Some Facts About Schizophrenia
What we call ‘Schizophrenia’, implying a unitary illness is in fact, a syndrome that may include many different types of illnesses with common presenting symptoms, Ali Madeeh explains.
Schizophrenia In History
Today, of all the illnesses that I treat, nothing depresses me more than schizophrenia. My despondency about the outcome of this dreaded disease is shared by a vast majority of mental health professionals who recognise that a diagnosis of ‘schizophrenia’ is akin to condemning a person to a life of disability and hopelessness.
German psychiatrist Emil Kraepelin (1856-1926), considered one of the gurus of early psychiatry, developed one of the first scientific classifications of mental illness and called the illness ‘Dementia Praecox’. “Kraepelin viewed dementia praecox as a progressively deteriorating disease from which no one recovered.
However, by 1913, and more explicitly by 1920, Kraepelin admitted that while there may be a residual cognitive defect (defect in thinking), in most cases, the prognosis was not as uniformly dire as he had stated in the 1890s. Still, he regarded it as a specific disease concept that implied incurable, inexplicable madness.” (from the Wikipedia entry on ‘Dementia Praecox’).
Nothing in the intervening one hundred years has encouraged us to become more hopeful. In fact, despite 60 plus years of the availability of psychiatric medicines, the prognosis of schizophrenia remains as dire as ever, with few recovering completely from it.
Most patients can be managed by medicines but they lose all potential to study, work or live their lives in meaningful ways. There are individual cases here and there where recovery may happen but they are few and far between. Interestingly, one historical case of psychosis is that of our very own Mir Taqi Mir, the ‘god of poetry’ (‘Khuda-e Sukhan’) which I wrote about in this essay https://desiwriterslounge.net/articles/dreams-are-wiser-than-men/ .
While one cannot say with certainty that Mir suffered an episode of schizophrenia, he certainly did have psychosis, the classic ‘break from reality’ with hallucinations, delusions and odd behaviour. However, he recovered completely and went on to live a long, full, productive life.
In more recent times, American Law and Psychology professor Elyn Saks wrote about her life long struggle with schizophrenia in her bestselling book ‘The Center Cannot Hold: My Journey Through Madness’. In her poignant, inspiring account, one can see how the illness evolves over time and never really leaves the person it inflicts.
What Is Schizophrenia?
A young girl was brought to the hospital to see me. She has been a top student and recently graduated from an elite public engineering university in Lahore. Beginning in about her fourth year of University, she began to have anxiety, sleeplessness and depression followed shortly by psychosis. The illness has waxed and waned but has never really left her. I treated her for a few months but she did not respond well to medicines and eventually dropped out of treatment. Yet again, schizophrenia has claimed another brilliant young mind.
It is now a well-recognised fact that what we call ‘Schizophrenia’, implying a unitary illness is in fact, a syndrome that may include many different types of illnesses with common presenting symptoms. There are certain features that appear to be common to this disorder: the typical onset is in a person’s late teens or early twenties, often when they are in high school or have just started college. This has significant implications for patients later in life as they are often unable to complete their education and thus cannot have a meaningful occupational or vocational life.
The illness usually begins with vague symptoms which may be mistaken for other things like aches and pains, sleep problems, mild anxiety, social withdrawal or academic problems, all of which are common enough in teenage and may be overlooked. Once the full-blown illness hits, it becomes clear that something is very wrong.
A person in the throes of an acute attack of schizophrenia begins to have disabling anxiety which quickly progresses to full blown paranoia and later to delusions (false fixed beliefs that are unshakeable and have no basis in reality) and hallucinations (perceptions of various stimuli in the absence of any actual stimulus-in lay language often referred to as ‘hearing voices and seeing things’ although they can occur in any sense modality (odd smells, tastes, touches/feelings etc).
A typical delusion in schizophrenia is often called a ‘paranoid delusion’ or ‘delusion of persecution’ which is just what it sounds like. Like the patient I alluded to earlier, patients suffering from the illness feel people are watching them, talking about them, pointing or laughing at them, plotting against them, planning to kill them etc. In latter stages, patients actually start hearing people talking about them or to them (when no one is actually there).
Men appear to be afflicted at about the same rate as women, unlike some other mental illnesses which show a gender bias (depression, for instance, appears to occur more often in women all over the world).
The first full blown episode of madness appears to be sensitive to medication resulting in significant or even complete relief. Often though, this is temporary with the illness flaring up again some months or a year or two later, often with greater intensity and this time with only partial improvement with medications.
The illness episodes continue to recur until they begin to meld into one another with no real periods of recovery in between, even with medication treatment. Eventually, we reach the dreaded stage of ‘chronic’ or long-standing psychosis with the person completely debilitated by the illness. Even if a person has a good response to prescribed medicines, symptoms that do not respond to medicine, called ‘residual’ (or remaining) symptoms, can be quite disabling.
Medicine can knock down the worst symptoms of schizophrenia including delusions, hallucinations, paranoia, agitation and aggression, but once these subside with the help of medicines, what remains is a person who is a shell of their former self. Generally unmotivated and often too apathetic to even care for their own hygiene, sleeping most hours of the day and sitting aimlessly while awake with no motivation to plan, work, study or do anything productive.
Worse, a person with these ‘negative’ symptoms of schizophrenia often cannot even be made aware that anything is wrong. A light has gone out in their brain taking the spark of life out of them and our modern science has yet to figure out how to re-light the spark.
Science has also shown conclusively that if a person remains in this vegetative state for more than a few months, permanent changes in the brain make it impossible for them to recover completely. The brain literally dissolves away. If one does a CT scan or an MRI of the brain of a person with long-standing schizophrenia, one can see that brain is shrunk and misshapen with large areas missing or distorted beyond recognition.
(To Be Continued)
The writer is a psychiatrist practicing in Lahore. He taught and practiced Psychiatry in the United States for 16 years. He tweets @Ali_Madeeh