Book Review
Schizophrenia
Schizophrenia Revealed: From Neurons to Social Interactions. Michael Foster Green. New York: WW Norton and Company; 2001. 240 p. US$32.00.
Reviewer rating*: Excellent
Review by Emmanuel Stip, MD
Montreal, Quebec
It is currently estimated that 24 million people on our planet have schizophrenia. That represents the entire population of Canada. Continuing the metaphor, it has always been difficult to write about the “country” of schizophrenia because of its complexity, heterogeneity, and weight of stigmatization. This year, interest in the disease was renewed by the release of A Beautiful Mind, a film about an exceptional life affected by this disease. The scientific literature on schizophrenia is abundant, and each year there are many congresses on the subject. However, it is even more difficult to interpret the findings and to explain the disease in lay terms. We are therefore lucky to see this splendid book appearing on the shelves of our libraries. Its author, Michael Green, is a professor at University of California, Los Angeles (UCLA), and head of the Department of Veterans Affairs. Known for his work on the importance of cognitive deficits in schizophrenia, Dr Green is a leader in his field. His contribution to this discipline is recognized in North America and in Europe. What is unusual is to find such a researcher and clinician able to explain schizophrenia in simple, accessible terms for all readers—a quality that also relieves the specialists in this field from boredom in reading. Dr Green tries to provide the general public with the information essential to understanding this disease. A challenge here is to explain and supply information without betraying the scientific way of thinking; however, Dr Green’s endeavour succeeds in every chapter.
As a member of the board of directors of the Société Québecoise de schizophrénie, I have had the chance on several occasions to exchange information, give explanations, and describe both the status of scientific research and the limits of our progress, bearing in mind that it relates to 1% of the world population. Today, I’m reassured to have this book in my possession. It allows me to tell my professional colleagues and my patients that there exists a work explaining what concerns them. Unfortunately, this work is not translated into French, but we hope for a future translation.
Dr Green brilliantly integrates the recent developments in our understanding of schizophrenia, which he organizes according to a train of thought proceeding “from neurons to social interactions.” When I closed the book on the train from Montreal to Toronto, I felt that I had read a good detective novel. I mentioned previously that this work describes the equivalent of a country with a population of 24 million inhabitants. It surprised me to think that I had just read a book that was scientific and objective, yet at the same time able to maintain a glimmer of hope, while drawing me into this tragic country.
The work is organized in 7 chapters, the first of which introduces the history of this mysterious disease. At the end of about 15 pages, the reader realizes that this disease consists of symptoms that can be looked at in a dimensional way; that is, positive symptoms, negative symptoms, and symptoms of disorganization, in conformity with Peter Liddle’s model (1). This chapter ends with the construction of the schizophrenia diagnosis and the characteristics of prodromal symptoms, which present a heterogeneous prognosis.
In chapter 2, the author concentrates on the development of schizophrenia. With exceptional clarity, he analyzes the various arguments that give way to the neurodevelopmental theory of schizophrenia. He is interested in population studies, risk factors, and abnormal developmental markers. With equal care, he inquires into the risks that trigger the disease and examines structural and molecular brain studies in schizophrenia. He finishes this chapter by concluding that the disease has neurodevelopmental elements but also elements in favour of a progressive disease, placing himself among the authors who favour a theory proposing the possibility of 2 phenomena that are not ultimately incompatible. As in the first chapter, he constantly provides illustrative clinical examples that refresh the reader absorbed in synthesizing a wealth of data.
Chapter 3 is concerned with the genetics of schizophrenia. It is a welcome chapter for those who have always found it difficult to establish the link between genetics and schizophrenia. With flawless simplicity, the author leads us gradually to realize the inevitability of the genetic factor in this multifactorial disease.
Chapter 4 finds Dr Green in his stronghold. Here, he writes about cognitive deficits in schizophrenia. This chapter displays undoubted mastery and confidence, but it is without arrogance. It serves to remind many skeptics that schizophrenia is a disease of cognition, that cognitive deficits are the most significant feature, that 85% of patients have cognitive deficits, that these deficits range from mild to severe, and that they contribute greatly to the prognosis and outcome of the disease.
Cerebral imagery is essential for understanding the processes implicated in schizophrenia. In chapter 5, the author presents a factual and didactic overview of neuroimaging. He describes the techniques and their role in understanding cerebral dysfunction as well as mental and emotional brain activation. He ends by describing the mechanisms of drug action on the brains of patients with schizophrenia.
In chapter 6, Dr Green approaches with reserve and in a critical spirit the current interventions to alleviate schizophrenia. He describes the effects and side effects of medications and the advantages of the new medications. He gives a relatively good idea of the current state of knowledge, with an optimism that will assure the public, for whom this work is intended. Although one might have expected more criticism from prominent scientists regarding the effects of medications, especially in the long term, it is interesting that this chapter confirms the enormous challenges remaining to be conquered in the field of psychopharmacology: the drugs developed to date relate only to positive symptoms—a single, small aspect of the disease. Regarding medication for neurocognitve deficits and negative symptoms, there is a desert. This chapter ends by describing the extrapharmacological interventions that make it possible to improve the functional existence of patients and their psychological well-being. It cheerfully integrates family interventions and the development of patients’ social abilities.
Chapter 7 is devoted to the results of all these interventions. The author includes the results of clinical trials, and he also devotes some pages to the patients’ subjective satisfaction with their well-being. Further, he elegantly introduces a subject that has for several years been precious to him in his writings: social cognition. Social cognition can be defined as the grey zone lying between what belongs to cognitive functions (such as memory, language, vigilance, and attention) and what belongs to social interactions. In this section, the author fully masters his arguments, which allows him to finish the whole work on a note of optimism. If written 20 years ago, this work would have dedicated more space to psychoanalytical therapy and community psychiatry. The current lack of text on these apsect might lead readers to think these areas are not appropriate—an unfortunate conclusion, because the quest to make sense of such a disease and the accompanying necessary social changes are always pertinent.
Overall, this book is a delight. It returns the focus to the families, the patients, and the professionals who have been interested in this disease for years. If readers are satisfied after reading this book, I believe it is because they realize that, for an author to achieve such a well-constructed work with such simplicity, we have indeed made significant progress in understanding the plague of schizophrenia.
Reference
1. Liddle P, Firston KJ, Frith CD. Patterns of cerebral blood flow in schizophrenia. Br J Psychiatry 1992;160:179–86.
*Reviewer
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