麻豆传媒

If you live in a Zambian village and are diagnosed with schizophrenia, you are a lot more likely to recover than a New Yorker. Some Londoners with the disease are being offered cash incentives to encourage them to continue taking the unpleasant drugs that are still the main treatment. And more than 10 per cent of 鈥渨ell鈥� people in surveys worldwide admit to hearing voices at some time. Don鈥檛 worry, says Richard Bentall, contradiction and confusion are sometimes a good thing

THERE鈥檚 a revolution going on involving more than 150 million people from every part of the globe. If you hadn鈥檛 noticed, that鈥檚 hardly surprising because it is a very quiet revolution, involving marginalised, often stigmatised people. They are the millions who suffer from the devastating diseases of schizophrenia or bipolar disorder, or at least fit the diagnostic criteria of the International Classification of Diseases (version 10): F20 to F29, and F30 to F39, respectively, if you鈥檙e a trainspotter in these matters.

For years there were just a few dissident voices: patients well enough to argue, their families, support groups and a handful of doctors. Now their cause is being taken up by a number of researchers in the UK, the US and elsewhere, who are developing a radical new approach to understanding and treating these diseases. This movement is challenging the fundamental assumptions that have driven psychiatric research into mental illness.

For most psychiatrists, schizophrenia and bipolar disorder are the most serious mental illness they will ever see. They are classed as psychotic disorders or psychoses, and they seem to involve a marked break with reality. During acute episodes, patients experience delusions (鈥渢he government is trying to kill me鈥�) or grandiosity (鈥淚 was the sole inventor of the helicopter and the pop-up toaster鈥�). Some sufferers also experience hallucinations, usually voices criticising them or telling them what to do. The main difference between the two conditions is the apparent absence of emotion in schizophrenia, and the extreme emotions of bipolar patients, who seem to flip between depression and manic euphoria.

For over a century, investigators struggled to pinpoint the causes of these illnesses. New ideas were often stimulated by the accidental discovery of drugs that seemed helpful: antipsychotics such as chlorpromazine for schizophrenia, and mood stabilisers such as lithium carbonate for bipolar disorder. Progress has been slow, and few theories remained uncontested for long. Recovery, too, remains problematic, becoming a perverse kind of geographical lottery. In poor countries like Zambia, where psychiatric services are underdeveloped, recovery is about 50 per cent, while in the west it鈥檚 about 30 per cent.

One of the biggest obstacle in the way of progress is the idea that these diseases are separate conditions. This dates back to the 19th century, mainly to the work of German psychiatrist Emil Kraepelin, who believed that patients with schizophrenia (or 鈥渄ementia praecox鈥� as he labelled it, meaning senility of the young) were suffering from a condition that would deteriorate and never get better. Patients with bipolar disorder (Kraepelin鈥檚 鈥渕anic depression鈥�) generally had a much better outcome. Statistical analyses of symptoms show, however, that they do not cluster in the way Kraepelin imagined. In fact, very soon after schizophrenia and bipolar disorder became widely accepted as diagnoses, it became apparent that many patients experience both types of symptoms.

Recent studies by molecular geneticists have reinforced the emerging consensus that schizophrenia and bipolar disorder are overlapping conditions. No important genes or gene clusters 鈥渇or鈥� either disease have ever been found. The best it gets is that defects in the actions of some genes 鈥� for example, neuregulin-1 or dysbindin 鈥� seem to slightly increase the risk of suffering from symptoms associated with both conditions.

Another challenge is that the dividing line between psychosis and normal functioning has become increasingly fuzzy.

One very surprising discovery is that 鈥減sychotic鈥� symptoms are far more widely experienced than anyone thought. These symptoms are mostly auditory hallucinations, which, with delusions, are likely to clinch a diagnosis of schizophrenia or bipolar disorder for about 1 per cent of the population. But studies in the west show that about 10 per cent of the population experiences auditory hallucinations at some time in their lives.

鈥淎bout 10 per cent of the west鈥檚 population will experience auditory hallucinations in a lifetime鈥�

This makes sense if there is a spectrum from psychosis to normal, with no clear dividing line between 鈥渘ormal鈥� and 鈥渟ick鈥�. On an optimistic note, it also suggests that many people cope with psychotic symptoms without seeking medical help.

Faced with these difficulties, psychologists now focus on specific symptoms. A lot of research, for example, links auditory hallucinations to inner speech, or verbal thought. Children learn to think in words by talking aloud to themselves. In adulthood, a neuromuscular echo of this persists as covert electrical activation of the speech muscles during thinking, called subvocalisation. Philip McGuire at the Institute of Psychiatry (IOP) in London, among others, used imaging studies to show that patients subvocalise when they hallucinate about hearing voices, which suggests that they can鈥檛 distinguish between their thoughts and external stimuli. Although no one understands the causes, there is some controversial evidence that trauma is involved. A 2005 study by Tony Morrison at the University of Manchester, and a study I published in 2003 both show very high rates of sexual abuse in patients who hear voices.

When it comes to delusions, cognitive psychologists have tried to identify abnormal reasoning processes that may lead to false inferences about the world. Paranoid (persecutory) delusions have received a lot of attention, and there is evidence these delusions follow long-term experiences of actual persecution and victimisation, perhaps leading to hypersensitivity to threat stimuli.

There is also evidence that more basic cognitive difficulties are involved. Philippa Garety at the IOP ran an experiment in which she showed patients two jars, one containing white beads mixed with a few red, and another red with a few white beads. The patients were then shown a sequence of beads, without knowing which jar they came from. Those with persecutory delusions made a guess at which it was (often wrongly) more quickly than did non-deluded patients.

As well as jumping to conclusions, people with persecutory delusions also experience difficulty understanding the thoughts, feelings and beliefs of others. It seems likely that some combination of these difficulties leads to full-blown paranoia.

All this research is very promising: we really are beginning to tease apart symptoms that previously looked like a big jumble. As a result, psychological treatments for people suffering from psychosis are a real possibility. Old views will take some changing, though.

After the advent of antipsychotic drugs, and the failure of psychoanalysis, psychiatry was clear: psychological treatments were not for schizophrenia or bipolar disorder. Drugs it was, and largely still is, leaving the problem of how to encourage those 20 to 50 per cent of patients who stop taking the drugs to persist. Newham Centre for Mental Health in east London, for example, recently tried a controversial scheme where it paid between 拢5 and 拢15 to people with schizophrenia each time they had a new 鈥渄epot鈥� injection of psychiatric drugs, usually once a month.

People often stop taking these drugs because of their unpleasant side effects, and the drugs are sometimes ineffective. So psychologists in the UK have braved disapproval to experiment with shorter-term psychological therapies. In particular, cognitive behaviour therapy (CBT) is used to help patients identify and evaluate reasoning processes that drive their psychotic thinking. This might take the form of asking them to find evidence for their beliefs and carry out experiments to test this evidence.

More excitingly, the UK鈥檚 Medical Research Council is funding a 拢1.5 million clinical trial (I am one of the investigators) to find out whether CBT can prevent people who show the very earliest symptoms of illness from developing full-blown psychosis.

It is too early to say where these new developments will lead, but optimists like me think that it may be possible to abandon altogether psychiatric diagnoses such as schizophrenia, once all of the symptoms of psychosis have been adequately explained. In the UK, most psychiatrists have come to see CBT as playing some role in treating patients, although they still believe that good drug treatment is essential. In the US, psychiatrists remain generally more sceptical.

Whatever the role of CBT, schizophrenia and bipolar disorders will never be the same again. This can only be a good thing. After all, no one likes an intellectual muddle, while everyone loves as much choice as possible when it comes to treatment.