Summary of the movie

In 1947, John Nash arrives at Princeton University. He is co-recipient, with Martin Hansen,
of the prestigious Carnegie Scholarship for mathematics. At a reception, he meets a group of
other promising math and science graduate students, Richard Sol, Ainsley, and Bender. He
also meets his roommate Charles Herman, a literature student.

Nash is under extreme pressure to publish, but he wants to publish his own original idea. His
inspiration comes when he and his fellow graduate students discuss how to approach a group
of women at a bar. Hansen quotes Adam Smith and advocates "every man for himself", but
Nash argues that a cooperative approach would lead to better chances of success. Nash
develops a new concept of governing dynamics and publishes an article on this. On the
strength of this, he is offered an appointment at MIT where Sol and Bender join him.

Some years later, Nash is invited to the Pentagon to crack encrypted enemy
telecommunication. Nash can decipher the code mentally, to the astonishment of other
decrypters. He considers his regular duties at MIT uninteresting and beneath his talents, so he
is pleased to be given a new assignment by his mysterious supervisor, William Parcher
(Harris) of the United States Department of Defense. He is to look for patterns in magazines
and newspapers in order to thwart a Soviet plot. Nash becomes increasingly obsessive about
searching for these hidden patterns and believes he is followed when he delivers his results to
a secret mailbox.

Meanwhile, a student, Alicia Larde (Connelly), asks him to dinner, and the two fall in love.
On a return visit to Princeton, Nash runs into Charles and his niece, Marcee (Cardone). With
Charles' encouragement, he proposes to Alicia and they marry.

Nash begins to fear for his life after witnessing a shootout between Parcher and Soviet agents,
but Parcher blackmails him into staying on his assignment. While delivering a guest lecture
at Harvard University, Nash tries to flee from people he thinks are foreign Russian agents, led
by Dr. Rosen (Plummer). After punching Rosen in an attempt to flee, Nash is forcibly sedated
and sent to a psychiatric facility he believes is run by the Soviets.

Dr. Rosen tells Alicia that Nash has paranoid schizophrenia and that Charles, Marcee, and
Parcher exist only in his imagination. Alicia investigates and finally confronts Nash with the
unopened documents he had delivered to the secret mailbox. Nash is given a course of insulin
shock therapy and eventually released. Frustrated with the side-effects of
the antipsychotic medication he is taking, which make him lethargic and unresponsive, he
secretly stops taking it. This causes a relapse and he meets Parcher again.

Shortly afterward, Alicia discovers Nash is once again working on his "assignment".
Realizing he has relapsed, Alicia rushes into the house to find her baby submerged in the tub.
Nash claims that Charles was watching the baby. Alicia calls Dr. Rosen, but Nash believes
Parcher is trying to kill her. He rushes in to push Parcher away, and accidentally knocks
Alicia and the baby to the ground. As Alicia flees the house with their baby, Nash jumps in
front of Alicia's car and begs her to stay. Nash tells her that he realizes that he has never seen
Marcee age, even though he's known her for three years. He finally accepts that Parcher and
other figures are hallucinations. Against Dr. Rosen's advice, Nash decides not to restart his
medication, believing that he can deal with his symptoms himself. Alicia decides to stay and
support him in this.

Nash returns to Princeton and approaches his old rival, Hansen, now head of the mathematics
department. He grants Nash permission to work out of the library and to audit classes. Over
the next two decades, Nash learns to ignore his hallucinations. By the late 1970s, he is
allowed to teach again.

In 1994, Nash wins the Nobel Memorial Prize in Economics for his revolutionary work
on game theory, and is honored by his fellow professors. The movie ends as Nash, Alicia, and
their son leave the auditorium in Stockholm; Nash sees Charles, Marcee, and Parcher
standing to one side and watching him.

Flow chart

1947: John Nash arrives at Princeton, He meets Martin Hansen, Richard Sol,
as a co-recipient of the Carnegie Ainsley, and Bender. He also meets his
Scholarship, to pursue a degree in roommate Charles Herman, a literature
mathematics. student.

Hansen quotes Adam Smith and
advocates "every man for himself", but
Nash argues that a cooperative
approach would lead to better chances
of success.
Nash is driven by the need to publish an
original idea and he is struck by inspiration
at a bar with his friends, when they discuss
how to approach a group of women.
 Based on this idea he
publishes an article,
forming a new concept of
governing dynamics
The strength of the theory and article
allows Nash to be offered an
appointment at MIT where Sol and
Bender join him.

A few years later Nash is
invited to the
Pentagon to crack encrypte
d enemy
telecommunication. He is
able to perform this task,
mentally, without much
effort
He meets a student, Alicia, during class and
soon later she asks him to dinner. On a visit to
Princeton he meets Charles and his niece
Marcee. On his encouragement, he proposes
to Alicia and they get married.

On one particular pattern drop-off, Nash

witnesses a shootout between Parcher
and Soviet agents, but Parcher
Based on this he is given a new blackmails him into staying on his
assignment by his mysterious
assignment. After this he begins
supervisor, William Parcher of
the United States Department of fearing for his life.
Defense. He is to look for
patterns in magazines and
newspapers in order to thwart
a Soviet plot, and drop them off
at a secret location. He becomes
His behaviour becomes extremely
increasingly obsessive.
erratic.

While delivering a guest lecture at Harvard University, Nash tries to flee from people he
thinks are foreign Russian agents, led by Dr. Rosen. After punching Rosen in an attempt to
flee, Nash is forcibly sedated and sent to a psychiatric facility he believes is run by the
Soviets.
 Dr. Rosen tells Alicia that Nash
has paranoid schizophrenia and
that Charles, Marcee, and
Parcher exist only in his
imagination.
Upon investigating Alicia discovers all of Nash’s
‘work’. She shows him all of the unopened
documents he believed he’d been dropping off at
the secret mailbox. He is given a course of insulin
shock therapy and eventually released.

Alicia discovers Nash’s

relapse. She is horrified as
she rushes back to the house
to find her baby submerged
in the tub with Nash claiming
that Charles was watching
the baby.
The effects of the antipsychotic drugs he is
taking are such that he feels lethargic and
unable to respond the way he used to. He
secretly stops taking the medication which
causes a relapse and he meets Parcher again

In the confusion Nash accidentally knocks

Alicia and the baby to the ground causing
Alicia to flee. But Nash jumps in front of her
Alicia calls Dr. Rosen but
car and tells her he has realized Marcee
Nash sees Parcher, believing
never ages even though he met her 3 years
he wants to kill her.
ago, accepting that Parcher and the others
are hallucinations

Against Dr. Rosen’s advice, Nash decides not to restart medication and find a way to deal with
his symptoms the way he deals with problems that have no solutions. Alicia decides to support
him.

Nash returns to Princeton where his old Over the course of 2 decades he
rival Hansen (now head of the dept.) learns to ignore his hallucinations
grants him permission to work out of and by the late 1970s begins
the library and audit classes teaching again.

1994: Nash wins the Nobel Memorial Prize in Economics for his revolutionary work on game
theory.
 In the end Nash, Alicia, and their son leave the auditorium in Stockholm; Nash sees Charles,
Marcee, and Parcher standing to one side and watching him.

Classification according to DSM-V symptoms for schizophrenia

Criterion A – characteristic symptoms

Two (or more ) of the following , each present for a significant portion of time during a 1
month period (or if less successfully treated).

At least one of these should include 1-3

1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms (i.e., diminished emotional expression or avolition)

Criterion B-
social / occupational dysfunction : for a significant portion of the time since the onset of the
disturbance, one or more major areas of functioning , such as work, interpersonal
relations, or self care , are markedly below the level achieved prior to the on set (or
when the onset is in childhood or adolescence, failure to achieve expected level of
interpersonal, academic or occupational achievement).

Criterion C- duration of 6 months

Continuous signs of disturbance persist for at least 6 months. This 6 month period
must include at least 1 month of symptoms (or less if successfully treated) that meet
 criterion A (i.e, active – phase symptoms) and may include periods of prodromal or
residual symptoms. During these prodromal or residual symptoms. During these
prodromal or residual periods, the signs of the disturbance may be manifested by nly
negative symptoms or by two or more symptoms listed in criterion A present in an
attenuated form(e.g, odd beliefs , unusual perceptual experiences .

Criterion D- schizoaffective and major mood disorder exclusion

Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been
ruled out because either 1) no major depressive or manic episodes have occurred
concurrently with the active phase symptoms or; 2) if mood episodes have occurred
during active –phase symptoms, their total duration has been brief relative to the
duration of the active and residual periods.

Criterion E- substance / general mood condition exclusion

The disturbance is not attributed to the direct physiological effects of a substance,
(eg. , a drug of abuse, a medication ) or another medical condition .

Criterion F – relationship to global developmental delay or autism spectrum disorder- minor

change
If there is a history of autism spectrum disorder or other communication disorder of
childhood onset, the additional diagnosis of schizophrenia is made only if prominent
delusions or hallucinations are also present for atleast one month (or successfully
treated).

Icd 10

The schizophrenic disorders are characterized in general by fundamental and characteristic

distortions of thinking and perception, and affects that are inappropriate or blunted. Clear
consciousness and intellectual capacity are usually maintained although certain cognitive
deficits may evolve in the course of time. The most important psychopathological phenomena
include thought echo; thought insertion or withdrawal; thought broadcasting; delusional
perception and delusions of control; influence or passivity; hallucinatory voices commenting
or discussing the patient in the third person; thought disorders and negative symptoms.
The course of schizophrenic disorders can be either continuous, or episodic with progressive
or stable deficit, or there can be one or more episodes with complete or incomplete remission.
The diagnosis of schizophrenia should not be made in the presence of extensive depressive or
manic symptoms unless it is clear that schizophrenic symptoms antedate the affective
disturbance. Nor should schizophrenia be diagnosed in the presence of overt brain disease or
during states of drug intoxication or withdrawal. Similar disorders developing in the presence
of epilepsy or other brain disease should be classified under F06.2, and those induced by
psychoactive substances under F10-F19 with common fourth character .

Paranoid schizophrenia

Paranoid schizophrenia is dominated by relatively stable, often paranoid delusions, usually

accompanied by hallucinations, particularly of the auditory variety, and perceptual
disturbances. Disturbances of affect, volition and speech, and catatonic symptoms, are either
absent or relatively inconspicuous.

Symptoms according to textbooks

Positive and negative symptoms

Two general symptoms patterns or syndromes of schizophrenia have been differentiated:

these are called positive and negative syndrome schizophrenia (Anderson et al’85)

Positive syndrome: signs and symptoms in which something have been added to the normal
repertoire of the behaviour and experience. Presence of characteristic psychotic symptoms
(hallucinations, delusions, etc). It responds to treatment much more than negative syndrome.

 Hallucinations: False sensory perceptions or perceptual experiences that do not exist

in reality
 Delusions: It is a faulty interpretation of reality that cannot be shaken despite clear
evidence to the contrary.
 Echopraxia: Imitation of the movements and gestures of another person whom the
client is observing
  Flight of ideas: Continuous flow of verbalization in which the person jumps rapidly
from one topic to another
 Perseveration: Persistent adherence to a single idea or topic; verbal repetition of a
sentence, word, or phrase; resisting attempts to change the topic.
 Ambivalence: Holding seemingly contradictory beliefs or feelings about the same
person, event, or situation.
 Associative looseness: Fragmented or poorly related thoughts and ideas

Negative signs and symptoms by contrast, refers to an absence or deficit of behaviors

normally present in a person’s repertoire. Absence of either a change in level of
consciousness, a significant disturbance of cognition, or a primary change in mood. Difficult
to treat. (All A’s and catatonia/immobility). However, not all negative symptoms may reflect
lack of emotions. In a study by Kring and Neale (1996) it was found that patients with
schizophrenia may not look emotionally expressive but may be internally experiencing plenty
of emotions (as measured by autonomic arousal).

 Alogia: Absence or little speech. Tendency to speak very little or to convey little
substance of meaning (poverty of content)
 Anhedonia: Absence of pleasure from life, i.e., Feeling no joy or pleasure from life or any
activities or relationships
 Apathy: Feelings of indifference towards people, activities, and events
 Affective blunting: Restricted range of emotions (i.e., emotional feeling, tone, or mood)
 Avolition: Absence of will, ambition, or drive to take action or accomplish tasks
 Catatonia: Psychologically induced immobility occasionally marked by periods of
agitation or excitement; the client seems motionless, as if in a trance.
 Flat affect: Absence of any facial expression that would indicate emotions or mood
 Lack of volition: Absence of will, ambition, or drive to take action or accomplish tasks

Main Symptoms of Schizophrenia

A. Disturbance of Associative Linking and Speech Disturbance:

Normal human thinking has three characteristics: Content, Form Stream. Abnormalities may
occur in any of these.

 Content: what is being thought about (in case of psychotic disorders,) abnormalities
in content would include delusions)
 Form: abnormalities of the way thoughts are linked together
 Stream or flow: how it is being thought about - the amount and speed of thinking

Schizophrenia is often referred to as a ‘formal thought disorder’ because it was earlier

believed that this is a disorder of form rather than content of thought. However, this is no
longer thought to be true although form disturbances (or associative disturbances) are one of
the main symptoms of Schizophrenia. Basically a person fails to make sense despite seeming
to confirm the semantic and syntactic rules governing verbal communication.

Following are some of the indicators of disordered thinking:

Cognitive slippage/Derailment: Meehl (1962) refers to this process as “cognitive

slippage” (and others refer to it as “derailment” or flight of ideas , “loosening” of
associations, or “incoherence”), which involves rapidly shifting from topic to topic, making
it very difficult to follow the conversation. The patient seems to be using words that are
communicative but the listener can’t make any sense of it as the person seems to be
switching topic mid-sentence or inappropriately. E.g. “The next day when I’d be going out
you know, I took control, like uh, I put bleach on my hair in California”.

This includes at one end of severity - Circumstantiality – to Word Salad at the other end of
the scale.

 Circumstantiality: A person talks at length about irrelevant and trivial details (i.e.
circumstances) and is very delayed at reaching its goal. (Excessive long windedness.).
However, there is a clear association between sentences. A patient afflicted with this
condition, for example, when asked about a certain recipe, could give minute details about
going to the grocery store, the shopping experience, people there, and so on.
 Tangentiality: - Replying to questions in an irrelevant manner and never reaching the goal.
However, there is a clear association between sentences (but end is not reached) e.g.: Q:
 "What city are you from?" A: "Well, that's a hard question. I really don't know where my
relatives came from, so I don't know if I'm Irish or French."
 Word Salad: (or incoherence) - Word salad is at the extreme end of the scale. Speech that
is unintelligible due to the fact that, though the individual words are real words, the manner
in which they are strung together results in incoherent gibberish, e.g. the question “Why do
people believe in God?” elicits a response like “Because he makes a twirl in life, my box is
broken help me blue elephant. Isn’t lettuce brave? I like electrons. Hello, beautiful.”

Thus, the words are just random words. E.g. Blue afraid you no carpet cat.

Neologisms - New word formations. e.g. “I got so angry I picked up a dish and threw it at
the geshinker”, “handshoes” (gloves).

Echolalia - Echoing of other people’s speech e.g. “Can we talk for a few minutes?”, “Talk
for a few minutes”.

Blocking - The patient stops speaking, and after a period of seconds, indicates that he/she is
unable to remember what he/she had intended to say. Blocking may give rise to the delusion
that thoughts have been withdrawn from the head (thought withdrawal).
“My thoughts get all jumbled up. I start thinking or talking about something but I
never get there. Instead I wander off in the wrong direction and get caught up with all
sorts of different things that may be connected with the things I want to say but in a
way I can’t explain. People listening to me get more lost than I do.”

Mutism: refusal or inability to speak.

Flight of ideas: Rapidly shifting from one topic to another which are related via superficial
associations. Still, in its extreme forms, flight of ideas involves cognitive incoherence and
disorganization. E.g. Doctor: How are you sleeping at night?
Patient: Why would I sleep tonight? Would you be able to do my work? I whistle
while I play and I am happy to do it all? Okay so that is like a haul.
(Types of flight of ideas: 1) where there is rhyming or clanging, eg, “well, hell bell”, 2)
where there is distraction, eg, a patient talking about his appetite sees another patient walk
past the window and assumes that patient is going for ECT and starts talking about ECT.)

B. Disturbance of Thought Content: Delusions

In DSM 1V, a delusion is defined as:

A false belief based about external reality that is firmly sustained despite evidence to the
contrary. The belief is not one ordinarily accepted by other members of the person’s culture.

In schizophrenia the delusions are usually bizarre (compared to non bizarre delusions in
delusional disorder). Delusions are deemed bizarre if they are clearly implausible, not
understandable, and not derived from ordinary life experiences (e.g. an individual’s belief
that a stranger has removed his or her internal organs and replaced them with someone else’s
organs without leaving any scars or wounds or when a person believes that he has invisible
wings and can fly).

Because of its importance in schizophrenia, delusion has been called “the basic characteristic
of madness” (Jaspers, 1963). Disturbances in thought usually involve certain types of
delusions or false beliefs. Various kinds of delusions may be there:

 Persecution; “out to get me”

 Control (Someone is influencing you): –“neighbour is an alien and has the power to
control my thinking for evil purposes”, “aliens make my body move”. Types: 1)Thought
broadcasting (the false belief that the affected person's thoughts are heard aloud),
2) Thought insertion, and

3) Thought withdrawal (the belief that an outside force, person, is removing or extracting
a person's thoughts) are also examples of delusions of control.

 Reference: “talking about me”

 Grandeur: A person with delusion(s) of grandeur would believe that he is famous and
important “I invented rock and roll”
 Nihilistic: Belief that something does not exist (one’s brain, part of the world)
 Jealousy: delusion that the individual's sexual partner is unfaithful.
 Somatic delusion: Usually the false belief is that the body is somehow diseased,
abnormal, or changed. An example of a somatic delusion would be a person who believes
that his or her body is infested with parasites.

Out of the above, the main type of delusion usually seen in schizophrenia includes
delusion of grandeur. A person with delusion(s) of grandeur would believe that he is
famous and important (such as Mother Teresa or Jesus Christ) and he would be trying to
“save the world”.

C. Disruption of Perception: Hallucinations etc

The following perceptual disturbances may take place:

1. Hallucinations: A hallucination is a false sensory perception experienced in the absence of

an external stimulus, as distinct from an illusion, which is a misperception of an external
stimulus. Usually the hallucinations are auditory although hallucinations may occur in any
sensory modality—visual, auditory, olfactory, gustatory, tactile, or proprioceptive (sense of
balance and position in space).

 Auditory: Hearing voices when there is no auditory stimulus is the most common type
of auditory hallucination in mental disorders. The voice may be heard either inside or
outside one's head and is generally considered more severe when coming from outside one's
head. The voices may be male or female, recognized as the voice of someone familiar or not
recognized as familiar, and may be critical or positive. In schizophrenia, the content of what
the voices say is usually unpleasant and negative. In schizophrenia, a common symptom is
to hear voices conversing and/or commenting. When someone hears voices conversing, they
hear two or more voices speaking to each other (usually about the person who is
hallucinating). In voices commenting, the person hears a voice making comments about his
or her behavior or thoughts, typically in the third person (such as, "isn't he silly").
Sometimes the voices consist of hearing a "running commentary" on the person's behavior
as it occurs ("she is showering"). Other times, the voices may tell the person to do
something (commonly referred to as "command hallucinations").
 Gustatory: A false perception of taste. Usually, the experience is unpleasant. For
instance, an individual may complain of a persistent taste of metal. This type of
 hallucination is more commonly seen in some medical disorders (such as epilepsy) than in
mental disorders.
 Olfactory hallucination: A false perception of odor or smell. Typically, the experience is
very unpleasant. For example, the person may smell decaying fish, dead bodies, or burning
rubber. Sometimes, those experiencing olfactory hallucinations believe the odor emanates
from them. Olfactory hallucinations are more typical of medical disorders than mental
disorders.
 Somatic/tactile hallucination: A false perception or sensation of touch or something
happening in or on the body. A common tactile hallucination is feeling like something is
crawling under or on the skin (also known as “Formication”).
 Visual hallucination: A false perception of sight. The content of the hallucination may
be anything (such as shapes, colors, and flashes of light) but are typically people or human-
like figures. For example, one may perceive a person standing before them when no one is
present.
 Research (e.g McGuire 1996) has indicated that auditory hallucinations occur when the
individual misiterprets his own self generated thoughts as coming from another source.

2. Breakdown of perceptual selectivity: The person seems unable to sort out and process
the mass of sensory information to which all of us are exposed to.

“I feel like I am too alert…..everything seems to come pouring at once….My nerves seem
supersenstive…..things seem so vivid and they come to me like a flood from a broken bank”

D. Disturbed Motor Behaviour:

Various peculiarities are seen especially in catatonic schizophrenia. Various forms may
include:

 Catatonia: immobility or excited agitation

 Mannerisms - odd, voluntary patterns of behaviour
 Bizarre grimacing
 Negativism - Resistance to suggestion, tending to do the opposite, as seen in catatonic
schizophrenia
 Waxy flexibility is a psychomotor symptom where a posture, into which placed, is
indefinitely maintained. For instance, if you were to move the arm of someone with
 waxy flexibility, they would keep their arm where you moved it until they are moved
again as if made from wax.
 Echopraxia: This involves imitation of movement. Called echolalia when it involves
pathological repetition by imitation of speech of another person.

E. Emotional Dysfunction:

The person suffers from inappropriate emotions or affect:

Anhedonia is an inability to experience pleasure from normally pleasurable life events such
as eating, exercise, and social interactions.

Emotional shallowness or “Blunting”: the person may appear almost emotionless so that
even the most dramatic events produce at most an intellectual recognition of what is
happening. This may reflect lack of expressiveness and not a lack of feeling.

Strong Affect: Strong Affect may be shown in certain situations but the emotion clashes with
the situation. For e.g. the person may respond to the news of parent’s death with gleeful
hilarity.

F. Confused Sense of Self:

Persons suffering from schizophrenia may be confused about their sense of identity and may
even have a delusion of a new identity such as Christ. He may also be uncertain about the
boundaries separating the self from the rest of the world leading to frightening “cosmic” or
“oceanic” feelings of somehow intimately tied up with universal powers including God or the
Devil.

G. Disrupted Volition:

The individual is unable to carry out goal directed activity even in areas of daily routine such
as work, self care etc.

For e.g. the person may no longer maintain minimal standards of personal hygiene or may
show profound disregard of personal safety and health. This has been attributed to frontal
lobes and executive functioning.
H. Retreat to an Inner World:

This involves disengagement from the external world and in extreme cases can be seen as a
deliberate attempt to avoid being overwhelmed. There is a rich elaboration of inner world
(fantastic ideas, creation of strange beings).

Subtypes

1. Paranoid Type (where delusions and hallucinations are present but thought disorder,
disorganized behavior, and affective flattening are absent. Delusions are mainly
characterized by persecutory -feeling victimized or spied on- or grandiose delusions,
hallucinations)
2. Catatonic Type (prominent psychomotor disturbances are evident. Symptoms can
include catatonic stupor and waxy flexibility i.e. the patient may be either motionless
or there may be excessive motor activity).
3. Disorganized Type (characterized by grossly inappropriate or flat affect,
incoherence, loose associations, and extremely disorganized behavior).
4. Residual Type (mild indications of schizophrenia shown by individuals in remission
following a schizophrenic episode) and

5.Undifferentiated Type (psychotic symptoms are present but the criteria for paranoid,
disorganized, or catatonic types have not been met).

Causation of the disorder according to the textbooks

Genetic factors-

Schizophrenia concordance rates for identical twins are routinely and consistently found to be
significantly higher than those for fraternal twins or ordinary siblings. Study has shown a
higher concordance for schizophrenia among identical, or monozygotic (MZ), twins than
among people related in any other way, including fraternal, or dizygotic (DZ), twins.

Two conclusions can therefore be drawn: First, genes undoubtedly play a role in causing
schizophrenia. Second, genes themselves are not the whole story. Twin studies provide some
of the most solid evidence that the environment plays an important role in the development of
schizophrenia .

If concordance is greater among the patients’ biological than adoptive relatives, a hereditary
influence is strongly suggested; the reverse pattern would argue for environmental causation.
Our genetic makeup may control how sensitive we are to certain aspects of our environments.
If we have no genetic risk, certain kinds of environmental influences may not affect us very
much. But if we have high genetic risk, we may be much more vulnerable to certain types of
environmental risks such as high communication deviance or adverse family environments.

Prenatal exposures-

Kraepelin (1919) suggests that “infections in the years of development might have a causal
significance” for schizophrenia.. Maternal infections such as rubella (German measles) and
toxoplasmosis (a parasitic infection) that occur during this time have also been linked to
increased risk for the later development of schizophrenia (Brown, 2011). Also,
incompatibility between the mother and the fetus is a major cause of blood disease in
newborns. Interestingly, Rh incompatibility also seems to be associated with increased risk
for schizophrenia Patients with schizophrenia are much more likely to have been born
following a pregnancy or delivery that was complicated in some way (Cannon et al., 2002). If
a mother experiences an extremely stressful event late in her rst trimester of pregnancy or
early in the second trimester the risk of schizophrenia in her child is increased (King et al.,
2010). Currently, it is thought that the increase in stress hor- mones that pass to the fetus via
the placenta might have nega- tive e ects on the developing brain, although the mechanisms
through which maternal stress increases risk for schizophrenia are not yet well understood.

Brain abnormalities-

People suffering from schizophrenia reveal abnormalities in the structure and function of the
brain as well as in neurotransmitter activities. Other cognitive deficits are also apparent.
Patients with schizophrenia have problems with the active, functional allocation of attentional
resources , i.e, they are unable to attend well on demand. Studies of chronically ill patients of
schizophrenia suggest that decreases in brain tissue and increases in the size of the brain
ventricles are not limited to the early phases of this illness. Instead, progressive brain
deterioration continues for many years.
Psychosocial and cultural factors

Theories that were popular many decades ago, for example, the idea that schizophrenia was
caused by destructive parental interactions (Lidz et al., 1965)—have foundered for lack of
empirical support. Patients who returned home to live with parents or with a spouse were at
higher risk of relapse than patients who left the hospital to live alone or with siblings. Brown
reasoned that highly emotional family environments might be stressful to patients. Being
raised in an urban environment seems to increase a person’s risk of developing schizophrenia.
Research is also showing that recent immigrants have much higher risks of developing
schizophrenia than do people who are native to the country of immigration. Also, it is found
that people with schizophrenia are twice as likely as people in the general population to
smoke cannabis (van Os et al., 2002).

Estimation of causes in the film

Genetic factors-

There is a strong association between the closeness of the blood relationship (i.e., level of
gene sharing or consanguinity) and the risk for developing the disorder. Towards the end of
the movie it is mentioned that john’s son is also diagnosed with schizophrenia. This could
depict that there is a tendency for schizophrenia to run in the genes of his family, which could
have been passed on to john from either his first degree relatives or second degree relatives.
Of course, just because something runs in families does not automatically implicate genetic
factors. e terms familial and genetic are not synonymous, and a disorder can run in a family
for non genetic reasons

Personality –

It is observed throughout the movie that john has an asocial personality. He tends to keep
things to himself, not sharing his emotions with others around him. He finds it difficult to
make conversations with people as he told his wife and charles in the movie. Also, many
around him consider his overt behavior strange. His body language and his reactions to things
are not familiar. This could be a causal factor in johns life that led to schizophrenia. He
shown to be consistently anxious and restless about things around him that usually led to a
nervous breakdown. Stress over everything that constantly presses him throughout the movie
can also be a predisposed factor that led to the disorder.

Environmental factors-

It is observed in the movie that Nash’s hallucinations and delusions get stronger once he is
found in stressful environments, i.e, when his workload is at its peak. He was found to be in
constant state of dilemma when he was given deadlines to finish his work. Such stressful
environment conditions could have led to his disorder. Even though his childhood is not
shown in the movie, but certain statements like how he does not like people and people do
not like him, made by john, show that probably the environment he was brought up in his
childhood wasn’t favorable or the people he lived with were troublesome.

Portrayal of schizophrenia in the movie –

The film A Beautiful Mind is based on the life of American mathematician, John
Nash. The film won four Academy Awards for Best Picture, Best Director (Ron
Howard), Best Adapted Screenplay and Best Supporting Actress (Jennifer Connelly).
John Nash was played by Russell Crowe who received a nomination for Best Actor.
The movie focuses on Nash's struggle with paranoid schizophrenia during the 1940s
and 1950s. While the movie takes a few dramatic liberties with its depiction of
schizophrenia, it also provides a fairly accurate portrayal of the disease. For
example, symptoms typically begin in early adulthood for males and often involve a
significant stressor, such as beginning graduate courses at Princeton University. The
film brings Nash's paranoid delusions to life through the character of William
Parcher, a fictional agent for the United States Department of Defense. Nash
becomes fixated on his missions, which ultimately leads to hospitalization and
psychiatric treatment. The psychosocial consequences the illness has on Nash's
career and family are also reality for many patients suffering from severe mental
illness. The movie also takes advantage of symptoms such as delusions, reduced
speaking/”flat effect”, and various cognitive symptoms such as poor executive
functioning but these are all valid and common symptoms of schizophrenia as we
know it (National Institute of Mental Health). These symptoms are put into effect in
the beginning of the movie when Charles appears and also when John is talking to
the other graduate students, although the cognitive symptoms do not appear until
other key scenes in the move. He does not speak a lot and when he does it is not
with a lot of emotion, which can be attributed to the onset of his disability. However,
although the symptoms are accurate, John never had delusions figures such as
Charles, he suffered mostly from auditory delusions. The movie also depicts
delusions of grandeur as well as delusions of persecution. John Nash starts to
believe himself as an extremely important person who is helping the US army to
break codes of the Russians. Delusions of persecution are portrayed when he fears
that there’s someone out to kill him and his wife because he is of importance. Until
the middle of the 20th century there were no drugs available for the treatment of
schizophrenia and treatment, such as it was, consisted of confining the person in one of the
large institutional asylums and administering powerful doses of sedative drugs to restrict
their psychotic behavior. The film highlights another important component of mental
health treatment; medication adverse effects. This scene takes place in the 1950’s,
and is reflected in the treatments that were used. It was during this time that new
treatments were being developed to attempt to cure schizophrenia, which is shown
when John is forced to undergo insulin shock therapy a couple times a week. The
results of this treatment were horrible and eventually were discredited as anti-
psychotic drugs were introduced (ABC News). The introduction of anti-psychotic
drugs plays a very important role in allowing schizophrenic people to lead normal
lives. Nash begins treatment with an antipsychotic medication and experiences
sedation and sexual dysfunction. He complains he is unable to think clearly and
develop new areas for research, which causes him to self-discontinue his
medication. After some time off the antipsychotic, his delusions return and he
decompensates. This scenario is an excellent teaching opportunity for pharmacy
students and conveys the realistic struggle with medication adherence in this patient
population. While the film does an impressive job with communicating many common
components of paranoid schizophrenia, there are a few inaccuracies or
dramatizations. For example, the film depicts Nash's hallucinations as complex
visual hallucinations, which is uncommon and most often reported as auditory
hallucinations (hearing voices).

Treatment and Prognosis according to the movie

The film depicts the early onset Nash’s mental illness in early adulthood, the customary
deterioration and reduction of thinking capacity, the various treatments methods and his
eventual recovery. The film promptly illustrates the typical symptoms of schizophrenia, as
Nash’s social awkwardness, isolation and lack of social skills are quickly apparent at the
Princeton University graduate student meet and greet. The emotionally detached, socially
isolated, bizarre and inward thinking of Nash were rationalized as normal behaviour of an
eccentric genius instead of early onset symptoms of a mental illness. As his mental illness
progresses, Nash becomes more guarded and nervous and Nash’s paranoid schizophrenia
symptoms begin to take over his life. The Department of Defence recruited Nash during the
Cold War due to his brilliance with mathematics to decode various strings of coded numbers
at the Wheeler Laboratory of Defense. Nash begins to experiences delusions of grandeur and
of persecution and hallucinations as his rational thought diminishes. Nash is involuntarily put
under the care of psychiatrist Dr. Rosen, who diagnoses Nash with paranoid schizophrenia.
The history of treatment of schizophrenia is evidenced in the movie as Nash undergoes
insulin coma therapy, electroshock therapy and with antipsychotic pharmaceutical drug
therapy. The trials and tribulations associated with a diagnosis and treatment of schizophrenia
are shown in Nash‟s attempt to regain control of his life. Nash demonstrates the aversive side
effects of antipsychotic medication, and the main issue with patients of such treatment:
compliance. While the symptoms of schizophrenia that Nash experience do not disappear, he
is able to consciously address them. Nash is able to regain his mind and return to his passion
for mathematics and teaching at Princeton University. The film A Beautiful Mind shows the
range of symptoms and complications of the mental disorder schizophrenia, but also the hope
for recovery and return to society through proper treatment. The film presents the typical
symptoms of schizophrenia and presents a timeline of the various treatment methods. A
Beautiful Mind adequately depicts the struggle of doctors in their quest to find a cure or at
least to find a treatment that adequately addresses the associated symptoms. The history of
treatment is accurately illustrated in A Beautiful Mind and follows the somatic therapy theory
where “each treatment was better than the former and less effective or more troublesome than
the next” (Doroshow, 2006, p. 215). After insulin was discovered in 1920, insulin coma
therapy was utilized as the main treatment for schizophrenia between 1930 and 1960
(Doroshow, 2006). This treatment was developed by Austrian physician Manfred Sackel,
who believed that “if the brain was deprived of sugar, which is what keeps it going, the cells
that were functioning marginally would die. It would be like radiation treatments for cancer”
(Nasar, 293). In A Beautiful Mind, Nash is committed involuntarily to the Macarthur
Psychiatric Hospital and is observed receiving insulin coma therapy treatment. In this
treatment, patients are admitted to a hospital and put under the watchful care of the insulin
coma therapy team. For each treatment session, patients were administered a high dose of
insulin intravenously, which would remove any glucose from the bloodstream, and the patient
would eventually lose consciousness in an insulin-shock coma (Doroshow, 2006, p 214). The
patients would remain in a „death-like‟ coma for a period of time ranging from a few minutes
to several hours, depending on the doctor‟s treatment plan. After this period, a sugar solution
would be administered intravenously to bring the patient back to consciousness (Doroshow,
2006). After the insulin-induced coma, the patient‟s “symptoms would temporarily vanish in
what [their physicians] deemed a „lucid period‟” (Doroshow, 2006, p. 214). The length of the
lucid period would gradually increase with treatment until no symptoms were observed
(Doroshow, 2006). A typical course of insulin shock treatment was five to six comas per
week for a time period of several weeks to several months, until a time which the attending
physician felt the patient recovered or incurable (Doroshow, 2006). Insulin shock therapy is
embedded in the biological paradigm through the hypothesis that faulty brain cells were the
cause the symptoms. Through the deprivation of glucose nutrients from the brain with
massive doses of insulin, it was theorized the faulty brain cells would die and would be
replaced with new healthy brain cells (Doroshow, 2006). It was theorized that as the length of
lucid period increased, the faulty brain cells would be destroyed and the patient would be
cured and would no longer exhibit symptoms. During its use, insulin coma therapy was
believed to be an effective treatment for schizophrenia among doctors and physicians. As one
doctor stated, it “was something we could do … there was a history of people who told us it
was useful treatment [and] we certainly didn‟t have much else to offer” (Doroshow, 2006, p
242). Insulin coma therapy was a treatment for schizophrenia based in the malfunctioning
biological processes of the mind, and was the most conclusive treatment available during its
utilization. While antipsychotics have been shown to improve the symptoms of
schizophrenia, they are not a cure for this mental disorder. It is argued that reducing
dopamine levels constitutes a “chemical lobotomy”, where the patient looses “spontaneity,
interest in the environment and passion” (Bemak & Epp, 2002, p. 17). This „chemical
lobotomy‟ and other adverse side effects often lead to patient‟s discontinuance of
medication. The aversive side effects of antipsychotic medication include an exacerbation of
symptoms, mental fog, weight gain, metabolic effects, sedation, movement disorders, heart
problems and sexual dysfunction. In A Beautiful Mind, Nash suffered the side effects of
drooling and sexual dysfunctions while under antipsychotic drug treatment. Nash also
suffered from the emotional flatness produced by antipsychotic medication and left him
unable to emotionally connect with his infant son. Due to these side effects and the mental
fogginess Nash experienced, he discontinued his medication and succumbed to the symptoms
once again. Antipsychotic drug therapy does not provide a cure and complete erasure of
symptoms, however, it does allow patients to reintegrate into society. Many patients may still
experience delusions and hallucinations albeit to a lesser degree and severity. As illustrated in
A Beautiful Mind, the hallucination experienced by Nash still persisted after taking
antipsychotics drugs for over thirty years who chose to ignore the hallucinations (2001). The
treatment history of schizophrenia through the biological paradigm is portrayed through A
Beautiful Mind. The film demonstrates a typical patent with schizophrenia through the timing
of Nash‟s illness with early adulthood onset, the withdrawal and reduced thinking capacity,
the inability to obtain relief from medication and his eventual reintegration into society. A
main concern with antipsychotics drug treatment is adherence and compliance, with frequent
discontinuation due to the inefficacy or intolerable side effects. In A Beautiful Mind, Nash is
able to attain the level of mental reasoning that he previously enjoyed and was able to return
to his passion for mathematics, and sharing his brilliance through teaching at Princeton
University

Treatments according to textbook


Before the 1950s the prognosis for schizophrenia was bleak. Treatment options were very
limited. Agitated patients might be put in straitjackets or treated with electroconvulsive
“shock” therapy. Most lived in remote and forbidding institutions that they were expected
never to leave (Deutsch, 1948). 
ramatic improvement came in the 1950s when a class of
drugs known as antipsychotics were introduced. Pharmaco- therapy (treatment by drugs) with
these medications rapidly transformed the environment of mental hospitals by calming
patients and virtually eliminating their wild, dangerous, and out-of-control behaviors. A new
and more hopeful era had arrived.

Pharmacological Approaches

FIRST-GENERATION ANTIPSYCHOTICS First-generation antipsychotics are

medications like chlorpromazine ( orazine) and haloperidol (Haldol), which were among the
first to be used to treat psychotic disorders. Sometimes referred to as neuroleptics (literally,
“seizing the neuron”), these medications revolutionized the treatment of schizophrenia when
they were introduced in the 1950s and can be regarded as one of the major medical advances
of the twentieth century (Sharif et al., 2007). ey are called first-generation antipsychotics (or
typical antipsychotics) to distinguish them from a new class of antipsychotics that was
developed much more recently. These are referred to as second-generation (or atypical)
antipsychotics.

There is overwhelming evidence that antipsychotic medications help patients. Large numbers
of clinical trials have demonstrated the efficacy and effectiveness of these drugs (Sharif et al.,
2007). Also, the earlier patients receive these medications, the better they tend to do over the
longer term (Marshall et al., 2005; Perkins et al., 2004). As we discussed earlier, first-
generation antipsychotics are thought to work because they are dopamine antagonists. is
means that they block the action of dopamine, primarily by blocking (occupying) the D2
dopamine receptors.

First-generation antipsychotics work best for the positive symptoms of schizophrenia. In

quieting the voices and diminishing delusional beliefs, these medications provide patients
with significant clinical improvement (Tandon et al., 2010). is comes at a cost, however.
Common side effects of these medications include drowsiness, dry mouth, and weight gain.
Many patients on these antipsychotics also experience what are known as extrapyramidal
side effects (EPS). These are in- voluntary movement abnormalities (muscle spasms, rigidity,
shaking) that resemble Parkinson’s disease.

SECOND-GENERATION ANTIPSYCHOTICS In the 1980s a new class of antipsychotic

medications began to appear. The first of these to be used clinically was clozapine (Clozaril).
is drug was introduced in the United States in 1989, although clinicians in Europe had been
using it prior to this. Although initially reserved for use with treatment-refractory patients
(those who were not helped by other medications), clozapine is now used widely.

Other examples of second-generation antipsychotic medications are risperidone (Risperdal),

olanzapine (Zyprexa), quetiapine (Seroquel), and ziprasidone (Geodon). More recent
additions include aripiprazole (Abilify) and lurasidone (Latuda). e reason why these
medications are called “second-generation antipsychotics” is that they cause fewer
extrapyramidal symptoms than the earlier antipsychotic medi- cations such as orazine and
Haldol. Although it was initially believed that second-generation antipsychotics were more
effective at treating the symptoms of schizophrenia, recent research findings provide no
support for this view (Lieberman & Stroup, 2011; Tandon et al., 2010). The disappointing
findings about the efficacy of second- generation antipsychotic treatments mean that there is
an urgent need for innovative approaches and new medications that work better than the ones
currently available.

Psychosocial Approaches

For a long time, medications were often the only form of treatment that patients with
schizophrenia received. But things are now very different. Psychosocial interventions are also
now available. Some of these approaches, which are typically used in conjunction with
medication, are briefly described below.

FAMILY THERAPY e literature that links relapse in patients with schizophrenia to high
family levels of expressed emotion (EE) inspired several investigators to develop family
intervention programs. e idea was to reduce relapse in schizophrenia by changing those
aspects of the patient–relative relationship that were regarded as central to the EE construct.
At a practical level, this generally involves working with patients and their families to
educate them about schizophrenia, to help them improve their coping and problem-solving
skills, and to enhance communication skills, especially the clarity of family communication.

In general, the results of research studies in this area have shown that patients do better
clinically and relapse rates are

lower when families receive family treatment (see Pfammatter et al., 2006). Studies done in
China indicate that these treatment approaches can also be used in other cultures (Xiong et
al., 1994). Despite this, family treatment is still not a routine element in the accepted standard
of care for patients with schizophrenia (Lehman et al., 1998). Given its clear benefits to
patients and its considerable cost-effectiveness (Tarrier et al. [1991] calculate that family
treatment results in an average cost savings of 27 percent per patient), this seems very
unfortunate.

CASE MANAGEMENT Case managers are people who help patients find the services they
need in order to function in the community. Essentially, the case manager acts as a broker,
referring the patient to the people who will pro- vide the needed service (e.g., help with
housing, treatment, employment, and the like). Assertive community treatment programs are
a specialized form of case management. Typically, they involve multidisciplinary teams with
limited caseloads to ensure that discharged patients don’t get over- looked and “lost in the
system.” The multidisciplinary team delivers all the services the patient needs (see DeLuca et
al., 2008; Mueser et al., 1998).

SOCIAL-SKILLS TRAINING Even when their symptoms are controlled by medications,

patients with schizophrenia o en have trouble forming friendships, nding and keeping a job,
or living independently. How well patients do in their everyday lives is referred to as
functional outcome. ( This is in contrast to clinical outcome, which is concerned with
symptoms.) Improving the functional outcomes of patients with schizophrenia is now an
active area of research.

One way to help improve the functional outcomes of patients with schizophrenia is through
social-skills training.

COGNITIVE REMEDIATION A major treatment effort is also being devoted to cognitive

remediation training. Using practice and other compensatory techniques, researchers are
trying to help patients improve some of their neurocognitive deficits (e.g., problems with
verbal memory, vigilance, and performance on card-sorting tasks). The hope is that these
improvements will translate into better overall functioning (e.g., conversational skills, self-
care, job skills, and so on).

COGNITIVE-BEHAVIORAL THERAPY results from the early research studies were

encouraging, whether CBT is an effective treatment for schizophrenia is now the subject of
some debate. Cur- rent data suggest that CBT is not very helpful for negative symptoms
(Tandon et al., 2010). A recent meta-analysis also suggests that CBT is no better than control
interventions (often supportive counselling) in the treatment of schizophrenia (Lynch et al.,
2010). Nonetheless, the possibility that CBT works very well for some subgroups of patients
is still a very real possibility.

INDIVIDUAL TREATMENT

Before 1960 the optimal treatment for patients with schizophrenia was psychoanalytically
oriented therapy based on a Freudian type of approach. This is what Nobel Prize–winning
mathematician John Nash received when he was a patient at McLean Hospital in
Massachusetts in 1958 (Nash’s story is told in Box 13.5 on page 490). By 1980, however,
things had changed. Research began to suggest that in some cases, psychodynamic treatments
made patients worse (see Mueser & Berenbaum, 1990). is form of individual treatment thus
fell out of favor.

Individual treatment for schizophrenia now takes a different form. Hogarty and colleagues
(1997a, 1997b) have re- ported on a controlled 3-year trial of what they call “personal
therapy.” Personal therapy is a nonpsychodynamic approach that equips patients with a broad
range of coping techniques and skills. The therapy is staged, which means that it comprises
different components that are administered at different points in the patient’s recovery. For
example, in the early stages, patients examine the relationship between their symptoms and
their stress levels. They also learn relaxation and some cognitive techniques. Later, the focus
is on social and vocational skills. Overall, this treatment appears to be very effective in
enhancing the social adjustment and social role performance of discharged patients.

Ethics-

Informed consent
Clinicians who treat patients with schizophrenia may encounter a variety of ethical issues
related to both psychiatric and medical treatment of patients. While informed consent is a
crucial aspect of the care of all patients, it may present special challenges for patients with
schizophrenia. Schizophrenia is a severe mental illness that is frequently accompanied by
neuropsychological deficits. These impairments, as well as psychotic symptoms and lack of
insight, can affect patients' abilities to make fully informed decisions about their own care.
Ensuring that consent for treatment is informed, voluntary, and competent can thus become a
more difficult endeavour. The ethical principles underlying treatment of these patients,
however, are the same as those guiding treatment of all patients. Informed consent, as an
embodiment of these ethical principles, represents the expression of individual rights in both
clinical and research contexts. Attention to the process of informed consent as an ongoing
dialogue strengthens the clinician-patient relationship, improves adherence, and helps the
patient clarify options, values, and preferences. In the research setting, psychiatric researchers
are increasingly concerned with maximizing the abilities of individuals with severe mental
illnesses such as schizophrenia to provide meaningful informed consent for protocols.
Telling Half-Truths to Patients with Schizophrenia Who Are Paranoid
Ethically, the degree to which a psychiatrist withholds information may disrespect a
patient’s autonomy and may even be regarded as lying by omission. However, this
ethical “price” may be warranted due to other competing and mutually exclusive
values that may benefit the patient in other ways.

This same conflict may exist when psychiatrists treat patients with schizophrenia
who have paranoia. Most psychiatrists generally believe that to be maximally
effective, they should not directly confront the delusions of patients. The use of this
partial truth may reduce the risk of avoidable harm, but others have carried this same
approach still further. The gains from psychiatrists sharing partial truths may not be
evidence-based.

Forming a relationship by using such half-truths, despite these possibly representing,

ethically, lies, is in Havens’ view the most critical first step in treating patients with
schizophrenia These patients, he asserts, are more likely to feel isolated due to their
symptoms, and thus are more likely to be alone. If a psychiatrist reframes how a
patient regards his or her heightened paranoid thoughts so that he or she sees these
thoughts as possible strengths, this may enable the psychiatrist to build a stronger
patient alliance, which may in turn help the patient feel less isolated and alone.

Supporting the “Risky” Ambitions of Patients with Schizophrenia

An emerging shift in both clinical thinking and the underlying ethics of psychiatry is
placing greater emphasis on the quality of life for patients with schizophrenia, as
opposed to primarily trying only to give them relief from their symptoms. One way to
improve a patient’s quality of life is by allowing more input by the patient regarding
his or her care.

Some patients with schizophrenia are exceptionally ambitious. This may cause some
conflict for them and for their psychiatrists.

Shared decision making is an approach some psychiatrists use with patients with
schizophrenia. Using this approach, the psychiatrist provides the patient with more
information and involves him or her more in treatment decisions. This approach,
according to Hamann,“explicitly goes beyond informed consent.” It aims to decrease
“the informational and power asymmetry between doctors and patients by increasing
the patient’s information and control over treatment decisions.”This may involve the
use of directional aids. These aids may depict for the patient the relative pros and
cons of different scenarios (e.g., switching to a different antipsychotic drug), and then
the choice is made to a greater extent by the patient. Respecting patients by
respecting their autonomy is a value independent of actual consequences. It may be
that this value should prevail, even over a psychiatrist’s more traditional value of
protecting patients, despite the fact that patients with schizophrenia may be more
prone to losing decision-making capacity.

Asking a Patient with Schizophrenia whether He or She Wants to Write Psychiatric

Advance Directives
By allowing the patient to participate in these decisions, the psychiatrist is respectful of the
patient’s autonomy and also able to provide optimal medical care. Some patients may not
want to pursue this option.
Persuading Patients with Schizophrenia to Involve Their Family Members

A substantial advance in the treatment of schizophrenia has been the understanding

that psychiatrists can benefit patients with schizophrenia by educating their family
members about the harmful effects of criticism and negative emotions, especially
when they are expressed in an exaggerated way. Thus, it may be beneficial if the
psychiatrist can persuade a patient to have his or her family maximally involved in
his or her care.

Ethically, attempts at persuasion may be regarded as coercion, just as withholding of

information may be regarded as lying by omission. Psychiatrists should not deny to
themselves that (some degree of) coercing (or lying) is a genuine risk of making
certain interventions. Psychiatrists should know that no action, including being
coercive or lying, should ever be ethically prohibited on this basis alone without also
considering whether there are other competing moral values in a given case that
may be more important. Thus, it may be ethically justifiable for psychiatrists to accept
even these actions and other (relative) harms in some instances.

Prodromal Schizophrenia

Perhaps the most difficult ethical question raised in regard to the treatment of
patients with schizophrenia over the last decade is if or when a psychiatrist should
tell a patient that he or she is at an increased risk of developing schizophrenia.
Furthermore, if the psychiatrist does inform the patient of the risk to develop
schizophrenia, another ethical dilemma is whether or not to initiate some form of
pharmacological treatment for the patient..

Some psychiatrists believe that telling persons that they are at risk for developing
schizophrenia, much less treating them, is not necessary. “Risk for schizophrenia is
generally not mentioned to either patients or family members, since we don’t believe
the available information justifies such use of diagnostic labels with only attenuated
symptoms.”

Others feel this same way because they believe that far too many of these persons
would later turn out to be “false positives” for schizophrenia. Disclosing the full truth
may scare these patients and their families profoundly. Informing a patient of his or
her prodromal state may become a self-fulfilling prophecy.

Psychiatrists treating patients with schizophrenia may face ethical conflicts. These
conflicts often are between helping these patients maximally and respecting their
autonomy optimally.

Achieving treatment adherence in schizophrenia is a great challenge. The reasons for lack of
treatment adherence are complex, vary considerably from patient to patient, and have been
categorized as follows: patient-related factors (e.g., persecutory delusions, lack of insight,
health care beliefs), medication-related factors (e.g., lack of efficacy, distressing side effects),
environmental factors (e.g., caregiver support, cost) and clinician-related factors (e.g.,
therapeutic alliance) (Fenton et al., 1997).

Our suggestion according to latest technology

Studies raise hope for new treatments, preventive approaches for schizophrenia

• The contributions of altered genetics and brain connectivity to the biology of schizophrenia.
While the idea that schizophrenia is a disease of "disconnectivity" is not new, it has recently
been validated by modern genetic and brain imaging techniques. Connectome-based studies
may inform the development of new approaches to schizophrenia treatment.
• A renewed focus on the schizophrenia "prodrome"—a critical early period with
opportunities for early detection and intervention. This line of research has enabled
identification of young people at "clinical high risk," with the potential to develop
interventions to prevent or delay development of schizophrenia.
• The identification of risks faced by offspring of parents with schizophrenia—including
increased rates not only of psychotic disorders, but also depression/anxiety and other mental
health conditions. Research suggests that children at "familial high risk" can be identified
early, with important implications for predicting later risk.

One promising therapy for patients early in the course of psychosis is "cognitive
remediation"—a psychological treatment to improve thinking skills, that may be especially
helpful during the prodromal period. Another paper highlights emerging treatment and
preventive approaches. Recent evidence suggests possible benefits of some "repurposed"
treatments and supplements, such as B-vitamins and omega-3 fatty acids.

Antipsychotic Drugs

There are many antipsychotic drugs currently on the market available to treat
schizophrenia, some of which have been available for many years. Generally
speaking, there are two broad classes of antipsychotics available: conventional
antipsychotics and atypical antipsychotics.

Conventional antipsychotics Atypical antipsychotics

Conventional antipsychotics are thought Atypical antipsychotics include

to act by targeting D2 receptors in the aripiprazole, olanzapine and quetiapine.
brain and interfering with dopaminergic They are often better tolerated than the
neurotransmission. Examples of conventional antipsychotic agents. They
conventional antipsychotic drugs include are generally associated with lower
chlorpromazine, prochlorperazine, incidence of extrapyramidal symptoms
haloperidol and trifluoperazine. and, as a result, are a welcome
Unfortunately, although blockade of alternative to conventional agents.
D2receptors in the brain can help treat
symptoms associated with
schizophrenia, it may also cause
extrapyramidal symptoms, something
that can be troublesome for patients.
Extrapyramidal symptoms consist of
parkinsonian symptoms (eg, tremor),
dystonia, dyskinesia, akathisia
(restlessness) and tardive dyskinesia
(involuntary movements of the face,
tongue and jaw). These symptoms can
be difficult to predict because they are
often dependent on a number of things,
such as dose, drug and patient factors.
Some of the symptoms may stop on
cessation of therapy, but other
symptoms, such as tardive dyskinesia,
may be irreversible.

Clozapine, another atypical antipsychotic, is also used in the treatment of

schizophrenia, but only in patients unresponsive to, or intolerant of, conventional
antipsychotic drugs because it has been associated with agranulocytosis.

Over the years a great deal of progress has been made in the management of
schizophrenia. The introduction of atypical antipsychotics has proved successful
since they are generally associated with fewer extrapyramidal side effects than the
conventional agents. It would also appear that the pharmaceutical industry still
considers this disease as an attractive target for drug design and there are, indeed,
many novel agents in early development. For this progress to continue, it is vital
research into developing new agents is maintained.

Magnetic pulses given to brain’s temporal lobe for relief

Scientists have pinpointed a part of the brain where “voices” torment schizophrenia sufferers,
and partially muted them with magnetic pulse treatment. . More than a third of sufferers
treated with magnetic pulses in a patient trial experienced “significant” relief. “We can now
say with some certainty that we have found a specific anatomical area of the brain associated
with auditory verbal hallucinations in schizophrenia,” “Secondly, we have shown that
treatment with high frequency TMS (Transcranial Magnetic Stimulation) makes a difference
to at least some sufferers.”, as reported by scientists.
The trial compared 26 schizophrenic patients who received active TMS to 33 patients who
received dummy or placebo treatment.The first group was given a series of magnetic pulses
over two sessions a day for two days to the part of the brain’s temporal lobe associated with
language.Two weeks later, participants were evaluated on the voices they were hearing.
Nearly 35% of the TMS patients reported a “significant” improvement.
Recovery Toolkit
Antipsychotic medicines are not the only treatments available and nor should they be the only
tool in the recovery toolkit. Talking therapies such as counselling and psychotherapy are
invaluable in helping people with schizophrenia cope with their symptoms however they
cannot treat schizophrenia on their own.
Counselling
Counselling in particular is to be very highly recommended. A weekly session with a good
counsellor can help you cope with the symptoms and also help you cope with the everyday
problems that life throws at you.
Psychotherapy
CBT seeks to connect the thoughts that a person is having with the way they feel and how
they are acting on their thoughts and feelings. The role of CBT in schizophrenia is to help the
sufferer cope with the delusions and hallucinations without engaging with them. It does not
initially seek to challenge the truth or otherwise of the person’s mad ideas. When used in
conjunction with medication, CBT has brought welcome relief to many people with
schizophrenia.

Support groups
Many people have had really positive experiences from support groups and have found that
the opportunity to discuss their symptoms and their everyday problems with other people
who have the same unique experience of the way that psychotic thoughts work has been a
valuable part of their recovery.
Family therapy
Studies have shown that the way that a person’s family and friends react to their
schizophrenia can greatly affect the pace of their recovery. Families who become very
intensely emotional because of their loved one’s behaviour, either hostile or overly
concerned, can often obstruct the sufferers pathway to recovery.
Alternative therapies
Some alternative therapies such as herbal remedies have a track record stretching back
centuries. Valerian, for instance, is a longstanding remedy for mental health problems and
was widely prescribed for anxiety during the blitz. However some of the newer alternative
methods have no such history to support them.
Diet and exercise
Every encouragement should be given to people with schizophrenia to have a regular, well
balanced diet and to avoid fasting or alternatively junk food and binge eating.
Professor David Horrobin whose pioneering work The Madness of Adam and Eve proposed
treating schizophrenia with Omega 3 and 6 supplements. However some practitioners have
gone further than this and suggested that some aspects of diet may be key to good mental
health. Professor David Horrobin has undertaken lengthy research into the effect of using
Omega 3 and Omega 6 fatty acid supplements to treat positive symptoms and has reported
good results even in some patients previously unresponsive to antipsychotics.
There has also been some work done on the usefulness of vitamin supplements. There is
some evidence that the extrapyrimidal effects of the typical antipsychotics may be alleviated
using vitamin E and B6 supplements. Frequent exercise is vital. It will not only help to
maintain your physical health but it will also help you relax and get a regular sleep pattern.
The importance of having a good diet and plenty of exercise should not be underestimated.
People living with schizophrenia also suffer a higher incidence of physical health conditions
such as diabetes and heart problems and infectious conditions such as hepatitis and HIV