The interplay between nature and nurture is a recurring theme in the debate over the development of schizophrenia or its relapse. The evidence for a genetic component to schizophrenia is strong, but environmental factors have always been considered as having a powerful role to play. In this posting I’ve mapped out some of the influential ideas to have shaped our ideas about the role the social environment in relation to schizophrenia.
During the 1940s, the notion of the schizophrenogenic mother, stimulated interest in the possibility that mothering style could influence relapse or even cause of the development of schizophrenia. Although no evidence was found to support this, the notion of a conflict-inducing mother who was domineering, smothering, yet also rejecting refused to go away. By the 1960s a variation on the theme found its way into the literature but with a new terminology. This time the double binding mother became the focus of attention.
The double binding mother was presented as an over-protective yet emotionally cold person who would frequently send out highly emotionally charged signals that were conflicting. Shaking a fist at the child while saying,"come here darling" might be one such example. Another might be cuddling the child whilst shouting at him or her for doing something perceived as wrong or dangerous. However, despite the ongoing appeal that the moralistic, judgemental and detached mother had a lot to answer for, very little in the way of empirical evidence ever emerged to support this as a viable explanation for the onset of schizophrenia or its relapse.
By the mid 1960s the emphasis had begun to shift away from mother style and more towards communication styles within the family structure. The notion of Communication Deviance (CD) was now in the research spotlight. Communication Deviance refers to ambiguous, oddly worded forms of communication that results in a communication mismatch of fragmented ideas between the speaker and the listener. Measures, such as the grandly named Thematic Apperception Test (TAT) were used as a way of trying to understand how patients perceived and described events around a particular theme. These themes were usually presented in the form of an ambiguous picture in which the patient would construct a story. An example might be the picture of a figure standing in a doorway. The picture in itself means nothing, but the story the patient articulates is measured in a way that is said to provide certain insights into their mental state. Again, although interesting, attempts to establish a causal link between CD and schizophrenia are problematic. There certainly are lines of evidence to show that disturbed but not psychotic people might go on to develop schizophrenia, but the fact that they were already disturbed means we can only conclude that CD may have some effect rather than be a cause of schizophrenia.
This brings me to the last of my selection of key ideas, that of Expressed Emotion (EE). The notion of expressed emotion is that high levels of emotional involvement, or criticism, or hostility, can lead to relapse in people with schizophrenia. In fact the evidence for this is fairly impressive and consistent. For example, Koenigsberg & Handley (1986) found that over 50 per cent of relapse cases came from high expressed emotion families, compared with just over 20 per cent of relapse cases from low expressed emotion families.
We can’t say that the social environment causes schizophrenia but it does seem very likely that certain facets of it have a profound influence on the wellbeing of people with schizophrenia.