CLINICAL HANDBOOK OF SCHIZOPHRENIA

84 I. CORE SCIENCE AND BACKGROUND INFORMATIONThe Influence of Psychoanalytic and Interpersonal TheoriesThe predominance of various psychoanalytic schools from the period 1930–1960 led to approachesthat refocused symptoms within the intrapsychic and interpersonal arenas. Work byHeinz Hartmann and others highlighted disturbances in ego function and object relations.For example, Hartmann (1964) contended that schizophrenia was characterized by severeimpairments in ego functioning. Hence, persons with schizophrenia could not deal easily withfrustrations because of ego deficiencies in defensive mechanisms, a lack of stabilized object relations,and the ego’s relation to reality. Harry Stack Sullivan (1953) conceptualized schizophreniaas arising from the organization of experience with significant people in early life(e.g., intense anxiety precipitated by an intense emotional response from the significant environment).This increased focus on impaired social interaction influenced Strauss and Carpenter(1974) in their pioneering study of outcome in schizophrenia to add problems of “rapport”to the classical schizophrenic dimensions of positive and negative symptoms.The Influence of Socioenvironmental TheoriesDuring the 1950s and 1960s, in tandem with the development of civil rights movementsto address racial and gender inequalities, the rights of mental patients became moreprominent. There was increased recognition that social and environmental factors playeda role in the observed symptoms of schizophrenic persons. For example, several writersdescribed “depersonalization syndromes” and “hospitalism” that developed in understimulatedpatients hospitalized long term. Such symptoms consisted of apathy andamotivation. Others noted how psychotic symptoms were exacerbated by overstimulationand conflicting messages from family or clinical staff. A number of models attemptedto make schizophrenia symptoms more comprehensible in terms of the communicationand alliances underlying family systems. Thus, psychotic symptoms might be symbolicexpressions of persons who felt trapped or confused within a dysfunctional family system.For example, Laing and Esterson (1970) illustrated how a patient’s ideas of referencecould be explained by observing the family’s interactions: “Her mother and fatherkept exchanging with each other a constant series of nods, winks, gestures, knowingsmiles . . .” (p. 40), which they adamantly denied when commented on by the interviewer.Finally, labeling and postmodern theorists elucidated sociohistorical factors that influencedthe construction of disease categories. Their work undermined the notion thatsymptoms were objectively conceived (i.e., “value-free”).The Era of DSMPrior to DSM-III (American Psychiatric Association, 1980), the descriptive symptoms ofschizophrenia were often interpreted in a broad sense, which led to inconsistencies in thediagnosis of schizophrenia. On the one hand, the World Health Organization landmark InternationalPilot Study of Schizophrenia (Hawk, Carpenter, & Strauss, 1975) in the 1960sdemonstrated that schizophrenia was diagnosed far more commonly in the United Statesand the Soviet Union than in other countries. Although this was attributed to multiple factors,including culture, it also demonstrated a much broader interpretation of diagnosticcriteria for schizophrenia in these two countries. On the other hand, the study foundmarked similarities in the key symptoms for rendering a diagnosis in all countries: delusionsof control, thought broadcast, thought insertion, thought withdrawal, flattened affect, andauditory hallucinations of various kinds.The first impetus in the United States for diagnostic clarity came from researchers whorequired standardization and uniformity in diagnosis. A group at the Washington Univer-