"The wonders of reason" is not the whole story

Health/ Despite the prevalence of schizophrenia and the suffering caused to those with it, research neglects the disease which is still a mystery

Uri Nitzan, Haaretz

The commonality between A, who is isolated in the corner of the room, R, who receives instructions from Shin Bet agents, and L, who is convinced that he is the Messiah, is that all three suffer from a mental illness called schizophrenia. Recently, thanks to the movie "The Wonders of Reason", the disease received some public attention, but not necessarily an adequate description The film emphasizes the drama and reduces the tragic dimension of the disease, which describes the life of the mathematical genius John Nash, was not chosen by Hollywood by chance.

Nash suffered from schizophrenia in his 20s, and after years of serious illness he managed to partially recover. The disease did not prevent him from succeeding in his field, and in the end he even won the Nobel Prize.

The reality is much harder and grayer. Tens of thousands of Israeli schizophrenics are actually dealing with an incurable disease. Beyond that, schizophrenia is still shrouded in prejudice. Everyone will agree with the statement that a person with a malignant tumor is sick, but many insist on treating schizophrenia as "madness" or "obsession" and not as an organic disease that damages the brain.

1% of the world's population suffers from schizophrenia, regardless of race and gender, and more than 70% of those hospitalized in psychiatric hospitals are schizophrenic patients. In most cases the disease erupts in adolescence (25-15), and its first manifestations are the psychotic attacks. The attacks are characterized by the patient's false thoughts ("I am the Messiah"), sensory perception without stimulation in reality (R. who hears the voices of Shin Bet agents), and the breakdown of the logical structure of thinking. The first years of the illness are turbulent, after which there is a decrease in the frequency of psychotic attacks. The symptoms of the disease vary and at this stage include a decrease in motivation, difficulty communicating with the environment and depression.

Despite its relatively high prevalence, and its traumatic consequences on the life of the patient and his family members, schizophrenia remains a scientific mystery. Its basic mechanisms of action have not yet been clarified, and the research is not yielding the hoped-for results. Dr. Pesach Lichtenberg, director of the psychiatry department at Herzog Hospital, notes with pain that "for decades there has not been a revolutionary breakthrough in research - neither in understanding the disease nor in our ability to cure the patients."

Today it is common to attribute the disease to a failure in the early development and organization of the central nervous system. The initial damage still develops in the life of the fetus, but only in adolescence do the conditions of life expose the brain to the threshold of pressures that lead to the "collapse" of the damaged system. According to the "gate theory", the brain mechanisms that are damaged are the ones responsible for filtering stimuli that come from the environment. The brain of the schizophrenic patient is flooded with a "sea" of stimuli, and the manifestation of this is the psychotic attack.

Schizophrenia was first described as a psychiatric illness at the end of the 19th century. The great psychiatrists realized that it was a difficult nut to crack, and the father of psychoanalysis, Sigmund Freud, stated that it was impossible to maintain a therapist-patient relationship with someone who does not communicate, and therefore paid little attention to the study of the disease. "Even today," says Prof. Haim Belmaker of Ben Gurion University, "we think there is no place for psychoanalysis or psychotherapy in the treatment system of most of these patients."

The fact that brain chemical mechanisms are involved in schizophrenia was discovered in the early 50s. Tranquilizers were given experimentally to schizophrenics, and it was found that they reduce the severity of psychotic attacks. The antipsychotic mechanism of action of the drugs was initially a mystery, and only in the 60s was it discovered that they inhibit the activity of dopamine - one of the most important neurotransmitters in the brain.

The psychiatric establishment has become convinced that an excess of dopamine activity is a possible cause of hyperexcitability of nerve cells and psychotic attacks. The research work on dopamine led to a pharmaceutical revolution, and to this day the most effective treatment for schizophrenic patients is based on drugs that inhibit dopamine. "A new generation drug like clozapine," says Bellmaker, "changed the quality of life of a third of the patients I treat. New generation drugs have fewer side effects, patient compliance is high, and the suicide rate among those taking clozapine or similar drugs is decreasing."

However, research into the causes of the disease and deciphering its mechanisms of action has not progressed to the extent that clinical treatment has developed. "To say that high levels of dopamine cause schizophrenia," says Lichtenberg, "is similar to trying to define pneumonia as a lack of penicillin in the blood. It is important to remember that, unlike a disease like Parkinson's, schizophrenia is not located in a specific area of ​​the brain, and researchers are forced to look for the causes of the disease in a maze where more than ten A billion neurons.

Prof. Binyamin Lehrer, director of the biological psychiatry laboratory at Hadassah Ein Kerem Hospital, does not agree with the statement that schizophrenia research has been left behind. "It is true that this is a complex disease," he says, "but our rate of progress is similar to that of other diseases in which many genes are involved (diabetes, hypertension, and cancer). Five years ago we did not know if there were any genes involved in the disease, certainly we did not know Where to start looking for them. Today, most researchers agree that the genetic component of the disease is 70% and there is increasing evidence of the location of various genes involved in it Chasing these genes, and in my opinion the discovery of the genes and their mapping is a matter of a few years."

But Dr. Lichtenberg is less optimistic. "In my humble opinion," he says, "even today it is impossible to point to a convincing genetic finding or to link genetic changes to the clinical appearance of the disease." One of the explanations for the slow progress in understanding schizophrenia lies in the fact that psychiatric research has an image Less glamorous than a field like cancer research. "The excellent researchers go to other fields," says Lehrer, "also because of the relative lack of budgets and workplaces in laboratories, but also because of a psychological barrier, and perhaps even a reluctance towards psychiatric diseases." "Young researchers are frightened by the gaping 'black hole' in the understanding of the disease," says Prof. Avi Weizman, director of the research unit at Gaha Hospital.

We must also not forget that the researchers live in a society and are influenced by prevailing moods. According to Lichtenberg, the wanderings of the Herzog Hospital largely reflect the relationship between Israeli society and schizophrenia patients. The hospital was initially built in the Old City, in the heart of Jerusalem. In the 20s, it moved to a building in the Nation Buildings area, and today it is located at the exit of the city, with a cemetery bordering it on one side and a municipal dump on the other.

"Western humanism obliges society to treat the sick, but the public prefers that this be done as far as possible from the residential areas of the bourgeoisie and at the lowest possible economic cost." Unfortunately, says Lichtenberg. "Psychiatric patients are at the bottom of society's priority scale. Our patients do not have a strong lobby, and in many cases the family members are also ashamed of them and find it difficult to provide the necessary support."
Bellmaker, on the other hand, does not believe that there is a place for beating for sin. "At least in the social aspect, we are not lagging behind other enlightened countries. In the USA and England there are hundreds of thousands of homeless schizophrenics, while in our country a schizophrenic patient is not released from the hospital without having a living arrangement in the community."

A complete cure of schizophrenic patients is still a dream, "but until then," says Weizman, "we are committed to helping these people, who are usually aware of their illness, and to respect their desire to live a full life."