Psychotic disorders are qualitatively distinct from other forms of mental illness in that they result in severe psychological distress and impairment in social functioning that grossly interfere with the capacity to meet the ordinary demands of life. In this essay I will explore several of the reasons for these differences using schizophrenia as the paradigm case of a severe psychotic disorder.
Severity of symptoms. The set of symptoms comprising schizophrenia described at DSM-IV is the most severe of any other DSM pathology. Taxonomically patients experience two types of symptoms: “positive” and “negative.” While these symptoms are comorbid with other mental illnesses no other DSM category makes this explicit distinction. Positive symptoms are those most people do not normally experience such as hallucinations (primarily auditory) or delusions. Negative symptoms involve the absence of normal abilities or traits such as flat affect, alogia, anhedonia, asociality and avolition.
Time of onset, Length of duration. Another indicator of how severe the DSM symptoms are is the specificity of their time of onset and length of duration. For example schizophrenia must last for at least six months and include at least one month of active-phase symptoms. On the other hand most Axis II personality disorders need only be “persistent” or “pervasive” with no specific onset or duration requirements.
Means of treatment. Schizophrenia is treated with powerful psychotropic medications such as thiothixene, chlorpromazine, haloperidol and thioridazine. Other forms of mental illness also are treatable psychopharmacologically, e.g. bipolar disease. Those used to treat schizophrenia however are especially powerful and can cause serious side effects. At the same time schizophrenia can be refractory to treatment. Since it involves hallucinations and an actual disconnection from reality it also entails a significant possibility of hospitalization with resulting consequences such as loss of employment and insurance, poverty, homelessness and stigmatization. These outcomes are less likely with milder DSM diagnoses.
Homelessness. There now is a substantial body of literature linking schizophrenia with homelessness, Padgett, Henwood, Abrams & Davis (2008); Kyle & Dunn (2008); Pickett-Schenk, Cook, Grey & Butler (2007); Bradford, Gaynes, Kim, Kaufman & Weinberger (2005). A recent study for example concluded that 15% of persons with schizophrenia are homeless (Folsom et al., 2005). These extensive correlations are not found with any other form of DSM pathology.
The tie between schizophrenia and homelessness in California has an interesting and unfortunate history. In 1966 Ronald Reagan who then was California’s governor initiated a program of closing California’s state-run mental health hospitals. While Reagan primarily was motivated by a desire to conserve governmental resources this action also aligned with then-prevalent trends in mental health philosophy to remit mentally ill patients to their local communities. The closure of state mental health hospitals to all but the seriously ill eliminated coalescence points where research into mental illness readily could be conducted (Lott 2008). The logic of secondment to local community-based care in turn was eradicated in 1978 with the passage of Proposition 13, which limited the ability of local governments to collect ad valorem property taxes. As a result even local facilities closed essentially leaving the mentally ill with no refuge other than private philanthropy or the street. It seems likely that cut-backs resulting from today’s California “budget crisis” also will fall disproportionately on those at greatest risk such as the homeless mentally ill.
Legal responsibility. The DSM recognizes that persons with various types of mental illness are predisposed to engage in socially undesirable behavior and commit crime. This crime however typically is not as impactful or catastrophic as it is with schizophrenia. Schizophrenia long has been recognized as a primary source of diminished legal capacity leading to pleas of “not guilty by reason of insanity” (Buchanan & Zonana, 2009). It also is one of the main causes of maternal filicide such as the cases of Andrea Yates and Susan Smith (Friedman & Resnick 2006). It is very difficult to image why a woman would kill her children absent acute psychosis such as schizophrenia as opposed to milder forms of DSM pathology.
Another area of potential involvement with the legal system for schizophrenic patients is deprivation of legal rights. For example California’s Lanterman-Petris-Short Act permits the involuntary detention of those thought to be “gravely disabled,” that is, unable to provide for basic personal needs such as food, clothing and shelter. It has six levels of holds: 72 hours; 14 days; an additional 14 days; 30 days; 180 days; and then a 360-day “permanent conservatorship” which can be renewed indefinitely. Court decisions hold that persons under hold can be denied legal rights such as the right to vote, hold a driver’s license and consent to medical treatment. They may be forcibly administered psychotropic medication and even subjected to ECT without consent. Most of the persons subject to LPS action have schizophrenia as opposed to other lesser DSM pathologies.
(1) 72 hours: Cal. Welfare & Institutions C. §5150. 14 days: Cal. Welfare & Institutions C. §5250. Additional 14 days: Cal. Welfare & Institutions C. §5260. 30 days: Cal. Welfare & Institutions C. §5270.15. 180 days: Cal. Welfare & Institutions C. §5352.1. One year: Cal. Welfare & Institutions C. §5361.
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