13 Clinical Movement: Schizophrenia

Learning Objectives

1. Examine how Schizophrenia diagnoses have evolved.
2. Understand the impact of different psychologists/philosophers in various time periods.
3. Explain how treatments of Schizophrenia have changed.

Introduction

In this essay, we will examine schizophrenia in different periods. This historical period starts from the ancient times of Rome and Greece and finally reaches the modern era. In each period of history, we will examine the approach of psychologists, researchers, scientists, and scholars to schizophrenia, and at the same time, by examining the symptoms raised, treatment methods, the method of diagnosis, and one or two influential people in each era, we present a comprehensive view of schizophrenia to readers.

Schizophrenia in Ancient Greek and Roman Time (Ericson)

Abstract

Schizophrenia is known as a complex mental disorder characterized by distorted thinking, hallucinations, and delusions. Throughout history, the approach of individuals, societies, scholars, and researchers to mental illnesses, especially schizophrenia, has been different. This article deals with the understanding, treatment, and social views of schizophrenia in ancient Greek and Roman times. It also examines the contributions of prominent figures such as Galen and Hippocrates and the methods of diagnosis and treatment available in this era. At the same time, it examines social perceptions and destigmatization around schizophrenia. In addition, it addresses little-known symptoms, treatments, and diagnostic methods, and provides a comprehensive insight into the historical context of schizophrenia.

Introduction

 Background of Schizophrenia

Schizophrenia is a mental disorder characterized by disturbances in thought processes, perceptions and emotions. Schizophrenia often manifests as hallucinations, delusions, disturbed thinking, and impaired social functioning (Smith, 2005). In the modern era, the approach of science and even societies towards it have undergone a lot of changes. Contemporary understanding and treatment methods have progressed a lot, but without considering the approaches of scientists and societies toward schizophrenia, it will be impossible to understand this progress. Also, the historical context of schizophrenia provides valuable insights into diverse cultural interpretations and responses to mental illness.

It should be noted that schizophrenia has existed throughout history with different interpretations and treatments in diverse cultures and periods, Previously, it was not known as schizophrenia, but the symptoms that some faced and reported at that time make us now consider it close to, or schizophrenia (Kingdon et al., 2022). n ancient Greece and Rome, popular beliefs about supernatural forces, divine punishment, and humor were among the factors that influenced the conceptualization and management of schizophrenia (Thumiger & Singer, 2018).

Purpose and Scope

In this part of this paper, an attempt is made to provide a comprehensive understanding of schizophrenia in historical contexts in ancient Greece and Rome, focusing on two prominent figures of that era, Galen, and Hippocrates, along with less known symptoms, treatments, and diagnostic methods. Greek philosophers such as Plato and Aristotle referred to the early theories of mind and soul and provided the context for the subsequent medical and psychiatric discourse, although the opinions of Plato and Aristotle are not examined in this article, it is necessary to understand that these two have had a great impact on the next steps and progress of treatments (Stylianidis, 2016).

Understanding Schizophrenia in Greek and Ancient Times

Historical Context

Mental illnesses, especially what we call schizophrenia in ancient Greece and Rome, were often understood through supernatural or divine forces, under the influence of popular philosophical and medical theories. The concept of “lunacy”, derived from the Latin word “luna” meaning the moon was used to attribute insanity (or mental disorders such as schizophrenia) to the moon’s phases (Kingdon et al., 2022). Madness was believed to wax and wane with the cycle of the moon. At that time, it was believed that the full moon aggravated the symptoms of mental disorders (Smith, 2005). For centuries, this belief was the dominant belief and was reflected in cultural traditions, medical treatises, and religious practices

Early Conceptions of Mental Illness

In ancient times, the understanding of mental illness was deeply mixed with religious and philosophical beliefs, and madness was considered a curse or divine possession, which was treated by some rituals, prayers, and exorcisms.

The Influence of Philosophers and Physicians

As mentioned, Greek philosophers such as Plato and Aristotle contributed to early theories of mind and spirit, and then physicians such as Hippocrates took a more empirical approach that emphasized the importance of observation and natural explanations for disease. The crucial point is that mental illnesses in ancient societies were often intertwined with religious, philosophical, and medical frameworks. For example, the ancient Greeks believed in the concept of “mania,” meaning a state characterized by divine inspiration or madness. However, philosophers like Heraclitus speculated about the nature of mental disorders and mostly attributed them to an imbalance in body fluids or pneuma (vital breath) (Thompson, 2015). The Hippocratic Corpus, attributed to the physician Hippocrates and his followers, considered it a cause of schizophrenia by introducing the concept of “phrenitis,” a condition characterized by fever-induced delirium, which may include symptoms like schizophrenia (Suvajdzic et al., 2016).

Hippocrates and Galen significantly impacted the understanding of schizophrenia in ancient times. Hippocrates is known as the father of Western medicine. He introduced the concept of the “four humors” to explain illness, including mental disorders (Evans et al., 2003).       In this theory, he explained that an imbalance between humor causes disease, a theory that influenced the formation of early thoughts about mental health. Galen was also one of the prominent Greek physicians who developed the humoral theory and developed treatments that were not transcendental. Among these treatments, we can mention restoring balance, such as diet and exercise (Evans et al., 2003).

Although these interpretations did not identify schizophrenia as we understand it today, directing science away from supernatural causes and emphasizing the natural causes of mental disorders, paved the way for the final departure from supernatural explanations for mental illness.

Symptoms and Manifestations

Schizophrenia has a wide range of symptoms. In the contemporary era, those symptoms are classified as positive, negative, and cognitive symptoms. But there was no such classification in this period. In this section, we will examine classic explanations, rarely known symptoms, and interpretations and observations (Stylianidis, 2016). Ancient texts such as religious scriptures, mythological narratives, and medical treatises provide glimpses into a diverse set of symptoms associated with schizophrenia (these symptoms were not recognized as symptoms of a specific illness called schizophrenia, but upon examination, these symptoms were indicators of what we know today as schizophrenia) (Evans et al., 2003).

Some archeological findings (ancient Egyptian medical papyri) show the treatment of some mental disorders through magical rituals and herbal medicines. For example, Homer in his epic poems depicted characters experiencing auditory hallucinations and erratic behaviour, which were indicative of underlying mental disorders. Plato’s dialogues refer to the concept of “divine madness,” in which individuals receive insights and prophecies during altered states of consciousness.

Classical Descriptions

Ancient texts describe people with symptoms like schizophrenia. Among these symptoms, auditory hallucinations, paranoid delusions, and irregular speech can be mentioned. There are limited reports from people who lived during that time that bear these symptoms.

Barely Known Symptoms

Although there is no exact evidence of these symptoms, in some texts, symptoms that can be considered related to schizophrenia have been mentioned in addition to the classic symptoms. These symptoms have been minor, such as social withdrawal, catatonia and emotional restlessness. Although these symptoms cannot necessarily be attributed to schizophrenia today (Thompson, 2015).

Interpretations and Observations

The interpretation of these signs has been highly dependent on cultural beliefs and social norms, and it has been treated differently in each culture and society. Some people who had symptoms of schizophrenia such as delusions were respected as prophets or mystics in some societies, while others were rejected and marginalized in other societies due to their insanity (Thompson, 2015).

Methods of Diagnosis

There were three main factors in the diagnosis of mental disorders in ancient times, cultural interpretations, empirical knowledge, and empirical observations, of course, the last two were seen more in the middle and end of this period. During this period, behavioral patterns were known to indicate insanity or mental disorder (Thompson, 2015). Doctors and healers used to diagnose symptoms of mental distress by examining the behaviour and emotional expressions and the way of communication of patients (Kingdon et al., 2022).

These diagnostic criteria were influenced by the cultural norms of that time and place and prevailing religious beliefs, considered specific behaviours that show divine favour or punishment. However, there were no precise universal criteria for these diagnoses, and the distinction between normal and pathological behaviour remained fluid, reflecting the complex interplay of biological, psychological, and sociocultural factors.

Diagnostic Criteria

There were no formal diagnostic criteria as we know them today, but certain behavioural patterns and symptomatology were recognized as signs of insanity or mental disorder. Of course, these criteria were determined by the cultural understanding of normality and deviance. For this reason, depending on where a person lived and with what culture, these criteria were different, and the diagnosis was also different (Kingdon et al., 2022).

Diagnostic Tools and Techniques

Diagnostic tools and techniques used in this period were very primitive compared to contemporary methods. At that time, there was no profession called psychology, and most doctors evaluated the mental state of patients. Doctors at that time relied on their senses and intuition and often used subjective experiences and anecdotal evidence, which was influenced by the dominant thinking of that society, religion, and culture (Thompson, 2015).

Treatments and Interventions

In ancient civilizations, the methods of treating mental illnesses, including schizophrenia, were a combination of medicinal, psychological, and spiritual approaches. For example, in this period, herbal potions derived from plants such as mangrove, henbane, and opium were used, which were used to reduce the symptoms of restlessness, insomnia, and hallucinations, although their efficacy was uncertain (Hooper & Chandler, 1984). It is interesting to note that some therapeutic methods such as music therapy, hypnosis, and cathartic ceremonies have also been used in this period (Bojuwoye, 2005). This ceremony was held to restore harmony to the damaged psyche. Also, some religious ceremonies such as exorcisms and gifts to the gods were performed to appease malevolent spirits that were thought to be responsible for mental illnesses (Bojuwoye, 2005).

Social Understanding and Stigmatization

The social perceptions of mental illnesses in this era have been formed by dominant cultural beliefs, religious teachings, and socio-economic structures. Mental patients, especially people who had schizophrenia, were looked at through the lens of divine authority, and of course, they were sometimes respected as conduits of divine wisdom or prophetic insight. However, these people were rejected due to deviation from social norms, and sometimes they were subjected to punishment measures such as physical punishment (Bojuwoye, 2005). The cycle of isolation, discrimination and intergenerational harm continued through the stigmatization of mental patients and caused them to be marginalized then (Kingdon et al., 2022).

Galen and Hippocrates

Galen was a prominent Greek physician and philosopher who made significant contributions to the understanding and treatment of mental illness. He advocated more of a comprehensive approach to health that relied on the connection of mind, body, and spirit (Evans et al., 2003).

Hippocrates, known as the father of Western medicine, introduced the foundations of empirical observations and rational research in mental health. He emphasized the importance of environmental factors, diet, and lifestyle in maintaining mental health. Both emphasized non-transcendental factors as the causes of mental illnesses for the first time, and the treatment methods they offered were experimental-medical treatments instead of treatment through religious ceremonies and rituals. Also, by emphasizing the biological, psychological, and social determinants of health, they laid the groundwork for the creation and progress of contemporary approaches for the diagnosis, treatment and prevention of schizophrenia and mental illnesses (Suvajdzic et al., 2016).

Galen’s ideas were more influenced by the popular medical theories at that time. He especially considered the humoral theory, which assumed that health depends on the balance of four body fluids or humors: blood, phlegm, yellow bile, and black bile. By extending the humoral theory to mental disorders, Galen suggested that the imbalance of humors can lead to abnormalities in mental performance. He believed excess black bile caused melancholia or “black bile madness,” a condition characterized by symptoms like modern-day depression and psychosis (Evans et al., 2003). Galen also emphasized the role of environmental factors and supported a comprehensive approach to health that paid attention to physical and psychological factors.

But Hippocrates’ approach was deeper and broader. His approach to mental illness was based on empirical observation, rational inquiry, and ethical practice. Hippocrates clearly and directly rejected supernatural explanations for mental disorders and sought naturalistic explanations rooted in the physiology of the body and environment. Like Galen, he supported the theory of the four humors, but he emphasized the importance of balance and balance in maintaining health and somehow expanded it. According to Hippocrates’ theory, a disturbance in the balance of humors can lead to mental disorders such as mania, melancholia, and hysteria (Suvajdzic et al., 2016).

Differences in Conformity between Genders

In this era, gender roles, cultural norms and social hierarchies were factors influencing people’s behaviour and their adaptation. The expectations of women and men were different concerning their roles, responsibilities, and ways of social expression, while cultures also differed in their attitudes toward conformity. Some societies emphasized collective harmony and social cohesion, while others valued individual independence and internal and external opposition. Psychological reactions, which are manifested as resistance to perceived threats against freedom and autonomy, appeared during this period in the fields of social control, coercion, and repression, which led to the formation of historical narratives of rebellion, revolution, and social changes (Kingdon et al., 2022).

Conclusion

The historical context of schizophrenia in ancient Greece and Rome has provided valuable insights to contemporary scientists. Some of these insights are cultural and some are philosophical, but the crucial point is that during this era, mental health gained value and the approach to it began to change. In this era, from the supernatural interpretations of divine madness to the experimental observations of early doctors, the understanding of schizophrenia has evolved over thousands of years under the influence of various cultural, social, and religious beliefs. In this era, people with schizophrenia were viewed through the lens of divine agency. Depending on the type of dominant culture, sometimes these people were revered as conduits of divine wisdom, and sometimes they were marginalized due to their perceived deviation from social norms. Many philosophers such as Plato and Aristotle proposed different theories about mental illnesses, and later those such as Hippocrates and Galen developed them and criticized them in some cases.

These theories were rooted in the philosophical and medical traditions of that time. Galen’s and Hippocrates’ emphasis on empirical observation, clinical reasoning, and holistic approaches to health laid the groundwork for the creation of modern psychology and experimental science. Galen’s humoral theory and Hippocrates’ naturalistic explanations were very influential in diagnostic criteria and subsequent treatment methods.

By integrating and examining these past insights and contemporary knowledge and perspectives, we can achieve a better understanding of schizophrenia and mental illnesses, and as a result, cause progress and development of treatment methods.

Schizophrenia in the Early 1900s (Holly)

Introduction

The study of Schizophrenia in the early 1900s is vastly different from what we know in modern society. Schizophrenia at the time was then largely misunderstood as a disorder due to the lack of knowledge surrounding it. Instead of being characterized as an individual disorder with internal causes, it was assumed to be caused by external/environmental sources (Kendler & Klee, 2023) . Terms like mania were frequently used as an umbrella term to describe the experience that we would now label as Schizophrenia, among other disorders (Kendler, 2020). However, this ambiguity towards the disease was reduced with the research from a German psychiatrist, Emil Kraepelin (Kendler, 2020).

Important Figures and Discoveries

Emil Kraepelin was a German psychiatrist that has been regarded as one of the most influential figures in the field of psychiatry regarding Schizophrenia studies (Kendler, 2020). He was especially interested in the treatment of psychological disorders while also making this information approachable for students (Kendler, 2020). To achieve this, Kraepelin detailed many disorders in a textbook called Klinik, which he revised several times (Kendler, 2020). In 1899, Emil Kraepelin founded the concept of dementia praecox and detailed the disorder in his textbook (Kendler, 2020). Dementia Praecox became the name of the disorder that we now call Schizophrenia.

Two psychologists, Schuppius and Wittermann, aimed to analyze the occurrence of Dementia Praecox based on Kraepelin’s writings (Kendler & Klee, 2023).  Schuppius especially studied the relationship between Dementia Praecox and other disorders through hereditary cause (Kendler & Klee, 2023). Schuppius did several studies on people diagnosed with Dementia Praecox but found little evidence to support the theory that Dementia Praecox is a hereditary disease. However, he did find that Dementia Praecox often occurs alongside other mental illnesses (Kendler & Klee, 2023). Similarly to Schuppius, Wittermann did a lot of research with pedigree tables to try and determine if Dementia Praecox is passed down genetically (Kendler & Klee, 2023). However, his research concluded that even if a family is healthy, mental illnesses can still occur (Kendler & Klee, 2023).

Dementia Praecox

A standout in Klinik is Kraepelin’s description of Dementia Praecox, which is described as a disorder that results in the disintegration of personality and morale, combined with mental disturbances (Kendler, 2020). Additionally, he stated that it causes cognitive decline, even at an early age (Nunomura, 2024) Before Kraepelin, mental disturbances had been characterized as either mania or a form of pure insanity (Ion & Beer, 2002). Also, Kraepelin claimed that most uncured or undiagnosed patients in mental institutions had dementia praecox (Kendler, 2020). Kraepelin described a series of events that lead to the diagnosis of Dementia Praecox (Kendler, 2020). He describes how a person begins with early symptoms of Dementia Praecox, where they begin to act more agitated than normal (Kendler, 2020). The individual then has positive symptoms, which include hallucinations and can sometimes lead to a weakening of emotions and joy in past pleasures (Kendler, 2020).  In the 8th edition of Kraepelin’s textbook, he describes several subtypes of Dementia Praecox, including a subtype of Dementia Praecox called Simple Praecox (Kendler & Klee, 2023). Simple Praecox is described as a “mild” form of Dementia Praecox, where the symptoms of disintegration are not as severe (Adityanjee et al., 2002).

By the end of his research, Kraepelin concluded that Dementia Praecox is a disease of the central nervous system, caused by lesions in the brain (Adityanjee et al., 2002).

Treatment

Although treatments for Dementia Praecox were not widely available in the early 1900s, there were shifts in techniques of study (Kendler, 2020). Schuppius described the shift of research at the time, from mass group research to research on individuals (Kendler & Klee, 2023). This shift was due to the popularity of hereditary research, where doctors can study an individual with a disease and contact all their family members to determine if there is a genetic basis.

Kraepelin did not believe that Dementia Praecox could be treated (Adityanjee et al., 2002). In fact, he stated that if any form of recovery would to have occurred, it would quickly be reversed (Adityanjee et al., 2002).  However, Kraepelin did emphasize the importance of institutionalization and the attempt to maintain the personalities of the patients (Kendler, 2020). Kraepelin suggests that to keep their personality, patients need to be directed to an environment that can adapt to their symptoms and not overwhelm them (Kendler, 2020).

Conclusion

Although there was a lot of new information coming out around the early 1900s, there was a lack of knowledge around different mental health disorders. Schizophrenia was not fully understood then, resulting in much confusion about the causes. Since they were limited by techniques and technology, it was extremely hard at the time to study diseases that were not physically observable. However, this period laid the foundation for more research on mental health disorders regarding hallucinations and personality change.

Schizophrenia in the late 1900s (Tina)

Abstract

Schizophrenia is a complex disorder that researchers, doctors and society have had different scientific and social approaches to during all periods. In this section, I address the complexities of schizophrenia in the late 1900s, examining its symptoms, treatments, diagnostic methods, and social perceptions. In addition, I will examine the influence of Dr. Jeffrey Lieberman in shaping our understanding and management of schizophrenia as an influential person. In this section, I will provide a comprehensive overview of schizophrenia in a broader sociocultural context by integrating social psychological learning objectives.

Introduction

Schizophrenia is a chronic mental disorder that varies in severity among people with it. Schizophrenia is characterized by disturbances in thoughts, perceptions, emotions and behavior. Schizophrenia usually appears in late adolescence or early adulthood and often continues throughout a person’s life. Understanding schizophrenia is considered essential for its impact on individuals and social consequences. The management of schizophrenia requires a multifaceted approach that includes biological, psychological, and social aspects (Fusar‐Poli et al., 2017).

Late 1900s Understanding of Schizophrenia

In the late 1900s, the understanding of schizophrenia was much better than before, but much more limited and often associated with misconceptions. The disorder was usually considered a single disorder rather than a spectrum of related conditions. Diagnostic criteria during this period, such as those listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM), underwent several revisions during this period, reflecting evolving conceptualizations of the disorder (Corrigan et al., 2014).

Since the late 1900s, significant progress has been made in understanding schizophrenia. These advances included advances in neuroscience, genetics, and psychopharmacology that provided insights into the biological underpinnings of the disorder. This research revealed the involvement of neurotransmitter systems, brain structure abnormalities and genetic predispositions in the development of schizophrenia (Keshavan et al., 2020).

Symptoms of Schizophrenia

Known Symptoms

Some symptoms of schizophrenia are better known than others. Symptoms classified in positive, negative and cognitive domains are among them. Positive symptoms include the presence of abnormal behaviours or experiences such as hallucinations, delusions, and disturbed thinking, and negative symptoms include a lack of normal functioning, which includes reduced emotional expression or social withdrawal, or lack of motivation. In the category of cognitive symptoms, attention, memory and executive function disorders can be mentioned, which target the cognitive system. These symptoms can be severe or mild in people with schizophrenia (Bond & Smith, 1996).

Barely Known Symptoms

Some of the symptoms of schizophrenia are less well-known than the previously mentioned symptoms. Symptoms such as anosognosia (lack of insight into one’s illness), catatonia (abnormal motor behaviour) and avolition (inability to start and maintain purposeful activities) are among these symptoms. These symptoms generally create challenges in diagnosis and treatment planning, because they may not show themselves easily during clinical evaluations (Tandon et al., 2013).

Methods of Diagnosis

Late 1900s Diagnostic Techniques

In the late 1900s, the diagnosis of schizophrenia relied primarily on clinical interviews, observation of symptoms, and adherence to diagnostic criteria outlined in classification systems such as the DSM and the International Classification of Diseases (ICD). This caused the diagnostic accuracy to be limited by subjectivity and diversity among doctors compared to the past. Contemporary diagnostic approaches combine clinical assessment, neuroimaging techniques (eg, MRI, PET scan) and genetic testing to increase accuracy (van Os & Kapur, 2009).

Classification systems such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD) were widely used during this period. However, diagnostic practices varied among clinicians and institutions during this era, and the understanding of schizophrenia was still evolving, and the use of these classifications varied among clinicians, psychologists, and researchers. During this time, doctors used the DSM-III, published in 1980, to determine whether a person’s symptoms met the threshold for a diagnosis of schizophrenia or other related psychotic disorders. At the end of that era, differential diagnosis was noticed. As such, it was very important to rule out other medical or psychiatric conditions that could be similar or concurrent with schizophrenia. Doctors performed thorough medical evaluations, laboratory tests, and imaging studies to rule out organic causes of psychosis, such as brain tumors, infections, or metabolic disorders, to confirm their diagnosis (van Os & Kapur, 2009).

Treatment Approaches

Traditional Treatments in the Late 1900s

In the late 1900s, antipsychotics, such as chlorpromazine and haloperidol, were the primary treatment for schizophrenia, although the use of antipsychotics was later questioned. These drugs generally target positive symptoms but are problematic because they cause debilitating side effects such as extrapyramidal symptoms and metabolic disturbances. For this reason, during this period, psychosocial interventions, including psychotherapy and professional rehabilitation, began to be used to support people with schizophrenia (Lehman et al., 2004).

In the late 1900s, treatment approaches to schizophrenia were largely centered around pharmacological interventions and institutional care, reflecting the prevailing medical model of mental illness at the time. This is if in the following periods and now, the use of antipsychotic drugs is not considered as the main treatment.

Regarding drug interventions in this period, first-generation antipsychotic drugs, such as chlorpromazine (Thorazine) and haloperidol (Haldol), were the mainstay of the drug treatment of schizophrenia in the late 1900s. These drugs primarily target the positive symptoms of psychosis by blocking dopamine D2 receptors in the brain. As a result of this, dopaminergic neurotransmission was reduced and hallucinations, delusions and mental disorders were also reduced. However, FGAs were associated with significant side effects, including extrapyramidal symptoms (eg, akathisia, dystonia, parkinsonism) and tardive dyskinesia, which limited their tolerability and long-term use (Lehman et al., 2004).

Traditional treatments during this period represented significant advances in psychiatric care compared to previous centuries, but still had limitations, including reliance on high-dose antipsychotics with significant side effects and isolation of people with Schizophrenia in institutional settings.

Modern Treatment Modalities

Contemporary treatment approaches for schizophrenia include a wider range of interventions aimed at addressing symptoms and functional impairment than in previous periods. Nowadays, second-generation antipsychotics, which have a more favourable side effect profile, are usually prescribed as first-line drug therapy. Psychosocial interventions, such as cognitive-behavioural therapy, supported employment, and family psychoeducation, are integral components of comprehensive treatment plans that specifically help individuals with schizophrenia (Lehman et al., 2004).

Social Understanding of Schizophrenia

Late 1900s Stigma and Discrimination

In the late 1900s, schizophrenia was still stigmatized, and people with the disorder often faced social exclusion, discrimination, and institutionalization. However, this social isolation and discrimination was no longer accompanied by punishment. In this period, more than punishment and physical violence, these people were isolated, and by separating them from the society, they were punished and subjected to modern violence in a way. Media portrayals perpetuate stereotypes of schizophrenia as synonymous with violence and unpredictability, contributing to fear and misunderstanding in communities (Thornicroft et al., 2008).

Today, efforts to fight stigma and promote social inclusion of people with schizophrenia have gained momentum. Advocacy organizations, mental health campaigns and educational initiatives work to raise awareness and challenge stereotypes. In this way, they try to strengthen empathy and support for people with schizophrenia. However, stigma persists in various forms and emphasizes the need for continued support and social change (Corrigan et al., 2014).

Influence of Dr. Jeffrey Lieberman

Dr. Jeffrey Lieberman is one of the leading psychiatrists and researchers who has made significant contributions to the understanding and treatment of schizophrenia. In the late 1900s, Dr. Lieberman conducted pioneering research into the neurobiology of schizophrenia, examining the role of dopamine dysregulation in the pathophysiology of the disorder. His work laid the foundation for the development of new pharmacological interventions and personalized treatment approaches (Lieberman & Dishy, 2021).

Today, Dr. Jeffrey Lieberman explores and advocates for evidence-based practices, neglect, and access to mental health services for people with schizophrenia. Lieberman’s legacy extends beyond his scientific contributions and includes his efforts to improve public awareness and policy initiatives related to schizophrenia (Lieberman & Dishy, 2021).

Dr. Lieberman has conducted extensive research and clinical work on schizophrenia and related psychotic disorders, focusing on understanding the biological mechanisms underlying schizophrenia as well as developing and testing new treatment approaches. He has also been involved in research on antipsychotic drugs that are the primary treatment for schizophrenia. Dr. Lieberman played a pivotal role in the Clinical Trials of Antipsychotic Intervention Effectiveness (CATIE) study. This is one of the largest trials comparing the effectiveness of antipsychotic drugs in schizophrenia. As a result of this study, a deep insight into the relative effectiveness of different antipsychotic drugs has been provided and it has caused psychiatrists and psychologists to make more informed treatment decisions.

CATIE

CATIE was a large-scale, multisite clinical trial funded by the National Institute of Mental Health (NIMH). The purpose of this research was to compare the effectiveness of different antipsychotic drugs in the treatment of schizophrenia, because antipsychotic drugs create many challenges for people with schizophrenia and take them away from their normal lives. The CATIE study, conducted from 2001 to 2005, included more than 1,400 participants with schizophrenia at 57 clinical sites in the United States. It was one of the largest and most comprehensive trials of its kind in psychiatry ever conducted (Swartz et al., 2008).

The primary objectives of the CATIE study were to evaluate the efficacy of several second-generation antipsychotics compared to an older, first-generation antipsychotic (perphenazine). They also targeted the level of tolerance and side effects of these drugs, the rate of discontinuation of treatment and the overall results of treatment over time (Swartz et al., 2008).

The key findings of this study (CATIE) examined and challenged the common belief that newer antipsychotic drugs are uniformly superior to older drugs in the treatment of schizophrenia. This study was conducted from 2001 to 2005 with more than 1400 participants. And finally, it showed a significant difference in effectiveness between different antipsychotic drugs. However, this study found differences in side effect profiles with drugs such as olanzapine being associated with more weight gain and metabolic effects. While ziprasidone had a lower risk of these side effects, the rate of treatment discontinuation was higher. This study highlighted the importance of considering individual patient factors such as tolerability and side effect profile when choosing antipsychotic treatments for schizophrenia and emphasized the individualization and personalization of treatment (Swartz et al., 2008).

Social Psychological Differences in Conformity

The research conducted during this period, regarding adaptation, has shown slight differences between men and women in their sensitivity to social influence. Both sexes show a tendency to conform, studies show that women may conform to social norms and group pressures more than men (Eagly & Carli, 2003).

Relationship between Culture and Conformity

In this era, culture plays an important role in shaping consistent behaviors and attitudes. Culture plays this role in almost all eras. Due to the dynamics of culture, this effect changes in different decades. Cross-cultural studies have shown variations in the levels of conformity in different societies. Studies show that these changes are influenced by cultural values, norms and socialization practices (Bond & Smith, 1996).

Conclusion

Schizophrenia has undergone significant changes in understanding, diagnosis, treatment, and social perception since the late 1900s. Although these changes have been very positive compared to their previous periods, they still have many limitations. Advances in neuroscience, genetics, and psychosocial interventions have revolutionized the approach of psychologists, psychiatrists, and researchers to the management of this complex disorder. Challenges in reducing stigma, improving access to care, and optimizing treatment outcomes for people with schizophrenia still exist in Indore. The type of exclusion from society in this era is different from the previous eras, but it still exists. In this era, the use of first-generation antipsychotic drugs is widely used and paid attention to, but by observing its long-term effects, researchers challenge it.

Schizophrenia in the Modern Era (Jessica)

Introduction

Throughout history schizophrenia has been misunderstood and mistreated, which included harming patients and labeling it as a spiritual experience. In the modern era, schizophrenia has logic-based diagnostics, symptoms, and treatments (Toshiaki, 2022). With technological advances and research, the mental field has narrowed down criteria for individuals with schizophrenia (Toshiaki, 2022). It is based on the patient’s symptoms, which results in personalized treatment plans to ensure they are receiving the right plan to move forward (Toshiaki, 2022). In the modern era there is more awareness of mental health and mental disorders, and there is not as much of a stigma to seek the proper help or receive treatment (Onitsuka, 2022).. With more people coming forward to get help, doctors are able to help diagnose and treat more people who are struggling and give them the treatment they need.

Symptoms

Some common symptoms of people who have been diagnosed with schizophrenia are disordered thinking, emotions, behavior, perception, and a sense of self (Onitsuka, 2022). It can also include hallucinations, disorganized speech and or behavior, delusions, and disturbances of emotions (Onitsuka, 2022). The severity of symptoms can vary by patient, and they include some episodes of worsening and remission (Onitsuka, 2022). But symptoms can vary over the course of the disease, with episodes worsening or improving symptoms (Toshiaki, 2022).

Criteria’s

The DSM-5 criteria are one of the main sources of criteria used by psychiatrists to properly diagnose and treat patients. The DSM-5 stands for a diagnostic and statistical manual for mental disorders (Toshiaki, 2022). Several disorders are listed in these criteria, with each having its own criteria or requirements for the diagnosis (Toshiaki, 2022). The American Psychiatric Association creates the DSM-5 criteria. Even though the DSM-5 is the most common used or sourced for medical professionals, there are other evaluation systems. For example, Schneider’s first-rank symptoms. This system accurately diagnosis individuals who are experiencing psychosis (Toshiaki, 2022). The symptoms include hallucinations, thinking others can hear their thoughts and hearing voices in their head (Toshiaki, 2022). Although the Schneider’s first-rank symptoms are not one hundred percent accurate and can lead to misdiagnosing individuals with schizophrenia (Toshiaki, 2022). However, it can be useful to triage patients that need to be assessed by a psychiatrist (Toshiaki, 2022). Another system used is the Bleuler’s 4As, and it’s made up of the fundamental, accessory, primary and secondary symptoms (Arantes-Gonçalves, 2018) which is also known as the 4 A’s, Alogia, Autism, Ambivalence, and Affect blunting (Arantes-Gonçalves, 2018). The four A’s terms are used to access the symptoms of a patient within the A’s (Arantes-Gonçalves, 2018). It allows for a patient care approach and explores new forms of therapeutic approaches (Arantes-Gonçalves, 2018). The following three criteria allow for a better understanding of the patient and how to properly treat and access individuals with schizophrenia.

Treatment

One individual who has schizophrenia can experience different symptoms than others who are diagnosed with the same mental disorder and the treatment they receive is based on their symptoms and severity of each symptom (Onitsuka, 2022). Medical professionals can prescribe antipsychotic medication to manage psychosis (Onitsuka, 2022). There are two types of antipsychotic medication, typical and atypical. These medications act on the dopamine and serotonin receptors in the brain. (Onitsuka, 2022). There are also several types of psychotherapy that can be recommended, along with the medication, such as cognitive behavioral therapy, cognitive enhancement therapy, group therapy and peer support, and acceptance and commitment therapy (Onitsuka, 2022). And basic and supportive therapy can allow patients to return to their daily life’s (Toshiaki, 2022) which includes social skills training with the whole body and regulating the mind and body through mental and physical interactions (Toshiaki, 2022). Overall treating schizophrenia is providing care for the individuals diagnosed, helping to prevent relapses, and continuously aiming for recovery (Toshiaki, 2022).

Conclusion

People with the mental disorder of schizophrenia were mistreated for centuries. Physical and mental harm was used on people with schizophrenia and other with other mental disorders (Onitsuka, 2022). Plus, there was a harsh stigma associated with individuals with mental disorders, including schizophrenia and people quite often did not seek help as a result (Onitsuka, 2022). But in the modern era there’s been a societal shift in the way we view mental disorders and how patients should be treated (Toshiaki, 2022). In this section, I have described the symptoms, criteria, and treatment of schizophrenia in the modern era. The modern era approach gives patients hope for recovery and can reduce the number of symptoms, as well as the severity patients experience.

Discussion questions

Ericson

Question 1:

In the context of ancient Roman and Greek civilizations, what were the perceptions and approaches towards schizophrenia? How did cultural and philosophical frameworks influence these views?

Answer 1:

In the ancient Greco-Roman world, the understanding of mental illness, of which schizophrenia was one of them, was influenced by cultural, religious, and philosophical beliefs. During this period, the diagnosis of mental disorders, such as schizophrenia, was often based on observed behaviours rather than a scientific understanding of the underlying neurobiology, a huge part of which was due to the lack of progress in science at the time. Schizophrenic symptoms, such as hallucinations, delusions, and disordered thinking, were interpreted in the context of popular religious or supernatural beliefs. The crucial point was that there was no independent disease called schizophrenia. During this period, the methods of treating schizophrenia in ancient times were diverse, most of which reflected the beliefs of society. For example, in Greece, part of the treatment included visits to healing sanctuaries such as the Asclepieion, where rituals, baths, and offerings were believed to cure ailments, including mental illness. In Rome, treatment mostly involved religious ceremonies or the use of herbal remedies. The understanding of the symptoms of schizophrenia was also influenced by the popular philosophical ideas of the time. For example, in ancient Greece, the concept of “miasma” or contamination was often associated with mental illness, which indicated moral or spiritual failure. Many philosophers such as Plato and Aristotle also influenced the perception of schizophrenia by considering mental illness as a disorder of the soul or the result of an imbalance in body fluids (humor).

In ancient societies, the stigma associated with mental illness had an impact on diagnosis and treatment. Those who showed symptoms of schizophrenia were ostracized from society, which led to social isolation. In some texts, it is also stated that this group of people who had mental illnesses were considered monsters or insane people, or people who were possessed by the devil.

In general, the approach to schizophrenia in ancient Roman and Greek civilizations was deeply rooted in cultural, religious, and philosophical beliefs, and this was the reason the diagnosis relied on observable behaviours. Treatment methods were also remarkably diverse and were often influenced by religious or philosophical teachings that were formed within the framework of popular cultural norms and beliefs.

Holly

Question 2:

During the early 1900s, what were the opinions around causes of Dementia Praecox? What aspects of this time do you think influenced these opinions?

Answer 2:

Dementia Praecox in the early 1900s was very misunderstood. At the time, it was largely assumed that mental illnesses had a genetic basis, meaning that the illnesses were passed down from previous generations of a person’s family.  However, psychologists such as Schuppius and Wittermann researched these claims and found very little evidence to support this claim. Instead, they did find evidence that Dementia Praecox often occurs alongside other mental illnesses. One possible factor as to why these opinions were formed is that technology wasn’t as advanced as today. They didn’t have the technology to scan brains to determine abnormal activity, so they had to measure what was available then. Family and medical records were much more easily accessible and gave researchers the opportunity to find patterns in families and individuals. Although those methods made it so there was not much evidence to support hypotheses, it was all that was available to use. Another possible cause is the fact that there was much more research done on non-mental illnesses, many of which can be passed down genetically. So, it is possible that the doctors/psychologists of the time thought that mental illnesses operated in the same way.

Tina

Question 3:

How has the understanding and treatment of schizophrenia evolved in the modern era, and how and to what extent do current social attitudes affect people with Schizophrenia?

Answer 3:

The treatment and understanding and approach to schizophrenia in the modern era has made a lot of progress, which is partly due to the progress of science. Schizophrenia and the approach to it, through scientific research and clinical practice, has moved away from the stigma and misconceptions of the past. Schizophrenia was historically thought of as madness, a manifestation of demonic possession or a morally wrong failure. As a result of this misunderstanding, people with schizophrenia were treated harshly and inhumanely, sometimes they were rejected by society and sometimes they were punished (sometimes even physically). But in the 20th century, antipsychotic drugs revolutionized and at first caused many of these people to recover. This marked a turning point in history. Along with medical advances, the development of therapeutic and psychological methods also improved the quality of life of these people and enabled them to manage their symptoms. One of these treatment methods was cognitive behavioural therapy (CBT). Meanwhile, the modern understanding of schizophrenia emphasizes the importance of a biopsychosocial model, which shows that genetics, brain chemistry, environmental factors, and social issues all play a role in the development and course of this disorder. By adopting a holistic approach, treatment plans have become more comprehensive and individualized, addressing not only symptoms but also the social and emotional needs of individuals. Despite all these advances, there is still stigma and discrimination against people with schizophrenia in many cultures, which can lead to isolation and away from having a normal life for them. Today’s approaches in the modern era, while trying to improve the condition of people with schizophrenia, try to make these people more capable and make them live good and normal lives.

Jessica

Question 4:

What are some of the obstacles to living with schizophrenia in the modern era?

Answer 4:

Schizophrenia is a very complex mental condition that can impact a person’s everyday life. And it can impact someone in many different ways including but not limited to behavior, thoughts, feelings, and perception. There are new medications in the modern era for schizophrenia and they can be very beneficial to some patients, although many have serious side effects. Some side effects patients can experience are issues with sleep, weight gain, extreme exhaustion during the day, abnormal cholesterol levels, and suicidal thoughts. And these side effects can negatively affect a person’s relationships, job, school, and even caring for themselves. All of this can be difficult so it’s very benefitable to have a good support system to help manage and navigate through. Overall, a normal life is reachable with medical support, medication, and a good support system.

Key terms

Ericson

1. Humors: During the ancient Greek and Roman period, humor was a popular theory that attributed health and disease to the balance or imbalance of body fluids, known as “humor”. The four humors were Blood (Greek: “sanguis” or Latin: “sanguis”), Phlegm (Greek: “phlegma” or Latin: “phlegma”), yellow bile (Greek: “cholē” or Latin: “cholera”), Black bile (Greek: “melaina cholē” or Latin: “melancholia”).
2. Lunacy: During the ancient Greek and Roman periods, the term “lunacy” was sometimes used to describe the symptoms associated with what we now understand as schizophrenia. The meaning of this word is madness. “Lunacy” is derived from the Latin word “luna” which means moon, and the reason for using this word was the belief that mental disorders, including schizophrenia, were somehow influenced by the phases of the moon. During this period, it was believed that certain behaviors, especially those caused by mental illness, were exacerbated during certain lunar phases.

Holly

1. Dementia Praecox: Coined by Emil Kraepelin, this term describes what we now know as Schizophrenia. It is characterized by changes in personality, hallucinations, delusions, and mood (Kendrel, 2021).
2. Pedigree Tables: A type of family chart that shows different generations, often separating genders by representing them as different shapes (Kendler & Klee, 2023).

Tina

• 1- Negative Symptoms: Negative symptoms are the reduction or absence of normal behaviors and experiences. Apathy (lack of passion), apathy (inability to feel pleasure), flat affect (decreased emotional expression), poor speech and social withdrawal are among these symptoms. These types of symptoms can significantly affect the quality of life and a person’s ability and performance. The effects of negative symptoms are generally more than positive symptoms.
• 2- Cognitive Symptoms: This category of symptoms includes problems and disorders that occur in intellectual and cognitive processes. These symptoms are memory, concentration, decision making and problem solving. This group of symptoms in schizophrenia can be severe or mild and can disturb the daily functioning of the person. Generally, tasks that require planning and organization will be challenging for a person with these symptoms.

Jessica

1. Positive symptoms – these are symptoms that add to or distort the person’s normal functioning (Mae, 2021). It affects the individual’s thoughts or behaviors, some of the symptoms include delusions, hallucinations, and confusion or thought disorder (Mae, 2021).
2. Acute Phase – The beginning of an onset symptom, with schizophrenia this means positive symptoms, disordered thoughts and behaviors are to occur (Toshiaki, 2022). Which causes anxiety, destress and social dysfunction (Toshiaki, 2022). Pharmacotherapy with antipsychotic drugs and other biological treatments are very important in this acute phase (Toshiaki, 2022).

References

Adityanjee, Aderibigbe, Y. A., Theodoridis, D., & Vieweg, W. V. (2002). Dementia praecox to schizophrenia: The first 100 Years. Psychiatry and Clinical Neurosciences, 53(4), 437–448. https://doi.org/10.1046/j.1440-1819.1999.00584.x

Arantes-Gonçalves, Filipe. Gama Marques, João. Telles-Correia, Diogo. (2018). Bleuler’s Psychopathological Perspective on Schizophrenia Delusions: Towards New Tools in Psychotherapy Treatment. PubMed Central. doi: 10.3389/fpsyt.2018.00306

Aronson, E., Wilson, T. D., Akert, R. M., Sommers, S. R., & Tucker, V. (2020). Social psychology. Pearson India Education Services Pvt. Ltd.

Bleuler, M., & Bleuler, R. (1986). Dementia praecox oder die gruppe der schizophrenien: Eugen Bleuler. British Journal of Psychiatry, 149(5), 661–664. https://doi.org/10.1192/bjp.149.5.661

Bojuwoye, O. (2005). Traditional healing practices in southern Africa: Ancestral Spirits, ritual ceremonies, and holistic healing. Integrating Traditional Healing Practices into Counseling and Psychotherapy, 61–72. https://doi.org/10.4135/9781452231648.n6

Bond, R., & Smith, P. B. (1996). Culture and conformity: A meta-analysis of studies using Asch’s (1952B, 1956) line judgment task. Psychological Bulletin, 119(1), 111–137. https://doi.org/10.1037//0033-2909.119.1.111

Corrigan, P. W., Druss, B. G., & Perlick, D. A. (2014). The impact of mental illness stigma on seeking and participating in mental health care. Psychological Science in the Public Interest, 15(2), 37–70. https://doi.org/10.1177/1529100614531398

Diagnostic and statistical manual of mental disorders: DSM-5-TR. (2022). . American Psychiatric Association Publishing.

Eagly, A. H., & Carli, L. L. (2003). The Female Leadership Advantage: An Evaluation of the evidence. The Leadership Quarterly, 14(6), 807–834. https://doi.org/10.1016/j.leaqua.2003.09.004

Evans, K., McGrath, J., & Milns, R. (2003). Searching for schizophrenia in ancient greek and roman literature: A systematic review. Acta Psychiatrica Scandinavica, 107(5), 323–330. https://doi.org/10.1034/j.1600-0447.2003.00053.x

Freedman, R. (2015). Shrinks: The untold story of Psychiatryby Jeffrey A. Lieberman, M.D., with Ogi Ogas. New York, Little, Brown and Company, 2015, 313 pp., $28.00. American Journal of Psychiatry, 172(5), 489–489. https://doi.org/10.1176/appi.ajp.2015.15030386

Fusar‐Poli, P., McGorry, P. D., & Kane, J. M. (2017). Improving outcomes of first‐episode psychosis: An overview. World Psychiatry, 16(3), 251–265. https://doi.org/10.1002/wps.20446

Hooper, S. N., & Chandler, R. F. (1984). Herbal remedies of the Maritime Indians: Phytosterols and triterpenes of 67 plants. Journal of Ethnopharmacology, 10(2), 181–194. https://doi.org/10.1016/0378-8741(84)90002-3

Jeffrey A. Lieberman, MD. Columbia University Department of Psychiatry. (2024, February 21). https://www.columbiapsychiatry.org/profile/jeffrey-lieberman-md

Keshavan, M., Lizano, P., & Prasad, K. (2020). The synaptic pruning hypothesis of schizophrenia: Promises and challenges. World Psychiatry, 19(1), 110–111. https://doi.org/10.1002/wps.20725

Ion, R. M., & Beer, M. D. (2002). The British reaction to dementia praecox 1893-1913. Part 1. History of Psychiatry, 13(51), 285–304. https://doi.org/10.1177/0957154×0201305103

Kendler, K. S. (2020). Kraepelin’s final views on dementia praecox. Schizophrenia Bulletin, 47(3), 635–643. https://doi.org/10.1093/schbul/sbaa177

Kendler, K. S., & Klee, A. (2023). The examination of Kraepelin’s diagnoses of dementia praecox and manic‐depressive insanity in pedigrees: Studies of schuppius in 1912 and Wittermann in 1913. American Journal of Medical Genetics Part B: Neuropsychiatric Genetics, 192(7–8), 113–123. https://doi.org/10.1002/ajmg.b.32950

Kingdon, D. G., Turkington, D., & Beck, A. T. (2022). Cultural context. Cognitive-Behavioral Therapy of Schizophrenia, 23–29. https://doi.org/10.4324/9781003210528-4

Lehman, A. F., Kreyenbuhl, J., Buchanan, R. W., Dickerson, F. B., Dixon, L. B., Goldberg, R., Green-Paden, L. D., Tenhula, W. N., Boerescu, D., Tek, C., Sandson, N., & Steinwachs, D. M. (2004). The Schizophrenia Patient Outcomes Research Team (port): Updated treatment recommendations 2003. Schizophrenia Bulletin, 30(2), 193–217. https://doi.org/10.1093/oxfordjournals.schbul.a007071

Leucht, S., Corves, C., Arbter, D., Engel, R. R., Li, C., & Davis, J. M. (2009). Second-generation versus first-generation antipsychotic drugs for schizophrenia: A meta-analysis. The Lancet, 373(9657), 31–41. https://doi.org/10.1016/s0140-6736(08)61764-x

Lieberman, J. A., & Dishy, G. (2021). Milestones in the history of schizophrenia. A comprehensive chronology of schizophrenia research: What do we know and when did we know it. Psychiatric News, 56(01). https://doi.org/10.1176/appi.pn.2021.1.7

Mae, Angela. (2021). What to know about the positive symptoms of schizophrenia. Medical News Today. What are the positive symptoms of schizophrenia? (medicalnewstoday.com)

Montoya, N., Hawkins, B., Townsend, J., & Lewis, S. (2020). Use of evidence-based practices in recreational therapy for schizophrenia spectrum disorder recovery: A descriptive study of current practices. Therapeutic Recreation Journal, 54(2). https://doi.org/10.18666/trj-2020-v54-i2-9962

Myers, D. G. (2010). Social Psychology 10th ed. McGraw Hill.

Nunomura, A. (2024). Is dementia praecox still the “graveyard of neuropathologists”? Psychiatry and Clinical Neurosciences, 78(1), 2–2. https://doi.org/10.1111/pcn.13609

Onitsuka, T., Hirano, Y., Nakazawa, T., Ichihashi, K., Miura, K., Inada, K., Mitoma, R., Yasui‐Furukori, N., & Hashimoto, R. (2022). Toward recovery in schizophrenia: Current concepts, findings, and Future Research Directions. Psychiatry and Clinical Neurosciences, 76(7), 282–291. https://doi.org/10.1111/pcn.13342

Smith, M. (2005). Interventions for schizophreniainterventions for schizophrenia Williams Emma speechmark first 200 £29.95 0863884350 0863884350. Mental Health Practice, 8(9), 33–33. https://doi.org/10.7748/mhp.8.9.33.s20

Stylianidis, S. (2016). Philosophical and sociological foundations of Social Psychiatry. Social and Community Psychiatry, 17–40. https://doi.org/10.1007/978-3-319-28616-7_2

Suvajdzic, L., Djendic, A., Sakac, V., Canak, G., & Dankuc, D. (2016). Hippocrates-the father of Modern Medicine. Vojnosanitetski Pregled, 73(12), 1181–1186. https://doi.org/10.2298/vsp150212131s

Swartz, M. S., Stroup, T. S., McEvoy, J. P., Davis, S. M., Rosenheck, R. A., Keefe, R. S., Hsiao, J. K., & Lieberman, J. A. (2008). Special section on implications of Catie: What Catie found: Results from the schizophrenia trial. Psychiatric Services, 59(5), 500–506. https://doi.org/10.1176/ps.2008.59.5.500

Tandon, R., Gaebel, W., Barch, D. M., Bustillo, J., Gur, R. E., Heckers, S., Malaspina, D., Owen, M. J., Schultz, S., Tsuang, M., Van Os, J., & Carpenter, W. (2013). Definition and description of schizophrenia in the DSM-5. Schizophrenia Research, 150(1), 3–10. https://doi.org/10.1016/j.schres.2013.05.028

Thompson, T. (2015). Ancient medicine. Biblical Studies. https://doi.org/10.1093/obo/9780195393361-0192

Toshiaki Onitsuka MD, PhD, Yoji Hirano MD, PhD, Takanobu Nakazawa PhD, Kayo Ichihashi MD, Kenichiro Miura PhD, Ken Inada MD, PhD, Ryo Mitoma MD, Norio Yasui-Furukori MD, PhD, Ryota Hashimoto MD, PhD. (2022). Toward recovery in schizophrenia: Current concepts, findings, and future research directions. PCN Frontier, Vol 76, pp. 282-291. https://doi.org/10.1111/pcn.13342

Thornicroft, G., Brohan, E., Kassam, A., & Lewis-Holmes, E. (2008). Reducing stigma and discrimination: Candidate interventions. International Journal of Mental Health Systems, 2(1), 3. https://doi.org/10.1186/1752-4458-2-3

Thumiger, C., & Singer, P. N. (2018). Introduction. disease classification and mental illness: Ancient and modern perspectives. Mental Illness in Ancient Medicine, 1–32. https://doi.org/10.1163/9789004362260_002

U.S. Department of Health and Human Services. (n.d.). Schizophrenia. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/schizophrenia

van Os, J., & Kapur, S. (2009). Schizophrenia. The Lancet, 374(9690), 635–645. https://doi.org/10.1016/s0140-6736(09)60995-8

Wright, C. W. (2002). Herb-CD4—herbal remedies. Journal of Ethnopharmacology, 83(1–2), 168–169. https://doi.org/10.1016/s0378-8741(02)00209-x