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by Michael Foster Green
W.W. Norton, 2002
Review by Jack R. Anderson, M.D. on Jan 29th 2003

Schizophrenia Revealed

I

As a curve approaches closer and closer to its mathematical asymptote but never quite reaches it, so the human mind has approached complete understanding of itself and its illnesses over the centuries and millennia of recorded time, and this philosophical asymptote will in all probability also remain forever just beyond our grasp. However, when you read this book I think you will agree that Professor Green has advanced our knowledge of the mental illness we call “schizophrenia” to a point closer to complete understanding than we have ever been before.

As I began reading, I wondered how and where the author had developed the communication skills that make his book such a pleasure to read and so easy to understand. Then when I glanced through the extensive bibliography I learned that since 1986 he has written 15 articles and two books, including this one, all about schizophrenia—some by himself and some in collaboration with other authors. His fluency is an encouraging example of the old saw “Practice makes perfect.”

II

 I didn’t agree with everything in the book. For example, Dr.Green doesn’t believe hydrotherapy was an effective treatment for schizophrenia. Back in 1939 when I was helping wrap disturbed patients in wet sheets and immerse them in continuous tubs, I thought the treatments were therapeutic. The patients became less agitated and their hallucinations and delusions abated noticeably. I have to admit that his opinion, based on a perspective of sixty-some years after the fact, has more claim to validity than mine, which was formed during the heat of battle so to speak—for a vigorous struggle was often required to physically control patients during the administration of wet sheet packs and continuous tub treatment.

I also thought that ECT and insulin coma were effective therapies for schizophrenia, but again I concede the unreliability of my opinions, which are not based on any sort of scientific rigor as are Professor Green’s. As he correctly points out in the book, the course of schizophrenia is so variable and unpredictable that no matter what is done to schizophrenic patients, some of them will improve immediately after the “treatment,” thus encouraging the kind of faulty reasoning called “post hoc, ergo propter hoc.”

III

The title,” Schizophrenia revealed” and the sub-title, “ From Neurons to Social Interaction,” make implicit promises to the reader—promises that the author faithfully keeps. He organizes his arguments around three key concepts: “neural connections,” “neurocognitive deficits,” and “functional impairment.”

He discusses the contributions of neuroimaging techniques such as MRI’s and PET scans to the understanding of neurodevelopmental factors that result in neurocognitive deficits. For example, studies have shown that a virus such as influenza can disrupt neurodevelopment of the fetus during the second trimester of pregnancy—the trimester when neurons produced in the inner layer of brain are transported outward to their final destination. Because some neurons do not arrive at their intended addresses, interneuronal communication is disrupted. From this neural disconnection syndrome, neurocognitive deficits develop.

Schizophrenogenic cognitive deficits include difficulties with executive functions such as planning, problem solving and alternating between two or more tasks; immediate and long-term memory; and social cognition—the ability to perceive what other people are thinking and feeling. These and similar neurocognitive deficits cause confusion and  misunderstandings and often result in functional impairment.

IV

In the chapter “Interventions for Schizophrenia,” Dr. Green explains that first generation anti-psychotic drugs, like chlorpromazine and haloperidol, reduced delusions and hallucinations but did little or nothing for neurocognitive deficits, so that patients, although no longer psychotic, were still functionally impaired to the point of being disabled. Newer antipsychotics—clozapine, risperidone, olanzapine, quetiapine and ziprasidone—to the contrary—show promise for improving verbal fluency, immediate memory and secondary verbal memory. (Another new antipsychotic medication, aripiprazole, which was introduced after this book was published, also promises to reverse some of the neurocognitive deficits.)

In addition to pharmacological interventions, this chapter discusses the possibility of training patients to develop better neurocognition, a treatment called “cognitive rehabilitation.” Assertive community training, “ACT, “ social skills training and family context interventions are also recommended as adjunctive therapies to maximize the number of patients who can resume community functioning.

V

The chapter “The Genetics of Schizophrenia” clears up a lot of misconceptions about its heritability. I can remember arguments in some of my pre-med classes in the mid-thirties about whether the schizophrenia gene was dominant or recessive. Now,  the chapter informs us,  most researchers believe that not one single gene, but rather the  interaction of a large number of genes, is involved in the transmission of the illness across generations.

Family studies verify the idea that mental illness is a family affair. 12 percent of the children of schizophrenic individuals develop the disease as compared with only 1 percent of the general population. Twin studies reveal that if one monozygotic twin has schizophrenia, the odds are about even that the other twin will too. With dizygotic twins the concordance rate is only 17 percent. Obviously, if only genetic factors were involved in the development of schizophrenia, then the concordance rate for monozygotic twins, who have identical genotypes, would be 100 percent.

One adoption study compared rates of schizophrenia in adoptees from non-schizophrenic mothers raised in families where one of the adoptive parents developed schizophrenia, with rates of similar adoptees raised in families without psychiatric problems. As the study found no difference in the rates of schizophrenic symptoms in these two groups of children, they concluded that, although schizophrenia runs in families,  “we do not ‘catch’ it just by living with our parents.”

Another adoption study, carried out in Northern Finland, compared rates of two groups of adoptees born of schizophrenic mothers, one group raised in healthy family environments and the other in families rated as “disturbed.” They found that the adoptees raised in healthy families, despite their mothers’ schizophrenia, had no higher rates of psychosis and other mental illness than a comparison group of adoptees born of non-psychotic mothers. To the contrary, those raised in disturbed families did have higher rates. The author concludes that what is inherited is not schizophrenia, but a disposition for schizophrenia and that many nongenetic factors are needed to produce a phenotype that qualifies for the schizophrenic diagnosis.

VI

Schizophrenic patients, their relatives and friends would benefit greatly from reading this highly informative and skillfully written book; Professor Green’s optimism is infectious and perhaps the high rate of suicide among patients would be ameliorated. Mental health professionals would do well to study it to better understand the persistence of disabling neurocognitive deficits after pharmacological treatments have relieved the psychotic, negative and disorganized symptomatology, and to realize the necessity for ongoing community based treatment and training programs.

“Schizophrenia Revealed” should be required reading for the powers that be who construct the invaluable Diagnostic and Statistic Manual of the American Psychiatric Association. The diagnostic criteria for schizophrenia might be more selective if they included Professor Green’s insight that schizophrenic patients are genetically vulnerable individuals who suffer disrupted neural connections during neurodevelopmental processes, which lead to disabling neurocognitive deficits and, with other developmental stresses, to the “Class A symptoms” listed in DSM-IV-TR. Such inclusion might reduce the number of patients who, over a period of a few years, are variously diagnosed as schizophrenia, schizoaffective disorder, bipolar disorder and schizotypal personality disorder.

The author is right—the book does an excellent job of demystifying schizophrenia. It is hoped that, as neuroimaging techniques are sharpened, disruptions of neural circuits can be identified more accurately and earlier. Then timely interventions may prevent or ameliorate neurocognitive deficits and minimize the occurrence of psychotic, negative and disorganized symptom complexes. Newer medications will focus more on socially and vocationally disabling behavior caused by the neurocognitive deficits.

The costs of schizophrenia—personal distress, family disruption, and the financial burdens of treatment expense and lost productivity—can be dramatically reduced by acting on the insights contained in this book. I think we all, schizophrenics and non-schizophrenics alike, owe Professor Green a vote of thanks.

 

© 2003 Jack R. Anderson

 

Jack R. Anderson, M.D. is a retired psychiatrist living in Lincoln, Nebraska.