People & Events: Recovery from Schizophrenia
At 30, John Nash suffered his first bout of full-blown schizophrenia, a disease sometimes called the "cancer of the mind." Alicia Nash, his wife, was 26 at the time.
"I wanted to help him," she remembered. "You just want things to go back to being okay again . . . I just thought maybe with some medication -- I didn't really know, but I thought it would be over soon."
But Alicia's hopes for a quick recovery never materialized. For the next three decades, Nash was plagued by paranoia, auditory hallucinations, disorganized thinking, and a decreasing ability to connect with others. Nash only stepped free of the disease for a few brief periods until his slow recovery in the 1980s, leading one colleague who had watched Nash's earlier ghost-like ramblings around Princeton University to declare the man "a walking miracle" in the early 1990s.
But was he? Was Nash's recovery unusual or remarkable, much less miraculous, when compared to the course the illness takes with other people with schizophrenia? Apparently not. "We know as a general rule, with exceptions, that as people with schizophrenia age, they have fewer symptoms, such as delusions and hallucinations," says E. Fuller Torrey, M.D., author of the best-selling book, Surviving Schizophrenia. "So that when Nash hits his late forties and fifties, and his life gets better, it's not shocking at all. Anyone who follows the literature would never characterize it as a miracle."
The assumption of recovery contradicts public perception. Most people still assume that schizophrenia is a permanent ailment that becomes more debilitating over time, a theory first put forward by the German psychiatrist Emil Kraepelin, who first classified schizophrenia's symptoms in 1896. Scientists today search for genetic, biological, or other factors that might cause the disease. Clinicians find that the disease is not only potentially reversible; it can also abate with age.
The possibilities of recovery and the search for treatments are the subjects of an enormous amount of research, and a wide range of opinion. The results of 25 independent studies that looked at people who had schizophrenia for longer than 10 years were analyzed in one literature review. The review found that a decade after an initial schizophrenic incident, one-quarter of schizophrenics were completely free of any symptoms. "These are not people who you hear about when schizophrenia is discussed," Dr. Torrey explains. "These are the cases where you hear a mother say, 'John had a nervous breakdown in his second year of Dartmouth but he's fine now.'" These people go on to live normal lives and often "become invisible" to those tracking schizophrenia, Dr. Torrey says. "This group recovers no matter what you do or don't do." The DSM-IV, the diagnostic mental health bible put out by the American Psychiatric Association, doesn't even consider someone to have schizophrenia if the symptoms persist for less than six months.
Ten years following a first schizophrenic episode, another 25% are "much improved," meaning they still might marry, live independently, or hold some kind of employment, although part-time. These people almost always rely on medications to reduce the psychotic symptoms of schizophrenia, whether the first generation of anti-psychotic medications of the 1950s or the 1990s generation, such as clozapine.
After 30 years of the initial onset, the number of these "much improved" cases increases to 35%. Despite stereotypes of the madman or -woman wandering institutional hallways, only 10 percent of people with an initial diagnosis of schizophrenia require hospitalization after 30 years. Another 10 percent of people with schizophrenia are dead after three decades, most from suicide. Still, the disease, like an ill-prepared long-distance runner, seems to fade in the later legs of life's race.
Contrary to what many people assume, Nash's recovery was not related to some new drug therapy. "I emerged from irrational thinking," Nash said in 1996, "ultimately, without medicine other than the natural hormonal changes of aging." In 1995, he wrote that he began to "intellectually reject some of the delusionally influenced lines of thinking."
Schizophrenia watchers have put together predictors that point to positive outcomes. Nash fit the portrait of a candidate with a better-than-average chance of recovery. Those with a sudden onset -- Alicia described her husband's illness as coming on over the space of weeks -- are more likely to recover than those with a gradual one. Affliction later in life is more likely to lead toward recovery than earlier. The prognosis for a fifteen-year-old, for example, is much more bleak than for a 30-year-old like Nash. Still, Nash's sex (men recover less frequently than women) and his family's apparent genetic disposition (Nash's younger son, John Jr., has also been diagnosed with schizophrenia), reduced his chances.
Courtenay Harding, director of the Center for Psychiatric Rehabilitation at Boston University, points to several additional factors that contribute to recovery. "They include a home, a job, friends and integration into the community," she says. "They also include hope, relearned optimism, and self-sufficiency."
"The people who are in the patient's social network who keep them going, who help that recovery, are the real unsung heroes in this business," says Dr. Peter Weiden, a psychiatrist at St Luke's-Roosevelt Hospital Center and Columbia University.
In Nash's view, he rationally willed his own recovery, although it took him a quarter-century to do so, a period during which he was often cared for by his devoted wife Alicia, his mother and sister, and a supportive mathematics community. There are no studies to prove this unscientific proposition, but this larger, caring community might have kept Nash alive, physically as well as socially, until a recovery slowly, yet finally, became possible.
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