Why does schizophrenia begin after puberty?
Schizophrenia researchers have long
been puzzled about why the illness normally begins in adolescence when important
risk factors, such as genetic loading and neonatal brain damage, are present
from birth or sooner. Many believe that the answer to this puzzle could tell us
a lot about the cause of the illness. We now have some good clues to this
We know, for example, that normal
brain development leads to the loss of 30 to 40 percent of the connections
(synapses) between brain cells during the developmental period from early life
to adolescence. Brain cells themselves do not diminish in number during this
period, only their connectivity. It appears that we may need a high degree of
connectivity between brain cells in infancy to enhance our ability to learn
language rapidly (toddlers learn as many as twelve new words a day). The loss of
neurons during later childhood and adolescence, however, improves our "working
memory" and our efficiency to process complex linguistic information. When we
are listening to someone talking, for example, and we miss part of a phrase or
sentence because someone nearby coughs or sneezes, our working memory allows us
to fill in the blank, using a memory store of similar familiar phrases we have
We now know that, for people with
schizophrenia, this normally useful process of synaptic pruning has been carried
too far, leaving fewer synapses in the frontal lobes and medial temporal cortex.
In consequence, there are deficits in the interaction between these two areas of
the brain in schizophrenia which reduce the adequacy of working memory. One
intriguing computer modeling exercise suggests that decreasing synaptic
connections and eroding working memory in this way not only leads to
abnormalities in the ability to recognize meaning when stimuli are ambiguous but
also to the development of auditory hallucinations.
It is possible, therefore, that
this natural and adaptive process of synaptic elimination in childhood, if
carried too far, could lead to the development of schizophrenia. If true, this
would help explain why schizophrenia persists among humans despite its obvious
functional disadvantages and its association with reduced fertility. The genes
for synaptic pruning may help us refine our capacity to comprehend speech and
other complex stimuli, but, when complicated by environmental assaults resulting
in brain injury, the result could be symptoms of psychosis. As yet, this
formulation is speculative, but it allows us to see more clearly how the
environment may interact with our innate qualities to increase our
predisposition to schizophrenia.
There is more agreement now about
what is important in the treatment of schizophrenia than ever before. In a
recent global project designed to combat the stigma of schizophrenia, prominent
psychiatrists from around the world agreed on the following principles:
schizophrenia can be treated effectively in a variety of
settings. These days the use of hospitals is mainly reserved for
those in an acute relapse. Outside of the hospital, a range of
alternative treatment settings have been devised which provide
supervision and support and are less alienating and coercive
than the hospital.
can improve the effectiveness of treatment. A solid body of
research has demonstrated that relapse in schizophrenia is much
less frequent when families are provided with support and
education about schizophrenia.
Medications are an
important part of treatment but they are only part of the
answer. They can reduce or eliminate positive symptoms but they
have a negligible effect on negative symptoms. Fortunately,
modern, novel antipsychotic medications, introduced in the past
few years, can provide benefits while causing less severe side
effects than the standard antipsychotic drugs which were
introduced in the mid-1950s.
include social rehabilitation. People with schizophrenia usually
need help to improve their functioning in the community. This
can include training in basic living skills; assistance with a
host of day-to-day tasks; and job training, job placement, and
Work helps people
recover from schizophrenia. Productive activity is basic to a
person's sense of identity and worth. The availability of work
in a subsistence economy may be one the main reasons that
outcome from schizophrenia is so much better in Third World
villages. Given training and support, most people with
schizophrenia can work.
schizophrenia can get worse if treated punitively or confined
unnecessarily. Extended hospital stays are rarely necessary if
good community treatment is available. Jail or prison are not
appropriate places of care. Yet, around the world, large numbers
of people with schizophrenia are housed in prison cells, usually
charged with minor crimes, largely because of the lack of
adequate community treatment.
schizophrenia and their family members should help plan and even
deliver treatment. Consumers of mental health services can be
successfully employed in treatment programs, and when they help
train treatment staff, professional attitudes and patient
outcome both improve.
towards someone with schizophrenia influence the person's course
of illness and quality of life. Negative attitudes can push
people with schizophrenia and their families into hiding the
illness and drive them away from help. If people with
schizophrenia are shunned and feared they cannot be genuine
members of their own community. They become isolated and victims
of discrimination in employment, accommodation and education.