Medical Panel

"Systems which create the self are just as capable of being disabled as the systems that permit us to walk or to talk." Dr. Peter Whybrow, M.D., explained in introducing the Mental Health & Public Policy Symposium presented concurrently at UC Berkeley's Wheeler Hall and UCLA's Health Sciences Center Jan. 12. The two sites were linked through UC's video teleconferencing system.

Dr. Whybrow, one of the world's foremost authorities on neuropsychiatric research, Chairs the Department of Psychiatry at UCLA and is Director of the Neuropsychiatric Institute, a center of cutting edge research on neuropsychiatric disorders. "The brain works not as a single organ," Dr. Whybrow explained, "but as a series of places in which functions are located and they cooperate for...comprehensive behavior.

"When illness invades the brain it invades the person and the person loses the social ability to do the things that make that individual a person. That creates the disabilities of the self that keeps people on edge."

Dr. Whybrow said that "the really important parts of the brain - the parts that make us a person" are the systems that become disabled in what we call psychiatric disorders. He said these illnesses are not static, but continuous, ongoing elements of ourselves.

Persons who suffered these disabling illnesses - unlike persons who were physically disabled - were incarcerated because of their illness, Dr. Whybrow said, adding:

"After World War II, science began to stumble into interesting things about the chemistry of the brain and neuroscience began to take off with new devices that allowed us to see how the brain works.

"This led to the deinstitutionalization of the mentally ill but funding for treatment and care in the community was inadequate. Nevertheless, scientific progress has been made on many fronts, particularly during the 1990s, the Decade of the Brain."

Dr. Whybrow presided over a panel that included a noted molecular biologist, a neuroimaging researcher and a specialist in biobehavioral treatment and psychiatric rehabilitation, each working in areas that have thrived in the past decade.

The molecular biologist, Samuel Barondes, M.D., Jeanne and Sanford Robertson Professor of Psychiatry and Director of the Center for Neurobiology and Psychiatry at UCSF, noted that until 1950 the only treatments available for psychiatric conditions were hospitalization or psychotherapy. Since then, he said, enormous growth in our understanding of medication treatments has come about.

Dr. Barondes explained that most of the early medications were discovered by accident, adding that these serendipitous discoveries changed how psychiatry was practiced.

For example, he said, in the early 1950s an antihistamine called chlorpromazine was found to have antipsychotic properties and went on to revolutionize the care of schizophrenia. Treatment with chlorpromazine was considered miraculous, he said, because some who had suffered through years of hallucinations and other psychotic symptoms, were suddenly free to enjoy life symptom-free.

He said chlorpromazine and its descendants had many disabling side effects, including abnormal muscle movements similar to those experienced by people with Parkinson's Disease (also known as parkinsonian symptoms). Since then, he said, the challenge facing neuropharmacologists is to develop new and improved medications with less debilitating and more tolerable side effects than the earlier drugs.

One way to foster this area of research is by studying the genetics of psychiatric disorders, Dr. Barondes said, noting: "Gene study could provide enormous advances in our understanding of these illnesses because once the genes linked to mental illness are identified, scientists can implant them in animals and study the way abnormalities unfold. These patterns can lead to new ideas about the pathology of illnesses, and ultimately, to better treatments."

Our great hope, Dr. Barondes said, is to learn about the causes so we can advance specific treatments. He called this research enormously productive and said it makes researchers very optimistic that these products will be found to the great benefit of all.

Dr. Jair Soares, M.D., Associate Professor of Psychiatry and Radiology and Chief, Division of Mood and Anxiety Disorders, Department of Psychiatry, University of Texas Health Sciences Center in San Antonio, detailed how better brain imaging tools allow us to look inside and study the functioning of the living human brain.

Using neuroimages projected on the screen, Dr. Soares cited as an example the case of Bipolar Disorder. He showed how changes can be detected in brain activation with changes in mood and how these changes could be correlated with positive and negative responses. This, in turn, he said, permits the identification of specific neurochemicals associated with the different mood states experienced by people with bipolar disorder; namely, mania, depression and normal mood or euthymia.

Dr. Soares was quick to note, however, that much more remains to be done, especially with longitudinal studies that will enable the course of the disorder to be more clearly understood.

Dr. Alex Kopelowicz, M.D., Assistant Professor in the Department of Psychiatry and Biobehavioral Sciences at the UCLA School of Medicine and Medical Director of the San Fernando Mental Health Center, told how he moved from the university into the community to help those individuals with mental disorders better manage their illnesses.

Explaining how the biological basis for the illnesses is dealt with on a daily basis, he said his research group was tying what we know of the biology of mental illness to the treatments offered to people with schizophrenia and other psychotic disorders. He pointed out, however, that not all psychosis is schizophrenia, adding that drug intoxication and severe manic or depressive illness can lead to psychosis. Sometimes schizophrenia is confused with split personality, but they are distinct entities. Schizophrenia, he added, is not a split between personalities; rather individuals with schizophrenia often experience a split between their thoughts and their emotions.

He continued: There are a number of symptom clusters within the spectrum of schizophrenia. The most well known symptoms are hallucinations, either visual or auditory, which represent perceptual experiences that are not shared by others. Also, people with schizophrenia often have delusions, false beliefs that can not be shaken by rational argument. Many patients also experience the absence of thoughts or motivation, the inability to express feelings and moods, and difficulties in memory and problem solving. Such problems sometimes culminate in a state of hopelessness, which may lead to suicide. Treatment, he said, seeks to help people by increasing their relationships, improving their grooming and personal hygiene, and enhancing their overall social and vocational functioning.

Harking back to Dr. Whybrow's opening remarks, Dr. Kopelowicz used a series of slides to show how schizophrenia is clearly a brain disease. Many parts of the brain are affected in schizophrenia. For example, schizophrenia impacts the frontal lobes that govern many of the important human functions such as the ability to create long range plans and to stick with them, the ability to work and live independently, and recognition of the actions and feelings of others.

The disability in the person with schizophrenia is visible in neuroimaging studies, he said, because when given a task to perform, the person with schizophrenia will use brain pathways that are inefficient. It is precisely in the attempt to identify and remediate these neurocognitive deficits that much future work will be focused.

Dr. Kopelowicz said that those with the illness experience difficulties in their ability to learn from experience. He showed images of the temporal lobes of people with schizophrenia demonstrating that those who had larger ventricles and less gray matter were more likely to be poor learners. Poor learning is also correlated in deficits in other brain regions, including the basal ganglia, the areas of interaction between the frontal lobe and the limbic system, and with the degree of cellular disarray in the amygdala and hippocampus.

Dr. Kopelowicz acknowledged the great strides made in the development of new antipsychotic medications, but he cautioned that medication is only the first step in the treatment process, adding: When used correctly, medication can help form the bridge to developing a relationship with a person suffering from schizophrenia. From there, he said, a number of powerful psychosocial techniques can be used to help patients develop the skills they need to deal with their illness.

He said that a biopsychosocial perspective based upon new developments in neurobiology and neuroimaging can help us understand how to better help patients rehabilitate in terms of community functioning, social relationships and return to work.

Dr. Whybrow concluded by noting that when you have a fragmented system of care it is very difficult for people to manage their illness. He said that the in Los Angeles the county mental health system is the only salvation for many people suffering from severe and persistent mental illness.

This, Dr. Whybrow said, is only the beginning of a very important debate, because if all patients are busy attempting to manage their finances instead of their care you create chaos for these individuals.