romansland

Schizophrenia

Schizophrenia is a very complex disease or diseases. People who have schizophrenia have recurring episodes, psychoses, which are characterized by delusions, often paranoid or megalomanic, and hallucinations. Thoughts can be disorganized and a sufferer from psychosis has difficulty determining what is real and what is not. The disorder usually appears in the late teens, early twenties. People with schizophrenia suffer from symptoms such as hearing internal voices not heard by others, or believing that other people are reading their minds, controlling their thoughts, or plotting to harm them. These symptoms are often terrifying for them.

There are things I’ve learned about schizophrenia I find surprising and interesting. Schizophrenia is not at all a rare thing: it is estimated that 0.5-1% of all people suffer from it. In the figure on the right you see that the prevalence of schizophrenia is actually quite high compared to other well-known diseases such as alzheimer and multiple sclerosis. Yet many people don’t know what it is, or have misconceptions about it. This is surprising, and I wonder why that is. In my opinion, the reason may be that after two centuries of study, we still can’t give a satisfactory answer to the questions: What is schizophrenia? What causes it?

There is no clinical test that can prove somebody has schizophrenia, the diagnosis is based just on symptoms. Therefore, it is not even known if we are talking about one disease, or multiple diseases with overlapping symptoms. Some have suggested that people with schizophrenia just have a peculiar personality and different ideas about the world and reality, and some theorize that the diagnosis only shows a broken relation between the individual and society, not necessarily an inherently sick person. Though I think this cannot give a complete picture, we must keep an open mind about these things, which are part of so called anti-psychiatry. The situation is made more complex by the fact that delusional thoughts are by definition impossible to classify as such by the person who has them. There are many people who will disagree with their diagnosis, even outside of a psychotic crisis.

Also, after all so much time and research, we still have no full understanding of the causes. Some risk factors have been identified. The strongest is a genetic one, roughly 25% of cases have a direct relative with the same disease, or a similar one such as bipolar disorder. Problems in the development of a child may be influential, especially around birth. Later, stress and social exclusion are related to the development of schizophrenia, and a stressful event often precedes onset of the disease. Here, distinguishing between cause and effect becomes confusing, and it has proven difficult to answer some important questions:  Must a person have a physical vulnerability that can be triggered to develop the disease? Is it pre-destined, and will a stress event just advance the onset? Similary, there are very little reliable predictors for predicting the prognosis of a first-episode patient. A person may improve, but often the disease becomes chronic.

The fact that the nature of schizophrenia is difficult to comprehend, that a patient seems to be very “different” in many ways, and that it can cause such great distress, may make people prefer to classify it as a “remote” problem. This increases stigma, already a serious issue.

The psychological effects of psychosis are devastating. Fortunately there are strong drugs, called antipsychotic drugs, that have turned out to be effective for many. The first such drug was chlorpromazine, which was accidently discovered in the 1950’s and has since been described as the greatest breakthrough in psychiatric medicine. This and other drugs have very serious side-effects which makes it very difficult to stay on treatment for years. Newer drugs have been developed, in the mid 90’s we saw the arrival of the so called atypical antipsychotics. These were hailed as a terrific breakthrough by the big pharmaceutical companies, but now it turns out that they’re not a fantastic improvement upon the old ones. The market for these drugs is enormeous, but we don’t seem to be making much progress.

This is mostly due to the fact that we are still not sure how these drugs work. They all block dopamine-receptors in the brain, which accounts for their effectiveness, but there are confusing issues. The chemical effects of the drug takes place within minutes, but the strongest treatment effects are visible only after two weeks. Maybe they work by breaking some self-enforcing loop, slowly diminishing the psychotic effects. Maybe you can compare this to treating somebody who is angry by a sedative: this will in no way cure the patient, but diminish his symptoms. Indeed, indifference is a side-effect of many antipsychotics. Part of the problem of developing new drugs is that since we have no clinical test for schizophrenia, we don’t know exactly what we are trying to cure. Animal testing is an important part of any drug development, but in this case it is not even clear how to give animals schizophrenia, and how to measure whether they have been cured. Nevertheless there is an impressive amount of research going on. Some research points out that our current drugs do not improve the long-term prognosis. Prognosis in developing countries where these drugs are generally not available may in fact be better than in developed countries, though it is very difficult to draw conclusions from this. Psychic therapy is also an important part of an effective treatment.

The latest science comes from genetic research. Many methods have become available to study which genes are contributing to a vulnerability for schizophrenia, and what is their function. The newest results add to the already complex picture we have: there are many small defects in many places that all contribute a little bit. Though this may explain why schizophrenia has never been elimated by evolution, it means that finding a cure will still be a very challenging task.