1 Boring Old Man

This month’s American Journal of Psychiatry has an editorial and several articles addressing the question of treating patients with symptoms suggesting a coming Schizophrenic Illness with antipsychotic medications as preventive medicine. The short editorial is available on-line and nicely summarizes the history of this debate [Early Intervention for Schizophrenia: The Risk-Benefit Ratio of Antipsychotic Treatment in the Prodromal Phase]. There’s little question that a Schizophrenic Psychosis can be a catastrophic event, marking an abrupt downturn in a person’s life – a phenomenon noted by Kraepelin and immortalized in his name for the condition – Dementia Praecox. But the notion of preemptive treatment is an issue bathed in controversy. Right now, the DSM-V task force is considering adding the Prodromal Risk Syndrome as an official diagnosis to their official manual. It is also a time when there’s a loud protest that psychiatrists are already overmedicating people, that antipsychotics do more harm than good [eg Anatomy of an Epidemic by Robert Whitaker]. Likewise, there’s a renewed focus on the toxic side effects of the antipsychotic drugs [neurologic and metabolic]. And because of the exposure of so many examples of intrusion of the profiteering motives of pharmaceutical companies into the halls of academic medicine, there’s the suspicion that this is just another example. I can’t imagine a more divisive issue – a lightening rod for several already contentious ongoing debates. I’m no expert on any of these issues, but I do have some thoughts on the topic, though it will take a couple of posts to explain them.

I’m something of a history buff, so when I encountered Schizophrenia as a resident, I read and reread the fascinating works of the old guys [Emil Kraepelin, Eugen Bleuler, Harry Stack Sullivan, etc.] from the pre-neuroleptic era with great interest. Kreapelin’s original descriptions portrayed the condition in the negative – a catastrophic illness coming in young adulthood with a deteriorating course leading to an early death. Bleuler came along later and renamed it Schizophrenia, hypothesizing a split between thought and emotion [ergo "schiz" and "phrenia" – divided mind]. He found that the prognosis was not so dire, with outcomes ranging from seemingly full recovery to the grim prognosis described by Kraepelin, with countless variations in between. [Sullivan’s contributions are "un-summarizable"]. Bleuler was a careful clinician, and talked about the personality of people who later developed the illness [the Schizoid Personality]. They were generally loners who occupied themselves with intellectual or other solitary pursuits rather than joining in the social world of their peers. He was quick to point out that most people with this personality style did not go on to develop the illness. Later writers in the pre-neuroleptic era  described the prodrome in more detail. At some point, the Schizophrenic-to-be person entered a period called the trema – a time when things just didn’t feel right. There might be vague physical symptoms ["my urine smells bad," "my skin is changing colors,"] or a syndrome called "homosexual panic" ["my genitals are shrinking," "I’m turning into a girl" or a "homosexual"]. There might be an abrupt change in religion, vocation, college major etc. The unifying theme is a loss of feeling "anchored." At the charity hospital where I trained, there was a visible marker, a "blue line." In the thick charts of older Schizophrenic patients, there was a visible blue line near the front of the chart [the emergency room sheets were blue]. Reviewing the charts, there was a flurry of ER visits for vague physical symptoms with no medical cause. Then there would be a note like "patient brought in by family acutely psychotic" followed by "transferred to Central State" [the old State Mental Hospital of the era]. The old psychiatrists called this kind of acute break with reality the apophany – a fantastic "aha" experience that explained the confusion in some bizarre, paranoid way.

Somewhere in my residency, a faculty member trained long before gave us a lecture on what he called the supportive psychotherapy of Schizophrenia – something I’ve never heard before or since. He started with Bleuler – the "split" between thought and emotion. He said that Schizophrenic patients had a relative inability to use emotion to direct their thinking, and that it caused constant havoc in their lives. The lecture was so long ago that I don’t recall if this example started as his or my own, but it’s of a person who became psychotic at a public cafeteria. The server asked her what she wanted, and she became catatonic in line. She later said that she had no idea how to answer that question. At a later time, she said that she’d figured out how to make such decisions. She picked the third meat – unless it was liver – and the third vegetable – unless it was cauliflower [I guess liver and cauliflower point to the relativity of the defect]. He called this "schizotaxia" or emotional ataxia. He then talked about the well known difficulty of Schizophrenic patients to understand abstract meanings – one of the "four As" in Bleuler’s diagnostic criteria. He said it was a daily problem to live in a world where everything was taken literally. He explained the fantastic delusions and paranoid ideas as what one does when abstract meanings in the world are unavailable or cryptic.

It was one of the most helpful lectures I ever heard. Later, working in a community mental health setting, his formulation was validated over and over by chronic patients who would come in with an exacerbation. When it was possible to trace back and identify the precipitating event, it was invariably something emotionally ambiguous or a "missed" abstract communication. Years later, it became the framework for treating a patient of my own. She was a young adult, a few years post college who I was asked to see in consultation. After graduating Magna Cum Laude from a prestigious college with a Liberal Arts Degree [American Studies], she returned to Atlanta unsure about what came next. She moved into an apartment with someone advertising for a roommate and began to work at a bank. She was from a well placed and close family. Her older siblings were all very successful professionals. The job was a solitary sales/promo job of some sort. She seemed to become increasingly depressed and saw several psychiatrists, taking a variety of medications – antidepressants, soft neuroleptics, and antianxiety drugs – all without benefit. At some point, she went to a large open-atrium hotel in downtown Atlanta and was standing by the railing on the 14th floor contemplating jumping. A cleaning lady saw her and the police were called. She ended up hospitalized with a friend of mine as her doctor. He asked me to see her as a consultant.

She was confused. My friend was confused. So was I. She didn’t seem depressed and had no explanation for her behavior. At the time I saw her, she was completely focused on getting out of the hospital because she didn’t want to be a financial burden on her parents. It was over thirty years ago, but I recall  the interview clearly. She was coherent with no signs of psychosis. She was ill-suited and untrained for her job, but mainly felt she’d failed her parents who had been instrumental in getting it through a friend at the bank. She had no explanation for her behavior. What I mainly recall from the interview was that she tried very hard to answer every question I asked her, but looked at me oddly, as if to say, "Why are you asking that?" I saw her several times, still feeling somewhat lost. By this time, the pressure to leave the hospital had escalated and they set up a plan. She would go home to her parents house, take a leave from her job, and see both my friend and I as an outpatient. Once home, she refused both options, or to take any medicine, or to see anyone else. She told her parents that she would see me in the future, when she’d "sorted things out."