as most beneficial to society and the individual with the illness. By treating on an outpatient basis, mentally ill of all types are able to maintain stable jobs and receive the medication and psychotherapy necessary to maintain their grasp on reality.

Unfortunately, when reality and the surreal become indistinguishable, relapses of episodes of schizophrenia occur. Relapses in schizophrenia are relatively common but when people think of a psychotic break, the media’s image of a crazed killer is the first picture that comes to mind. Statistically, seventy-eight percent of schizophrenics will experience “a pattern of relapse and recovery” and their life expectancy is significantly less than the normal population due to a higher rate in successfully committing suicide (Barlow & Durand, 2009).

Most schizophrenics are completely harmless. The only potentially violent schizophrenic is the paranoid type, and there is no evidence to indicate that such people need be institutionalized without cause. Criminals are often assumed crazy because the general public refuses to admit that evil can exist in the mind of a sane and rational individual. Considering the extensive number of mentally ill people in the world, particularly schizophrenics, the number of peaceful, non-violent psychotics greatly outnumbers the violent episodes. The occasional violent outburst from a formally institutionalized individual makes amazing headlines, which has produced a negative view of schizophrenics that makes some people want them to be locked up indefinitely. Arieti (1974) suggests that “a schizophrenic patient, especially if mildly sick, could commit a crime that is not in any way motivated, caused, or facilitated by the illness” (p. 310). If a schizophrenic does commit homicide, the easier concept to hold liable is the disorder, because to consider otherwise is to accept faults in humanity.

The study in the mid-20th century that followed over 300 schizophrenics over five years, was just one of a multitude of studies aimed at discovering causal factors of schizophrenia. A genetic influence of schizophrenia is a widely accepted theory. However, other factors deserve consideration, because there are a number of schizophrenics families that are affected by their loved ones illness but are not schizophrenic themselves. The nature-nurture debate is an ongoing discussion, with most people agreeing upon the idea that both factors play a role in schizophrenia. In terms of behavior, “there are no genes for behavior,” this makes it impossible to blame one’s genetic makeup entirely for developing schizophrenia (Fischer, 1946). A genetic predisposition is a more plausible explanation to explain why people in similar situations react differently in terms of schizophrenia. The study of twins show a higher incidence of schizophrenia and other psychotic disorders. In one study, out of forty-five schizophrenics with twins studied, only “fourteen [of their twins] were considered clinically normal” and not diagnosed with some type of disorder (Planansky, 1955). There is a higher incidence of psychosis in the families of schizophrenics, according to research on benign psychosis. A study consisting of seventy-nine cases of “verified psychogenic psychoses,” there was a “family predisposition found in forty-four cases,” with varying disorders (Planansky, 1955). Neither genes nor the environment can facilitate the occurrence of schizophrenia alone. The environment of a person with a genetic predisposition for schizophrenia may “engender, add to, or make it more difficult to compensate for, those interfamily psychodynamic conflicts” that families possess (Arieti, 1974). Conversely, a positive “social environment may compensate for the unfavorable psychodynamic development or even for some hereditary predisposing and make the psychosis less likely to occur,” which may explain why people raised in similar environments, positive or negative, may or may not develop schizophrenia (Arieti, 1974). One theory for the origin of schizophrenia involves variations in the levels of the neurotransmitter, dopamine, which stimulates other neurotransmitters and assists in exploring and gratifying behaviors (Barlow & Durand, 2009). Presently accepted notions regarding neurobiological influences indicates three neurochemical irregularities that interact within the schizophrenic brain, including an increase of stimulating striatal dopamine receptors, a shortage of stimulating prefrontal dopamine receptors, and “alterations in prefrontal activity involving glutamate transmission” (Barlow & Durand, 2009). Some research indicates a correlation between the environment of a fetus and the development of schizophrenia. If a fetus is exposed to a “viral infection, pregnancy complications, and delivery complications,” then the fetus can be considered as exposed to factors in the environment that can affect the onset of schizophrenia (Barlow & Durand, 2009). The “vulnerability-stress model of schizophrenia” suggests that the amount of stress that one has throughout their life may affect their development of the disorder (Barlow & Durand, 2009). Much of the research for this theory is based on evaluations of past of events of current schizophrenics, however, it serves promising in developing preventative methods for people with genetic predispositions to schizophrenia.

While there are still significant mysteries in schizophrenia, there are efforts to provide preventative measures at primary, secondary, and tertiary levels, directing attention to “the incidence of psychiatric disorder, the early recognition of the disorder, and reducing the defect caused or left by the disorder,” respectively (Arieti, 1974). Silvano Arieti (1974) outlines “basic, longitudinal, and critical” as the three categories of primary prevention of schizophrenia (p. 514). For basic prevention of schizophrenia, two people suffering from the disorder would be wise not to reproduce because their offspring would have over a 50% chance of having schizophrenia. Also, the “early psychogenic environment,” or e.p.e., must be prevented by avoiding unhealthy stress factors that may contribute to the development preexisting vulnerabilities (Arieti, 1974). If the e.p.e. does establish, then longitudinal prevention is geared toward “altering the original e.p.e. and its effects,” and ensuring essential needs are readily available to the individual and that unnecessary stress does not overwhelm the person’s ability to cope (Arieti, 1974). Critical prevention involves handling a patient in a critical situation. Although “any stressing event is not a precipitating event,” it is important to recognize which situations effect the patient’s “special vulnerability’ that will wound their self-image (Arieti, 1974). The most effective way to prevent schizophrenia “is to identify and treat children who may be at risk,” but since we know that only “17% of the children born to parents who have schizophrenia are likely themselves to develop the disorder,” it is difficult to pinpoint who else in society may be at risk (Barlow & Durand, 2009). Based on research about the onset of the disorder, “interventions such as vaccinations against viruses for women of childbearing age and interventions related to improving prenatal nutrition and care may be effective preventative measures,” and although it is not certain, the benefits of attempting prevention outweigh the risks of doing nothing (Barlow & Durand, 2009).

While there are still significant mysteries in schizophrenia, there are efforts to provide preventative measures at primary, secondary, and tertiary levels, directing attention to “the incidence of psychiatric disorder, the early recognition of the disorder, and reducing the defect caused or left by the disorder,” respectively (Arieti, 1974). Silvano Arieti (1974) outlines “basic, longitudinal, and critical” as the three categories of primary prevention of schizophrenia (p. 514). For basic prevention of schizophrenia, two people suffering from the disorder would be wise not to reproduce because their offspring would have over a 50% chance of having schizophrenia. Also, the “early psychogenic environment,” or e.p.e., must be prevented by avoiding unhealthy stress factors that may contribute to the development preexisting vulnerabilities (Arieti, 1974). If the e.p.e. does establish, then longitudinal prevention is geared toward “altering the original e.p.e. and its effects,” and ensuring essential needs are readily available to the individual and that unnecessary stress does not overwhelm the person’s ability to cope (Arieti, 1974). Critical prevention involves handling a patient in a critical situation. Although “any stressing event is not a precipitating event,” it is important to recognize which situations effect the patient’s “special vulnerability’ that will wound their self-image (Arieti, 1974). The most effective way to prevent schizophrenia “is to identify and treat children who may be at risk,” but since we know that only “17% of the children born to parents who have schizophrenia are likely themselves to develop the disorder,” it is difficult to pinpoint who else in society may be at risk (Barlow & Durand, 2009). Based on research about the onset of the disorder, “interventions such as vaccinations against viruses for women of childbearing age and interventions related to improving prenatal nutrition and care may be effective preventative measures,” and although it is not certain, the benefits of attempting prevention outweigh the risks of doing nothing (Barlow & Durand, 2009).

One of the first medications attempted to alleviate the symptoms of schizophrenia was “massive doses of insulin,” which people later learned was extremely risky and could cause death (Barlow & Durand, 2009). After prefrontal lobotomies and electroconvulsive therapy (ECT) were shown to be ineffective in treating schizophrenia, a revolution for the disease was made in the 1950s, when neuroleptic medications “provided the first real hope that help was available” (Barlow & Durand, 2009). Many drugs have appeared on the market to help both positive and negative symptoms of schizophrenia. Unfortunately, finding the right cocktail of medication is a “trial-and-error process to find the medication that works best,” if at all (Barlow & Durand, 2009). Even when an effective combination of drugs is attained, noncompliance with continued use of their medication is extremely common for schizophrenics. Fortunately, Lucy was able to function more when she found the right medication combined with attending our weekly sessions. After a time, Lucy was no longer feeling “crazy” and she discontinued her medication regimen and relapsed into her own world. Eventually, with enough family persistence, she resumed therapy and her medication. Today she is able to function relatively independently. Medications combined with psychosocial interventions are necessary for successfully treating schizophrenic patients. While there is no cure for the disorder, and complete recovery is extremely rare, there is hope for successfully containing the symptoms presented, even by some of the most disturbed patients.

Various people argue that the diagnosis of schizophrenia “does not really exist but is a derogatory label for people who behave in ways outside the cultural norm,” however, research clearly shows it is an actual disorder that no one fully understands (Barlow & Durand, 2009). Schizophrenia is a very real disorder with very real symptoms, which means that the symptoms can be treated chemically. Several cases of medicated schizophrenics with symptom improvement from these medications should be proof enough. Some schizophrenics refuse treatment to the extent that they never recover and regain control of their lives. Another former client, we will call Arnold, was diagnosed with paranoid schizophrenia and bipolar disorder. When he was medicated and receiving counseling, Arnold was able to be a loving father and husband. However, after a few months he stopped taking the medications and refused therapy treatments, relapsing into a violent psychosis which cost him his family. Because the mental health community is a small one, through the grapevine I learned Arnold frequently sits in a Waffle House talking to god, leaving his wife to support their two year old son on her own. In the publication, “The Unfortunate Concept of Schizophrenia,” Lawrence Kubie (1966) not only questions the existence of schizophrenia, but denounces the clinicians that research and write publications about the disorder (p. 66). However, in all his ranting, Kubie (1966) does not offer an alternative for what he calls “an excuse for our therapeutic failures, and as an epithet to express the irritation, frustration, and annoyance of defeated doctors” (p. 71). Numerous clinicians and researchers have published well documented cases of schizophrenia and empirical evidence to support their claims. The two clients discussed in this article were diagnosed with schizophrenia and each serve as an example of the direction that schizophrenia can take in one’s life.

Should the circumstances of schizophrenia become more understood, maybe those with the disorder would not be stigmatized as freaks, but welcomed into the community. Outpatient programs help people to achieve their goals in society while struggling with their illness. Thankfully, most mental health facilities today have the aim to institutionalize individuals that are a danger to society and themselves, rather than treating all schizophrenics as needing permanent residency and constant care. Research and studying of schizophrenics has identified subtypes, symptoms, treatments, prevention, and even argued the validity of the concept of this particular disease. Cumulative efforts continue to be put forth by clinicians and researchers to understand the disorder, however, there is much to be discovered. Further experiments and research that expand information on causation, treatment, or possibly prevention of schizophrenia will contribute immensely to the study of this illness and many other mental illnesses. People no longer run from schizophrenics, instead they throw rocks at them and taunt them further into depression or other disorders. The public should be educated on being sensitive to schizophrenics rather than fearing them. Only upon recognizing their abound presence in communities and recognizing them as human beings perfectly capable of functioning, will schizophrenics be welcome in the world.