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Biology 202
2001 Second Web Report
On Serendip

Schizophrenia: A Question Of Reality

Rachel Kahn

Last month, I shadowed a physician for four days. When I arrived at her office on the first day, she said to me, "Prepare yourself, we are going to the Provident." The Provident is a nursing home for the severely mentally ill. Many of the patients living there are under fifty years old, some are as young as thirty. None of the residents have any money. All are receiving welfare and are on Medicare.

We entered the building into a room where approximately 15 people were sitting in chairs. Most were staring straight ahead, eyes glazed. Some were chattering quietly to themselves, some were walking around with an awkward gait. As I walked further through the floor looking into rooms, I saw many people sleeping in their beds.

I couldn't help but wonder what it would be like if the people living at the Provident were suddenly not taking any medication. Would they be out of control? Was it possible that beneath all of the drug-induced stares, shakes and speech impediments that an alert person existed? Perhaps their diseases had prevented them from interacting with other people in what would be considered a "normal" way. But are they better off now that they are too drug-altered and often depressed to interact at all?

As a society, we try to get rid of things we are afraid of, things which make us nervous and things we don't understand. Perhaps mental illness is not so much a problem for the mentally ill, but for their communities who can not and will not empathize with them. I wonder if people suffering from a mental illness are not really suffering at all, but are simply a behavioral minority. Their behavior prevents them from being accepted by the majority. They can not find work or often even a place to live, as these things are controlled by the majority. Instead, for those that are ironically considered lucky, the majority gives them medication and often sends them away to a locked facility.

For this second web-paper, I will try to explore these questions by learning about schizophrenia, a common diagnosis at the Provident. Some have argued that people "afflicted" with schizophrenia have a damaged I-function. That is, schizophrenics are not capable of responding appropriately to their environment because their I-function is not fully grown or as well-developed as a "healthy" person. In this paper, I argue that the opposite may be true.

One of the men I met at the Provident, "Greg," is a schizophrenic. He has prostate cancer, and his doctor has tried to convince him that he will become very ill and possibly die without an operation. Greg adamantly refuses the operation, saying that he has "the power," and if he has an operation, he will no longer have "the power." Greg's grandiose delusion is one of many positive symptoms which can lead a physician to make a diagnosis of schizophrenia. Other symptoms include: delusions of reference, persecutory delusions, somatic delusions, religious delusions, delusional jealousy, erotomanic delusions, delusions of guilt, delusions of being controlled, delusions of thought broadcasting, thought insertion and/or thought withdrawal, auditory, visual, tactile, olfactory and/or gustatory hallucinations, disorganized speech, and/or disorganized behavior(3). The other general category of symptoms are negative symptoms. Negative symptoms include: loss of will, lack of goal-directed activity, anhedonia, and flattened affect(4).

Based on the criteria for diagnosis of schizophrenia, it seems that positive symptoms indicate an overactive I-function. Schizophrenics are aware of things that, according to the majority of society, are not present. However, whether or not the feelings the person is experiencing are "real " or not brings up an interesting debate. What is reality and how do we know whose reality is "right"? While we may think that what we are aware of is "real," interesting experiments have been done to show that our brains actually make up, or "fill in" a great deal of our "reality."(5) We can't prove without a doubt that what anyone feels or believes is wrong. Probably the best way to think about schizophrenia is that the reality of a schizophrenic is wildly different from the reality of the rest of society. Although it seems silly, we should resist the temptation to automatically assume the schizophrenic reality is wrong. Consider the following testimony of Michele Misurelli, an airline ticket agent with schizophrenia:

"I believed that some of the people I worked with were Communist spies who travelled from airport to airport trying to blow things up. In schizophrenia you take in information from all five senses properly but you interpret it wrong. If someone followed me down a hallway, I thought they were going to kill me. I thought Communists sprayed gas under my apartment door at night and performed brain surgery on me while I was sleeping. I thought they stuck a pick in my ear and pulled my brain out bit by bit. I woke up screaming in my apartment. I phoned my mother and told her that the Communists were going to kill me."(6)

If we resist the temptation to immediately disregard Misurelli's testimony as false and ridiculous, we can see that her reality is simply different from and at odds with the reality of everyone around her. The serious issue for Misurelli is that she can not possibly have a happy existence due to the world she lives in. She is essentially living in a reality that is not her own. There is no easy solution for her. Because she is miserable, the only option is to try to medicate her, to dull her reality. This option is rarely a perfect solution.

Historically, treatment resistance has been a very serious issue for patients with schizophrenia. More than 80% of people who have a single psychotic episode never recover, and most have increasingly severe symptoms with each successive episode. The majority of schizophrenia sufferers can not hold down a job or complete their eductaion. For a long time, anti-psychotic drugs which acted on the D2 dopamine receptor were prescribed. These drugs, however, produced numerous unpleasant side effects including tremor, akathisia, stiffness and pseudoparkinsonism. Because of the side effects, patients would understandably discontinue taking their medication.(2) It is hard to believe that a drug which had so many side effects that the patient could barely function while taking it was deemed effective. The positive schizophrenic symptoms may have ceased, and the person may no longer have been a threat, but the person is also practically dead. The once over-active I-function is now clouded and dulled by drugs. Which is better?

For me, the most convincing reason not to dismiss the reality of the schizophrenic is that researchers are having a great deal of difficulty coming up with any physical abnormalities which lead to schizophrenia. A great amount of research has been done investigating possible biological bases for schizophrenic behavior. A recent experiment done by Jens Jakob Thune, Harry B. M. Uylingsb, and Bente Pakkenberga tested the possibility that schizophrenia is caused by a deficit of neurons in the prefrontal cortex. In their study they examined 8 brains of schizophrenic patients and 10 control brains of the same age. They found that the average number of neurons in the schizophrenic brain was 2.76x109 and the average number of neurons in the control brain was 3.11x109. The difference in the values was determined to be non-significant, and the researchers concluded that loss of neurons is not a cause of schizophrenia(1).

In other mental illnesses, such as Alzheimer's disease, the brain deteriorates causing dementia. Schizophrenia does not involve brain deterioration. Schizophrenia is also different from dementias in that there are no plaques, tangles, or Lewy bodies. There is also no gliosis (a signal of neuronal death). Some studies have suggested that genetic factors may lead to the disease. However, the disease continues to occur even though schizophrenics generally do not marry or have children. Also, in identical twins, the concordance rate is only 40%, indicating that genetics are not the most significant factors in the cause of schizophrenia.(4)

In this paper I have tried to challenge the popular notion that schizophrenia is a disease and should be treated as such. I certainly do not believe that schizophrenics should be untreated. We really have no choice but to medicate people, in order to give them the chance to function as best they can in the only world that exists. The unfortunate truth is that drugs are not effective for the majority of schizophrenics. It seems the only purpose of the drugs is to dull people and make them less of a threat to a society which is made uncomfortable by that which it can not explain. I feel that schizophrenics would receive significantly more respect and dignity if their individual realities were recognized as valid, regardless of how irrational they seem.

WWW Sources

1)No deficit in total number of neurons in the prefrontal cortex in schizophrenics

2)Schizophrenia Article from the New England Journal of Medicine

3)A schizophrenia online diagnosis quiz

4) Understanding the Causes of Schizophrenia Article from the New England Journal of Medicine

5)Grobstein, Paul. Lecture, Neurobiology and Behavior 202, April 2001.

6)"Walls Were Closing In" Testimony from a woman with schizophrenia

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