Non-Psychiatric Doctors Beliefs about Schizophrenia Adversely Impact Care

Differential beliefs about the biogenetic vs. psychosocial causes of schizophrenia influence doctors’ views about treatment and prognosis, study finds.

Madison Natarajan, MS
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A study in Psychology and Psychotherapy: Theory, Research, and Practice, investigates non-psychiatric doctors’ causal beliefs about the origins of a diagnosis of schizophrenia. The authors, a research team led by Lorenza Magliano from the Department of Psychology at Campania University in Italy, unpack the ways these beliefs influence treatment and prognosis among physicians who endorse biogenetic causes versus psychosocial causes.

Of the 264 participants who expressed their opinion about the most important causes of ‘schizophrenia,’ 54% indicated a belief in a biogenetic cause. The researchers provide practitioners with key points of consideration for understanding how their belief systems impact patients that are given the diagnosis of schizophrenia. Magliano and co-authors explain:

“Presenting schizophrenia as a ‘disease like any other,’ that is, equating the experience of psychosis with that of having a physical disease, was intended to improve social acceptance of ‘schizophrenics’ by reducing blame for this condition. In fact, explaining schizophrenia as caused by genetic factors, chemical imbalances, and brain anomalies causes prognostic pessimism, perceptions of dangerousness and unpredictability, and desire for social distance from these people.”
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Schizophrenia is a contested diagnosis that captures a diverse range of experiences, often characterized by psychotic symptoms, such as paranoia, delusions, or hallucinations. Despite a lack of conclusive evidence, psychiatry has promoted the idea that schizophrenia is a brain disease. This biological approach to understanding ‘schizophrenia’ has been the dominant viewpoint among medical professionals for decades, despite the public (including those with lived experience and their families), who are more likely to endorse psychosocial causes than biogenetic ones.

While there have been a large number of studies documenting the influence of causal beliefs on public attitudes towards people diagnosed with schizophrenia, few studies have investigated non-psychiatric doctors’ etiological explanations and how this impacts their clinical practice. Due to the high prevalence of physical health problems that people diagnosed with schizophrenia often incur, and the suboptimal medical care they often receive, research among non-psychiatric medical professionals is needed.

Beliefs about the causes of psychosis and schizophrenia can significantly influence the therapeutic choices and clinical approaches of medical professionals, including influencing physicians’ empathy for their patients. Notably, a study found that psychiatrists who explained symptoms in terms of biological rather than psychosocial factors showed less empathy towards their patients and placed less emphasis on psychotherapy. There have been similar findings among mental health staff, also showing that the biogenetic model belief system attributes greater usefulness to drugs. In contrast, those who endorse psychosocial belief systems tend to rate psychotherapies as more effective.

The researchers investigated the impact causal explanations of schizophrenia have on treatment from a sample of 192 general practitioners and 114 non-psychiatric medical specialists working in outpatient community centers. The participant’s completed the revised “Opinions on Mental Disorders Questionnaire” (OQ).

The OQ questions were dichotomized as biogenetic causes (heredity, chemical imbalance, illness during the pregnancy, use of alcohol and street drugs), and psychosocial causes (stress, work difficulties, family conflicts, adverse childhood experiences including sexual, physical, and psychological abuse or violence). Responses that included both biogenetic and psychosocial explanations were considered biopsychosocial. Further analysis was done on the respondents’ beliefs about the usefulness of drugs and psychological therapies, the need for long-term drug treatments, and recovery prognosis.

The results found that 16% of the medical professionals endorsed biogenetic causes only, 75% supported both biological and psychosocial, and 9% endorsed only psychosocial causes. While the majority of participants endorsed both biological and psychosocial causes, most placed more emphasis on biological factors and genetics (65%).

While it was a positive finding to see that most non-psychiatric doctors have a balanced biopsychosocial interpretation of the diagnosis of schizophrenia, there remains alarming evidence of the belief that the most important cause is biological and mainly hereditary. This result suggests that many respondents may consider psychosocial causes as mere trigger factors rather than as true causal factors.

Additionally, these findings indicate the pervasiveness of a hereditary perception of the controversial diagnosis, despite numerous reviews and critiques demonstrating that the studies on the role of genetics in the development of psychosis have not only been greatly exaggerated but are hampered by methodological issues.  The researchers elaborate on their results:

“The results of this study confirm previous findings that viewing schizophrenia as mainly due to a biological cause is associated with greater confidence in drugs, higher conviction of the need for lifelong pharmacological treatments, and prognostic pessimism. Moreover, adherence to a biologically oriented model of schizophrenia may lead to an underestimation of the value of psychologists.”

Notably, despite growing concern about the long-term efficacy and safety of antipsychotic medication, these results highlight the continued belief in pharmacological treatments among medical professionals. Seventy-five of the sample believed that people with the diagnosis of schizophrenia must take psychotropic drugs for the entirety of their life, and 64% thought that these individuals would become dangerous if they stopoed psychiatric medication.

This belief contradicts a growing body of evidence on risk factors for violence in people diagnosed with schizophrenia and related disorders. While 56% of physicians thought psychological interventions are useful, only 29% of the total participants believe that people “with the disorder” can recover.

The findings in this study suggest the importance of efforts to provide non-psychiatric doctors with training on the varied interacting causes of the symptoms that elicit a diagnosis of “schizophrenia,” including education on psychosocial factors, efficacy and safety of the broad range of evidence-based treatments, information on actual rates of recovery, and the actual risks of dangerous behaviors among those diagnosed with schizophrenia.

The authors conclude with the following key points for practitioners to consider:

  1. Viewing schizophrenia as having primarily a biological cause is associated with greater confidence in the usefulness of drugs, firmer belief in the lifelong need for drugs, and greater prognosis pessimism.
  2. A biologically oriented belief model may lead doctors to underestimate the value of psychologists.
  3. Prognostic pessimism among doctors may negatively influence clinical decisions, the information doctors provide, and the clients’ own beliefs about their chances of recovery.
  4. Belief in the need for lifelong pharmacological treatments may lead doctors to resist drug withdrawal in case of severe side effects.

 

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Magliano, L., Citarelli, G., & Read, J. (2019). The beliefs of non‐psychiatric doctors about the causes, treatments, and prognosis of schizophrenia. Psychology and Psychotherapy: Theory, Research, and Practice. https://doi.org/10.1111/papt.12252 (Link) 

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Madison Natarajan, MS
Madison Natarajan is a master’s level psychotherapist and current doctoral student at the University of Massachusetts Boston. As a researcher, her focus is on the impact of religious trauma on female sexual development, specifically assessing the subculture of the evangelical purity movement. Madison has a family history that has been intertwined with psychiatric care, ranging from family members who were institutionalized to those practicing psychiatry, both in the US and India. Madison seeks to challenge the current structure of psychiatric care in the West and disseminate honest and empowering information to the community at large.

16 COMMENTS

  1. It is a privilege to “view” people with “pathology”. It is a privilege to “talk” about “IT”, “THEM”. It is a privilege to be able to discriminate against “Them”.

    People make a lot of money from the ones they abhor.

    I doubt it makes any difference how anyone is mis-represented. The treatments and attitudes cannot be changed.

    The biggest hoax is when research is done into “stigma” or “suicides”. When a person has been shunned by the system who pretends to be a “health” system, that system has no business delving into pretentious papers.
    If anything, any “researcher” should start protesting the hoax.
    The research does nothing more than to keep ideas alive.

  2. You’ve neglected to mention the likely primary etiology of “psychosis,” “hallucinations,” and “schizophrenia” itself.

    Which is that, since the “schizophrenia” treatments – the antipsychotics/neuroleptics- can create “psychosis” and “hallucinations,” via anticholinergic toxidrome. And those treatments can also create the negative symptoms of “schizophrenia,” via neuroleptic induced deficient syndrome.

    The reality that the primary etiology of “schizophrenia” may likely be iatrogenic – not biologic or genetic – should be mentioned.

    And of course, this reality would contradict the current paradigm of care, which calls for lifelong neurotoxic drugging.

  3. You mean like when a group home staff insists you help push her stuck car in a freak snow storm because “you are young and healthy” and you feel something pop? You mean like when you go to the MD for that back injury because you know it is bad and he asks what meds you are on and then stands with his hand on the door knob ready to run away?

    Or like when your leg starts dragging that night so you go to the ER and that MD asks what meds you are on and then accuses you of wanting pain pills?

    Or the group home boss that tells you your “borderline” is really acting up when you cry from the pain at dinner, so you choose to drag yourself back to your walk up apartment. Only the bus driver believing something is really wrong? Even stopping as close to your door as he can get.

    And then when you can’t do the stairs to go get groceries and you can’t get anyone to help you, so give all your possessions away because you can’t even pull pants up let alone move stuff so your Dad can move you back to the small town from the city and the MD who knows you enough to order tests finds out you have a blown disk and have herniated two others?

    Like that? Like when you go back to the group home to ask if they have insurance to compensate for your injuries now that you have MRI proof and they accuse you of a worsening of your Mental Illness so you go away quietly to avoid the wellness check? Like that?

  4. Like when you are taken to the ER by your mental health aide because you are so weak you can’t hold your head up and the ER doc asks over and over if you see anything that isn’t there instead of doing a medical check?

    When you get so tired of trying to redirect him back to your physical illness that you point between him and the mental health aide and say, “I don’t see anything that isn’t there except for that guy.” And the aide gets the joke and starts laughing uncontrollably, but refuses to say anything in your defense when the doctor takes control of the situation? Like that?

  5. Or when you make an appointment because your finger joints are changing before your eyes. And the doctor takes you seriously until she opens your electronic record? Then tells you to see your psychiatrist for it? And the psychiatrist says “can you still do art?” “Well you are okay then.” And that’s the end of it. Like that?

  6. “A biologically oriented belief model may lead doctors to underestimate the value of psychologists.”

    I don’t care! Clearly the doctors who can’t see me past a diagnosis are the ones who need a psychologist to address the rampant discrimination they are perpetrating. What I was seeing an MD for couldn’t be helped by a psychologist! STOP! STOP! this idea that I’m the one in need of a psychologist, when my back was injured is just more of the same CRAP!

    • Just like that O.O.
      EXACTLY like that. THAT is CANADA. Where one gets to look into the future of what is in store as one gets sick.
      And if you get too sick, you can no longer protest and no one protests for you. And they really let you feel the power, because on an ER bed, in that doc office, it is you against thousands.
      Ever seen them gloat?

      • Yes I have seen them gloat and smirk. Smirking is the worst. And I’ve heard an ER doctor impersonate my manner of explaining over the phone, like even my desperate attempts to be seen are just “crazy”. Welcome to Canada! Where the insurance for psychiatry never runs out.

        But we have butter tarts, so that’s awesome. And ketchup chips.

        • “Where the insurance for psychiatry never runs out.”

          This is precisely my fear under a Medicare for All scenario. Getting off Medicare was one of the best parts of marrying into a modicum of money and becoming ineligible for my SSI payments, which was 90% of my disability. Went off disability, finally got off Medicare. I have good private insurance but it’s still insurance. I go to the doctor only if I truly need it.

          I’d love for everyone to have the medical care they need but I fear for the day that we all have access to unlimited amounts of psychiatric “care”. It won’t come from psychiatrists for most people. There aren’t enough of them. It will come from primary doctors who will drug you into a stupor for being crazy enough to complain about your physical illnesses.

          O.O., your story could easily have been my journey with Lyme Disease, with ever worsening health to the point that I ended up with pericarditis before the various doctors finally believed there was something legitimately physically wrong.

          • I would like to know more about your Lyme story Kindred. I was bit by a tick at 16, but the doctors said there was no Lyme in Alberta. I am sure that I have it. It is the only thing that makes total sense.

  7. I remember how Julie Greene emphasized that the whole point to psychiatry was eugenics. It is based upon the philosophy of social darwinism.

    I admit I was slightly skeptical. Eugenics?

    Not sure the mainstream shrink at your friendly neighborhood mental illness center knows. Probably clueless. Most of mine were friendly and tried to keep me from suffering too much.

    But I believe there’s an inner circle at the top–the guys who invent new “diseases” and make guest appearances on national TV warning Joe Schmoe how evil and dangerous all the “untreated mentally ill” are. They know what they’re doing and show no pity.

    The whole premise to psychiatry is certain groups of people are “defective criminal types.” This grew popular in the 19th century. According to eugenicists these “defectives” need to be weeded out from society and prevented from breeding more “inferior stock.” Regardless of the content of their characters and actual behaviors “blood will tell” and these Men of Science must weed out the defectives.

    This demonizing of those they claim to help is necessary for psychiatrists since if others saw them as ordinary people they would call them out on the inhumanity of the cruel, pointless experiments they persist in inflicting on hapless test subjects.

    This defamation campaign has proven highly effective. Stigma is a shrink’s best friend. They WANT to turn our families and friends and everyone including other doctors against us.

    Most people don’t think this through. But they believe the SCIENCE. In their defense many think they’re helpful telling us to take drugs. But thinking we’re all dangerous monsters makes them avoid us. (Duh.) And my guess is doctors don’t care about the quality or quantity of our lives. They have similar attitudes about the disabled and elderly but the notion that we’re all would-be-mass-shooters rendered temporarily harmless via SCIENTIFIC MAGIC makes them treat us worse.

    When I moved I managed to not get “bipolar” on most medical records. Just “depression” and all those physical problems inflicted by psychiatry. Amazing how helpful and nice doctors are now.

  8. Two of the most exclusive eye hospitals in the world The Western Eye Hospital and Moorefields Eye Hospital are based at London in the UK.

    When I attended both of these NHS Eye Hospitals with eye problems and mentioned, that Psychotropic drugs I had consumed in the early 1980s had affected my eyesight, doctors at both of these hospitals kept what I said off my Records and entered negative Mental Health entries instead.

    At Moorefields Eye Hospital the Consultant himself recorded “takes Seroquel for his Psychiatric Problems” into my Notes. Whereas my prescription of Seroquel at 25 mg per day – would NOT have been suitable for any “Psychiatric Problem” whatsoever. Seroquel at 25mg per day is only used for Off Label Purposes.

    The Consultants casual approach might reasonably predict the actual standard of medical care available to a person “with Psychiatric Problems” in some Nhs medical facilities in the UK.

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