Schizophrenia: The making of a troubled mind
Rachel had just given birth to her third child when she became overwhelmed by the noise on the obstetrics ward, grew sharply paranoid about her sister, and in short order descended into her first schizophrenic episode. She was 28. Although it was only then that she started hearing voices — those of her family, distant screams, messages from spaceships — she and her psychiatrist came to see that there had been whisperings of this long before.
As a child — bright, but awkward both socially and physically — Rachel tended to keep to herself. She crammed her drawings full of the sort of elaborate fractal detail often seen in the work of psychotic artists. In her teenage years, some of her difficulties worsened. Acutely sensitive to noise, she was aware of the refrigerator cycling off and on, footfalls from the apartment next door, the traffic outside. Only in retrospect did any of these peculiarities seem ominous.
The Madness Within Us, where he writes about Rachel, that's how it is with the early flickers of paranoia, confusion, hypersensitivity and hallucination in people who develop schizophrenia. They often emerge exactly when adolescence is throwing the body and brain for a loop, and years before the disease manifests itself fully. "The problem with early symptoms," says Freedman, who is chair of psychiatry at the University of Colorado, Denver, and editor-in-chief of the American Journal of Psychiatry, "is that they're not very specific. At a time when thinking, emotion and behaviour change a lot anyway, these early indicators are very hard to separate from normality."
As Rachel's psychiatrist Robert Freedman explains in his bookEven so, this overlap of schizophrenia's early signs with the hallmarks of adolescence has made this period a beacon to researchers. Over the past 20 years, studies have shown that the adolescent brain undergoes major developmental changes. Autopsy and imaging studies, for instance, have revealed that during childhood and adolescence the brain routinely prunes away vast numbers of synapses — the junctions between neurons across which electrical signals flow — and that this pruning seems to go on longer and farther in people with schizophrenia. Other work has shown that adolescence brings major upgrades to the neural networks that generate powers of judgement, cognition and behavioural control — building new circuits, remodelling old ones and discarding some altogether. The idea that schizophrenia arises from miscues or shoddy work in this complicated and delicate project has sparked a huge variety of research. Many basic neuroscientists are trying to work out what goes wrong on genetic, cellular, circuit and systems levels. Meanwhile, at the level of diagnostic practice, some researchers argue that subtle symptoms can not only be distinguished from normal adolescence, but can provide a reliable indicator of future disease.
In a pattern all too familiar to students of schizophrenia, none of these efforts has revealed the secret of this fiendishly complex disorder. One leading researcher, David Lewis, at the University of Pittsburgh's Western Psychiatric Institute and Clinic in Pennsylvania, has spent the past two decades exploring schizophrenia's developmental roots. Yet even Lewis says it's still too soon to know whether any given line of study, no matter how promising, is homing in on the schizophrenia puzzle's most essential component, if such a thing exists.
"It's more like getting a much better picture of one part of the elephant," he says, referring to the old parable of blind men collectively describing an elephant's nature by individually feeling its different parts. "I think it's working. When I talk with other researchers working other ideas, I'm encouraged that I'm onto something important, and even more encouraged that we all seem to be feeling our way around the same animal."