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.

Categories: MentalHealth, Psychology