Friday, March 25, 2011

Delusions of Progress: The Difficulty of Schizophrenia

An essay I wrote on Schizophrenia and the difficulty of diagnosis and treatment of the illness:

Schizophrenia is a devastating mental illness that affects about 1 percent of the world’s population, that’s 65 million people. The diagnosis of schizophrenia seems to be very direct: hallucinations, delusions, disorganized speech, grossly disorganized or catatonic behavior, and affectivity (emotional indifference, autistic withdrawal, and loss of drive and initiative). The diagnosis is not the disease though. Schizophrenia appears to be something far different from what we know and expect. It is an elusive and possibly false disease. That is not to say that there aren’t people that suffer from these symptoms, but that schizophrenia may be an umbrella statement for multiple diseases and conditions. Schizophrenia has become the poster child for many of the issues plaguing our modern sciences; instead of an objective and concerted approach to deciphering schizophrenia’s mystery, the psychiatric community finds itself fighting political agendas from the outside and within its own field. This politically charged misdiagnosis extends all the way into treatment and therapy of the individual. Beside the current issues, schizophrenia even suffers from revisionist history to a certain extent. These issues have culminated into our modern vision of schizophrenia as a controlled disease with progressive diagnosis and treatment filled with a history of powerful scientific efforts to find a cure in the near future. This is not the case. While people continue to be diagnosed with and suffer from this debilitating condition, doctors, politicians, and the American public continue to argue about how to deal with it.

At its heart is the issue of what schizophrenia is beyond the list of symptoms. Symptoms can be treated; symptoms can fade away and disappear. Symptoms are not the illness. Even after extensive study and massive amounts of energy poured into efforts to better understand the nature of schizophrenia, it still remains a mystery.

The reasons behind schizophrenia vary widely. Many doctors involved in the diagnosing process acknowledge that developing schizophrenia is a complex process. To cut through the double-speak and proposals, schizophrenia’s origin is unknown. The various proposals include environment, nature, nurture, genetics, viruses, bacteria, neurology, sociology, and any combination thereof. Each hypothesis has very impressive numbers to back up the claim. A recent Scientific American article asserted “that up to one fifth of all schizophrenia cases are caused by prenatal infections (Wenner, 1).” But then there is the strong genetic link. “There is evidence for up to 14 ‘risk’ genes (Heinrichs, 188)” that could be heavy contributing factors for schizophrenia, but even amongst identical twins there is still only a 48 percent chance of developing schizophrenia (Heinrichs, 186). Even beyond the genetic, environmental factors such as stress could be the trigger that forces schizophrenia to exhibit itself. The general consensus is that nature and nurture have an intertwined relationship that has each element playing off of the other. Someone with a genetic predisposition could, given the right environmental factors, eventually develop schizophrenia. There are a lot of conditional parts of that statement.

These conditional factors make predicting schizophrenia an extremely hard prospect, and scientists are constantly looking for a test that would make diagnosis straightforward. The nearest test that exists is a brainwave analysis relating to an auditory test. If a person is schizophrenic, they will have a certain brainwave pattern called P50. This test is not nearly as accurate as its proponents would want the public to believe. In fact, it is easily confounded by variables as mundane as smoking. Researchers continue to point to this test as evidence of schizophrenia’s imminent breakthrough cure even though the test is shaky and inconsistent.

The prospect of diagnosis on the basis of a test or a gene is just too exciting and doctors are eager to find the one root cause of schizophrenia, but the evidence available indicates that psychiatry is facing a far more complex dilemma. Schizophrenia may not be one illness. All the tests, all the diagnoses, and all of the work seem to indicate that schizophrenia is not a uniform disease. Based on the variety of people diagnosed with the illness—their non-uniformity as a group—schizophrenia is most likely several conditions or diseases where the symptoms are similar. This could explain the varying and unpredictable results of different treatments. If the origin is viral, therapy would have very little effect; it would be like curing the flu by talking it out. Therapy does work for some though, which indicates that some schizophrenics could be mentally damaged as opposed to infected virally, lending strong support for the multiple disease theory.

Further confounding the crisis of diagnosis is the definition of a schizophrenic. A schizophrenic does not even have to exhibit one symptom to be diagnosed with schizophrenia: “Although schizophrenia, like all diseases, is defined by its symptoms…no single symptom is obligatory…There is no uniform, invariant presenting symptom or set of symptoms for schizophrenia.(Heinrichs, 27)”. What? The DSM-IV-TR, aside from its flaws as a tool for diagnosis, is still a baseline for making any sort of assessment, but doctors don’t have to follow it at all. Schizophrenia, as well as any mental illness, can be a completely subjective diagnosis.

This is all a major reflection of the egotism that is involved in the process. As an example is an article by Nicholas Tarrier contained in the very thick Clinical Handbook of Psychological Disorders called “Schizophrenia and Other Psychotic Disorders” which outlines CBTp (Cognitive Behavioral Therapy ) as the predominant method of treatment for schizophrenics in preventing relapse. The editor, Barlow, touts Tarrier as “represent[ing] the front line of our therapeutic work with these severely disturbed patients (Barlow, 463).” Throughout this “promising” article the author references himself. That’s right, the author’s predominant source of studies or articles is himself, and for the ones that his name does not appear are colleagues that he works with in other articles that he references.

While, the benefits of CBTp are touted in the 2008 Clinical Handbook of Psychological Disorders the results tend to be statistically insignificant considering the correlation varies widely from -.32 to .99 over 16 studies. What does this tell us? It tells us that the correlation is not statistically uniform; it does not cluster itself around a mean of .4. Effectively, the benefits touted by the article can be nullified by the huge standard deviation of .32. in simpler terms, the numbers represent a correlation between the two variables, usage of CBTp and effective treatment of schizophrenia on a sliding scale of -1 (a negative correlation) to 1 (a positive correlation). The closer to zero the two variables are, the less related they are. The mean represents a 40 percent correlation between the two variables, which sounds good. The problem is that because the 16 studies are so inconsistent in their correlations, a 40 percent correlation is misleading. The median of the 16 studies is probably more representative of the actual correlation because it is more resistant to outlying studies. The median takes the most common result as its measure. The number is even lower, it is .33, 33 percent of the variation in the recovery of schizophrenic patients can be correlated to the use of CBTp. The .33 is higher than zero, but is it statistically significant? Let’s take a look at the range of the results of the studies. One study found the correlation to be as low as -.32, meaning that CBTp actually had a negative effect on patients in at least one study. Furthermore, a look at the standard deviation (.32) reveals that the studies encompass over a third of the possible outcomes on the scale of correlation. The standard deviation is so large that it renders the median statistically insignificant. Half of the studies are contained in close to half of the scale’s range, rendering the numbers useless. The article does start to acknowledge these setbacks: “Evidence that CBTp speeds recovery in acutely ill patients to the level of achieving a significant clinical benefit is more equivocal [to other treatments] (Tarrier, 465).” But then the author reneges on this point: “There are promising…results that full psychosis can be prevented in vulnerable individuals (Tarrier, 465).”

This article is just a mild reflection of the group think that occurs in the field. The Clinical Handbook of Psychological Disorders is supposed to be a Step by Step Treatment Manual as its sub-heading states. The inside covers even state that this book is a “widely adopted text and clinical resource” that “provides state-of-the-science guidelines.”

The psychiatric community is suffering from a vicious cycle; long the runt of the scientific community, psychiatry has been struggling since the 1950s to be seen as valid by the public. This fight for legitimacy has put the whole field on the defensive. Every study that comes from the psychiatric community has to reaffirm the importance of the field in its results. There isn’t some great conspiracy, but, rather, it is because psychiatry has lost its vision as Sheldon Gelman states in her critique Medicating Schizophrenia. Psychiatry wants to be on the cutting edge. Psychiatry wants to progress and make progress.

What is progress though? How can it be defined in such an elusive disease? Even Gelman acknowledges that there are several periods of “progress” in psychiatric medicine and therapy. This means that there has to have been at least some progress over the years. According to Gelman “better results equal psychiatric progress; dramatically better results, revolutionary psychiatric progress (Gelman, 13).” This seems like a very agreeable definition, but Gelman continues on:
Assessments of therapeutic outcome often provoke hopeless, apparently irreconcilable disagreement. The effectiveness of nineteenth-century moral treatment (humane care in an intensely regulated setting) remains sharply disputed; lobotomy garnered powerful endorsements, including the Nobel Prize, as well as opprobrium; some distinguished psychiatrists of the 1950s regarded insulin coma as better than medication. (Gelman, 13).

Obviously, progress is not clear cut. In this instance, we’ll stick to Gelman’s initial definition of progress to see if methods are progressing or just changing. Even the terminology used in psychiatry disguises the fact that modern treatment has advanced very little. Jesse F. Casey performed two studies of Thorazine in the 1960s. Casey found that it was effective in minimizing symptoms of schizophrenia “yet his write-up of the results differed in notable ways (Gelman, 51).” Chief among the differences was a language change. In the first study chlorpromazine (Thorazine) was referred to as “tranquilizing agents” whereas the second consistently referred to the same drugs as “phenothiazines.” According to Gelman, “the idea of medications as tranquilizers was…falling out of favor (Gelman, 51).” Psychiatry was willing to change terminology because the field was afraid of failure. But it did fail. Psychiatry, under intense scrutiny, became consumed with the idea of progress. Psychiatry has repeatedly failed in the past or “overreached (Gelman, 12)”. For psychiatry, progress “imparts a sense of momentum,” and “this puts the often mixed outcomes of using medication in a better light (Gelman, 12)”. Eventually, this dedication to progress became an obsession. Gelman likens it to a religion; the psychiatric community, without adequate scientific basis for their work, according to critics, continued looking for answers and ways to progress without having a clear vision of the future. Psychiatry eventually behaved as if past studies proved the hypothesis of the 80s and 90s. The reality of the situation was that there was very little research into psychotropic medications and their side effects during the 60s, 70s, 80s, and early 90s. In the 1960s and 1970s, medication of patients was seen as a universal solution. By 1986, schizophrenics were still being diagnosed at the same rate as well as being medicated with the same or similar drugs. All of this despite the fact that leading researchers in the field, George Gardos and Jonathan Cole, wrote: “The recognition of tardive dyskinesia …and the realization that the drugs are far from curative and often fall short of producing satisfactory symptom relief (Gelman, 179).”

The current methods of treatment are relatively similar to the ones in the past. The changes in treatment are less one of evolution and more one of diversification. In the 1950s and 1960s the main medication was Thorazine. Eventually, the available medications multiplied into a whole family of phenothiazines. All of these medications have severe side-effects, but for the psychiatric community “alarming findings were not refuted; rather, the entire matter was largely ignored (Gelman, 183)”. Finally, in the first half of the 1990s, several studies came out and declared tardive dyskinesia a severe problem, but even these undermined the dramatically damaging effects of the condition. As newer research came out, it appeared that change could happen: research into atypical medicines began, tardive dyskinesia was given a more thorough look, and psychiatry began to step outside of its shell. Sadly, the “progress” has slowed down again; after a burst of creativity on the matter, psychiatry found a new equilibrium, and that continues today; tardive dyskinesia is seen as a side effect, but not serious enough for doctors to cease treatment, even though it can be potentially lifelong and debilitating.

Gelman notes that the field of psychiatry is perpetually trying to prove its validity and its place in the public eye. Psychiatry is a puppy looking for attention and affirmation. As such, it is unwilling to admit its mistakes. Schizophrenia is probably one of psychiatry’s largest shortcomings, and so it quietly ignores the spotty treatment record and moves forward cautiously. Schizophrenia is an enigma; treatment is a difficult proposition. It is therefore easy to see how group think has perpetuated itself in the field. If a new treatment has a fractional bit of success, it is easy to jump on board. Schizophrenia’s elusive cure has been frustrating the medical community since the 1950s, when anti-psychotics first came into use.

Medicine isn’t just to blame. Psychiatry has withdrawn into itself because damaging findings would take away from the prestige of the field. The progression of treatment from revolutionary new drugs and therapies to the stagnant atmosphere of today is because we (observers of the field) feel that the journey is done, but as Heinrich’s last chapter states, it is just “the beginning of the end.”

The idea that therapy combined with powerful drugs in this age of science can adequately treat our mentally ill is a sad reflection on the unreal expectations pressed upon a field that already feels the pressure of previous failures. Unless there is a concerted effort on the part of all parties to openly acknowledge the unknown and embrace the necessity of change, the field will continue to stagnate, and schizophrenics will continue to suffer.

Stephen Hawking said, "The greatest enemy of knowledge is not ignorance; it is the illusion of knowledge.” That’s where psychiatry is now on the issue of Schizophrenia: Schizophrenia is supposed to be a definite illness, Schizophrenia is supposed to be easily manageable, and Schizophrenia is supposed to be closer to a cure. But that is not the status quo; schizophrenia’s true nature needs to be analyzed; it needs to be re-examined carefully. If schizophrenia is multiple diseases, syndromes, or conditions then it needs to be divided out into its corresponding elements and treated individually. The human body is still an enigma, especially the brain and its corresponding illnesses. The uncertainty within the “modern age” must be acknowledged. Psychiatry needs to be allowed to make mistakes; it needs to get back to its scientific roots and explore the possibilities. These elements combined will allow schizophrenia to stop being the elephant in the psychiatric room. Progress will not be a goal or a catchphrase, it will be a real and powerful force that opens up new avenues for diagnosis, treatment, and possibly a cure.

Bibliography

Gelman, Sheldon. Medicating Schizophrenia. New Brunswick: Rutgers University Press, 1999.

Heinrichs, R. Walter. In Search of Madness. New York: Oxford University Press, 2001.

Tarrier, Nicholas. “Schizophrenia and Other Psychotic Disorders.” Clinical Handbook of Psychological Disorders. Ed. Barlow, David H. New York: Guilford Press. Fourth ed. 2008.

Wenner, Melinda. “Infected with Insanity: Could Microbes Cause Mental Illness?” Reprinted from Scientific American 17 April 2008.