Tracking the Causes of Madness
By: E. Fuller Torrey
From: Schizophrenia and Civilization, published by Jason Aronson
J. Geffen
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1.
For a young man growing up in the West of Ireland, the expectation that he will
be hospitalized for schizophrenia sometime during his lifetime is one in 25. If he were
growing up in England, Germany, Japan, or the United States, his chance of
hospitalization would be about one in 100, only one-fourth the Irish rate. This
difference illustrates some dramatic new findings in schizophrenia research that may
help point the way toward unraveling the causes of this disease.
2.
For years, the schizophrenia hospitalization statistics in Ireland were dismissed
as artificial. Some researchers said the Irish were just calling more people
schizophrenic. Others speculated that schizophrenic individuals were hospitalized
more readily there. In Ireland, many believed that the healthier people migrated to
America and left the sick behind – a theory put to rest when a high schizophrenia rate
was found among Irish immigrants in America. Thanks to extensive epidemiological
studies by English and Irish mental-health professionals led by Dermot Walsh and
Aileen O’Hare of the Medico-Social Research Board in Dublin, the other simple
explanations are now known to be inadequate as well. Ireland, especially the West of
Ireland, really does have a very high rate of schizophrenia and this has probably been
true for at least 100 years.
3.
It is not only the professionals who are aware of the prevalence of schizophrenia
in the West of Ireland. Conversations with many people there, most recently in
August of 1978, convinced me that the man in the street also knows of the problem. A
bar-tender in the picturesque village of Ballyvaughn, County Clare, made it quite
clear: “Oh, yes,” he said. “That madness is a big problem here, all right. Last winter
some of the boys here were sitting around the fire discussing it, and counting all the
folks who have had to go down to the county asylum. It’s a bad problem, all right, and
the boys figure it’s getting worse.” When asked what “the boys” think causes it, the
bartender said they blamed everything from the weather to alcohol intake; as among
professionals, there was a clear consensus on the problem, but not on its causes.
4.
The “madness” to which the bartender referred is mostly schizophrenia, a term
undoubtedly covering several diseases of brain dysfunction. The predominant
symptoms are disorders of perception (the person may hear voices, or smell poison
gas in his room), disorders of emotion (the person may laugh or cry completely
inappropriately), and disorders of thinking, such as loose associations and delusions
(the person may pick up a rubber band and tell you that it is a musical instrument
because it is a “band” – that in turn may remind him of the instruments used in the
hospital emergency room where the FBI planted electrodes in his brain). True
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schizophrenia usually begins in the late teens or 20s and runs a variable course: some
people have only a single attack; some have recurrent attacks; others stay
continuously sick.
5.
Schizophrenics all over the world show these symptoms, and look remarkably
alike. Although the content of their delusions may differ (the paranoid schizophrenic
in Ireland may feel persecuted by the IRA rather than the CIA), their shape is
basically the same. In the United States, unfortunately, the term “schizophrenia” is
used more broadly and often imprecisely. Schizophrenia is not, for example, a “split
personality” like that of the main character in Sybil or The Three Faces of Eve; these
are examples of a rare psychiatric condition called a dissociative reaction.
6.
The treatment for schizophrenia all over the world is antipsychotic drugs whose
effectiveness ranges from complete to nonexistent. In the United States, many
psychiatrists still treat schizophrenia with psychotherapy and psychoanalysis,
although those treatments have been largely discredited in the rest of the world.
7.
As a disease, rather than a psychiatric catchall term, schizophrenia would be
strange indeed if it did not show marked geographical differences. Virtually every
major disease known, including diabetes, cancer, hypertension, and heart disease, has
variations in prevalence in different groups.
8.
But the fact that schizophrenia varies in frequency around the world conflicts
with what virtually all mental-health professionals have been taught; textbooks of
psychiatry and psychology all say that schizophrenia is found everywhere in the world
in about the same prevalence. It is now known that this teaching was not based on any
research, but rather was simply an early impression passed on from textbook to
textbook. All the recent research refutes it.
9.
In addition to the West of Ireland, there are other areas of the world where
schizophrenia seems to be especially common. The Istrian Peninsula on the northwestern coast of Yugoslavia is one of them; 10 years of research by a team from
Zagreb and Baltimore have confirmed that schizophrenia is about three times more
common there than it is in the rest of Yugoslavia. As in Ireland, local lore suggests
that the high prevalence dates back at least 100 years.
10. Another very high prevalence area is a small part of northern Sweden where a
team of researchers has studied the problem during a 26-year period. There are also
suggestions that parts of Eastern Europe, especially Poland and the Ukraine, may have
an abundance of schizophrenia, but it is unlikely that their regimes will permit that to
be confirmed.
11. Much less work on regional variations of prevalence has been done in the
United States. In 1903, psychiatrist William A. White, in “The Geographical
Distribution of Insanity in the United States”, concluded: “We are at once confronted
with a condition of affairs which is so well marked that when I first saw it I was very
much surprised. The greatest proportion of insanity is in the Northeast, in the New
England and middle states, of which New Hampshire, Vermont, Massachusetts,
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Connecticut and New York all have one insane person to less than 400 of the
population. If from this center of greatest prevalence of insanity we draw a line in any
direction – west, south, or southwest – we see that no matter which way we go we
find a steady decrease until we strike the Pacific slope.”
12. Psychiatric-hospital admission statistics since White’s time tend to bear out his
impressions. For example, between 1922 and 1960, the average schizophrenia firstadmission rate in Massachusetts, Connecticut, and New York was two and a half
times the rate for Kansas, Idaho and South Dakota; some people in the Northeast still
refer to schizophrenia as the “New England disease.” But systematic prevalence
surveys are needed to back up the hospital figures.
13. On the other end of the prevalence spectrum, there are areas of the world where
schizophrenia appears to be distinctly uncommon. Many impressions to this effect can
be found in psychiatric and anthropological literature on rural and developing nations,
especially tropical ones; but vast methodological problems have precluded definitive
studies. The best research project on this question was done 25 years ago by Tsung-yi
Lin and Hsien Rin on Taiwan. They found a relatively low rate of schizophrenia
among Chinese immigrants to Taiwan, and a rate half again lower among the
aboriginal Formosans who live in rural mountain villages. Less precise studies of
Papua New guinea and several African countries have also reported very low
prevalence rates, even taking into account such possibilities as patients being hidden
in the villages or not surviving.
14. Anthropologist and psychologist Meyer Fortes reported a particularly interesting
finding. From 1934 to 1937, he studied intensively the Tallensi people in northern
Ghana and found only one schizophrenic in a population of approximately 5,000. In a
population that size in Europe or the United States, one would expect to find 10 to 25
schizophrenics. In 1963, Fortes returned to the area with his wife, who is a
psychiatrist. In the same villages where 27 years earlier there had been a single
schizophrenic, there were now 13. The research team was convinced that the dramatic
rise in schizophrenia in the 27-year period was real, and that it could not be explained
by population growth: “What was quite startling, from my point of view,” wrote
Fortes, “is that several of these cases occurred in families which were specially well
known to me in 1934-37 and which were basically the same in structure in 1963 as in
the early period. I knew some of the patients as young wives or youths or children.
These were the families of my best friends and informants, some of whom are still
living. Had such cases occurred among them in 1934-37 I could not have missed
them.”
15. In India, six separate studies since 1930 have all found a higher prevalence of
schizophrenia among members of the most highly educated, and most Westernized,
castes. This contrasts with the United States, England, Japan, Norway, Ireland, and
Iceland, where more schizophrenia has been reported among lower socio-economic
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and the least educated groups. Whether schizophrenia-prone individuals “drift”
downwards to these lower classes is hotly debated.
16. Even more intriguing than the geographical data are figures that have emerged
over the past 10 years showing that individuals who later in life become schizophrenic
are born disproportionately more often in the late-winter and spring months. Studies
of over 125,000 schizophrenic patients have shown this to be true in nine northern
hemisphere countries: England and Wales, Ireland, Sweden, Norway, Denmark,
Germany, Japan, the Philippines, and the United States. Studies of South Africa,
Australia, New Zealand and Tasmania, southern hemisphere nations with reversed
seasons, have tended to confirm that more schizophrenic patients are born in the
cooler months.
17. Other aspects of the seasonality of schizophrenic births have recently come to
light. Studies in Japan and England suggest that the peak months for schizophrenic
births may have shifted over time from winter toward spring. In Missouri, this shift
was confirmed, showing that in the 1920s, the peak month was February; in the
1930s, March and April; and in the 1940s, April and May. The change was highly
significant statistically.
18. All of this information raises many more questions than it answers. But they are
important questions, for hiding among them are almost certainly clues to the ultimate
question: what are the causes of this disease? Prevalence studies of lung cancer,
hypertension, and heart disease have yielded much guidance in the study of those
diseases, and it is reasonable to expect the same for schizophrenia.
19. What have we learned to date from those studies? First, the overall data derived
from them are compatible with thinking of schizophrenia as a series of diseases rather
than as a single disease. In other words, schizophrenia may simply be a final common
pathway of abnormal brain dysfunction, no more specific than the term “mental
retardation.”
20. Second, the data appear to provide no support for psychoanalytic theories of
schizophrenia (which say, for example, that it is caused by bad mothering), and little
support for sociocultural theories, which hold that it is caused by cultural stress.
Sociocultural theorists might cite the data from Ghana and India in support of such
ideas, but other data directly contradict them. In Ireland, for example, the
schizophrenia rate is much higher in the rural, relatively peaceful, western section
than in the turbulent, warring north, where the stress is very high – and this difference
has been present for many years. Genetic theories of the disease appear to be
supported by some of the findings (for example, the northern Swedish highprevalence area is marked by inbreeding), but not by others.
21. The emerging epidemiological data would appear to be most compatible with
biological theories of schizophrenia: they reinforce other evidence that shows
schizophrenia to be a series of brain disorders. Neurophysiological studies have
shown, for example, that schizophrenic patients have certain anatomical anomalies
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that can be picked up on computerized brain X rays; they also demonstrate “soft”
neurological signs, such as the inability to identify, without looking, a number traced
on their palms. Laboratory studies have revealed a low level of monoamine oxidase in
the blood platelets of some patients, setting them apart, again, as somehow biologically different. The search for the precise causes of schizophrenia – there are
probably several of them – is likely to be the most exciting development in the
mental-health field in the next decade. Possible causes of schizophrenia might include
such things as environmental toxins, viruses with long latency periods, heavy metals,
or nutritional deficiencies – all of which could be linked to geographical areas,
helping to explain the differing rates.
22. Finally, the seasonality of schizophrenic births strongly implies that, for at least
one subgroup of schizophrenic patients, the original damage to the brain occurred
either in utero or shortly after birth. (Such fetal injuries cause rubella heart damage,
cleft lip, and stillbirth, all of which show marked seasonality.) This theory dovetails
with what we know of the development of the brain, which shows it to be very
susceptible to injury from the time of conception until the child is a year old. It is also
compatible with emerging knowledge of other brain diseases, such as multiple
sclerosis, which is probably contracted in the first few years of life, but doesn’t show
symptoms until 20 to 30 years later.
23. In short, the distribution of schizophrenia has emerged as a respectable and
potentially valuable area for research. By looking beyond our traditional research
frontiers, we may extend the horizon of our knowledge immeasurably.
_____________________________________________________________________
E. Fuller Torrey is a clinical and research psychiatrist in Washington, D.C. He is the
author and editor of six books.
For further information, read:
Torrey, E. Fuller and M.R. Peterson. “The Viral Hypothesis of Schizophrenia”,
Schizophrenia Bulletin, Vol. 2, No. 1, 1976.
Torrey, E. Fuller, B.B. Torrey and M.R. Peterson. “Seasonality of Schizophrenic
Births in the United States”, Archives of General Psychiatry, Vol. 34, No. 9, 1977.
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Answer in your own words.
1.
2.
3.
Answer the following question in English.
Compare the ratio of schizophrenia incidence in West Ireland with that in
England or the United States.
Answer: _____________________________________________________________
Answer the following question in English.
How was the high incidence of schizophrenia in West Ireland previously
accounted for (paragraph 2)?
Answer: _____________________________________________________________
Answer the following question in English.
How was the notion proved – paragraph 2 – that people originating from
Ireland, but not necessarily living in Ireland, are schizophrenia prone?
Answer: _____________________________________________________________
Answer the following question in Hebrew.
4.
List the predominant symptoms – paragraph 4 – observable among
schizophrenics?
Answer: _____________________________________________________________
5.
6.
7.
Answer the following question in English.
What particular piece of information – paragraph 4 – may offer some glimmer
of hope?
Answer: _____________________________________________________________
Answer the following question in English.
On what cardinal point do some American psychiatrists fail to agree – paragraph
6 – with most of their colleagues in other countries?
Answer: _____________________________________________________________
Answer the following question in English.
What commonly accepted notion on the issue of schizophrenia – paragraph 8 –
has recently been refuted?
Answer: _____________________________________________________________
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8.
Answer the following question in English.
What do the figures presented in paragraphs 12-13 suggest?
Answer: _____________________________________________________________
Choose the best answer.
9.
In the case of schizophrenia – paragraphs 12-13 – modernization and
urbanization lead to
a. the extinction of schizophrenia.
b. a decline in the incidence of schizophrenia.
c. a higher incidence of schizophrenia.
d. the eventual appearance of schizophrenia.
Answer the following question in Hebrew.
10. Suggest two possible connections between schizophrenia – paragraph 15 – and
low socio-economic status.
Answer: _____________________________________________________________
11.
12.
Answer the following question in English.
What treatment – still occasionally offered by some psychiatrists – would be
completely ruled out should schizophrenia prove to have biological sources?
Answer: _____________________________________________________________
Answer the following question in English.
Provide the information that clearly suggests that schizophrenia is related to
environmental causes.
Answer: _____________________________________________________________