Vulnerability to schizophrenia and psychotherapeutic treatment of schizophrenic patients: towards an integrated view.

My approach to schizophrenia and its treatment has evolved gradually over my forty-year experience as a family researcher and a psychotherapist to schizophrenic patients. I am convinced that we must maintain a comprehensive view, both with regard to the factors contributing to vulnerability to schizophrenia and concerning our treatment activities, and not limit our views with studies focusing on restricted spheres of interest. I will present some viewpoints concerning both the biological and the psychosocial factors contributing to the vulnerability to schizophrenia. My aim is to indicate that these factors are heterogeneous and differently weighted in different cases. However, an integrated notion of the pathways leading to schizophrenia can be proposed. I will also review the therapeutic approach-the need-adapted treatment of schizophrenic psychoses-which I and my coworkers have developed in Finland and which, in many respects, is related to these views.

A critical review of genetic studies of schizophrenia. II. Molecular genetic studies.

Recent molecular genetic studies of schizophrenia have, until now, been unable to demonstrate any specific major gene for schizophrenia. On the contrary, linkage and association studies have yielded almost exclusively negative or contradictory results. Such studies have involved certain candidate genes, such as the genes for dopamine receptors and other brain neurotransmitters. Some of these candidate genes have now actually been excluded as specific aetiological factors in schizophrenia. Similarly, studies searching for a major gene for susceptibility to schizophrenia involving the whole human genome or large parts of chromosomes have not yielded unambiguously positive results. However, the most recent empirical evidence suggests that many polygenes, acting together, could constitute a risk factor for schizophrenia. It is thus most probable that genetic susceptibility to schizophrenic psychoses is polygenic, and that their effects are dependent on interaction with physical and psychosocial environmental factors.

A critical review of genetic studies of schizophrenia. I. Epidemiological and brain studies.

Family, twin and adoption studies suggest that susceptibility to schizophrenia is based at least to some extent on genes. The results of these studies vary and depend greatly on the diagnostic criteria used. When a broad definition of schizophrenia is employed, even high degrees of heritability are observed. However, when more narrow criteria are employed, the degrees of heritability decrease. According to a large Finnish adoption study, the patient-family interaction has an even more important role in the origin of schizophrenia than purely genetic factors. Interaction between the genetic factors on the one hand and physical, psychological and psychosocial factors on the other hand is emphasized.

An attempt to integrate the individual-psychological and interactional concepts of the origins of schizophrenia.

Individual-psychological studies (psychoanalytical) and interactional studies (based on family research and family therapy) approach the psychological processes connected with the origins of schizophrenia from different angles. They thus complement each other. Five major propositions are formulated to integrate the psychodynamic concepts dealing with vulnerability to schizophrenia. The integration of family- and individual-centred starting-points has proved to be very useful in developing treatment methods for schizophrenic patients.

[Schizophrenia Project in Abo. Psychotherapy-oriented broad-based mental health care]. / Schizofreniprojektet i Abo. Psykoterapeutiskt orienterad psykosvård med bred bas.

The concept of need-related care for schizophrenia patients, evolved in Abo during the 1980s, consists in a flexible form of psychotherapy oriented care, which in its planning and execution is tailored to meet varying individual needs. It is based both on family and individual therapy and therapeutic groups, drugs being used as support. The results have been promising and it has been possible to reduce hospitalisation.

Need-adapted treatment of new schizophrenic patients: experiences and results of the Turku Project.

This article describes a psychotherapeutically oriented approach to schizophrenia developed especially to meet the needs of the community psychiatric field. Because of the heterogeneous nature of the schizophrenic psychoses, the authors emphasize that these patients should always be treated based on case-specific premises. The main principles of the need-adapted approach are: 1. The therapeutic activities are planned and carried out flexibly and individually in each case so that they meet the real and changing needs of the patients as well as of their family members. 2. Examination and treatment are dominated by a psychotherapeutic attitude. 3. The different therapeutic activities should support and not impair each other. 4. The process quality of therapy is clearly perceived. A family-centred initiation of the treatment is especially emphasized for both diagnostic and therapeutic reasons. The positive experiences of this led the Finnish national programme for the treatment and rehabilitation of schizophrenic patients to recommend the establishment of family- and environment-oriented acute psychosis teams (APT) in the mental health districts. In later phases of treatment, the significance of individual psychotherapy is increased. The preliminary results of the approach are presented and compared with an earlier sample of patients.

Maintenance of grip on life and goals of life: a valuable criterion for evaluating outcome in schizophrenia.

This article describes the evaluation of schizophrenia patients' maintenance of grip as a comprehensive assessment of the total psychosocial status of these patients. This evaluation was tested with new schizophrenic patients (DSM-III) who took part in a standardized interview at entry and after a 2-year follow-up. The interviews and examinations were conducted by the psychiatric teams responsible for the treatment of the patients. There was a clear positive correlation between the evaluation of maintenance of grip and interpersonal interaction, heterosexual development, hobbies, level of activity and productivity (working) of the patients, and a negative correlation with negative symptoms. The psychodynamically interpreted evaluation of the degree of regression correlated positively with maintenance of grip, but only after the 2-year follow-up. At entry the other variables describing the psychosocial status of the patient explained 22% of the variation in maintenance of grip, but 41% at the follow-up stage. The evaluation of maintenance of grip presented at baseline also predicted the coping of the patients during the follow-up stage. The authors recommend that the evaluation of maintenance of grip be used as an auxiliary tool in the assessment and treatment of schizophrenia patients.

Developing a global psychotherapeutic approach to schizophrenia: results of a five-year follow-up.

This is an account of a long-range action research project to determine indications for and effects of a comprehensive psychotherapeutic approach, including various treatment modalities, in the treatment of schizophrenics. Four diagnostic groups were established among the 100 patients. In the course of data analysis, the group of typical schizophrenics (56 percent) was contrasted to or compared with the entire series. A further diagnostic differentiation was established according to ego functioning; i.e., imminent, acute, regressive, and paranoid ego disintegrations, respectively. Patients and family members were interviewed upon admission, and again two and five years later, and the data recorded on a 163-item form from which 40 clinical and psychosocial variables were constructed after the baseline examinations. In addition to cross-tabulation, logistic regression analysis was employed. The conclusion that the follow-up study supports the effectiveness of our global psychotherapeutic approach to treating schizophrenia seems justified. Results so far indicate that five modes of therapy in addition to drug treatments are optimal for different patients. The five modes are long-term individual psychotherapy, couple or conjoint family therapy for married patients, family therapy with the family of origin, flexible short-term crisis intervention with a family focus, and extensive long-term treatment focused on social rehabilitation for the most ill-starred patients.

Psychotherapeutically oriented treatment of schizophrenia: results of 5-year-follow-up.

The authors have developed a psychotherapeutic approach to schizophrenia within the community psychiatric health care system. The orientation is psychodynamic but global in the meaning that the therapeutic plans are made on the basis of case-specific need of the patients and of their families and include both individual psychotherapy, family therapy and therapeutic communities. The material is composed of 100 successive patients of the schizophrenia group aged 16 - 44 years and for the first time admitted for treatment into the different units of the Turku Mental Health District in 1976 - 77. A multiprofessional staff was acting as therapists, supported by a continuous and intensive on-the-job -training and supervision. The results preliminary reported in this paper are based on a follow-up study 5 years after admission to treatment. 56 patients could be included in the psychotherapy group given at least some mode of psychotherapy in an adequate amount. The background variables of patients selected for various modes of therapy as well as the prognostic results are studied with the aid of logistic regression analyses. The findings indicate that the development of a global psychotherapeutic orientation is possible in the field of community psychiatry and yields results that demonstrate its meaningfulness. The implementation of psychotherapy had clearly positive explanatory connections with a favourable prognosis, and although these connections were not equally strong as the connections of some central clinical and psychosocial variables, they were obvious and manifold.

Marriage and the development of schizophrenia.

The families of orientation of schizophrenic patients have already been the subject of much research. By shedding light on the nature of the disturbed interactions between parents and children, such research has added greatly to our understanding of the psychodynamics of schizophrenia. This research has also provided a basis for the development of the family therapy of schizophrenic patients. However, little attention has so far been given to the psychydynamic study of schizophrenic patients' own marital relationships. Yet the study of the mutual relationships of patients and their spouses--particularly in cases where the psychosis set in only after the patient was already married--might elucidate the problems associated with the onset of schizophrenia and, at the same time, be of significance for family therapy. The present paper, which reports a study of 30 married couples in which one spouse had fallen ill with schizophrenia during the marriage, had its origin in expectations of this kind.