Neglect of the body to the detriment of the patient...

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INTRODUCTION

The good management of a schizophrenic illness, apart from drugs, was probably more successfully achieved in the 1930s-1950s than it is now. Then, care was taken to improve the physical well-being of psychiatric patients by good nutrition, exercise and plenty of sleep. Nowadays there seems to be a belief among some psychiatrists that the neuroleptic (anti-schizophrenic and anti-psychotic) medications developed since the 1950s improve psychoses so greatly that all they have to do is to prescribe them to patients admitted to hospital and then quickly discharge the patients back into the community. This is not good management.

COMMUNITY CARE AND PALLIATIVE DRUGS--DO THEY PROVIDE THE BEST ANSWER FOR SCHIZOPHRENIA?

Community care in many, but not all, areas is working very badly, often to the detriment of medically neglected patients. On discharge, if the patient has no family home to go to, he or she may end up not well enough to care for him or herself in a bedsit or other unsatisfactory accommodation. Seldom will such a patient be able to find employment or to live a happy and normal life. In the last century, a Dr Connolly was able to achieve a 50% cure rate for his schizophrenic patients without the help of neuroleptics. Such cure rates are not claimed now let alone achieved. These drugs do not cure. They relieve the worst psychiatric symptoms if well prescribed. It is still not known how they exert their therapeutic actions. If they are stopped the symptoms return. The causes of schizophrenia have not been found. Little has changed in the last 40 years to benefit the patient. This is probably because psychiatrists take little notice of the patients' bodies. They do not care for the patient physically.

WHAT HAPPENED BEFORE NEUROLEPTICS?

In a Textbook of Psychiatry [ 1] written by Henderson and Gillespie in 1937 the authors said: "A thorough physical examination is absolutely essential in every case--schizophrenics are commonly poorly nourished--during the period of their illness they often lose a great deal of weight and their general physical condition is not up to the average level". The authors also said that another well-known psychiatrist, Lewis, had remarked on "the lack of development, particularly of the circulatory system, the low blood-pressure and the well-marked vasomotor disorders. The hands and feet, the nose and the ears show cyanosis and oedema dilatation and irregularity of the pupils of the eye". These days it seems to have been forgotten that an ill body can disturb the proper functioning of the brain. Once it was commonly accepted. We hope this will be coming back into fashion.

SOME HOPE

A 1988 publication by Schiffer et al. [ 2] quotes Erin Koranyi: "No single psychiatric symptom exists that cannot at times be caused or aggravated by various physical illnesses". The authors of the book give a clinical rule: "There are no psychiatric patients--only medical patients with varying degrees of psychopathology" (i.e. psychiatric symptoms). It is our belief, in The Schizophrenia Association of Great Britain, that the search for physical disease in psychiatric patients should be very thorough indeed before any drugs are given which will widely alter the chemistry of both the body and brain, as the neuroleptics do. The disease, which is the direct cause of the psychiatric symptoms, may arise in the brain, as in the case of a brain tumour or meningitis, for example, but may just as often arise in the body. It must be stressed that the delusions, hallucinations, thought disorder, anger and violence which are the psychiatric manifestations of the disease are in themselves often only indications of the disease affecting the chemistry of the brain. They do not tell anything about cause. They are an indication that all is not well with the functioning of the brain. The symptoms may not be present all the time. They may change frequently and eventually they should prove to be reversible when the disease which causes them is rationally treated.

COMMONLY FOUND PHYSICAL DISEASES IN PSYCHIATRIC PATIENTS WITH A DIAGNOSIS OF SCHIZOPHRENIA

Thus, the psychiatric symptoms, on which so much emphasis is placed in making a diagnosis of schizophrenia, are in fact shared by many diseases. Schizophrenia is an umbrella term covering many diseases of the body and brain which disturb the proper functioning of the brain. In some cases, perhaps all, there is a genetic vulnerability to developing illnesses which produce psychiatric symptoms. No genetic cause has yet been found for schizophrenia. If, as we think, it is an umbrella term, a number of distinct genetic causes may eventually be found. As each is separated off from the diagnosis of schizophrenia it can be rationally treated. Richter [ 3], for example, wrote about one of his patients who had been suffering for years from a supposed schizophrenic illness. Richter [ 3] found that he was, in fact, suffering from homocystinuria, a well-understood genetic disease for which a treatment was available. Thus, this patient had not had schizophrenia. There are certain diseases which carry a high risk for schizophrenic patients. An excess mortality has been found from lung, gastrointestinal, urogenital and cardiovascular diseases and infections. An Australian, Dr Snars, has reported heart disease to be twice as common among those diagnosed as schizophrenic as in the general population.

It is extraordinarily important to seek these other diseases assiduously so that, if found, they can be treated and, possibly, the patient relieved of his or her schizophrenia. It is also very important to seek the reasons for the high incidence of these diseases causing death in those diagnosed as having had schizophrenia. It is possible that they were the cause of the psychiatric symptoms. We must also ask: do these other diseases arise from one genetic defect, affecting perhaps the dopamine pathway, so important in the body and brain, or is there a single fault causing damage throughout the body to membranes, including the gut membranes? We do not know. Perhaps both genetic errors may co-exist.

NEUROLEPTICS AND VITAMINS

It is difficult to make nutritional suggestions in view of the lack of information about the causes and in view of the universal use of neuroleptic drugs. We do know, however, that these medications lower the levels of certain vitamins in the blood and for this reason alone certain vitamins should be taken by probably the majority of patients receiving neuroleptics. We know that, in the long run, neuroleptics are mainly palliative not curative. We have to find the causes and improve the treatment.

THE BACKGROUND TO THE USE OF DIET AND NUTRIENTS IN THE TREATMENT OF SCHIZOPHRENIA

H. M. Sinclair wrote: "Medicine arose from dietetics. The Pythagoreans (including Hippocrates) used diet to prevent and cure diseases, and drugs only if these failed." This is an excellent approach to disease and one which we would like to apply to schizophrenia. A French psychiatrist, Pincl, also wrote in 1807 "that the primary seat of insanity generally is in the region of the stomach and intestines". However, these days, to suggest diet to the majority of psychiatrists is to be scorned. Because psychiatry has, for the most part, over fairly recent years, preferred to cast the blame on families for the production of schizophrenia, they have not had the time or inclination to think about the diet and schizophrenia. Thus, progress in this area has been slow. We do not yet know enough to make firm recommendations.

At the Schizophrenia Association of Great Britain's first conference in 1971, Cott [ 4] reported on some Russian work by Professor Nicolayev. He fasted his patients and found that 64% of them became sane. Apparently, paranoid schizophrenics did very well while fasting but relapsed on resuming a normal diet, particularly with protein. No meat was allowed for 6 months after the fast. That sort of regime was risky and had to be undertaken in hospital.

DO GRAINS DAMAGE THE GUT OF SOME PATIENTS WITH SCHIZOPHRENIA?

In 1966, Dohan [ 5, 6] reported that in certain parts of the world people appeared much freer from mental illness than those in the West. He wrote: "The kinds of cereal grain from products customarily eaten may be a factor in the production of psychiatric symptoms". He suggested that there might be a relationship between schizophrenia and coeliac disease, a disease of known sensitivity to wheat and sometimes to milk. Dohan [ 5, 6] said the wheat-and rye-eating areas of the world had the highest incidence of schizophrenia, with oats and barley areas next, followed by the rice-eating areas (with approximately 60% of the incidence of the wheat areas). In sorghum- and maize-eating areas the incidence of schizophrenia was approximately 25% of the wheat areas and in the highlands of New Guinea a practically nil incidence was found. Here no grains were eaten. William Philpott, an American psychiatrist, found that half his sample of schizophrenic patients could not tolerate milk and 64% were wheat sensitive.

The Italian researcher, Buscaino [ 7], reported that he had found damage to the gut lining in unmedicated patients, in part similar to that now found in coeliac disease. Baruk [ 8], a famous Parisian psychiatrist wrote that "It is not necessary to believe that the origin of mental illness is always in the brain, but that very often, on the contrary, the cause is very far from the brain, and the brain is only functionally disturbed by the toxins coming from the abdominal organs". Is a faulty digestive system, then, often the cause of disturbed brain function in schizophrenia? It seems very likely in many, if not all, cases.

MEMBRANES AND INFECTIONS

Horrobin and his colleagues [ 9, 10] have very recently reported a genetic defect which alters the activity of an enzyme regulating phospholipids in membranes, making them potentially unstable. If there is a generalized membrane defect in schizophrenia, as Horrobin and his colleagues [ 9, 10] think, the gut membranes may also be affected and the passage of infectious organisms (bacteria and viruses) into the blood may become easier.

Wheat protein (gluten) is thought to damage the gut membranes in coeliac disease. In the light of Buscaino's [ 6] work, they may act in a similar way in schizophrenia and again lead to both an invasion into the body by microorganisms and a malabsorption of nutrients. Peck [ 11] stated that "lipids have especially potent and complex effects on the body's response to infections and stress".

We do not know at this time if these two sorts of membrane abnormality are related. We do know, though, that there is still a raised mortality rate from infections in schizophrenia. Earlier this century there was a high death rate from infections, particularly tuberculosis. Viral infections, such as influenza, measles and glandular fever, have been reported by our members as having been frequent precipitants of schizophrenia in their families. One of the benefits of neuroleptics may be, perhaps, because they stabilize membranes at a certain concentration and may in this way prevent invasion of the body by microorganisms. Some neuroleptics have also been found to have anti-viral properties. Perhaps a long course of antibiotics might kill any bacterial organisms which were causing disease within the body. It would probably be worth considering.

CARDIOVASCULAR DISEASE IN SCHIZOPHRENIA

The disease which may be the most common disease in those with a diagnosis of schizophrenia may be cardiovascular disease, linked sometimes to kidney disease. Panic is a very common symptom in those diagnosed as having paranoid schizophrenia and panic has been linked, stated Coryell [ 12], to cardiovascular disease. Panic or intense fear, with no obvious cause, may be the symptom which produces anger and violence in patients and may well be caused by an imbalance in the chemicals in the sympathetic nervous system. Magnesium salts, which are proving an important part of the treatment of those who have had a heart attack, were used long ago in the treatment of manic episodes and more recently have been found in some cases to be as effective as lithium carbonate in stabilizing moods in manic depression. Magnesium is an important body nutrient and a shortage of it has been found to cause hallucinations as well as tachycardia (fast beating of the heart) and high or low blood pressure.

Thus, gut disease and heart disease should be particularly assiduously sought in patients said to have schizophrenia.

DIABETES

A very high incidence of diabetes has also been found in the families of those with schizophrenia. It should be sought in the patients themselves. Schiffer et al. [ 2] stated that vascular disease, diabetes mellitus and endocrine disease are likely to be particularly commonly found in psychiatric patients. It has recently been suggested by Holden and Mooney [ 13] that schizophrenia may be a diabetic brain disease. It is possible that the pancreas is involved in some cases of schizophrenia.

OTHER DISEASES, INCLUDING AUTOIMMUNE DISEASES

Reading [ 14] believed that grain allergies are the most common cause of psychosis in families where there is a history of autoimmune diseases, such as gastric cancer, diabetes, disorders of the thyroid, adrenal, parathyroid, pituitary glands, coeliac disease, pernicious anaemia and connective tissue disorders, or if there are frequent viral infections. If none of these conditions has actually been diagnosed, their signs and symptoms, vague aches and pains, arthritis, butterfly rash on the face, burning easily in the sun, premature grey hair, early baldness, chronic indigestion and frequent diarrhoea should be taken as an indication of grain allergy. Reading [ 14] noted that if you have some of these things in your family tree, as well as psychosis, the chances are very high that the psychoses are the result of grain allergies and the malabsorption of essential vitamins and minerals that these cause. Such autoimmune diseases are common in the families of our members where one individual suffers from psychosis (schizophrenia or manic depression). These other diseases also may respond to a grain-free diet.

That, then, is the basis for a consideration of nutrition in schizophrenia, but there are few firm recommendations we can make. The following are very tentative suggestions.

( 1) It would be worth considering a grain-free (gluten-free), milk-free, low sugar diet for at least a year to see if there is an improvement. There are a number of non-grain flours available from health food shops, including soya and buckwheat flour. Recipe books are available from many sources. Cantassium Ltd, 225 Putney Bridge Road, London have quite a selection.

( 2) Plenty of other foods should be eaten, particularly fruit and vegetables, both raw and cooked, and chicken and fish. Fatty fishes, such as mackerel, herring, sardines and salmon, should be preferred for their beneficial effects on membranes.

( 3) Extra vitamins should be taken, in particular the B vitamins and vitamin C, whose levels in the blood may have been reduced by neuroleptics. These should include vitamins B1, B2, B3, B6 and B12 and folic acid.

( 4) In coeliac disease, supplements of vitamin B12, folic acid and iron are sometimes given. These supplements are suggested for those with a diagnosis of schizophrenia in case they are not absorbing them properly because of gut damage. High levels of vitamin B12 may be needed--500 and 1000 Mu g tablets are available. Vitamin B12 should always be given at the same time as folic acid.

( 5) Vitamin C should be taken: 1-2 g daily.

( 6) Cod liver oil capsules containing A and D vitamins and vitamin E should be helpful if there is a malabsorption problem. These are fat-soluble vitamins and the dosage should be as given on the label.

( 7) Magnesium may be the most important element both for its beneficial effects on the heart and circulatory system and for its anti-manic properties. There are a number of different magnesium salts available, for example, magnesium orotate and magnesium phosphate. Sellig [ 15] thought that magnesium chloride or magnesium aspartate hydrochloride are to be preferred. Kerov et al. [ 16] suggested that oral magnesium supplements should be tried as an adjunct to treatment in psychiatric patients and that, again, neuroleptics lower plasma magnesium levels. The symptoms that seem to be associated with magnesium deficiency are high levels of anxiety, agitation, fear, hallucinations and depression. Diets high in saturated fats increase magnesium requirements as does alcohol. Cardiac arrhythmias respond to magnesium. Foods that contain high levels of magnesium include cocoa, chocolate, nuts, shellfish, peas and beans (legumes), grains, dried food and dark leafy green vegetables.

( 8) Patients should avoid alcohol in any amount as it increases symptoms of schizophrenia, smoking, street drugs and constipation. Ashton wrote about the effects of cannabis thus: "Many cases have been reported in which the use of cannabis caused a recurrence of acute psychotic symptoms even in schizophrenia patients well controlled with neuroleptics because cannabis, like LSD and amphetamines, seems to constitute a special risk for schizophrenia". Le Duc and Mittelman [ 17] stated that the "incidence of psychostimulant abuse in schizophrenia is 2-5 times higher than that of the general public". Such drugs must be avoided at all costs.

( 9) Patients should go to bed early, before becoming overtired, as the early sleep seems more beneficial. Adequate sleep is essential. Patients should exercise daily, moderately, though not to excess. Gardening and walking are very therapeutic. Patients should not socialize too much as this is exhausting. Patients should find a rewarding hobby.

REFERENCES
[1] Henderson DK, Gillespie RD. Textbook of Psychiatry. Oxford: Oxford University Press, 1937.

[2] Schiffer RB, Klein RF, Sider RC. The Medical Evaluation of Psychiatric Patients. London, New York: Plenum Publishing, 1988.

[3] Richter D. The biological investigation of schizophrenia--academic address. Biol Psychiat 1970; 2: 153-64.

[4] Cott A. Controlled fasting treatment of schizophrenia in the USSR. Schizophrenia 1971, 3: 2-10.

[5] Dohan FC. Schizophrenia: possible relationship to cereal grains and coeliac disease. In: Sanker S ed. Schizophrenia Current Concepts and Research. Hicksville, NY: PJD Publications, 1969, pp. 539-51.

[6] Dohan FC. Schizophrenia. Are some food-derived polypeptides pathogenic? Coeliac disease as a model. In: Hemmings GP, Hemmings WA eds. Biological Basis of Schizophrenia. Lancaster: MTP Press, 1978, pp. 167-77.

[7] Buscaino GA. The amino-hepatoenterotoxic theory of schizophrenia: an historical evaluation. In: Hemmings GP, Hemmings WA eds. Biological Basis of Schizophrenia. Lancaster: MTP Press, 1978, pp. 45-54.

[8] Baruk H. Psychoses of digestive origins. In: Hemmings GP, Hemmings WA eds. Biological Basis of Schizophrenia. Lancaster: MTP Press, 1978, pp. 37-44.

[9] Horrobin DF, Glen AM, Vaddadi K. The membrane hypothesis of schizophrenia. Schizophrenia Res 1994; 13: 195-207.

[10] Hudson CJ, Kennedy JL, Gotowiec A, et al. Genetic Variant Near Cytosolic Phospholipase A2 Associated With Schizophrenia. Schizophrenia Res 1996; 21: 111-16.

[11] Peck MP. Interaction of lipids with immune function. Biochemical effects of dietary lipids on plasma membranes J Nutr Biochem 1994; 5: 466-77.

[12] Coryell W. No details supplied.

[13] Holden RJ, Mooney RA. Schizophrenia is a diabetic brain state: an elucidation of impaired neurometabolism. Med Hypotheses 1994; 43: 420-35.

[14] Reading C. Your Family Tree Connection. Connecticut: Keats Publishing Company, 1988.

[15] Seelig MS. Cardiovascular consequences of magnesium deficiency. Am J Cardiol 1989; 13: 195-207.

[16] Kerov GK et al. Magnesium, schizophrenia and manic depressive disease. Neuropsychobiology 1990; 23: 79-81.

[17] Le Duc PA, Mittelman G. Schizophrenia and psychostimulant abuse: a review and reanalysis of clinical evidence. Psychopharmacology 1995; 121: 407-27.

Reproduced by kind permission of the Schizophrenia Association of Great Britain.

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By SCHIZOPHRENIA ASSOCIATION OF GREAT BRITAIN, International Schizophrenia Centre, Bryn Hyfryd, The Crescent, Bangor, Gwynedd LL57 2AG, UK

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