Rubbish in the margin

One of the most influential and controversial papers in psychiatry was from a 1976 study published in The Lancet that found that people with schizophrenia had larger fluid filled ventricles in the brain.

Yesterday, I looked up the original paper in London’s Institute of Psychiatry library and was amazed to see that the controversy seems ingrained into the paper copy, which has been ripped, repaired, damaged and defaced.

In the early days of scientific psychiatry, during the 1800s, many famous German psychiatrists expended a great deal of effort examining the post-mortem brains of patients with schizophrenia (also known at that time as dementia praecox) attempting to demonstrate Wilhelm Griesinger’s theory that “all mental illness is disease of the brain.”

Despite numerous studies, they were unable to replicate the success of studies on dementia, which they linked to specific changes in the brain. So for generations, schizophrenia came to be defined as a condition in which the brain was structurally normal.

This fact was often highlighted by the antipsychiatry movement to suggest that ‘mental illness’ was nothing more than a difference in human experience and there was no medical evidence supporting the work of psychiatrists.

But the fact was also cited by many psychiatrists resistant to the relatively new wave of medications that had appeared on the scene. The drugs were claimed to ‘fix’ the brain with the assumption that the discovery of clear evidence for brain differences would just be a matter of time.

Enter Eve Johnstone and her colleagues at Northwick Park Hospital in London, who, in the midst of this politically charged environment, completed a study that compared CAT brain scans of 18 patients with schizophrenia to a group of healthy control participants. Alongside the scans, the researchers also tested the participants’ mental abilities with psychological tests.

The results were striking. They found the size of the ventricles, the fluid filled spaces in the brain, was, on average, larger in patients with schizophrenia and that it was correlated with the degree of difficulty with tests of memory, concentration and problem solving.

This caused enormous interest and controversy at the time. The paper copy from London’s Institute of Psychiatry library clearly reflects this, as it has been read so many times (and possibly ripped out) that it is virtually in tatters and has been reattached with sticky tape in an otherwise pristine copy of the journal.

There are a few annotations on the page, including the word “Rubbish” written in the margin!

Although seminal, the study has been rightly criticised and one of the major difficulties with these sorts of studies is that because patients are normally taking antipsychotic medication, it’s hard to distinguish where the effect is linked to schizophrenia or the treatment.

While some medication is thought to also thought to affect brain structure, a study on patients that have never taken medication seem to suggest some differences in ventricle size, on average, are still apparent.

The ‘on average’ bit is important though, as these differences are not present in everyone with the diagnosis. They’re just an average difference when you compare a group of people with and without schizophrenia. Furthermore, we’re still not quite sure of its significance.

So the topic is still as controversial as when Johnstone’s study first appeared in 1976, although the argument has shifted from whether differences in the structure of the brain are associated with schizophrenia, to whether they are telling us anything useful.

Link to scan of article from Institute of Psychiatry library.
Link to PubMed entry for same.

6 Comments

  1. Posted October 4, 2009 at 4:03 pm | Permalink

    Facinating, but wished I could view the original in a bit more detail ( closer look) Zooming in doesn’t quite produce the desired effect!
    Thanks for posting this

  2. Posted October 4, 2009 at 4:06 pm | Permalink

    Oops just noticed the link to the original scan..
    sorry

  3. Tom Michael
    Posted October 4, 2009 at 11:19 pm | Permalink

    There’s nothing wrong with my ventricles god-damnit! They just want you to THINK there’s something wrong with them. Those damn Lizards…

  4. Jennifer R. Ewing
    Posted October 5, 2009 at 3:09 am | Permalink

    I wonder if this means that people with hydrocephalus (like me) are at greater risk for actual mental illness (schizophrenia)?

  5. Mark(p.s.)
    Posted October 8, 2009 at 2:02 am | Permalink

    Does Tom Michael make fun of overweight people? smokers?
    How about blind people?
    Amputees?
    Gun shot victims?
    People with cancer?

  6. Posted February 4, 2010 at 10:42 pm | Permalink

    Fair point Mark – I work with people with various mental health issues (mainly brain injury and depression). Its not right to make fun of anyone with a mental health difficulty – I just meant it as a throwaway joke and didn’t consider that I might offend someone. Sorry if it has upset you.


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