The Environment and Mental Illness

In biological terms, the word “environment” means the host of influences, besides DNA, which affect our inherited genes, turning them on and off, and having marked consequences for human development and health. These influences include viruses, neo-natal injury, exposure to toxic substances, auto-immune processes (where cells mysteriously destroy each other) or changes involved in aging. They also include the effects of countless variables arising from our interactions with others and with the world around us.

Two theories are now an important focus of research – the virus theory and the neuro-developmental theory.

Virus Theory: The fact that similar risk factors operate for both schizophrenia and mood disorders suggests that these illnesses

have some common infectious causes. There is the well-documented fact that an excess of births occur, in the winter and spring months, of people who later develop these illnesses. This means there may be a seasonal “slow virus” involved. Mothers may have caught the virus during pregnancy; the virus could affect the fetal brain, but pathological changes would not show up until many years after birth.

Being raised in a city is another shared risk factor for people who develop these illnesses; areas of dense population mean that viruses are more easily transmitted. Moreover, pregnant women known to have viral infections, or compromised immune systems due to malnutrition, are at much greater risk of having children who develop these illnesses.

Recent studies at the National Institute of Mental Health have yielded the first antibody evidence that the common parasitic infection, toxoplasmosis, doubles or triples the risk for schizophrenia. Pregnant women can get this infection quite easily from undercooked meat, unwashed, hands, or from handling cat litter. The risk for schizophrenia stems from the mother’s immune system antibody response which can affect the fetus.

Neuro-developmental Theory: There is growing consensus among researchers that schizophrenic illness results from damage to the frontal lobes, in utero or during early childhood, which lies dormant until the late teens when the frontal cortex of the brain reaches full development. In other words, as one researcher recounts, the illness “begins before birth, spares the brain through childhood, only to erupt in psychotic breakdowns and profound disability at the beginning of productive life.” This “silent lesion” could be hereditary, or the result from epigenetic factors such as birth complications, head injuries (both of which occur at an unusually high rate in schizophrenia), viruses, toxins, or auto-immune reactions – all of which could affect a vulnerable neonatal brain.

It is now widely believed that central nervous system maturation plays a crucial role in this illness in late adolescence, as frontal and limbic circuits do not reach functional maturity until early adulthood. In this sense, then, schizophrenia is an organic brain disease resulting from an early injury whose consequences are there, from the beginning, but do not “unfold” or make a behavioral impact, until the time when cortical connections fully develop. Various perinatal forms of neuro-developmental damage may also occur in bipolar disorder and depression.

An awareness of the effects of brain biology, genetics, and environmental factors could hopefully lead to a greater understanding of people with mental illness. It could lead families and people with mental illness to actively seek treatment. It can reassure people that mental illness is not caused by character weakness, the devil, or poor parenting. It is a treatable condition. There is hope.

 

Genetic Influences on Mental Illness

There is more that contributes to the onset of mental illness besides the factors discussed in last month’s article concerning the brain and mental illness. In addition to looking at the biological origins of brain dysfunction, researchers are looking at another major component -genetics. It is hoped that these studies can lead to the prevention of mental illness and/or devising effective medication.

More than half of our genes are responsible for the development and functioning of our brains. Genes contain instructions that carry the code for the building blocks of our mind and body. Unhappily, things can go awry with this hugely complicated biological process-our forebears may be giving us DNA where critical genes are deleted altogether, or we get too many duplications of them, or some of the genes we get “miscode” proteins-all giving rise to genetic defects which will fundamentally compromise the developing brain.

Some research has identified a substantial overlap in genetic risk for schizophrenia and bipolar illness, caused by sub-microscopic mutations –a risk also shared in autism. A “hotspot” has been detected in a single stretch of genetic code, implicating immune system involvement in these disorders. The largest genetic analysis of this kind to date for bipolar disorder has found that a variation in only two genes causes the imbalance of sodium and calcium in brain cells which may be responsible for this illness.

Several studies of schizophrenia identified a wide range of small gene variations, which taken together accounted for 30% of the risk for schizophrenia. A mutation that deleted chunks of DNA increased the risk of schizophrenia eight-fold.

In another startling finding, the studies discovered that the rare occurrence of one extra copy of a gene can cause a sizeable risk for schizophrenia. These micro-deletions can be inherited, but they can also happen spontaneously, which is why some individuals can develop schizophrenia without having any family history of the illness. This could explain why – in spite of the fact that 80% of the risk of schizophrenia is familial - the incidence of schizophrenia remains at 1% of the population even though many people with this illness do not have children.

One of the hottest new areas in brain research is neurogenesis, a still-controversial hypothesis claiming that brain cells can heal, or regenerate. Physical and mental “workouts” are proposed to rejuvenate fatigued brain cells, and even create new ones, while preliminary animal research suggests that anti-depressants and lithium may actually spur development of new cells, and increase neuronal connections in the brain.

Because of research, medication and treatment for mental illness are constantly improving, but there is hope for even more and better.

Now is the time for the reminder: no one is to blame for mental illness any more than a person with mental illness or their family can be blamed for autism, Parkinson’s, epilepsy, diabetes, or other such illnesses.

The brain and mental illness

“What did I do to cause the illness to my loved one?”  This a common question of someone who thinks they are to blame for the mental illness. On the other hand, the person with the illness often blames a family member for their problems. The fact is NO ONE IS TO BLAME.

No one can cause another person to have a mental illness any more than a family member can cause another to have epilepsy, diabetes, Parkinson’s, or any such illness. The research on the brain is convincing that mental illness is not something that one person can do to another. Most of the current research is focused on schizophrenia.

One study shows two “working” brains, one with schizophrenia and one a “normal control.” The brain scan measures blood flow during a planning task. The pictures show that the normal control is able to use the frontal cortex (top of the brain) while performing the task, but the person with schizophrenia has a brain scan that is not “lighting up” in this region at all. Marked sluggishness in circulation and metabolism is typical in schizophrenia.

Other research in cortical dysfunction shows the following:

• Difficulties in working (or short term) memory: People with schizophrenia have difficulty holding information in the mind from moment to moment. This problem is thought to cause the persistent cognitive disabilities experienced in the
• Dramatic reduction in gray matter: A long- term study of teenagers with schizophrenia revealed a pattern of gray matter loss, beginning at the back of the brain and moving toward the frontal cortex. The chief investigator reported, “We were stunned to see a spreading wave of tissue loss that began in a small region of the brain. It moved across the brain like a forest fire, destroying more tissue as the disease progressed.”
• Lack of cortical cell migration: During normal fetal growth brain cells migrate from deep within the brain to the outer layers, and some will undergo natural cell death. Examinations of autopsied brains of people with schizophrenia reveal an excess of cells remaining deep in the cortex. Either they did not ever migrate at all, or they were victims of over-programmed cell death. As a result, the cortex is not well formed.
• Loss of glial cells in mood disorders: Post-mortem brain research has found a severe depletion of glial cells in brains of individuals with depression and bipolar disorder. The study indicated that 40-90 percent of the glial cells were gone.

Research on the size of the ventricles in the brain shows that the size of the ventricle (the fluid-filled cavities in the brain) in those diagnosed with schizophrenia is larger than average compared to normal controls. This means that the brain of the person with the illness is smaller. Individuals with the highest ventricle-to-brain ratio tend to have more sever forms of the disease, have poorer life adjustments before onset, and show a less favorable response to medication. This condition is also found in bipolar disorder and Alzheimer’s disease.

Research on limbic system dysfunction reveals that this powerful emotional processing center is implicated in every major mental illness and accounts for the excess emotionality in depression, bipolar illness, panic disorder, and OCD. This interferes with the normal control of response to anxiety-provoking stimuli.

Studies indicate that people with schizophrenia produce abnormal brain waves; therefore, the brain cannot tone down external stimuli or screen our unwanted stimuli. Nicotine from cigarettes or the patch provide brief relief from sensory overload – even tone down the voices in the head.

Some people who have undergone a psychotic episode say they are left feeling like they were hit by an 18 wheeler. It would be easier to accept the disability if they looked like they had been in an accident: wheelchair, crutches, casts, bandages. However, they still look intact.

This causes a lack of understanding and leads to questions. “Why are you sleeping so much?”  “Why can’t you go back to work?”  “Why can’t you just get it together?”

So……where is the HOPE? With education and understanding – with guidance from the professionals – with medication.

Don't fight mental illness alone

This is one young man’s story of coping with the thought of fighting mental illness alone. It appeared in The NAMI Advocate, Winter 2014, page 25.

“I was diagnosed with schizoaffective disorder in 1999. I was experiencing mood swings, delusions, and hallucinations about evil spirits. I felt like I was very much alone. There are times I still do think I am uniquely singled out to suffer.

But through the help of NAMI and other support groups available to me at my mental health behavior provider, I see clearly that the focus doesn’t have to be on myself anymore. Many people come to the meetings and get to share their difficulties, which are a lot like mine. My meds help me a thousand times over, as well as pastoral care, counseling and case management. When I struggle now with feeling like I am alone, I usually am able to use some of the skills I’ve learned in the support group to realize I am not alone. For example, cognitive behavior therapy (CBT) has rewired my thought processes in a positive way, bringing hope and confidence which bring both balance and happiness to my life.

The fight is real. Those living with mental illness need real intervention-from meds and doctor’s visits to attending NAMI groups and classes to see our own struggles through someone else’s life. Often, counseling should be added to the regiment, because counseling and meds, at least in my experience are the primary means for getting better, being able to copy and to gain confidence over our disorders.

When we think we are alone, we start ‘psyching ourselves out’ and obsessing on top of the original disorder.  Hope diminishes, and despair takes over. Deep depression takes a place in our minds, which adds to the confusion we are already experiencing.

The best places to go from there is some kind of meeting-be it NAMI, support groups offered through your behavioral health office or support telephone lines. I’ve even used the emergency line offered through our behavioral health office just to talk. I think they know me personally.

I always feared as a very young boy that I was going to be affected by a mental illness. I read about it in our old encyclopedias we had at home and the notion just scared me. I grew up and found myself fighting myself all alone, unable to express what was really going through my mind-until the day I got treatment and support. Then I knew I could cope with my disorder.”

Our gratitude goes to this young man who is brave enough to tell his story. It gives us HOPE.

"Just get over" the mental illness?

This story was printed in the NAMI ADVOCATE, Winter 2014, page 23.

For years, I was told by friends and family that I was overly dramatic and overreacting to situations around me. I was told to “just get over it” and “be normal.” For all those years, I tried desperately hard to act like everyone around me. Yet I always realized that they had something that I didn’t have. They were able to process events and not get upset. They weren’t changing from extremely

happy to super sad in a matter of hours. They didn’t think about killing  themselves every moment of the day. They didn’t get relief by cutting up their bodies. Something was different, and I just couldn’t figure it out.

In college, I decided to major in psychology. We learned everything there is to know about the human brain and all of the chemical imbalances that go along with different disorders. My sophomore year, I had my first incidence with suicide. Before I was able to do anything, my friends caught wind of it and called the police. From that day through the next few years, suicide was about the only thing on my mind. The police were called intermittently during these years, but no treatment or counseling was ever sought.  Besides, I had found a different outlet for my pain: cutting and alcoholism.

My drinking quickly evolved into full-blown alcoholism within weeks of taking my first drink. At the time, I knew that alcohol was basically the only thing that was keeping me alive. Then February 15, 2013 happened.

That morning, I went to work chemically altered with a lot of the new anti-anxiety pills that were just prescribed to me. I was going to kill myself that night. I had given away my dog, packed up my house, and got everything all set. Somehow my boss caught wind of it and ended up calling the police. I was sent to a special psychiatric hospital, where I stayed for about a month.

There I was officially diagnosed for the first time in my life with borderline personality disorder and bipolar II disorder. However, I did not want to admit that I had a mental illness. After being told this information, something snapped in my brain and I began getting violent and ended up on four-point restraints.

(After repeated hospitalizations, more restraints, and many more medications, Ashley’s journey took a more positive turn.)

Finally, I was sent to a local hospital with a psychiatric unit after another attempt to kill myself. I was blessed with being assigned an amazing psychiatrist who finally figured out my medication. He took me off the boat load of medications that were basically just sedating me and put me on a mood stabilizer and an antidepressant. Suddenly, life was beginning to feel easier to handle. My moods weren’t swinging from one extreme to another, and I no longer wanted to kill myself every day. He set me up with a community agency that would provide me my medication and therapy on a long term basis. I was able to return to school and pursue psychiatric nursing while obtaining a new job. I was finally beginning to function like those “normal” people that I had admired ever since childhood.

Throughout my journey, I have been hit with many negative views and criticisms about what I was going through. The stigma of having a mental illness began to flood into my life and affect everything. However, thanks to NAMI’S Peer-to-Peer classes, I began to understand that I wasn’t alone in the fight against stigma and that together we can enlighten the world one person at a time.Its danger is not to be underestimated. It is the leading cause of disability in the United States and other developed countries. If left untreated, it can lead to suicide.”

The good news is it is a highly treatable illness.

A closer look at symptoms reveals these characteristics of mood: sad or very irritable; cannot be cheered up; loss of interest in pleasure in daily activities.

Among physical symptoms are insomnia or sleeping too much; change in appetite or a significant unintentional change in weight; being visibly slowed down or agitated; extreme fatigue and lack of energy; decreased sexual drive, catatonia (psychotic stage).

Behavioral symptoms include decreased motivation; decreased task performance; withdrawal and isolation; loss of gratification in effort; lack of attention to hygiene and appearance; no desire to talk, interact, socialize; grossly disorganized (psychotic stage).

Symptoms associated with thinking include accusatory, self blaming thoughts; feelings of worthlessness or excessive guilt; having very low self-esteem; marked indecisiveness or the inability to think, remember, concentrate; recurrent thoughts of death, suicidal thoughts, suicidal plans; delusions (psychotic stage), disorganized, incoherent speech (psychotic stage).

Symptoms involving the senses are hypersensitive to noise, light, stress;

hallucinations (psychotic stage).

Psychosis is a break with reality in which the person sees, hears, or feels things that are not there.  Psychosis can be manifested in bipolar disorder, schizophrenia, as well as depression.

Abraham Lincoln gives a glimpse of the depths of his depression when he said, “I am now the most miserable man living. If what I feel were equally distributed to the whole human family, there would not be one cheerful face on earth. Whether I shall ever be better, I cannot tell. I awfully forbode I shall not. To remain as I am is impossible. I must die or be better, it appears to me.”

Because the physical signs of a major depressive episode can mimic other illnesses of the thyroid and adrenal glands, and illnesses like MS and heart disease are known to cause depression, these physical disorders need to be ruled out. It is absolutely essential for people experiencing depressive symptoms to ask for, and get, a complete physical as part of their diagnostic work-up.

It is important to know there is good treatment for depression. A person should not try to “tough it out.” There is HOPE. Treatment works.

Mental illness and terror

The people who live with schizophrenia and other illnesses with psychosis are our heroes. What they have to deal with is terrifying and beyond imagination.

The following is “David’s Story,” an excerpt from Private Terror/Public Life by James M.  Glass.

It’s like all my cells are exploded over the universe, and I live in each of those millions and millions of nuclei shooting in every direction. In the midst of all this, how could I possibly deal with the concrete, even tie my shoelaces, much less find my shoes?

I convinced myself several things were happening: Unrecognizable voices invaded my ears; transmitters had been planted in the ceiling; everyone on the Hall spoke about me; my behavior was watched and discussed by staff; nursing reports, patients’ journals, were filled with hundreds of pages describing my appearance and movements; spies were sent into the Hall exclusively to keep track of me and to report any suspicious behavior to the hospital administration; therapists ignored their own patients and spent hours in endless discussion, looking at the ramifications of my case; TV cameras, hook into the walls taped my facial expressions; every morning, around 3 a.m., three thousand spotlights aimed directly into my eyes; staff prepared elaborate strategies to humiliate me, to expose me and leave me naked in the front Hall; killers hid behind closed doors and waited until night to sneak into my room; food poisoned my insides and rotted out my intestines. Lying down, my body became so brittle I felt it cracking into a thousand pieces; at night, my roommate fed on my blood. Not exactly sane thoughts. In my frame of mind, if I were to stay alive, I had to be attuned to every movement on the Hall.

I hear this voice sometimes. I call it the “maelstrom of manufactured criticism” because it tears at me, rips my identity into shreds, and slices away at everything I am. The verbal abuse never lets up. It goes on and on for hours. Nothing outside touches me when it’s here: I refuse to talk to anyone; I sit, stare, smoke cigarettes until the voice leaves.

Nothing really stops the madness. I rarely change clothes; hygiene and meals become too much. And I have more important things to do than be bothered with my nutrition or cleanliness. Contact with people seems closed off. I lose interest in what happens on the Hall. I forget what day it is. Something as simple as selecting a shirt paralyzes me. That’s what begins my psychotic episodes, little things, nothing more dramatic than trying to find a shirt. It’s like this huge problem overtakes you: moving towards the closet, opening the door, searching through the rack. Each step of the process is like climbing Mount Everest, so you say to yourself, “Why bother, let it be, stay with the one on your back. Little things are magnified a thousand times, and what happens inside your mind takes on much greater importance than your own hygiene or appearance.”

The NAMI Family-to-Family class teaches the importance of patience and understanding in supporting a family member with this illness. They are taught how the brain works and malfunctions. They come to understand that no one is to blame for this illness or its effects. They are given information about how to work with the psychiatrist and are given hope in light of the new medications that can help their family member maintain their mental equilibrium. THERE IS HOPE.

Violence and mental illness

It is hard to focus on the facts about mental illness and violence when the news is peppered with horror stories making one think that mental illness and violence go hand- in- hand. Nothing is further from the truth. The incidence of violence committed by someone with a mental illness is the same as the incidence of violence committed by the general population: about one percent of the population. In fact, a person with mental illness is more likely to have an act of violence perpetrated on them. Let’s look at some facts as enumerated in the NAMI Family-to-Family Education Program, 2013.

• People with schizophrenia and mania who take medication regularly and who do not abuse alcohol or other drugs are no more violent that the rest of the population. Most people with schizophrenia are customarily withdrawn, frightened and passive.
• Similar to the general population, people with untreated schizophrenia and mania are more liable to commit a violent act if they are on street drugs (crack, meth, cocaine, speed, PCP-even marijuana) or if they are abusing alcohol. The use of street drugs or alcohol increases the likelihood that the untreated individual may act on the violent thoughts and paranoid delusions they are having. The combination of major mental illness and substance abuse is a significant predictor of aggressive behavior.
• The likelihood of violence is greatest among males in their late teens or early 20’s.
• The best prediction of future behavior is past behavior. There is good reason to be wary of an individual who was aggressive before becoming ill, or of individuals who have previously been violent when they were particularly disturbed. If your relative has never been aggressive in a period of psychosis, it is unlikely that s/he will become so.
• Warning signs of imminent physical violence that inpatient staff in psychiatric facilities are taught to look for are as follows: impulsivity, talking more about violent ideas, a sudden change in eye contact (staring or avoiding looking others in the eye), pacing, becoming visible angry, yelling, tremors, a rigid posture, clenching jaws and fists, pulsing arteries in the temples, verbal abuse, profanity, and hyperactivity.
• Besides our concern about aggression, we all deal with our dread that our family members will do something harmful to themselves. Some people, especially those with more insight into the damage caused by their illness, may become depressed after a psychotic or manic episode. Many families struggle through the active phase of schizophrenia or intense mood episodes only to be stunned by a family member’s suicide attempt when they felt that things were getting better. Even if these critical events don’t happen in our experience, it is important to know about them. If you have an opportunity to spread the truth about violence and mental illness, you can reduce stigma.