Wednesday, August 19, 2009

Schizophrenia Controversy

Schizophrenia is considered a thought disorder with a genetic predisposition triggered by environmental factors. It is a deteriorating disorder that affects cognition, emotional stability and overall personality. It is commonly associated with delusions and hallucinations. The most prevalent form is paranoid. It affects approximately 1 % of the population and seems to exist in all cultures. The nature of the delusional material is related to the prevailing culture. Where the community is predominantly religious the content is often of a religious nature whereas in the modern world with computer chips and space age technology the content is often government or alien based technological. The onset can be insidious or more abrupt and classically affects adolescents and young adults though a sub group appears late in life. It is associated with a higher incidence of suicide. Psychosis or the feeling of being out of touch with reality is central. Also to the community the person appears odd or unusual.
Where the controversy arises is not with the diagnosis of 'psychosis' a rather straightforward and relatively easily made diagnosis but rather with the diagnosis of prevailing perpetuating state of schizophrenia. Schizophrenia as a label is life saving for those indeed with the disease though there is concern that it can be a 'self fulfilling' diagnosis. Yet, there are many schizophrenics I have known who are thankful for the diagnosis as it makes sense of a very fragmented reality and helps them and their family cope with this devastating disease. Friends of Schizophrenia brings hope and resources to the families, friends and patients suffering this tragic mental illness.
Though Schizophrenia was once the principle diagnosis of those in asylums, today the vast majority of those with schizophrenia will live full lives outside of the hospital and many will engage in important occupations and have full family and social lives. The movie Beautiful Mind, directed by Ron Howard and starring Russell Crowe is a very fine depiction of such schizophrenia.
The controversy is however with the diagnosis. For decades the Europeans have required prolonged psychosis before making the diagnosis whereas the Americans would make the diagnosis almost as a hip shot. The diagnosis of Brief Psychotic Reaction in DSMIV discouraged this latter cowboy diagnostic group and encouraged patience. Too often a person would present with psychosis and then the psychiatrist would retrospectively take a history which would then validate the a priori schizophrenia diagnosis rather than accepting the first visit to a psychiatrist as the point from which the diagnostic clock should begin. The French even suggested that a mid diagnois between Brief Psychosis and Schizophrenia be established which demanded over 6 months of frank psychosis. There are still the hip shooters but the evidence is overwhelming now in supporting the European approach. Research now establishes that early psychosis appropriately treated does not need to progress to schizophrenia. The black and white Americanism of the Old School is now replaced by a much more reasonable continuum. The new American approach actually suggests the potential for a cure.
Psychosis or first break Schizophrenia cannot be defined at initial intervention. The diagnosis of schizophrenia conservatively should wait for a year or more while the treatment for psychosis is nonetheless initiated immediately.
Schizophrenia is thought more of a degenerative brain disorder and the expected course is slow deterioration in social competence and decreasing independence. There may well be a link to the Autistic disorders or it may follow that schizophrenia is some slow virus type infection.
There's a quality of oddity and emotional lack.
In contrast the diagnosis of Schizoaffective Disorder is a schizophrenia/bipolar type illness with more stable outcome, less deterioration and alienation and more emotionality.
Bipolar is the mood disorder that is thought somehow related to the more positive outcome schizophrenics.
In the 80's when new thinking regarding schizophrenia and bipolar arose with new affective disorder treatments I witnessed some hundred or more schizophrenics responding to the new medications and having the diagnosis changed to fit the medication response. Schizophrenia was recognised to be a bit of 'garbage bag diagnosis' with a lot of bipolar and schizoaffective mixed in with the historically more definitive schizophrenia. It was recognised that schizophrenia responded to antipsychotics however these others responded to the type of drugs which were being used on mood disorders, such as the anti seizure drugs and lithium carbonate. Also ECT tended often to make schizophrenia worse whereas it was a definitive and excellent treatment for mood disorders often 'curing' them with a brief course of treatments.
A particular sub group of interest were the drug related psychosis. A forensic psychiatrist typified the gross ignorance and bias of the old school saying, "what we need is a marijuania anti psychotic mix injectable to improved compliance in schizophrenia." What wasn't recognised was that chronic or even intermittent marijuania use could cause and maintain psychosis leading eventually to schizophrenia. This is even more true with cocaine and the amphetamine. Some of the drugs of abuse cause such severe brain damage that it shows up as 'holes' in various brain imaging surveys. Gas sniffing and other inhallants are such profoundly damaging 'high's".
Schizophrenia itself appeared to be related to the length of time that the person remained in the psychotic state. Persisting paranoia for instance almost appeared to 'burn out ' some brain circuits which did not easily repair. Stopping marijuania and other drugs of abuse including alcohol and placing people in a supportive but reality testing environment proved highly effective in stopping the progression of the disease.
Many churches, temples, synagogues, and 12 step programs know those who were crazy as loons for the longest time only to eventually improve in the 'holding environment' of the loving community that did not support the delusional world. New treatments developed in psychotherapy that did not behaviourally reward psychosis but rather acknowledged it but then expected the schizophrenic's bed to be made anyway proved far more effective than the old 'drug em and leave em' approach. Maintenance of function rather than allowing isolation resulted in the most positive outcomes which included increasing numbers of 'cures'.
Today one can hear a person say, "I had schizophrenia but it's cured and I no longer have it" whereas that was unheard of only a decade or so ago. Indeed the old school tended to get around this 'problem of recovery and cure" by begging the question and 're diagnosing' those who did well." The circular reasoning said 'schizophrenia doesn't get well so these can't be schizophrenia". It's called 'saving the appearances' and we're all at fault for it some of the time.
Thankfully today it's no longer necessary as increasingly it's recognised that the continuum disease is such that there are those who resolve early if treated appropriately and hopefully and given sufficient time, resources and treatment to have a cure and those who have milder forms of the illness while indeed there remain those who are often now called 'intractible schizophrenia". Medications help all, though the milder cases may do better with lower dosages whereas severe cases often require dosage of medication far outside the 'label' use of the medication. The new atypical antipsychotics are a god send having fewer side effects and more specific action.
Drug addiction was a major source of schizophrenia too as persisting drug abuse not only interfered with performance of the antipsychotic medication but acted like opening a wound. Cocaine psychosis was once considered the best 'induced schizophrenia' model available. DSMIV now recognises a psychosis, thought disorder, anxiety disorder, or mood disorder associated with all drugs of abuse including alcohol. New MRI data suggest that the persistence of the influence of drugs on the brain is a minimum of three months in many cases clearly at variance with the old school approach that said the psychosis had to be associated with the presence of the active compound for it to be drug related. Today it is recognised that just as traumas like war and rape can have long lasting effects, as can head injuries, so can the chemical effects of drugs and alcohol. Addiction medicine has further shown that while cognitive function may restore initially so that a person is no longer frankly delusional, the problems with emotional stability and social functioning may persist well past the three months that a direct organic consequence can be documented.
Genetic research suggests that there is a need for three different locations of genetic change to predispose for schizophrenia itself, (damage at only two sites may influence the overall outcome or course for instance) ,a psychosis inducing trigger and now the lack or innappropriate treatment and the persistence of the psychosis for a year or two. With this the old life long disease will likely follow however with new medications and treatments patients even with this are least likely to spend time in hospital and may function extremely well with continued psychiatric care preventing any deterioration.
In the end it's also important to remember that Freud, to paraphrase him, as he accepted the Nazi government for what it was, said, Sometimes the Paranoids are right.
That's even more true today given the changing perceptions of the fabric of reality, the economic crisis and the lack of faith in the truthfulness of government, a wide variety of competing sources of internet information, the continued predation of the mentally ill and the greater stigma attached to schizophrenia and psychosis itself in the overall stigmatization of mental illness in general.
There remains a controversy regarding diagnosis with a spread still existing between those who hip shoot diagnose too early with devastating nocebo effects and those who diagnose too late and act initially ineffectively. Fortunately, it's recognised that psychosis needs treatment and protection but most importantly protection. In time continued research and improved treatments will ensure fewer with psychosis progress to schizophrenia and that schizophrenics can hope that the course of the disease may no longer involve continued deterioration.
It may indeed prove that patients will heal better than society at large which often appears more fragmented, psychotic and schizophrenic by the day.
One interesting finding was that schizophrenics appeared to vote with identical distribution to the normal voting population. While the researcher argued this showed that only some aspects of judgement were affected in schizophrenia I noted that he'd made an equally strong case for the poor judgement of the general population in political elections.
All of us though who have the priviledge of working with the mentally ill, especially the schizophrenics and those with psychosis know these individuals as frightened and a far cry from the way they have too often been portrayed by the media. There is indeed a powerful link between the sensitivity of those with psychosis or those who go onto schizophrenia and those with genius or special gifts. Family studies consistently show that the two run together. That certainly has been my clinical experience.


leanne: Truth said...

I am a student and I have to write a term paper about Schizophrenia based on the fact that it is a controversial topic. In your writings I see that you explain the controversy concerning the treatment of this mental illness. I was wondering if you could enlighten me on exactly what you believe or what medical findings that you have researched point to as the proper treatment of diagnosis for this mental illness.

haykind said...

The controversy as I see it is mostly in the 'diagnosis'. Diagnosis is supposedly 'specific' and 'sensitive'. Sensitivity means that the diagnosis 'captures' that which it hopes to describe whereas 'specificity' means it excludes that which it is not.

The diagnosis is far too 'sensitive' and not nearly 'specific' enough. Too many PTSD and Drug and Alcohol conditions and Personality Disorders and Mood Disorders are being picked up by the diagnosis.

Further the way we treat a mentally ill person early may affect how he or she is seen or becomes later. Increasing research shows that this is very important in the diagnosis of schizophrenia. There are those who would 'diagnose early' and claim to be helping sz that way and those who would diagnose later and claim to be helping sz that way. The French were very different on this compared to the Americans.

In my career I have undiagnosed many schizophrenics mostly those who had a form of bipolar disorder or had PTSD and some who had head injury and many who had drug and alcohol abuse. I know many drug addicts who were wrongly diagnosed as schizophrenic becuase that's how they presented phenotypically whereas in fact the drugs obscured the diagnosis. The halls of AA and NA are made up of many people in successful recovery who were once diagnosed and treated as schizophrenics. Now we have dual diagnosis units aimed and preventing that.

My tendency and I believe most of my colleagues tendency is to use the safest most conservative treatments possible. The pharmaceutical companies are also making far better and safer medications than the days of the "Thorazine shuffle". There is also a movement to using the least medication necessary to help the patient return to a fulfilling life. In the past the 'chemical straightjacket' was often true but today this is much rarer though there clearly are those parental authoritarian military types that want everyone to march like them. Fortunately advocacy groups for the mentally ill keep these radical (by today's standard) sorts in check.

Enlightened modern day psychiatry treats schizophrenia with medication, supportive psychotherapies, and living and financial assistance according to the best standard of treatment of anyone with a severe disability. The problem with schizophrenia is that it so commonly interferes with a persons ability to be competitive in the world.

R.D. Laing's love for schizophrenic patiients was shown in his having them live in his home. His treatment ideas might be questioned today but his heart was clearly in the right place. L'Arche developed by Jean Vanier and friends has demonstrated very clearly that the profoundly mentally ill can be treated by community with amazing results. There is a tendency to use a full range of biopsychosocial approaches to an illness like schizophrenia as well as treating the family and community involved. Medication is view clearly as part of this process as it would be in say a severe seizure disorder. Yet while in some milder cases it's enough in most schizophrenia it's just a part of the overall approach to treating this illness. Friends of Schizophrenia and the Canadian Mental Health Association to obtain further information for research projects. In addition contact your university department of psychiatry and ask who is doing research or working most clinically with schizophrenia. In Vancouver Dr. Phillip Long was and probably still is the person who was most admired for his long term work as a clinician who took a special interest in schizophrenia. But really most psychiatrists who are working clinically do and the Mental Health Teams in inner city community health units are often doing the hardest work with the end stage illness where so much effort needs to be made to protect them from the predators that often dominate the areas where 'drift' so often takes schizophrenics.