Parental Stress in the Development of Schizophrenic Offspring George Serban
T
HIS PAPER reports the findings that relate most directly to the significance of the influence of parental mental illness on schizophrenic offspring in the context of familial stressful interaction. It will attempt to define, as well, the relationships between various familial environmental factors within a sample of 641 hospitalized schizophrenics, as part of a study conducted to determine the predictive factors leading to readmission of schizophrenics to a municipal psychiatric hospital. The etiology of schizophrenia has been linked to two main factors: one, heredity, based on the high incidence of schizophrenia in the relatives of the schizophrenic,‘-3 and the second, exposure to deviant familial interaction.4-6 The main difficulty was to separate the genetic factor from the psychological transmission of it by the disturbed familial interaction. The inconclusiveness of genetic findings is emphasized by geneticists like Shields and Gottesman,’ who concluded that hereditary factors “are necessary, but not sufficient for the disorder to occur.” Penrose, summarizing the evidence on the validity of the genetic basis in schizophrenia, stated that both hereditary and environmental factors enter into its causation.8 By contrast, Heston’s study of psychiatric disorders in foster-home-raised children of schizophrenic mothers showed that schizophrenia in the offspring occurred despite the separation of the child from its schizophrenic mother.g Recent research on adopted schizophrenics further suggests that seriously disturbed parents are not a necessary condition for the development of schizophrenia in the offspring.‘* All of these studies are somewhat biased due to methodological difficulties encountered in the systematization of the volunteer group, selectivity of adoptive sample,‘* or use of the proper control group.g The identification of family etiological factors also poses objections related to the limitations of the clinical observations and the questionable research value of retrospective recall.” To overcome some of these difficulties, the present approach combined the retrospective with observational methods, in addition using informants (close relatives) for corroboration of patients’ experiential data. The familial pathological interaction and parental hereditary factors were studied in a sample of acute and chronic schizophrenics in an attempt to determine the minimal and maximal risk conditions for development of schizophrenia. As a departure from previous research, the present study attempted to assess the
From
the New York
University-Bellevue
Serban.
Principal
George
University-Bellevue Reprint
requests
Supported
M.D.: Medical should
Cenler.
New York,
be addressed
by, the Kittaj,
Medical
Investigator
Foundation
Center. and
New k.ork. N. I’.
Director.
Readmission
Study.
New
York
N. Y.
to Dr. G. Serban. with matching
45 E. RSth Street. funds Jrom
New York,
Nekp York
N. k.. 10018
liniver.~it,~ Medical
Center. @ 1975 bv Grune
Comprehensive
& Stratron,
Inc.
Psychiatry, Vol. 16, No. 1 (January/February),
1975
23
24
GEORGE SERBAN
effect of familial and hereditary factors on schizophrenics based on the experiential reactions of the patient independent of the factual reality, on the assumption that the individual’s perception and interpretation of environment perceived as threatening and stressful became the reality that led to his hospitalization. METHOD
Subjects The Bellevue population tested represented a random sample of 125 (19.5%) acute (first hospitalization) and 516 (80.5%) chronic (multiple hospitalizations) schizophrenics. The patients’ diagnoses established at admission were subsequently verified by ward and project psychiatrists. The concordance rate for diagnosis of schizophrenia ranged from 90% to 95%. All doubtful cases were eliminated from the sample prior to admission to the project (alcoholics, drug addicts, and mentally retarded with psychotic reaction). The tested population represented approximately 0.4% of the U.S. 1970 statistics of inpatient facilitiesle and 5% of New York State first admissions and readmissions to state hospitals. The sex breakdown and the age group are consonant with U.S. and New York State schizophrenic populations.12 The sample could be considered as falling mainly in groups 4 and 5 of the Hollingshed and Redlich socioeconomic classification index.13 A random sample of 95 normals of the same socioeconomic background served as controls.
Measures The data of this report were derived from a specially designed social stress and functionability inventory for psychotic disorders (SSFIPD) standardized on 130 schizophrenics at Bellevue Hospital. The inventory provides information related to psychiatric history, social-demographic factors, genetic and personality variables associated with illness and regarding social functioning and associated stress subsumed under the following four areas: social performance (6 dimensions: Table 1 Sample Chronic
Sociodemographic
Group
Total Pt.
Acute
Normal
Variable
N
%
N
%
N
%
N
%
Male Female Total Age: Under 25 25-44 45+ Marital status: Single Married Separated Employment status: Welfare Unemployed Part-time Full-time Race: White Black Puerto Rican Oriental Other
329 187 516
63.8 36.2
65 60 125
52.0 48.0
394 247
61.5 38.5
43 52 95
45.3 54.7
119 352 44
23.1 68.2 8.7
57 62 6
45.6 49.6 4.8
176 414 50
27.5 64.6 7.8
27 58 10
28.4 61.1 10.5
306 67 143
59.3 13.0 27.7
80 20 25
64.0 16.0 20.0
386 87 168
60.2 13.6 26.2
25 34 36
86.3 35.8 37.9
205 182 23 106
39.7 35.4 4.6 20.4
25 47 7 46
20.0 37.6 5.6 36.8
230 229 30 152
35.9 35.7 4.7 23.7
10 2 1 82
10.5 2.1 1.0 86.3
292 192 22 1 9
56.6 37.2 4.3 0.2 1.7
60 57 5 2 1
48.0 45.6 4.0 1.6 0.8
352 249 27 3 10
54.9 38.9 4.2 0.5 1.6
42 33 17 1 2
44.2 31.7 17.9 1.1 2.1
PARENTAL
education,
25
STRESS
job, housekeeping,
dependence
on welfare,
management
of finances,
living circumstances);
family interaction (4 dimensions: relationship to parents, relatives, marital partner, and children); social interpersonal interaction (7 dimensions: dating, sex, relationships with close friends, neighbors, and community at large, use of leisure time, and religion); social maladaptive activities (4 dimensions: drinking, use of addictive and psychedelic drugs, antisocial acts). Social functioning was measured in terms of the level of the individual’s ability to fulfill his needs in relationship to the four general areas outlined above. Stress reflects the degree of imbalance between environmental demands for psychosocial performance and the capacity for successful fulfillment of these demands. For each of the 21 areas of functioning and stress, a patient could earn three possible scores. Nonfunctioning was assigned a score of 0 (NF), low level of functioning a score of 1 (LF), and adequate functioning (F) a score of 2. Presence of stress = 0 (S); low stress = 1 (LS), and non-stress = 2 (NS). The computation for each of the 21 areas in terms of functioning and stress used a formula (D) derived from a weighted sum of scores in each section divided by the sum of frequency of the raw scores of that section. Interrater reliability was measured in terms of percentage agreement and was found to range between 85% and 91%. The SSFIPD was also given to an informant (a close member of the family). The percentage agreement for factual information computed for 228 patients and their informants ranged from 83% to91%. The test-retest reliability (6 months interval) for the scores for the 7 dimensions for functioning reflecting 40% factual data and 60% attitudinal data computed for 78 cases showed the range from 0.46 to 0.77. The extraction of factual data from these variables increases accordingly the correlation index. The administration of tests was conducted by either a project psychiatrist2 or a clinical psychologist holding a Ph.D. degree in the ward of Bellevue Hospital only to patients in contact with their surroundings The history of parental mental illness was verified with the New York State Department of Mental Hygiene. Psychiatric histories were available for patients’ mothers only. However, since the relationship between mother and child has been particularly stressed in the psychodynamic literature, this relationship was of primary focus in this study, although a subset of patients who reported psychiatrically hospitalized fathers were also included for analysis’l On the basis of genetic history and family-interaction data, the subjects were divided in four subsamples labeled as groups la, lb. II, and III for statistical treatment. Group la represented patients who in the interview reported having mothers hospitalized for a similar mental condition and for whom there was no confirming evidence at the New York State Department of Mental Hygiene. Group II consisted of patients who denied having mothers hospitalized, but for whom New York State had hospitalization records. Group lb comprised patients who reported hospitalization of their mothers with corroboration from New York State. Group 111 was composed of patients who in the interview reported hospitalized fathers for a mental illness similar to theirs. It should be noted from Table 2 that these subsamples represent both chronic and acute patients, but do not include all patients in these samples. The small size of group Ib is due to the difficulties inherent in studying a drifting schizophrenic population. Since many of the patients immigrated to New York City, psychiatric records for mothers of these patients were not available in New York State. It is equally likely that mental illness of the mother may have occurred before the patient was aware of it, or the mental hospitalization may have been concealed from the patient as a child. The patient’s report of mother’s hospitalization may also be a distortion due to his illness. As a check for accuracy of the patient reports, the interview was also given whenever this was possible to close informants (parents, spouse, siblings, or others familiar with the patients). The percentage agreement between patients and their informants (N=228: 182 chronics, 46 acutes)on the SSFIPD item ranged from 94% to 97%. except for cases where either the patient or informant had partial knowledge of the relative’s illness (see Table 4). ANALYSIS
Comparisons of frequencies normals are shown in Tables applied to test the differences.
OF
RESULTS
of hospitalized relatives for the various groups and 2 and 3. Whenever possible, chi-square tests were
8
7
0
0
Siblings
Other ret.
Children
Spouse
6.1
14
0
1.4 0
1.6
0.6
9.5
%Chr
la
f-d
1
0.2
N
mothers
acutes la X acutes II**,
Mother:
< 0.01.
la X lb X II***
acutes la X chronics la: NS; acutes II X chronics
Mother:
X* = 8.16,~
2.1 mother
II*,
< 0.001.
1
Mother:
X2 = 22.926.p
18.2
4.2
100.0
%I I
Group
1.7
0.4
9.3
%Chr
II
5
31
4
N
16.1
100.0
12.9
0.2
1
3.2
0.2
0
0
20.0
0
100.0
%la
Group
acutes
II
%Ib
0
0
33.0
0
100.0
reported
0
0
1
0
3
N
Group
Mother
Acute
N
0
1
2
0
19
III
=
patients
on interview
0
0
0.8
0
2.4
%Acu
lb
III
*, X2 = 926, p < 0.01.
list; Group
who
X normals*
to Albany
0
0
0.8
0
4.0
%Acu
la
lb = patients
0
1
0
5
N
according
group
X 2 = 384, p < 0.05;
were hospitalized
was hospitalized;
1.0
6.0
0.8
%Chr
III
Group o/.111
III
Father
722.61.40 4 8.3 0.8 00000000000000000000
9
2
that
whose
on interview
7.7
0.4
0.6
0.2
2.5
49
Chronic
%Chr
lb
II = patients
(chronics),
list; Group
23.1
7.7
100.0
%Ib
Group
III
0
who
reported
0
III
0
0
2.4
0
%Acu
III
on
interview
was hospitalized
0
0
0.8 0
100
0
%I11
00
3
0
N
Father Group
1.60
0
15.2
%Acu
II
that mother
0
5.3
10.5
0
100.0
%II
Group
Frequencies and Percentages of Specified Groups with Relatives Hospitalized for Mental illness
2 16.4 000
3
1
13
who reported
16.3
on Albany
was hospitalized.
confirmed
% Ia
100.0
la = patients
3
Father
Group
N
49
Relative
Mother
Hospitalized
Group
Mother
Table 2.
Normal
0
5.3
2.1
2.1
2.1
%Nor
that father
and Were
0
5
2
2
2
N
Sample
PARENTAL
STRESS
27
Table 3.
Total
Sample for Acutes and Chronics Total Sample
Hospitalized
(la + lb + III) Total
Chronic (la
Sample
& lb)
Acute (la
81 lb) % Acu
N
N
% Chr
Mother
62
12.0
8
Father
31
6.0
3
2.4
Siblings
JO
13.6
14
11.2
Other
65
12.6
7
5.6
6
1.2
3
2.4
16
3.1
4
3.2
Relative
Rel.
Children Soouse
6.4
Comparing the total acute and chronic groups to the normal sample, it can be seen that the chronic patients had the highest percentages of hospitalized mothers, fathers, siblings, and other relatives, followed by acutes, with the normals showing the lowest percentages in every category of mental illness. Two slight reversals of the indicated trends are observed in the data. A somewhat higher percentage of acutes as compared with chronics had hospitalized spouses and children. This may be due to either a low marriage rate or low fertility rate found among schizophrenics. l6 Of the first three chronic subgroups, subgroup Ib contained the highest percentage of relatives hospitalized (except for group III), as did subgroup Ib of the acute group. Subgroup Ib presents the most reliable information on heredity, since patient reports and New York State records coincided. These data lent strong support to the assumption that a genetic element was present in subgroups Ib and II of our schizophrenic population. It may be observed from Table 3 that the total ratio of state-reported hospitalized parents to their chronically ill offspring is 18.6% (16.2% by patients’ statements). The percentage is within the limits of Kallman,’ 16.4%; Shields,’ 12%; Essen-Moller,3 11%; and Alanen, I5 12%-patients who had mothers diagnosed as schizophrenic, or 23% with functional psychosis included. It corresponds as well to the work of Slater,2 who showed a ratio of two schizophrenic mothers to one schizophrenic father in his schizophrenic sample. Of main interest, however, was the study of patients’ emotional responses, based upon their reaction and interaction with their ill parents, independent of the factual reality of heredity. First, the extent of disturbance of family relationships by mental illness of parent was evaluated by asking the patient how he felt about his sick or allegedly sick relatives. Comparison of Tables 2 and 5 shows that only 34 of 49 patients who reported schizophrenic mothers were upset about their Table 4. Chronic Who N
Had
Patients’ and Informants’
Statements
about
Patients Informants % Chr
Hospitalization Acute
Inf.
Chronic N
Who
Informants % Chr
Inf.
N
Had
of Patients’
Relatives
Patients Informants
Acute
% Acu
N
Inf.
Informants % Acu
29
15.9
32
16
a.7
16
8.8
3
6.5
3
6.5
32
17.5
26
14.2
7
15.2
7
15.2
28
15.3
39
21.4
5
10.9
6
13.0
4
2.1
6
3.2
3
6.5
1
2.2
10
5.4
7
3.7
3
6.5
2
4.4
17.5
5
10.9
6
13.0
Inf.
34
2
5
3
00
00
Mother
Father
Siblings
Relatives
Children
spouse
Grandparent0
N
0
6.1
10.2
4.1
69.5
%~a
Group
Frequencies
Hospitalized Relative
Table 5A.
0
0
0
0.6
1 .o
0.4
6.6
%Chr
la
0
1
00
2
2
1
11
N
0
7.7
15.4
15.4
7.7
84.6
%Ib
Chronic
0
1.4
0
0
8.7 3.1 7.6 3.9 0.4 1.9 0.6
45 16 39 20 2 10 3
Father
Siblings
Relatives
Children
spouse
Grandparent
0
0
00
0
20
0
100
%la
Group
0
0
0
0.8
0
4.0
%Acu
la
0
0 0
0
0
33.3
0
100
%Ib
Group
0
0
0
0.8
0
2.4
0
1
0
1
9
3
8
N
0
0.8
0
0.8
7.2
2.4
6.4
Total Acute Sample %
%Acu
lb
0
0
0
0
0
0
0.8 0
5.3
1
0
0
00
0
0
0
0 0
%Acu
00
%II
N
II
ill behavior
Group
Acute Sample
in Table 3.
000
0
1
0
3
N
Specified
“Were You upset by the mentally
la, lb, and II for Acutes and Chronics
Total Chronic Sample
of Groups
0.2 0
0
0
1
0
5
N
Mother
Total
0
3.2
0
0.8
0.6
3.1
0.6
%Chr
III
%
5B.
0
1
00
9.7
51.6
9.7
%I11
412.9
3
16
3
N
Group
of Groups
N
Table
0.2 0
0
0
2.1
0
1
14.6
7 0
0.2
0
0
2.1
1
0
0
0
%Chr
II
00
%II
N
Group
Sample
2 for Description
” Yes” Responses to the Question, of Table
Hospitalized Relative
0.2
0
0.4
0.4
0.2
2.1
%Chr
lb
Groups’
See Caption
of Specified
Group
and Percentages
0
0
0
0
0
3
0
N
00
0
00
00
0
100
0
%I11
Group
0
0
2.4
0
1
11.1
0
00
3
3
2
-
0
3.3
3.3
2.1
1.1
Normal Sample
specified)?”
%Acu
III
of (relatives
PARENTAL
STRESS
29
relationships with them (69%), while for the state-list group the percentage was zero. Group Ib showed the highest percentage of patient upset at the hospitalization of a relative (84.9% for mothers). In general, the chronic sample showed the highest percentage of patient upset for every category of relative except father, where group III was highest. Second, the patient’s recent emotional interactions with family and relatives were examined. These data were extracted from the response given by the patient to the stress scale built into the psychosocial inventory instrument (SSFIPD). For the present analysis, only the categories relating to family interpersonal relationships (i.e., parents, relatives, marriage, and children) are considered. Mean stress scores are presented in Table 6. According to the score construction, it should be noted that higher numerical values indicate lower experienced stress. We may observe from Table 6 that higher percentages of chronics than acutes, particularly group Ib, experienced stress in every one of the categories under consideration, and the normals exhibited the lowest stress. In addition, we analyzed, as well, their recent interactions with parents. It is quite obvious from Table 7 that group I measured a higher proportion of subjects who had difficulty with their mothers than group II, indicating that the direction of perception of mental illness of mothers was based mainly on patients’ emotional relationships with them. It should be noted that in the chronic group 24.2% reported getting along “terribly” with their mothers, while 22.6% got along very poorly with their fathers as well. Yet mental illness of the parents was a stress factor only for subgroup Ib. It is particularly interesting that a substantial proportion of every group had only rare contact with their parents (23.5%) or no contact at all (19.6%). In order to have a retrospective dimension of the environmental climate in which the disturbed family relationship could have precipitated a schizophrenic reaction, we investigated the structure of the family as well. In terms of parental death, the chronics most often experienced death of the mother, followed by acutes, with the lowest percentage occurring for normals. It should be noted that the replacement of a dead mother by a mother figure apparently did not help, especially for subgroup Ib. The group Ib chronics had 45.5% surrogate mothers, who apparently were mentally sick as well, and they are the ones who produced the most disturbed family interactions. The same order, with chronics first, followed by acutes, followed by normals, is maintained with the deaths of fathers. It can be inferred from these data that the death of a parent in childhood had a marked effect on the children who were later to become chronic schizophrenics. During the adolescent years (lo-19 years) the acute patients had the highest percentages of mother and father deaths, followed by chronics, with normals again showing the lowest percentages. This is interesting from the point of view of recent trauma (precipitating factor), since acutes are a younger population (45% under age 24). Obviously the family structure may be disrupted by causes other than the death of a parent. Either the patients themselves, through socially intolerable behavior, or the parents, through divorce, separation, or other reasons, may cause radical changes in the living circumstances of the patient as a child, which alters the social climate in which the patient-to-be is raised. Other causes of family breakup of the patients’ families were examined.
*Indicates
2.16
1.90
1.50
t value significant
at 0.05
at 0.01
2.58
2.35
2.71
2.22
II
lb
2.05
Group
Group
t value significant
2.25
Children
**Indicates
2.71
2.19
Relatives
2.16
Parents
Marriage
Ia
Group
Category
Sample
level.
level.
2.44
2.23
2.65 2.43
2.58
2.50
2.23
2.01
Both
Mentally
with
4 Chronics III
Group
Chronic
III
Par.
2.18
2.33
2.66
2.22
Chron.
1.67
1.70
2.19
2.22
Ia
Group
Sample
0.00 1.00
2.93 2.37 2.50
2.00 0.00 0.00
2.43
1 SO
2.35
Group
2.37
lb
Ill
Group
Acute
II
Group
Mean Stress Scores
Total
Table 6.
Total
2.20
2.46
2.76
2.43
Acute
Normal
2.61
2.51
2.85
2.56
Sample
Significant
* **
l
**
**
Chronic
Normal/
Difference
t Test
Mean
1
Acute
Normal/
by
8 10 25 4 62
Terribly
Poorly Fair Wel I INAP Total
13
7 13 18 11 62
Terribly
Poorly Fair Wel I INAP Total
Got Along With Father
N
15
Got Along With Mother
21.0 11.3 21.0 29.0 17.7 100%
12.9 16.1 40.3 6.5 100%
24.2
%I
Group
5 6 9 25 3 48
8 10 8 21 1 48
2.9 1.6 1.9 4.8 0.8 9.7
2.5 1.4 2.5 3.5 2.1 9.7
N
%Tot
I
10.4 12.5 18.8 52.1 6.3 100%
16.7 20.8 16.7 43.8 2.1 100%
%II
Group
1.0 1.2 1.7 4.8 0.6 9.3
1.6 1.9 1.6 4.1 0.2 9.3
7 6 5 11 2 31
7 6 5 11 2 31
N
22.6 19.4 16.1 35.5 6.5 100%
22.6 19.4 16.1 35.5 6.5 100%
%II I
Group
How Patient
Sample
7.
%Tot
II
Chronic
Table
1.4 1.2 1.0 2.1 0.4 6.0
1.4 1.2 1.0 2.1 0.4 6.0
%Tot
III
86 69 106 176 79 516
77 75 109 226 29 516
N
with
16.7 13.4 20.5 34.1 15.3 100%
14.9 14.5 21.1 43.8 5.6 100%
%
Tot Chr
Got Along
1 2 1 3 1 8
2 4 2 0 0 8
N
Mother
12.5 25.0 12.5 37.5 12.5 100%
25.0 50.0 25.0 0 0 100%
%I
Group
0.8 1.6 0.8 2.4 0.8 6.4
1.6 3.2 1.6 0 0 6.4
%Tot
I
and Father
2 4 6 3 4 19
1 3 7 8 0 19
N
10.5 21.1 31.6 15.8 21.1 100%
5.3 15.8 36.8 42.1 0 100%
%II
Group
1.6 3.2 4.8 2.4 3.2 15.2
0.8 2.4 5.6 6.4 0 15.2
%Tot
II
Acute
in Last 6 Months
0 1 1 1 0 3
0 1 1 1 0 3
N
0 33.3 33.3 33.3 0 100%
0 33.3 33.3 33.3 0 100%
%I I I
Group
Sample
0 0.8 0.8 0.8 0 2.4
0 0.8 0.8 0.8 0 2.4
%Tot
III
11 23 25 48 18 125
9 14 32 66 4 125
N
8.8 18.4 20.0 38.4 14.4 100%
7.2 11.2 25.6 52.8 3.2 100%
%
Tot Acu
6 6 33 40 10 95
5 5 24 61 0 95
N
6.3 6.3 34.7 42.1 10.5 100%
5.3 5.3 25.3 64.2 0 100%
0%
Normal Sample
9.7 12.9
1.6
42.0
%I
4.1 12.0
1.2 1.5
0.2
5.0
%Tot
Group I
21 33.9 62100%
6 8
Illness Death INAP: Family
Not Broken Total
1
26
(Parent) LongTerm Mental
LongTerm Prison
I Ilegitimate
Divorce Separation
N
21 48
0 8
0
19
N
43.7 100%
0 16.7
0
39.6
%I1
Group
4.1 9.3
0 1.5
0
3.7
3.2 13.0
0
41.9
%I11
Group
2.5 6.0
0.2 0.8
0
2.5
%Tot
III
250 516
10 74
1
161
N 1
N
50.4 100%
7 8
1.90 14.3 0
0.20
31.2
%
Tot Chron
87.6 100%
0 0
0
12.6
%I
Group
5.6 6.4
0 0
0
0.8
%Tot
I
0 10.5
0
31.2
%II
Group
0
1
N
8.8 15.2
2 3
0 0 1.60
0
4.8
%Tot
II
Acute Sample
11 57.9 19 100%
0 2
0
6
N
Reasons for Family Breakup before Age 18
13 42.0 31 100%
1 4
0
13
N
Sample
%Tot
II
Chronic
Table 8.
66.7 100%
0 0
0
33.3
%I11
Group
III
1.6 2.4
0 0
0
0.8
%Tot
76 125
0 14
0
35
N
100%
60.8
0 11.2
0
28
%
Tot Acute
Normal
54 95
2 10
0
29
N
56.8 100%
2.1 10.5
0
30.5
%
Sample
PARENTAL
STRESS
33
The major causes of breakup were divorce, separation, or de facto division that occurred with the birth of an illegitimate child (who later became a patient). In this respect, separation due to death of a parent, long-term prison, or mental illness were considered separately. There were no significant differences between acute, chronic, and normal patients (14.3% of the chronics had families broken by death, as compared to 11.2% of the acutes and 10.5% of the normals). While it is reasonable to assume the trauma of a broken home as a schizophrenogenic agent, those patients who did have the experience of a family as a harmonious social unit in their childhoods could not be said to be better adjusted as a result of that experience than the ones from broken homes.” In order to identify retrospectively the stressful factors that might have contributed to the development of schizophrenia, the childhood problems of the schizophrenic in the context of environmental interaction were also analyzed. Table 9 shows the response frequencies to a set of questions asking the patients to describe their major difficulties before age 18. The same questions were asked of their informants. The problem area “parents” was cited as the major problem before 18 for: chronic patients, group 1 (61.3%), group II (45.7%), and group III (71%) disturbed by the mentally ill father; acute patients, group I (87.5%), group II (36.8%), and group III (33.3%). For normals, 37.9% reported parents as the major problem before age 18. After age 18, problems with the opposite sex became of primary importance, but parents still were the second most frequently cited problem for chronics. DISCUSSION
These results indicate that disturbed family relationships have significance only to the extent to which the patients perceive them as such. Though the genetic factor cannot be denied, it failed to explain the large number of the subjects of our sample who were schizophrenics independently of it. Moreover, the patients had difficulty in distinguishing psychologically between the truly mentally ill parent as reported by the state and the one they perceived as such; however, whenever the two groups overlapped (group Ib), the combination of hereditary factor and disturbed familial interaction produced the maximal disturbed response in the patient, which shows the importance of their interaction. However, the experiential factor played the determinant role in producing stress in the patients whenever they perceived the family interaction as disturbed, independent of the confirmed existence of mental illness or lack thereof in the parents. It appears that multiple stressful factors contributed to the development of schizophrenia in the majority of the sample. Whatever family psychodynamics might appear to explain the disturbed family interaction, the results became obvious: from childhood on the schizophrenic has difficulty in establishing proper relationships with parents or society.5.6 Within this context, we evaluated the reaction of the patient to various experiences of his life. The results appear to indicate that the chronics of groups Ib and III experienced a higher amount of stress in family interaction. Contrary to the general opinion oEthe concept of schizophrenogenic mother, a father might
changes
drugs
Drinking/
3.7
9 14.6
m. Other
1.7
0.6
4.8
3
1.7
4.8
19 30.7
I.
problems
9 14.5
25 40.3
Death
k. Physical
j.
Personality
3.3
17 27.4
h. Authorities
i.
5.4
28 45.2
g. People
3
13
6
5
6
17 12
8.3
6.3
27.1
12.5
10.4
12.5
25.0
35.4
33.3
4
16
29 46.8
3.9
20 32.4
Friends
f.
5.6
5.2
22.9 41.7
41.6
43.8
%II
Group
11 20
4.5
21
20
5.8
N
7.4
27 43.5
23 37.1
I
%Tot
d. School e. Job
problems
c. Sexual
sex
30 48.4
%I
Group
38 61.3
N
b. Opposite
18
a. Parents
Before
Major Problem
0.6
2.5
1.2
1.0
1.2
3.3
5.4
3.1
0.8
2.1 3.9
3.9
4.1
19.4
12.9
19.4
48.4
29.0
35.5
35.5
19.4
58.1
5
16.1
83
1.0
1.7
0.8
1.2 10.1
16.9
30.0
20.2
32.2
35.3
16.1
29.1 43.2
39.9
56.0
%Tot
45
8.7
13225.60
52
87
155
104
1.7 2.9
166
2.1
182
1.2 2.1
150 223
206
2.1
1.2 3.5
289
4.3
35.5
71.0
N
Tot Chron
%Tot
III
%lll
Group
929.0
4
6
15
9
11
11
6
18
6
11
22
N
Sample
%Tot
II
Chronic
Table 9.
0
2
3
2
1
4
3
0
3 4
4
7
N
0
0
23.1
37.6
25.1
12.5
50.1
37.5
0
37.5 50.1
50.1
87.5
%I
Group
0
0
1.6
2.4
1.6
0.8
3.2
2.4
0
2.4 3.2
0.8
15.8 5.3 1
2.4
26.3
4.0
1.6
1
1
1
1
2
0
1.6 3.2
0
3.2
3
10.5
21.1
10.5
21.1
1
1
2.4 4.8
1 2
1
1
N
4.8 4.8
7.2
5.6
%Tot
II
Sample
5
2
4
2
4
15.8 31.6
3
31.6 31.6
6
6 6
36.8
3.2
47.4
7 9
5.6
Group % II
%Tot
N
I
Acute
33.3
33.3
33.3
33.3
66.7
0
0
33.3
33.3
33.3 66.7
33.3
33.3
%I11
Group
Ill
0.8
0.8
0.8
0.8
1.6
0
0
0.8
0.8
0.8 1.6
0.8
0.8
%Tot
9
26
13
20
28
10
29
34
12
20 36
36
55
N
Tot
7.2
20.8
10.4
16.0
8
24
20
5
10
8 22.4
13
8.0
15
9
3 38
15
36
N
23.2
27.2
9.6
16.0 28.4
28.8
44.0
%Tot
Acute
8.4
25.3
21.1
5.3
10.5
8.4
13.7
15.8
9.6
3.2 40.0
15.8
37.9
%Tot
Normal Sample
PARENTAL
STRESS
35
be a contributing factor as well, especially when he is identified as mentally ill by the patient. This is in agreement with new research on this subject. If we take the normal as a base, the chronics showed twice the amount of difficulty in family interactions with mothers and fathers as did normals. Even in childhood relationships chronics already showed a higher degree of difficulty in relating to parents than did the acutes and normals. A final stressful experience of the child, which apparently contributed to the development of schizophrenia, is related as well to the destruction of the family structure through the death of the parents, but is not, as was generally thought, due to the breakup of the family. This is supported by the finding of the highest proportion of deaths of both parents among the chronics. For acutes, not yet differentiated as reactives and chronics, the death of a parent during adolescent years (1CL10 years) appears to be significant. They have the highest percentage of parental death in adolescence, which becomes a precipitating factor related to their schizophrenic hospitalization. No definite trend could be established otherwise about acutes, since they are in a transitional stage. Some of them will remain in the group of reactives (episodic schizophrenia), while others will progress toward chronicity (process schizophrenia). Only a long-term follow-up will reveal their direction. In view of these findings, we might envision schizophrenia as a manifestational entity with possible multiple etiologies where one could identify a genetic etiology separately from the environmental one the interaction between them producing the most stressful form of all.
ACKNOWLEDGMENT Acknowledgment is made to Gerald W. Woloshin, Ph.D., Research University Medical Center, for his help in the statistical analysis of results.
Assistant.
New
York
REFERENCES I. Kallman F: The Genetics of Schizophrenia. New York, J.J. Augustin, 1938 2. Slater E: A Review of Earlier Concordance on Genetic Factors in Schizophrenia. Proceedings of the Third World Congress of Psychiatry, vol I. Montreal, Toronto Press, 1961, p I5 3. Essen-Moller E: The calculation of morbid risk in parents of index cases or applied to a family of schizophrenics. Acta Genet 5:334-442, 1955 4. Lidz T, Cornelson A. Terry D: The intrafamilial environment of the schizophrenic patient: II. Marital schism and marital skew. Am J Psychiatry ll4:241, 1958; Parental personalities and family interaction. Am J Orthopsychiatry, l958b, 28:464, 1958; The transmission of irrationality. Arch Neurological Psychiatry 79:305, 1958 5. Singer M, Wynne L: Thought disorder and family relations of schizophrenics: IV. Results and implications. Arch Gen Psychiatry 12:201. 1965 6. Bateson G. Jackson D, Haley J. Weakland
J: Toward a theory of schizophrenia. Behav Sci l:251, 1956 7. Gottesman, Shields: Schizophrenics and Genetics. New York, Academic, 1972 8. Howells J (ed): Modern Perspectives in World Psychiatry. New York, Brunner/Mazel. 1971 9. Wender T, Rosenthal D, et al: The psychiatric adjustment of the adopting parents of schizophrenics. Am J Psychiatry 1971. p 127 IO. Heston LL: Psychiatric disorders in foster home reared children of schizophrenic mothers. Br J Psychiatry ll2:819, 1966 I I. Fontana AF: Familial etiology of schizophrenia. Psycho1 Bull 66:214, 1966 12. Taube AC, Redlick R: Utilization of mental health resources by persons diagnosed with schizophrenia. NIMH Statistical Report, May 1972 13. Hollingshed AB, Redlick FC: Social Class and Mental Illness: A Community Study. New York, John Wiley & Sons, 1958 14. Fromm. Reichman F: Notes on the de-
36 velopment of treatment of schizophrenics by Psychiatry psychoanalytic psychotherapy. 11:263, 1948 15. Alanen Y: The family of schizophrenic patients, in Concro R (ed): The Schizophrenic Syndrome, vol 1. New York, Brunner/Mazel, 1971 16. Bleuler M: A 23-year-long study of 208 schizophrenics, in Rosental D, Kety S (eds): The Transmission of Schizophrenia. New York, Pergamon, 1968, p 3
GEORGE SERBAN
17. Langner T, Michael S: Life Stress and Mental Health, vol II. Free Press of Glencoe, 1963, p 159 18. Vaillant GE: Prospective prediction of schizophrenic remission. Arch Gen Psychiatry I1:50!2,1964 19. Lidz T, Cornelson A, Fleck S, Terry D: intrafamilial environment of the The schizophrenic patients: I. The father. Psychiatry 20:329, 1957
T
HIS PAPER reports the findings that relate most directly to the significance of the influence of parental mental illness on schizophrenic offspring in the context of familial stressful interaction. It will attempt to define, as well, the relationships between various familial environmental factors within a sample of 641 hospitalized schizophrenics, as part of a study conducted to determine the predictive factors leading to readmission of schizophrenics to a municipal psychiatric hospital. The etiology of schizophrenia has been linked to two main factors: one, heredity, based on the high incidence of schizophrenia in the relatives of the schizophrenic,‘-3 and the second, exposure to deviant familial interaction.4-6 The main difficulty was to separate the genetic factor from the psychological transmission of it by the disturbed familial interaction. The inconclusiveness of genetic findings is emphasized by geneticists like Shields and Gottesman,’ who concluded that hereditary factors “are necessary, but not sufficient for the disorder to occur.” Penrose, summarizing the evidence on the validity of the genetic basis in schizophrenia, stated that both hereditary and environmental factors enter into its causation.8 By contrast, Heston’s study of psychiatric disorders in foster-home-raised children of schizophrenic mothers showed that schizophrenia in the offspring occurred despite the separation of the child from its schizophrenic mother.g Recent research on adopted schizophrenics further suggests that seriously disturbed parents are not a necessary condition for the development of schizophrenia in the offspring.‘* All of these studies are somewhat biased due to methodological difficulties encountered in the systematization of the volunteer group, selectivity of adoptive sample,‘* or use of the proper control group.g The identification of family etiological factors also poses objections related to the limitations of the clinical observations and the questionable research value of retrospective recall.” To overcome some of these difficulties, the present approach combined the retrospective with observational methods, in addition using informants (close relatives) for corroboration of patients’ experiential data. The familial pathological interaction and parental hereditary factors were studied in a sample of acute and chronic schizophrenics in an attempt to determine the minimal and maximal risk conditions for development of schizophrenia. As a departure from previous research, the present study attempted to assess the
From
the New York
University-Bellevue
Serban.
Principal
George
University-Bellevue Reprint
requests
Supported
M.D.: Medical should
Cenler.
New York,
be addressed
by, the Kittaj,
Medical
Investigator
Foundation
Center. and
New k.ork. N. I’.
Director.
Readmission
Study.
New
York
N. Y.
to Dr. G. Serban. with matching
45 E. RSth Street. funds Jrom
New York,
Nekp York
N. k.. 10018
liniver.~it,~ Medical
Center. @ 1975 bv Grune
Comprehensive
& Stratron,
Inc.
Psychiatry, Vol. 16, No. 1 (January/February),
1975
23
24
GEORGE SERBAN
effect of familial and hereditary factors on schizophrenics based on the experiential reactions of the patient independent of the factual reality, on the assumption that the individual’s perception and interpretation of environment perceived as threatening and stressful became the reality that led to his hospitalization. METHOD
Subjects The Bellevue population tested represented a random sample of 125 (19.5%) acute (first hospitalization) and 516 (80.5%) chronic (multiple hospitalizations) schizophrenics. The patients’ diagnoses established at admission were subsequently verified by ward and project psychiatrists. The concordance rate for diagnosis of schizophrenia ranged from 90% to 95%. All doubtful cases were eliminated from the sample prior to admission to the project (alcoholics, drug addicts, and mentally retarded with psychotic reaction). The tested population represented approximately 0.4% of the U.S. 1970 statistics of inpatient facilitiesle and 5% of New York State first admissions and readmissions to state hospitals. The sex breakdown and the age group are consonant with U.S. and New York State schizophrenic populations.12 The sample could be considered as falling mainly in groups 4 and 5 of the Hollingshed and Redlich socioeconomic classification index.13 A random sample of 95 normals of the same socioeconomic background served as controls.
Measures The data of this report were derived from a specially designed social stress and functionability inventory for psychotic disorders (SSFIPD) standardized on 130 schizophrenics at Bellevue Hospital. The inventory provides information related to psychiatric history, social-demographic factors, genetic and personality variables associated with illness and regarding social functioning and associated stress subsumed under the following four areas: social performance (6 dimensions: Table 1 Sample Chronic
Sociodemographic
Group
Total Pt.
Acute
Normal
Variable
N
%
N
%
N
%
N
%
Male Female Total Age: Under 25 25-44 45+ Marital status: Single Married Separated Employment status: Welfare Unemployed Part-time Full-time Race: White Black Puerto Rican Oriental Other
329 187 516
63.8 36.2
65 60 125
52.0 48.0
394 247
61.5 38.5
43 52 95
45.3 54.7
119 352 44
23.1 68.2 8.7
57 62 6
45.6 49.6 4.8
176 414 50
27.5 64.6 7.8
27 58 10
28.4 61.1 10.5
306 67 143
59.3 13.0 27.7
80 20 25
64.0 16.0 20.0
386 87 168
60.2 13.6 26.2
25 34 36
86.3 35.8 37.9
205 182 23 106
39.7 35.4 4.6 20.4
25 47 7 46
20.0 37.6 5.6 36.8
230 229 30 152
35.9 35.7 4.7 23.7
10 2 1 82
10.5 2.1 1.0 86.3
292 192 22 1 9
56.6 37.2 4.3 0.2 1.7
60 57 5 2 1
48.0 45.6 4.0 1.6 0.8
352 249 27 3 10
54.9 38.9 4.2 0.5 1.6
42 33 17 1 2
44.2 31.7 17.9 1.1 2.1
PARENTAL
education,
25
STRESS
job, housekeeping,
dependence
on welfare,
management
of finances,
living circumstances);
family interaction (4 dimensions: relationship to parents, relatives, marital partner, and children); social interpersonal interaction (7 dimensions: dating, sex, relationships with close friends, neighbors, and community at large, use of leisure time, and religion); social maladaptive activities (4 dimensions: drinking, use of addictive and psychedelic drugs, antisocial acts). Social functioning was measured in terms of the level of the individual’s ability to fulfill his needs in relationship to the four general areas outlined above. Stress reflects the degree of imbalance between environmental demands for psychosocial performance and the capacity for successful fulfillment of these demands. For each of the 21 areas of functioning and stress, a patient could earn three possible scores. Nonfunctioning was assigned a score of 0 (NF), low level of functioning a score of 1 (LF), and adequate functioning (F) a score of 2. Presence of stress = 0 (S); low stress = 1 (LS), and non-stress = 2 (NS). The computation for each of the 21 areas in terms of functioning and stress used a formula (D) derived from a weighted sum of scores in each section divided by the sum of frequency of the raw scores of that section. Interrater reliability was measured in terms of percentage agreement and was found to range between 85% and 91%. The SSFIPD was also given to an informant (a close member of the family). The percentage agreement for factual information computed for 228 patients and their informants ranged from 83% to91%. The test-retest reliability (6 months interval) for the scores for the 7 dimensions for functioning reflecting 40% factual data and 60% attitudinal data computed for 78 cases showed the range from 0.46 to 0.77. The extraction of factual data from these variables increases accordingly the correlation index. The administration of tests was conducted by either a project psychiatrist2 or a clinical psychologist holding a Ph.D. degree in the ward of Bellevue Hospital only to patients in contact with their surroundings The history of parental mental illness was verified with the New York State Department of Mental Hygiene. Psychiatric histories were available for patients’ mothers only. However, since the relationship between mother and child has been particularly stressed in the psychodynamic literature, this relationship was of primary focus in this study, although a subset of patients who reported psychiatrically hospitalized fathers were also included for analysis’l On the basis of genetic history and family-interaction data, the subjects were divided in four subsamples labeled as groups la, lb. II, and III for statistical treatment. Group la represented patients who in the interview reported having mothers hospitalized for a similar mental condition and for whom there was no confirming evidence at the New York State Department of Mental Hygiene. Group II consisted of patients who denied having mothers hospitalized, but for whom New York State had hospitalization records. Group lb comprised patients who reported hospitalization of their mothers with corroboration from New York State. Group 111 was composed of patients who in the interview reported hospitalized fathers for a mental illness similar to theirs. It should be noted from Table 2 that these subsamples represent both chronic and acute patients, but do not include all patients in these samples. The small size of group Ib is due to the difficulties inherent in studying a drifting schizophrenic population. Since many of the patients immigrated to New York City, psychiatric records for mothers of these patients were not available in New York State. It is equally likely that mental illness of the mother may have occurred before the patient was aware of it, or the mental hospitalization may have been concealed from the patient as a child. The patient’s report of mother’s hospitalization may also be a distortion due to his illness. As a check for accuracy of the patient reports, the interview was also given whenever this was possible to close informants (parents, spouse, siblings, or others familiar with the patients). The percentage agreement between patients and their informants (N=228: 182 chronics, 46 acutes)on the SSFIPD item ranged from 94% to 97%. except for cases where either the patient or informant had partial knowledge of the relative’s illness (see Table 4). ANALYSIS
Comparisons of frequencies normals are shown in Tables applied to test the differences.
OF
RESULTS
of hospitalized relatives for the various groups and 2 and 3. Whenever possible, chi-square tests were
8
7
0
0
Siblings
Other ret.
Children
Spouse
6.1
14
0
1.4 0
1.6
0.6
9.5
%Chr
la
f-d
1
0.2
N
mothers
acutes la X acutes II**,
Mother:
< 0.01.
la X lb X II***
acutes la X chronics la: NS; acutes II X chronics
Mother:
X* = 8.16,~
2.1 mother
II*,
< 0.001.
1
Mother:
X2 = 22.926.p
18.2
4.2
100.0
%I I
Group
1.7
0.4
9.3
%Chr
II
5
31
4
N
16.1
100.0
12.9
0.2
1
3.2
0.2
0
0
20.0
0
100.0
%la
Group
acutes
II
%Ib
0
0
33.0
0
100.0
reported
0
0
1
0
3
N
Group
Mother
Acute
N
0
1
2
0
19
III
=
patients
on interview
0
0
0.8
0
2.4
%Acu
lb
III
*, X2 = 926, p < 0.01.
list; Group
who
X normals*
to Albany
0
0
0.8
0
4.0
%Acu
la
lb = patients
0
1
0
5
N
according
group
X 2 = 384, p < 0.05;
were hospitalized
was hospitalized;
1.0
6.0
0.8
%Chr
III
Group o/.111
III
Father
722.61.40 4 8.3 0.8 00000000000000000000
9
2
that
whose
on interview
7.7
0.4
0.6
0.2
2.5
49
Chronic
%Chr
lb
II = patients
(chronics),
list; Group
23.1
7.7
100.0
%Ib
Group
III
0
who
reported
0
III
0
0
2.4
0
%Acu
III
on
interview
was hospitalized
0
0
0.8 0
100
0
%I11
00
3
0
N
Father Group
1.60
0
15.2
%Acu
II
that mother
0
5.3
10.5
0
100.0
%II
Group
Frequencies and Percentages of Specified Groups with Relatives Hospitalized for Mental illness
2 16.4 000
3
1
13
who reported
16.3
on Albany
was hospitalized.
confirmed
% Ia
100.0
la = patients
3
Father
Group
N
49
Relative
Mother
Hospitalized
Group
Mother
Table 2.
Normal
0
5.3
2.1
2.1
2.1
%Nor
that father
and Were
0
5
2
2
2
N
Sample
PARENTAL
STRESS
27
Table 3.
Total
Sample for Acutes and Chronics Total Sample
Hospitalized
(la + lb + III) Total
Chronic (la
Sample
& lb)
Acute (la
81 lb) % Acu
N
N
% Chr
Mother
62
12.0
8
Father
31
6.0
3
2.4
Siblings
JO
13.6
14
11.2
Other
65
12.6
7
5.6
6
1.2
3
2.4
16
3.1
4
3.2
Relative
Rel.
Children Soouse
6.4
Comparing the total acute and chronic groups to the normal sample, it can be seen that the chronic patients had the highest percentages of hospitalized mothers, fathers, siblings, and other relatives, followed by acutes, with the normals showing the lowest percentages in every category of mental illness. Two slight reversals of the indicated trends are observed in the data. A somewhat higher percentage of acutes as compared with chronics had hospitalized spouses and children. This may be due to either a low marriage rate or low fertility rate found among schizophrenics. l6 Of the first three chronic subgroups, subgroup Ib contained the highest percentage of relatives hospitalized (except for group III), as did subgroup Ib of the acute group. Subgroup Ib presents the most reliable information on heredity, since patient reports and New York State records coincided. These data lent strong support to the assumption that a genetic element was present in subgroups Ib and II of our schizophrenic population. It may be observed from Table 3 that the total ratio of state-reported hospitalized parents to their chronically ill offspring is 18.6% (16.2% by patients’ statements). The percentage is within the limits of Kallman,’ 16.4%; Shields,’ 12%; Essen-Moller,3 11%; and Alanen, I5 12%-patients who had mothers diagnosed as schizophrenic, or 23% with functional psychosis included. It corresponds as well to the work of Slater,2 who showed a ratio of two schizophrenic mothers to one schizophrenic father in his schizophrenic sample. Of main interest, however, was the study of patients’ emotional responses, based upon their reaction and interaction with their ill parents, independent of the factual reality of heredity. First, the extent of disturbance of family relationships by mental illness of parent was evaluated by asking the patient how he felt about his sick or allegedly sick relatives. Comparison of Tables 2 and 5 shows that only 34 of 49 patients who reported schizophrenic mothers were upset about their Table 4. Chronic Who N
Had
Patients’ and Informants’
Statements
about
Patients Informants % Chr
Hospitalization Acute
Inf.
Chronic N
Who
Informants % Chr
Inf.
N
Had
of Patients’
Relatives
Patients Informants
Acute
% Acu
N
Inf.
Informants % Acu
29
15.9
32
16
a.7
16
8.8
3
6.5
3
6.5
32
17.5
26
14.2
7
15.2
7
15.2
28
15.3
39
21.4
5
10.9
6
13.0
4
2.1
6
3.2
3
6.5
1
2.2
10
5.4
7
3.7
3
6.5
2
4.4
17.5
5
10.9
6
13.0
Inf.
34
2
5
3
00
00
Mother
Father
Siblings
Relatives
Children
spouse
Grandparent0
N
0
6.1
10.2
4.1
69.5
%~a
Group
Frequencies
Hospitalized Relative
Table 5A.
0
0
0
0.6
1 .o
0.4
6.6
%Chr
la
0
1
00
2
2
1
11
N
0
7.7
15.4
15.4
7.7
84.6
%Ib
Chronic
0
1.4
0
0
8.7 3.1 7.6 3.9 0.4 1.9 0.6
45 16 39 20 2 10 3
Father
Siblings
Relatives
Children
spouse
Grandparent
0
0
00
0
20
0
100
%la
Group
0
0
0
0.8
0
4.0
%Acu
la
0
0 0
0
0
33.3
0
100
%Ib
Group
0
0
0
0.8
0
2.4
0
1
0
1
9
3
8
N
0
0.8
0
0.8
7.2
2.4
6.4
Total Acute Sample %
%Acu
lb
0
0
0
0
0
0
0.8 0
5.3
1
0
0
00
0
0
0
0 0
%Acu
00
%II
N
II
ill behavior
Group
Acute Sample
in Table 3.
000
0
1
0
3
N
Specified
“Were You upset by the mentally
la, lb, and II for Acutes and Chronics
Total Chronic Sample
of Groups
0.2 0
0
0
1
0
5
N
Mother
Total
0
3.2
0
0.8
0.6
3.1
0.6
%Chr
III
%
5B.
0
1
00
9.7
51.6
9.7
%I11
412.9
3
16
3
N
Group
of Groups
N
Table
0.2 0
0
0
2.1
0
1
14.6
7 0
0.2
0
0
2.1
1
0
0
0
%Chr
II
00
%II
N
Group
Sample
2 for Description
” Yes” Responses to the Question, of Table
Hospitalized Relative
0.2
0
0.4
0.4
0.2
2.1
%Chr
lb
Groups’
See Caption
of Specified
Group
and Percentages
0
0
0
0
0
3
0
N
00
0
00
00
0
100
0
%I11
Group
0
0
2.4
0
1
11.1
0
00
3
3
2
-
0
3.3
3.3
2.1
1.1
Normal Sample
specified)?”
%Acu
III
of (relatives
PARENTAL
STRESS
29
relationships with them (69%), while for the state-list group the percentage was zero. Group Ib showed the highest percentage of patient upset at the hospitalization of a relative (84.9% for mothers). In general, the chronic sample showed the highest percentage of patient upset for every category of relative except father, where group III was highest. Second, the patient’s recent emotional interactions with family and relatives were examined. These data were extracted from the response given by the patient to the stress scale built into the psychosocial inventory instrument (SSFIPD). For the present analysis, only the categories relating to family interpersonal relationships (i.e., parents, relatives, marriage, and children) are considered. Mean stress scores are presented in Table 6. According to the score construction, it should be noted that higher numerical values indicate lower experienced stress. We may observe from Table 6 that higher percentages of chronics than acutes, particularly group Ib, experienced stress in every one of the categories under consideration, and the normals exhibited the lowest stress. In addition, we analyzed, as well, their recent interactions with parents. It is quite obvious from Table 7 that group I measured a higher proportion of subjects who had difficulty with their mothers than group II, indicating that the direction of perception of mental illness of mothers was based mainly on patients’ emotional relationships with them. It should be noted that in the chronic group 24.2% reported getting along “terribly” with their mothers, while 22.6% got along very poorly with their fathers as well. Yet mental illness of the parents was a stress factor only for subgroup Ib. It is particularly interesting that a substantial proportion of every group had only rare contact with their parents (23.5%) or no contact at all (19.6%). In order to have a retrospective dimension of the environmental climate in which the disturbed family relationship could have precipitated a schizophrenic reaction, we investigated the structure of the family as well. In terms of parental death, the chronics most often experienced death of the mother, followed by acutes, with the lowest percentage occurring for normals. It should be noted that the replacement of a dead mother by a mother figure apparently did not help, especially for subgroup Ib. The group Ib chronics had 45.5% surrogate mothers, who apparently were mentally sick as well, and they are the ones who produced the most disturbed family interactions. The same order, with chronics first, followed by acutes, followed by normals, is maintained with the deaths of fathers. It can be inferred from these data that the death of a parent in childhood had a marked effect on the children who were later to become chronic schizophrenics. During the adolescent years (lo-19 years) the acute patients had the highest percentages of mother and father deaths, followed by chronics, with normals again showing the lowest percentages. This is interesting from the point of view of recent trauma (precipitating factor), since acutes are a younger population (45% under age 24). Obviously the family structure may be disrupted by causes other than the death of a parent. Either the patients themselves, through socially intolerable behavior, or the parents, through divorce, separation, or other reasons, may cause radical changes in the living circumstances of the patient as a child, which alters the social climate in which the patient-to-be is raised. Other causes of family breakup of the patients’ families were examined.
*Indicates
2.16
1.90
1.50
t value significant
at 0.05
at 0.01
2.58
2.35
2.71
2.22
II
lb
2.05
Group
Group
t value significant
2.25
Children
**Indicates
2.71
2.19
Relatives
2.16
Parents
Marriage
Ia
Group
Category
Sample
level.
level.
2.44
2.23
2.65 2.43
2.58
2.50
2.23
2.01
Both
Mentally
with
4 Chronics III
Group
Chronic
III
Par.
2.18
2.33
2.66
2.22
Chron.
1.67
1.70
2.19
2.22
Ia
Group
Sample
0.00 1.00
2.93 2.37 2.50
2.00 0.00 0.00
2.43
1 SO
2.35
Group
2.37
lb
Ill
Group
Acute
II
Group
Mean Stress Scores
Total
Table 6.
Total
2.20
2.46
2.76
2.43
Acute
Normal
2.61
2.51
2.85
2.56
Sample
Significant
* **
l
**
**
Chronic
Normal/
Difference
t Test
Mean
1
Acute
Normal/
by
8 10 25 4 62
Terribly
Poorly Fair Wel I INAP Total
13
7 13 18 11 62
Terribly
Poorly Fair Wel I INAP Total
Got Along With Father
N
15
Got Along With Mother
21.0 11.3 21.0 29.0 17.7 100%
12.9 16.1 40.3 6.5 100%
24.2
%I
Group
5 6 9 25 3 48
8 10 8 21 1 48
2.9 1.6 1.9 4.8 0.8 9.7
2.5 1.4 2.5 3.5 2.1 9.7
N
%Tot
I
10.4 12.5 18.8 52.1 6.3 100%
16.7 20.8 16.7 43.8 2.1 100%
%II
Group
1.0 1.2 1.7 4.8 0.6 9.3
1.6 1.9 1.6 4.1 0.2 9.3
7 6 5 11 2 31
7 6 5 11 2 31
N
22.6 19.4 16.1 35.5 6.5 100%
22.6 19.4 16.1 35.5 6.5 100%
%II I
Group
How Patient
Sample
7.
%Tot
II
Chronic
Table
1.4 1.2 1.0 2.1 0.4 6.0
1.4 1.2 1.0 2.1 0.4 6.0
%Tot
III
86 69 106 176 79 516
77 75 109 226 29 516
N
with
16.7 13.4 20.5 34.1 15.3 100%
14.9 14.5 21.1 43.8 5.6 100%
%
Tot Chr
Got Along
1 2 1 3 1 8
2 4 2 0 0 8
N
Mother
12.5 25.0 12.5 37.5 12.5 100%
25.0 50.0 25.0 0 0 100%
%I
Group
0.8 1.6 0.8 2.4 0.8 6.4
1.6 3.2 1.6 0 0 6.4
%Tot
I
and Father
2 4 6 3 4 19
1 3 7 8 0 19
N
10.5 21.1 31.6 15.8 21.1 100%
5.3 15.8 36.8 42.1 0 100%
%II
Group
1.6 3.2 4.8 2.4 3.2 15.2
0.8 2.4 5.6 6.4 0 15.2
%Tot
II
Acute
in Last 6 Months
0 1 1 1 0 3
0 1 1 1 0 3
N
0 33.3 33.3 33.3 0 100%
0 33.3 33.3 33.3 0 100%
%I I I
Group
Sample
0 0.8 0.8 0.8 0 2.4
0 0.8 0.8 0.8 0 2.4
%Tot
III
11 23 25 48 18 125
9 14 32 66 4 125
N
8.8 18.4 20.0 38.4 14.4 100%
7.2 11.2 25.6 52.8 3.2 100%
%
Tot Acu
6 6 33 40 10 95
5 5 24 61 0 95
N
6.3 6.3 34.7 42.1 10.5 100%
5.3 5.3 25.3 64.2 0 100%
0%
Normal Sample
9.7 12.9
1.6
42.0
%I
4.1 12.0
1.2 1.5
0.2
5.0
%Tot
Group I
21 33.9 62100%
6 8
Illness Death INAP: Family
Not Broken Total
1
26
(Parent) LongTerm Mental
LongTerm Prison
I Ilegitimate
Divorce Separation
N
21 48
0 8
0
19
N
43.7 100%
0 16.7
0
39.6
%I1
Group
4.1 9.3
0 1.5
0
3.7
3.2 13.0
0
41.9
%I11
Group
2.5 6.0
0.2 0.8
0
2.5
%Tot
III
250 516
10 74
1
161
N 1
N
50.4 100%
7 8
1.90 14.3 0
0.20
31.2
%
Tot Chron
87.6 100%
0 0
0
12.6
%I
Group
5.6 6.4
0 0
0
0.8
%Tot
I
0 10.5
0
31.2
%II
Group
0
1
N
8.8 15.2
2 3
0 0 1.60
0
4.8
%Tot
II
Acute Sample
11 57.9 19 100%
0 2
0
6
N
Reasons for Family Breakup before Age 18
13 42.0 31 100%
1 4
0
13
N
Sample
%Tot
II
Chronic
Table 8.
66.7 100%
0 0
0
33.3
%I11
Group
III
1.6 2.4
0 0
0
0.8
%Tot
76 125
0 14
0
35
N
100%
60.8
0 11.2
0
28
%
Tot Acute
Normal
54 95
2 10
0
29
N
56.8 100%
2.1 10.5
0
30.5
%
Sample
PARENTAL
STRESS
33
The major causes of breakup were divorce, separation, or de facto division that occurred with the birth of an illegitimate child (who later became a patient). In this respect, separation due to death of a parent, long-term prison, or mental illness were considered separately. There were no significant differences between acute, chronic, and normal patients (14.3% of the chronics had families broken by death, as compared to 11.2% of the acutes and 10.5% of the normals). While it is reasonable to assume the trauma of a broken home as a schizophrenogenic agent, those patients who did have the experience of a family as a harmonious social unit in their childhoods could not be said to be better adjusted as a result of that experience than the ones from broken homes.” In order to identify retrospectively the stressful factors that might have contributed to the development of schizophrenia, the childhood problems of the schizophrenic in the context of environmental interaction were also analyzed. Table 9 shows the response frequencies to a set of questions asking the patients to describe their major difficulties before age 18. The same questions were asked of their informants. The problem area “parents” was cited as the major problem before 18 for: chronic patients, group 1 (61.3%), group II (45.7%), and group III (71%) disturbed by the mentally ill father; acute patients, group I (87.5%), group II (36.8%), and group III (33.3%). For normals, 37.9% reported parents as the major problem before age 18. After age 18, problems with the opposite sex became of primary importance, but parents still were the second most frequently cited problem for chronics. DISCUSSION
These results indicate that disturbed family relationships have significance only to the extent to which the patients perceive them as such. Though the genetic factor cannot be denied, it failed to explain the large number of the subjects of our sample who were schizophrenics independently of it. Moreover, the patients had difficulty in distinguishing psychologically between the truly mentally ill parent as reported by the state and the one they perceived as such; however, whenever the two groups overlapped (group Ib), the combination of hereditary factor and disturbed familial interaction produced the maximal disturbed response in the patient, which shows the importance of their interaction. However, the experiential factor played the determinant role in producing stress in the patients whenever they perceived the family interaction as disturbed, independent of the confirmed existence of mental illness or lack thereof in the parents. It appears that multiple stressful factors contributed to the development of schizophrenia in the majority of the sample. Whatever family psychodynamics might appear to explain the disturbed family interaction, the results became obvious: from childhood on the schizophrenic has difficulty in establishing proper relationships with parents or society.5.6 Within this context, we evaluated the reaction of the patient to various experiences of his life. The results appear to indicate that the chronics of groups Ib and III experienced a higher amount of stress in family interaction. Contrary to the general opinion oEthe concept of schizophrenogenic mother, a father might
changes
drugs
Drinking/
3.7
9 14.6
m. Other
1.7
0.6
4.8
3
1.7
4.8
19 30.7
I.
problems
9 14.5
25 40.3
Death
k. Physical
j.
Personality
3.3
17 27.4
h. Authorities
i.
5.4
28 45.2
g. People
3
13
6
5
6
17 12
8.3
6.3
27.1
12.5
10.4
12.5
25.0
35.4
33.3
4
16
29 46.8
3.9
20 32.4
Friends
f.
5.6
5.2
22.9 41.7
41.6
43.8
%II
Group
11 20
4.5
21
20
5.8
N
7.4
27 43.5
23 37.1
I
%Tot
d. School e. Job
problems
c. Sexual
sex
30 48.4
%I
Group
38 61.3
N
b. Opposite
18
a. Parents
Before
Major Problem
0.6
2.5
1.2
1.0
1.2
3.3
5.4
3.1
0.8
2.1 3.9
3.9
4.1
19.4
12.9
19.4
48.4
29.0
35.5
35.5
19.4
58.1
5
16.1
83
1.0
1.7
0.8
1.2 10.1
16.9
30.0
20.2
32.2
35.3
16.1
29.1 43.2
39.9
56.0
%Tot
45
8.7
13225.60
52
87
155
104
1.7 2.9
166
2.1
182
1.2 2.1
150 223
206
2.1
1.2 3.5
289
4.3
35.5
71.0
N
Tot Chron
%Tot
III
%lll
Group
929.0
4
6
15
9
11
11
6
18
6
11
22
N
Sample
%Tot
II
Chronic
Table 9.
0
2
3
2
1
4
3
0
3 4
4
7
N
0
0
23.1
37.6
25.1
12.5
50.1
37.5
0
37.5 50.1
50.1
87.5
%I
Group
0
0
1.6
2.4
1.6
0.8
3.2
2.4
0
2.4 3.2
0.8
15.8 5.3 1
2.4
26.3
4.0
1.6
1
1
1
1
2
0
1.6 3.2
0
3.2
3
10.5
21.1
10.5
21.1
1
1
2.4 4.8
1 2
1
1
N
4.8 4.8
7.2
5.6
%Tot
II
Sample
5
2
4
2
4
15.8 31.6
3
31.6 31.6
6
6 6
36.8
3.2
47.4
7 9
5.6
Group % II
%Tot
N
I
Acute
33.3
33.3
33.3
33.3
66.7
0
0
33.3
33.3
33.3 66.7
33.3
33.3
%I11
Group
Ill
0.8
0.8
0.8
0.8
1.6
0
0
0.8
0.8
0.8 1.6
0.8
0.8
%Tot
9
26
13
20
28
10
29
34
12
20 36
36
55
N
Tot
7.2
20.8
10.4
16.0
8
24
20
5
10
8 22.4
13
8.0
15
9
3 38
15
36
N
23.2
27.2
9.6
16.0 28.4
28.8
44.0
%Tot
Acute
8.4
25.3
21.1
5.3
10.5
8.4
13.7
15.8
9.6
3.2 40.0
15.8
37.9
%Tot
Normal Sample
PARENTAL
STRESS
35
be a contributing factor as well, especially when he is identified as mentally ill by the patient. This is in agreement with new research on this subject. If we take the normal as a base, the chronics showed twice the amount of difficulty in family interactions with mothers and fathers as did normals. Even in childhood relationships chronics already showed a higher degree of difficulty in relating to parents than did the acutes and normals. A final stressful experience of the child, which apparently contributed to the development of schizophrenia, is related as well to the destruction of the family structure through the death of the parents, but is not, as was generally thought, due to the breakup of the family. This is supported by the finding of the highest proportion of deaths of both parents among the chronics. For acutes, not yet differentiated as reactives and chronics, the death of a parent during adolescent years (1CL10 years) appears to be significant. They have the highest percentage of parental death in adolescence, which becomes a precipitating factor related to their schizophrenic hospitalization. No definite trend could be established otherwise about acutes, since they are in a transitional stage. Some of them will remain in the group of reactives (episodic schizophrenia), while others will progress toward chronicity (process schizophrenia). Only a long-term follow-up will reveal their direction. In view of these findings, we might envision schizophrenia as a manifestational entity with possible multiple etiologies where one could identify a genetic etiology separately from the environmental one the interaction between them producing the most stressful form of all.
ACKNOWLEDGMENT Acknowledgment is made to Gerald W. Woloshin, Ph.D., Research University Medical Center, for his help in the statistical analysis of results.
Assistant.
New
York
REFERENCES I. Kallman F: The Genetics of Schizophrenia. New York, J.J. Augustin, 1938 2. Slater E: A Review of Earlier Concordance on Genetic Factors in Schizophrenia. Proceedings of the Third World Congress of Psychiatry, vol I. Montreal, Toronto Press, 1961, p I5 3. Essen-Moller E: The calculation of morbid risk in parents of index cases or applied to a family of schizophrenics. Acta Genet 5:334-442, 1955 4. Lidz T, Cornelson A. Terry D: The intrafamilial environment of the schizophrenic patient: II. Marital schism and marital skew. Am J Psychiatry ll4:241, 1958; Parental personalities and family interaction. Am J Orthopsychiatry, l958b, 28:464, 1958; The transmission of irrationality. Arch Neurological Psychiatry 79:305, 1958 5. Singer M, Wynne L: Thought disorder and family relations of schizophrenics: IV. Results and implications. Arch Gen Psychiatry 12:201. 1965 6. Bateson G. Jackson D, Haley J. Weakland
J: Toward a theory of schizophrenia. Behav Sci l:251, 1956 7. Gottesman, Shields: Schizophrenics and Genetics. New York, Academic, 1972 8. Howells J (ed): Modern Perspectives in World Psychiatry. New York, Brunner/Mazel. 1971 9. Wender T, Rosenthal D, et al: The psychiatric adjustment of the adopting parents of schizophrenics. Am J Psychiatry 1971. p 127 IO. Heston LL: Psychiatric disorders in foster home reared children of schizophrenic mothers. Br J Psychiatry ll2:819, 1966 I I. Fontana AF: Familial etiology of schizophrenia. Psycho1 Bull 66:214, 1966 12. Taube AC, Redlick R: Utilization of mental health resources by persons diagnosed with schizophrenia. NIMH Statistical Report, May 1972 13. Hollingshed AB, Redlick FC: Social Class and Mental Illness: A Community Study. New York, John Wiley & Sons, 1958 14. Fromm. Reichman F: Notes on the de-
36 velopment of treatment of schizophrenics by Psychiatry psychoanalytic psychotherapy. 11:263, 1948 15. Alanen Y: The family of schizophrenic patients, in Concro R (ed): The Schizophrenic Syndrome, vol 1. New York, Brunner/Mazel, 1971 16. Bleuler M: A 23-year-long study of 208 schizophrenics, in Rosental D, Kety S (eds): The Transmission of Schizophrenia. New York, Pergamon, 1968, p 3
GEORGE SERBAN
17. Langner T, Michael S: Life Stress and Mental Health, vol II. Free Press of Glencoe, 1963, p 159 18. Vaillant GE: Prospective prediction of schizophrenic remission. Arch Gen Psychiatry I1:50!2,1964 19. Lidz T, Cornelson A, Fleck S, Terry D: intrafamilial environment of the The schizophrenic patients: I. The father. Psychiatry 20:329, 1957
