Saturday, September 15, 2007

Breaking out of the mental prison

15 Sep 2007, ST


One in 100 people suffers from this mental condition. Over 16,000 people with this condition cope with it daily, holding down a job or going to school.

Health Correspondent SALMA KHALIK looks at those with schizophrenia, who face a lifelong struggle to get out of their mental prison to lead near-normal lives

DESIREE is a student leader with everything going for her. Her bubbly personality makes her a favourite with teachers and fellow students.

Then schizophrenia hit.

It sapped her confidence. She got depressed, saw herself as a failure and tried to kill herself.

JOHN is a successful, inventive businessman with an engineering firm. He is married, lives in a condominium and owns a couple of nice cars. He has lived with voices in his head for over 15 years. Many times, those voices told him to kill himself. He has survived those attempts.

ENTER the world of schizophrenia. A world of mental anguish and darkness, where one hears voices others cannot hear, sees things invisible to others, thinks thoughts others do not understand, and starts to be suspicious of everyone, even one's closest family.

Locked in the mental prison caused by the disease, people with schizophrenia feel estranged from society.

In Singapore, there is not much awareness of this condition.

In fact, it is a common mental illness, affecting one in 100 people. Half the 32,000 outpatients treated at the Institute of Mental Health (IMH) suffer from this, which means there are over 16,000 Singaporeans living a relatively normal life, coping with schizophrenia.

Eighty per cent of the 6,600 - or 5,280 - of the patients warded at IMH each year suffer from schizophrenia.

Every day, a child is born in Singapore who will suffer from schizophrenia.

Far from the stereotype of violent lunatics foaming at the mouth, many people with schizophrenia in fact are able to lead a relatively stable, normal life. Like John, the businessman. Or William, the draughtsman.

Fearsome disease

SCHIZOPHRENIA remains one of the most feared and least understood of mental illnesses. Dr Swapna Verma, a psychiatrist with IMH, explains: 'Schizophrenia is a syndrome, and no two patients behave the same way.'

A medical condition is referred to as a 'syndrome' when no one knows its exact cause and so defines it by a collection of symptoms.

Even symptoms vary: many schizophrenia patients will hear voices or see things that don't exist. Some believe they have super powers. Others become suspicious of people around them, to the point of paranoia.

In its mild form, this mental illness that causes people to lose touch with reality is called psychosis.

One in 40 people here will suffer from a psychotic episode some time in their lives. If a psychosis persists for six months or longer, or is a recurring problem, it is called schizophrenia.

About a third of schizophrenia patients recover after treatment.

Another third would appear to recover and may be fine for some years, before relapsing.

The rest are chronic sufferers, who need to manage the disease throughout their lives.

The latter two categories need medication all their lives.

Catch it early

RECENT research has been promising in pinpointing several facts about schizophrenia.

First, it is now accepted that schizophrenia often shows up first in the young adult years - late teens to 20s - at a time when the brain is still growing.

The brain does not mature fully till about 25. Schizophrenia occurs when something goes wrong during this developmental stage.

Doctors consider the teen years 'the most mentally unhealthy' time in a person's life.

That's when a lot of mental disorders appear - depression, anorexia, substance abuse, personality disorders, and schizophrenia.

These are the years when the brain's frontal lobe is developing. This part of the brain deals with how a person plans, organises and strategises - in other words, all the high-level processing.

The temporal lobe, which deals with emotions, is also changing during these years, causing the emotional see-saws of adolescent years.

Some doctors speculate that it takes both a predisposition and a trigger to set off the chain of chemical reactions in the brain that leads to schizophrenia. Others think that either factor - a genetic link, or a traumatic event - is enough.

Dr Alison Yung, who runs a state clinic for young people with mental problems in Melbourne, said a child has a 12 per cent risk of getting schizophrenia if one parent has the disease, and 40 per cent if both parents suffer from it. For those with no family history, the risk is 1 per cent.

Dr Tan Hao Yang, of the National University of Singapore (NUS), who is doing research into what happens to the brain of someone with a mental disorder, described schizophrenia as 'a terrible chronic disease starting early in life that lasts a lifetime'.

The second promising development is that early treatment appears to make a real difference to patients' lives. So the trick is in identifying patients early, as soon as symptoms appear.

A pilot project in Melbourne University is doing precisely that. Scientists there have come up with a list of things to look out for to identify those who are at risk of developing schizophrenia, before full-blown symptoms appear.

For example, teachers and counsellors are trained to identify young people who start becoming suspicious of others or talk of hearing 'whispers'. This is the stage before they become fully paranoid or start hearing voices.

At this Melbourne centre, schizophrenia patients are picked up two months after symptoms appear, compared to a year in other programmes. Many are young people seeking treatment on their own.

Professor Patrick McGorry, a world expert in schizophrenia based in Melbourne, said that if a patient goes without treatment for a couple of years, the disease becomes relatively permanent and 'treatment at that point is largely ineffective'.

Singapore has started an early psychosis intervention programme at IMH, modelled on the Melbourne experience. So far, the results have been positive. Of the 1,100 people identified and helped in the last six years, none has required long-term treatment. The Ministry of Health is pumping more resources into this programme.

Enigma in the brain

SCHIZOPHRENIA spares no one and has a wide spectrum of victims - from brilliant students and sports enthusiasts to the less successful. It affects the rich and poor like.

Specialists are still fumbling around for an explanation of what causes schizophrenia.

NUS' Dr Tan said: 'There's a great deal of research on schizophrenia in the world. But we still know relatively little because the brain is such a complex organ, locked in the skull, making it very difficult to study.'

One theory is that the hallucinations and other symptoms of schizophrenia are caused by high levels of dopamine. This is a neurotransmitter - or chemical messenger - which controls the flow of information in the brain.

Many anti-psychotic drugs reduce the supply of dopamine, thus reducing or shutting off these problems. Unfortunately, a shortage of dopamine affects a person's development of cognitive behaviour.

This means that the medicine needed to suppress the symptoms may also cause his intelligence level to go down.

But Professor Kua Ee Heok, a senior psychiatrist at NUS, said there are indications that this drop in ability is caused by the illness itself, and not just the medicine.

One of the first signs that something is wrong with the youth is often his falling grades, Prof Kua said. Almost invariably, it is mathematics that suffers first. And this comes before he is even diagnosed and given medicine.

Anti-psychotic medicine works by altering the brain chemistry. Medication can remove the irrational fears, voices and delusions that plague patients, so they can behave more 'normally'.

But there are side effects, ranging from weight gain or diabetes to muscular spasms and blank-looking faces.

So, when a patient appears to be doing well, doctors will want to take them off the medicine.

If they stop medication too suddenly, symptoms may flare up again. Hence, doctors often phase in the withdrawal from medication and seek the support of family members to make sure the patient remains stable while medication is being reduced.

The mental anguish

PEOPLE with schizophrenia may lose touch with reality but retain enough self-awareness to know their mental faculties are impaired.

Dr Tan said: 'Many will unfortunately suffer long-lasting cognitive deficits that make it difficult for them to work as well as before. Many will have difficulty with social relationships, in thinking or reacting as fast as before.'

Some attempt suicide when they realise they can no longer reach the intellectual and performance levels they used to take for granted.

Some learn to accept their limits, like William, who has a master's degree and chose a simpler job as a draughtsman. Some are unable to cope with the loss.

In Singapore, as with the rest of the developed world, one in three schizophrenia patients attempts suicide. In spite of all that the doctors, case managers and their families can do, one in three attempts succeeds.

In other words, nearly one in 10 schizophrenia patients dies at his own hands - with more than half of them doing so within the first five years of being diagnosed.

For someone diagnosed with schizophrenia, the journey is lifelong.

They have to accept that they suffer from a mental illness and need medication when symptoms flare up.

As Dr Swapna said: 'It's hard to tell a 19- or 20-year-old, when they feel better, that they will need the medicine for a long time, maybe even all their lives.'

Next, if they are taken off medicine, they have to be self-vigilant, and be proactive in seeking help or taking medication at the first sign of symptoms. If put back on medication immediately, symptoms like hearing voices usually subside.

If symptoms persist and a patient loses touch with reality, he may end up in hospital. Others may become irrational, or lose control and do things like strip in public.

In the past, when less was known about the disease, it was often left untreated till symptoms got so bad that the patient was sent to Woodbridge Hospital.

As a result, more than 900 patients, or three in four of the long-term stayers at IMH, are there because of severe schizophrenia. But even at IMH, some patients are well enough to go back on home visits occasionally.

These days, the promise of early treatment holds hope that many schizophrenia patients can lead relatively stable lives with medication.

With over 16,000 people seeking outpatient treatment for schizophrenia, the chances are good that someone you know or come across, is a silent sufferer.

With greater awareness of this condition, each person can help create a climate that is accepting of people with this condition, so they are not more isolated than the illness already makes them.


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