MARTY MOSS-COANE: I'm Marty Moss-Coane. Welcome to our webcast. Schizophrenia is a worldwide phenomenon, and in the United States it's estimated that 2.5 million people suffer from schizophrenia -- that's 1% of the population -- but many people know little about what the disease is. It's not, for example, the same as having a split personality, as you may have thought. Today, while myths and stereotypes persist, much more is known about what the disorder is, what the symptoms are, and how the disease progresses. Schizophrenia is the topic for today's webcast, and joining us to bring a very personal perspective to our discussion is Nathaniel Lachenmeyer. His father, Charles Lachenmeyer, was a devoted family man and a professor of sociology before he began his descent into mental illness. When Nathaniel was still young and his father's behavior began to change, his family's marriage fell apart and his father eventually left the family. He was diagnosed paranoid schizophrenic, convinced that the CIA was trying to control his thoughts and steal his research. He lived for many years alone and homeless. Nathaniel's book about is father is called "The Outsider: A Journey Into My Father's Struggle with Madness." Nathaniel joins us today. Thank you very much.
NATHANIEL LACHENMEYER: Thank you.
MARTY MOSS-COANE: Let me introduce our next guest, Dr. Joseph Battaglia. He is clinical director of the Bronx Psychiatric Center. Nice to have you with us, as well.
NATHANIEL LACHENMEYER: Thank you.
MARTY MOSS-COANE: Dr. Salerno is our third guest. He's the director of rehabilitation services at Rockland Psychiatric Center in New York. Nice to have you with us, as well.
ANTHONY SALERNO, PH.D.: Thank you.
MARTY MOSS-COANE: Let me begin with you, if I can, Nathaniel, to talk a little bit about your father. You were young when he began to lose his grip on reality. What do you remember as a little boy? What do you remember in terms of how your father began to change?
NATHANIEL LACHENMEYER: Prior to onset he had been a very loving and caring parent. As he began to change, the progression was slow and he became slightly hostile and aggressive -- not toward me, but toward other people. It wasn't until after my parents were divorced that it really became schizophrenia, and at that point I would receive calls and letters that were openly delusional and references to the government and a conspiracy that involved my family and things like that.
MARTY MOSS-COANE: You write about how your father began to look different. He had a different face.
NATHANIEL LACHENMEYER: He did early on. I think it was mainly the tension and probably having to negotiate the emerging symptoms and try still to be who he had been. He never recognized the fact that he was ill, so from his perspective he was grappling with an ongoing conspiracy, but even that had a definite physical imprint on him.
MARTY MOSS-COANE: But I got the feeling the way you wrote that he had some kind of awareness that something about him was changing and he was holding on very tight to who he was.
NATHANIEL LACHENMEYER: I think so. I think so. I don't think he ever recognized, though, that it was schizophrenia. I think prior to onset he was aware that he had problems that he was trying to address, in part, in his work as a sociologist. His graduate work, for example, was on schizophrenia, and I make the argument in the book that he did sort of anticipate what would happen. But once the symptoms actually emerged, that insight was lost. He had total lack of insight into the disorder.
MARTY MOSS-COANE: As a young boy, did you grow afraid of your father even while he was in the family and you noticed things were changing?
NATHANIEL LACHENMEYER: Not fear. It wasn't a fear of physical danger, but the behavior became so strange -- Mainly what I saw when I knew him before he left -- when I was about 11 -- was just an increased sense of desperation, and I think that can instill fear anyone.
MARTY MOSS-COANE: Let me turn to you, Dr. Battaglia. Help us understand what schizophrenia is. We talked a little bit about what it isn't. What is it?
JOSEPH BATTAGLIA, MD: Actually, many people feel now that there are the schizophrenias, that it's not one disease. There's a disease process and it affects people in different ways. This is about the 100th-year anniversary of the term "schizophrenia." In Europe, there's Dr. Kreplin and Dr. Boyler, who at the same time are working with Dr. Alzheimer -- of Alzheimer's dementia -- and they noticed that there was a group of people who seem to develop a dementia-like syndrome with loss of intellectual functioning. Dr. Kreplin called this dementia praecox, meaning early-onset dementia, and he felt that very much had a deteriorating course, that if someone had this, it was as if they had Alzheimer's but at earlier onset. Dr. Boyler, however, felt that it wasn't the course of illness that was characteristic of the disorder, necessarily. He looked at it as affecting several domains of functioning. One was what we would call association, meaning how we string thoughts together. That's reflected in our speech -- how we string thoughts together -- but it's also how we communicate nonverbally, because a lot of our communication is nonverbal. It affects someone's attentional capacity, how they deal with information in the environment. It affects someone's affective display, either blunting it or making it unpredictable, not connected to the environment. It affected their thinking in an autistic way, meaning they would be preoccupied with ideas that were very important to them but to no one else. At times it would make them avolitional, meaning very little motivation to do or move. Because it affected these domains, he coined the term schizophrenia, meaning "breakdown of the mind," so it's a breakdown of these mental functions.
MARTY MOSS-COANE: Is it helpful for us today to think about schizophrenia like that, as a breakdown of the mind, a kind of mental, thought disorder?
JOSEPH BATTAGLIA, MD: Right. Because it affects us differently. Those capacities are affected to a lesser or greater degree in any person. However, the problem was in trying to diagnose it along those domains. It casts a very wide net, so it was easy to diagnose many people as having schizophrenia. His idea that hallucinations and delusions were not primary in the disorder, but outcomes of those processes, changed. Now, if you made the diagnosis based on having hallucinations and delusions, you could become very specific in your diagnosis. The pendulum swayed in that direction, so the diagnosis today in the DSM-IV is based on having hallucinations -- sensory perceptions of things that are not there -- delusions, believing in things that no one else could believe in, that are not verifiable -- and a deterioration in function in major areas of ones life -- work, school, family.
MARTY MOSS-COANE: Let me turn to you, Dr. Salerno, because it seems that there are very strong myths, stereotypes, misperceptions about schizophrenia. Why do you think it's so difficult for people really to truly to understand what the disease is?
ANTHONY SALERNO, PH.D.: The first reaction that people have when they're behaving in a bizarre way is to be fearful, and it's not something you can see. It isn't like you can point to a lesion or point to a particular physical thing that you can say "Hey, that's the problem." What happens is, it really affects the personality. It's a transformation and a deterioration, really, of the integration of that person. So I think our reaction to it is very strange and bizarre, and I think humans tend to want to shy away from that, and then there are a lot of myths about what is this all about. Everywhere from, there's some kind of moral deterioration in the individual or laziness that was really symptoms of withdrawal, or the patient is kind of weird in the idea of demons or somehow inhabited by strange things. It's very, very difficult. It's only recently that we have been able to get into, basically, understanding the brain. When you look at people with schizophrenic illness, they have structural abnormalities. It's a brain disorder. Yes. In fact, males, in particular, tend to have stronger structural abnormalities in the brain than females do. There are also chemical imbalances. A lot of the medications -- which we'll talk about later -- have to do with trying to balance out these medications.
So what happens? The mind plays tricks on the individual. They see things that aren't there, feel things that aren't there, or come to believe things that are not true, yet it affects their behavior tremendously. Mr. Lachenmeyer had a delusion, a paranoid delusion, which is very common out of all the delusions that people have -- strange beliefs, suspiciousness, fearfulness of others, the notion that there's a conspiracy around you -- is one of the most common symptoms of mental illness.
MARTY MOSS-COANE: Nathaniel, you were telling us that for many years, really until you were a young boy, your father was the family man. He had a job, he was well-educated, a very intelligent man, and it sounded like he was a very good father, at the same time. I'm curious why schizophrenia seems to happen, take place, affect someone once they get into adulthood or late adulthood. Tell us what you observed.
NATHANIEL LACHENMEYER: In my father's case, actually, his onset was later than most because it really wasn't until his early 30s. Prior to that there would be sort of aberrant thoughts that I picked up from people that I interviewed for the book, but overall he was in control, and if you define -- in part, any disorder is defined by level of social functioning, and he was doing quite well. Generally, onset is late adolescence, early adulthood -- they can speak to it, as well -- but I think, in general, one idea is that it's a genetic predisposition with environmental stress is the general model for what causes schizophrenia. So one idea is that adolescence is a time of tremendous stress. There are also other ideas along those lines.
MARTY MOSS-COANE: That's pretty typical, then. It would be late adolescence, early adulthood.
ANTHONY SALERNO, PH.D.: For males.
MARTY MOSS-COANE: For males.
ANTHONY SALERNO, PH.D.: Females, onset in the mid-20s to the mid-40s.
MARTY MOSS-COANE: Is it something happening to the brain, something happening chemically?
ANTHONY SALERNO, PH.D.: The problem is that when you think the illness started is when they start to behave really differently, but there is what is called a prodromal phase, and in the book, I think there's a very good description of those experiments your father was doing. That's not atypical if you look at the socialization and way of perceiving the world, that although it doesn't stand out that you would call it schizophrenia at that point, there's this prodrome phase which can be two to three years and longer before someone has what's called a nervous breakdown and gets treatment.
MARTY MOSS-COANE: So there is a kind of progression that happens with this disease.
JOSEPH BATTAGLIA, MD: There is a progression. In fact, a defining characteristic of schizophrenia is that there is a deterioration in functioning for a minimum of about six months or so. So people really are going from a higher level of functioning, and over time the situation is getting worse. It isn't as if one day you're normal and the next day you have somehow something happen, something snap. We often talk about that. People get this notion that, "Oh, I just snapped," but that's not really the way it occurs. People often go for a long period of time without getting treatment while they're having the symptoms. People don't just sit there and take all of this. They know something is going on. They're trying to understand it. They're trying to explain it. Sometimes they gravitate towards drugs or alcohol to try to self-medicate, other times have other explanations. They're hanging on as best they can, and really during this time they could be receiving treatment, but they're very ashamed, they're very frightened of what's taking place. Even other family members who may observe things don't know what to make of all this.
NATHANIEL LACHENMEYER: One thing, I think, also, to some extent, with a certain percentage of people with schizophrenia, there is also lack of insight -- would you agree? -- as a symptom of the disorder, and I find also within the mental health community there tends to be a sort of -- In fact, I was at a talk yesterday where a woman maybe in her 60s -- whose son has schizophrenia and has been living out of his car for five years, but has been with schizophrenia for 30 -- was saying how he's unwilling to recognize that he has schizophrenia. I think that's a mistake. I think, at a certain point -- in certain cases anyway -- it has to be considered --
ANTHONY SALERNO, PH.D.: An additional feature of the disorder.
MARTY MOSS-COANE: That you don't know.
ANTHONY SALERNO, PH.D.: It's one of the symptoms. Some people can, but many can't. In mental health advocacy, I think, there isn't a lot of recognition of that. You have the people who have better outcomes who recognize that the illness is a function of that and are more likely to comply with medication, for example.
MARTY MOSS-COANE: I want to pick up with that you said about people medicating themselves with alcohol, and certainly that seemed to be clear with your father. He was drinking more.
NATHANIEL LACHENMEYER: For him, alcoholism predated onset. I think that's a tricky thing. Early on you would say he's an alcoholic. Later on, one sees he has symptoms that are as bizarre as they were and as constant as they were over a period of 20 years. You'd say it's self-medication. So, yeah, I suppose it is. I think it's an attempt to cope with stress. And he drank quite a bit.
MARTY MOSS-COANE: He was diagnosed as paranoid schizophrenic. In the hierarchy of diagnosis, is that the most serious form of schizophrenia, Dr. Battaglia?
JOSEPH BATTAGLIA, MD: According to the DSM they break it down into five. In paranoid type you don't see the severity of thought disorder, so what you see are delusional beliefs, grandiose type or paranoid type, without severe breakdown in your ability to communicate. The onset tends to happen later. Of the five categories, that's the one that seems to actually continue that way over time, whereas the other ones can change and not be that way the second or third time they have a breakdown.
MARTY MOSS-COANE: More fixed in their personality or their belief system?
JOSEPH BATTAGLIA, MD: More fixed.
MARTY MOSS-COANE: You wanted to add something.
ANTHONY SALERNO, PH.D.: What I'd like to add to that is, because an individual is paranoid and sees others not as supports or resources as threats, what happens is, they're not able to really commit themselves to the treatment, to the helpers that are available, to the services that are available, because trust is a critical element of any kind of helping relationship. So the supports that you could have within your family or friends, it's just often a matter of time before they become part of the entire group of people that you're suspicious, so it alienates you from others. In doing so, that also alienates you from the services and the treatments that could be beneficial.
NATHANIEL LACHENMEYER: At the same time, I think that -- if I'm wrong -- just from a strictly perspective rather than in terms of outcome, don't they tend -- because there's less cognitive deficit, there is a higher level of functioning that's maintained, right? Maybe outcome can be worse than other subtypes?
JOSEPH BATTAGLIA, MD: The issue about outcome is that if you're patient enough, if you go out 25, 30 years, the majority -- 50 to 60% -- actually have not returned, necessarily, to baseline, but can be functioning, having part-time jobs and an increased social network. So prognosis is really hard to make on the short-term basis. The paranoid type, in terms of its outcome, doesn't appear to be different than the other types, necessarily. The issue of how you alienate people -- for instance, your experiencing your own thoughts but you don't realize they're yours.
MARTY MOSS-COANE: There is much more to talk about. I hate to cut in there. I thank all three of you for joining us and telling us a little bit about what schizophrenia is. Thank you very much. And thank you very much for joining us. I'm Marty Moss-Coane.