Parents of Patients With Schizophrenia Can Stop Feeling Guilty Now

Schizophrenia is not something I really wanted to focus on much in this blog.  Certainly, family dysfunction (and a variety of other stresses including someone just leaving home for the first time to go to college or join the military - an extremely common scenario) may trigger or exacerbate a first psychotic episode in a vulnerable patient, leading to the hallmark delusions and hallucinations. 

However, the vast majority of neuroscientists, physicians, and psychologists no longer believe schizophrenia to be primarily a "functional" (psychological or behavioral) disorder.

As I have mentioned several times, given the current state of our knowledge about neural networks in the brain (100 billion nerve cells with over a thousand separate connections each), the idea that schizophrenia is a brain disease is extremely difficult to "prove" beyond a shadow of a doubt, as some mental illness deniers insist we must. 

It would be hard to believe that the brain is the only organ in the body that is immune from any chronic developmental disease that would cause microscopic deterioration to its parts - in this case its neural network connections.

The fact that our current treatments for psychosis suck big time, while an important issue in itself, is not really relevant to the argument about the nature of the illness. 

Still, because some of my readers keep bringing schizophrenia up, I would like to describe a new study that I think should finally lay at least one argument to rest.  The study is brilliantly designed and the results very clear.

In my post Antipsychotics Are for Psychosis, Not Insomnia, I discussed an earlier study that looked at the role of antipsychotic medications in the development of severe brain shrinkage (cerebral atrophy) that is seen in many severe cases of chronic schizophrenia.  That study concluded that both the underlying disease and the medication both contributed to this phenomenon.  The study was not conclusive, however, because there was no actual control group.

At last, we now have the very first prospective study about this issue by Andrew M. McIntosh, David C. Owens, William J. Moorhead, Heather C. Whalley, Andrew C. Stanfield, Jeremy Hall, Eve C. Johnstone, and Stephen M. Lawrie.  It has been published on line in the journal Biological Psychiatry. 

A prospective study is one that follows over time a group of similar individuals (cohort) who differ with respect to certain factors under study, in order to determine how these factors affect rates of a certain outcome.  In this case, 162 individuals at high genetic risk of schizophrenia and 36 healthy control subjects were followed over 10 years. 

The high risk subjects had at least two first- or second degree relatives affected with schizophrenia.  None of the subjects in the study had any psychotic symptoms or other evidence of schizophrenia at the beginning of the study.

Participants received detailed clinical and up to five MRI scan assessements at 2-year intervals. The results?  17 of the 146 high-risk subjects who were scanned developed schizophrenia over the 8 years of the study. People at high genetic risk of schizophrenia had significantly greater reductions over time than the control group for whole brain volume and left and right prefrontal and temporal lobes.

Greater prefrontal reductions were shown in high-risk subjects who subsequently became unwell compared with those who did not. These changes were significantly associated with increasing severity of psychotic symptoms.

In other words, cerebral atrophy was developing in these patients before they had been treated with any antipsychotic medication.  In fact, it started to develop before they even had any symptoms!  So the atrophy is clearly present in the absense of any treatment at all.

Oh, and guess what?  The study was not funded by the drug companies, nor do any of the authors declare any drug company connections.

So, if you are the unfortunate parent of a person with schizophrenia who is dead set on blaming yourself for the condition of your child, I would ask two questions.  These are rhetorical questions, since I have no way of evaluating the accuracy of your anwers:

First, were you an abusive or neglectful parent or the spouse of an abusive or neglectful parent?  If not, what on earth are you feeling so guilty about?



When and How Can a Parent Stop Parenting

In her column of 9/13/09, a letter writer asked Dear Abby:  “At what point does a parent stop giving unsolicited advice? It is painful to watch my "child" repeatedly make choices that aren't in her best interest.”  The writer's daughter was 43. 

After describing some self-destructive behavior by her daughter, the writer added, “Although I am trying to keep my mouth shut, she tells me she "feels" my disapproval… Must I duct tape my mouth shut?

The relationship between parents and adult children is by its very nature a bit of a mine field. In order to rear their children properly, parents have to discipline them. Parents have to tell children what to do, what not to do, and how to behave in various social situations. Parents have to find ways to make their children follow these parental directives. Good parents continually set limits with their children.

The difficulty is, when is this supposed to stop?

Does the child suddenly become capable of making his own enlightened choices by virtue of having lived eighteen years? Should parents ignore the wisdom of their added years and never advise their adult children about anything? If the parents do persist in giving counsel, how upset are they going to be if the child chooses not to follow their sage advice? If a parent suggests a course of action over a particular issue, will the adult children feel infantilized?

Even with peers who are not relatives, the issue of when and when not to give advice can get to be problematic.  In Eric Berne’s psychotherapy model, transactional analysis, he shows how asking for and giving advice can become a “game.”  On the surface, two people may seem to be engaged in an “adult to adult” conversation, but the subtext may be entirely different.  One member of the dyad may be acting like, say, a helpless yet petulant child trying to frustrate the other member, who may be acting out the role of an exasperated parent who thinks he or she knows what is best for the other person.

A game people play

When the two parties actually are parent and child, the question of whether or not there is a hidden agenda being acted out becomes that much more complicated.  The parents may claim that they are “just expressing their opinion,” while the adult children feel like they are being told what to do as if they had no valid opinions on the subject themselves.  Is the parent’s advice merely an opinion, or is it a directive (a commandtelling the child how to behave)?

 

Unless parents and adult children are adept at metacommunicating about this issue (talking about the way they talk to one another), tension is bound to develop.

This situation becomes compounded exponentially in those situations where the parents themselves are highly conflicted about the advice they give.  They may be unsure of and unhappy with their own choices in life, but cannot admit that even to themselves - let alone to their adult children.

In such a case, two events frequently transpire: the parents bring up the issue involved rather often — because they are themselves preoccupied with it — and they give out a double message.  The offspring often interpret the advice to mean “Do it because I did,” but almost simultaneously, the way the advice is given may also have elements suggestive of “I hope you don’t have to do what I did and become miserable like me.” Whenever this chain of events takes place, a question about the motivation behind the parental advice giving is invariably created for the child.

The child must choose between two possible presuppositions. As mentioned, either the advice is meant as a directive or is merely the parent's opinion about a controversial issue. The frequency of the advice giving will most usually indicate to the child that how he or she behaves is a matter of grave concern to the parent. Therefore, the younger family member will presuppose that the parent's statements about the issue are directives or instructions.

But which part of the double message should the children heed? In situations where the advice is given ambivalently or is part of a double message, they will then make an effort to determine, using principles of ordering environmental cues that I describe in my book, Deciphering Motivation in Psychotherapy, which side of the double message to follow.

  

Consider the example from that book of a woman I will call Trudy and her mother. Trudy was having all kinds of anxiety symptoms over making a decision to really commit to her boyfriend.  Her mother had said on numerous occasions that "marriage is a mixed blessing: one has to take the bitter with the sweet."

One could interpret this as sage advice on the wisdom of not expecting perfection and retaining one's equanimity in the face of unavoidable adversity. Nothing in the lexical content of the statement indicates that Trudy's mother was commanding her to behave in any particular fashion or make any particular choices regarding marriage or spouse selection. The statement can be viewed as an expression of the mother's opinions about life and as good advice - nothing more.

  

On the other hand, the fact that the mother seemed compelled to drive this point home by repeating it over and over again suggested otherwise. The statement began to sound like a warning: "You'd better watch out! If you get married, you'd better be prepared for all the bitter you're going to get along with any sweet!" Every time the mother would talk about the good points of relationships, she seemed to be throwing in a warning about it.

Not only that, but her frequent repetitions indicated to the daughter that the mother was very concerned about whether the message had been heard loud and clear by Trudy. Perhaps she was worried that Trudy had not understood it the first twenty times it was said.

  

Naturally, Trudy began to worry about the consequences of getting involved with men. She became concerned not only that she might be in for a rough time, but also, for some reason, that her mother might become very upset about it. What Trudy did not realize was that the mother's repetitions indicated that she was trying to convince herself, not Trudy. In any event, the motivation presupposed by the mother's statement was in question, and the patient had been forced to guess what was correct. A good therapist would be alert to the possibility that Trudy may have guessed wrong.