How to Understand Schizophrenia


By Mary Carpenter

POSSIBLY the most remarkable thing about [Robert Oppenheimer’s] adolescence was the diagnosis he was given to explain his dark character: dementia praecox, i.e. schizophrenia,” according to El Pais. “He was always enormously generous as well as petty and arrogant; puny, in poor health and aggressive to the point of two attempted murders…”

After seeing the movie “Oppenheimer,” Minnesota-based neuroscientist N.A. asked several friends to explain schizophrenia. He also sought further clarification by reading three books: The Center Cannot Hold by Elyn Saks, Hidden Valley Road by Robert Kolker and The Best Minds by Jonathan Rosen. N.A.’s conclusion: “I’m no further ahead in understanding the definition or classification of schizophrenia… but I now have examples and anecdotes.”

Examples and anecdotes are, in fact, the only way to explain schizophrenia—with infinite variations among individual sufferers. The disease usually begins with a psychotic break from reality that involves disordered thinking, such as delusions, auditory and visual hallucinations and paranoia. Even within one family, the six schizophrenic brothers in Hidden Valley Road have very different symptoms, treatments and outcomes—with each illuminating different aspects of this complicated and poorly understood disease.

For Elyn Saks in The Center Cannot Hold, and for Rosen’s close friend since childhood, Michael Lauder, in The Best Minds, their symptoms become increasingly disabling when both attend Yale Law School. Despite receiving surprisingly impressive, ongoing support from faculty and administrators, the two go on to have very different experiences with the disease.

Complicating the diagnosis and treatment of schizophrenia are delusions—notably anosognosia. Defined as “lack of insight,” the symptom “impairs the person’s ability to be aware they have an illness and explains why those with the disorder refuse medications or don’t seek treatment,” according to Colorado’s Gazette. “About 30 percent of people with schizophrenia…might show up at the ER and present as a homeless person who’s using drugs or alcohol”—and their release has led to death.

Another delusion, Capgras syndrome, creates the belief that friends and family look familiar but are actually imposters. As Oliver Sacks wrote in a 2012 New Yorker article, “An elderly woman got out of the taxi, and, galvanized into action, I ran toward her, shouting, “I know who you are—you are a replica of Augusta Bonnard! You look like her, you have her posture and movements, but you are not her… the logical though absurd conclusion that she was a ‘duplicate.’”

Sacks’s delusions emerged, however, not from disease but after extensive use of psychedelic drugs—demonstrating similarities but also vast differences in these experiences. As Sacks writes about his hallucinations: “My attention was caught by a spider on the kitchen wall. As I drew nearer to look at it, the spider called out, “Hello!” It did not seem at all strange to me that a spider should say hello… I said, “Hello, yourself,” and with this we started a conversation, mostly on rather technical matters of analytic philosophy.”

Also true of mind-altering drugs—as with schizophrenia—“anecdotal accounts are provided to give a better understanding,” according to Philadelphia osteopath Ashley Przywitowski. “Because hallucinogens and schizophrenia act on similar neurotransmitters and areas of the brain, the study of hallucinogens can allow for more insight into the cause of schizophrenia and allow for more effective treatment.”

But crucial differences make the “overall positive” mind alterations induced by hallucinogens unlike the debilitating experiences of schizophrenia. In the latter, paranoid delusions are the most frequent abnormalities of thought, along with confused thinking and an “overall depressed mood with a decline in functioning” —all of which can be frightening and lead to dangerous behavior —compared with “feelings of love and euphoria” of the psychedelic experience.

Another connection: Taking psychedelic drugs has led to episodes and eventually to a diagnosis of schizophrenia for about 20% of individuals, who may have had prior susceptibility to the disease, based on variables such as genetics and childhood trauma.   Alternatively, explains The Best Minds author Rosen, about 25% of people diagnosed with schizophrenia recover completely in the first two years “because their correct diagnosis was short-term psychosis, which mimics schizophrenia.”

Along with such reports of recovery comes the most common question about schizophrenia: whether someone with this diagnosis can get better. Among the three books’ sufferers, only Elyn Saks ended up leading a fairly typical life —though in N.A.’s words “as a functional person, but not cured or in remission [who] manages with medication and psychotherapy, and a lot of both.”

As with schizophrenia, Rosen points out about antipsychotic medications used to treat it: no one knows exactly how they work and their effects “could differ wildly from person to person.” Since the early 1950s when the drug chlorpromazine (Thorazine) first showed positive effects, psychological vs. biological approaches to treatment have gone back and forth, according to a review article by Orlando and Boston psychiatrist Mark Ruffalo, with “renewed interest in psychotherapy for schizophrenia among some clinicians and researchers in the past two decades.”

The first psychotic break—mental detachment from reality—often predicts increasing disability for sufferers, a prognosis not much better than that portrayed more than 40 years ago in Susan Sheehan’s 1981 New Yorker series, “The Patient.”  But now, as a caption in last week’s Washington Post article on the summer’s record-breaking temperatures notes: “schizophrenia may be the most dangerous preexisting condition in a rapidly warming world.”

For Robert Oppenheimer, most people dismiss the schizophrenia diagnosis—along with tales of his attempted murders.  According to one view, when the physicist Max Born directed Oppenheimer toward theoretical physics—away from the mathematical and lab-based physics he had been struggling to perform well—that helped Oppenheimer focus his energy and led to his success, after which there was no cause for debilitating psychiatric diagnoses.

All three books fascinated me by weaving emotionally moving tales of sufferers into the history of research and dramatically changing views about schizophrenia. But what I most appreciated was the eloquent portrayals of the variability of the disease and experiences for these patients.

—Mary Carpenter regularly reports on topical subjects in health and medicine.



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