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Identical Twin Brother Develops Schizophrenia

Author: Larry H. Bernstein, MD, FCAP

 

 

 

My identical twin brother develops schizophrenia

I graduated college as a chemistry undergraduate prior to entrance into medical school in 1973, and my brother had not exhibited signs of serious mental distress until that point.  He was dating a young woman who rejected him, and he was also under pressure from our father, who thought he did not have direction. The oldest daughter was married and was well prepared in piano and in mathematics, and she has prepared students in piano to the present day. The triplet sister was married to a medical student who went on to become a psychiatrist. The two sons were still living at home.  There was considerable pressure on my brother to complete his studies.   The trigger seemed to be the breakup of his relationship. It was in the months prior to my graduation that my mother was deeply concerned and our parents pursued a psychiatric evaluation.   He was put on chlorpromazine, but then developed jaundice. Schizophrenia was not understood in those years, and for many years was an illness that brought shame to the parents.  I shared a bedroom with my brother for all the years prior to this event and I only saw it develop at the surface.

We both had worked as waiters at a resort on Lake Michigan for some years prior to my entrance to medical school, and Leslie had an interest in biology.  He was closer to our younger sister, and I was trying to keep up with Sharon, who was 2 years older and had an infant that I visited often.  I had a close friend who was my buddy.  I could talk to him often, and we compared notes after a double date.  Leslie had a friend who we had played chess with in high school.  My brother showed no progress and his psychiatric visits were costly. My father was a dental technician who was skilled at making dentures.

It was the summer prior to my entry into medical school that I worked in a biochemistry research laboratory under the supervision of my brother in law.  The first year medical studies were pressured with anatomy, biochemistry, inborn errors of metabolism, neuroanatomy and embryology, and dissection of cadavers.  Leslie was admitted to the Lafayette Clinic at Wayne State University. He was now receiving the best care available. I visited him at that time, and he played chess with the attendant.
It was also during the first year of medical school that the progressive Rabbi Adler, at Rodeph Shalom who had a national reputation was shot in front of the Bima by Richard Wishnetsky, a troubled man our age who was mentally ill, probably with a mood disorder. My good friend was home from Berkeley and tried to avoid the problem, but he was released by a law school student. Richard’s parents were leaders in the congregation.  My friend and I knew there was a problem early because Richard had received a Woodrow Wilson scholarship, and he considered graduate studies under a faculty member at the Catholic University in Detroit, but he did go to the University of Michigan.

At the end of the first year, the triplets went to Washington, DC to participate in an ongoing Schizophrenia twin study.  I was engaged in studies of radiation on virus in an NIH lab during the study. Three years later, when I was rotating through psychiatry at Herman Kiefer Hospital in my third year having taking time out for a Master of Science degree in Anatomy (the evolution of the proteins of the eye lens), I found myself in the Detroit riots.

 

My brother grew a beard and became somewhat disheveled. He had hallucinations, and he could tell about his dreams.  For instance, so and so visited him.  He began living in an apartment on Woodward Avenue, the largest street in Detroit. He became very spiritual, and he wrote poetry.  One day he stood in the middle of Woodward Avenue wearing a tallis (prayer shawl) and directed traffic.  He did manage to finish his undergraduate studies, but when he took a job teaching biology, he just couldn’t. He also knew that a Croatian girl who graduated high school with us, who was a talented dancer, developed schizophrenia.

My mother was very stressed. She was helping to care for my older sister’s daughter, and she was grieving over her son.  She developed abdominal pain in 1978, when I graduated and went to my residency in Pathology at University of Kansas Medical Center in Kansas City, in what was to be a residency and PhD program. I had joined the Berry Plan during my medical school years and when I graduated I was randomly selected to go into the Navy, but got a deferment to complete my studies.

It was during that time that I learned that my mother had had an exploratory laparotomy for what turned out to be an infiltrating carcinoma of the stomach, through the wall and on the peritoneal surface (linitis plastic).  No biopsy was taken.  I flew home frequently until the end.  She was on morphine to ease the pain.  I began seeing a woman I had known in high school, who was now teaching. We were married in December of 1979, after my mother died.  My mother’s father had always been well and was a mechanic in Cleveland. I was told that he died of a broken heart with the loss of my mother.

I went to University of California, San Diego in January, 1980, to work in Enzymology, the inhibition of the pyridine nucleotide linked malate dehydrogenase reaction, under Nathan O. Kaplan, and there I also completed my residency.  It happens at that time, my brother had moved to San Diego, and he was looked after our triplet sister.  It was a fortunate circumstance for the triplets.

 

 

 

 

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3:15PM 11/12/2014 – 10th Annual Personalized Medicine Conference at the Harvard Medical School, Boston

REAL TIME Coverage of this Conference by Dr. Aviva Lev-Ari, PhD, RN – Director and Founder of LEADERS in PHARMACEUTICAL BUSINESS INTELLIGENCE, Boston http://pharmaceuticalintelligence.com

 

3:15 p.m. Discussion Complex Disorders

Complex Disorders

During the past 30-40 years, it has become well established that most human disorders affecting large groups of individuals have a genetic basis. Based upon this information there are several efforts to conduct genetic analysis on very large populations of individuals to identify genetic factors that cause susceptibility to complex disorders. In this session, two examples where such studies are bearing fruit will be discussed.

Complex Disorders

Discussion Leader:

Anna Barker, Ph.D.
Director, Transformative Healthcare Knowledge Networks;
Co-Director, Complex Adaptive Systems Initiative:
Professor, School of Life Sciences, Arizona State University

World of Biomarkers following NIH Career – Molecular based Medicine

get all the facts right straight then distort them

Speakers:

Roy Perlis, MGH, Bipolar Specialty, Prof of Psychiatry

Specialist in Schizophrenia, Autism

  • Complexity – overlapping diseases, genomics discovery
  • Psychiatry Genomics – Susceptibility, variance explained by common variation, intervention studies for susceptibility
  • depression is hereditary
  • 2000 schizophrenics genome,
  • phenotype models is only partially indicative of help if you are on Klonopin, is this enough for the diagnosis
  • CRISPR — HOW to use it — not discovered yet for psychiatry disorder — it may be the solution, though

Joe Vockley

COO, Inova Health System

CSO, Inova Translational Medicine Institute

  • Preeclempsia – preterm Birth is a complex disease many factor can cause it, 12% of birth are Preterm birth
  • 10,000 genome vs full term birth, clinical phenotypes,
  • model 81% predictive — triage screening based on markers – genomics to follow phenotyping.
  • Genomics — indicative — not fully used from diagnostics to therapy
  • ancestor data (familial info) of the 10,000 in the cohort was done filter variant
  • whole genome sequencing, reimbursement does not support  to path to therapy based on genomics

Robert Plenge, M.D., Ph.D.   @rplenge
Vice President and Worldwide Head Genetics and Pharmacogenomics
Merck Research Laboratories – Specialist RA

ex- Pharmacogenetics at MGH

  • sample size 100,000 genomes completely sequenced  – PM is at present in Oncology – use Genetics to discover diagnostics markers, clinical diagnosis, protocols – worst in cancer
  • genetic effect are important component requires big cohort to identify large effect
  • dysfunctional variant
  • Proteomic predictors, in drug discovery not sufficient, marker of disease  it is helpful

 

 

– See more at: http://personalizedmedicine.partners.org/Education/Personalized-Medicine-Conference/Program.aspx#sthash.qGbGZXXf.dpuf

@HarvardPMConf

#PMConf

@SachsAssociates

@WeillCornell

@ASU

@rplenge

@Merck

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Author: Dr Anayo Unachukwu, MBBS, LLM

 

Modern society is built on the twin pillars of Judaeo-Christian jurisprudence and Graeco-Roman civilisation. The jurisprudence has provided us with the moral[1], ethical and legal system that has sustained the civilisation. The civilisation prides itself with the legacy it bequeathed modern society-science. Revolution in science has often been preceded by revolution in measurement. The scientific endeavours have led to delineating, characterising, validating and reliably predicting and identifying the origin of concepts, phenomena, etc encountered by mankind and seeking remedies for these with some degree of certainty and accuracy. The prodigious advances in science and technology within the ethico-legal framework that stemmed from it have brought with it advantages in medical science and related fields. These pervade our every day environment; and we are all witnesses to the consequences of its innovation and creativity. Given the new found confidence in these fields, there have been attempts by medical and behavioural scientists to stretch its research frontiers further in providing succinct explanation to often complex human behaviour and interaction within social spheres. The science behind these quests usually has aural of purity-value free and bereft of ideology. However as Rose puts it: “It may well be that it is only in the periods of social and intellectual crisis that we can glimpse the interconnections between science and social system.[2]

One of the preoccupations of prehistoric man has been attempts at classification and categorisation; this heuristic pursuit-through generalisation-is a way of navigating the complex environment he finds himself. Attempts at generalisation by extrapolating from medical model to account for mental disorders[3] have not altogether been helpful. This could be due to lack of clarity in understanding the aetiological underpinnings; stigma and labeling intrinsic to the sufferers and skepticisms that surround the practice of psychiatry.

The mentally disordered offender raises questions which have troubled theologians, moral philosophers and lawyers throughout the Christian era.[4] It is not only these professions that grapple with this group of offenders; as Eastman puts it psychopaths[5] are the moral and scientific junctional case between the mad and the bad, both in terms of treatment and of punishment.[6]

Psychopathy[7] as a construct throws up more questions than answers-origin, remedial attempts[8] and heuristic generalisation as regards prognostic inferences. There is larger debate on whether psychopathy and personality disorder[9] are primarily legal or diagnostic categories, or neither.[10] Given that psychopathy straddles interpersonal and social domain in everyday human endeavours which impacts on both clinical and legal settings; one would have thought that a complete delineation and categorisation would have been understood by relevant practitioners[11] involved, but this appears not to be the case. Some researchers both clinical and non clinical strongly disagree on the nosological certainty of psychopathy and its inclusion in the medical classificatory system.

However, all agrees that the disorder generates a lot of controversy; and the emotive[12] issue that it provokes-social, psychological, economic and legal-reverberates further afield way beyond the field of clinical sciences.

From social policy perspective, other characteristics of psychopathy notwithstanding, criminal and violent behaviours are the main hallmarks of the disorder.[13] Psychopaths are high risk offenders with many criminogenic needs (i.e., personal characteristics correlated with recidivism).[14] In fact, recent research efforts have shown that there is a relationship between psychopathy and both general and violent crimes.[15] The criminogenic derivative that stem from the disorder had a legal ringing endorsement.[16]

In contrast to the relationship between psychopathy and rate of recidivism; Gibbens et al[17] eight-year comparative follow-up study on criminal psychopaths (diagnosed as ‘severe cases’) and criminal non psychopaths as regards their reconviction rates showed insignificant differences in the reconviction rate for both groups. The conclusion from this study was broadly similar to a two year follow-up study by Walker et al[18] which compared the rates of reconviction amongst psychopaths and non psychopaths who were diagnosed with severe mental illness, schizophrenia and those diagnosed as subnormal (learning disability); the rate of recidivism for both groups were not statistically significant.

Without making an extraordinary reading of the follow-up studies, Cooke et al[19] had argued that criminal behaviour should not play a central role in the diagnosis of psychopathy; instead such behaviour is best viewed as a secondary feature; or sequel of the disorder. This view is consistent with Cleckley’s original classical description of psychopathy where criminal behaviour was not intrinsic to the disorder; the motivation of the behaviour when it is present is usually obscure.[20] Criminality and psychopathy are not the same construct; the core features of the disorder-glib charm, callousness, arrogance, shallow affect, deceitfulness, and lack of empathy do not necessarily involve or imply criminal behaviour.[21] Why then is there such a great emphasis in diagnosis of this disorder? The answer partly lies in the society we live. There appears to be an inverse relationship between the tolerance of risk[22] in a given society and its level of affluence. There is a political imperative driven by popular lay press for a ‘risk free’ society; such an unrealistic expectation has led to the bourgeoning of research in risk instruments for assessment and management of risks. The trend in the wider society, technological advances and rise in consumerism has all further fueled this gusto-risk intolerance. Risk assessment as a concept is not a legal issue per se as competence to stand trial or criminal responsibility; however, it forms important part of different decision making in law. As Fennell puts it, there is a role redefinition whereby risk management has assumed increasing centrality in the role of psychiatrists and other mental health professionals, and philosophies of risk management now permeate decision-making in both the psychiatric system and penal system.[23] It is a given that psychopaths are involved in violent crimes and they recidivate for both violent and non violent crime compared to non psychopath; hence violence risk is an “indirect” legal issue often relevant to ultimate decisions but rarely defining the ultimate issue specifically.[24] Therapeutic jurisprudence[25] partly relies on risk assessment and management in deciding on disposal options available when dealing with mentally disordered offenders. As Leacock and Sparks remarked; Risk…is a fashionable idea—one whose moment would appears to have arrived.[26] Risk is now so integral to every day discourse given the high profile homicides; most notable was the killing of Jonathan Zito (in England) by a stranger, Christopher Clunis, who suffered from schizophrenia. As a result, the risk management/public protection agenda is now prominent-in England and Wales-and since 1992, health authorities have a duty to carry out an independent inquiry in any case of homicide or suicide by a mentally disordered person in their care.[27]

Conclusion

 

Mentally disordered offenders-like the poor-will always be in our midst. Labelling and stigmatising this group as a whole may be unhelpful at best and amounts to discrimination. Managing risk out every day discourse is naivete to the extreme, given that in any society a trade-off has to be made as far as risk goes. Criminality as a construct should not be synonymous with psychopathy, given that not all psychopaths offend and not all criminals are psychopaths.


[1] Psychopathy which under the Mental Health Act 1983 is classified as a mental disorder is seen by some philosophers, lawyers, clinicians and the society at large as essentially a moral disorder. See Maibon, H.L. The Mad, the Bad, and the Psychopath. Neuroethics (2008) 1:167-184. DOI 10.1007/s12152-008-9013-9.

[2] Rose, S., Rose, H. (1971). The myth of the neutrality of science. In Watson Fuller (ed). The SOCIAL IMPACT OF MODERN BIOLOGY.Routledge & Keegan Paul. London. p.233

[3] The adoption of this term was recommended in the Report of the Royal Commission on the law relating to Mental Illness and Mental deficiency 1954-1957 (Cmnd 169 (1957)) Pt 3 paras 146-198. The Commission recommended its use as a general term covering all forms of mental ill-health or disability. S (1) of the amended Mental Health Act 2007 gives a broader description of mental disorder-any disorder of the mind; ‘mentally disordered’ shall be construed accordingly.

[4] Walker, N. (1968) Crime and Insanity in England. vol. I. Edinburgh University Press. p. 6

[5] Psychopathy is a personality disorder defined by a cluster of interpersonal, affective, and lifestyle characteristics that results in serious, negative consequences for society.

[6] Eastman, N (2002). The Ethics of Clinical Risk Assessment and Management:Developing Law and the Role of Mental Health Professionals. In Gray, N,  Lain, J,  Noaks, L. (Eds.). Criminal Justice, Mental Health and the Politics of Risk.(pp. 49-66). Cavendish Publishing Limited.

[7] The adverb psychopathic means literally ‘psychically damaged’ and was introduced in the 19th century Germany to cover all forms of psychopathology. From the outset it should be distinguished from psychopathic disorder which is a legal concept. Authors disagree on its definition; sometimes the usage is in vernacular, and this paints a derogatory picture. See Gunn, J. and Robertson G. (1976b) Psychopathic Personality: a conceptual problem. Psychological Medicine, 6, 63-4 (386).

[8] Cleckley, H. (1941). The mask of insanity. St. Louis, MO: Mosby. The present day conceptualisation of psychopathy is credited to the systematic writings and observation of Cleckley. He expressed concerns about the progressive nature of the disorder, social malady it posed to the society and therapeutic nihilism associated with it.

[9] The defining characteristic of personality disorder more than any symptom is the incomprehensibility and inaccessibility that the sufferer provokes in other people. It is classified as a mental disorder by both two international classificatory systems- World Health Organisation. (1992) International Classification of Disease and Related Health Problems: ICD-10. Geneva: WHO; and American Psychiatric Association. (1994) Diagnostic and Statistical Manual of Mental Disorders. DSM-IV. WashingtonDC: Mental Health Service.

[10] Ogloff, J.R.P., & Lyon, D.R. (1998). Legal issues associated with the concept of psychopathy. In D.J. Cooke, A.E. Forth, & R. D. Hare (Eds) Psychopathy: theory, research, and implications for society (pp. 401-422). Dordrecht, The Netherlands: Kluwer.

[11] Unfortunately among various practitioners not just legal practitioners, but most clinicians the conceptual cousins of psychopathy-sociopathy, dissocial personality and antisocial personality have been mistaken for psychopathy. See Gacono, C.B., Nieberding, R., Owen, A., Rubel, J., & Bodholdt, R. (2000). Treating juvenile and adult offenders with conduct disorder, antisocial and psychopathic personalities. In J. Ashford, B. Sales, & W.Reid (Eds.), Treating clients with special needs. WashingtonDC: American Psychological Association.

[12] Hare, R.D. (1996a). Psychopathy: A construct whose time has come. Criminal Justice Behavior. 23, 25-54.

[13] Patrick, C.J. (2006). Handbook of Psychopathy The Guilford Press. p.555

[14] Zinger, I., & Forth, A.E. (1998). Psychopathy and Canadian criminal proceedings: The potential for human right abuses. Canadian Journal of Criminology, 40, 237-276.

[15] Salekin, R.T., Rogers, R., & Sewell, K. W. (1996). A review and meta-analysis of the Psychopathy Checklist and Psychopathy checklist-Revised. Clinical Psychology: Science and Practice, 3, 203-215

[16] Carraher v HM Advocate 1946 JC 108 at 117, per Lord Normand: it is to my mind descriptive rather of a typical criminal than a person…regarded as being possessed of diminished responsibility.

[17] Gibbens, T.C.N., Pond, D.A. and Stafford-Clark, ‘A Follow-up Study of Criminal Psychopaths’ in (1959) 105, Journal of Mental Science, 108 ff.

[18] Walker, N., McCabe, S. (1973) Crime and Insanity in England. Vol. II. p.212. Edinburgh University Press.

[19] Cooke, D. J., Michie, C., Hart, S. D., et al (2004) Reconstructing psychopathy: Clarifying the significance of antisocial and socially deviant behavior in the diagnosis of psychopathic personality disorder. Journal of Personality Disorders, 18, 337-357.

[20] Cleckley,H. (1988) The Mask of Sanity (5th edn). Mosby. p.279

[21] Hare, R.D. (1998). Psychopathy, affect, and behaviour. In D.J. Cooke, A.E.Forth, & R.D. (Eds.), Psychopathy, theory, research, and implication for society (pp104-137). Dordrecht, the Netherlands: Kluwer.

[22] Risk is defined as the uncertainty of outcome whether opportunity or negative threat, of actions and event

[23] P, Fennell (2002) .The Ethics of Clinical Risk Assessment and Management:Developing Law and the Role of Mental Health Professionals. In Gray, N,  Lain, J,  Noaks, L. (Eds.). Criminal Justice, Mental Health and the Politics of Risk.(pp. 49-66). Cavendish Publishing Limited.

[24] Roesch, R., & McLachlan, K. (2007). Clinical Forensic Psychology and Law. Ashgate Publishing Ltd.

[25] Wexler, D., & Winck, B. (Eds.) (1996). Law in a therapeutic key. Durham, NC: Carolina Academic Press. At p. 32 describe it as a concept that addresses the issue of how knowledge, theories and insight of the mental health disciplines can help shape the development of law.

[26] R.D. Mackay (2002). Criminal Justice, Mental Health and the Politics of Risk. Crim. L.R. 2002, Sep, 765-767.

[27] Fennell, P (2010). HISTORY AND CONTEXT OF MENTAL HEALTH LAW AND POLICY. In Gostin, L., Bartlett, P., McHale, J., Mackay, R. (eds). PRINCIPLE OF MENTAL HEALTH POLICY AND LAW. Oxford University Press. p.53.

 

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