seroquel VI: an mid-course interlude…

Posted on Saturday 12 February 2011

What follows is a pre-DSM III version of the illness, Schizophrenia, being treated in these studies we are currently examining:
    We don’t know what Schizophrenia is, but it is a disease  in the word’s original meaning – "dis-ease." The typical course was described by Eugene Bleuler at the turn of the twentieth history and remains the paradigm:
      Somewhere in late adolescence or young adulthood, a person who has seemed normal, if perhaps a bit shy or reclusive, enters a period [of variable length] where things become troubled. They may have hypochondriacal concerns, withdraw from their usual activities, make abrupt life changes, or any number of things – but they seem confused, upset. This was called by some The Trema – things just aren’t right anymore. At some point in this period of confusion, there is the first psychotic experience – called The Apophany or The Break [with reality]. They may hear threatening or directive voices, develop paranoid beliefs, have disjointed and confusing thoughts and emotions, or behave oddly [or badly]. What has been a quiet withdrawal before becomes very public as the patient-to-be responds to these private troubling experiences. Bleuler’s view of this illness was from inside the Mental Hospital. Many recovered and left, never to be seen again. But others did not recover and went on to develop one of the chronic forms of the illness – Paranoia, Catatonia, Hebephrenia, Chronic Undifferentiated Schizophrenia [all of the above]. The term, Dementia Praecox, coined by Kraeplin referred to the chronic forms – people who came into the hospital as young adults and went on to an early death.

    Bleuler described four Primary Symptoms, called the "four A’s" by generations of medical students:
    • Associations:
      The flow of Schizophrenic thought is disjointed, often impossible to follow. Thoughts are associated with each other in a "loose" way.
    • Affect:
      While the classic description is "inappropriate" emotions, the more basic problem is that patients with Schizophrenia have difficulty knowing their emotional experience and using it in their lives. Bleuler’s term, Shizophrenia, referred to a disconnect between emotions and thought.
    • Ambivalence:
      People with Schizophrenia have difficulty making decisions, staying lost in the push and pull of conflicting motivations.
    • Autism:
      Bleuler coined this term [now used for other things] to describe the "private logic" of the Schizophrenic person’s thoughts.
    To which we can add two other more basic "A’s":
    • Abstraction:
      Patients with Schizophrenia have difficulty with abstract meanings, living in a concrete, literal world where they miss the "music" of life. It’s no paradox that they come up with such elaborate meanings for everyday events. They don’t see the simple or the obvious.
    • Anhedonia:
      Literally, the absence of pleasure or experience of pleasurable emotions.
    These are not simply symptoms or diagnostic criteria. They are problems of a chronic schizophrenic life with or without active psychotic ideas or experience. Anti-psychotic Medication controls the "psychotic" symptoms, but the patient often continues to live in a literal and often confusing world with a relative absence of emotional nuance for guidance.
The old guy who wrote that piece up there sees Schizophrenia as an Affliction that manifests itself in the era of life where identity is usually formed and follows a widely variable course. The relative disconnect from an emotional steering wheel and abstract meanings can make living difficult, and the recurrent florid psychotic symptoms are often an attempt to deal with the confusion. Medications block these symptoms, but don’t "cure" the basic problem. In addition, medication mercifully prevents some of the deterioration in mental functioning seen in Bleuler’s day. The cause of Schizophrenia is unknown, but likely biologic. Such old men don’t know why this happens in approximately 1% of human beings, but doubt that the current medications reverse the "basic" problem.

In a post-DSMIII world, Schizophrenia is a Disease of unknown etiology with signs and symptoms divided into positive symptoms [hallucinations, delusions, paranoia] and negative symptoms [anhedonia, "emptiness," literalness]. Current medications help the former, and the search is on to find medicines that help the latter. While not stating it explicitly, there seems to be a belief that the current medication research trajectory may be headed towards something close to a cure. While the cause is assumed to be biologic, it’s not much discussed.

People seem to be of three minds about the medications used to treat Schizophrenia. There’s the enthusiastic group [usually in the post-DSMIII Psychiatrist group] that seem sure that medication is the treatment for Schizophrenia. There’s a group that sees the downside of medication, emotional blunting, side-effects, Tardive Dyskinesia, etc. This group sees the first group as "druggers," – sort of a Clockwork Orange or 1984 view [they are in turn seen by the first group as naive "tree-hugger-types"]. The third group [often old guys] sees Schizophrenia as a dilemma. The modern medications are better that the older treatments like life-long institutionalization, lobotomy, and early death – but dangerous and prone to overzealous use. While many patients do very well on medications, there are also a lot who don’t do so well no matter what one does, and require intermittent care in a variety of forms.

I’m obviously in group three, but that doesn’t mean that I don’t follow the drug research with interest. Like members of all three groups, a medication that "worked" with fewer side effects would be welcomed with cheers. A medication that "worked" on the negative symptoms would be a modern miracle we’d all love to see. "Is Seroquel that miracle medication?" No. "Is Seroquel effective?" "Is Seroquel safe?" "Does Seroquel add something to what we already have?" Those are the real medical questions all of these studies we’ve been looking over propose to address. Profitability to Zeneca or AstraZeneca is important to a lot of people, but not the afflicted…
    February 12, 2011 | 8:03 PM

    Thanks for this series, I look forward to continued thoughts from you on this topic. I would be interested in a book review of Robert Whitaker’s new book ‘Anatomy of an Epidemic’. Carlat read and reviewed it recently.

    There is a link to Whitakers pdf document ‘Affidavit of Robert Whitaker’ I would enjoy hearing your thoughts after reading his take on the antipsychotics, efficacy and long term outcomes for SZ and antipsychotic use, and take a look at the Finland study he talks/writes about.

    It seriously opens doors to the 3rd group you are in, seeing the SZ in patients and remaining without answers after all these decades (lifetimes), to take a serious look at antipsychotic use in America. Doctors like you have the chance to influence peers toward weaning off of the medication based paradigm and onto others with open minded thought for successful living, such as Soteria house programs etc.

    Thanks, keep picking apart the AstraZeneca documents!

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