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A book by William H. Calvin UNIVERSITY OF WASHINGTON SEATTLE, WASHINGTON 98195-1800 USA |
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The Throwing Madonna Essays on the Brain Copyright 1983, 1991 by William H. Calvin. You may download this for personal reading but may not redistribute or archive without permission (exception: teachers should feel free to print out a chapter and photocopy it for students). Scanned, OCR'ed, and webbed -- but NOT proofread (14 Jan 97) |
13Thinking Clearly About Schizophrenia
If schizophrenia is a myth, it is a myth with a strong genetic component.SEYMOUR KETY, in reply to THOMAS SZASZ
Ask most people for a definition of schizophrenia and they'll say something about split personality. Indeed, the word has entered popular usage: "I feel rather schizophrenic on that subject," meaning that you have two different opinions on the matter. Even the etymology suggests it: it comes from the two Greek roots meaning "to split" and "mind or heart." But two plus two isn't always four in the history of words, and certainly not in science, where our understanding improves with time but the names remain the same.
Ask someone in the mental health professions for a capsule description of schizophrenia and you'll get an entirely different response: "It's a thought disorder. The person often hears voices commanding him, or giving a running commentary on his actions, or perhaps hears his private thoughts being spoken aloud (even though they aren't). He or she has trouble maintaining a train of thought, often jumping to a totally irrelevant topic. Just as in the hard-of-hearing, a feeling of being persecuted or spied upon is very common in the schizophrenic. People who have suffered the disease for a long time are more likely to be withdrawn, not know what day it is, not say very much, be intellectually impaired, not have normal emotional responses to disturbing news." Schizophrenics certainly have trouble thinking clearly, but that is no excuse for the rest of us thinking fuzzily about schizophrenia. But views of schizophrenia have varied from T. Szasz's "it doesn't exist" and R. D. Laing's "it is a sane response to an insane world" to notions that it is a biochemical disorder like diabetes.
The split-personality notion of schizophrenia is really a description of a very rare personality disorder which has been seized upon by a public unfailingly entertained by Dr. Jekyll and Mr. Hyde. In terms of statistics, one can essentially forget about it--but one cannot forget about the 1 percent of the population that becomes schizophrenic, usually as young adults. Nor, apparently, can the English language do without a word to serve the role which the misnomer, schizophrenic, has been serving.
To tackle the easy problem first, there is a perfectly good word that will fill the bill: chimeric. A chimera, just in case you have forgotten Greek Mythology 101, is a she-monster with the head of a lion, the body of a goat, and the tail of a snake (it was slain by Bellerophon astride the winged horse Pegasus). The word has found a home in at least two aspects of the scientific literature: genetics and cognitive psychology. Genetic engineering techniques make it possible to mix the genes from two different animals, provided that it is done early enough in development. One can wind up with, for example, a fly that is a patchwork mosaic of colors and other surface properties which illustrate different "compartments" in development under control by different precursor cells. Since some of those cells belonged to one embryo and some to another, the resulting animal is an admixture. An individual that is composed of parts of several individuals is called a chimera. The only humans who might qualify are the recipients of transplanted kidneys and such.
Cognitive psychologists aren't studying such chimeric humans; they are studying how normal humans react to artificial chimeras. They have demonstrated that, when you look at a picture of a person's face, it is the right side of that face which impresses you most strongly as regards emotion. The psychologists take pictures of an actor acting out various emotions: happiness,rage, sorrow, disgust, and so forth. Then they take a razor blade to each picture and cut it down the middle of the face. Thus they can paste together a right face which is happy with a left face which is sad: a chimera. Such a picture is briefly flashed on a screen--and the subject reports that it was a happy face. The right side of the face was in the subject's left visual field, which reports first to the subject's right brain, which has an interesting cortical region specialized for judging the emotions on other people's faces (discussed back in Chapter 5).
Thus, the next time you are tempted to describe yourself as "schizophrenic" when you are torn between two different opinions, don't forget that someone may take you literally and suspect that you are experiencing hallucinations. Instead, call yourself "chimeric." It may, however, be the better part of valor to revert to "schizophrenic" should you see someone approaching on a winged horse.
In which case, of course, you may actually be schizophrenic.
Psychiatrist: Why do you flail your arms around like that?This patient not only suffers from visual hallucinations but also from what is called "knight's move" thinking--linking concepts whose connection requires a novel dogleg leap of the imagination, such as the cause-and-effect of arm waving and no elephants. This sideways leap need not be that absurd. Some would explain the allegedly increased numbers of artists and scientists who suffer schizophrenia [1997 update: actually, they turn out to be suffering from manic-depressive illness, not schizophrenia] by saying that a small amount of this trait aids creativity, enhancing the ability to perceive novel interrelationships, to break free of the bonds of straightjacket thinking. So that preschizophrenics might become employed in creative jobs in disproportionate numbers to their usual 1 percent prevalence in the population as a whole. Full-blown schizophrenia, however, can be so disorganizing that serious creative work becomes impossible; one can no longer sort out the metaphorical wheat from the chaff, nor communicate understandings to others.
Patient: To keep the wild elephants at bay.
Psychiatrist: But there aren't any wild elephants here.
Patient: That's right. Effective, isn't it?
But auditory hallucinations are much more common in schizophrenia than visual ones. People who hear voices, realizing that others do not also hear them, quite reasonably rub their ears to make sure that an earphone isn't there. That possibility eliminated, they may wonder if some secret technology is at work, bypassing their ears and directly inserting the voices into their head as if it were a radio receiver. The voices can seem far more real than in a dream, and suspecting a secret CIA technology is more logical than trying to deny that the voices exist.
I have actually had schizophrenics seek me out for an expert opinion on this subject, on the suspicion that their psychiatrist wasn't up on the latest in neurophysiological techniques. It is not easy to convince them that such broadcasting into brains is presently technically impossible, because their personal experience tells them otherwise. It is easier to believe in secret CIA methods than to deny the evidence presented by your own brain. It is easier to believe that the CIA has kept the method secret even from the neurophysiologists. However, the technology simply doesn't exist. A method of inserting voices directly into the brain (or of reading out detailed information from a person's brain) would have revolutionized neurophysiology research if it existed, and one cannot successfully keep hot new technologies like that a secret from the professional researchers in the field. It would take many decades of gradually improving techniques to lead up to such a technology; it would take a revolution in our knowledge about hearing and speech; and it just hasn't happened.
Persons experiencing such voices usually do not know enough about the brain to appreciate the most likely explanation: that the mechanism which the brain uses to distinguish between incoming sensory messages, and vivid memories of previous experiences, is temporarily not working well. The hallucinations, just like ordinary nighttime dreams, are recalled information from the person's memories--though often pieced together so creatively that they may seem new. They may try to tune out the voices by suppressing auditory input, which may be why they suffer the same feelings of paranoia as some people whose hearing is impaired. If the voices are bothersome, they can often be quieted by antipsychotic drugs. A friend of mine, when in his late twenties, was hospitalized after hearing voices commanding him to take off all his clothes and perform pushups in the middle of a downtown street. He followed orders. The antipsychotic drugs had him back to work within weeks.
Effective drug treatment for schizophrenia is only a few decades old. A French naval surgeon, H. Laborit, was treating sailors with worm infections, no less. He noticed that his favorite antiworm medicine, chlorpromazine, also had a calming effect in mentally disturbed sailors with worms. In the fifteen years that followed, many related drugs were tried out by many investigators. What the effective ones all had in common was that they blocked the actions of a neurotransmitter known as dopamine. Now, after even more experience, we know that it isn't just dopamine.
Schizophrenia is a set of symptoms; like epilepsy and the common cold, it is not just one simple disease. So it is not surprising that the antischizophrenic drugs do not have uniformly good results. Yet which drugs work on what symptoms tells us something about the neurochemistry of schizophrenia. Nothing much seems to work on the social withdrawal and the flat emotions of some schizophrenics, though there are some promising new leads.
Dopamine is a neurotransmitter in common use in many areas of the brain; too much of it (or supersensitivity to a normal amount) appears to be responsible for some schizophrenia symptoms such as stereotyped behaviors. Indeed, you can induce such schizophrenialike symptoms with drugs that enhance dopamine; it is a common side effect of levodopa, used to treat Parkinson's disease. My elderly landlady in Jerusalem started hearing voices after accidentally taking a double dose of her medication for Parkinsonism. Overdoses of amphetamine (which are thought to stimulate dopamine release) induce a schizophreniclike psychosis, one which is readily overcome by the usual antischizophrenic drugs; this provides a way of inducing "schizophrenia" in laboratory animals, an all-important step in furthering medical research.
Other symptoms, such as withdrawal and autistic behaviors, flatness of affect, and lack of motivation, have been blamed upon disorders of another neurotransmitter, norepinephrine, which is manufactured from dopamine. Some research groups think that the enzyme that controls the conversion of dopamine into "norepi" may be at fault.
Another line of investigation notes that people with schizophrenia do not develop arthritis, and vice versa. Furthermore, schizophrenics are often resistant to pain. And they improve mentally when running a fever (a fact first noted by Hippocrates). It is even said that people with both schizophrenia and epilepsy have an unusual alternation between the symptoms of the two diseases, with seizures being rare during periods of madness. Whatever can the medical detective make of these fascinating clues?
David Horrobin, a Montreal endocrinology researcher, notes that all these facts could be explained if prolactin, a hormone secreted by the pituitary gland at the base of the brain, protected us against schizophrenia. Prolactin, via stimulating the manufacture of fatty acids called prostaglandins, is all tied up with arthritis, pain, fevers, and seizures.
And it explains the therapeutic effects of the common antischizophrenia drugs that block dopamine: they enhance prolactin output, so there are more prostaglandins around to do their antischizophrenic thing. Whatever that turns out to be maybe the enzyme mentioned earlier?
- Rheumatoid arthritis is a disease where there is excess production of prostaglandins.
- Prostaglandins play a key role in inflammation and pain.
- Prostaglandin levels rise during fevers and seizures.
Such research proceeds slowly; corrected for inflation and the number of investigators, our basic research efforts have been steadily shrinking. Considering the enormous social costs of mental illness, society's lack of investment in research seems both stupid and inhumane. I was just going to say shortsighted, but stupid does seem the right word.
Schizophrenia is especially a disease of the young adult-- people with their whole life ahead of them. It lays them low, and in addition to the personal and family tragedy, it often disables them at great cost to society. After puberty, case after case appears until, by middle age, 1 percent of the population has been affected, uniformly across social classes. Initial hospitalizations for men peak at about age 18, with many cases first occurring in the twenties. For women, the cases peak at about age 30. Few cases first appear when people are in their forties (for severe depressions, in contrast, first hospitalizations peak at age 55).
How many friends do you have from high school who were hospitalized for mental illness as young adults? Given the percentages, you should know a few. Two of my high school friends died in their twenties; both were very gifted socially and academically, one serving as the president of my senior class. They were identical twins, and when one identical twin gets schizophrenia, the chance of the unaffected twin eventually coming down with schizophrenia is about fifty-fifty. Until I heard the news about my twin friends at my class reunion, that had always just been one of those impersonal statistics that I carried around in my head.
For fraternal twins and other siblings in general, the chances are about one in six of coming down with schizophrenia if a sibling is affected. Twins aren't any more likely to get schizophrenia than anyone else, unless they have close relatives with the disease. It's just that a monozygotic twin has a closer relative than anyone else has. The "concordance" holds even if twins are raised apart, when one's illness could not affect the environment of the other (many pairs of separated twins with schizophrenia have now been discovered and studied).
That strongly suggests a genetic predisposition, that schizophrenia is inherited (though it is not via simple Mendelian genetics, unfortunately). And there are now many findings that demonstrate a biological basis, the latest being a valuable new series of studies coming out on the brain anatomy of schizophrenics, thanks to CT and MRI scans which allow cross-sectional views of living brains. The fluid-filled areas are sometimes a little bigger than normal, and characteristic asymmetries in the left brain compared to the right brain are sometimes absent in schizophrenics (they are more symmetric). Not all schizophrenics show the nonstandard anatomy, but many do. Timothy J. Crow, a British psychiatric researcher, proposes that there are two major subdivisions of schizophrenia: that the negative symptoms (flatness of affect, intellectual deterioration, poverty of speech) accompany the anatomical changes and are not affected by drug treatments; and that the positive symptoms (hallucinations, illusions, thought disorder) reflect a neurohumoral component to the disorder that is treatable with drugs.
And indeed the twin studies also demonstrate that environment has a role in schizophrenia. Since monozygotic twins have identical genes, how else can you explain one twin developing schizophrenia but the other one not? That is, after all, the other side of the fifty-fifty statistic: half of the twins with a schizophrenic twin do not themselves come down with schizophrenia. So environment too must play a role in the disease. But it has been an elusive factor to identify, compared to the biological ones.
What follows is a story that I'd like to forget, like a bad dream--but it pointedly illustrates what is known as stereotyped behavior and flat affect. If you wondered about that bit of technical jargon earlier, and have a strong stomach, read on. But don't blame me if you can't sleep tonight. You can always skip the next page.
I was once the foreman of a jury in a first-degree murder trial, where the defendant did not contest the facts but argued insanity under the classical McNaghten rule. He was 20, with a history of mental problems, poorly treated (this was back in the old days before community mental health clinics became common; I suspect he never saw a psychiatrist until he landed in jail). Weeks earlier, he had choked his girlfriend to the point of unconsciousness, but no one had done anything about the warning signal (girlfriend included, which caused some jurors to comment upon her sanity).
Jobless, he had begun hanging around a neighborhood where he had once lived as a child. In one house there lived a deaf woman, 76, who always worried about being murdered for her money, an attitude the defendant had probably absorbed while growing up nearby. Though the run-down condition of her house would not have suggested more income than a social security check to anyone sane, the defendant broke into it in the middle of the night and beat the poor old woman to death in a frenzy. She was stabbed thirty-five times with a long knife and sixty-seven times with a metal bedpost. Thereafter, the defendant burglarized the house across the street, skillfully emptying the pockets of a sleeping man. Then, at seven in the morning, he hitched a ride downtown from a neighbor who knew him, who politely asked what he was doing back in the old neighborhood.
He was not walking about in a daze, totally incompetent-- which caused the jurors no end of trouble in deliberating the insanity defense. But the flatness of his emotions got through to us: How could any sane person show such lack of reaction to a frenzy of brutal violence as to be cool enough to go pick someone's pocket within the following hour? Only a dream, forgotten upon awakening, could allow the disassociation of such emotions. And in schizophrenia, dreams and reality can often become confused. The inhibitions of muscle movement which we have during dreaming usually keep us from acting out our dreams. But in some schizophrenics, reality can be insecure, it can come and go, intermixed with what are only dreams--but which are sometimes acted out. (Let me hasten to emphasize that only a few schizophrenics are dangerous to others.)
The defendant's facial expressions had been consistently "weird," as the arresting police officer described them (he was arrested while returning to the house a week later to view the body). He smiled a silly, inappropriate smile (a stereotyped behavior), even when sad (flat affect). One judge had been so impressed by that weird smile that he decided to ignore the current medical opinion which said that the defendant was now sane enough to help his attorney. So the judge delayed the trial again. Finally, three years after the murder, physicians and lawyers and judges agreed that he was capable of assisting his attorney in his own defense--though everyone seemingly agreed that he was probably still medically psychotic.
We poor jurors had to keep straight three different definitions of insanity: (1) the criteria for being able to stand trial now; (2) the criminal insanity criterion: "not responsible for his actions at the time"; and (3) the medical definition of psychosis whose elements I have outlined above. Our job was to make a judgment about the second criterion, and we eventually decided that he was not guilty by that criterion. Though we were charged to judge the past, some jurors may also have had unspoken thoughts about the future: that surely the defendant would be better off in a treatment setting such as a state mental hospital than in a punitive warehouse setting such as a state prison (and eligible for parole in eight years). I am sure, however, that no one had any illusions about whether the defendant was safe to mingle in society.
Jurors seldom get much feedback about how things turn out. By happenstance, I did. The state mental institutions had found this psychotic young man too dangerous to the other residents and, lacking proper facilities for such high-risk troubled people, they simply transferred him to the state's maximum-security prison.
When I was the state president of the American Civil Liberties Union, one of our staff attorneys came back from a visit to that prison telling of a really spooky guy, quite unlike the other prisoners, who had cornered him while he was interviewing inmates for a class-action lawsuit on poor medical care. I surprised the attorney by guessing the inmate's name. I then wrote to the judge about the quality of the medical care that this not-guilty defendant was receiving--and in which kind of state institution, at that. The judge investigated and the institutional officials explained their problem with inadequate facilities, record populations, and budget cuts. The defendant-patient-prisoner did find one way of getting attention: he escaped (and was recaptured).
Not all medical problems are treatable (and his, admittedly, were not encouraging), but there is no excuse for compounded neglect. Not only are the taxpayers' representatives reluctant to invest money in medical research ("it's someone else's responsibility") but they often simply ignore people for whom they have direct responsibility. If they were parents failing to look after their children, they would be hauled into court for their willful neglect and subjected as well to the attentions of press and media. Yet they, and the taxpayers themselves, fail in their responsibilities and get away with it in the name of holding down taxes. We do not suffer from lack of resources, but we certainly have a problem in setting priorities for their use. It says something about our society that we spend many times more money on tobacco and cosmetics than on biomedical research. And more on pet food than on rehabilitation.
Despite my week-long education on insanity defenses, I still don't understand them; they certainly bear little relationship to the body of knowledge represented by modern biological psychiatry. Nor do I have a revolutionary new system to propose for relieving the confusion they engender in our courts. So I have a lot of sympathy for the newspaper reader who cannot understand insanity pleas. It is indeed a complicated business, and not just because human behavior and schizophrenia are so complicated. It is not easily encapsulated in those little bite-size tidbits favored by newspapers and television news when they need something to fill in between ads; you need to approach the legal policy on insanity more the way a dog tackles a bone, by chewing on the subject for a while from one direction, and then from another angle.
The first step is to be suspicious of glib generalities, such as those uttered in outrage over the not-guilty-insane verdicts for presidential would-be assassins. Back when I was a beginner on this subject myself, I got to see how eleven other ordinary nonexpert citizens approached the criminal insanity issue. I suspect that most of the people who write indignant letters to the editor would probably, after spending a week locked up in a jury room facing such issues themselves, see things much as average jurors do. It is surely a sobering experience. And such considered sober opinion from a jury of peers is where most of those not-guilty-insane verdicts originate.
Schizophrenia is not a myth but a very real disease, distressing to its sufferers and to society. The real reason why we have such trouble talking about it realistically, however, probably has little to do with confusing the disease with that suffered by Dr. Jekyll (or was it Mr. Hyde?). Schizophrenia is a disorder of thought, of our perception of reality. And we have little idea how our brains work to create thought, how we form a mental picture of reality and test it against the facts. We don't even understand dreams: how we can inhibit our actions during them, how we readily forget them unless we replay them immediately after awakening. Until basic neurophysiology gets a better grasp on such subjects, until it translates such an understanding into a form readily comprehended by jurors and newspaper readers, our reactions to schizophrenia are going to continue to be well, chimeric.
The Throwing Madonna:
Essays on the Brain (McGraw-Hill 1983, Bantam 1991) is a group of 17 essays: The Throwing Madonna; The Lovable Cat: Mimicry Strikes Again; Woman the Toolmaker? Did Throwing Stones Lead to Bigger Brains? The Ratchets of Social Evolution; The Computer as Metaphor in Neurobiology; Last Year in Jerusalem; Computing Without Nerve Impulses; Aplysia, the Hare of the Ocean; Left Brain, Right Brain: Science or the New Phrenology? What to Do About Tic Douloureux; The Woodrow Wilson Story; Thinking Clearly About Schizophrenia; Of Cancer Pain, Magic Bullets, and Humor; Linguistics and the Brain's Buffer; Probing Language Cortex: The Second Wave; and The Creation Myth, Updated: A Scenario for Humankind. Note that my throwing theory for language origins (last 3 essays) has nothing to do with the title essay: THE THROWING MADONNA is a parody (involving maternal heartbeat sounds!) on the typically-male theories of handedness.AVAILABILITY poor.
Many libraries have it (try the OCLC on-line listing, which cryptically shows the libraries that own a copy), and used bookstores may have either the 1983 or the 1991 edition.
- Powell's Books in Portland lists used copies in their web database.
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