Thursday, March 14, 2013

Schizophrenia -- Taming the Dragon

Imagine you have a dragon in the house.

It has been there a long time.  When it was little, you could hide it.  You knew your parents didn't like it when you talked about it.  So you guarded it as a secret for the longest time, even with its nasty habit of singeing your fingers.  But when the couch caught fire, they knew, and insisted you get help.

They want you to get rid of the dragon.  Some of them think you can.  Others think you can tranquilize it, and the couch will never catch fire again, and nobody need ever know you have a dragon in the house.

Iron Rule #1:  You cannot get rid of the dragon.  It is here to stay.


They say St. George slew the dragon.  But don't believe it.  He was a soldier, and may have killed a lot of people, I don't know.  But the dragons are alive and well today.


Iron Rule #2:  You cannot move.  The house is you.  Doh!  Have you never heard of Jung or gone to a dream workshop?  The house is always you.  Don't burn it down.



St. Martha, on the other hand, tamed the dragon.

The trick is, how to live with a dragon in your house.

Medication Compliance

They tell us to weigh our costs and benefits.  What they mean is, Take your damn meds, and it's on you what happens next.

People with schizophrenia don't always take their meds.

The latest weapon in the power struggle called compliance is a new label, anosognosia.  Even the professionals can't pronounce it -- it has such power.  It means lack of awareness.  But lack of awareness you can pronounce, and you know what it means without paying the speaker's fee to find out.  So it doesn't have near the power of anosognosia.

The idea is, when you are psychotic, you don't know it.  People with schizophrenia do not understand that they are sick.  That is why they don't take their meds.

Well, maybe.  But you know, all kinds of people don't take their meds.  People with high blood pressure, who have no symptoms, go off their meds.  Do they have anosognosia?  Or do they just want their sex life back?

Okay, lack of insight is real.  People who think their delusions are real don't trust the people who want them to take a pill to make the delusions go away.  But there is much more to this struggle over compliance.  Personally, I think anosognosia is how family members and doctors are bleeding off their frustration about noncompliance, while still refusing to take seriously the effects of the medication.

Medication for Schizophrenia

The medication for schizophrenia changes what happens with dopamine in the brain.  We all have voices and strange thoughts.  Most of us are able to ignore what does not make sense or is not helpful.  People with schizophrenia have difficulty screening out the nonsense.  Antipsychotic medication helps.


But here is the dance.  When the antipsychotic tamps down the dopamine, it also tamps down all the good stuff that dopamine is supposed to do.  It quiets the voices, but then it sucks the motivation, expression and energy right out of you.  It nails you to the sofa.  Read that list of negative symptoms.  You have enough trouble with these already.

Lack of motivation sounds like a character defect.  Pull yourself together!  You would feel better if you go outside!  You wouldn't gain so much weight if you exercise!  Get a job!  Get a hobby for God's sake!

You lazy bum.

Lack of motivation is one of the most devastating symptoms of mental illness, heaping the pain of shame onto the pain of the inherent disability.  It has a biological cause, a screw up in the dopamine system -- or, the results of a taking a medication that is designed to suck the dopamine out of you.  Words fail me to describe the feeling of having a desire, actually wanting to go outside, or write the next paragraph, but not being able to get yourself to do it.  (Depression manifests with this symptom, too.  It made my last years on the job an agony, for the shame of it.  Give me suicidal ideation any day.)

The medication helps still the voices.  But they don't go away; they recede.  People who take their meds faithfully for five years can anticipate outcomes of 35% poor, 29% intermediate, 36% good.  If you tell your doctor you still hear the voices, the doctor increases your medication.  If you tell your doctor you want to get off the sofa and get a job, the doctor tells you all the terrible things that will happen if you don't take the medication.  The doctor's job is to get rid of the voices, not help you go back to work.

So you don't tell your doctor about your voices, like you didn't tell your parents.  And you throw away the pills.  68-82% quit taking antipsychotics within 18 months.  So you are in good company, albeit company that has double the relapse rate as the 18-32% who hang in there and/or get appropriate modifications.  This is called noncompliance.  And the doctor and family think it is because you have anosognosia.  It has nothing to do with them not listening to your concerns about the soul-sucking side effects.

Note: I am not recommending noncompliance.  I am explaining it.  The reader might be confused about this point, because my explanations are not the ones usually given by people who do not have schizophrenia.

(Let's leave other side effects out of this today.)

Other Treatments for Schizophrenia

The following are not covered by your insurance and are not available where you live, anyhow.  (That is the voice of my own distorted thinking, which means I operate under the distortion of not living in a major metropolitan area, and think maybe you don't, either.  My thinking is also distorted by paying attention to the rates of unemployment among people with schizophrenia, the likelihood of holding a job with good mental health coverage, and cuts in Medicaid.  So call me a loon.)

But here they are:

Cognitive Behavioral Therapy

My statistics above come from Ann K. Morrison's excellent review of literature, Cognitive Behavioral Therapy for People with Schizophrenia.  [Sidebar: How refreshing to put the people back in it; she writes about the people with schizophrenia, not schizophrenics!]  Here is the meat:

After an antipsychotic reduces the most acute positive symptoms, CBT has successfully reduced residual positive symptoms as well as the negative symptoms that antipsychotics do not address.  The table below comes from this article.  Read the whole thing for more details.

Table 1:  Targets and Techniques of Cognitive Behavioral Therapy for Schizophrenia

           TARGET                                TECHNIQUE

Positive symptoms                Alternate explanations to the patient

           Hallucinations                     Normalizing
                                                          Enhancing coping strategies
                                          
            Delusions                            Inference chaining
                                                         Peripheral questioning

Negative symptoms              Behavioral interventions

            Avolition                             Behavioral self monitoring
            Amotivation                        Activity scheduling
            Anhedonia                           Mastery and pleasure ratings
            Affective blunting               Social skills training


Cognitive Enhancement Therapy

Schizophrenia's primary focus of attack is the frontal cortex, where we do our thinking.  Not the only focus of attack, but the primary one.  Literally, it shrinks.  In an MRI, you can see the holes.



Bloodless sectioning is an unfortunate use of language.  What it means is that MRIs can take pictures of a living brain.  We don't have to rely on autopsies anymore to study the changes inside the brain wrought by different mental illnesses.  I will put in a plug here for Nancy Andreasen, National Science Medal winner and my wife's boss, who pioneered the use of MRIs for this purpose.  Anyway, there are pictures more dramatic than the one in the youtube, where there are dark spaces in and around the brain that indicate holes.  These holes grow over time.

People with schizophrenia have trouble with functions that would be performed by the part of the brain that is missing.  The holes in the frontal cortex cause the cognitive symptoms, difficulty with setting priorities, doing certain memory tasks and directing attention, also slowed processing speed and rigidity in thinking.

Though psychosis gets all the attention, these cognitive deficits are a more significant impairment of functioning than the positive symptoms.  Reducing psychosis through medication turns out not to improve job prospects.  Meanwhile, medication does not touch cognitive symptoms, the symptoms that really do interfere with work.

However, the brain is plastic.  It can learn to think its way around the holes.  Using a combination of computer exercises and group work, Cognitive Enhancement Therapy teaches the brain to do just that.  And as you might expect, if you have followed my writing on BDNF, brain-derived neurotrophic factor, the learning brain is the growing brain.  CET actually increases brain volume, as new pathways of dendrites fill in the holes.

Is that cool, or what?!

I attended a presentation about CET at NAMI's 2012 convention and, noting that CET is currently available at twenty-one sites in ten states, asked whether doing Lumosity-style games on ones own would be of benefit to people who experience cognitive deficits in processing speed, attention and memory from mental illness.  The presenter did not respond to the question.  He repeated the importance of the group work.  Well, yes.  He had a program to sell, and was not there for people who live in the hinterlands where there would be no program.  After the presentation, I was still on my own.  But if you are part of an organization that wants to make the next difference in the treatment of schizophrenia, there is the resource.

Medication Plus Therapy Plus Support

Both Cognitive Behavioral Therapy and Cognitive Enhancement Therapy go to work after the psychotic symptoms have receded.  To start, you need meds.  But to build a solid recovery, for negative and cognitive symptoms, you need non-chemical therapy, too.

Again, I am not recommending to anyone with schizophrenia that they go off their meds.  The point is, people with schizophrenia, or people with any mental illness need more than meds.

Moe Armstrong, founder of Vet to Vet USA says nobody ever teaches us how to live with mental illness.  I have never had a doctor talk with me about how to manage my symptoms.  It's always about tweaking the meds to get rid of them.  This Chemistry Experiment just might kill us, before it ever kills the dragon.

That is why Moe is into peer education.  We can learn from and teach each other how to tame the beast.

Anyone got marshmallows?

One more post on the Fabulous People Who Have Schizophrenia still to come...

photo of burning house by Michael Maggs and used under the Creative Commons license
painting of St. George by Martorell, 1430-35, in the public domain
illustration of St. Martha and the Tarasque from a 15th c. manuscript, in the public domain
book cover from Amazon.com
clip art from Microsoft Office.
photo of campfire by Polimerek, and used under the Creative Commons license

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