Schizophrenia. A Life-Course Developmental Perspective

332 Pages·1991·8.114 MB·English

by  Elaine F. Walker (Eds.)

This is a volume in
PERSONALITY, PSYCHOPATHOLOGY, AND PSYCHOTHERAPY
A Series of Monographs, Texts, and Treatises
Under the Editorship of David T. Lykken and Philip C. Kendall
SCHIZOPHRENIA
A Life-Course Developmental Perspective
Edited by
Elaine E Walker
Department of Psychology
Emory University
Atlanta, Georgia
ACADEMIC PRESS, INC.
Harcourt Brace Jovanovich, Publishers
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This book is printed on acid-free paper. ©
Copyright © 1991 by ACADEMIC PRESS, INC.
All Rights Reserved.
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United Kingdom Edition published by
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Library of Congress Cataloging-in-Publication Data
Schizophrenia : a life-course developmental perspective / [edited by]
Elaine F. Walker.
p. cm. — (Personality, psychopathology, and psychotherapy
series)
Includes index.
ISBN 0-12-732080-6
1. Schizophrenia—Etiology.. 2. Developmental psychology.
I. Walker, Elaine F. II. Series: Personality, psychopathology, and
psychotherapy.
[DNLM: 1. Schizophrenia-etiology. WM 203 S337234]
RC514.S3342 1991
616.89'82071-dc20
DNLM/DLC
for Library of Congress 91-4588
CIP
PRINTED IN THE UNITED STATES OF AMERICA
91 92 93 94 9 8 7 6 5 4 3 2 1
Contributors
Numbers in parentheses indicate the pages on which the authors' contributions begin.
Joan Rosenbaum Asarnow (95), Department of Psychiatry, Neuropsychi
atrie Institute, School of Medicine, University of California, Los An
geles, Los Angeles, California 90024
Robert F. Asarnow (95), Department of Psychiatry, Neuropsychiatrie In
stitute, School of Medicine, University of California, Los Angeles, Los
Angeles, California 90024
Christopher E. Barr (9), Social Science Research Institute, University of
Southern California, Los Angeles, California 90089
Tyrone D. Cannon (9), Social Science Research Institute, University of
Southern California, Los Angeles, California 90089
Barbara A. Cornblatt (123), Elmhurst General Hospital, and Mount Sinai
School of Medicine, New York, New York 10032
Dana M. Davis (299), Department of Psychology, Emory University,
Atlanta, Georgia 30322
Jeri A. Doane (213), Yale University School of Medicine, New Haven,
Connecticut 06520
L. Erlenmeyer-Kimling (123), New York State Psychiatric Institute, and
Columbia University College of Physicians and Surgeons, New York,
New York 10032
Sherryl H. Goodman (59), Department of Psychology, Emory University,
Atlanta, Georgia 30322
Lisa A. Gottlieb (299), Department of Psychology, Emory University,
Atlanta, Georgia 30322
XI
xii Contributors
Sydney L. Hans (33), Department of Psychiatry, University of Chicago,
Chicago, Illinois 60637
Courtenay M. Harding (257), University of Colorado School of Medicine,
University of Colorado Health Sciences Center, Denver, Colorado
80262
Philip D. Harvey (139), Department of Psychiatry, Mount Sinai School of
Medicine, New York, New York 10029
Nancy Hornstein (95), Department of Psychiatry, Neuropsychiatrie In
stitute, School of Medicine, University of California, Los Angeles, Los
Angeles, California 90024
Richard R. J. Lewine (195), Department of Psychiatry, Emory University
School of Medicine, Atlanta, Georgia 30322
Joseph Marcus (33), Deparment of Psychiatry, University of Chicago,
Chicago, Illinois 60637
Sarnoff A. Mednick (9), Social Science Research Institute, University of
Southern California, Los Angles, California 90089
Michael F. Pogue-Geile (277), Department of Psychology and Department
of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
15260
Andrew Russell (95), Department of Psychiatry, Neuropsychiatrie Insti
tute, School of Medicine, University of California, Los Angeles, Los
Angeles, California 90024
Christopher Saiz (157), Department of Psychology, University of Denver,
Englewood, Colorado 80111
Elaine F. Walker (1, 299), Department of Psychology, Emory University,
Atlanta, Georgia 30322
Norman F. Watt (157), Department of Psychology, University of Denver,
Englewood, Colorado 80111
Jay A. Weinstein (299), Department of Psychology, Emory University,
Atlanta, Georgia 30322
Lynn Winters (123), State University of New York at Purchase, and New
York State Psychiatric Institute, New York, New York 10032
R. Yassa (243), Department of Psychiatry, McGill University, and Douglas
Hospital, Verdun, Quebec, Canada H4H 1R3
Preface
The chief aim of this volume is to draw together research findings and
ideas concerning the entire life course of schizophrenia. The develop
mental focus represented by this volume has expanded in recent years and
now constitutes a significant force in psychopathology research. The chap
ters discuss data spanning from infancy to old age, and some of the authors
report links between characterstics and/or events separated by decades in
the individual's life span. Clearly, we have made progress in our efforts to
elucidate the developmental course of schizophrenia, although many tasks
lie ahead of us.
It is not uncommon to hear disparaging comments regarding the lack of
progress in research on schizophrenia. Many believe that an enormous
amount of effort has been expended and that a voluminous literature has
evolved with relatively little payoff in the way of reliable findings. Al
though it may be true that no one finding has constituted a "major break
through," investigators have been slowly, but steadily, fitting together the
myriad of pieces that comprise the puzzle of schizophrenia. Each rep-
licable finding that is added represents a small step toward the identifica
tion of etiologic mechanisms.
Significant progress has also been achieved in the areas of concept
ualization and methodology. Researchers have become increasingly sens
itive to the likely etiologic complexity of the schizophrenic syndrome. The
accumulated data base suggests that there are multiple contributing fac
tors to vulnerability, and this compels us to reject all previous theories and
models that posited a unitary etiologic agent, be it genetic or environ
mental, and to eliminate from consideration the notion that there is a
xiii
XIV Preface
uniform premorbid or postmorbid course. For the sake of linguistic con
venience, many writers in the field, including myself, often use the singu
lar term "schizophrenia"; however, most assume the existence of multiple
schizophrenias with differing etiologic determinants.
As our conceptualizations have become more complex, the sophistica
tion of our methodologies has concomitantly grown. A perusal of the
literature indicates that multivariate, multimodal studies are more com
mon now than in the past. Many studies simultaneously examine biolog
ical, cognitive, and phenomenological aspects of patients. Moreover, lon
gitudinal designs are more apparent. Researchers are relating antecedent
variables to various aspects of clinical outcome, as well as exploring the
longitudinal features of the clinical symptoms.
Schizophrenia undoubtedly is a disorder that presents formidable chal
lenges to researchers; however, it is not unique in this respect. Tremendous
investigative resources have been devoted to many physical illnesses (e.g.,
cancer) with relatively modest progress. Given that the resources devoted
to research on schizophrenia pale in comparison to those allocated for
many other debilitating illnesses, we should not be disheartened by the
modest advances we have made in understanding the nature and origins
of this disorder. Instead, we should acknowledge the likely complexity of
the investigative tasks ahead, and confront these tasks with the awareness
that we must be prepared to gain gratification from the modest incre
mental gains in knowledge we are likely to achieve.
This volume features the work of a talented group of researchers. They
are distinguished by a broad base of knowledge in the biological and
psychological mechanisms that subserve behavioral development. All of
them have devoted their careers to the study of psychopathology, in part
because they possess the determination and tolerance for ambiguity that
this endeavor requires. I have no doubt that the work featured in this
volume will be followed by further creative research from these investiga
tors.
Special appreciation is extended to the contributors to this volume. They
are excellent colleagues who make participation in this research enterprise
more fulfilling. The completion of this volume is also due to the efforts of
the research assistants and graduate students who work in my laboratory.
Dana Davis, Lisa Gottlieb, Kathleen Grimes, Lauren Hill, and Jay Wein
stein contributed substantively to the completion of this project. In par
ticular, Dana Davis devoted many hours to the editing and preparation of
the manuscripts for publication.
Elaine F. Walker
1
Research on Life-Span Development
in Schizophrenia
Elaine F. Walker
Schizophrenia is a disorder that has posed a tremendous challenge to
investigators. The clinical symptoms of the disorder are often so pervasive
and debilitating that the patient is unable to function occupationally and
interpersonally. Yet the symptoms, which typically have their onset in
early adulthood, are often preceded by a developmental history that was
perceived as unremarkable by the parents. The emergence of such perva
sive impairment, against a background of apparent normalcy, baffles fami
ly members and challenges the conceptual abilities of investigators.
But the unremarkable developmental course preceding the onset of
schizophrenic symptoms may be more apparent than real. Gradually ac
cumulating evidence indicates that behavioral abnormalities are present
long before psychiatric symptoms are manifested. Moreover, it is becom
ing increasingly apparent that the course of schizophrenia is highly vari
able and that a chronic, deteriorating course represents only one of several
pathways. This volume documents our expanding knowledge of the life-
span developmental course of schizophrenia, from signs of vulnerability in
infancy to geriatric outcomes.
Most would agree that the literature abounds with comparative, cross-
sectional studies of the cognitive, affective, interpersonal, neurological,
SCHIZOPHRENIA 1 Copyright © 1991 by Academic Press, Inc.
A Life-Course Developmental Perspective All rights of reproduction in any form reserved.
2 Elaine F. Walker
and biochemical aspects of schizophrenic disorders. Also, within the past
two decades, intensive effort has been directed at reliably specifying the
clinical symptoms and diagnostic boundaries of schizophrenia. But com
mensurate effort has not been directed at elucidating the developmental
features of the illness. Compared with cross-sectional studies, systematic
longitudinal investigations of schizophrenia have been relatively rare.
Consequently, although we can speak with some degree of precision about
the phenotypic adult outcome labeled "schizophrenia," we are just begin
ning to build a data base on the precursors and long-term outcome.
The importance of expanding our data base on the life span of patients
with schizophrenia is becoming increasingly apparent. First, as illustrated
by the chapters in this volume, the results of research on genetic factors,
obstetrical complications, and morphological brain abnormalities indicate
that constitutional vulnerability is congenital for many patients. Because
the emergence of clinical symptoms probably does not mark the onset of the
neuropathological process, documenting the developmental trajectories
leading to schizophrenia takes on greater importance.
Second, as part of the evolution of neuroscience, investigators have shed
new light on neurodevelopment (e.g., Goldman-Rakic, 1987; Nowakowski,
1987). Research findings in this field have altered conceptual frameworks
for understanding the interplay between neural and behavioral develop
ment. For example, we now have animal models of neuroanatomical im
pairments that are relatively age-specific in their effects on behavior. Le
sions in some structures have relatively little impact on the behavior of the
immature animal but dramatically alter adult behavior. Other neuroana
tomical lesions disrupt early behavior but are "silent" in adulthood. Fur
thermore, a singular lesion or biochemical challenge can influence differ
ent functional domains, depending on the organism's developmental
stage. Clearly, neurodevelopment is a complex process that involves
simultaneous anatomical and physiological changes that have implica
tions for the behavioral capacities of the organism. The elucidation of the
behavioral sequelae of specific neural lesions or pathology requires a
developmental approach. And, conversely, attempts to elucidate a neu
ropathological process are likely to benefit from a developmental approach
to the study of manifest behavior.
Finally, the results of numerous investigations force us to contend with
the probability that schizophrenia is heterogeneous in etiology. Most no
tably, recent applications of sophisticated molecular genetic techniques fail
to yield replicable findings, indicating that there is not a unitary genetic
liability for schizophrenia (Owen et al, 1990). In current usage, then, the
term "schizophrenia" refers to a syndrome, not to a specific disease.
As Dalen and Hays (1990) point out, the assumption of heterogeneity
dictates our approach to research. Cross-sectional comparisons of schizo-
1. Life-Span Development in Schizophrenia 3
phrenic patients with control groups of normals, or other patients, implies
the assumption that schizophrenia is a single disease. In contrast, the
elucidation of heterogeneous etiologies requires the careful study of dif
ferences among schizophrenic patients. This includes differences in puta
tive etiologic factors, premorbid course, and postmorbid course, as well
as current status. In other words, cross-sectional studies focusing on with-
in-group differences in symptoms, brain morphology, biochemistry, or
cognitive performance are necessary but unlikely to be sufficient. In addi
tion, we must extend our study of heterogeneity backward and forward in
time. This will enable us to describe heterogeneity from a longitudinal
standpoint, thus increasing our opportunities for identifying etiologic sub
types.
The application of developmental approaches to the study of psycho-
pathology is receiving greater attention from investigators in the field
(Cicchetti, 1984). By charting the developmental courses associated with
schizophrenia, we will be in a better position to speculate on the neuro-
pathology subserving the disorder. The temporal characteristics of the
cognitive, interpersonal, and motor abnormalities shown by patients
across the life span are especially important. From a biological standpoint,
temporal factors are important because the development of the central
nervous system is characterized by changes in the functional ascendance
of various structures and systems that subserve behavior. For example,
motor dysfunction with an onset in infancy suggests a different neuropath-
ological process from motor dysfunction that first appears in adulthood.
Temporal aspects are also of critical relevance to the elucidation of inter
actional process. The dominant etiologic models of schizophrenia, such as
the diathesis-stress and vulnerability models, posit an interactional proc
ess in which exogenous Stressors trigger behavioral dysfunction in con
stitutionally vulnerable individuals. By examining the convergence be
tween environmental events and the developmental course, we can better
understand the nature of such interactions.
IMPEDIMENTS TO THE STUDY OF
THE LIFE COURSE OF SCHIZOPHRENIA
Given the many potential benefits of a developmental approach to
research on schizophrenia, we are left with the question of why there has
been a relative dearth of investigations of this type. Specifically, why has
so much of the literature on schizophrenia concerned itself with various
behavioral and biological aspects of samples of young and middle-aged
adult patients, while relatively little attention has been focused on earlier
and later points in the life span of patients? Undoubtedly, methodological
problems are a major part of the answer.