New research on schizophrenia suggests that the drugs won't always work
The psychiatric establishment is about to experience an earthquake that will shake its intellectual foundations. When it has absorbed the juddering contents of the latest edition of one of its leading journals, Acta Psychiatrica Scandinavica, it will have to rethink many of its most cherished assumptions. Not since the publication of RD Laing's book Sanity, Madness and the Family, in 1964, has there been such a significant challenge to their contention that genes are the main cause of schizophrenia and that drugs should be the automatic treatment of choice.
With his colleagues, guest editor John Read (whose name I shall use as a generic term for this body of evidence), a leading New Zealand psychologist, slays these sacred biological cows. The fact that some two-thirds of people diagnosed as schizophrenic have suffered physical or sexual abuse is shown to be a major, if not the major, cause of the illness. Proving the connection between the symptoms of post-traumatic stress disorder and schizophrenia, Read shows that many schizophrenic symptoms are directly caused by trauma.
Before proceeding any further with Read's evidence, two important caveats must be entered. Firstly, many parents of offspring with the illness may find what follows deeply upsetting or infuriating. But this is not about blame, and it is not being suggested that all cases are caused by parental care. It is also important to realise that the new evidence is far more optimistic in its implications than the psychiatric establishment's view, for patients, parents and carers alike. Secondly, it is important to stress that plenty of psychiatrists do not subscribe to all the tenets of the establishment view. I recognise that many are working in good faith with an incredibly testing patient population, and do a tremendous amount to help them.
The cornerstone of Read's tectonic plate-shifting evidence is the 40 studies that reveal childhood or adulthood sexual or physical abuse in the history of the majority of psychiatric patients (see, also, Read's book, Models of Madness). A review of 13 studies of schizophrenics found rates varying from 51% at the lowest to 97% at the highest. Crucially, psychiatric patients or schizophrenics who report abuse are much more likely to experience hallucinations. The content of these often relate directly to the trauma suffered. At their simplest, they involve flashbacks to abusive events which have become generalised to the whole of their experience. For example, an incest survivor believed that her body was covered with ejaculate. The visual hallucinations or voices often tyrannise and belittle the patients, just as their tormentors did in reality, creating a paranoid universe in which intimates cannot be trusted.
More research is needed to establish if abuse also heralds the other key symptoms of the illness, for example, incoherent, confusing or downright weird language. Studies already show that this is much more likely if the subject of conversation is emotionally charged. When asked to talk about sad rather than happy memories, speech becomes measurably more disordered, increasingly so the more personal the subject matter. We need research to investigate if verbal incoherence is abuse-related.
Another symptom is dissociation (feeling disconnected from oneself and surroundings). This has been shown many times over to be more common in the abused. It remains to be seen if catatonia (complete withdrawal from the world) is so related, although it seems extremely likely that it will be because elements of this are often found in victims of trauma. The same may be true of depressive thoughts, which many schizophrenics suffer and which are rife in the abused. About 15% of schizophrenics die by suicide, and depression is the norm in the suicidal. Suicide attempts are more common among people who have been abused as children, suggesting an abuse-schizophrenia connection, via depression and suicide.
Among the sexually abused there is a greater risk of developing schizophrenia the earlier the abuse happened, the closer the relation to the abuser and the more invasive the acts. Of course, not all schizophrenics suffered trauma and not all abused people develop the illness. What makes the difference? Apart from the possible role of genes, less overtly cruel early childhood maltreatment, other than actual abuse, may be important. In a review of the 33,648 studies conducted into the causes of schizophrenia between 1961 and 2000, Read found that less than 1% was spent on examining the impact of parental care. What is more, the amounts have decreased steadily, from 1.6% during the 1960s, to four times less than that during the 1990s. Despite this, enough studies have been done to suggest negative or confusing early care may be an important addition to abuse as a cause.
Since mothers spend far more time caring for children than fathers (who account for much of the abuse), their role may be critical in this regard. There is now a vast body of evidence that early infantile deprivation and erratic or unresponsive care as a toddler make adults more vulnerable to depression and personality disorder (a close diagnostic relative to schizophrenia. See my book They F*** You Up - How to Survive Family Life).
It is very possible that maternal deprivation creates a vulnerability to schizophrenia if there is subsequent abuse. Children with schizophrenic mothers are twice as likely to develop the illness as those with an afflicted father. This could be because disturbing mothers are a major factor. Equally, it could be due to gender-linked genetic inheritance, but there are strong reasons to doubt it.
For instance, the mothers of 11,000 Finns were asked if they had considered an abortion for their child during pregnancy, a clear sign that the child was unwanted, increasing the likelihood of subsequent maternal deprivation. Followed up 28 years later, the offspring of mothers who had sought abortions were four times more likely to be schizophrenic - not likely to be anything to do with genes.
Parents' negativity and tendency to be mystifying - paradoxical, contradictory injunctions - may also be important. These were measured in families with problem boys who had not yet developed signs of schizophrenia. After 15 years, the more negative and mystifying the parents had been in a son's childhood, the greater his likelihood of being schizophrenic or of having symptoms.
Of course, that does not rule out the possibility that genes may play a significant role in plenty of schizophrenia, but, even in these cases, the only recent study of the role of early environment shows how important it is. Fifty-six children born to schizophrenic mothers who had subsequently been adopted at a young age and who were therefore, in theory, put at higher genetic risk of developing the illness, were compared with 96 adoptees who were at low risk because none of their biological parents had it. The families were observed extensively when the children were small and all the adoptees were assessed for psychiatric illness in adulthood.
On its own, simply having a greater genetic risk (because of schizophrenia in the biological mother) did not increase the likelihood that the child would develop schizophrenic symptoms. Genes alone did not cause the illness. However, if there was a high genetic risk and it was combined with mystifying care during upbringing, the likelihood was greater. This suggests that genes can be implicated, but only if the family environment is of the kind that fulfills schizophrenic genetic potential.
What, then, is the main case for genes playing a role? A recent review by Robert Plomin, the world authority on genetic causes of human behaviour, revealed that, apart from for Alzheimer's, not a single gene has been shown to play a critical role in any mental illness. There is no evidence that the genetic material of schizophrenics differs in any way from people without the illness.
For the time being, this places the burden of genetic proof on studies of identical twins and adoptees. Putting to one side the fact that there are serious doubts over the validity of twin studies as a method (see Jay Joseph's The Gene Illusion), suppose 100 schizophrenics all had genetically identical siblings. Studies show that half of the identikits will also have the illness. What explains its absence in the other half? Because both have exactly the same genes, the one thing of which we can be certain is that differences in genes are not the reason. It proves beyond peradventure that environment plays an important role in causing some schizophrenia.
More general evidence of the crucial role of environment comes from sociological studies. Schizophrenia is around 12 times more common in children of West Indian immigrants to Britain. Increased rates have been found for immigrants to other countries. Poor people are several times more likely than the rich to suffer schizophrenia, and urban life increases the risk.
Rates of schizophrenia vary as much as 16-fold around the world, as does its course. It is less common in developing nations and tends to last much longer and be more severe in rich, industrialised nations compared with poor, developing ones (even so, about 20% of schizophrenics in developed nations recover completely without taking anti-psychotic drugs). In fact, if you become ill in a developing nation where hardly anyone is treated with drugs, you are 10 times less likely to have any recurrence of the illness - a huge difference, also nothing to do with genes.
What it may have a lot to do with is the administration of drugs (see British psychologist Richard Bentall's book, Madness Explained). They have been shown to impede traumatised people from understanding their voices or visions and recovering from them. There is a close relationship between the drug companies and the psychiatric establishment. While it may not be the intention, the establishment explanation of the causes of and solutions to schizophrenia are crucial components in the process of selling drugs. If patients can be persuaded their illness is an unchangeable genetic destiny and that it is a physical problem requiring a physical solution, drug companies' profits will grow. Read shows those who buy this genetic fairytale are less likely to recover, and that parents who do so are less supportive of their offspring.
The huge importance to drug company profits of the bio-genetic refrain becomes apparent when you learn that most people do not hum along with it. Surveys find that the majority of people mention such environmental factors as trauma, stress and economic hardship as the commonest causes of schizophrenia. It may be seen that the drug companies have an uphill struggle to persuade them otherwise, for which they badly need the help of the psychiatric establishment's towrope. In Read's analysis, letting go of that rope will prevent it strangling the many schizophrenics whose illness has been caused by abuse. Genes may still emerge as a major cause of vulnerability to schizophrenia, as may problems during pregnancy. There is already no question that illicit hallucinogenic drugs are a major reason some vulnerable people become ill. But even if this is true, following Read's important work, it will be hard to ignore its implications.
All patients will need to be asked in detail about whether they have been abused. Anti-psychotic drugs will no longer be doled out automatically, psychological therapies will be employed much more frequently. The psychiatric establishment will have to spend more research money on investigating the role of nurture in causing the illness. Above all, as advisers to government, it will have to recommend much better systems for early detection of traumatised individuals and the funds to provide the kind of support for parents that could prevent much, if not most, schizophrenia.
There are already signs of a change in perspective. In August, the president of the American Psychiatric Association bemoaned his profession's subservience to drug companies and the fact that "we have allowed the bio-psycho-social model to become the bio-bio-bio model". As Read reports in his earth-shattering edition of Acta Psychiatrica Scandinavica, for too long the role of trauma has been ignored by the establishment and "the possibility of a relationship with psychosis has been minimised, denied or ignored". Read's earthquake may trigger a landslide.
á Oliver James trained and worked as a clinical psychologist. He is the author of They F*** You Up - How to Survive Family Life
By Mary O'Hara posted 27 October 05
UK: In May, 24-year-old Azrar Ayub, a patient at the Edenfield secure mental health unit, part of Prestwich hospital near Manchester, died after being restrained by hospital staff. It was a tragic reminder of the death of the 38-year-old mental health patient David "Rocky" Bennett in similar circumstances in a Norwich hospital in 1998. Bennett's death caused a public outcry and resulted in an official inquiry, which led earlier this year to the issuing by the National Institute for Clinical Excellence (Nice) of new guidelines on the use of restraint. So why, six years after Bennett's death, does it appear that deaths as a result of restraint are still occurring?
First, the big picture. There were 116,000 incidents involving violent or verbal abuse in the NHS in England and Wales in 2002/03. About half were in mental health settings. Many of these would have involved a patient being restrained. It is generally believed that deaths caused by restraint are rare, but there are no reliable figures on injuries or deaths.
Restraint is often regarded by mental health nurses as a vital, if undesirable, measure of last resort for dealing with violence on wards. Establishing why some techniques might lead to injury or death is not easy. Each individual case is different, and a range of factors need to be taken into account - for example, whether staff were trained properly or whether the technique had been applied incompetently.
The Nice guidelines were designed to help guide staff and trusts on what is acceptable, but have been criticised for not going far enough to protect vulnerable mentally ill people against, in particular, prone restraint, where the patient is held face down, and which risks death from asphyxiation.
At a conference called Care or Abuse? last week in Derby, more than 100 mental health professionals, trainers, educators and service users discussed and challenged some of the most controversial and questionable restraint methods. During one dramatic presentation, a former mental health service user recounted - at times in tears - what it was like to come close to death while being held face down on the floor by four nurses when she suffered a "psychotic episode" in 2003.
One mental health trust director called for a ban on methods that, in his view, caused distress or pain to patients. He claimed that at his trust, such methods had been abandoned, leading to a cut in the number and severity of violent incidents. But he was accused by one delegate (a restraint trainer) of being sensationalist. Their exchange illustrated that even after the Bennett inquiry and the Nice guidelines, there is still a fissure in the mental health establishment over what is and what is not ethical and acceptable practice when it comes to restraint.
The conference shed light on why some forms of restraint remain problematic. Some acute mental health services in the UK are managed badly and are short of cash and staff, putting extraordinary pressure on nurses to react to incidents by restraining patients rather than talking to them to defuse potentially violent situations. These difficulties are exacerbated because trusts do not agree on which restraint methods to use or when to apply them.
There are around 2,500 restraint techniques currently being taught by a multitude of private companies, but there has never been a national evaluation to standardise training. Some research has been conducted but it is patchy and the results are far from conclusive. The Department of Health has plans to collect more accurate figures on injuries and deaths caused by restraint, but scepticism persists over their reliability because of fears of under-reporting.
In the absence of robust evidence on physical restraint or injuries caused by it, we are gambling with the lives of some of the most vulnerable people in our society. It is a matter of urgency that we identify what works, what does not, and that we act on it.
