Thursday, December 8, 2011

“The Making of a Troubled Mind”

David Dobbs describes new developments in schizophrenia research, prodromal schizophrenia, and potential new treatments for the disorder in “The Making of a Troubled Mind”. He cites several recent advancements in researchers’ understanding of the disease and indicates that targeting GABA receptors is a promising pharmacological therapy. Like many psychiatric and medical diseases, schizophrenia presents itself in various subtle ways before it may be clinically recognized and diagnosable. This is because the mechanisms behind the disease—dysfunctional pyramidal and chandelier cell structure and activity, at least in part—are present throughout a person’s life but only start causing significant, noticeable problems in adolescence. Pre-clinical signs of schizophrenia may include paranoia, cognitive impairments, hallucinations or “peculiar” thoughts.

Dobbs mentions a survey to assess a young person’s risk of developing schizophrenia—the Structured Interview for Prodromal Syndrome. It has shown up to an 80% accuracy rate for predicting which young people will go on to have a psychotic episode over the next two-and-a-half years. Diagnosing someone with prodromal schizophrenia could provide the opportunity for them to begin an antipsychotic regimen early, as well as “psychotherapy, cognitive training [and] family therapy”. It seems perfectly benign on the surface, but herein lays the question of ethics: how beneficial is it to administer this survey to adolescents?

Til Wykes presents the argument that “false positives”—that is, classifying someone as “high risk” of developing schizophrenia when they are not going to develop the disorder—in fact outweighs the “good” that true early diagnoses might accomplish. Falsely diagnosing someone with prodromal schizophrenia will, in many cases, cause family members, friends, and the person himself to view a patient differently. A diagnosis of schizophrenia may cause anxiety. These psychological stressors may turn into a self-fulfilling prophecy: they could “generate just the thing [i.e., schizophrenia] that you’re trying to protect against.” Wykes claims that these false-positive patients are “not really” at risk of developing schizophrenia.

This is a claim with which I whole-heartedly disagree. I posit that these people are at the same exact high risk of developing schizophrenia as are the individuals who do actually experience psychoses within the following two years. They are merely the “lucky ones” whose particular gene-environment interaction was not substantially conducive to develop psychosis. Perhaps they are just somehow more resilient, or perhaps they have not yet experienced psychosis. Maybe they will in the next five years. As Dobbs’ graph indicates, schizophrenia does not only target adolescents or 20-somethings. 

Wykes does not cite any research substantiating her claims that anxiety regarding a diagnosis of prodromal syndrome could independently lead to psychosis. A quick PubMed search did not turn up any evidence showing this exactly; however a few studies indicate that a patient’s home life and family relationships may predict the onset of his first psychotic episode.

In any case, the thoughts and behaviors measured by the Structured Interview for Prodromal Syndrome are indicative of some abnormality. Hallucinating “whisperings”, experiencing paranoia, and having fragmented thoughts are not hallmarks of normal adolescent development. Perhaps they are not certain signs of schizophrenia, but they are certainly symptoms which should be addressed clinically.

Wykes’ assertion that the risk of making errors of false-positive diagnoses in up to 20% of adolescents outweighs the potential benefits for diagnosing other teens early is also a fallacy. Dobbs cites the statistic that screening for cardiovascular disease has a similar accuracy rate, and mild cognitive impairment (a prodromal stage of dementia) predicts conversion to clinical dementia with an accuracy of about 60%. Anxiety also has exacerbating effects to these two clinical disorders; it would be ridiculous to suggest that we not identify those who are at risk for heart disease or Alzheimer’s disease because it might cause unnecessary worry. Early treatment for each of these disorders, including schizophrenia, may result in an improved prognosis, or at least a delay or lessened severity in the clinical onset of the disorder. 

Schizophrenia, though a serious and scary disorder, there are many misconceptions surrounding the diagnosis. For those who are fearful of unnecessary anxiety regarding a false diagnosis of prodromal schizophrenia, efforts should be made to lessen this anxiety. First of all, it should be possible to make this screening completely voluntary. Patients and their families should be given ample resources and information should be made available to them in an attempt to lessen the potential misconceptions and anxiety, even before administering a screening. Family and cognitive therapy should also be a part of these adolescents’ early intervention regimen.

While there are no sure-fire treatments or preventions for schizophrenia currently, Dobbs alludes to the fact that promising therapies are being researched. Several studies have shown that current therapies (some pharmacological, some psychotherapy-based) may slow the progression of or improve the outcome of early-stage schizophrenia. Furthermore, with improved understanding of and treatments for schizophrenia, it is likely that early-intervention outcomes (as well as screening measures) will improve.

--Amy Luce
Neuroscience Graduate Program


Want to cite this post?
Luce, A. (2011). “The Making of a Troubled Mind”. The Neuroethics Blog. Retrieved on , fromhttp://www.theneuroethicsblog.com/2011/12/neuroethics-blogpost.html



Sources

(2003). Early intervention for people with psychosis. Retrieved from National Institute for Mental Health in England website: http://www.p3-info.es/PDF/NIMHE.pdf
Coentre, et al. (2010). Early intervention in psychosis: Prepsychotic period. Acta Med. Port., 23 (6). 1083-90.
Dobbs, D. (2010). The making of a troubled mind. Nature, 468. 154-156.
Marshall, M. & Rathbone, J. (2011). Early intervention for psychosis. Cochrane Database Syst. Rev., 6.
Onwumere, J. et al. (2011). Family interventions in early psychosis: Specificity and effectiveness Epidemiol Psychiatr Sci, 20, (2). 113-119.

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