Psychodynamic Perspectives on Psychosis

Early psychoanalytic conceptions of psychosis explained psychotic symptoms as a manifestation of the conscious mind being invaded by the unconscious and by dreams (Federn, 1928/1952). More contemporary approaches underline the importance of early relationship patterns (e.g., Bion, 1962; Winnicott, 1991). Internal representations of experiences with significant others and current relationships are assumed to result in tension and psychotic symptoms are considered to be a constructive way of dealing with this tension (von Haebler & Freyberger, 2013). Psychodynamic therapy focuses on these processes and helps the patient to gain self-awareness and understanding of the influence of the past on present behavior, and it fosters new positive relationship experiences. An empathic, respectful, and supportive attitude allows re-enactment of internalized relational patterns in the therapist–patient interaction (Lempa, Montag, & von Haebler, 2013). Some early theories of psychoanalytic thought argued that psychosis could result from poor parenting behaviors (e.g., the schizophrenogenic mother stereotype) and the concept of double-bind communication, which refers to parental communication that is contradictory (rejecting while demanding affection), have not been supported in later research.^[1] Additionally, studies have generally shown that insight-oriented forms of psychotherapy do not typically work well with most persons with schizophrenia because of their difficulty in self-reflection and abstract thinking due to thought disorder.

Humanistic Perspectives on Psychosis

The Cognitive Perspective of Schizophrenia

When we think of the core symptoms of psychotic disorders such as schizophrenia, we think of an individual who may hear voices, see visions, and have false beliefs about reality (i.e., delusions). However, problems in cognitive function are also a critical aspect of psychotic disorders and of schizophrenia in particular. This emphasis on cognition in schizophrenia is in part due to the growing body of research suggesting that cognitive problems in schizophrenia are a major source of disability and loss of functional capacity (Green, 2006; Nuechterlein et al., 2011). The cognitive deficits that are present in schizophrenia are widespread and can include problems with episodic memory (the ability to learn and retrieve new information or episodes in one’s life), working memory (the ability to maintain information over a short period of time, such as 30 seconds), and other tasks that require one to control or regulate one’s behavior (Barch & Ceaser, 2012; Bora, Yucel, & Pantelis, 2009a; Fioravanti, Carlone, Vitale, Cinti, & Clare, 2005; Forbes, Carrick, McIntosh, & Lawrie, 2009; Mesholam-Gately, Giuliano, Goff, Faraone, & Seidman, 2009). Individuals with schizophrenia also have difficulty with what is referred to as processing speed and are frequently slower than healthy individuals on almost all tasks. Importantly, these cognitive deficits are present prior to the onset of the illness (Fusar-Poli et al., 2007) and are also present, albeit in a milder form, in the first-degree relatives of people with schizophrenia (Snitz, Macdonald, & Carter, 2006).

These findings suggest that cognitive impairments in schizophrenia reflect part of the risk for the development of psychosis, rather than only being an outcome of developing psychosis. Further, people with schizophrenia who have more severe cognitive problems also tend to have more severe negative symptoms and more disorganized speech and behavior (Barch, Carter, & Cohen, 2003; Barch et al., 1999; Dominguez Mde, Viechtbauer, Simons, van Os, & Krabbendam, 2009; Ventura, Hellemann, Thames, Koellner, & Nuechterlein, 2009; Ventura, Thames, Wood, Guzik, & Hellemann, 2010). In addition, people with more cognitive problems have worse functioning in everyday life (Bowie et al., 2008; Bowie, Reichenberg, Patterson, Heaton, & Harvey, 2006; Fett et al., 2011).

The Cognitive-Behavioral Perspective

Cognitive-behavioral interventions for psychosis (CBTp) build on the assumption that psychotic symptoms lie on a continuum with normal experiences. They are also informed by research suggesting that psychotic experiences result from normal, though exaggerated, mechanisms of perception and reasoning. This understanding has formed the basis for cognitive models of psychosis. As one of the most influential of these models, Garety, Kuipers, Fowler, Freeman, & Bebbington (2001) postulate that psychotic symptoms develop when stressors overload a person, causing them to have unusual experiences. According to this model, the unusual experience itself is not crucial, but its appraisal—how it is understood or evaluated by the person—is. Most descriptions within the cognitive-behavioral interventions for psychosis (CBTp) framework converge in stressing the importance of building a stable therapeutic relationship through the process of listening and validating, of taking a collaborative approach, and of working with an individual case formulation. The use of cognitive and behavioral interventions for working with psychotic symptoms as well as for changing dysfunctional beliefs and interventions to prevent relapse are also essential elements.^[3]

Social Cognition

Some people with schizophrenia also show deficits in what is referred to as social cognition, though it is not clear whether such problems are separate from the cognitive problems described above or the result of them (Hoe, Nakagami, Green, & Brekke, 2012; Kerr & Neale, 1993; van Hooren et al., 2008). This deficit of social cognition includes problems with the recognition of emotional expressions on the faces of other individuals (Kohler, Walker, Martin, Healey, & Moberg, 2010) and problems inferring the intentions of other people (theory of mind) (Bora, Yucel, & Pantelis, 2009b). Individuals with schizophrenia who have more problems with social cognition also tend to have more negative and disorganized symptoms (Ventura, Wood, & Hellemann, 2011) as well as worse community function (Fett et al., 2011).

Diathesis-Stress Model

Figure 1. We know that biological and genetic components play a large role in influencing the development of schizophrenia, although biological factors alone cannot explain why a person may develop the disorder.

The diathesis-stress model helps to settle the debate of nature versus nurture; it explains how the two have a bidirectional relationship and a dual influence on the development of many mental health illnesses, especially schizophrenia. The diathesis refers to the genetic predisposition or risk an individual has of developing a certain disorder. This predisposition comes from the individual’s unique genetic makeup as well as the increased risk if a first-degree blood relative such as parent or sibling has been diagnosed with a disorder. The diathesis is the nature component of the model, reflecting the biological vulnerability an individual possesses. An environmental stressor can trigger the onset of a disorder, especially in those genetically vulnerable to developing the disorder. If an individual is greatly susceptible to developing a disorder, only a small level of stress is needed to catalyze the onset of the disorder. Extreme trauma or the use of a drug such as cannabis can serve as environmental stressors and aspects of nurture that influence the onset of schizophrenia and related disorders.

Childhood trauma has specifically been shown to be a predictor of adolescent and adult psychosis. Approximately 65% of individuals with psychotic symptoms have experienced childhood trauma (e.g., physical or sexual abuse and physical or emotional neglect). Increased individual vulnerability toward psychosis may interact with traumatic experiences promoting an onset of future psychotic symptoms, particularly during sensitive developmental periods. Importantly, the relationship between traumatic life events and psychotic symptoms appears to be dose-dependent, in which multiple traumatic life events accumulate, compounding symptom expression and severity. This relationship suggest trauma prevention and early intervention may be an important target for decreasing the incidence of psychotic disorders and ameliorating its effects.

Sociocultural Perspective

Figure 2. In some cultures, some of the symptoms of schizophrenia may not be considered abnormal.

There are also a number of environmental factors that are associated with an increased risk of developing schizophrenia. For example, problems during pregnancy such as increased stress, infection, malnutrition, and/or diabetes have been associated with increased risk of schizophrenia. In addition, complications that occur at the time of birth and cause hypoxia (lack of oxygen) are also associated with an increased risk for developing schizophrenia in the child (M. Cannon, Jones, & Murray, 2002; Miller et al., 2011). Children born to older fathers are also at a somewhat increased risk of developing schizophrenia. Further, using cannabis increases risk for developing psychosis, especially if when other risk factors are present (Casadio, Fernandes, Murray, & Di Forti, 2011; Luzi, Morrison, Powell, di Forti, & Murray, 2008). The likelihood of developing schizophrenia is also higher for kids who grow up in urban settings (March et al., 2008) and for some marginalized ethnic groups (Bourque, van der Ven, & Malla, 2011). Both of these factors may reflect higher social and environmental stress in these settings. Unfortunately, none of these risk factors is specific enough to be particularly useful in a clinical setting, and most people with these risk factors do not develop schizophrenia. However, together they are beginning to give us clues as the neurodevelopmental factors that may lead someone to be at an increased risk for developing this disorder.

Cross-Cultural Perspectives and Cultural Influences

Culture plays a role in the way we view mental health disorders and their corresponding features. There are cultures around the world, such as in Peru, who do not perceive features of schizophrenia like hearing voices (hallucinations) as abnormal. Rather, they may even be seen as special abilities and connections to the spirit realm, where the individual who hears voices could be the community Shaman, or medicine man. These individuals actually help to provide insight and healing to themselves and to others.

In Western societies, the same feature of hearing voices would be considered to be abnormal and a symptom of an underlying disease such as schizophrenia. An individual experiencing these symptoms would not be placed in a position of reverence or admiration, but would most likely be placed in a treatment facility or hospital for further care and treatment to manage and reduce the experienced symptoms. Even in Western society, however, there have been advocates, like Dorothea Dix and Philippe, who emphasized respecting and admiring those with mental disorders.