Robert Freedman, MD, is Professor and Chair of Psychiatry at the University of Colorado and the Editor-in-Chief of the American Journal of Psychiatry. His new book, The Madness Within Us: Schizophrenia as a Neuronal Process, is a discussion of these two aspects of the illness. Freedman outlines the emerging understanding of schizophrenia as a neurobiological illness. In the excerpt below we learn about the basic brain dysfunction in schizophrenia.
The earliest observers of how people with schizophrenia seemed to react to their environment noted a peculiarity in the ability of persons with schizophrenia to appear unaware of the environment and yet overly responsive to it. Eugen Bleuler first developed the concept of an attentional dysfunction in schizophrenia in his essay on attention in schizophrenia…
Rachel not only hears voices but she hears noises as well, noises that her family members also hear but have learned to ignore. She hears screaming all the time, and she sometimes wanders the neighborhood to find out who is screaming. When my colleague Merilyn Waldo suggested to her that it might be traffic, she told us that her mother had said the same thing. There is a busy corner near the front of her house, and there are always cars stopping and then accelerating away. My wife and I experienced the very same perceptual abnormality ourselves on the night we brought our first son home from the hospital. We put the baby to bed and tried to sleep ourselves, but I heard screaming. I checked on the baby, and he was asleep. Then my wife heard it too. We checked again. Then we listened at the door. The screaming must be coming from another apartment, and we wondered if we should call the police to alert them to child abuse, but we knew that no other couples with babies lived in the building. Finally, when the traffic on the highway in front of the building stopped at 2 a.m., we understood how two very anxious, hypervigilant new parents can misinterpret the world around them.
For Rachel, the problem is not a single stressful night. It is a lifelong problem, which she has struggled with since she was a teenager, long before the onset of her illness at 28. She could never concentrate at school. The least noise captured her attention. As she put it, “My mind has to be here, it has to be there, I can’t concentrate on anything.” Unlike a typical child with attention-deficit disorder (ADD), whose attention is rarely captured, her attention was captured by everything, from the traffic squeaking to the refrigerator cycling on and off, to the neighbor’s ongoing argument next door. As a result, she could concentrate on very little.
Paul, on the other hand, seems to be aloof in his environment. When he was first ill and worried about snakes, I wondered if their voices arose out of noises around him in the dormitory. He acknowledged that the noise of the dormitory was exquisitely painful, but he could not connect it to the snakes. Now he seems withdrawn. When I walk out to get him in the waiting room, he seems oblivious to the people around him. He has constructed a psychological shell around himself, a solution many patients use to shield themselves from their otherwise overwhelming environment.
The most dramatic experience of the phenomenon of seeming to ignore the environment is catatonia, a rarely seen syndrome in schizophrenia today. The patient gradually stops responding to environmental stimuli and then eventually stops moving altogether. In the most advanced cases, the person suddenly freezes. If he is moved passively, then he may retain the position into which he is moved, a symptom termed “waxy flexibility.” These patients can often be drawn back to awareness by family members and sometimes even a familiar physician, which leads to the supposition that they may be faking their symptoms. They are not, and it is sometimes shameful to watch medical personnel positioning them in uncomfortable poses or raising their arms over their faces to see if they will prevent their arms from hitting their eyes, a misguided attempt to uncover what they believe to be malingering.
Patients with catatonia have hyperactive electroencephalographic activity, consistent with the minds being quite active, rather than asleep or anesthetized. They respond to barbiturates and benzodiazepines, drugs that are sedatives, with a paradoxical “awakening,” in which they resume normal movement. This paradoxical response suggests that they have actively withdrawn from the world around them, perhaps to inhibit the response to stimuli. When the barbiturate or benzodiazepine partially inhibits their brain’s responsiveness, they lose this withdrawal and temporarily resume normal interaction. They often report that they were fully aware, indeed acutely hyper-aware, of their surroundings during the catatonia. Catatonia takes several years to develop and most persons receive drug treatment before it becomes an obvious symptom. I have occasionally seen it develop in patients from religious families who resist treatment and expend great effort to interact with their loved one, who is descending into deepening catatonia. The otherworldly trance adds to the spiritual mystique of their loved one’s experience.