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 | Science in the Cinema 2008 Transcript: Canvas |
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National Institutes of Health
Science in the Cinema 2008—Canvas
Post-Film Discussion—Daniel R. Weinberger, M.D.
At the NIMH, Dr. Weinberger’s research is focused on brain mechanisms involved in the pathogenesis and treatment of neuropsychiatric disorders, especially schizophrenia. He was instrumental in focusing research on the role of abnormal brain development as a risk factor in schizophrenia, and his lab has identified the first specific genetic mechanism of risk for schizophrenia. In addition, he and his colleagues developed the first high-fidelity animal model of schizophrenia.
In 2003, the journal Science highlighted the genetic research of his lab as the second biggest breakthrough of the year, second to the origin of the cosmos.
So please help me in welcoming Dr. Weinberger.
Dr. Weinberger: Well, thank you. It’s a pleasure to be here.
This is actually the second time I’ve seen this movie, and I must say it’s even more powerful the second time than it was the first time. Obviously this is much more than science at the cinema; it is the story of extraordinary humanity. It’s told by a child who obviously lived this, which gives it a very, very special tenderness and meaning.
Let me just say a few things first about schizophrenia, the medical subject of this movie, and then talk a little bit about some aspects of the film and its fidelity. In 1950, an organization called the American Foundation, a charitable organization that surveyed the state of public health in the United States for the government, came to the remarkable conclusion at that time—and I quote from the American Foundation report on the state of health in America. They stated that “schizophrenia is the most serious disease of world societies.”
In 1988, Nature magazine, which is arguably the premier science journal in the world, concluded, and I quote, “that schizophrenia is the worst disease of mankind, even AIDS not excepted.”
At the turn of the 21st century, the World Health Organization did a survey of the cost to societies of various medical conditions. Four of the top ten most costly disorders of human beings were psychiatric illnesses, one of the top ten being schizophrenia. This is a tremendously disabling, serious, and costly disorder which occurs generally in the early years of one’s adult life and is a life-long disorder with profound personal, family, social, and economic costs. I think this is depicted very clearly in this movie.
The movie is remarkable, I think, not only because it obviously is the story told by the recollections of a child who lived with a mother that has this illness, but also because the movie doesn’t really pull a lot of punches. It’s sentimental. It’s a Hollywood production. But it doesn’t cop out. And it makes it very clear that this is a profoundly serious disorder with enormous cost and disability associated with it and that, unfortunately, most people don’t recover from it.
The movie is fairly accurate in depicting the sort of classic symptoms that make everybody know there is something profoundly wrong with people who are suffering from this condition. It depicts the paranoia, the failure to understand things that are happening in the real world in real terms; it depicts the tormenting perceptual distortions and hallucinations that many patients suffer from.
It depicts the withdrawal from the social world very, very poignantly and the tremendous price that’s paid. I think it also depicts the effect of treatment—that is, that treatments do improve most individuals with these conditions, but they don’t cure them.
This was an individual with a particularly treatment-refractory form of schizophrenia. There are many individuals who have fairly substantial and in some cases almost complete recoveries, maybe not complete cures, but in many instances good recoveries. This was not an example of someone that had that sort of recovery, but medications do work. They do improve symptoms; they make people able to live more effectively in the world of their families and their neighborhoods. But in many instances, it does not do much more than you see in this film.
I think the film—interestingly enough, in the current world, there are not many patients with as severe a form of schizophrenia as this individual who get as good care as she does. This is one of the unfortunate things that have happened to the mental healthcare system, certainly the public mental healthcare system. I wish I could say that most individuals who are treated in the public mental healthcare system would get as caring and consistent treatment as this person got. This is one of the real failings, the increasingly severe failings of our public mental health system.
There were side effects of treatment that were depicted actually—interestingly, a little bit subtle—but they included the weight gain, which is a common side effect of the medication. I’m not sure that was intentional, but I suspect it was. Not mentioned in the movie is the enormous progress that’s been made in understanding these disorders. This is really one of the remarkable things that we’ve seen in the past ten years.
When I first started to research schizophrenia, almost thirty years ago, it was still a prevailing idea out there that these disorders were caused by something related to parenting. And we all know that there was a generation—several generations of families—who were made to feel very guilty and shameful of the occurrence of these disorders in their families, because they were held accountable for them.
We now know from a generation of scientific investigation that parenting is not a cause of schizophrenia. These are disorders that are, for the most part, related to genes and how genes affect the development and function of the human brain. These are brain disorders in the same sense that epilepsy is a brain disorder and Huntington’s disease is a brain disorder. But they’re not brain disorders of the parts of your brain that control how you walk, how you talk, how you balance, how you have a seizure or not. They affect the development and function of the parts of your brain that have to do with processing the environment in a coherent, contextually appropriate, and realistic way.
They allow you to make critical judgments when you’re confronted with very complex environmental conditions. They allow you to manage your emotions. These are very highly evolved, uniquely human parts of the brain, that when they don’t quite get all the wiring diagram right, they produce problems with managing and the resulting breakdown in that kind of function. This is what we increasingly understand the picture of schizophrenia to be.
We know this as a disorder related to genetic risk. The genes are increasingly being identified. We now have genes for schizophrenia that look very promising. They are helping us to understand the mechanisms of this disorder. Genes relate to schizophrenia in the same way they relate to many common medical disorders like diabetes, asthma, heart disease, and cancer. They create risk factors. They affect the development of your brain in such a way that you interact with the environment in particular ways. This is what we increasingly understand about this disorder.
The hope is that by having clues to the basic mechanisms, basic genetic mechanisms, and, ultimately, the basic cellular mechanisms—because genes are about how cells work—we will be able to design treatments based on a fundamental understanding of the causes and mechanisms of this disorder. Theoretically, this should lead to much more effective treatments with much less untoward side effects.
So again, I think this is a profoundly moving film which characterizes the extraordinary cost and pain associated with the disorder. Like most serious chronic medical disorders, there’s a lot of pain in the family.
There’s something somewhat unique about mental disorders, particularly schizophrenia, because the individuals are still themselves, but they’re not quite themselves.
I would be more than happy to answer any questions or respond to other comments.
Question: You mentioned that this parallels a brain disorder. I was wondering how you would differentiate that from a neurological disorder. And in the same vein, it seems like there’s less stigma associated with neurological disorders than psychiatric disorders. Would it be helpful to characterize them in both areas?
Dr. Weinberger: I think stigma is a huge problem in all psychiatric disorders, and the problem is one that detracts people from doing research on these disorders. It sort of discourages people from encouraging financial contributions to support research in these conditions. And it obviously creates all kinds of problems for affected individuals and their families. I believe the stigma is largely because of ignorance, as we’ve achieved a much greater scientific understanding of these disorders. I think stigma is less than it was.
Having genes for mental disorders like having genes for epilepsy, diabetes, and heart disease, etc., changes the world view of what these conditions are. If they’re clearly related to factors in DNA, then they’re not about somebody necessarily not listening, or not doing what they’re supposed to do, etc.
Now, are they neurological disorders? I like to say to my neurological colleagues that they are brain disorders in the sense that all neurological disorders are brain disorders, but they are neurological disorders of these parts of the brain that handle cognition, thinking, emotion, and social judgment. Your brain doesn’t just control talking, walking, and feeling. Your brain controls so much more.
Most neurological disorders are diagnosed and understood in terms of how they impact on those parts of your brain that deal with walking, talking, and feeling. But that’s actually a very small part of your brain. The human brain has evolved, compared to all other animal species, to have most of it related to functions other than walking, talking, and sensation. Those are the parts of the brain that seem to be affected by psychiatric disorders. They are, and in many senses, the neurological disorders—meaning that they involve the nervous system of those systems, those circuits, those wiring diagrams related to aspects of brain function that have to do with how we think, how we perceive, how we learn, how we understand events in our environment, how we regulate our emotions, how we make social judgments, etc.
Question: Two things. One, I was a little puzzled that people in Florida seem to think that building a boat in Florida was weird behavior. If I was in Florida, I would probably build a boat. I’m not sure if that’s quite a psychiatric question.
The second thing: at one point, Chris feels that he’s hearing voices and all. I was wondering how much genetic factors or socialization, living with his mother, that sort of thing, make it likely that he’s going to have problems as he gets older as well?
Dr. Weinberger: Those are two very good comments. First, I think the depiction of the neighborhood having difficulty with him building the boat was actually a very telling observation about how hard it is for a family to cope with this kind of problem because they really are isolated in the neighborhood. There are very few people who are trying to help them. Certainly, the insurance industry doesn’t try to help them. There isn’t a great deal of the public healthcare dollars trying to help them. Unfortunately, because of people’s unfamiliarity, fear, and discomfort with the signs and symptoms of psychiatric illness, one’s neighbors and friends often shy away from being helpful. I think that was depicted very nicely in the film.
The genetics of being at risk is pretty well worked out actually from about fifty years of family studies. We know if you have a parent who has schizophrenia, you have about a five to ten percent chance of having schizophrenia, which means that the odds are about 9 to 1 that you won’t have schizophrenia. This is similar to most common medical disorders where the genetics is very complicated.
It’s a little bit like if you have a parent with diabetes. Most of the children will not have diabetes. The odds are remote that you will, too. The odds are much greater than if you don’t have a relative with diabetes or asthma or epilepsy. The odds are still very much in your favor that you won’t manifest those conditions because they’re not accounted for by one gene. It’s not like Huntington’s disease or cystic fibrosis, where the genes more or less determine your fate. The genes for psychiatric disorders are just like the genes for diabetes, obesity, asthma, heart disease, cancer, and stroke. They’re genes for risk. They’re not genes for fate.
Question: From what little I know about schizophrenia, it seems that the biggest hurdle to successful treatment is often getting the patient to acknowledge that they have a mental illness in the first place. Is there anything which is successfully being done to help get patients over this denial so that then they’re able to buy into working with doctors to find the most successful treatment beyond that?
Dr. Weinberger: So this is an extremely insightful and important observation. One of the great challenges and tragedies of trying to treat an illness like schizophrenia is that it’s a disorder of the parts of your brain that allow you to make critical judgments, have insight, and understand cause and effect. These are parts of your brain that make you move your hand, talk, etc. You have a brain in part to allow you to make critical judgments and critical observations and have insight, etc. So, to the extent that those parts of your brain are the targets of this disorder and the disease process, the disease itself conspires to resist its own treatment. This is one of the big challenges. Now, the best treatment for that is treatment, because the more a patient can receive treatment, the less this conspiracy to obscure judgment and insight can dominant their resistance to treatment.
There is no substitute for a good medical-delivery system, a good healthcare-attention system, family and friends to try to help work with that resistance. But this is one of the big challenges. There’s no secret formula for making it work.
Question: I have two questions. One, I know that because of certain factors, in some people, schizophrenia may not come out, but in certain people, certain circumstances that they live in, such as city areas and things, sort of pull it out of them. Are there certain beliefs that these schizophrenic people may hold, or certain circumstances, that are a lot more likely to make them become schizophrenic? And what are these?
And also, I know that they hear voices, but so do a lot of people who believe in God and religious people and mystics. And so how does the hearing of voices differ? Couldn’t some people who are religious and hear voices of demons and such be considered schizophrenic by the medics?
Dr. Weinberger: Those are very good questions. Let me try to answer the first one and then I’ll get to the second one.
There’s no question that the environment is important. So, the genes are not enough. This is very clear because if you look at identical twins where one twin has schizophrenia, there's only a fifty percent chance that the other twin will have schizophrenia. So, they have identical genes. There's more to it than just genes. Now, fifty percent, you wouldn't want that to be a flip of the coin. There's a huge increase in risk in people who share the same genes when one twin has schizophrenia, and that illustrates how important the genetics is—but it's not the only factor.
Clearly, environment matters. There's been a lot of effort to understand what environmental risk factors are. A few have been identified. For example, we know that problems during gestation, obstetrical complications, problems related to aspects of early development seem to become additional risk factors. We know that drug use, recreational drug use in early adolescence, is associated with increased risk of schizophrenia during adult life. We don't understand how these factors increase the risk, but they have been identified as additional risk factors.
There's some evidence that people who grow up in urban environments have a slightly increased risk relative to populations in rural environments. How these are important factors, we don't understand.
There's been a longstanding effort to look at the role of stress in environmental complexity as a risk factor. Whether this is a risk factor or just a sort of environment that is impossible for individuals who are genetically at risk or in the process of no longer being able to cope—they're just environments that they can't work under. We don't really know this yet. So there's no single environment or environmental factor that's been identified as a cause of the factor.
Let me speak to the second point about hallucinations, because clearly, you're right. Every individual who has what seems to be a hallucinatory experience does not manifest this condition that we call schizophrenia. I think one of the things the movie depicts is that over centuries, psychosis, schizophrenia, insanity, whatever it's been called, has generally been characterized by florid hearing of voices. We know that schizophrenia, as depicted in this movie, is much more than voices. It has to do with a profound change in the experience of reality and a profound change in the ability to work in the real world.
In fact, one of the things that I think the movie depicted very nicely is when she was invited to go with them on the boat the first time. She refused to do that because as she was getting better, she was beginning to realize that she could not expose herself to that kind of stimulation because it would lead to her not functioning as well.
Schizophrenia is much more than hallucinations. We’ve become increasingly aware of the role of cognitive problems and many, many other problems than these classic symptoms.
Question: My question also has to do with risk factors. Do you see that adolescents who have been diagnosed with depression, anxiety, ADHD, or any number of other psychiatric diagnoses are more at risk for schizophrenia than others?
Dr. Weinberger: There’s no evidence that those conditions, as they are currently diagnosed in clinics, are increased risk factors for schizophrenia.
Question: My question relates to nature-nurture issues as well. Have there been any studies done of the rest of the family who have a family member who have schizophrenia?
For example, Chris was already showing some adjustment disorder in the film. And what happens when your limbic system, at that young age, is exposed to schizophrenia or severe mental illness?
The other nature-nurture issue: sometimes people look at personality disorders and schizophrenia and a lot of other severe mental illnesses as sort of merging and being similar. And trauma, I know, is associated with personality disorders and severe paranoia. I'm wondering if you could speak a little bit about the environmental factors that go into that.
Dr. Weinberger: Schizophrenia is a diagnosis that is based purely on phenomenological characteristics. It's not based on a medical test. It's not based on any known pathological finding. It's based purely on features and characteristics of a person that gets the diagnosis. We know that those features and characteristics are not very precise. We can't really define them with great validity.
We know that this is a diagnosis that's very blurry around the edges. There are conditions like paranoid personalities that seem to be a little bit more common in the families of individuals who also have schizophrenia. This has lead to the idea that the genetics is about a spectrum of changes and how the brain relates to the environment. As we increasingly identify genes that are related to risk, we are seeing that these genes not only about schizophrenia. They're about other conditions where aspects of psychosis or cognitive functional problems that patients with schizophrenia have are also found.
As we begin to get a better hold on these genes, we'll have a much better understanding of what these conditions really are, not in terms of the phenomenologic diagnosis, which are labels, but in terms of the basic underlying biology of how a brain gets this way.
I think the first point you made, nature-nurture, is a key point, obviously. To have a parent with this kind of psychiatric difficulty is profoundly stressful. We know from every study that's ever been done objectively, that very stressful childhood environments are deleterious to the general psychiatric health of children. That doesn't mean that they produce schizophrenia. The evidence is very clear that they don’t produce schizophrenia by having a stressful childhood; however, you do produce other psychiatric problems.
There have been very few studies of the offspring of schizophrenic parents, other than looking at the likelihood that they develop schizophrenia. There actually have been a few anecdotal reports that there are sort of two poles of offspring of schizophrenic parents; one is the pole where offspring are very stressed and have chronic life-long stress-coping problems. And then there's another population, which may actually be Chris in this movie, who are unusually resilient and have extraordinary coping skills. This is more anecdotal than actually scientific.
Question: My question, I think, might be similar to what you were talking about. In the paper we got, it said some people with schizophrenia may seem perfectly fine until they start talking about what they're thinking about. And in one of the videos that are produced by the National Alliance for Mental Illness, there's one of the people in the videos that says he has schizophrenia and he ended up as a CEO of a big fortune 500 firm until he retired.
So my question is, if you only know about it from what the person is telling you, then couldn't somebody go through their whole life and if they didn't go for treatment or say anything about what they were thinking, then the community and where they work might consider them weird. But if only their family knew and were exposed to the worst of what they couldn't hide, and they went through their whole life like that and didn’t get diagnosed, would that mean they didn't have schizophrenia?
Dr. Weinberger: This is another key point. This brings me back again to the comment that these diagnoses are blurry around the edges. We wish we had a spot on a chest X-ray that you see it up there on the view box and you say, the patient has pneumonia and everyone that looks at that spot says, “Yep, it’s pneumonia.” We don't have that.
One of the criteria for this diagnosis, which actually was an effort, to move psychiatry in the 1970s from this tradition of its being very subjective and soft to being a little bit more rigorous and scientific. And that was that it has to be disability. Because we know that people have all kinds of ideas. I like to say everybody has their own map of the world. No one has exactly the same map as somebody else. People have a lot of ideas that sometimes don't characterize their best friends. And sometimes people have ideas that, if they actually tell them to you sitting around a dinner table, you look at the person next to you and go, “Is he serious?” But that's not schizophrenia.
The way we diagnose it—and this has to do with recognizing that we're trying to treat illnesses—is there has to be clear disability. Disability means a loss of function relative to their prior state before the symptoms or the disorder appeared. If someone has been the CEO of AT&T, despite having a lot of secret ideas, fantasies, and even notions, they don't have schizophrenia as we refer to it in the psychiatric diagnosis.
Question: There was a reference earlier to a discovery of yours that involved one gene. There have been points made over the years of discoveries that many of the mental illnesses are clusters of genes. Could you elaborate on that and more on what you discovered?
Dr. Weinberger: We are very convinced that schizophrenia is like most common medical disorders. Most common medical disorders have genetic components, e.g., diabetes, high blood pressure, and heart disease. Everybody doesn't get these things. There are genetic risk factors, like genes that effect cholesterol and metabolism or genes that affect how resilient your arteries are to high blood pressure, etc.
These are the architectures of risk made up by multiple genes. What happens to people who manifest these conditions is that they have a sort of convergence or coalescence of a lot of risk factors in one less fortunate individual. Everybody gets something. Everybody has risk factors for something.
There's an old saying “nobody gets out of this alive,” and we all come into it with a certain constellation of risk factors. We think that mental illness is just like this. The evidence is increasingly clear. This is true of depression, anxiety disorders, schizophrenia, bipolar disorders, autism, and all psychiatric disorders. All major psychiatric disorders are determined primarily by genetic risk factors. There is no single factor. There are multiple factors. There may be hundreds of factors, any few combinations of which can explain an individual’s risk.
One of the genes that we studied was a gene called COMT, which is a gene that affects how your frontal lobe works. We spent a lot of time trying to understand this gene. It has been linked through a variety of studies to risk for psychosis. Not just schizophrenia, but psychosis in bipolar and even psychosis in Alzheimer's disease. The gene affects aspects of how your frontal lobe works. So the gene does not cause psychosis. No gene causes mental illness. Genes are part of the building blocks of the individual risk architecture and this is one of those building blocks.
We have spent a lot of time trying to understand how it represents a building block. A gene is just sort of a sequence of letters in the DNA code. But for it to be a building block of an architecture of risk, it has to do something to your brain to make your brain a little bit more like a risk-sensitive brain.
That's the kind of work that we've done. We try to understand how it affects how your brain works. We've done a good deal of work demonstrating that it affects how efficiently your frontal lobe can handle certain kinds of cognitive information.
Question: You previously mentioned that there were several factors involved, such as genetics as well as the environment. Can you speak more to those categories and which one has a higher percentage? Is there a balance between the two?
Dr. Weinberger: There are scientific studies that are done to address the question of how much risk is in genetic versus how much is environmental. These are generally done in two ways. They are done with twin studies where you compare the likelihood, if you're one member of an identical twin pair or one member of a fraternal twin pair, what is the likelihood that you have schizophrenia if your co-twin has schizophrenia?
Identical twins share all their genes, so they’re genetically identical. Fraternal twins share half their genes, like all siblings. The difference between monozygotic (identical twins) and dizygotic (fraternal twins) is the genes. They basically share the same environment to the extent they have the same parents, same cultural circumstances, same school circumstance, etc.
If the disorders were mainly environmental, you would find that the fraternal twins and the identical twins would both show the same concordance rate. That is, it would be just as likely—regardless of whether you're an identical or fraternal twin—that if your co-twin had schizophrenia, you would have schizophrenia. But that's not what the data show at all. What the data show is that if you’re an identical twin where your identical twin has schizophrenia, you have about five times the likelihood that you’ll have schizophrenia than if you're a fraternal twin and your fraternal twin has schizophrenia. That illustrates that genes make up a much bigger percentage of the likelihood that you will have this illness than environment.
There have been several studies of adopting away children of schizophrenia parents and looking at what happens. There at studies looking at the probability of developing schizophrenia when they're adopted to well parents. The data are very clear from these adoption studies that what determines the risk—even if you're adopted away at birth—is the fact of schizophrenia in your genetic parents and not in your adoptive parents. These studies have made it very clear that genes matter a great deal.
The relative weight is, it’s thought, that the variation in risk in a population for having schizophrenia is determined about seventy to eighty percent by genetic factors. Twenty to thirty percent is determined by nongenetic factors, which are thought to be environmental factors. That’s not a trivial amount, by the way. Those environmental factors could still be exceedingly important. They could be targets for treatment. For example, we know that smoking causes lung cancer and that clearly, there are people who don’t get cancer when they smoke because of genes. Genes may be the critical factor in who gets lung cancer related to smoking. But smoking is an exceedingly effective target for public health intervention. By stopping people from smoking, you can have a much bigger impact on the risk of lung cancer than anything we’re likely to do in the near future with genes.
It may be that even though relative risk in a population related to environmental factors is small compared to the role of genes, we may be able to do something very important about environmental factors that we might not be able to do with genes.
Question: Are there any studies using MRI or CAT scans of individuals who have schizophrenia and who have also responded to medications? Can you see that their brain functions differently on a CAT scan? Secondly, there’s the issue of plasticity of the brain. It has been shown in stroke patients that they learn to do things because a different part of their brain takes over. Is there a possibility of this occurring in patients diagnosed with schizophrenia?
Dr. Weinberger: I don’t want to sound too pessimistic because it’s very clear that treatment works, and many patients get better. Approximately seventy-five percent of schizophrenic patients have significant improvement with treatment. There is certainly a population of people with schizophrenia who go back to relatively good adaptations in life. Clearly, there is restorative capacity.
There’s no reason to think that the neuroplasticity phenomenon that we associate with recovery from other brain disorders is not something that’s possible with schizophrenia. If we had better treatments, the opportunity for increased neuroplasticity would be greater than it is right now. Clearly, restoration does happen. Most people do not go progressively downhill throughout their lives. Hopefully, this will get better and better in the future, but for now, there’s still considerable capacity for restoration.
There hasn’t been any good way to use an MRI scan or a CAT scan to identify improvement in patients with schizophrenia. In general, patients with depression and anxiety who improve after treatment of symptoms, show signs of improvement on their MRIs; however, it not clear what is the cart and what is the horse in that situation.
Question: I just want to say thank you for coming here from a person who grew up with a schizophrenia mother. It’s a very stressful situation. It continues to be a stressful situation since she’s living with us again.
I wanted to make an observation first, and then ask a question. First, in the movie, it’s really obvious to the family that the mother is schizophrenic. It’s not always obvious to the family members that the family member is schizophrenic. Often they’re very rational and have lots of wonderful justifications for the supposedly crazy things that they believe. From the inside, it’s very difficult to determine that the person is schizophrenic and needs help.
Second, as a child in the family, it wasn’t clear to me and it also wasn’t clear to my father how to get help because unless there was a clear physical threat to our safety, we really didn’t feel like there was anything that we could do. Short of calling the police, as happened in this movie, what do you do? Do you physically force the person to go and see a therapist or a doctor? That’s not very likely. I’m wondering if you could talk about strategies to intervene before the person gets to a situation in which you need to call the police.
Dr. Weinberger: I really appreciate your comments. I think you’ve articulated another aspect of how difficult these problems can be. When you see a loved one suffering and behaving erratically, it’s a natural human reaction to somehow explain it away. It’s very difficult to see the possibility that something is very wrong. That’s a difficult thing to appreciate.
In most states, you can only involve the police if there’s harm committed. I think the movie sort of skipped over this, but probably the fact that she was wielding a knife and actually cut the boy was reason enough for the police to come. It wasn’t clear how the police came, but you can’t call the police because someone is acting in a threatening, scary, or erratic way in the house. They literally have to be in grave danger to themselves or others for the police to respond. It falls on families, friends, and neighbors to somehow try to have a conversation with the loved one that things are not going well. I wish I could give you or anybody a simple formula for how you make contact with the part of the individual that recognizes that something is wrong. In my experience, there’s always some part that recognizes that something is wrong. But it’s very hard to build an alliance with that part because that part is being drowned out by the part that’s misreading all the intentions of the people around them. Ultimately, that’s what the challenge is for the family—to engage their loved one in a plan to seek help.
We all use whatever contrivances you can come up with, e.g., “this is an experiment,” “let’s see what they say,” “what do you got to lose,” and “look at how upset everyone is.” Ultimately, it takes continuous effort to bring someone to treatment.
Question: I read an article the other day that said that they believe that schizophrenia might be caused by the father being of older age. Is that true? Secondly, I’ve known two people in my life who have been kind of schizophrenic. One was in college. I am curious about the age. That person exhibited very bizarre behavior. The second person was really self-aware at first, received treatment, and was better.
Dr. Weinberger: There is no one schizophrenia. The diagnosis is blurry around the edges, and there is tremendous variation. As in most psychiatric disorders and many classical medical disorders, everyone is biologically different and the risk factors are different. There is a lot of coloring and flavoring that varies between people. There is variation in severity. There is variation in how much some people can compensate or hide their symptoms and how much they are able to function in spite of these problems.
There are many risk factors. There’s no one risk factor. There’s some evidence that being a father over fifty does increase the risk for schizophrenia in the offspring. Obviously, most people with schizophrenia don’t have a father who’s over fifty when they fathered them. But it makes the point that there’s no one single Holy Grail type of risk factor.
Question: What’s the age group? In the movie, it seems like the woman was a lot older. But when my friend became schizophrenic in college, I was told that it generally occurs in early adulthood. Is that true?
Dr. Weinberger: About two-thirds of the cases of schizophrenia are diagnosed in males. Approximately eighty percent of males who develop schizophrenia are diagnosed before the age of twenty-five. In women it is a little bit older. Approximately eighty percent of females who develop schizophrenia are diagnosed around the age of thirty. So the woman in this film was probably diagnosed at about thirty years old.
Dr. Fuchs: Dr. Weinberger, I would like to ask you the converse of one of the earlier questions. I have a friend who had his schizophrenia afflict him in the second year of medical school at the University of Virginia. I met him about twelve years later. His schizophrenia was under pretty good control, so he was working. He was working a series of menial jobs, i.e., a night watchman at a mall—probably the best job he had ever had to that point—and delivering glass to construction sites. The thing that I noticed about him on a continuing basis was depression. He recognized what he had lost and he was dealing with that. So is this a common feature?
Dr. Weinberger: It’s important to remember that people with schizophrenia are human beings. Depression is very common in schizophrenia. In fact, as the woman in this film was getting better, I think you could perceive that she was sadder and much more introspective. She was probably thinking about what she had lost and how much suffering had occurred. This is not uncommon. Depression is very common in people with schizophrenia. It can be very disabling. It’s clear to many individuals that they cannot get back to their normal lives.
Actually, the story tells a very poignant story. It’s even the story of John Nash, who A Beautiful Mind was about. This man, despite his extraordinary intellect, never achieved anything close to a major mathematical discovery or formula or proof or anything after his illness really became the dominant aspect of his life.
Dr. Fuchs: Before I ask you to help me thank Dr. Weinberger, I’m going to invite you back to next week’s film. It’s The Quiet Duel. It’s by a famous Japanese director, Akira Kurosawa. It is one of his early films.
Help me thank Dr. Weinberger. You are a wonderful teacher.
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