According to the latest World Health Organization figures, 24 million people have schizophrenia, a disorder that is often serious, disabling, and relapsing. Perplexing yet intriguing, it beckons experts of an authorial bent to provide enlightenment and guide readers through a thicket of confusions, complexities, and misunderstandings. The uncommon skill needed to succeed in such a task is reflected by the fact that recently there have been very few good books about this illness for a broad readership. Michael Foster Green's excellent Schizophrenia Revealed is written in an engaging and uncomplicated manner that ensures ready accessibility. It, as well as Nancy C. Andreasen's recently published and more general Brave New Brain: Conquering Mental Illness in the Era of the Genome (New York, Oxford University Press, 2001), has lifted the bar in this realm of explanatory neuroscience-based psychiatry to a height that could well deter most would-be authors in the field of psychosis for at least a couple of years.
The book's integrated style and clear sense of direction are an advertisement for the virtues of single authorship in an era in which teams of chapter contributors are in favor. The book is of an agreeable size: it is long enough to cover most topics but brief enough to not be intimidating. With a stated focus on the developments of the past decade, the contents are impressively up to date. Not only has Green ensured that recent findings are included; he has also selected those likely to be of enduring importance. One example is his reference to recent work in which both in vitro studies and positron-emission tomography revealed the brevity of action of certain antipsychotic drugs at the dopamine D2 receptor -- specifically, those with favorable neurologic side-effect profiles.
Any general book about schizophrenia is likely to include -- as this one does -- a core of standard fare. Thus, there is coverage of both the positive symptoms (including hallucinations and delusions) and the negative symptoms (such as loss of motivation and reduced emotional expression) associated with the disorder; the strong evidence supporting a substantial genetic contribution to the cause of schizophrenia; a description and discussion of the most consistent neuroradiologic findings in the disorder, such as enlargement of the cerebral ventricles; improvements in treatment with nontraditional antipsychotic drugs such as clozapine, risperidone, olanzapine, and quetiapine; and innovations in community care and training in social skills. It is hard for a book to address these core issues in any more than a satisfactory way, but Schizophrenia Revealed exceeds expectations because it is enlivened by evocative analogies, experiments for the reader, brief case histories, quips, quotations, and literary allusions.
Interwoven with this material are valuable reminders about how much there is yet to learn about the disorder, despite the onward march of scientific discovery. For example, Green makes the important point that because the diagnosis of schizophrenia is based arbitrarily on a constellation of symptoms and since the choice of one constellation over a similar one is essentially a matter of expert opinion, current ``official'' definitions of the disorder are works in evolution and are unlikely to map to specific biologic entities. Thus, the failure to validate the schizophrenia phenotype with the use of objective measures (such as the plaques and tangles of Alzheimer's disease), together with the likelihood that schizophrenia is a polygenic disorder, explains the frustrating lack of progress in the identification of genes that predispose people to the disorder.
If you require a special reason to read this book, you will find it in the crystal-clear sections relating to Green's own area of expertise, neurocognition. He groups and describes the neurocognitive deficits in schizophrenia that have been identified by many research groups, including impairments in problem solving and in sustained attention and deficits in working memory, sensory gating, and the perception of emotion. He then thoughtfully considers how these deficits might be used to construct phenotypes that are alternatives to those that are purely symptom-based for purposes of studying the neurobiology and genetics of the disorder. In addition, he explains how the investigation of these deficits can help us understand the disabilities and functional impairments that affect persons with schizophrenia, such as social awkwardness and difficulties in carrying out the normal tasks of daily living. Remediation and rehabilitation strategies can be based on an understanding of this nexus.
The book is not flawless. There is insufficient emphasis on progress in the neurochemistry and molecular biology of the disorder. There is also uncritical support of both the early developmental hypothesis of schizophrenia and the proposition that the disorder involves specific abnormal neuronal connections. Competing ideas about which circuits, neurons, and synaptic elements are primarily involved and the conflicting and generally inconsistent findings in this area of research make these attractive hypotheses very difficult to confirm.
If you wish to read an enjoyable and instructive primer on what we know about schizophrenia at the beginning of the 21st century, or wish to recommend such a book to your patients or their families, you could do no better than to choose Schizophrenia Revealed. If you read it, you will understand why those of us in the area of schizophrenia research share Green's optimism about better outcomes for our patients, even though we work in a discipline in which our advances are characterized by steady increments rather than spectacular breakthroughs.
David Copolov, M.B., B.S., Ph.D.
Copyright © 2001 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
