“To some extent, people who are insane are nonconformists, and society and their family wish they would live what appear to be useful lives.” – Nobel Prize Winner John Nash Who Suffered From Schizophrenia
The median global prevelance of schizophrenia has been estimated at 4.6 per 1000 of the general population. In the UK, a GP with an average list size of just under 2000 patients can expect to care for about eight patients with Schizophrenia, and possibly 12 if their practice is in an urban area. But the incidence rates of Schizophrenia in UK-resident Black-Carribeans have been consistently reported to be a great deal higher. When these findings were first reported many assumed it to be a first generation migrant effect or merely the result of methodological artefacts associated with inconsistencies in the diagnosis of schizophrenia in black carribeans. More recently however it has become clear that incidence rates of schizophrenia is even higher in second generationUK Black-Carribeans.
There was an enormous study conducted by the UK based Aetiology and Ethnicity in Schizophrenia and Other Psychoses (AESOP). It looked to examine the ethnic variations in schizophrenia incidence in the UK. In 2006, it was reported that there is a ninefold increase in the risk of developing schizophrenia in the UK Black-Carribeans when compared to the white British population. To put it into perspective Black Africans had a 5.8 increased likelihood and South Asians had a 1.4 increase. These findings are a big concern to Black-Carribean communities in Britain, to their GPs and to health service management responsible for their wellbeing. So why is Schizophrenia more prevalent in UK based Black Carribean communities?
Genetics seems to be quite a powerful risk factor in the development of schizophrenia.
The lifetime risk increases with genetic relatedness: 2% in third-degree relatives (first cousins); (uncle/aunt) to 6% (half-siblings) in second degree relatives; and 6% (parents) to 9% (siblings) in first degree relatives of suffering individuals. For twins, the risk is highr still: 17% for dizygotic twins and 48% for monozygotic twins.
Since studies have demonstrated a genetic contribution, it would then be that schizophrenia among Black-Carribeans are a feature of the emigrated rather than the native community. And indeed studies have found pretty similar levels of Schizophrenia in both populations. But there is still a huge argument stating that UK-based clinicians can do more to better protect the UK-resident Afro-Carribean community.
Alot of the time with psychiatric diagnoses, the process has a slightly subjective element. This may mean that clinicians may diagnose incorrectly at times. Clinicians are like average people, and can sometime carry limited biases that may impact the diagnosis of schizophrenia in UK based Black-Carribeans. To quantify the possibility of clinical bias, British and Jamaican psychiatrists were compared. The british psychiatrists classified 62% of Afro-Carribean patients as having schizophrenia where as the Jamaican psychiatrists recorded this diagnosis for 55% of these patients. ‘Race thinking’ (resorting to cultural stereotypes), and examples of institutional racism within the mental health service (discriminatory within an organisation) may also result in a degree of clinican bias in everyday practice. Cultural differences may also contribute to diagnostic error. At one extreme, Fernando has argued that existing cross-cultural incidence studies are flawed by the ‘category fallacy’ whereby western definitions of mental illness are applied to non-western cultures. Differences between cultures in the way hallucinations and religious experiences are regarded may have contributed to excess diagnoses in ethnic minority groups, as many non-western cultural beliefs could be considered to overlap with features of schizophrenia. The role that clinician bias plays in diagnoses of Schizophrenia in UK Black-Carribeans is often overlooked, but it is an incredibly important discussion to be had.
TREATMENT AND PATHWAYS TO CARE
Another issue that has to be mentioned is the marked differences between African-Carribean and white British patients with psychosis in terms of their pathways to care. Black Carribeans typically follow adverse pathways during their first and subsequent episodes of psychosis they are more likely to experience compulsory admission, more likely to be referred to psychiatric services through the criminal justice system, less likely to be referred by a GP, and have more protracted untreated symptoms during their first episode of psychosis. This difference in treatment between the two ethnic minority groups is slightly alarming to say the least. Are UK Black-Carribeans receiving the same care that White British people are when their psychotic epsiodes begin?
The association of schizophrenia with unemployment, poverty, and lower social class is well known. Urbanicity itself is associated with the incidence of schizophrenia, even allowing for confounding by known socioeconomic indicators, with growing up in an urban environment increasing the risk of developing schizophrenia later on in life by a factor of around 1.7. Since most Black-Carribeans in the UK live in inner city areas, and growing up in an urban area contributes to the risk of developing schizophrenia, it can be argued that undertermined factors operating in an urban environemnt may account for some of the ethnic variations in incidence. Levels of social and family support may also play a role in the excess incidence of schizophrenia in UK Black-Carribeans. Parental separation and loss before the age of 16 years were found to be strongly associated with the onset of psychosis. UK resident Black-Carribeans living in predominantly white neighbourhoods have been found to have a higher incidence of schizophrenia. This has been termed, the ‘ethnic density effect’, and may be another expression of social isolation. Individuals living in areas where their own ethnicity constitutes a smaller proportion of the local population have been reported to feel excluded from local social networks. It seems that many Schizophrenic episodes may be triggered by feeling of social isolation. Being Black-Carribean in a largely white society with limited community support may be a reason behind the increased incidence of Schizophrenia in these communities.
Psychological factors appear to play a large role in the development of Schizophrenia, adversity in many forms appears to contribute to higher rates of Schizophrenia, but attitudes to adversity are also likely to play a role. Studies show that migrants whose skin colour is substantially darker than that of the native population are most vulnerable to schizophrenia. Racism based on the darkness of skin colour rather than merely on ethnic grouping may account for such findings, and perception of racism have been found to increase according to skin darkness. Larger visible differences between an ethnic group and the host population may enhance an outside status. Again it seems that the darker you are in a predominantly white society means the greater amount of racism you may receive.
The higher level schizophrenia in Black-Carribeans living in the UK probably reflects the interaction of multiples risk factors, many of which cluster in the Black-Carribean community in the UK. Particularly significant factors appear to be the combination of isolation and exclusion, both within society (living in areas of low ethnic density and reduced participation in society) and within the family (family break-up and paternal separation). These factors seem to be more powerful than socioeconomic disadvantage, which is more likely to be a consequence than causal. Racism itself may contribute to social exclusion, further increasing the vulnerability to schizophrenia.
In the last 50 years there has been increased focus on the scientific study of daydreaming. Most researchers identify similar themes: the striking continuity between night dreaming and day dreaming and the ability of creative people to harness this continuity. Neuroscience has allowed us to take this research to new and creative heights by identifying what actually occurs in the brain of day dreamers and it’s links to creativity.
As we drift off to sleep, our working memory network, consisting primarily of the lateral frontal and parietal cortices, switches off. This brain network is the one that involves attention to the outside world, immediate conscious perceptual and linguistic processing. Once this brain network deactivates our default brain network takes over; also referred to as the resting brain. It involves aspects of our self, such as our self representations, dreams, imagination, current concerns, autobiographical memory and perspective taking ability. The default network involves our most inner streams of consciousness. Interestingly, those with higher default brain network activity during rest have a tendency to day dream more frequently.
When most of us awaken, our working memory brain network re-engages, and our default brain network withers into the background. In most people the working memory network and default network ‘anti correlate’ with each other, meaning that when one network is activated the other is deactivated. This is definitely a good thing! Proper connectivity between the two networks allows people to know when to distinguish between pure fantasy (their inner stream of consciousness) and reality (the external world). But that’s most people…
Schizophrenics tend to have an overactive default network. Creative folks also exhibit an overactive default network. Prior research has suggested that the thing that seems to differentiate creative but functional individuals and those with mental illnesses is that creatives have the ability to engage their default network and working memory network simultaneously. Those who lose grip on reality and become paranoid and delusional have let the floodgates down, so to speak, letting too much of their default network control their attention.
Researchers investigated the functional brain characteristics of participants while they engaged in a working memory task. No participants had a history of neurological or psychiatric illness, all had intact working memory abilities. They administered two different versions of the same working memory task during an fMRI scanning session, one vision requiring much more concentration than the other. The more difficult working memory task required constant updating of information in memory while having to resist distraction.
They also explored creativity and the default brain network by asking participants to display their creativity in a number of ways. They had to generate unique ways of using a typical object, imagine desirable functions in ordinary objects and imagine the consequences of unimaginable things happening. These tests have previously been linked to openness to experience and frequency of visual hypnagogic experiences (e.g. Lucid dreaming, hallucinations) which in turn have been linked to vividness of mental imagery.
The researchers found that the more creative the participant, the more activity in their default mode network was altered. Particularly, creative individuals had difficulty suppressing the preceneus area of their default network while engaging in the more effortful working memory task. The preceneus is the area of the default network that typically displays the highest levels of activation during rest (when a person is not focusing on an external task). Creatives exhibit more activation in this area than those that are not, and so do those with schizophrenia. The preceneus has been linked to self-related mental representations and episodic memory retrieval.
How is it conducive to creativity? Researchers state that an inability to suppress seemingly unnecessary cognitive activity may actually help creative subjects in associating two ideas represented in different networks. Intriguingly, prior research has shown a similar inability to deactivate the default network among those with working memory deficits, as well as schizophrenic individuals and their relatives (who are more likely to have schizotypy). The key to functional creativity then seems to be the ability to keep ones internal stream of consciousness ‘on call’ while being able to concentrate on a task.
Jonah Lerner discusses the importance of daydreaming and distractions for creativity. He mentions a recent study showing that A.D.H.D. is associated with creative acheivement. A Harvard study found a sample of high I.Q. individuals that were eminent creative achievers were seven times more likely to have reduced latent inhibition. Latent inhibition is a filtering mechanism that we share with other animals, and it is tied to the neurotransmitter dopamine. It involves the ability to consider something as relevant even if it was previously tagged as irrelevant. A reduced latent inhibition allows us to treat something as novelty, no matter how many times we’ve seen it before.
However, latent inhibition is not related to cognitive style; intelligence and latent inhibition seem to be independent abilities. Those with a reduced latent inhibition have more confidence in their intuitions! This is likely down to the fact that those with a reduced latent inhibition actually have more accurate intuitions. It is not a measure of distractibility, latent inhibition tasks measure a form of mental flexibility. It’s not that people who have a reduced latent inhibition always treat the irrelevant as relevant; it’s just that they consider everything as potentially relevant. And this is conducive to creativity because sometimes the seemingly irrelevant is relevant.
How can this research impact our lives? We need to broaden our definition of ‘productive’ thinking. For too long we’ve assumed that every thought process that is not focused attention is a waste of time. We have trained our children to believe that the only way to succeed is to stare at the blackboard or to fixate on the lesson plan. That may not be the way.
It’s reflected in how teachers view their students. A study showed that although teachers said they wanted a classroom full of creatives they were mistaken. In fact, when the teachers were asked to rate their students on a variety of personality measures – the list included everything from ‘individualistic’ to ‘risk-seeking’ to ‘accepting authority’. The traits most closely aligned with creative thinking were also closely associated with their least favourite students.
Judgements for the favourite students were negatively correlated with creativity; judgements for the least favourite students were positively correlated with creativity
The classroom then is not designed for impulsive expression – that’s known as talking out of turn. Instead it’s all about obeying group dynamics and paying strict attention. Those are important life skills of course but psychological research seems to suggest such skills have little to do with creativity.