Whole Psychiatry and Schizophrenia
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The late Abraham Hoffer, founder of the Orthomolecular revolution in psychiatry and medicine, felt that abnormalities in the requirements for certain vitamins (Vitamin B3, also called Niacin) were at the root of the problem. He advocated very high doses of Niacin. In the Whole Psychiatry approach this approach is combined with providing a humane structured environment, correction of nutritional deficiencies and hormonal problems, detoxification (e.g., elimination of mold from an environment), reducing inflammation and infection, and hormonal regulation.
John was psychotic and hospitalized. He had nearly died by climbing an electrical utility pole, and was left with severe burns on his hands. When he came to me, with his very supportive and well-balanced parents, he was heavily drugged, still hallucinating, and not able to function at all. Using the Whole psychiatry approach, we were able to restore him to the point that he began playing tennis daily, and attended community college. He began interacting with his peers. This gradual change took about 10 months, and we were able to reduce his medication by about 30%. We were all quite happy and hopeful about the results. Unfortunately, his friends were drinking and perhaps using drugs, and he was not able to refrain from partaking in the festivities. He began to deteriorate and refused medication or to continue with the program. This case and others have convinced me that the most difficult part of treating this disorder is the person’s unwillingness to accept treatment. I feel non-medicinal treatments exist that can markedly improve function, particularly if instituted early in the disease process. They can lessen medication use, but the structured, productive, drug free environment to support recovery is a challenge. I am the medical director of The New Hope Foundation, which is in the process of developing such an on-site, living environment.
Neurochemistry of schizophrenia
It is now known that there are five dopamine (DA) receptor types (DA1-DA5). Older antipsychotic medications seem to bind to the DA2 receptor, while the newer ‘atypical’ antipsychotic clozapine (Clozaril) binds preferentially to the DA4 and serotonin receptors. This is interesting to researchers since it is quite clear that patients who do not respond to the standard neuroleptics do respond quite well to clozapine. The newer atypical anti-psychotics have additional effects at serotonin receptors, adding some anti-depressant effects.
Summary of the Biology of schizophrenia
Schizophrenia represents one or more core (very likely genetically transmitted) vulnerabilities which interact reciprocally with environmental factor(s) (e.g.,virus, malnutrition, obstetrical complications in early life; ) during the early development of the surface layers (cortex) of the frontal and temporal lobes of the brain, during the second trimester of pregnancy and later in life (e.g., perceived warmth of social support system and drug abuse). The result is disturbed function of one or more cortical brain circuits. Which circuits are affected and to what degree may affect the clinical presentation. The mechanism that goes awry as a result of the gene-environment interaction may be an inability of the involved cortical circuits to link up, recruit or interconnect properly with other brain regions as well as other cortical circuits. It is currently believed that the psychotic manifestations of schizophrenia are due to impaired intra-cortical connectivity. Antipsychotic medications may act at the level of the nucleus acumbens, (an integrating station for frontal and temporal lobe cortex input), via neuromodulation, to compensate for the abnormal connections of these circuits.
A successful outcome
Fran was a 27-year-old single, very pleasant and friendly woman who was severely obsessive compulsive as a child. She reports her father as being emotionally abusive and depressed. In her late teens and early twenties, Fran had the abrupt onset of three psychotic episodes. These episodes were marked by bizarre and inappropriate sexual and social behavior, lack of sleep, auditory hallucinations, and delusions. Despite the tremendous upheavals in her life caused by these hospitalizations Fran was able to recover and return to work, almost always retaining a positive outlook. She has not been hospitalized since her early twenties.
Fran’s family and employer are quite supportive. As part of Fran’s treatment, I have had regular educational and supportive contact with her employer, particularly during times of stress. This has helped her to maintain her job, since she continues to have ideas of reference, inappropriate affect at times, delusional thinking of a paranoid nature, and a clear disturbance in her ability to fully attend to and interpret social stimuli. She will frequently absorb parts of a conversation, recalling only one or two words, which she then neatly fits into her delusional system. Although the delusional system is quite disturbing to her, attempts to rationally help her dissect and analyze her faulty thinking are grasped briefly, and then lost to her within seconds. Despite her ongoing disabilities, with the support of her family, her employer, low dose antipsychotic medication, lithium and valproic acid, and much contact between different parts of her system, Fran is able to live independently in her own condo, maintain friendships, continue her employment, and usually maintain a quite impressive and inspiring positive outlook.
Three years ago, Fran met a man who loves her, and they married. I had the honor and privilege of attending her wedding. Given the years of medication, Fran has gained weight. I have over the years prevailed upon her to work with her diet, and certain supplements. She has improved, and as of this writing, we have been able to forestall diabetes, and increase her exercise.
Both of these cases (John and Fran) unequivocally fulfill criteria for the diagnosis of schizophrenia, yet the outcome is significantly different. John’s outcome was worse for a number of reasons including the fact that he was a young male, and abused alcohol and drugs. Given this, it is not surprising that John’s more than adequate support system failed to maintain his initial improvement. In Fran’s case we see the opposite: a woman with abrupt onset, rapid initial treatment, family support, physician support of her family and employer, employer support, and absence of deficit symptoms (despite persistence of positive symptoms).
At the current time, optimal treatment of schizophrenia is a continuous and seamless multidisciplinary team approach involving a Whole Psychiatrist, cognitive-behavioral therapist (social skills training), psychiatrist (pharmacotherapy and family, employer, landlord, and co-worker education), social worker (coordination of medical, housing, and social supports), vocational trainer (retraining and placement). One individual must oversee the treatment to assure that the patient follows through with appointments (etc.), and that all caregivers are integrated (the system must provide the integrating function that the patient cannot provide for themselves). The immediate environment of the patient (usually family, staff, and physician) must be educated regarding the disease process, and supported in order to minimize excessive emotionality.