FPR-UCLA 4th Interdisciplinary Conference - Summaries

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Session 5 Summary: Cultural and Biological Contexts of Schizophrenia

Bilder’s team suggests that schizophrenia should also be thought of in terms of degrees rather than kind. Further, drugs are non-specific to syndromes; clinics and insurers (and ultimately patients) are in the “trap” of academia (DSM construction), the government (FDA regulation) and industry (pharmaceuticals that conform to FDA rules). Bilder concluded that a severity continuum of illness is more valuable than categorical taxonomy in understanding the biology of psychoses, which in turn can lead to better prevention and treatment.

Next, UCLA neuroscientist Tyrone Cannon presented current research from his group and others on prevention of psychosis in at-risk youth. His talk was divided into two parts: (1) recent work in the prediction of psychosis; and (2) understanding the neurobiological mechanisms underlying onset, especially particular aspects of brain development in late adolescence that seem to “go awry.”

The research paradigm for identifying prodromal patients (which is based on “the recent emergence of sub-psychotic intensity or psychotic-like symptomotology”) grew out of what were initially retrospective observations by Patrick McGorry and colleagues (University of Melbourne, Australia). McGorry’s group identified a period of substantial deterioration prior to onset of full-blown symptoms of psychosocial functioning, combined with the gradual emergence of paranoid ideation, and changes in perception, thinking, and behavior that are characteristic of or on a continuum with what is observed in full-blown illness, albeit not at the same levels of disorganization or intensity. An independent group at Yale led by Thomas McGlashan developed the Structured Interview for Prodromal Syndromes (SIPS) and a severity scale (SOPs). But transition rates in follow-up studies have varied due to the intrinsic limitation of small sample sizes and difficulty in detecting individuals at risk, given the tendency of health care systems to be “reactive” instead of “proactive.”

To increase sample size, eight prodromal psychosis research centers formed a consortium (the North American Prodrome Longitudinal Study; NAPLS) and pooled their data. The new data set has been used to (1) explore the rate of conversion to psychosis and the shape of the survival function over a 30-month follow-up period; and (2) develop a multivariate risk prediction algorithm that can guide the selection of high-risk cases in future studies. Cannon is hopeful that monitoring at-risk individuals will give us a “unique window” into the underlying changes in brain structure and function associated with onset of psychosis.

In the second part of the talk, Cannon focused on neurobiological changes. During adolescence, normal pruning eliminates 40% of cortical synapses. People with schizophrenia show gray matter changes, in particular a greater decrease in dendritic complexity and synaptic density with respect to healthy controls, as well as significant brain surface contraction, primarily in the prefrontal cortex. Potential genetic candidates for gray matter changes include sequence variations in or altered expressions of DISC1, a known susceptibility gene for schizophrenia. Additionally, UCLA prodromal participants failed to show normal age-related increase in medial temporal lobe white matter, which prospectively predicted poorer functional outcome. Cannon concluded that future studies should incorporate neurobiological assays in order to develop a panel of predictive biomarkers for risk of psychotic illness.

The third presentation featured USC law professor Elyn Saks, author of the memoir The Center Cannot Hold: My Journey Through Madness, who discussed her personal experience living with schizophrenia. As a young adult, Saks was given “very poor and grave prognoses”; she was not expected “to live independently, let alone to work” for the rest of her life. Her memoir describes how she fashioned a different life.

By the age of 5, Saks suffered from phobias, obsessions, and night terrors. She also experienced episodes of disorganization: “It was as if my mind was a sand castle with all the sand sliding away in the receding surf and no center to take things in, put them together, and make sense of them.” She experienced her first psychotic episode at 15. Saks graduated first in her class from Vanderbilt University. But her condition worsened while at Oxford University as a Marshall Scholar. She became “officially mentally ill” and was hospitalized twice at Warneford Hospital. On the advice of a sympathetic consulting psychiatrist trained in psychoanalysis (Anthony Storr), Saks resumed her studies in ancient philosophy while under psychoanalysis with a British practitioner and eventually attended Yale Law School. (For Saks, a woman of prodigious intelligence and infectious good humor, work is generally “the last thing to go.”) She was re-hospitalized and diagnosed with “chronic paranoid schizophrenia” in New Haven and, this time, put in restraints, force-fed an antipsychotic, and periodically secluded. Upon release, Saks re-entered psychoanalysis, graduated from Yale, and eventually joined the faulty of University of Southern California. Although she continued to experience psychotic episodes, she was never hospitalized again, which she attributes to medication and psychoanalysis. Saks said that, “Ironically, the more I accepted I had a mental illness, the less the illness defined me.” Talk therapy in particular allowed her to “take the chains” off her mind and fall apart. To her British psychoanalyst, “my thoughts and feelings were not right or wrong, good or bad, they just were.” She also said that psychoanalysis “has been the key to every other relationship I hold precious.”

Based on her experiences in both British and American psychiatric hospitals, Saks called for a change in treatment policy, particularly in such dehumanizing practices as the use of restraints. She also said that psychoanalytic or psychodynamic therapy is underrated, and should be central to treatment. Finally, echoing Kay Redfield Jamison, she stressed the importance of social bonds in recovery. Saks emphasized that her success was facilitated by the support and care of her close friends and husband. She is currently working on a joint UCLA-USC study on the lives and success of high-functioning schizophrenics in Los Angeles.

In the session’s final presentation, psychological anthropologist Robert Lemelson screened his ethnographic film, Shadows and Illuminations. The film, which is the first of a 3-part series entitled Afflictions, is based on 12 years of anthropological fieldwork in Indonesia to assess long-term recovery from serious mental illnesses. It focuses on the personal life narrative of a rural Balinese man in his late sixties known as Pak Kereta, who suffers from a psychotic-like illness. In the film, Pak Kereta describes a continuous intrusion of “shadows” or spirits in the form of sounds, apparitions (which he calls “illuminations”), and voices, which have made him fearful and reclusive and disrupted his marriage and working life.

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