The Madness of Young People

In 1861 Benedikt Morel, a physician in France, described a terrifying new illness. It involved young people in their late teens or early twenties about to enter what should have been the prime of their lives who instead sank into a profound and seemingly incurable state of what he termed precocious dementia. Morel painted a picture of a terrifying and seemingly close to incurable loss of cognitive function.

In short order all around Europe, there were similar reports of the new illness. Some called it adolescent insanity, others hebephrenia, and later dementia praecox.

A short while before, the English, French and Germans had begun to build the first specialist hospitals for any set of medical disorders. They were designed to promote recovery from mental illness by offering a focus on hygiene and a behavioral approach that would build up the morale of the affected person.

Very soon after opening however the beds filled so that fresh wards had to be built which in turned filled rapidly. Asylum superintendents in their annual reports asked whether insanity was increasing. Those who thought it was, put the changes down to urbanization or industrialization and the increasing pace of modern life.

In mid-nineteenth century, the patients who came into the asylums mostly had melancholia or acute and transient disorders. Very few patients had dementia praecox. But by the end of the century, dementia praecox accounted for by far the largest number of admission.

The early asylums were geared for patients who were expected to recover but few recovered from dementia praecox. Some of these new young mad patients only stayed in hospital for a short time. Three to five years after admission, the women in particular caught tuberculosis and died from it. But among those who did not die from tuberculosis, some  were there 10, 20, 30 and in some cases 60 years later. The mission of the asylums changed from recovery to warehousing. The reputation grew that you only ever came out in a box.

Briefly around 1920 soon after its name switched to schizophrenia, the illness became popular. Artists, and others like Carl Jung who thought creatively might be allied to madness were happy to brand their struggles as schizophrenic.

But it is almost impossible to interest the media in schizophrenia now. Nobody wants to have anything to do with this graveyard of hope.

In 1980 a controversy blew up in the ivory towers. Some argued that schizophrenia had only appeared in the nineteenth century and if so we should redouble our efforts to pinpoint a cause – especially as the antipsychotics were definitely not the cure. Indeed worryingly, dementia paralytica (tertiary syphilis – General Paralysis of the Insane/GPI) looked very similar to dementia praecox. If we had had the antipsychotics when patients with GPI came into hospitals they would have controlled these patients just as much as they control schizophrenia making it harder to recognize that penicillin rather than antipsychotics were the cure for GPI.

Most of psychiatry dismissed this idea, as did I. The increase in insanity was apparent rather than real – most argued. We were warehousing awkward patients. Doctors had a conflict of interest – the more patients the more powerful they were.

Then the data on admissions to the North Wales asylum fell into my hands. Yes there was an increase in first admissions for insanity in line with increases in the population. But beyond this there was a tripling of first admission rates for schizophrenia between 1875 and 1905 over and above the increases linked to population change, while the rates of admission for other disorders remained constant.

These findings cannot be explained by industrialization, urbanization, or culture change as North West Wales did not urbanize, or industrialize and had no shift in ethnic mix.

All the old textbooks from 1900 say schizophrenia affected men and women equally. All the textbooks from 2000 say it affects 2 or more men for every woman. In our records the figures for 1875-1924 show almost exactly the same number of women and men but the figures for 1994 to 2010 show 2 men for every woman. (See Healy et al, 2012).

But even more surprising, starting in 2005, perhaps a good deal earlier for women, first admission rates for schizophrenia have plummeted. Other surveys which look at admission rates for schizophrenia will miss this as first admissions only account for 15% of admissions. The figures have dropped from 15-20 new cases per year to 5 per year – figures not seen in North Wales since 1876.

A ward has closed. This is the kind of thing that speaks louder than academic articles.

What’s going on? The drop cannot be explained by early intervention services or home treatment teams or any other change in service because there has been no change of service in North Wales during this time.

The North Wales nineteenth century figures nail down for the first time a specific increase in schizophrenia reinforcing calls to pinpoint what might have caused it. The modern data add to the urgency of these calls. While the factors that led to this increase in schizophrenia may not be the same as those leading to its decrease now, it would be very satisfying to find something that might both account for some of the increase and some of the decrease.

Two strong candidates come to mind. In the nineteenth century we began to use lead for more and more purposes. Lead pipes carried our water. Lead solder closed the tin cans in which food was increasingly put. Lead was added to food and even to the medicines we took. The paint we coated our houses in had high concentrations of lead. The paint on bars of cots that teething babies gnawed on were impregnated with lead. Our children wrote with lead pencils in school. When the automobile arrived, we put lead in gasoline and concentrations of lead in urban air grew rapidly.

Lead is neurotoxic to children in particular. If the brain damage it can cause is what made some psychoses chronic in later life, then to see a drop in admission rates around 2005 in North Wales, where lead was once mined, we would want to see a fall in lead concentrations around 1980. And in 1980 lead was being removed from water-pipes, paint, gasoline, and had already been removed from food and medicines. The soil concentration of lead in North Wales began falling fast at this time. Elsewhere in the USA in particular, rates of admission for schizophrenia track lead levels and those admitted have higher levels of lead than controls.

Another possibility lies in changing childbirth practices. In mid-nineteenth century we introduced anesthesia and this led male obstetricians to ever greater feats of heroism with forceps and other instruments, delivering blue and sometimes close to black babies from “mid-cavity”. Around 1980 there were major changes in practice with increased rates of Caesarean Sections and the active management of labor aimed at delivering pink babies.

It would be wonderful to pinpoint a cause. We are probably though looking for a cause for chronicity rather than a cause for schizophrenia. What may be happening is that what might have been acute and transient psychoses against a background of subtle brain insults turn into chronic psychoses. The question then will be what the original conditions look like – are they in fact acute and transient psychoses?

Some reviewers of our findings have been intensely hostile. They seem to hear a message that mental illness is disappearing. It isn’t. In same way that we will have respiratory illnesses as long as we have respiratory systems, but respiratory disorders like tuberculosis rise and fall – this is what happens to real medical disorders, so also as long as we have brains we will have mental disorders but specific disorders like dementia paralytica and dementia praecox can come and go.

There is good news here for anyone interested in recovery in mental disorders. The patients we see in future may be much more likely to recover. This opens up the possibility of reconfiguring services. But if something like lead poisoning once made some psychoses chronic we need to keep an eye out for other things that might do this in future. For example we should track what the outcomes are when we save intensely premature babies – in so doing do we cause the kind of damage that might lead on to chronic psychosis.

There is a message for anyone treating chronic psychoses. The patients are right when they say the drugs don’t cure. The antipsychotics can be helpful if used judiciously but realizing that a cure is not going to appear if we just hammer the dopamine system a little bit harder might let us devise more sensitive and nuanced treatment approaches.

We need more sensitive and nuanced approaches because at present more patients are dying earlier than they should and these deaths are linked to the way we are using antipsychotics.

7 COMMENTS

  1. Lead poisoning? Interesting and disturbing for me to read this after asking psychiatrists if the lead pellet I carry in my neck from a shooting incident when I was 12 years old, could be a contributing factor. The question was always routinely dismissed by a person focused on their immediate need of dealing with a patient and prescribing recommended medication.

    An overwhelming focus on treatment with zero interest in causation because its not relevant to the psychiatrist’s immediate need, while said patient sits with the mythic hope of care and concern. “Sorry, its genetic,” the most common symptom of caring concern.

    Yet three generations of family history show no obvious signs of mental illness, while I have four grown children of my own, who all exhibit strong signs of normal coping skills and consensual beliefs. That is to say they believe in mental illness, while having no experience of it, “it must be just like cancer or diabetes, and you just need to take the right medications,” soothes their immediate needs.

    Still, thank God the body/brain is incredibly adaptable and learning about how its supposed to work, can help us become internally self-aware, rather than mindlessly appeasing immediate needs. And of coarse the patients are right when say the drugs don’t cure!

    There is no cure for the human condition, while the vast majority of people walk around with no clue as to what makes them tick, inside, including psychiatrists? How many of us act out the habitual rituals of our social nature, with no idea as to how such behavior is internally stimulated? How many people can say they believe in evolution theory and actually embody what the word “evolution” really means?

    We live in a consensus denial about the primary process reality of the human body, and our immediate survival needs. We shy away from real self-awareness, preferring the pretense of a dissociated “I think therefore I am!” A game of hide and seek, we all play?

    Real stories are written on the human face, like David’s “look at me,” need. The cognition and its articulation, part of a competition for social status and rank? If you look closely at David’s smile, you will see the little boy who is father to the man? You can see the underlying emotion and understand its immediate gratification needs? How it stimulates an unconscious orienting response.

    Are we back to Freud’s “unconscious” motivation, here in 2012, albeit with aid of technology? Or is that word “unconscious” far to discomforting to try to embody, just like the word evolution? Is it easier to maintain the limited comfort-zone of intellectual beliefs, than feel the instinctual roots of our primary, emotional orienting responses, in the motivation of immediate need?

    Is madness, simply nature “acting out,” just as normality is?

    Best wishes,

    David Bates.

    • Dave,

      Have you ever had your blood lead levels checked? Lead is a toxic substance.

      Although children are primarily at risk, lead poisoning is also dangerous for adults. Signs and symptoms in adults may include:

      High blood pressure
      Declines in mental functioning
      Pain, numbness or tingling of the extremities
      Muscular weakness
      Headache
      Abdominal pain
      Memory loss
      Mood disorders

  2. It’s my impression that bipolar disorder is being diagnosed now for a lot of people who had would have been diagnosed as schizophrenic decades ago. The relations between one bipolar and the next is no more defined than that between schizophrenics in the sixties and seventies. It’s a one size fits all diagnosis, but more convenient because bipolar disorder can be “revealed” by a person’s reaction to an antidepressant.

  3. Dear Dr. Healy,

    Writing in plain English, thank you for pointing out the fact that exposure to lead can make SOME people (not ALL people) seem and act like “crazy people”.

    Research on the link between manic/psychotic symptoms and past exposure to lead is something that I have been very interested in since 1997.

    SIDE NOTE: for anyone who reads this and does not appreciate the fact that I use the term “crazy people”, that is the same term Robert Whitaker uses repeatedly in the following video. If you have a complaint about the plain English use of “crazy people” to describe manic/psychotic symptoms, kindly take it up with Bob and not me:

    http://isepp.wordpress.com/2012/01/09/robert-whitaker-at-the-isepp-2011-conference-in-l-a-part-ii/

    From my personal experiences, most psychiatrists, psychologists and other professionals who treat “mental illness” use a “Rubber-Stamp” diagnostic approach that fails to acknowledge, detect or treat underlying causes of psychosis and mania. I feel the failure on the part of mental health professionals in the US to assess psychosis according to the Best Practice guidelines published in the British Medical Journal leads to unethical, ineffective and costly treatment.

    I am curious to know if Robert Whitaker would agree to those statement, as if we consider the “Economy of an Epidemic” money is made by failing to recognize and treat the underlying problems.

    Past exposure to lead and other heavy metals is clearly one of the underlying problems that need to be considered and sought after for liability.

    You might find the book “Toxic Truth: A Scientist, a Doctor, and the Battle over Lead” by Lydia Denworth an enlightening read.

    When considering sources of occupational exposure, the advent of computer aided equipment in the early 80’s welcomed more women into industries that were traditionally male dominated and involve exposure to chemical solvents and heavy metals that even at low-levels of exposure, are recognized as causing neuropsychiatric conditions and birth defects. Gender differences in lead metabolism are also reported.

    I began employment in the printing industry in 1983. At the time it was the third largest industry in the world and was a male dominated profession. During the course of my 15 year employment in the prepress department of a high volume printing company, 5 women had miscarriages and I am aware of 5 of my former co-workers who have children with learning disabilities labeled as autism. Two of whom are men who worked around toluene, n-hexane and leaded inks.

    As you are aware of, screening for blood lead levels only detects current exposure and when lead gets into the blood stream, the body confuses it with calcium/other essential nutrients and stores it in soft tissue or it is used to make bones, muscle, and brain connections.

    We know that lead was among the earliest recognized neurotoxins. The Greek physician, Dioscorides (A.D. 40-90), wrote: “Lead makes the mind give way.” And Benjamin Franklin, a printer at a time when type was made of lead, described classic symptoms of lead poisoning among typesetters.

    In a long-term childhood lead study from Cincinnati, Ohio, Kim Dietrich, PhD, and his team determined that elevated prenatal and postnatal blood-lead concentrations are associated with higher rates of criminal arrest in adulthood.

    “Previous studies either relied on indirect measures of exposure or failed to follow subjects into adulthood to examine the relationship between lead exposure and criminal activity in young adults,” explains Dietrich, principal investigator of the study and professor of environmental health at UC.

    “We have monitored this specific sub-segment of children who were exposed to lead both in the womb and as young children for nearly 30 years,” he adds. “We have a complete record of the neurological, behavioral and developmental patterns to draw a clear association between early-life exposure to lead and adult criminal activity.”

    In my opinion, three decades is a hell of a long time to research a problem without trying to fix it.

    Despite the laws on lead based paint, thousands of toys with lead paint have been imported from China. Old books also were printed with leaded inks and as you point out there are many sources of exposure to lead/mercury/other heavy metals.

    In 1998 I pulled out all of the books and research I could find at the medical library on lead toxicity. At the time I was undergoing chelation therapy after high levels of lead were found in hair analysis. My blood lead levels were normal.

    The onset of manic/psychotic symptoms included visual hallucinations but prior to that I had experienced seeing halos around objects, poor night vision, slight memory problems, glaucoma readings were high and the whites of my eyes were noticeably yellow.

    One of the symptoms of lead poisoning is swelling of the retinas which can cause one to see light in circles like halos around objects as a higher percentage of lead is stored in the visual cortex. Van Gogh is thought to have experienced this.

    Chelation treatments not only eliminated the visual hallucinations, but improved my night vision, glucoma reading and cognitive abilities. Within 6 months of starting Chelation therapy I was able to taper off of all medications. I would not have been able to successfully taper off of psychiatric medications without eliminating some of the toxic overload first.

    One of the studies that I pulled out of the medical library to support my worker’s comp case was this pilot study: Lead Levels in the Hair of Bipolar Patients and Normal Controls, Medical Hypotheses 20: 151-155, 1986 which concludes: preliminary results suggest that in some susceptible individuals-people predisposed to bipolar illness-a relatively high lead burden can tip their balance towards illness. If these results are substantiated, future workups of bipolar patients should routinely include evaluations for extent of lead burden.

    Also, “Several pertinent case histories were given by Machle in 1935. He mentioned the recurrence of a “schizophrenic” condition in two male workers following excessive exposure to lead. These recurrences strikingly resemble what now would be called an episode of mania in one case and a mixed bipolar disorder in the second case.

    The American Journal of Psychiatry published the article, Organic Affective Illness Associated with Lead Intoxication, 141:11, Nov. 1984 which states: We suspect that ignorance about the psychiatric and medical manifestations of lead intoxication and about the sources of occupational exposure to lead contribute to the failure to recognize, report and properly treat psychiatric disturbances associated with lead intoxication….Since psychiatrists receive little information about toxic behavioral syndromes during training, toxic etiologies of psychiatric syndromes and, in particular the less spectacular manifestations of intoxication are often not recognized.

    I hope that you will continue to consider lead and other organic causes of psychosis.

    Kind Regards,
    Maria Mangicaro

    Posted on Mad in America 10/26/2012

  4. Dear Dr Healy

    You conclude this blog post with “We need more sensitive and nuanced approaches”. Do you include ECT/electroshock as a part of this type of approach?

    I wrote a blog post today entitled ‘women get ECT in Scotland twice as much as men’:
    http://chrysmassociates.blogspot.co.uk/2012/10/women-get-ect-in-scotland-twice-as-much.html
    where I express concerns at the statistics, and about the fact that older women get even more ECT, doubly discriminated against.

    I cannot support the doing away with psychiatric drugs just for shock treatment to increase, which would be like going from the frying pan into the fire.

    I’d be interested in hearing your response to the place of ECT in therapeutic ‘care’ and what other approaches you think could be a suitable replacement for antipsychotics.

    Regards, Chrys