Here’s a line from The Dark Knight script written by Christopher Nolan and David Goyer. To set the scene, good guy Harvey Dent has one of the Joker’s henchmen and is roughing him up. The Batman appears and suggests that he might like to act more responsibly (’You’re the symbol of hope I could never be’ etc). During this exchange Batman reflects upon the mental health of the Joker’s man:

His name’s Shiff, Thomas. He’s a paranoid schizophrenic, a former patient at Arkham. The kind of man the joker attracts script page 82

This sort of casual unthinking prejudice and stigmatization I cannot let pass without comment. Someone who suffers from schizophrenia is a not simply a ’schizophrenic’ but a person. Although many people suffering from schizophrenia, as well as other disorders of mental health, are vulnerable, it does not follow that they would be easily perverted in this way. You may think that I am being needlessly pedantic, but this has been an extremely popular film and this scene will influence many people’s perceptions of what it is to have a serious mental illness.

Stigma has been found to be highly prevalent among people with a serious mental health problem living in the community. Due to exchanges like the above both former psychiatric patients and members of the general population internalise negative cultural conceptions and attitudes about people who have been diagnosed with a mental illness. This results in discrimination, leading to to people who have been labelled mentally ill being denied important life opportunities. For example, people with mental illness are frequently unable to obtain good jobs or find suitable housing because of the attitudes of key members of their community such as employers and landlords.

As a result, many psychiatric patients form a negative self-concept emerges from both their primary disorder and from the cumulative reaction of others. Social rejection is an ongoing and recursive experience in the community setting and a persistent form of social stress.

More reading:

How stigma interferes with mental health care Patrick Corrigan American Psychologist 2004

4th International stigma conference - 21 - 23 January 2009 IoP London -  looks interesting if you’ve got £260 to spare

“What is Schizophrenia?”

Someone asked me this at a party recently. It’s a difficult question to answer in a single sentence.

For a start, schizophrenia is not a single disorder. According to the ICD-10 it is a group of disorders, classified under F20 in a chapter called ‘Schizophrenia, schizotypal and delusional disorders’.

F20 is split into the following sub-classifications:

F20.0 Paranoid schizophrenia

F20.1 Hebephrenic schizophrenic schizophrenia

F20.2 Catatonic schizophrenic schizophrenia

F20.3 Undifferentiated schizophrenia

F20.4 Post-schizophrenia depression

F20.5 Residual schizophrenia

F20.6 Simple schizophrenia

F20.8 Other schizophrenia

F20.9 Schizophrenia, unspecified

(I can’t immediately find out what happened to F20.7 – maybe it suffered the same fate as floor number 13 in New York skyscrapers)

The aetiology of schizophrenia is unknown; as this is the case we are forced to define schizophrenia on the basis of a number of symptoms which appear together sufficiently frequently to merit a grouping. In this way schizophrenia is a syndrome rather than a disease. A disease is a disorder with a specific cause and recognizable signs and symptoms whereas a syndrome is combination of signs and/or symptoms that form a distinct clinical picture. The ICD-10 classification system deliberately avoids including aetiology in its definition.

Schizophrenia is a disorder which covers a wide range of cognitive, emotional and behavioural disturbances; there is disintegration in the process of thinking, of contact with reality and a pattern of emotional unresponsiveness.

ICD-10 puts it nicely:

The schizophrenia disorders are characterized in general by fundamental and characteristic distortions of thinking and perception and by inappropriate or blunted affect.

There is no one sign that ‘guarantees’ a diagnosis of schizophrenia. For instance many of the characteristic symptoms of schizophrenia can occur during a manic phase of bipolar disorder or during psychotic depression. However the following ‘fundamental and characteristic disorders of thinking and perception’ are considered to have special importance in the diagnosis of schizophrenia. They are based on Schneider’s first rank symptoms, proposed in 1959 and are:

a) thought echo, thought insertion or withdrawal, and thought broadcasting;

(b) delusions of control, influence, or passivity, clearly referred to body or limb movements or specific thoughts, actions, or sensations; delusional perception;

(c) hallucinatory voices giving a running commentary on the patient’s behaviour, or discussing the patient among themselves, or other types of hallucinatory voices coming from some part of the body;

(d) persistent delusions of other kinds that are culturally inappropriate and completely impossible, such as religious or political identity, or superhuman powers and abilities (e.g. being able to control the weather, or being in communication with aliens from another world);

(e) persistent hallucinations in any modality, when accompanied either by fleeting or half-formed delusions without clear affective content, or by persistent over-valued ideas, or when occurring every day for weeks or months on end;

(f) breaks or interpolations in the train of thought, resulting in incoherence or irrelevant speech, or neologisms;

(g) catatonic behaviour, such as excitement, posturing, or waxy flexibility, negativism, mutism, and stupor;

(h) “negative” symptoms such as marked apathy, paucity of speech, and blunting or incongruity of emotional responses, usually resulting in social withdrawal and lowering of social performance; it must be clear that these are not due to depression or to neuroleptic medication;

(i) a significant and consistent change in the overall quality of some aspects of personal behaviour, manifest as loss of interest, aimlessness, idleness, a self-absorbed attitude, and social withdrawal.

(Source of (a)-(i) ICD-10)

The final thing to say is that the conception of schizophrenia is to a certain extent historical and many textbooks choose to explain schizophrenia as a disorder with reference to the history of its classification. The term itself was Bleuler introduced the term in his 1911 book ‘Dementia praecox or the group of schizophrenias’

Insulin is a hormone produced in the body by the pancreas; its main role is to cause cells to take up glucose from the blood thus regulating its level. The history of the discovery of insulin is an interesting one, albeit involving the death of a pack dogs.

In 1889, the physicians Oscar Minowski and Joseph von Mering removed the pancreas from a dog to test its assumed role in digestion. Several days after the dog’s pancreas was removed, it was noticed that there was a swarm of flies feeding on the dog’s urine. On testing the urine they found that there was an unusually high sugar content, establishing for the first time a relationship between the pancreas and diabetes mellitus.  In 1901, it was established that the diabetes was caused by the destruction of a part of the pancreas called the Islets of Langerhans. These islets had been identified by Paul Langerhans whilst a medical student in 1869. 

We now know that what the islets were producing was insulin, but this proved difficult to isolate. Nicolae Paulescu a professor of physiology in Bucharest was the first one to succeed and published his work in 1921. Use of his techniques was patented in Romania , but no clinical use resulted.  At almost the same time, Canadian Frederick Banting hypothesised that the reason for the difficulties was that some of the other products of the pancreas, digestive enzymes, were destroying the islet secretions before they could be extracted.  In the summer of 1921 he was supplied with a laboratory, Charles Best, a medical student assistant, and ten more dogs.  The idea was to ligate the dog’s pancreatic ducts; the pancreatic secretions would then pool in the pancreas, but the digestive elements would be reabsorbed leaving the islets.  It was found that an extract from these islets was able to keep a pancreatectomized dog alive all summer as the extract lowered the level of sugar in the blood. 

Efforts continued by Banting and Best to purify the extracted insulin enough to allow administration to humans, which was underway by late 1921; commercial quantities were available by 1923.  Banting received the Nobel Prize for his work, although controversially Paulescu was not recognised.

******

In the sadly now departed spirit of have-a-go experimentalism, the newly discovered insulin was then tried out on patients suffering with illnesses for which no treatment was known. In Berlin , between 1928 and 1931, Dr. Manfred Sakel used insulin to reduce the unpleasant symptoms of patients undergoing opiate withdrawal. With insulin, they became calm, gained weight, and were much more cooperative.  When the dose of insulin was high, the patient went into stupor; after such events, the patients were less argumentative, less hostile, and less aggressive. 

Noting these results, Sakel moved to Vienna , and was assigned to treat patients with schizophrenia.  He further investigated the benefits of insulin, and reported that when the patients developed stupor or coma, they lost their psychotic thoughts.  His experience was reported to the Vienna Medical Society in January 1933, and by May 1936, favorable reports of the benefits of insulin coma therapy in schizophrenia from 22 countries were presented at a major meeting of the Swiss Psychiatric Society.

The German name for the treatment was ‘Insulin-shock-behandlung’. Translated into English, the phrase became ‘insulin-shock-treatment’.  Sakel interpolated the word ‘shock’ to emphasize his belief that the essential element of ICT was the lowered blood pressure, sweating, increased heart rate, and increased breathing rate that resulted from the stresses produced.  It was later understood that, that the medical shock aspects were not important to the treatment results, and any benefit was mostly likely due to the insulin induced coma.  Insulin coma therapy was regarded as a specific treatment for schizophrenia, and was probably the first in this regard.

Essentially the treatment involved a large dose of insulin which lowered the patient’s blood glucose enough to produce a coma.  This would be maintained for one to three hours and terminated by either tube feeding or intravenous glucose.  A course of treatment could include up to 60 comas.  Serious side effects were common, and a mortality of at 1-10% could be expected depending on the standard of the clinic and physical state of the patient.  Epileptic seizures could occur during the beginning stages of treatment, roughly 45–100 minutes into the procedure, but before the onset of the comatose state.  Seizures occurring during the coma were more dangerous, requiring immediate interruption of the procedure and coma termination, and were often followed by delayed recovery or severe hypotension.  Complications would also occur from the unconsciousness reaching excessive depths and that the coma would not end despite the administration of feeding or glucose.   Administrators would monitor the patient’s vital signs, to determine the level of danger.   

Despite these risks, insulin coma treatment was rapidly taken up throughout Europe and many specialized treatment units were built.  It is worth remembering that at this time there were no effective treatments for psychotic disorders and that the physical effects of prolonged psychosis were also severe, such that it was felt at the time that the risks were worth taking.  Indeed there was a great improvement in the morale of patients and staff because of the belief that this dramatic treatment could cure symptoms of the most serous psychiatric disorders. 

There were always some doctors who doubted the efficacy of insulin coma treatment.  Their doubts were reinforced by a controlled trial by Acker and Oldham (1962) who found that, in patients with schizophrenia, insulin coma was no more effective than a similar period of unconsciousness induced by barbituates.  It may be that the treatment had a tranquillising effect on patients by inducing brain damage through the prolonged deprivation of the brain cells of glucose, as suggested in a journalist Robert Whitaker’s book Mad in America*. It was also a very dramatic procedure, with patients being put into a long coma, and then re-awoken quite suddenly by the injection of glucose. This raises the possibility that coma therapy may have owed its perceived effect to a placebo effect, and a result of the drama of the whole procedure.

The Acker and Oldham study was published about the same time that chlorpromazine was introduced and both factors lead to a rapid decline in the use of insulin coma treatment.  It should be said though that some controlled studies did not exclude the efficacy of insulin treatment in certain circumstances and a number of workers continued to maintain that it was effective**.  Recent experimental studies have shown that insulin administration causes changes in the release of monoamine neurotransmitters, suggesting a possible mechanism of action**.

Links:

The Insulin Treatment of Schizophrenia From An Introduction to Physical Methods of Treatment in Psychiatry (First Edition) by William Sargant and Eliot Slater (1944, Edinburgh, E & S Livingstone).

A History of Shock Therapy in Psychiatry by Renato M.E. Sabbatini, director of the Center for Biomedical Informatics and Chairman of Medical Informatics of the Medical School of the State University of Campinas Brazil

Drug Treatments in Modern Psychiatry: A History of Delusion Dr Joanna Moncrieff Senior lecturer UCL UK

A Brilliant Madness PBS minisite about Nobel Prize winning schizophrenia sufferer John Nash.  In the same site Dr. Max Fink, the head of the insulin coma unit at the Hillside Hospital in Glen Oaks, Queens, New York from 1952 to 1958 writes about the treatment

Wikipedia on insulin shock therapy

* I haven’t read this, Joanna Moncrieff, Senior Lecturer in Social and Community Psychiatry UCL and chair of the Critical Psychiatry Network cites it in the above presentation.  He’s a journalist though, so I can’t shake the suspicion that he’s making it up.

**Source Shorter Oxford Textbook of Psychiatry by Michael Gelder, Richard Mayou and Philip Cohen Oxford 2001 pg 648.  They don’t cite a source.

Catherine commented:

‘I disagree with the comment about bipolar and schizophrenia being chronic, remitting etc. There are a minority who are so badly affected that they never live independently, but the majority go on to either recover, or manage their illness very well, working, hobbies etc and have a good quality of life.’

The point I was making about the chronicity of schizophrenia/bipolar disorders is that in the film ‘Ruth’ is presented to us has having recovered from her mental health crisis with no mention of follow up.  For anyone who doesn’t know, it’s often common practice in healthcare for a patient to be seen by a doctor on at least a short term basis after a problem has resolved as there may be a chance of it coming back, and psychiatry is no exception to this. We know from the film that she already has a diagnosis of BPAD and so she must have had trouble before.  The episode presented to us is quite severe, so I would say that her chance of having another relapse is high, especially with bipolar disease

Schizophrenia is considered to have a wide variety in outcomes, that said, there are not millions of long term studies; here are the ones mentioned in the Shorter Oxford Textbook of Psychiatry:

Kraeplin Dementia praecox and paraphrenia 1919
Concluded that only 17% of his patients were socially well adjusted many years later

Mayer-Gross Die Schizophrenie in Bumke’s Handbuch der Geisteskrankheiten Vol 9 Springer Berlin 1932
Reported social recovery in 30% patients at 16 years all from the same clinic

Brown et al (1966) reported social recovery in 56% in Schizophrenia and social care Maudsley Monography 17 Oxford University Press  London

Manfred Bleuler (1972,1974) followed up 208 patients who had been admitted into hospital in Switzerland between 1942 and 1943.  Twenty years after admission 20% had complete remission of symptoms and 24% were severely disturbed. 

Ciompi did a larger study looking at 1642 records diagnosed as having schizophrenia between 1900 and 1962, with an average follow up of 37 years.  A third of patient were found to have good or fair social outcome.  Symptoms were often less severe in later life. 

Johnstone E.C. (1991) Disabilities and Circumstances in Schizophrenic patients: A follow up study British Journal of Psychiatry  159 supplement 13 5-46, did a 3-13 year follow up of patients with schizophrenia discharged from 1975 - 1985 and found that almost half had a good social outcome. 

Tsoi and Wong (1991) A fifteen year follow up of Chinese Schizophrenic patients Acta Psychiatrica Scandinavica 84 217-220  did a 15 year follow up of 330 patients with first admission Schizophrenia and in this found that almost one third recovered but 17% remained unable to function outside the hospital. 

Finally in the USA Carone et al (1991 - a busy year) found that only 15% of patients meeting DSM-III criteria for schizophrenia recovered after 5 years. 

Full admission: I haven’t read any of these papers/books, and for these papers to be comparable then they should all use similar definitions for schizophrenia and select similar patients - there would be no utility is comparing patients after their first admission and patients who have been admitted countless times.  With these caveats, it appears that prognosis has improved since schizophrenia was first studied.  In the earlier studies the patients would have had no access to modern pharmaceutical treatments 

Schizophrenia outcome is further discussed in  Schizophrenia Research Volume 1, Issue 6, November-December 1988, Pages 373-384

The factors associated with good prognosis in Schizophrenia:

Sudden onset; Short episode;No previous psychiatric history; Prominent affective symptoms; Paranoid type of illness; Older age of onset; Married; No personality disorder; Employed; Good social support; Good compliance with treatment

Poor prognosis is associated with:

Insidious onset; Long episode;Previous psychiatric history; Negative symptoms; Enlarged lateral ventricles; Male gender; Younger age of onset; Single/separated/widowed/divorced; Personality disorder; Poor work record; Social isolation; Poor complicance with treatment

If you’ve still got the strength, read on for outcome of bipolar affective disorder.  Again this is from the Shorter Oxford Textbook of Psychiatry:

The average length of a manic episode (treated or untreated) is six months

At least 90% of patients with mania experience further episodes of mood disturbance

Over a 25 year follow up on average bipolar patients experience 10 further episodes of mood disturbance

The interval between episodes becomes progressively shorter with both age and the number of episodes

Nearly all bipolar patients recover from acute episodes, but less than 20% of patients with this disorder achieve a period of 5 years of clinical stability with good social and occupational peformance

It is estimated that 10% of patient with unipolar depression will eventually turn out to have a bipolar illness.   

So, with both bipolar affective disorder and schizophrenia, I do think that if a patient has one episode they are likely to be troubled by the illness at a later date and this is what I meant by a chronic condition.