Views From The Couch: Schizophrenia – an enigmatic mental illness with exact cause still not known

SINGAPORE - “When all is said and done, they are stranger to me than the birds in my garden,” said Swiss psychiatrist Eugen Bleuler of his patients with schizophrenia.

It was Dr Bleuler who, after years of socialising with his patients and studying them at close quarters, coined the term “schizophrenia” in 1911.

More than a century later, schizophrenia remains arguably the most unusual and enigmatic of all the mental illnesses. We don’t have a definitive cure, largely because we still don’t know its exact cause.

But we know that genes matter – more than a hundred independent sites scattered across the genome have been associated with schizophrenia, though each confers only a very small risk.

Adverse childhood experiences may matter, along with a host of other implicated factors like birth complications, urban living, stress of migration and demoralisation from racial discrimination. But in a large number of cases, there are no discernible risk factors.

In my long practice, I have seen hundreds of patients with schizophrenia, and in almost every case, I have been asked by bewildered patients and families why they have ended up with this illness.

Often, the only answers are words that are thoroughly unscientific (and that I sometimes can’t bear to say) – luck, chance, destiny.

Schizophrenia is the most serious form of psychosis, which is defined as a major mental disorder in which the individual’s ability to think, respond emotionally, interpret reality, and behave appropriately is impaired to the extent that it interferes grossly with his capacity to meet the ordinary demands of life.

Globally, somewhere between 0.5 per cent and 1 per cent of the world’s population – men and women of all ethnic and cultural groups – will be stricken with schizophrenia in their lifetimes. It is not the most common psychiatric condition; depression and anxiety disorders are the most common.

But various analyses by different bodies, including the World Health Organisation, have consistently shown that it is schizophrenia that has a disproportionately high social cost.

Moreover, owing to the nature of the illness and the infrequent, albeit widely publicised, tragic episodes, it is probably the mental illness with the most stigma attached – a stigma that remains almost unyieldingly durable as those who have fought it have discovered time and again.

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Typical of the manifestation of schizophrenia is the presence of delusions, which could be of different themes:

And there may be delusion of reference, whereby incidents and events in the outside world are interpreted as having a direct personal reference to the individual.

Common too are auditory hallucinations, in which individuals hear, inside or outside their heads, one or multiple voices, of people they know or of strangers. It may be a running commentary on their behaviour, or a conversation about them. The voices can be cruel and threatening, or strident and demanding, or friendly and comforting, or just plain annoying and distracting.

There may be difficulty in communicating with others because their thinking can be so bogged down in a morass of trivial details that it impedes any meaningful exchange, or their ideas keep slipping off one track and on to another, completely unrelated, one.

They may invent words and use them insistently, to the consternation of others. And there are what we refer to as “negative” symptoms, which are those that detract, such as loss of motivation, social withdrawal and apathy, as well as various cognitive impairments such as shortened attention span, poor memory, inability to plan and poor judgment.

The inevitable consequences of these myriad difficulties are educational, vocational and social impairments that can upturn their life, rupture relationships, and destroy hope, ambition and dreams.

Insight

Something we always assess in our patients with schizophrenia is their awareness of their predicament, or as we like to call it, “the insight” into their illness.

Patients are considered insightful when they can reinterpret their unusual experiences as symptoms indicative of a mental illness and recognise their need for help from mental health professionals.

But many do not see it that way, or accept the fact that they are ill. One of the peculiar – not to mention cruel – aspects of schizophrenia is that it often takes away the self-awareness that something is terribly wrong. The corollary of this is a frustrating ambivalence or outright antagonism towards any overtures of help.

The underlying cause of this lack of awareness (which is present in nearly half of the people with schizophrenia) is most likely due to some cognitive deficit intrinsic to the illness – in other words, it has nothing to do with wilfulness, it’s just that the person has lost the capacity to know.

Although researchers haven’t uncovered the distinct neurological anomalies linked to this lack of insight, they have referred to it as “anosognosia”.

This term is more commonly used in neurology to describe patients with brain damage who have subsequent paralysis of limbs or loss of senses about which they remain blithely oblivious (nor will they acknowledge), despite the new disabilities caused by their losses.

A person who has lost sight, for instance, will insist that he can still see even if he keeps knocking things down, and makes up all sort of excuses for the mishaps.

For the treating psychiatrist, this lack of insight and subsequent refusal to engage in treatment poses a challenging problem.

Having patients acknowledge that they are ill is a medical ethical imperative, because implicit in the principle of informed consent is the notion that before agreeing to have any treatment, patients should be aware of the nature and course of their own illnesses.

Psychiatrists are caught in a dilemma because it is only in psychiatry where the refusal of treatment is commonly viewed as a manifestation of illness rather than an authentic wish. Hence, the person is in need of treatment, though he may vigorously resist it.

Covert medication

If this is a common and troubling quandary for psychiatrists, it is the patient’s other caregivers who have the hardest time.

Adam (not his real name), a patient of mine, was the only child of doting parents. When young, he excelled academically in primary and secondary school.

But in his junior college years, his mother noticed that he became more distant and started withdrawing from his parents and from his friends. He did poorly in his A levels and seemed rather indifferent, though his parents took care to hide their disappointment.

Two weeks after his enlistment into national service, he was taken to the emergency department of the Institute of Mental Health (IMH) as he had expressed thoughts of wanting to kill himself in the belief that his platoon commander and the entire platoon were plotting against him.

When he came under my care, he was already in his early 30s and long diagnosed with paranoid schizophrenia, with a history of numerous hospitalisations at IMH.

Each hospitalisation was necessitated by a relapse of his illness, which was brought on by his refusal to take his medication in any form or manner.

Each relapse would be some variation of his paranoia of his family being in cahoots with their neighbours and the police, and whose multifarious voices he could hear day and night.

At times, there would be angry confrontations and threats, when the police would be called. These would end with his being taken to IMH for involuntary admission and treatment. His delusions and hallucinations would recede and return when he stopped his medication.

His mother, a worn and sad woman going on 70, said to me: “It’s exhausting to me. I can’t focus on doing things.” And of her son: “It pains me greatly... In my heart, I know he’s struggling and suffering.”

And she asked what many relatives of my patients ask – she pleaded with me to prescribe his usual medication for her to collect without his knowledge, which she would secretly mix with his food.

But I would not – could not – go along with that. It could be the first step on an insidious path leading to disaster. There may be danger of physical violence to his mother should Adam catch her in the act.

There are also risks to Adam, who could experience side effects of medications he did not consent to and had unknowingly taken, and he might misinterpret these side effects as further evidence of malevolent forces working against him; or he could take other drugs that may interact adversely with the one he was receiving covertly and cause him harm.

To collude in this deceptive act of using an untrained third party to surreptitiously deliver medication to a patient in the absence of a clear care plan is a betrayal of whatever trust he might have in me, and by extension could potentially undermine the trustworthiness of the psychiatric profession.

I tried to explain all this to Adam’s mother, but the reasoning was abstract and unhelpful to her – as with family members who are desperate for any remedy and in a lonely state of hypervigilance and fearful anticipation.

Involuntary commitment

What, then, is the alternative course of action in these fraught situations? We may activate our team of community nurses and case managers to coax him to come in for treatment. However, if he refuses, they do not have the legal right to compel him.

We will then have to wait until Adam becomes ill enough to justify calling the police to “escort” him to IMH.

As with many other countries, Singapore has laws for the involuntary commitment of a person to a mental health facility without his consent.

Under a specific section of the Mental Health (Care and Treatment) Act, it is stated that it “is the duty of every police officer or special police officer to apprehend any person believed to be dangerous to himself or herself or other persons and such danger is reasonably suspected to be attributable to a mental disorder and take the person to a designated psychiatric institution”, which, in Singapore, is IMH.

It is this waiting for that line to be crossed that causes much anxiety all round – putting the family on tenterhooks and causing the psychiatrist to worry if the family is being put in harm’s way or if the patient might end up harming himself.

Once the individual is taken to IMH, the Act empowers us to detain the patient for treatment if “it is necessary in the interests of the health or safety of the person or for the protection of other persons”.

I have committed many patients under this Act. In most instances, I know that it was the right decision (and it might have been life-saving). Eminent American psychiatrist Edwin Fuller Torrey once said, with some exasperation, that “to keep talking about civil liberty is illogical”.

“Patients are anything but free when they’re at the beck and call of their own delusions,” he said (Dr Torrey has a sister with schizophrenia, and he is the founder of the Treatment Advocacy Centre, which has lobbied for stronger commitment laws in the US).

The decision for involuntary commitment is also made with the expectation (and hope) that after the patient has been treated, he would recover his true sense of reasoning and retroactively agree that the intervention was in his best interest.

Research, however, shows that only about half of the patients who have been involuntarily hospitalised subsequently say that they needed the treatment.

To be honest, there have also been many instances when I have been plagued with this nagging doubt if I had done the right thing in committing the patient or whether I acted defensively out of self-interest (and I sometimes resent the societal implicit expectation for us psychiatrists to do the impossible of predicting danger perfectly and saving everyone).

I have practised long enough, spoken to enough patients to know that the effect of being forcibly hospitalised is traumatising, and in some instances, my relationship with my patients has been ruined after such an intervention.

The American Chinese author Esme Weijun Wang, in her book The Collected Schizophrenias, has written of her experiences of being committed involuntarily: “For those of us living with severe mental illness, the world is full of cages where we can be locked in. My hope is that I’ll stay out of these cages for the rest of my life, although I allow myself the option of checking into a psychiatric ward if suicide feels like the only other option. I maintain, years later, being held in a psychiatric ward against my will remains the most scarring of my traumas.”

As for Adam, he was subsequently admitted with the help of the police and was involuntarily hospitalised. He now comes regularly for his appointments at the outpatient clinic and is compliant with his medications – not because he has attained insight, but because he and I have reached an uneasy agreement that it’s the best way for him to avoid being committed.