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Journal of Clinical EEG & Neuroscience, April, 2008Understanding Schizophrenia in the 21st CenturyDean Salisbury, Guest EditorOver 100 years ago the constellation of psychotic symptoms defining the disorder we now call schizophrenia were presciently aggregated by Emil Kraepelin into his idea of dementia praecox, an early onset, precocious dementing disorder. As indicated by the use of the term dementia, he believed there was an invariable progressive decline into mental enfeeblement in the disorder, and made some initial suggestions as to the defects in the neocortex underlying the disorder. His contemporary Eugen Bleuler, proposing the alternative nosology of groups of schizophrenias, disagreed with the notion that all patients would become demented as a function of progressive brain deterioration, and focused on their cognitive and affective behavior patterns, and, as the name schizophrenia (split mind) implies, the failure to integrate these different facets of personality. Despite Bleuler’s optimism, until the late 20th century a diagnosis of schizophrenia was, in fact, usually accompanied by a life sentence as an inmate in a mental hospital. With the accidental discovery of antipsychotic medications during the development of anaesthetics, many schizophrenia patients were able to remain in the general society with symptoms at the least dampened. However, even today with second generation antipsychotics, persons with schizophrenia are more often than not unable to work even part time, and tend not to function well in society. These two figures remain the most influential in understanding schizophrenia, with Kraepelin representing the biology and Bleuler representing the psychology of the disorder. The argument can be made that the field did not progress substantially since their time until very recently. At the beginning of the 21st century, we stand on the verge of a new period in schizophrenia research. Application of the new imaging technologies developed in the last 30 years allows for a precision heretofore unknown in examining brain pathologies in the disorder. Application of multimodal imaging has identified brain areas deficient in the disorder on both structural and functional measures. Sophisticated electrophysiological measures have led to a greater understanding of the disordered cognition in schizophrenia, particularly as related to language and hallucinatory behavior. Likewise, the underlying neurobiological deficits causing emotional problems in the disease are under investigation. The newest area of psychiatric genetics is increasing identifying genes that may be related to the pathophysiology of the disorder. Combining genetic studies with intermediate endophenotypes provides an exciting new area that should lead to new discoveries about the basic biological disorders involved in this complex genetic disorder. Thus, more than a century after its description, we now have the tools at hand to perhaps provide not only better treatment of symptoms, but early identification and preventive treatment in schizophrenia. In the Preface to the 1919 English translation of Kraepelin’s Dementia Praecox and Paraphrenia, George M. Robertson of the University of Edinburgh writes:
It is remarkable that this could have been written today, in these days of managed care and the closure of most long-term psychiatric facilities, and lends support to the earlier contention that most of the same issues near the time of identification of schizophrenia remain today. However, we now have the understanding of the pathophysiology of schizophrenia and the tools to develop not only better treatment, but perhaps to deliver on the request more than 100 years ago for a cure or alleviation of the disorder. The papers collected in this special issue represent the vanguard of thinking about the biology and psychology of schizophrenia. It is an exciting time to be studying this disease. With the knowledge at hand as described in this issue and the tools and methods to understand the basic genetic components of the disorder, there is great confidence that 100 years from now, we will not still be clamoring for a study to help cure or alleviate schizophrenia.
Dean Salisbury, PhD |
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