by D. F. Swaab
Brain damage at an early age appears to foster the development of savant qualities, because at that stage the brain is still fully able to make new connections with other structures. A Japanese savant caught whooping cough and measles at the age of four. It impaired his speech development, but when he was only eleven he made extraordinarily beautiful drawings of insects.
Some claim that savant talents are entirely due to training. Tammet jokes that he learned to count so well because he was one of nine children. It’s true that savants are able to focus strongly and train obsessively, thus honing their skills. But they have to have a talent to start off with. And these talents are expressed at a very early age, both in savants and in child prodigies like Mozart, which conflicts with the training theory. When the young Mozart heard Gregorio Allegri’s Miserere in St. Peter’s in Rome, he made a few notes and then wrote out the music from memory back at his lodgings, in contravention of a papal ban. Stephen Wiltshire was producing remarkable drawings by the age of seven, an ability that didn’t markedly improve afterward. Some children are able to perform calendar calculations from the age of six.
Talents sometimes disappear with age. The autistic girl Nadia showed a remarkable talent for drawing between the ages of three and seven. First she drew horses and other animals, later people. By the time she was nine, however, she had lost her unusual ability. It would seem that the improved functioning of the left side of the brain, which is responsible for speech, inhibited her drawing skills. In that respect, too, Daniel Tammet is an exception. Developing his social skills didn’t cause him to lose his numerical and linguistic talents. He has a remarkable brain in every respect.
10
Schizophrenia and Other Reasons for Hallucinations
There is only one difference between a madman and me. The madman thinks he is sane. I know that I am mad.
Salvador Dalí (1904–1989)
SCHIZOPHRENIA, A DISEASE OF ALL AGES AND CULTURES
When he arrived at the other side in the region of the Gadarenes, two demon-possessed men coming from the tombs met him. They were so violent that no one could pass that way. “What do you want with us, Son of God?” they shouted. “Have you come here to torture us before the appointed time?” Some distance from them a large herd of pigs was feeding. The demons begged Jesus, “If you drive us out, send us into the herd of pigs.” He said to them, “Go!” So they came out and went into the pigs, and the whole herd rushed down the steep bank into the lake and died in the water.
Matthew 8:28–32
Schizophrenia has been “treated” in various ways over the centuries. In China, four-thousand-year-old skulls were found with holes trepanned into them, to let out the evil spirits believed to possess schizophrenia sufferers. In some cases bone had started to grow over the hole, showing that the patients had survived the operation for some considerable time. Jesus set a long religious tradition with his banishing of evil spirits (see the epigraph to this section). The Catholic Church ordained exorcists up to around 1970. That profession has since disappeared, though Catholic bishops still appoint priests to carry out exorcisms. In the Protestant church, exorcisms are performed by ministers. Demon banishing goes on in the Islamic tradition, too. When she lived in the Netherlands, the sister of the Somali feminist and activist Ayaan Hirsi Ali received medication for her schizophrenia. But back in Somalia she fell into the hands of Islamic clerics, who put her in an empty room containing only a mattress. They took her medication away and beat her to ritually banish her demons. This treatment proved fatal.
A painting by the medieval artist Hieronymus Bosch in the Prado, in Madrid, represents “the stone operation.” A doctor is pretending to remove a stone from the head of a schizophrenia sufferer in a placebo operation. Bosch portrayed the doctor with an upturned funnel on his head to show that he was an impostor, and next to him a nun with the Bible on her head to show that the church was equally culpable.
A picture on the gable stone of the old asylum in the Dutch town of Den Bosch shows how in 1442, schizophrenic patients were locked up in prison. For a few cents, families could go and gawk at the “lunatics” on Sundays. In the 1920s and 1930s, when my mother was a seventeen-year-old trainee psychiatric nurse, the straitjacketed patients were put in baths of alternately cold and hot water. She said she would never forget the sound of them endlessly banging their heads on the edge of the bath, the only movement they could make. Up until the 1950s, schizophrenia was “treated” by means of a lobotomy, an outpatient procedure that involved severing the connections to and from the prefrontal cortex. Opponents called it “partial euthanasia,” since it turned patients into robots. This made their care extremely easy, though, and the terrible procedure became popular (see chapter 13). Fortunately modern antipsychotics have made it obsolete.
In China, a relative sits next to every hospital bed in order to help the nursing staff and make sure that their loved one has everything they need. If no relative is available, a co-worker will take their place. It makes Chinese hospitals rather jolly, chaotic places. But in the closed psychiatric wards, the picture is totally different. On my visit to one, I felt as if I were walking onto the set of One Flew over the Cuckoo’s Nest. The enormous ward contained two seemingly endless rows of beds with identical bedding. Next to every bed hung an identical towel, while each bedside table had on it only a glass, no personal belongings. The patients on this male ward all wore identical striped pajamas. They received no visits at all; their families had disowned them. I was the first visitor for many years, and a foreigner at that. One of them was a sailor who spoke good English. He had seen much of the world, including Rotterdam, and acted as an interpreter for the excited group of patients who crowded around me, tugging at my arms in an effort to draw attention to their personal stories. I was moved and saddened by these accounts. It was very hard to abandon them once more to their isolation.
On that occasion I traveled on from China to Jakarta to give a series of lectures. I was picked up by a young chauffeur whose car radio was blasting out house music at full volume. I asked him cautiously whether he could perhaps turn it down a bit, at which he smiled understandingly and asked what kind of music I liked. “Mozart’s Requiem,” I replied, thinking that it would prove a conversation stopper. The next morning he came to pick me up for the first lectures. To my utter amazement, amid the din of chaotic traffic—Jakarta is one gigantic slow-moving parking lot—he suddenly put on Mozart’s Requiem. I must confess that I was extremely moved. The next day, when we were stuck in traffic, he asked me what I knew about the treatment and care of schizophrenia sufferers. It turned out that his brother had schizophrenia and lived at home. When he was in a very bad way, they would give him a few drops of medicine. The little bottle of haloperidol had been very expensive, and they’d been making it last for years. I asked him where they kept the bottle. Just in the living room, he told me. Thinking of the average room temperature in Jakarta, I told him that that wasn’t such a good idea, because medicine kept that long could lose its efficacy or even become toxic. He fell silent for a while, then said, “Oh, that explains it.” Apparently the medicine hadn’t worked so well the last time they’d given it to his brother, so they tried a drop on the parrot, which fell down dead on the spot.
Treatment for schizophrenics can be even worse elsewhere in the world, as I saw from an award-winning World Press Photo exhibited in Amsterdam in 2004. Taken in Bangladesh, it showed an eighteen-year-old boy in the completely empty cell of a psychiatric clinic. He was lying on a stone floor, wearing only a pair of shorts. His legs were pinioned in a medieval contraption of wooden blocks. His arms were raised in despair, his fists clenched and his face twisted in a grimace. Apparently there were twenty-four such rooms in the “clinic” in question, and according to its director, thousands of patients had been “cured” in this way since its founding in 1880.
The afflictions of psychiatric patients in the Netherlands may be heartrending, but the sufferings of their counterparts
in many other regions of the world are of a different order entirely. Our wealthy nation should never use this as an excuse to sanction cuts in treatment, though, because that would mean putting more patients in isolation cells, and isolation only makes their symptoms worse.
SCHIZOPHRENIA SYMPTOMS
Our hope for the future lies … in organic chemistry or in an approach to [psychosis] through endocrinology. Today this future is still far off, but we should study analytically every case of psychosis because the knowledge thus gained will one day direct the chemical therapy.
Sigmund Freud in a letter to Marie Bonaparte, 1930
Schizophrenia affects 1 percent of the population, but because sufferers have it for such a long time it fills almost half of the beds in psychiatric hospitals. Schizophrenia patients are often depressed and feel that their lives are pointless. Around 10 percent attempt to kill themselves. Suicide makes the burden imposed on their families even heavier.
Schizophrenia is characterized by “positive” and “negative” symptoms. Positive symptoms are abnormal experiences, like delusions and hallucinations. During a psychosis, people see things and hear voices that they experience as completely real. (“Later, after I’d lost my job, I started to hear voices when I was at home … and to be troubled by different voices in my head. Sometimes they’re very aggressive, and cut right through me.”). Scans show that during these hallucinations the areas of the brain that normally process auditory or visual input are extremely active. They can’t be distinguished from real experiences because they take place in the same areas of the brain where external stimuli are normally processed. Other patients suffer from delusions. They believe that they are being watched or controlled by mysterious powers. (“In the last week of my work and the two weeks that followed they treated me without my consent, using an extremely advanced system.… What’s more, they modified my brain with this apparatus, so I can communicate with people in the street by transmitting thought waves.”) During the hallucinations, patients may hear voices giving unwanted instructions. Some are even told to kill someone (see chapters 8 and 17). While in the grip of a psychosis, one woman believed that she could fly. She threw herself out of the window and was killed.
Negative symptoms entail the loss of normal abilities, like taking initiative, organizing one’s life, tidying up one’s room, and looking after oneself. They also include muted emotions and cognitive deterioration. Many patients end up as vagrants, sleeping on city streets. They often take addictive substances, which might work early on as a form of self-medication against negative symptoms. In the long run, such substances can exacerbate the positive symptoms and cause damage. Negative symptoms are caused by reduced activity in the prefrontal cortex. A current therapy is to apply transcranial magnetic stimulation to that area. Stimulating the areas of the cerebral cortex that are extra active can also reduce hallucinations.
Schizophrenia is more common in men, who are also more affected by it than women. The initial symptoms of the disease can be difficult to identify. A year or two before their first psychosis, young people often show signs of paranoia, start taking drugs, abandon their studies, and become withdrawn. Isolation can exacerbate the condition. Schizophrenia is largely genetic, so having a relative with schizophrenia heightens your risk of this disorder. The first experience of psychosis peaks around the age of twenty. In women there’s a second peak that coincides with menopause. Changing hormone levels during puberty and menopause bring on the disease, though a predisposition for it arises in the womb. Female hormones reduce the negative symptoms of schizophrenia if taken together with standard medication.
As the disease progresses, the brain shrinks and its ventricles (cavities) become larger, creating too much space between the convolutions of the brain, just as in the case of many elderly people. This shrinking certainly isn’t caused by treatment, because it was shown to exist back in 1920, long before medication for schizophrenia had been developed. Nor is it specific to schizophrenia. It’s also seen in the aging process and in various forms of dementia. In fact, there are no brain changes that are specific to schizophrenia, so diagnosis is entirely dependent on psychiatric investigation. It is, however, important to rule out rare brain diseases whose symptoms can mimic those of schizophrenia. But once the diagnosis has been made, early treatment is very important to prevent further brain damage from psychosis.
SCHIZOPHRENIA, A DEVELOPMENTAL BRAIN DISORDER
Schizophrenia is a developmental brain disorder that is caused by a combination of factors and is present at a very early stage—indeed, the main foundation is laid at conception. Studies of families and twins show that the genetic component of schizophrenia is around 80 percent. The genetic factors are many and varied, differing in each family, but all involve tiny variations in the genes that affect brain development or in the production and breakdown of chemical messengers in the brain. The normal development of the fetal brain can subsequently be further disrupted by a host of nonhereditary factors. Maternal malnourishment during the first three months of pregnancy doubles the risk of schizophrenia. This first emerged in studies of children born in Amsterdam after the famine of 1944–1945 (see chapter 2). It was recently confirmed by studies of children born in China during and after the mass starvation in Anhui province in 1959–1961, in the wake of Mao’s “Great Leap Forward.” The same risk arises if the fetus is malnourished due to a malfunctioning placenta. Toxic substances in the environment, like lead, can also impair brain development in the womb and increase the likelihood of schizophrenia. In addition, you’re more at risk of developing schizophrenia if you were born in the winter or if your mother was exposed to flu during the sixth month of pregnancy. How those two factors interact isn’t clear. Toxoplasmosis and the Borna disease virus can also be passed on to the fetus, increasing the risk of schizophrenia. Psychological factors, such as stress during pregnancy, play a role too. Moreover, life events, like the death of a relative and pregnancy during wartime, increase the likelihood that a child will develop schizophrenia in later life.
A strong correlation has been found between problems at birth (e.g., forceps delivery, low birth weight, a period in an incubator, and premature birth) and subsequent schizophrenia. Traditionally, it was assumed that these problems at birth affected a child’s brain, increasing the likelihood of their developing schizophrenia. For childbirth to proceed normally, however, subtle interaction is needed between the brains of both mother and child. So you could see birth as the first functional test of a child’s brain. Disruptions to the birth process can therefore be regarded as the first symptoms of malfunctioning brain development, which are later manifested as schizophrenia (see chapter 1).
After birth, an environment full of stimuli increases the risk of schizophrenia. You’re more likely to develop the disease if you live in a city than in the country. Migrants are also at increased risk, probably because of the difficult social circumstances in which they often live. Quite a few adolescents go to their doctor with the first symptoms of schizophrenia after smoking joints. Whether cannabis induces the disease or simply brings forward the moment at which symptoms occur is still a subject of fierce debate.
It is clear from the brains of schizophrenia patients that the disorder arises very early in life. In schizophrenics, a high percentage of cells in the hippocampus are in disarray—something that can only have happened during the first half of pregnancy. Abnormal patterns of brain convolution are also found, as well as groups of cells that have failed to migrate to the right place in the cerebral cortex. This too can only happen during early development.
So although most people with schizophrenia are admitted to clinics as young adults, the foundation for the disease is laid in the womb. It’s terrible to think that as late as the 1970s, psychotherapists were spreading the pernicious message that schizophrenia was caused by a mother’s coldness and mixed messages (the double bind theory). Family therapists were given the task of reeducating mothers or even of “rescuing” chi
ldren from the clutches of their pathological environment, a situation that caused extra pain for parents struggling to do their best for their children. The Dutch psychiatrist Carla Rus was so alienated by this approach that she stopped training as a family therapist. My mother, on the other hand, had her own views on what caused schizophrenia. She had a button printed with the words, “Madness is inherited, you get it from your children.”
HALLUCINATIONS DUE TO A LACK OF STIMULI
I doubt if a single individual could be found among the whole of mankind free from some form of insanity. The only difference is one of degree. A man who sees a gourd and takes it for his wife is called insane because this happens to very few people.
Desiderius Erasmus (1469–1536)
If brain structures stop receiving information in a normal way, they start making up information. This applies both to sensory information—from ears, eyes, and limbs—and memory information. A fifty-seven-year-old man who had been suffering from a disease of the inner ear for twenty years found that in the space of twelve months his hearing had greatly deteriorated despite his two hearing aids. During that year he was plagued by nonstop music in his head. Day and night he heard the national anthem, Christmas carols, psalms, and sometimes children’s songs. Though distorted, he could always recognize the tune and sometimes sang along. These musical hallucinations are a form of tinnitus better known to patient associations than to the average doctor.