Summer 2012

Beyond the Brain

by Tanya Marie Luhrmann

In the 1990s, scientists declared that schizophrenia and other psychiatric illnesses were pure brain disorders that would eventually yield to drugs. Now they are recognizing that social factors are among the causes, and must be part of the cure.

By the time I met her, Susan was a success story. She was a student at the local community college. She had her own apartment, and she kept it in reasonable shape. She did not drink, at least not much, and she did not use drugs, if you did not count marijuana. She was a big, imposing black woman who defended herself aggressively on the street, but she had not been jailed for years. All this was striking because Susan clearly met criteria for a diagnosis of schizophrenia, the most severe and debilitating of psychiatric disorders. She thought that people listened to her through the heating pipes in her apartment. She heard them muttering mean remarks. Sometimes she thought she was part of a government experiment that was beaming rays on black people, a kind of technological Tuskegee. She felt those rays pressing down so hard on her head that it hurt. Yet she had not been hospitalized since she got her own apartment, even though she took no medication and saw no psychiatrists. That apartment was the most effective antipsychotic she had ever taken.

Twenty years ago, most psychiatrists would have agreed that Susan had a brain disorder for which the only reasonable treatment was medication. They had learned to reject the old psychoanalytic ideas about schizophrenia, and for good reasons. When psychoanalysis dominated American psychiatry, in the mid-20th century, clinicians believed that this terrible illness, with its characteristic combination of hallucinations (usually auditory), delusions, and deterioration in work and social life, arose from the patient’s own emotional conflict. Such patients were unable to reconcile their intense longing for intimacy with their fear of closeness. The science mostly blamed the mother. She was “schizophrenogenic.” She delivered conflicting messages of hope and rejection, and her ambivalence drove her child, unable to know what was real, into the paralyzed world of madness. It became standard practice in American psychiatry to regard the mother as the cause of the child’s psychosis, and standard practice to treat schizophrenia with psychoanalysis to counteract her grim influence. The standard practice often failed.

The 1980s saw a revolution in psychiatric science, and it brought enormous excitement about what the new biomedical approach to serious psychiatric illness could offer to patients like Susan. To signal how much psychiatry had changed since its tweedy psychoanalytic days, the National Institute of Mental Health designated the 1990s as the “decade of the brain.” Psychoanalysis and even psychotherapy were said to be on their way out. Psychiatry would focus on real disease, and psychiatric researchers would pinpoint the biochemical causes of illness and neatly design drugs to target them.

Schizophrenia became a poster child for the new approach, for it was the illness the psychoanalysis of the previous era had most spectacularly failed to cure. Psychiatrists came to see the assignment of blame to the schizophrenogenic mother as an unforgivable sin. Such mothers, they realized, had not only been forced to struggle with losing a child to madness, but with the self-denigration and doubt that came from being told that they had caused the misery in the first place. The pain of this mistake still reverberates through the profession. In psychiatry it is now considered not only incorrect but morally wrong to see the parents as responsible for their child’s illness. I remember talking to a young psychiatrist in the late 1990s, back when I was doing an anthropological study of psychiatric training. I asked him what he would want non-psychiatrists to know about psychiatry. “Tell them,” he said, “that schizophrenia is no one’s fault.”

It is now clear that the simple biomedical approach to serious psychiatric illnesses has failed in turn. At least, the bold dream that these maladies would be understood as brain disorders with clearly identifiable genetic causes and clear, targeted pharmacological interventions (what some researchers call the bio-bio-bio model, for brain lesion, genetic cause, and pharmacological cure) has faded into the mist. To be sure, it would be too strong to say that we should no longer think of schizophrenia as a brain disease. One often has a profound sense, when confronted with a person diagnosed with schizophrenia, that something has gone badly wrong with the brain.

Yet the outcome of two decades of serious psychiatric science is that schizophrenia now appears to be a complex outcome of many unrelated causes—the genes you inherit, but also whether your mother fell ill during her pregnancy, whether you got beaten up as a child or were stressed as an adolescent, even how much sun your skin has seen. It’s not just about the brain. It’s not just about genes. In fact, schizophrenia looks more and more like diabetes. A messy array of risk factors predisposes someone to develop diabetes: smoking, being overweight, collecting fat around the middle rather than on the hips, high blood pressure, and yes, family history. These risk factors are not intrinsically linked. Some of them have something to do with genes, but most do not. They hang together so loosely that physicians now speak of a metabolic “syndrome,” something far looser and vaguer than an “illness,” let alone a “disease.” Psychiatric researchers increasingly think about schizophrenia in similar terms.

And so the schizophrenogenic mother is back. Not in the flesh, perhaps. Few clinicians talk anymore about cold, rejecting mothers—“refrigerator” mothers, to use the old psychoanalytic tag. But they talk about stress and trauma and culture. They talk about childhood adversity—being beaten, bullied, or sexually abused, the kind of thing that the idea of the schizophrenogenic mother was meant to capture, though in the new research the assault is physical and the abuser is likely male. Clinicians recognize that having a decent place to live is sometimes more important than medication. Increasingly, the valuable research is done not only in the laboratory but in the field, by epidemiologists and even anthropologists. What happened?

The first reason the tide turned is that the newer, targeted medications did not work very well. It is true that about a third of those who take antipsychotics improve markedly. But the side effects of antipsychotics are not very pleasant. They can make your skin crawl as if ants were scuttling underneath the surface. They can make you feel dull and bloated. While they damp down the horrifying hallucinations that can make someone’s life a misery—harsh voices whispering “You’re stupid” dozens of times a day, so audible that the sufferer turns to see who spoke—it is not as if the drugs restore most people to the way they were before they fell sick. Many who are on antipsychotic medication are so sluggish that they are lucky if they can work menial jobs.

Some of the new drugs’ problems could be even more serious. For instance, when clozapine was first released in the United States in 1989, under the brand name Clozaril, headlines announced a new era in the treatment of psychiatric illness. Observers described dramatic remissions that unlocked the prison cage created by the schizophrenic mind, returning men and women to themselves. Clozaril also carried the risk of a strange side effect: In some cases, blood molecules would clump together and the patient would die. Consequently, those who took the drug had to be monitored constantly, their blood drawn weekly, their charts reviewed. Clozaril could cost $9,000 per year. But it was meant to set the mind free.

Yet Clozaril turned out not to be a miracle drug, at least for most of those who took it. Two decades after its release, a reanalysis published in The Archives of General Psychiatry found that on average, the older antipsychotics—such as Thorazine, mocked in the novel One Flew Over the Cuckoo’s Nest for the fixed, glassy stares it produced in those who took it—worked as well as the new generation, and at a fraction of the cost. Then there was more bad news, which washed like a tidal wave across the mental health world in the late 1990s, as if the facts had somehow been hidden from view. These new antipsychotics caused patients to gain tremendous amounts of weight. On average, people put on 10 pounds in their first 10 weeks on Clozaril. They could gain a hundred pounds in a year. It made them feel awful. I remember a round young woman whose eyes suddenly filled with tears as she told me she once had been slender.

The weight not only depressed people. It killed them. People with schizophrenia die at a rate far higher than that of the general population, and most of that increase is not due to suicide. In a now famous study of patients on Clozaril, more than a third developed diabetes in the first five years of use alone.

The second reason the tide turned against the simple biomedical model is that the search for a genetic explanation fell apart. Genes are clearly involved in schizophrenia. The child of someone with schizophrenia has a tenfold increase in the risk of developing the disorder; the identical twin of someone with schizophrenia has a one-in-two chance of falling ill. By contrast, the risk that a child of someone with Huntington’s chorea—a terrible convulsive disorder caused by a single inherited gene—will go on to develop the disease goes up by a factor of 10,000. If you inherit the gene, you will die of the disease.

Schizophrenia doesn’t work like that. The effort to narrow the number of genes that may play a role has been daunting. A leading researcher in the field, Ridha Joober, has argued that there are so many genes involved, and the effects of any one gene are so small, that the serious scientist working in the field should devote his or her time solely to identifying genes that can be shown not to be relevant. The number of implicated genes is so great that Schizophrenia Forum, an excellent Web site devoted to organizing the scientific research on the disorder—the subject of 50,000 published articles in the last two decades—features what Joober has called a “gene of the week” section. Another scientist, Robin Murray, one of the most prominent schizophrenia researchers in Europe, has pointed out that you can now track the scientific status of a gene the way you follow the performance of a sports team. He said he likes to go online to the Schizophrenia Forum to see how his favorite genes are faring.

The third reason for the pushback against the biomedical approach is that a cadre of psychiatric epidemiologists and anthropologists has made clear that culture really matters. In the early days of the biomedical revolution, when schizophrenia epitomized the pure brain disorder, the illness was said to appear at the same rate around the globe, as if true brain disease respected no social boundaries and was found in all nations, classes, and races in equal measure. This piece of dogma was repeated with remarkable confidence from textbook to textbook, driven by the fervent anti-psychoanalytic insistence that the mother was not to blame. No one should ever have believed it. As the epidemiologist John McGrath dryly remarked, “While the notion that schizophrenia respects human rights is vaguely ennobling, it is also frankly bizarre.” In recent years, epidemiologists have been able to demonstrate that while schizophrenia is rare everywhere, it is much more common in some settings than in others, and in some societies the disorder seems more severe and unyielding. Moreover, when you look at the differences, it is hard not to draw the conclusion that there is something deeply social at work behind them.

Schizophrenia has a more benign course and outcome in the developing world. The best data come from India. In the study that established the difference, researchers looking at people two years after they first showed up at a hospital for care found that they scored significantly better on most outcome measures than a comparable group in the West. They had fewer symptoms, took less medication, and were more likely to be employed and married. The results were dissected, reanalyzed, then replicated—not in a tranquil Hindu village, but in the chaotic urban tangle of modern Chennai. No one really knows why Indian patients did so well, but increasingly, psychiatric scientists are willing to attribute the better outcomes to social factors. For one thing, families are far more involved in the ill person’s care in India. They come to all the appointments, manage the medications, and allow the patients to live with them indefinitely. Compared to Europeans and Americans, they yell at the patients less.

Indian families also don’t treat people with schizophrenia as if they have a soul-destroying illness. As an anthropology graduate student, Amy Sousa spent more than a year in northern India, sitting with doctors as they treated patients who came with their families into a dingy hospital where overworked psychiatrists can routinely have 10 appointments an hour. Many of the doctors didn’t mention a diagnosis. Many of the families didn’t ask. There was a good deal of deception—wives grinding medication into the flour for the daily chapattis they made for their husbands, doctors explaining to patients that they were completely well but should take strengthening pills to protect themselves from the ravages of their youth. As a result, none of the patients thought of themselves as having a career-ending illness, and every one of them expected to get better. And at least compared to patients in the West, they generally did.

The most remarkable recent epidemiologic finding relates to migrants: Some fall ill with schizophrenia not only at higher rates than the compatriots they leave behind, but at higher rates than the natives of the countries to which they have come. Dark-skinned migrants to Europe, mostly from the Caribbean or sub-Saharan Africa, are at risk of developing schizophrenia at rates as much as 10 times higher than those of white Europeans. This is a dramatic increase, and it has been shown by so many studies conducted with such methodological care that it cannot be dismissed as diagnostic racism, as if white clinicians confronted with angry black men simply called them “schizophrenic” (even though this sometimes happens). Nor does it seem that biology alone can explain the increased risk, although serious research is now being done to test the hypothesis that vitamin D deficiency plays a role.

Some observers think that the epidemiologic finding is a stark story about the way racism gets under the skin and drives people mad. It is probably more complicated than that. Another young anthropologist, Johanne Eliacin, spent two years doing fieldwork among African-Caribbean migrants living in London. Eliacin saw racism, and she felt viscerally her subjects’ stinging sense of being unwanted and out of place. But she also saw a social world shot through with hostility and anger, in which people were isolated and often intensely lonely. The African-Caribbean people in Tottenham spoke of there being no community in the community. They held up schizophrenia as the symbol of what had gone wrong. Yes, racism lay at the root of the problem, but the tangible distress was the sense of being hopelessly trapped.

Epidemiologists have now homed in on a series of factors that increase the risk of developing schizophrenia, including being migrant, being male, living in an urban environment, and being born poor. One of the more disconcerting findings is that if you have dark skin, your risk of falling victim to schizophrenia increases as your neighborhood whitens. Your level of risk also rises if you were beaten, taunted, bullied, sexually abused, or neglected when you were a child. In fact, how badly a child is treated may predict how severe the case of an adult person with schizophrenia becomes—and particularly, whether the adult hears harsh, hallucinatory voices that comment or command. The psychiatrist Jean-Paul Selten was the first to call this collection of risk factors an experience of “social defeat,” a term commonly used to describe the actual physical besting of one animal by another. Selten argued that the chronic sense of feeling beaten down by other people could activate someone’s underlying genetic vulnerability to schizophrenia.

All this—the disenchantment with the new-generation antipsychotics, the failure to find a clear genetic cause, the discovery of social causation in schizophrenia, the increasing dismay at the comparatively poor outcomes from treatment in our own health care system—has produced a backlash against the simple biomedical approach. Increasingly, treatment for schizophrenia presumes that something social is involved in its cause and ought to be involved in its cure.

You can see this backlash most clearly in the United States in the Recovery Movement, which explicitly embraces the idea that the very way you imagine an illness will affect the way you experience it—an idea that seems, well, almost psychoanalytic. As the movement’s manifesto defined it, “recovery is a process, a way of life, an attitude, and a way of approaching the day’s challenges.” One of the most influential patient-driven initiatives in decades, the Recovery Movement received a federal imprimatur of sorts in 2003, when the Bush administration issued a mandate promoting “recovery-oriented services.” Treatment providers paid by Medicare and Medicaid were told that schizophrenia would no longer be understood as an illness with a chronic and debilitating course, a death sentence for the mind. Instead, patients and mental health professionals were instructed to believe that people with schizophrenia could live as effective members of a community, able to work and to be valued. The expectation of permanent impairment was to be replaced with hope.

In practice, the ascendency of the Recovery Movement has meant that many programs and day treatment centers once run by nonpatients have been turned over to clients (so as to empower them), and that the staff allows clients to make more decisions about how to spend their money and what to do with their time. These changes have not come without bumps. Clients have not always made good choices; the staff has sometimes been reluctant to allow clients a free hand. The anthropologist Neely Myers, who spent months doing ethnographic fieldwork in client-run recovery services in Chicago, points out that this very American expectation that everyone will be an independent, productive citizen sets a high bar for people struggling with serious psychosis.

But the point is that the very idea of the recovery intervention upends the bio-bio-bio vision. Clients are encouraged to take their medication, of course, but the real therapeutic change is thought to come through something social: something people learn to do, say, and believe.

That is also true for other innovative strategies to treat schizophrenia. In Europe, the Hearing Voices network teaches people who hear distressing voices to negotiate with them. They are taught to treat the voices as if they were people—to talk with them, and make deals with them, as if the voices had the ability to act and decide on their own. This runs completely counter to the simple biomedical model of psychiatric illness, which presumes that voices are meaningless symptoms, ephemeral sequelae of lesions in the brain. Standard psychiatric practice has been to discount the voices, or to ignore them, on the grounds that doing so reminds patients that they are not real and that their commands should not be followed. One might think of the standard approach as calling a spade a spade. When voices are imagined as agents, however, they are imagined as having the ability to choose to stop talking. Members of the Hearing Voices movement report that this is what they do. In 2009, at a gathering in the Dutch city of Maastricht, person after person diagnosed with schizophrenia stood up to tell the story of learning to talk with the voices—and how the voices had then agreed to stop.

This lesson—that the world as imagined can change the world as it is—lies behind the intervention that helped Susan so much. In care as usual, people diagnosed with schizophrenia are regarded as severely disabled and thus as appropriate recipients of supported housing and other benefits. People are required to get their diagnosis to justify their placements, sometimes being asked to collect an actual piece of paper from one office and turn it in at another. Many people with schizophrenia cycle through long periods of homelessness. Few of them like it. You would think that they would line up to be housed. But they dislike the diagnosis even more than they dislike being out on the street, because the idea of being “crazy” seems even more horrifying to them than it does to those of us who have roofs over our heads. For many months, I spent time with homeless women on the streets of Chicago who clearly met criteria for schizophrenia. They talked about going crazy as something the street did to people who were too weak to handle the life, and they thought of being crazy as having a broken brain that could never be fixed. They often refused to accept housing that required a psychiatric diagnosis, or they would take it for a while and then leave. They lived lives of restless nomadism, intermittently being hospitalized or jailed by the police when their behavior got out of hand, then being released to supported housing, then, in turn, finding their way back to the bleak streets.

The new kind of intervention simply gives people housing without asking them to admit to a diagnosis. Programs like the one that helped Susan are supported by federal funding set aside for people with serious mental illness, but the benefit is not described that way to clients. Though Susan knows that she has subsidized housing, she thinks she got it because she entered a program at a shelter to help her get off crack. Those who created programs like the one Susan is in believe that the social setting in which a patient lives and imagines herself have as much to do with her treatment as any medication. In general, the data prove that they are right. People are more likely to accept housing when offered it in these programs than in care-as-usual settings, and after they are housed their symptoms lessen—whether or not they are taking medications.

The pushback against purely biomedical treatment is also occurring with other psychiatric illnesses. The confident hope that new-generation antidepressants would cure depression—those new miracle drugs such as Prozac and Zoloft that made people thinner, sharper, and “better than well,” in psychiatrist Peter D. Kramer’s apt phrase—dimmed when the public learned that teenagers committed suicide more often while taking them. No simple genetic cause for depression has emerged. There is clearly social causation in the disorder, and it too looks different in different cultures, shaped by particular causes, social settings, and methods of treatment. In the standard psychiatric textbook, Harold I. Kaplan and Benjamin J. Sadock’s Comprehensive Textbook of Psychiatry, depression is now mapped out with a host of factors, some of them biological, many of them not, and the recommended treatment includes psychotherapy.

In part, this backlash against the bio-bio-bio model reflects the sophisticated insight of an emerging understanding of the body—epigenetics—in which genes themselves respond to an individual’s social context. There is even an effort within psychiatry to abandon diagnosis altogether and instead to treat dimensions of specific behaviors, such as fear or working memory. Realistically, this project—the Research Domain Criteria—won’t dismantle the diagnostic edifice. Too much of the structure of reimbursement and care depends upon the fiction of clear-cut, biologically distinct diseases. Still, the scientists are trying.

The pushback is also a return to an older, wiser understanding of mind and body. In his Second Discourse (1754), Jean Jacques Rousseau describes human beings as made up out of each other through their interactions, their shared language, their intense responsiveness. “The social man, always outside of himself, knows only how to live in the opinions of others; and it is, so to speak, from their judgment alone that he draws the sentiment of his own existence.” We are deeply social creatures. Our bodies constrain us, but our social interactions make us who we are. The new more socially complex approach to human suffering simply takes that fact seriously again.

Photo: Illustration by a schizophrenic patient, courtesy Tanya Marie Luhrmann

Full text PDF available here.

Tanya Marie Luhrmann is the Watkins University Professor at Stanford University. She is the author of Of Two Minds: The Growing Disorder in American Psychiatry (2000) and When God Talks Back: Understanding the American Evangelical Relationship With God (2012).
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COMMENTS (34)

The opinions expressed here are solely those of the author and in no way represent the views or opinions of the Woodrow Wilson International Center for Scholars. This section is moderated by Wilson Quarterly staff.

Now they are recognizing that social factors are among the causes...

Why am I the only one who writes about how the exposure to stimulus (non-verbal) - stimulus (verbal) contingencies when you with a short delay are able to restore a verbal message can generate a tendency to interpret what people normally ignore? Can the exposure to stimulus (non-verbal) - stimulus (verbal) contingencies (classical conditioning) when you with a short delay are able to restore a verbal message or interpret what subjectively seems to be a verbal message have such a profound effect that some people develop a mental illness? Can all the factors that contribute to the development of an integration disorder referred to as schizophrenia be assumed to increase the exposure to the kind of stimulus (non-verbal) – stimulus (verbal) contingencies you are exposed to when you are able to restore a verbal message? Can the need to restore a verbal message in a noisy environment, due to a hearing impairment or when volition and emotion make you listen to indistinct, maybe distant and hard to hear voices be assumed to trigger an integration disorder like this? My attempts to understand some of what I with this illness experience started off several years ago with a metacognitive approach and this is what I now ask myself: http://www.lingforum.com/forum/viewtopic.php?t=512 Stefan Andersson

Posted by: Stefan Andersson | 9/6/12

Beyond the Brain

Schizophrenia is beyond the brain. The most important line in the article is: The African-Caribbean people in Tottenham spoke of there being no community in the community. We are social animals and society has three basic pillars: religion, family, and the law. Religion has been laughed at my new modern thought; the family has been warped by the newest idea in the world, the idea that same sex marriage is on par with traditional marriage. The first two pillars of society have been removed, so now we rely on 'laws' to do what religion and family did for people. Religion has been replaced with the idolatry of materialism: environment. The priest of this new idolatry are the scientist. Traditional family has been replaced by the Brave New World's idea of family. All are equal. There are no ideals of a child being raised by a loving father and mother who are still living in the same household as the child. The fact that it is better to have children living in loving same-sex households or single-parent households than having them spend a childhood in foster care does not mean that they are equal to a loving traditional household. They are not. At the same time it doesn't mean that we should not support such loving families. Being tolerant does not mean being blind to reality. Instead we now have laws telling parents what is best for their families and their children. Basically, if you read the article again carefully, there is one factor that should standout: the love the Indian families had for their family members and their belief in their traditional family. The Indian family do what they know is best for their loved ones; they don't rely on scientist or government.

Posted by: Dabe Morgan | 9/18/12

Multiple odd historys of Schizophrenics I have known

My mother, the mother of my children, her mother and one of my two children have this spectrum of disorders. I think of it as a spectrum rather than a complex. I am a radiologist getting ready to retire, but for the last five years I have worked in a VA station with an inpatient psych unit and a drug rehab program. I have dealt with many schizophrenics and usually without incident. I did my internship is San Francisco in 1976, one of the patients I treated that year was the first person to survive jumping from the Golden Gate bridge, This man was Iranian and schizophrenic. What impresses me most with this disease is the "locked-in" nature of their posturing during disease flare-ups, the obviousness of their auditory halucinations, how distracted and inattentive to the "real" world they become during these events and how closely the disease parallels any particular intellectual skill or (+/-) manual dexterity they may have. I know that the book is extraordinarily hard to interpret; but rereading Gregory Bateson's book; Steps to an Ecology of Mind with your your new paridigm of understanding may unlock some doors for you...

Posted by: Phil Grimm | 9/18/12

There is more to human physiology than gentics and environment. You completely neglect infectious vectors and immune responses. Depression seems to be caused by food allergies. And mania is caused by Streptococcal bacteria. And dementia is caused by high brain insulin levels. Once you factor out those things- and all the other possible reality based mechanisms- then maybe you will reconsider writing this long article about how Psychotherapy is appropriate to treat Schizophrenia. www.endofinsanity.com Scientists shocked to find antibiotics alleviate symptoms of schizophrenia http://tinyurl.com/7ww73yg

Posted by: Heidi Lindborg | 9/19/12

Genes less predictive than social status

Excellent article. Similarly, in his book "Incognito: The Secret Lives of the Brain", neuroscientist David Eagleman writes: "no single gene mutation is as predictive of schizophrenia as the color of your passport." He goes on to explain research showing that the social stress of being an immigrant to a new country is a critical factor for developing schizophrenia -- more so than any genetic test can tell you. It's a great book if you haven't read it.

Posted by: Bartley Anders | 9/19/12

Marijuana

i wonder whether the marijuana has any contributing factors in cases like these. the author discounts the patient's marijuana use early on, so we don't know how much she smoked. there might be social tensions involved, but paranoia about them may have been exacerbated by smoking too much of the good stuff?

Posted by: Susan Jane | 9/20/12

Great Article but . . .

I really appreciate the way this author has highlighted the complex array of psychosocial factors that clearly contribute to the onset of psychosis. I really hope that we see much more of this! However, I feel compelled to pick a few nits. First, I'm confused by the way that Tanya initially seems to outright reject the idea that emotional conflict plays a role in the onset of psychosis: "When psychoanalysis dominated American psychiatry, in the mid-20th century, clinicians believed that this terrible illness, with its characteristic combination of hallucinations (usually auditory), delusions, and deterioration in work and social life, arose from the patient’s own emotional conflict. Such patients were unable to reconcile their intense longing for intimacy with their fear of closeness. " Tanya does then go on mention many clearly emotional and relationship factors that correlate with the onset of psychosis (bullying, child abuse, neglect, etc.), so I'm confused by this earlier comment seeming to reject this idea. My own research on people who have made full recoveries from schizophrenia and other psychotic disorders (and many other first person accounts and qualitative studies) suggest quite robustly such emotional conflict very like IS one of the most fundamental factors in the onset of psychosis. (You can download my dissertation here: http://gradworks.umi.com/34/54/3454336.html ...or read a more accessible and elaborated version of it in my book, Rethinking madness: www.RethinkingMadness.com) Second, I appreciate her bringing in the very robust finding of the World Health Organization that those in the poorest countries of the world have far higher recovery rates. However, I was disappointed to see that she then seems to ascribe much of these superior outcomes to better management of their meds: "They come to all the appointments, manage the medications..." This is a complete misrepresentation of the actual results of these studies. This research found a clear INVERSE correlation between the use of psychiatric drugs and recovery rates. Those in Chandigarh, India exhibited the highest rates of full and sustained recovery (between 71% and 79% depending on which criteria was used), and they also had the LOWEST percentage of participants maintained on antipsycotics--only 5%(!) In addition, more recent research has found that when people in developing countries are maintained on antipsychotics at a much higher rate, more similar to what we see in the West, their recovery rates correspondingly diminish, approaching the much worse recovery rates we generally see in the West. Third, even though Tanya does mention a lot of the very serious important problems with psychiatric drug use, she somehow continues to perpetuate that idea that we still shouldn't really question the idea that antipsychotics should remain an unquestioned part of the mainstream treatment protocol with comments like, "Clients are encouraged to take their medication, of course." Yes, she encourages more psychosocial interventions, but come on, let's face the very robust research that for the majority of people, the long-term use of antipsychotics make it much LESS likely that people will go on to make full and lasting recoveries. Of course I'm not discounting that the short-term use of antipsychotics does seem to often be helpful for those in crisis (especially when not used in a coercive manner), and that for a minority of the population, long-term use may lead to less distressing lives. But, while we're moving in the direction of looking at a more broad picture of onset and recovery of psychosis, let's please stop regurgitating the same old myths and taboos (such as the very harmful taboo of questining the myth that everyone should immediately be placed on a regimen of antipsychotics and stay on them for the rest of their lives). Every single major study I have come across that assesses the harms and benefits of antipsychotic drug use over the long term tells the same story about antipsychotic drug use--short term benefit (sometimes) and long term harm (in the vast majority of cases). For a more detailed summary of this research, I recommend my own book, "Rethinking Madness," and the books by Robert Whitaker, "Mad in America," and "Anatomy of an Epidemic." Anyway, nit-picking aside, thank you, Tanya, for this otherwise excellent article.

Posted by: Paris Williams | 9/20/12

Fantastic article

What a fantastic article. Well done.

Posted by: Martin | 9/22/12

Great article, excellent comment too

It is so liberating to have someone with integrity vindicate in such clear terms ideas that up until now were essentially persecuted. Now, as to "This research found a clear INVERSE correlation between the use of psychiatric drugs and recovery rates." Well well. Of course, medication ALONE isn't an answer at all, any more than eating whey protein while watching tv will grow muscle. But big pharma has a track record of always winning all fights. Enough said. By the way, did you know that up until 1970 mainstream medicine formally declared that nutrition had absolutely nothing to do with health? Thank you Dr. Luhrmann.

Posted by: Jason Taylor | 9/22/12

Back to the future

Anthropology has recognized for years the role the social plays in mental illness and now we are back.

Posted by: Kevin Gilds | 9/23/12

This was an absolutely wonderful article. There's such a fine balance in the way that social factors can so easily turn into blame, even though these factors are the ones that show promise for people to potentially recognize and improve. This must not have been easy to write. Thank you.

Posted by: S | 9/23/12

schiz

I have been diagnosed with schizoaffective disorder, and went through two rather bad psychotic spells that lasted for months, followed by more than a year of persistent delusions. I'm rather high functioning now. I have found that when I am socially and intellectually engaged, I do well. My social engagement consists of participating in purposeful activities (volunteering at an animal shelter) and the cognitive engagement consists of intellectually stimulating activities (reading quite a bit). I still take my medicine. I would echo what the author wrote about the importance of an appropriate social structure, but I would add that it is important for the sufferer to feel like he or she is doing something purposeful and challenging in some way.

Posted by: David | 9/28/12

Narrow and divisive view

What a confusing and internally contradictory article from the stable of anti-psychiatrists. Its time that the Luhrmans of the world realised that no psychiatrist ever was taught that schizophrenia was a 'bio, bio and biological brain disorder'; the ignorant may have thought so or said so. All psych trainees are brought up on the 'bio-psycho-social' model which is not what many non-psychiatrists can claim. Nor do they wish to claim when patients assault them or dont turn up for their sessions - these very socially orientated clinicians turn these patients away. Without the 'decade of the brain' research one would not have been able to predict who might be at higher risk of developing the disorder, or which ones should be targetted for early interventions to prevent rapid disorganisation of personality and mental health. The romantic idealisation of condition of patients' in India is laughable (I've lived and worked in 'asylums' in India) as naive researchers sit with psychiatrists who 'dont mention a diagnosis and families dont ask for them': that wouldn't be my idea of recovery-centric model of mental healthcare where the patient is an equal partner. It would be frightening prospect to return to the prospect of the schizophrenic mother being both a 'cause' as well as panacea (the Indian mother) of the problem Migrant psychosis was well known in Afro-carribeans in the UK but at that time the social scientists screamed ' Racism in psychiatry' . Just as politiicans can never be trustd, psychiatrists are not trusted by non-medics.. and the whole discourse would be better served if the focus is 'power' rather than psychiatry. Its time to truly accept the notion of multidisciplinary working rather than consider that phrase to mean antipsychiatry.

Posted by: Jay Sarkar | 9/28/12

BPD similarity

My stepson has BPD so we deal with blurred reality quite often. Sometimes it feels hopeless to keep supporting him and holding him accountable for the mundane issues. I see many similarities and I appreciate this article.

Posted by: TexasTexasTexas | 9/29/12

A few factual mistakes

While I agree with the main point of the article, which is that schizophrenia has a complex pathogenesis that involves both biological and social factors, the presentation of the data is at times disingenuous. First, there is strong evidence that Clozapine has superior performance compared to both older and newer antipsychotics in the study that was cited to compare the two (CATIE trial). Secondly, the author (as well as commenters) repeatedly make causal inferences based on associations. For instance, the fact that taking medications is inversely related to disease severity can be interpreted as medication makes you worse, OR it can be interpreted as only people who are suffering badly enough are compelled to take the medications. At risk of sounding like a third grader, I just want to repeat the idiom "correlation does not imply causation." The gold standard for both medication and psychotherapy (broadly speaking, including community based mental health recovery initiatives) is the randomized controlled clinical trial, and a body of evidence has developed that for schizophrenia and severe psychotic illnesses the combination of consistent medication compliance and community based psychotherapy and behavioral treatment is most efficacious. The modern treatment of psychosis is not slanted to medication vs. behavioral treatment, but a rational, sensible combination directed by well trained professionals.

Posted by: Sean Luo | 10/2/12

social tonic

Thank you for such a well written article. I think even if a person doesn't have a genetic vulnerability to schizophrenia, "a chronic sense of feeling beaten down by other people" wouldn't possibly cause no damage to the person's mental health. Cultural improvement would greatly benefit the entire society, beyond the scope of medical health. Indeed, so often people feel insecure toward someone else's attribute, knowledge or possession, and they react to their own insecurity by 'beating down' that someone else. In some cases, they also had a rotten childhood or some other back story of their own, but if we could all just be more in touch with our own feelings and have some considerations for others' feelings, the whole world would be a better place. Of course, there will still be global warming left to be dealt with.

Posted by: ZF | 10/4/12

general comments

"...most efficaious", Sean writes, of the favored treatment combining medication and talk therapy. This is not very helpful, I'm afraid, in reassuring clients and families. We need more long term studies to back up our biases. I loved the Luhrmann article because it gives us not only understanding, but hope. The Indian study reinforces Rousseau's thinking that the family must embrace the patient challenging as this might be. What's the alternative? The streets? The Hearing Voices Network offers each a society where courage and hope are born. Would love to see this catch on in the USA.

Posted by: ange d'andre | 10/7/12

antidepressants

A very interesting article with one caveat. If you look at the ACTUAL STUDIES about Prozac and Zoloft, not the news articles that reported on them, actual suicides did not increase at all. It was thoughts of suicide. And the results were not conclusive; different trials of the same study got different results, and the differences were very small. Also, note that the teenage suicide rate has gone up since the black box warning on Zoloft and Prozac.

Posted by: anon | 10/11/12

individuals

As someone who has struggled with depression all her life, and known many others who do, what strikes me about mental disorders as a whole is that we all cope with adverse circumstances differently. Having schizophenia is clearly an adverse circumstance. i can't imagine social support and encouragement NOT helping; I would also, if I heard voices, rather engage with them than try to shut them out. We all want to be who we are and make that work, which may involve drugs, but most importantly involves agency.

Posted by: Margaret Diehl | 10/20/12

studies and trials...

This is more of comment to the commentators, if people do indeed sign up for alerts. Many of you bring up "randomized controlled clinical trials" and that these are not to be discounted. Some of you are speaking from personal experience. I know not a lot of Americans understand anthropology, but it would benefit anyone one of these commentators greatly to look into it. Upon exploring Tanya's other works, or other works on schizophrenia and anthropology (see. Janis Jenkins 2003) you would come to appreciate how anthropology addresses all of these caveats you point out. By focusing on the significance and data (and here I imply said "clinical trials"), we fail to take into account, holistically, what schizophrenia means socially and globally. It has been well documented that one with schizophrenia has a better chance for remission if else-where than the Western industrialized context (Jenkins 2003). Clinical trials and medications do not penetrate the further reaches of humanity. Only anthropology does that.

Posted by: Erica | 10/28/12

Cause of schizophrenia

Schizophrenia is mainly caused by consciously experiencing pain in the womb as a fetus. Just as infants and children become neurotic if exposed to physical pain during childhood; fetuses that experience pain in the womb become prone to schizophrenia. In the womb the fetus knows just its own self as all reality and so experiencing physical pain in the womb causes it to blame itself. It does not understand the pain and so becomes confused. In fact I developed a whole hypothesis based on the reasoning that as negative experiences in the womb cause schizophrenia then positive experiences in the womb must also cause changes in the brain and mind. I developed a whole new hypothesis on the cause of human nature that has tons of practical applications. I even figured out wisdom. I grew up in a family where my parents were always fighting. I was put in the care of a neurotic wet nurse who would scare me to keep me from crying. I grew up extremely nervous, shy and depressed. From very early on I became obsessed with trying to figure out why I was so shy and nervous. While I was in 4th grade I won the art prize in my class. On the prize distribution day I had to go to the stage to get my prize from the Governor. I was terrified. When I went to the stage I could not look him in the eye and I kept looking at my classmates. The whole gathering was bursting with laughter. I almost forgot even to take the cup from the Governor and he had to hold me to hand it over. I was crushed. Till the time I came back and sat in my chair they were still laughing. My classmate’s father was sitting next to me. I over heard him tell his daughter that I was a schizophrenic. I confronted him and asked him why he called me something that I felt was an insult. My classmate said that every one was laughing because I was lost on the stage, was walking off without getting the cup. I was not paying attention to the chief guest and my fly was open. The father said to me not to worry about anything. He said that I stole the show. I was the only pleasant part of a very drab evening. I came home and looked up schizophrenia. I was crest fallen.. I couldn’t sleep. My whole life became an obsession to find out every thing there was to know about schizophrenia and how to get out of it. I was a very talented swimmer and was also good at badminton. I gave up everything. I even lost interest in studies. All I did was study the human mind, psychology and human nature. I discovered that schizophrenia starts in the fetus stage due to negative conscious feed back. So I reasoned that if negative feelings have an impact on the brain then positive feelings must also have an impact on the brain. I finally developed a hypothesis that explains the cause of human nature! My patented hypothesis has dozens of practical application in the mind sciences.

Posted by: Sajid Khan | 12/28/12

It's deja vu all over again

Fascinating article and I'm glad David Brooks' column in today's NYT drew attention to it. Skepticism about schizophrenia being purely rooted in medicine rather than social (or conscious) cues has a long history -- a lot longer than you'd guess. (This paper is one take on that history in western medicine: http://www.academia.edu/1860451/On_Being_Sane_in_an_Insane_Place--the_Laboratory_of_Plautus_Epidamnus_preprint_revised_). At least in most social settings today, however, expressing skepticism in the eternal power of medicine (drugs) to cure the scourge of hearing voices engenders paroxysms of emotion on par with denying other taboos. This article may well start to change that, and all for the better if it helps us find new ways to help victims of schizophrenia.

Posted by: An observer | 12/28/12

Terrible

So many things wrong with this article that it's difficult to know where to start. For one, the "the simple biomedical approach" was never all that simple. The "cold mom" was a medical theory. Like many medical theories, it has been shown to be inaccurate and incomplete. And why is this? Because the biomedical approach is not simple. It is robust and seeks self-correction. And while the genetic story is known to be incomplete (and has been known to be incomplete for many decades), it offers great insights. We know that the SCH phenotype results from a complex interplay between genes and environmental stimuli. One of the biggest genetic influences, which the author appears not to grasp as genetic, is being male. Similar glass tigers are found in dismissing the medications. As soon as these medications were developed (in the 1970s), it was known that they were not cures. They helped manage the positive symptoms of the disease. But again, if you call this the "simple" approach of dopamine, then you miss the fact that psychiatrists knew that there remain deep problems with the disease and the meds. The current neuroscience of schizophrenia isn't touched on, but instead easily dismissed as being simple. Well it isn't. Too much is known about this disease to pretend that nothing is known, or that our understanding is simple or even thought to be complete. This ignorance wouldn't be so horrible if it did not have consequences. Unlike the author's false belief that Huntington's disease is "a terrible convulsive disorder," (it isn't a convulsive disorder, it is a dementia and movement disorder and although clearly cherry picked, it is also a measure for depth of medical ignorance, ie., this author is full of shit) asking for "pushback against purely biomedical treatment" is dangerous. Should patients and their families isolate them away from society? Of course not! But they should enter into a relationship with a psychiatrist and work with medications and trials that can help manage their disease.

Posted by: Dave | 12/28/12

Beyond the Brain

Excellent article! But could we please stop referring to people as "schizophrenics," and refer to them as people with schizophrenia? Perhaps this simple semantic change could precipitate a necessary change in the way we see and respond to people with mental illness.

Posted by: Kathy Neuman | 12/28/12

Schizophrenia is 'asthma of the brain'

There is a much simpler model for schizophrenia that accounts for all of this very well. Namely, schizophrenia is the ‘asthma’ of the brain. Rather than spit out histamines, brains subject to whatever airborne agonist is inducing it spit out neurotransmitters. If this is indeed the case, we should expect those climates given to allowing whatever airborne agonist induces it (cold and dry for schizophrenia) to exhibit greater rates. Likewise for those opposite. Examine the pathologic similarities – stress as agonist, chronic condition, some hereditary linkage but not all, is seasonal to some degree, rule of thirds. How have I come to this conclusion? Simple. I myself have suffered from schizophrenia for 25 years now and have been carefully observing the patterns, especially any deviations across climates and seasons. During the summer of 2010, here in Indiana we suffered a mild drought starting in mid June. By late August we had had no rain for over two months. I started noticing that the quality of the leaves, bark and ground was similar to that of late October. The air truly had a Fall feel to it. All of a sudden, over the course of the next week my symptoms skyrocketed. Paranoia, hearing voices, not sleeping, visual hallucinations, feeling my death was imminent at any time – all these appeared in spades. Being a responsible person, I called my doctor to make an emergency appointment. Upon asking if any of his other patients had seen such a dramatic increase he said “Every psychiatrist in the city has their hands full right now. Something is in the air. Sometimes crazy season comes in August.” At that moment I made the connection between what the air literally felt like and the October climate in Indiana. I was able to confirm my suspicions over this last summer’s (2012) drought. About a month and a half into it, I told my wife “If we get no rain, in two weeks my symptoms will come back and I’ll have to up my meds.” Three weeks later, sure enough that happened. Since then, I’ve realized that I did best as a young man in Kentucky, worst as a young man in Wisconsin and about middling for the last 18 years here in Indiana. Of these climates, Kentucky has the warmest / wettest, Wisconsin the least warm / wet and Indiana in between. India has an entire monsoon season that would be warm and wet. Those Caribbean and Sub-Saharan immigrants to Europe? They are moving from a warm and wet climate to a cold and dry one. I had long wondered about rates in warm, wet climates compared to cold, dry ones. That immigrants begin to suffer in higher numbers as they move confirms my suspicions. Mark my words, the day we solve asthma is the day we solve schizophrenia.

Posted by: Neal Jettpace | 12/28/12

0verview

The biopsychosocial model proposed by George Engel over 50 years ago is alive and well as attested to by the excellent overview by Ms Lehrman. But over that time, we still do not understand the cause nor the cure of schizophrenia. Of all medical specialties, psychiatry has made the least advances of any in understanding disease states related to the brain. As such it remain both art and science. And a frontier science as well. Ms Lehrman does a great service by providing a longitudinal survey of where we were and are. One hopes that the future will bring greater relief than now possible for those with mental illness, especially those with schizophrenia.

Posted by: Bal Dors | 12/28/12

Schizophrenia

Luhrmann's essay on schizophrenia is the update on the disease we need. I have used Dr. VanDelinde's 1971 Norwich State Hospital notes on the subject with my present students in Clinical Pastoral Education programs since they showed the lack of movement in understanding the disease. And also the lack of funds dedicated to discovering the answer to Jay Haley's old question: "What are schizophrenics for?" Rosemary Radford Reuther's, the Roman Catholic theologian, recent book co-authored by her schizophrenic son is another powerful new resource. Luhrmann should be read in every school of psychiatry and all the helping professions. Thanks to David Brooks for keeping all of us up to date on important writing.

Posted by: the Rev. Paul D. Steinke | 12/29/12

Beyond the brain

What an amazing essay by Ms Luhrmann. As a black woman from the Caribbean with schizophrenia in my own family, this essay gave me more insight on the disease. I have always believed that it is strongly associated with poverty. Indeed it seems in my own country in Jamaica, the disease is very prevalent. I believe my mother is schizophrenic, though she has never been treated. However, she does do better in an environment 'less poor' in all areas. Having schizophrenia is taboo, so most families affected by it, would never say it, much more to be treated for it. My younger brother died because of the disease even though he had been treated with medication he refused to take "because it doesn't make me feel right." Such a complex issue. An excellent, excellent essay

Posted by: Sharon Brown | 12/29/12

Mother of a schizophrenia sufferer

One of the most down to earth, sensible essays on schizophrenia - from a mother whose son suffered from paranoid schizophrenia in the Cloapine and Risperidol era when those medications were hailed as wonder drugs. My son committed suicide after suffering for 16 years and I often wondered what would have occurred if he had never taken a drug. Maybe one of the alternative treatments might have helped? we will never know. I never refer to anyone as being schizophrenic as I feel it is insulting. We do not refer to a person suffering from cancer as cancerous, now do we? I intend to read and reread this article. Thank you, Jill

Posted by: Jill Sadowsky | 12/29/12

sometimes being in a different sort of environment could help

I would say that psychiatric institutions, along with the coercion inherent with the psychiatric system, could worsen what are described as "symptoms" of schizophrenia. For the woman referred to as "Susan" in this article, being in an environment where she had some control over her life and wasn't subjected to the suppressive controls of an institution likely helped her mental functioning, along with not being on the often suppressive drugs used by psychiatry. This was also an environment where she could take some initiatives on things that would help herself, such as taking some community college classes. Simply having a steady place to live and not being in the often oppressive type of environment in institutional settings likely helped her to become more stable.

Posted by: Laura Borst | 12/30/12

Diagnostic categories

Agree that there are useful aspects of this article...but am bewildered by the author's uncritical use of the term 'schizophrenia' as if it was a reliable and valid category, which it clearly is not. The points she makes are not about 'schizophrenia' . They are about certain types of (often but not always) distressing experiences such as hearing voices. 'Schizophrenia' is a concept that exists only in some people's heads, rather like witches or devils - there are no objective confirming signs that can be detected by X ray, blood tests etc. Rather, there is a circular argument that runs: 'Why does this person hear voices? Because they have schizophrenia. How do we know they have schizophrenia? Because they hear voices.' Exactly the same logic convinced people in Biblical times that distress was caused by spirit possession. And while we are on the topic of language.... 'anti-psychotic' is a deeply misleading and inaccurate example of drug-company rhetoric, since these drugs have no specific effect on 'psychosis' at all - and nor was this even claimed when they were first introduced. If we cannot use language clearly and think logically, we will never achieve the paradigm shift that is needed in psychiatry.

Posted by: Lucy Johnstone | 1/1/13

socially complex approach to human suffering

Non diagnostic responsiveness as culture, familial and community process is the approach that I used as the basis for the therapeutic models that I developed at the Lincoln Square Neighborhood Center. I loved reading this history and analysis. I feel it gives me a context in which to think about my work.

Posted by: Ann Marie Sacramone | 1/1/13

Very good article, minor complaints

Very good article, though it would have been even better had it gone into more depth about things like the extent to which pharmaceutical companies have systematically misrepresented both the safety and efficacy of their drugs (it's not simply that they haven't panned out as well as hoped for, the companies have been burying and even falfisying data for many years—virtually every psychopharmaceutical released in the past 10-15 has been the subject of a class action lawsuit settled for hundreds of millions of dollars in exchange for sealed court records; the companies can afford to pay these fines because the pharmaceutical industry is the most profitable sector per capita in the entire economy even more than Big Oil.) Also welcome would have been discussion on the (upcoming version of the) DSM, and how subjective, political and arbitrary the whole work is (it's what defines mental disorders)…it's what creates the basis for overreifying mental disorders, which in turns what justifies the demand for "concrete" solutions (i.e. drugs). Also studies on genetic links have proven woefully difficult to reproduce, and often have conclusions which are not supported by the data (no one ever bothers to parse through the logic, it's assumed that it's sound since it got published by definition). I could go on but I would encourage anyone interested in learning more to Google ISEPP (International Society for Ethical Psychiatry and Psychology).

Posted by: Oliver Lu | 1/2/13

What about age of onset?

I'm glad we're giving nature and nurture their due. But I'm wondering what each has to say about the age of onset of schizophrenia. If I remember correctly, onset in males is generally late teens to early 20's and a little bit later for females. Why is this? And is anyone looking at this question? As for medications and the pharmaceutical companies - I'm not huge fan, but they did help with my schizophreniform disorder back in the mid-80's. The side effects were not good and I fought my psychiatrist to get off the meds, but was a compliant patient. I think being compliant w/treatment helped my recovery. I think my caring family helped as well.

Posted by: Reggie E | 2/9/13

Beyond the Brain

Open Doors

The Tocquevillean Moment . . . and Ours

The Dawn of Market Urbanism