Tuesday, October 22, 2013

60 Minutes on Schizophrenia and Violence



Dr. Torrey: We have a grand experiment: what happens when you don't treat people. But then you're going to have to accept 10 percent of homicides being killed by untreated, mentally ill people. You're going to have to accept Tucson and Aurora. You're going to have to accept Cho at Virginia Tech. These are the consequences, when we allow people who need to be treated to go untreated. And, if you are willing to do that, then that's fine. But I'm not willing to do that.
60 Minutes did a piece on schizophrenia and violence recently. The video clip is worth watching, and the transcript is worth reading.


I have my doubts about E. Fuller Torrey's statement about 10% of all homicides being committed by the untreated mentally ill. He's a public policy advocate and those folks are known to make up statistics on the fly during interviews (e.g., Mitch Snyder on the number of homeless in the U.S.). The LA County Jail will probably be disappointed to hear that the Cook County Jail has passed them as the nation's largest mental health facility.

Here's the part of the piece I would be most cautious about:

Dr. Lieberman: You can be the most popular student, you can be the valedictorian of your class. And if you develop schizophrenia it will change the functioning of your brain and change the nature of your behavior.
Steve Kroft: You could be completely normal at age 20, perhaps a good student or a gifted student and a solid citizen, and at 21 or 22 be psychotic?
Dr. Lieberman: Absolutely.
Dr. Lieberman, who runs the psychiatry department at Columbia University's medical school, says that schizophrenia has a genetic component and tends to run in families, affecting the way the circuits in the brain develop. You can see the structural abnormalities in a brain scan.
Dr. Lieberman: And you see people, a young adult, with a normal brain, same age with, who has schizophrenia, and you see that degenerative process has already begun.
Steve Kroft: This is really a disease of the brain. Not a disease of the mind?
Dr. Lieberman: Absolutely.
It lies dormant during childhood and usually emerges in late adolescence and early adulthood, affecting perception and judgment. People see things that aren't there and hear voices that aren't real.

Elaine Walker's home movie studies certainly challenge the "completely normal" premorbidity hypothesis. The typical course for most people with schizophrenia involves an insidious (i.e. gradual) onset, not a "sudden change." It might seem sudden to us, because we haven't been privy to that person's slow-motion unravelling -- social withdrawal is often one of the first signs of incipient schizophrenia. Dr. Lieberman actually does consider the disease a neurodevelopmental disorder, which it probably is. The point is that the brain abnormalities were already present, years before the bizarre symptoms and behavior emerge. I wouldn't say that they were quite "dormant" -- I'd say that they are "subtle" (which suggests that if one possessed a sensitive enough method, one could detect the abnormalities even before the first full-blown psychotic break).

Lastly -- what is the point of the false distinction between "disease of the brain" and "disease of the mind"? Are they trying to say that schizophrenia doesn't affect your mind? Or that purely mental acts (e.g., learning algebra) aren't associated with physical changes in the brain? Just because a disorder is associated with brain abnormalities doesn't mean that those brain abnormalities caused the disorder (even the formerly much vaunted Genain quadruplets, once thought to be a slam dunk example of genetic inheritance of schizophrenia, turned out to have suffered harsh punishments and sexual abuse during childhood). And it certainly doesn't mean that a disorder with a biological basis must therefore be treated only using biological interventions (e.g., ECT, prefrontal lobotomy, chemotherapy). And when Dr. Lieberman says that "you can see the structural abnormalities in a brain scan," be aware that he is referring to comparisons of group means (schizophrenics v. normals) -- there are no pathognomonic signs or symptoms of schizophrenia. It is not diagnosable by brain scan (nor is any other mental disorder).

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