A Beautiful Mind – a review for healthcare staff

(See also what the International Movie Database says about A Beautiful Mind)

Please note: This article may spoil your spontaneous enjoyment of the film. A number of significant events are revealed, so if you want to watch the film without preconceptions, we advise you to read the article after watching the film.

THEME: Schizophrenia

Balancing on a precipice

A story of a person gifted with genius and afflicted with schizophrenia

A BEAUTIFUL MIND based on the true story of John Nash, Nobel Prize Winner in Economics

A Beautiful Mind
– a difficult balancing act

By Göran Nordström, Senior Consultant at the Rehabilitation Centre in Malmö

"A Beautiful Mind", directed by Ron Howard, was met with critical acclaim when it premiered in December 2001. Its success continued, winning four Oscars and many other prizes; and it is easy to see why. "A Beautiful Mind" is told in an effective way, has an interesting theme and is based on a true story.
However, the story itself is not what is responsible for the many surprises and exciting moments the film has to offer. In this case, it is an advantage to know that the mathematician John Nash, who the main character in the film is based on, was actually awarded the Nobel Prize even though he suffered from schizophrenia. The denouement would otherwise seem unbelievable.
The surprises also come from how the story is told. First watch the film, and then read this article.

Hat

After suffering from schizophrenia for many years, John Nash is given the opportunity to go back to do some teaching at the university. He behaves in a strange way, writing down formulae and mathematical conclusions on window panes.
He goes around wearing an old knitted hat, both indoors and outdoors. He is an unusual man, clearly affected by the disease.
However, there are times when he is able to conduct a line of reasoning with students – at least with those who are not put off by his strange behaviour.

Biopic – portrayal of schizophrenia – Hollywood drama

"A Beautiful Mind" is easy to watch. However, it is more difficult to fully understand afterwards what you have just seen. The film is about a psychotically ill mathematician and the difficult life he led up until the time he was awarded the Nobel Prize. It is also about how love can conquer delusions; about how genius and schizophrenia can both exist in the same person.

A true story gives special emotional power to a film as it is not just another fictional story. The team behind "A Beautiful Mind" also had a mission: to show schizophrenia in a different light; where it is linked to success, performance and recognition; with a person displaying normal human emotions in the midst of a psychotic existence. They wanted to portray a person with schizophrenia as more than just the sum of his symptoms. This is, of course, admirable.

Comorbidity, exclusion, worsening health and mortality; this is what life is really like for many people who suffer from schizophrenia. For a film to engage a viewer, it must have a main character that the viewer can identify with. The Nobel Prize is at completely the other end of the spectrum for people with schizophrenia, but it is more acceptable than misery to the viewing public.

"A Beautiful Mind" is a biopic, a portrayal of schizophrenia, and a Hollywood drama with a message, all at the same time. However, having all these elements together creates problems. The film is so full of goodwill that it is bursting at the seams. The devices used to create dramatic excitement negatively affect the credibility of how schizophrenia is portrayed.

The dramaturgy is classic and predictable, using a strong opening, the presentation, a turning point and a climax – but real life is not like this. Love conquers all – maybe in films, yes. But was his real life like this? Does it say anything about schizophrenia? Incredible intellectual achievement despite almost inhuman obstacles – the Hollywood version has characteristic traits that we are all familiar with, but often it does not mirror reality.

Compromises

If you want to produce a traditional and effective dramatic portrayal of a person's life in a film, you have to distort the truth. The true story must be adapted to the logic of a specific narrative form. In this instance, you also have to take into consideration the fact that the film is about a named person who is still alive. All of this sets the framework for how you can maximise the drama and portray the symptoms of the disease.

The requirements of dramaturgy and personal consideration allow you to embellish the story. It must be interesting, but not too challenging. The message must be powerful – and can therefore not be clouded with too many complications. If you want to have a respectful portrayal of a schizophrenic in a feature film, you have to be prepared to compromise with the truth. But how can you respectfully portray a mentally ill man, if you are taking sections of his life away and making additions just to improve the story?

Comorbidity, exclusion, worsening health and mortality.

This is what life is really like for many people who suffer from schizophrenia.

Turning point – "She never gets old!"

In the film's turning point, Alicia, John Nash's wife, appeals to her husband. She wants him to distance himself from his hallucinatory world and live in the real world with her and their child. She appeals not to his brilliant intellect, but to his heart.

Before this conversation, John Nash suffered a relapse as he has not been taking his medication. In the midst of a chaotic episode, he tries to work out which people – both hallucinatory and real – exist in which "interactive fields". His hallucinatory employer also threatens to kill Alicia. When John Nash goes to protect her, he ends up hitting her. Alicia becomes afraid, takes their son and runs out of the house. Just as she is about to drive away, John Nash rushes forwards and places himself in front of the car. It is a powerfully dramatic scene. Has he completely lost touch with reality? Is he going to turn to violence?

He then utters the words, "She never gets old". John Nash is talking about Marcee, the niece of Charles who had been his friend at university. He has met Marcee over the years in different situations and she is always 8 years old. He realises that she cannot be real. Both Charles and Marcee are hallucinations.

It is only some way into the film that the viewer knows for certain which of Nash's friends and work colleagues are real and which are hallucinatory. The filmmakers chose to do this to give people an idea of the difficulties that a psychotic person has in distinguishing reality and psychotic experiences.

They keep the viewer unaware for a long time of where the boundary lies, allowing the hallucinatory characters to be drawn into the plot; possibly in a similar way to how people who are having a psychotic experience feel. This creates an exciting course of events based around the 1950s cold war. It is a narrative device that is not as well executed throughout, but it does give dynamism to the narrative.

Let us return to the turning point in the film. It is difficult to believe that an extremely gifted individual like John Nash had never previously thought about why some his friends never aged. However, this sudden realisation is unavoidable in the film. It is necessary for the kind of story that builds on contrasts, contradictions, and situations where everything is taken to the extreme. In Hollywood terms: John Nash chooses life, not the disease. And it is not psychiatric treatment that helps him to make the choice; it is Alicia's love.

Is this what happened in reality? This would have been incredibly exciting if this were true. However, if it is an invention produced by Hollywood logic, then it is a deceit: ideology instead of life. No-one doubts that love is important for the quality of a person's life, and undoubtedly affects the progression of schizophrenia in different ways for many people.

However, if the film's central message is that love is the cure, then it brings into question whether it really is a serious portrayal of schizophrenia. Love is, of course, important, however trite this may sound. However, the flip-side to the message that love is paramount, is that a person with schizophrenia who does not "come out" of their psychosis in any way did not receive enough love or did not receive the right kind of love. This echoes Frieda Fromm-Reichmann's "schizophrogenic mother" with the implicit laying of blame that comes with it.

It is possible that those involved experience something similar to what is portrayed in the film. However, it is more likely to be a portrayal based on the techniques of standard (American) storytelling, used to solve the problems of the main characters. It becomes misrepresentative, dishonest, yet enticing. As viewers, we run the risk of sitting there and being gripped. We should feel ashamed if we do not feel like this while watching what is being played out in front of our eyes.

A truthful portrayal would have been more complicated, less dramatic.

In reality, we know that Alicia filed for divorce in 1962 after only a short marriage and they got back in contact with each other around the time of the Nobel Prize in 1994. In the film John Nash says that he is taking newer kinds of medicine (he suffered from unpleasant side effects from the original medication he had been prescribed). In reality he did not take any medication after 1970.

There are other deviations from what actually took place. (For example, the real John Nash only suffered from auditory hallucinations. However, visual ones are undeniably more cinematic.) These two deviations are the most significant for how the film's message has been formulated. A truthful portrayal would have been more complicated and less dramatic. However, the power behind a film based on real life is lost through misrepresentations.

The only thing that remains unharmed is Hollywood dramaturgy.

However, it does BECOME a good story if you accept conventional dramaturgy. A more truthful portrayal would not have had such dramatic impact, but would have moved us in a way that "A Beautiful Mind" cannot, specifically because it has been idealised.

Family and schizophrenia

Frieda Fromm-Reichmann was a psychoanalyst of German descent, who was forced into exile by Nazism and worked in the USA from 1935. At the end of the 1940s she presented a theory that schizophrenia was the result of growing up with a cold and distant mother. Her theory was never proved through empirical studies, which would not have been easy to do.

Later on this theory was criticised from different perspectives. People said that there could be a number of reasons for an unsuccessful interaction between a mother and her mentally ill child. In addition, by portraying a parent as the reason for their child's schizophrenia is a way of attributing blame and can prevent a parent from giving the help and support that is required.

The view of schizophrenia as a result of unsuccessful family relationships had many advocates particularly in the USA in the 1940s and 1950s. However, this theory was later abandoned, partly because of subsequent empirical research.

When neuroleptics started to be administered in depot form, it was discovered that treatment could prevent relapses. In the 1970s a group of British researchers showed that the risk of relapse was also affected by the emotional climate in the home environment. A high level of expressed emotions (EE) could increase the risk of relapse, particularly if they were negative, critical expressions of emotions or excessive devotion.

As a result of these studies, a new kind of family therapy was developed that focussed on helping relatives find a supportive way of communicating. This kind of family work has shown to produce good results, unlike family therapy that focuses on conflict.

Genius and madness

You will often hear people saying that genius is related to madness, but there is no evidence to suggest a link between a high level of ability and schizophrenia; rather the opposite. However, it is possible to trace similarities between creative thinking and the thinking of people who exhibit schizotypal tendencies, particularly those suffering from bipolar disorder. It is possible that both artistic and scientific creativity are overrepresented among people with bipolar disorder.

There are not many famous people who have been diagnosed with schizophrenia. One of the most well-known is the founder of Pink Floyd, Syd Barrett. Jack Kerouac was also said to have been diagnosed with schizophrenia, but it is debatable whether this was the correct diagnosis.

By Göran Nordström, Senior Consultant at the Rehabilitation Centre in Malmö (Beroendecentrum Malmö), University Hospital MAS

"It has definitely not always been "correct" to express a positive view of biological psychiatric treatment.

In recent years there has been a lot of interest and speculation caused by the discovery of a protein molecule, DARPP-3 2. This molecule has been linked to different transmitter substances, including dopamine.

A link has been shown between the DARPP-3 2 gene and improved cognitive ability. However, they have also found that there may be a link to increased schizophrenia, possibly in combination with other genetic or environmental factors.

Psychiatry in the film world

Psychiatry in films is either idealised or demonised. When psychiatrists are the liberator, they are often depicted as Freudian analysts. The classic example is Ingrid Bergman as Dr Constance Petersen in Hitchcock's "Spellbound".

The strong, but anti-psychiatric film "Family Life" by Ken Loach has a young Laing-inspired psychiatrist who could have been a hero. However, he is driven away because of his radical treatment methods, leaving the door open for a traditional biological psychiatrist to finally crush the young female patient.

The normal variant is the psychiatrist as the willing helper in an oppressive regime. The psychiatrist is not given many minutes in "A Beautiful Mind", but Christopher Plummer's advocate of insulin coma, with his Mephistophelian smile, does not provoke any empathy. The positive effects of neuroleptics are described as are the side effects.

The film gives more recent anti-psychotic drugs some merit for helping John Nash to manage his psychotic symptoms, a concession to political correctness rather than the truth. However, it has definitely not always been correct to express a positive view of biological psychiatric treatment. The portrayal of ECT in the Swedish film "Gökboet" is a striking example of this.

One section of the film that is not as successful is when psychiatry enters Nash's life. Nash is giving a guest lecture, and suddenly psychiatric staff members creep up on him from different directions. He leaves the rostrum in a panic and runs away, believing that Russian agents are following him.

By this point in the film, the viewer starts to realise that some of the people they thought were real are actually hallucinations. However, the film then makes us believe the opposite. It portrays "actual events" in a way that makes us as a viewer believe that Dr Rosen (Plummer) and his helpers who are following Nash are hallucinatory Russians. The price of this special effect is that the psychiatrist is portrayed as being more absurd, incompetent and inconsiderate than was actually the case in 1950s America.

Choice of actor

The choice of such a major star as Russell Crowe to play John Nash means two things: idealisation and audience.

Russell Crowe gives an excellent performance. He conveys the difficulties of human contact, the joy of finding algorithms for complex phenomena, the vulnerability and the febrile intensity of a psychotic world. However, Russell Crowe also brings with him the sulky policeman from "L.A. Confidential", the reluctant whistle-blower from "The Insider", and Maximus from "Gladiator".

Russell Crowe is not the obvious choice when searching for psychological credibility in this kind of role. When Catherine Deneuve played the lead role in "Repulsion", Polanski's portrayal of psychosis in 1965, it is true that she was not unknown ("The Umbrellas of Cherbourg" had been released in the previous year), but she was not an established star. It is possible that this helped her to convey vulnerability and helplessness.

The moment

"A Beautiful Mind" walks a difficult balancing act between being honest to a complex reality and giving in to the simplification needed to convey the message. The elements that I take most from the film are some simple scenes; moments that accurately portray what I see in people who suffer from schizophrenia. Scenes that are more phenomenologically believable than those that simply convey the plot:

-John Nash with his crying son in his arms, unable to meet his son's needs. Emotionally blunted – from a psychotic experience or from overmedication?

-Some scenes when Alicia (Jennifer Connelly), in a restrained performance, portrays all the confusion, powerless rage, tenderness and resignation that life with a severely psychotically ill person can lead to.

-And the wonderful scene where Alicia believes that John is becoming psychotic again. She hears him speaking outside the house and is convinced that he is hallucinating. John says that he was speaking to the garbage man. He does not come at night, says Alicia. However, tonight he did. Alicia is surprised – and Russell Crowe's John Nash smiles a smile that is so rare and so full of understated triumph that this in itself is worth the ticket price.

-John Nash on his way from campus, puffing away on a cigarette as he always does; scruffy clothes, clumsy movements. And then a student runs behind him, imitating him in a ridiculous way, much to the delight of his friends.

These scenes are perfect – concentrated, unsentimental, without any dramatic excess. For me, the major qualities of "A Beautiful Mind" lie mostly in these pure, clear, gripping moments.

FACTS

INSULIN COMA might appear strange as a kind of therapy, but its background lies in clinical experience. In the 1920s the Austrian psychiatrist Manfred Sakel worked at a private clinic in Berlin. His work included treating people from the artistic world and people from hospitals who had become addicted to morphine.

The hormone insulin had been discovered in 1922. Sakel noticed that some morphine abstinence could be relieved with limited doses of insulin. Some patients went into an insulin coma – this happened by chance and was not the intended therapeutic effect. However, Sakel did note that some of his patients who did go into a coma reported that their longing for morphine had disappeared or that previous nervous problems had considerably improved. When the Nazis took power in Germany, Sakel returned to Vienna, where he started experimenting with insulin coma therapy for schizophrenia.

There was of course a risk with this therapy with over 1% of patients dying. However, this "insulin shock" therapy spread throughout the world and was part of the treatment of schizophrenia for ten years. This was because of the clear improvements that people noticed in patients, even though most were shown to be only temporary.

Another kind of "shock therapy" was introduced in 1934 by a Hungarian psychiatrist, Ladislas von Meduna. The background to this therapy is also remarkable. Meduna noted that people with epilepsy who developed schizophrenia improved as a result of their epilepsy. He thought that an antagonistic relationship could exist between the two diseases.

If this were the case, then people could perhaps treat schizophrenia by inducing convulsions. Meduna's convulsive therapy was developed at the end of the 1930s by the Italians Bini and Cerletti. They moved from chemically to electrically induced convulsions, which were shown to be safer.

Although ECT THERAPY, like insulin coma therapy, showed that it could give temporary positive effects for people with schizophrenia, it soon became clear that patients with affective diseases were the ones that responded best to ECT. There were no effective biological treatment methods when ECT started to spread during the 1940s. Even after the introduction of anti-depressants during the 1950s, ECT therapy maintained its position as the most effective treatment for extremely depressive states, despite its controversy.

The discovery of the antipsychotic effect of chlorpomazine (Hibernal) was also a result of anything but targeted systematic research. Henri Laborit was a French naval surgeon, who worked at the end of the 1940s at a hospital in Tunisia with different anti-histamines to intensify anaesthetics.

When he moved to a military hospital in Paris in 1951, he continued working with a new substance (chlorpromazine) which had already been seen to have an effect on mental functions. After testing the toxicity of chlorpromazine by giving it to a female colleague (she fainted), Laborit discovered that final testing was being carried out on this drug at the hospital where this female colleague was working. Laborit went back to the military hospital and managed to convince some mildly enthusiastic psychiatrists to allow a patient to try the substance.

In January 1952 chlorpromazine was tested on a 24-year-old man with acute mania. After less than three weeks, the patient had shown a clear improvement. It did not take long before news spread throughout Paris of a potentially interesting drug that had an effect on psychiatric symptoms. Two of the most prominent psychiatrists in Paris, Delay and Deniker, started to give it to their patients as early as March 1952.

In June 1952 they were able to report a remarkable effect on psychotic symptoms. By May 1953 chlorpromazine was used at psychiatric hospitals around Paris. In the autumn of 1953 the effects of chlorpromazine were reported in the New England Journal of Medicine. It took only a year before Hibernal was introduced around the world as a treatment for psychotic states.

Over the period of a few years, discoveries came thick and fast: anti-depressants, lithium, benzodiazepines. At the beginning of the 1960s people thought that it was only a matter of time before a tailored pharmacological treatment could be offered for mentally ill people. Although this has not been the case, neuroleptics still remain a cornerstone in the treatment of schizophrenia.

Neurocognitive disturbances in schizophrenia

By Eva Lindström, Senior Consultant, UM AS, Malmö

Our high cognitive ability is what distinguishes human beings from other primates. Human activities, such as planning for the future, learning a large amount of complex information and leading a socially active life are all examples of high cognitive performance. If we lose some of these cognitive functions, other human activities will be disrupted.

Cognition can be described as the ability to learn things, understand things and recognise the world around us. Objects around us have to be recognised, identified, stored in our memory bank and then accessed at a later stage. Other important aspects of cognition include problem-solving, planning and understanding complex verbal information.

Cognitive symptoms and deficits have been regarded as the cardinal symptoms of schizophrenia since the syndrome was described by Kraepelin and Bleuler. Kraepelin showed that individuals with schizophrenia could have functional impairments, when it came to attention, motivation and problem-solving. Bleuler thought that deficits in cognitive ability were central to the clinical picture of the disease and could give rise to the splitting and disruption of a person's identity.

Knowledge of cognitive symptoms and deficits has been mainly acquired from the results of neuropsychological tests. The results from neuropsychological tests can be affected by many different factors: other symptoms associated with schizophrenia (hallucination and delusions); treatment with antipsychotic drugs, the patient's motivation when being tested; and more general intellectual deficits as a result of schooling or social deprivation. However, studies have shown that the test results in many cases are relatively unaffected by the factors listed above.

How common are cognitive disturbances in schizophrenia? In a study from 1997, 70 percent of a group of patients who were neuropsychologically examined were shown to have cognitive symptoms. Only 30 percent were judged to be neuropsychologically healthy. Current research has shown that individuals with schizophrenia show generalised cognitive deficits, which means that they perform at a lower level than healthy control subjects in a number of cognitive tests.

The most common cognitive symptoms for schizophrenia are attention deficit, memory deficit and deficits in problem-solving.

Cognitive symptoms and deficits have been regarded as the cardinal symptoms for schizophrenia

When the film's main character starts at university, he displays deficits primarily in social cognition, in addition to his visual hallucinations. Despite his ability to solve and construct complex mathematical formulae, he is relatively unaware of signals between other humans. He finds it difficult to understand and interpret both jokes and bodily signals from his classmates.

He even finds it difficult to understand how other people feel to be given a "truth" when it is not expressed in a delicate manner. He is watching a girl who asks him straight out to buy her a drink. Instead of beating around the bush, he gets straight to the point. Instead of getting the date he wants, he gets a slap in the face.

Before the people around John become aware that he is ill, he displays clear deficits in his cognitive abilities. John Nash finds it increasingly difficult to solve complex problems. He spends his working hours covering the walls of his office with newspaper cuttings. Part of John's psychotic existence is that he has to look through the press to find any hidden messages that could reveal the location of Soviet bombs.

Although John Nash displays an extraordinary ability to see patterns in almost impossibly complex information, the method of papering his walls with newspaper cuttings is a poor way of achieving his task; even though it is hallucinatory. It is not clear whether he still has the ability to solve mathematical problems.

Following his stay in hospital and his treatment, it is clear that his problem-solving ability has been affected

Following his stay in hospital and his treatment, it is clear that his problem-solving ability has been affected. When a friend and former colleague comes to visit him, Nash tells him that he spends some of his days trying to construct a mathematical formula. When the friend asks to see his work, John Nash shows him a notebook which the viewer can see only contains scrawl.

Nash does not function optimally at home either. His wife does the majority of things around the house: she looks after their child, prepares food and does the washing-up and cleaning. She is clearly surprised when she asks him to take out the garbage bag and he does this. She had definitely not expected him to be able to solve this problem without specific and direct instructions; e.g. he opens the cupboard door, removes the garbage bag, ties it up, etc.

At the end of the film Nash comes back cognitively, slowly, but surely. However, he does not regain the same cognitive level that he had when everyone around him realised that he had fallen ill. He starts to go to the library to read, most probably to remind him of the basic mathematical facts that he has forgotten during his disease. He then goes to maths classes that are probably at a much lower level than the ones he had actually taught. With a great deal of effort, he starts to teach again. However, he does not solve or construct any new revolutionary formulae.

To summarise, the film's main actor provides an excellent interpretation of how schizophrenia can impair cognitive performance and the kind of fight that is required to recover from it. And that unfortunately people often do not return to the same level of functioning they were at before the illness.

COMMENTS

By Eva Lindström, Senior Consultant, Forensic Psychiatric Clinic, UMAS, Malmö

Schizophrenia and the treatment of schizophrenia – some historic landmarks

EMIL KRAEPELIN is a prominent figure in the history of schizophrenia. He was born in 1856, trained as a doctor and started to become interested in the psychological aspects of mental illness at the end of the 1870s. The main focus of German psychiatry of that time was neuroanatomical, which Kraepelin thought had come to a dead end, based on the level of knowledge at that time.

In the middle of the 1880s, Kraepelin started to work as a clinical psychiatrist to help provide for his family. He became a Professor of Psychiatry in Dorpat (now known as Tartu) and then Heidelberg. As a clinician, Kraepelin was interested in the course of the disease of his patients. What would happen to his patients in the long term, given that there was so little active treatment he could offer?

Instead of sending articles to scientific journals, Kraepelin published his reflections and conclusions in his book on psychiatry. This was first published towards the end of the 1880s. In its sixth edition in 1899 Kraepelin came to the final version of his classification of mental diseases.

The aspect that provoked the greatest amount of interest in the psychiatric world was his division of psychotic diseases into two distinct groups. One group included psychoses with affective traits, which Kraepelin called manic-depressive psychoses, while the other covered psychoses without significant affective traits.

However, his dividing line between the two groups of psychoses was not primarily the symptoms, but the actual course of the disease. Manic depressive psychoses had a circular progression with a tendency for spontaneous remission. The second group showed no signs of spontaneous remission, but a gradual deterioration instead. (It should be pointed out that 25% of Kraepelin's dementia praecox patients showed signs of improvement in the long-term). This is why Kraepelin proposed a term for this group that had already been used in the papers on mental diseases from other researchers: dementia praecox.

Kraepelin's report on the clinical picture of dementia praecox is similar to the key features included in our current concept of schizophrenia. As early as the beginning of the 20th century, there were suggestions on how to modify Kraepelin’s terminology. The patients did not suffer from dementia in the true meaning of the word, and the disease did not always come about early (praecox) in life.

In 1908 Eugen Bleuler, Professor of Psychiatry in Zürich, proposed the term schizophrenia. This term has lasted since then, despite the fact that "split mind" (which is the meaning of this word) is not the best description of the central features of schizophrenia. In 1911, Bleuler published a famous monograph called "Dementia Praecox oder die Gruppe der Schizophrenien".

In this he developed a description of the symptoms and proposed four kinds of symptoms that are central to the disease:

• associative disorders (thought disruptions)
• affective disorders (emotional blunting, inadequate emotions)
• autism (self-absorption, loss of contact with reality) and
• ambivalence (co-existence of opposing attitudes and feelings)

Bleuler saw delusions and hallucinations as secondary phenomena, not as core symptoms. Bleuler also highlighted the fact that the course of the disease did not always have to be negative. He was extremely interested in psychology (including psychoanalysis) and proposed that there could also be psychological reasons for schizophrenia.

Bleuler's name is still linked to a model for sub-grouping schizophrenia. He believed that it was not one single disease but a group of syndromes. One of the subgroups was characterised by patients whose symptoms had not fully developed but were latent (latent schizophrenia). In many respects, Bleuler's description of symptoms and subgroups dominated western psychiatry far into modern times.

At the beginning of the 20th century, the treatment of psychotic conditions was limited to sedative drugs: morphine, sodium bromide, and eventually barbiturates. One exception was Wagner von Jauregg's discovery of a treatment by inducing a fever (for example using malaria) for paralysie générale (neurosyphilis), a discovery which gave him the Nobel Prize in 1927.

The stigma of schizophrenia and tablets in the desk drawer

By Cecilia Brain, Senior Consultant, Research and Development Centre for Schizophrenia,
Göteborg

Suffering from schizophrenia at a young age can be traumatic, full of crises and extremely difficult to accept. Life itself – a young budding adult life that is only just blooming – is often surrounded by many disappointments and tumultuous situations: the strait-jacket of happiness itself; shattered dreams, disrupted studies, broken hearts and often painful psychotic symptoms that are ever present.

For patients, suffering from schizophrenia, is a balancing act between a true existence in the present, and the stray flights from delusions inflicted by the mind and thoughts filled with paranoid tormentors.It is a  fight to be in charge of their own feelings, opinions and intellect, soiled with periods when they wander into a psychotic imaginary world – at times alluringly comfortable while at other times suffocating in their frightening powerlessness. Many patients are living for many years like John Nash in the film "A Beautiful Mind" with undiagnosed schizophrenia and gradually become paralysed by the whims of their delusions.

Dealing with schizophrenia, its changing symptomatology and its accompanying effects, is a burden of unimaginable weight for those afflicted with it and the people around them. Watching someone you know gradually breaking down, both cognitively and in their personal care and personality is like an unhappy story that has an uncertain end. Life has to be restarted using the replay button. You have to lift your head high in the backwater of a thousand shattered dreams.

Evidence-based psychiatry

Modern psychiatry should be able to give a lot of comfort and help: provided that the message hits the mark; that there is enough involvement and that we use medication that has been sufficiently proven to be effective.

The team work involved in the Case Management method is one example of a cost-neutral, evidence-based form of healthcare that has shown good results for a patient's quality of life; providing a feeling of empowerment and shared decision-making. The Case Manager works like a spider in the web of point-of-care services and in contact with the doctor and care associates, providing the security that is often lacking in the chaotic world of a person with schizophrenia.

Patients also have access to even better anti-psychotic drugs that they can take in the lowest effective dose, while receiving psychological and psychosocial treatment, as well as social support and care, in accordance with the directives of the Swedish National Board of Health and Welfare (2003).

These are simple clear cornerstones in the guidelines of the Swedish National Board of Health and Welfare, but for schizophrenia care they can at times seem like unfathomably deep ravines to overcome to reach the patient and those close to them with the necessary help.

What prevents success in the treatment of psychoses?

Why are psychiatrists often fumbling around in the dark when there is so much collective knowledge about diseases of the brain? Why all this suffering?

Finding the right medicine – Alliance and adherence

What comes across with perfect clarity in the film "A Beautiful Mind" is that many jigsaw pieces have to come together in the right place to be able to provide the right help at the right time when a person becomes psychotically ill. One of the major challenges in the care of psychoses is to establish a worthy alliance, despite the patient's cognitive difficulties, lack of awareness of their disease and an unwillingness to take prescribed medication.

An alliance that lasts over time – maybe a lifetime – often starts in the worst possible way, with a person being taken into compulsory institutional care, accompanied by a police escort. The need for involvement is indispensable as is incredible perseverance in the patient work. And despite all this, John Nash still hides his tablets in his desk drawer.

Discrimination can be expressed as rage, threats, the withholding of care or other actions.

Studies have shown that non-adherence to prescribed drug therapy is the single largest reason for patients relapsing into periods of psychosis. Within an 18-month period of starting treatment, as many as 75% of patients will stop taking anti-psychotic drugs. Recurrent psychotic episodes then in turn lead to greater disintegration in cognitive functions and, in the long term, reduced global functioning.

These are cold scientific facts. However, where are the sadness and fear in the tear-filled eyes of John's wife, Alicia Nash, in these figures? Where is the power she exhibits as she tries to approach her husband despite the fact that he has become more a relic of his former intellectual and sexual self? The film emphasizes in no uncertain terms the importance of including those close to the sufferer in the treatment, and of providing them with the knowledge and accessibility to show them ways out, to give them strength to remain and to dare to try to continue to love and hope.

STIGMA OF MENTAL ILLNESS

Stereotypes and discrimination

All of the difficulties mentioned above derail all good intentions to provide good and effective care. However, the most taboo area has not yet been mentioned: the shame, blame and stigma of mental illness. Some particularly important reasons why patients do not adhere to psychopharmacologic drug treatment are the prejudices, attitudes and stigma that are linked to mental illness and its treatment.

In society there are common judgments that are shared within social and cultural groups which form the basis for how these groups jointly perceive different phenomena. These are normally called stereotypes. For example, the view that people have of mentally ill people is that they are dangerous, incompetent, lazy and spineless. People belonging to this social group may be aware of the prevailing stereotypes without adopting this behaviour themselves.

If an individual believes these stereotypes to be correct and this leads to a judgement being formed, then these, often negative, stereotypes are called prejudices. These are often linked to negative emotional reactions. A prejudice that leads to an action, i.e. an expression of behaviour, is called discrimination.

Discrimination can be expressed as rage, threats, the withholding of care or other actions. Other common forms of discrimination include the unwillingness of someone to employ or rent out a house to a person who is mentally ill.

The concepts described above (stereotypes, prejudice and discrimination) are features of both public stigmatisation and self-stigmatisation. With self-stigma, the mentally ill person often develops low self-esteem and a strongly reduced belief in their own ability to cope with different tasks, such as their daily care, professional life and starting a family. This often results in a lower quality of life.

Image of psychiatry in the media

The image of mentally ill people that is generally portrayed in film and the media reinforces three common misconceptions of mental illness. These are the beliefs that people who are mentally ill are murderous madmen who should be feared; that they have a childish or different perception of the world; that they are idealised as something admirable (misunderstood shamans, divine contact, clairvoyants) and that people with a mental illness are rebellious, free souls.

The most exceptional feature of "A Beautiful Mind" is the fact that the real John Nash actually did receive the Nobel Prize, and was essentially extremely gifted and intellectually intact early on in his disease. This is certainly very rare indeed, but does form the basis for creating a successful Hollywood production and for portraying a real life story.

However, the screen version of his life shows that later on he was unable to live up to his originally high level of scientific excellence, creativity or problem-solving ability because of the cognitive difficulties and the constant productive or "positive" psychotic symptoms that he probably suffered.

Mental illness is often linked to drug-dependency, prostitution and criminality and this image is often reinforced by the media. Studies have shown that mentally ill people are seen as being responsible for their disease and have themselves to blame to a much greater extent than people with physical diseases.

In a research project, the people interviewed were more likely to react with anger to mentally ill people; they did not believe that mentally ill people deserved as much help, support or attention as physically ill people. Some of the arguments that are given to qualify these attitudes include the view that mentally ill people are lazy, less gifted and lack morals.

Early intervention for better prognosis

Stigma could also have a role to play in the delay before a person with schizophrenia or their relatives try to find help for the symptoms. For psychoses, the time between the initial symptoms, such as delusions or hallucinations, and the patient asking for help is on average 1-3 years. (DUP: duration of untreated psychosis).

Before this, the patient often suffers from non-specific prodromal symptoms such as listlessness and social avoidance for an average of 2-5 years. (DUI: duration of untreated illness). Early intervention, which is generally recommended on the basis of sound evidence, is therefore made more difficult when a psychosis starts.

“Infectiousness” of stigmatisation

Stigma has been described in many different ways in literature and many studies have been conducted among relatives of mentally ill people and different professional and other groups. Relatives state that stigma often leads the patient to suffer from low self-esteem; they find it difficult to make and keep friendships; they have problems finding work on the open labour market and they are hesitant and unwilling to admit that they suffer from a mental illness.

Relatives of mentally ill people often experience similar negative consequences to those described above. This is known as associative stigma. The prevalence of this phenomenon reinforces the need to look further into the issue of stigma to include groups outside the actual patient populations themselves.

There have not been as many studies into stigmatisation among the patients themselves. For them, stigma makes them feel singled out as being less reliable and often removes their autonomous influence over their personal circumstances. They are often victims of stereotypical verbal attacks and incidents that make them feel socially isolated.

They are often subjected to emotional reactions from those around then, including fear. They also experience loss of status, position and authority, feel discriminated against and often avoid their surroundings. It is well know that health professionals working in psychiatry feel stigmatised by colleagues from other specialities and the press.

Victims of stereotypical verbal attacks and incidents that make them feel cut off from the rest of society and socially distanced.

In "A Beautiful Mind" Alicia and John Nash move from a life with a relatively secure financial base, a comfortable home and a respected position in an academic community to being out in the cold and facing the biting wind of exclusion as John becomes increasingly ill.

Alicia, the wife and the mother of a small child, now has to provide for her family in a society where this was not the norm. John's natural place and status are pulled away from under him, and he is made fun of when he tries to get back to being involved in life on the university campus. He is even more of an outsider than before; an even bigger victim of stigmatisation and exclusion now that he has lost his university job and his respected position.

Looking ahead

A lot has changed within healthcare since John Nash fell ill, particularly in the field of psychiatry. The 21st century has heralded considerable advances in schizophrenia research. Professor Arvid Carlsson was awarded the Nobel Prize for his discoveries in the area of Dopamine and these discoveries have contributed to even more refinement in modern anti-psychotic drugs.

We now know much more about how important medicine is to avoid multiple psychotic relapses in the long term and there is a lot more research to support this. There is now greater awareness of the consequences of cognitive difficulties in schizophrenia, which has led to the development of good validated cognitive testing methods and practical clinical aids for this mental disability. By acknowledging the disability and the need for help, different specialities can join forces to help the patient, which is the aim of Case Management.

The insulin comas shown in the film, the electric shock therapy and the formalities of the past also seem far away. Much closer is the assurance that there is a bright future even within schizophrenia.