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The Schizophrenia Source
Winter 2003
The NSF launches consumer brochure series
Schizophrenia: The State of the Illness in Year 2003
Study identifies 10 key factors to recovery from schizophrenia
The NSF launches consumer brochure series
Have you ever picked up a brochure on schizophrenia and found it difficult
to read because it was too technical? Have you ever wondered what that brochure
would look like if it were written by a consumer?
The National Schizophrenia Foundation (NSF) has been working with a group of
consumers to write a literature series, entitled “For Persons in Recovery, By
Persons in Recovery.”
The first three brochures in the five-document series will be available in
early 2003. The remainder will be produced shortly thereafter.
The purpose of this series is to address the issues and concerns of people
affected by schizophrenia. Topics will include how to talk with your doctor;
coping with schizophrenia; and symptoms and treatments of schizophrenia.
“While there’s a lot of literature already out there,” said Toni S., Project
Coordinator, “these issues are not necessarily addressed in current literature
from a consumer perspective.”
For more information on the “For Persons in Recovery, By Persons in Recovery”
series, contact the NSF at (517) 485-7168.
Schizophrenia: The State of the Illness in Year 2003
An interview with Rajiv Tandon, M.D. By John P.
What is the current knowledge on the nature and treatment of schizophrenia?
To answer this question, we interviewed Dr. Rajiv Tandon, a Psychiatrist and
Professor of Psychiatry at the University of Michigan. Dr. Tandon is one of
the foremost experts on schizophrenia, an author of over 150 scientific publications
and a recipient of several awards related to schizophrenia research, including
such recognitions from the American Psychiatric Association and National Alliance
for Research on Schizophrenia and Depression (NARSAD).
“In the last five years,” said Tandon, “scientific research has led to advances
in the understanding of schizophrenia and has raised the prospects for much
better medical treatments for the illness. At the same time, we see a greater
need for the social treatments for schizophrenia.”
The genetic component is high as a cause for schizophrenia, according to Tandon.
It appears that 70 to 80 percent of the risk factor for schizophrenia can be
attributed to genetic variables. Genes currently linked to schizophrenia can
be attributed to genetic variables. Genes currently linked to schizophrenia
are on chromosomes 6, 8 and 22.
“Those now appear the most promising genetic links, though in the past there
have been false leads in the genetic search for schizophrenia.”
Another important point is that schizophrenia is not a monolithic illness.
When all is understood, according to Tandon, what is now diagnosed as schizophrenia
may in actuality turn out to be three, four, or more distinct illnesses or disorders.
“Schizophrenia is a brain disease,” asserts Tandon. “Virtually every credible
expert now believes that it is a biological illness of the brain. Personal ion
of schizophrenia, but are not the cause of the illness. I doubt that even old
hold-outs like Thomas Szasz,” he furthered, “believe anymore that some schizophrenia
is sort of myth, especially in the light of recent scientific research. This
research shows that schizophrenia is an illness born of physical abnormalities
in the brain.”
The Nature of Schizophrenia
Tandon states that schizophrenia involves abnormalities in the structure, function,
and chemical balance of the thinking and emotional parts of the brain. Current
research is elucidating the processes involved with this, and it appears that
some of these abnormalities can occur very early on, even pre-natal, or can
also occur later at the onset of the illness. The brain abnormalities in schizophrenia
can be developmental or deteriorative — developmental in the sense that the
brain is not developing properly over time, and deteriorative in the sense that
brain tissue is damaged later.
The symptoms of schizophrenia (what current medical diagnoses are based on)
can be placed into three categories: 1) positive symptoms (e.g., hallucinations
and delusions); 2) negative symptoms, (e.g., lack of motivation and energy,
impaired ability to express and experience emotion, long silences, or a sense
of vacancy or apathy); and 3) cognitive impairment (e.g., confusion or disorganized
behavior).
According to Tandon, these symptoms can increase or decrease “depending on
how the person responds to medication, other treatments, and the degree of structure
and social support.”
The Dopamine Theory
“In the early 1990s, the Dopamine Theory of schizophrenia was the primary focus
for explaining what was happening with schizophrenia,” said Tandon. “It made
sense, and to a large extent it still does. The symptoms of schizophrenia appeared
to result simply from too much of the neurotransmitter dopamine in the brain.
We knew that we could reduce the symptoms of schizophrenia via the antipsychotic
medications, which blocked dopamine receptors in the brain. Recently, the Nobel
Prize in medicine went to a scientist who developed this theory on dopamine
many years ago.
“But the really interesting thing is that current research is showing our explanation
power for schizophrenia and the prospects for future treatments don’t all need
to be limited to the Dopamine Theory. There are other brain neurotransmitters
that can also come to play in schizophrenia.”
Tandon points to three other such brain chemicals having a bearing on the symptoms
of schizophrenia: glutamate, acetycholine, and serotonin. For instance, too
little glutamate can result in the positive symptoms of schizophrenia. Too little
acetycholine can result in cognitive impairment symptoms. Even too little dopamine
in some parts of the brain can result in the negative symptoms of schizophrenia
or in depression.
“Further down the road, there may be whole new classes of medications to reduce
the symptoms of schizophrenia which work by impacting on the glutamate, acetycholine
and serotonin transmitters in the brain,” said Tandon.
Early Treatment
Experts agree that early treatment of schizophrenia can reduce the level of
deterioration in the brain, and thus improve the patient’s prognosis. Early
interventions normally occur after the symptoms of schizophrenia first occur.
Tandon points to some controversial methods for early treatment now under investigation,
where treatments begin in persons with high risk for schizophrenia, though not
having had the initial symptom episode.
“It’s difficult to say whether this whole approach will work over the long
run, though some data coming out of Australia and Finland show some progress.
Clearly, at this time, this form of early intervention is controversial and
requires more study.”
Social Treatments
“Far too little attention is given to the social aspects of the overall care
for those with schizophrenia. The so-called psychosocial treatments are very
important. These include case management, schizophrenia education, self-help
groups, social skills training, help in independent living, improved housing,
vocational rehabilitation, and supported employment. Psychological treatments,
too, can be helpful.”
Myths of Schizophrenia
Schizophrenia is not a split personality, the latter which is a different mental
illness. People with schizophrenia are not more violent than the general population.
In fact, they are often the victims of violence and exploitation. Sometimes
extreme psychosis can increase the risk of violence, but treatment significantly
reduces this risk of violence. And bad parenting is not a cause of schizophrenia.
It is a brain disease that can happen in any family.
“Although schizophrenia can’t be cured, control of major symptoms is possible
for many persons if careful psychiatric help and other services are available
on an ongoing (generally lifelong) basis,” Tandon concludes.
Study identifies 10 key factors to recovery from schizophrenia
A study from the University of California at Los Angeles:
UCLA Neuropsychiatric Institute researchers have identified 10 key factors
to recovery from schizophrenia. The findings open opportunities to develop new
treatment and rehabilitation programs and to reshape the negative expectations
of doctors, patients and their families.
Based on analyses of the professional literature and the cases of 23 schizophrenia
patients who successfully returned to work or school with their symptoms under
control, the findings appeared in the November 2002 edition of the International
Review of Psychiatry.
Factors detailed in the study that influenced recovery included 1) family relationships,
2) substance abuse, 3) duration of untreated psychosis, 4) initial response
to medication, 5) adherence to treatment, 6) supportive therapeutic relationships,
7) cognitive abilities, 8) social skills, 9) personal history and 10) access
to care.
“Our findings join a growing body of research that flies in the face of the
long-held notion that individuals diagnosed with schizophrenia are doomed to
a life of disability with little expectation for productive involvement in society,
a fatalistic view that in itself is damaging to prospects for recovery,” said
lead author Dr. Robert P. Liberman, a research scientist at the UCLA Neuropsychiatric
Institute and Professor of Psychiatry at the David Geffen School of Medicine
at UCLA.
“By understanding the dynamics of recovery, we can design more effective courses
of treatment and combat the pessimism held by many doctors, patients and families
struggling to cope with this debilitating disease,” said Liberman, Director
of the UCLA Psychiatric Rehabilitation Program and Center for Research on Treatment
and Rehabilitation of Psychosis. “Increasing the rate of recovery from schizophrenia
will help destigmatize this disease, reduce the emotional burden on families,
and lighten the financial weight on communities, states and the nation.”
Liberman and his collaborator, Dr. Alex Kopelowicz, Medical Director of the
San Fernando Mental Health Center and Associate Professor of Psychiatry at UCLA,
edited the November 2002 edition of the International Review of Psychiatry.
Their articles are joined by those from an international array of investigators
on the process of recovery, prospects for improving schizophrenia treatment
and suggestions for future research.
Factors identified as keys to recovery from schizophrenia included:
- Family relationships: Family stress is a powerful predictor of relapse,
while family education and emotional support decrease the rate of relapse.
Among study participants, 70 percent reported good or very good family relationships.
- Substance abuse: National Institute of Mental Health research estimates
the prevalence of lifetime substance abuse among schizophrenia patients at
47 percent, well above the overall rate. Though three-quarters of the study
participants reported substance abuse prior to treatment, just 17.4 percent
reported abuse after the onset of schizophrenia. None reported illicit drug
use in the past year, and just two reported occasional alcohol consumption.
- Duration of untreated psychosis: Longer duration of symptoms prior to treatment
correlates directly with greater time to remission and a lesser degree of
remission. Among study participants, only 13 percent reported a delay of more
than a year between the onset of symptoms and treatment.
- Initial response to medication: Improvement of symptoms within days of receiving
antipsychotic drugs significantly predicts long-term results of treatment.
Among the study group, 87 percent reported effective control of symptoms with
their first antipsychotic medication.
- Adherence to treatment: Failure to take antipsychotic medication as prescribed
hampers both short-term and long-term recovery. All study participants reported
adherence to psychiatric care and medication regimens.
- Supportive therapy: Positive relationships with psychiatrists, therapists
and/or treatment teams engender hope and are essential to improvement. Among
study participants, 91 percent reported ongoing psychotherapy, and 78 percent
reported that accessible and supportive psychiatrists and therapists contributed
to their recovery.
- Cognitive abilities: Neurocognitive factors such as working memory, sustained
attention and efficient visual perception are strong predictors of recovery.
Among study participants, all showed normal or near normal functioning on
tests of flexibility in solving problems, verbal working memory and perceptual
skills.
- Social skills: Negative symptoms, or poor interpersonal skills relative
to social expectations, correlate with the degree of disability caused by
schizophrenia. No study participants showed more than very mild negative symptoms.
- Personal history: Premorbid factors, or those in place prior to the onset
of the disease, that affect treatment outcome include education and IQ, age
of onset, rapidity of onset, work history, and social skills. Among study
participants, level of education was used as a measure of premorbid history.
A total of 70 percent graduated from college before becoming ill, and an additional
13 percent completed two years of college. Three of the remaining four subjects
worked full time before their illness began.
- Access to care: Continuous, comprehensive, consumer-oriented and coordinated
treatment is crucial to recovery. Among study participants, 91 percent reported
receiving antipsychotic medication and psychotherapy, 47.8 percent social
skills training, 56.5 percent family participation, 26 percent vocational
rehabilitation, and 61 percent benefited from self-help groups.