‘Intruders’ in the Brain!!

In a book titled, Surviving Schizophrenia: A Manual for Families, Patients and Providers, Dr. Edwin. Fuller Torrey, M.D., expertly highlights the confusion and misinformation about Schizophrenia in the following excerpt:

“Your daughter has schizophrenia,” I told the woman. “Oh, my God, anything but that,” she replied. “Why couldn’t she have leukemia or some other disease instead?” “But if she had leukemia she might die,” I pointed out. “Schizophrenia is a much more treatable disease.” The woman looked sadly at me, then down at the floor. She spoke softly. “I would still prefer that my daughter had leukemia.”

Though this paragraph was first published along with his book in 1983 and we have made significant strides in treatment procedures, and minimizing stigma to some extent, there still remains negative connotations, stereotypes, and a lack in knowledge and therefore empathy with respect to this disorder. In this piece, I will seek to better characterize schizophrenia by playing a detective whose armed with a flashlight and sets of to search for these ‘intruders’ in the brain.

What is Schizophrenia and what causes it?

• Well, it is a common and chronic psychiatric disorder that is major cause of disability globally and that distorts cognitive function with respect to physical behavior, expression of emotions, relation to others, and one’s perception of reality.
• Schizophrenia is a complex and multi-factorial disease, however recent research has implicated disruptions in the signaling of several pathways in the etiology of this disease, one of  which includes the Wnt pathway. Here the activity of one of the pathway’s components, glycogen synthase kinase 3 (GSK3), is increased resulting in lower levels of β-catenin and consequently, inhibition of  transcription factor (TCF/LEF) mediated transcription.
• Some genetic risk factors such as Copy Number Variations (CNVs) and single genes such as DISC 1 have been associated with Schiz0phrenia, and research data supports the notion that they do through impacting β-catenin- TCF/LEF mediated transcription and/or impacting brain size in the case of CNVs.

Who gets Schizophrenia and what is its prevalence?

• Schizophrenia is most likely to first arise in early adulthood, although rare cases of children and older adults have been recorded.
• Its rate of diagnosis increases in the teen years, with the risk heightening between 16 and 25 years. Patterns of susceptibility differ by gender, with men experiencing a heightened risk of diagnosis between 18 and 25 years and females between 25 and 30, as well as around 40 years of age.
• Globally, about 1% of the world’s population are living with Schizophrenia  (70 million) and about 3.2 million Americans are living with this disorder today, of which about 100,000 more will be diagnosed with it in the United States this year alone.
• Approximately 200,000 individuals with schizophrenia or manic-depressive illness are homeless, constituting one-third of the approximately 600,000 homeless population (as per the Department of Health and Human Services). In other words, the 200,000 individuals mentioned above rival more than the entire population of many U.S. cities, such as Hartford, Orlando, Winston Salem, Ann Arbor, and Topeka.
•  Approximately 90,000 individuals with schizophrenia or manic-depressive illness are in hospitals receiving treatment for their disease, as per data obtained from the Treatment Advocacy Center

What are the symptoms?

• Symptoms of Schizophrenia can be grouped into three categories: positive, negative, and cognitive symptoms.
• Positive symptoms amplify otherwise normal behavior e.g. delusions (strange beliefs not based in reality), hallucinations (perceiving sensations that aren’t real), and catatonia (being physically fixed in a single position for a very long time).
• Negative symptoms reflect an absence of normal behavior e.g. exhibiting a lack or limited range of emotion, withdrawal from social interaction, lack of motivation, poor hygiene, and loss of pleasure or interest in life.
• Cognitive symptoms include poor executive function, trouble focusing, and trouble with working memory.

In Fuller’s book mentioned above, a Schizophrenic patient describes his symptoms saying,

“For about almost seven years—except during sleep. I have never had a single moment in which I did not hear voices. They accompany me to every place and at all times; they continue to sound even when I am in conversation with other people, they persist undeterred even when I concentrate on other things, for instance read a book or newspaper, play the piano, etc.; only when I am talking aloud to other people or to myself are they of course drowned by the stronger sound of the spoken word and therefore inaudible to me.” (p. 34)

How is it diagnosed?

• Schizophrenia is diagnosed by Psychiatric and psychological sub-specialists who evaluate the patient in question using specially designed interviews and assessment tools.
• The evaluation is based on the patient’s family history of  mental illness symptoms and the specialists observation of the patient’s attitude and behavior.
• For a confirmed diagnosis of schizophrenia the patients must display characteristic symptoms that last for at least six months.

How is it treated?

• The most common type of medications for it are anti-psychotics, which not only treat acute psychosis but also reduce the risk of future psychotic episodes.
• The treatment of Schizophrenia thus has two main phases: an acute phase that is characterized by high doses to mitigate positive symptoms, followed by a maintenance phase, which is life-long and during which doses are reduced to the minimum necessary to prevent further episodes and control inter-episode symptoms.
• Antipsychotics used in Schizophrenia can be classified into two subtypes: 1st Generation, and 2nd Generation antipsychotics.
• 1st Generation (conventional or typical) antipsychotics, are strong D2 (Dopamine receptor) antagonists. However, the effects of the drugs in this class on other receptors such as serotonin type 2 (5-HT2), alpha 1, histaminic, and muscarinic receptors are variable. These drugs have a high rate of extrapyramidal side effects such as rigidity, tremors, and Tardive dyskinesia (TD)- involuntary movements in the face and extremities.
• 2nd Generation (novel or atypical) antipsychotics, with the exception of aripiprazole, are also dopamine D2 antagonists, but are associated with lower rates of extrapyramidal adverse effects than the 1st Generation ones. However, the have higher rates of metabolic side effects such as weight gain.
• Other methods of treatment include: Psychosocial therapy (e.g. Rehabilitation and cognitive remediation), Electroconvulsive therapy, and Psychosurgery (e.g. Deep Brain Stimulation surgery)

So what now?

Schizophrenia has been dubbed the most chronic, debilitating and costly mental illness, which in the U.S. presently consumes about $63 billion a year for direct treatment, societal and family costs. Richard Wyatt, M.D., chief of neuropsychiatry at the National Institutes of Mental Health, has said that nearly 30 percent ($19 billion) of schizophrenia’s cost involves direct treatment and the rest is absorbed by other factors (e.g. absences from work for patients and care givers). It is necessary to invest public and private funds into research for the development of more effective treatments that minimize side effects, and it is imperative that we continue to combat the fear and stigma that surrounds this disorder. It is my firm belief that pursing both of the latter in concert would reduce the need and dependency on costly long-term psychiatric institutions, opting for family and community settings that encourage Schizophrenic patients to consistently take their medications and thus, better manage their symptoms.
In case you were wondering who the other intruder in the brain was, a Schizophrenic patient describes his in Fuller’s book saying,

“My greatest fear is this brain of mine….The worst thing imaginable is to be terrified of one’s own mind, the very matter that controls all that we are and all that we do and feel.” (p. 2)

We have a two pronged enemy in this disorder, the disease itself and fear. While our medications may partly manage to reign in this disease, our will can totally crush the fear and negativity that surrounds it. Join me in fighting these intruders which ever way you can!