“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.
As Neuroscience, computer science and robotics research develops at exponential rates; scientists are beginning to realise things that once seemed like distant fantasies. Research that would not be out of place in a state of the art sci-fi blockbuster are right here right now, and may be accessible to the average person within the next 10 years. Scientists are making huge strides in Brain-Computer Interface (BCI), which refers to a direct communication pathway between the brain and external devices. In today’s world, there are products on Amazon that can read your brainwaves through electroencephalography (EEG), there are robotic arms in laboratories that can be controlled by brain waves and demonstrations of brain controlled exoskeletons that allow paraplegics to walk again simply by thinking about it. A direct relationship between computers and the brain is here, and it might become an everyday thing sooner than people think. Below are two new technologies that demonstrate the power and rapid rise of BCI; technologies that have the potential to greatly impact people’s lives. Technologies that will ultimately change the way we view computers.
Brain Implants That Allow people to control robotic arms
BCI is being used to greatly improve the standard of people’s lives, and this no more evident than in the development of new robotic arms for paralysed individuals. There has already been demonstrations of mind control robotic technology in amputees, however, an amputee still has their spinal cord and nervous system in tact. This means that electrical impulses can be read out from nerves in the arms and chest before they are used to control the prosthetic limb. However, in the case of spinal injury patients, these signals need to be decoded directly from the brain.
More recently, the prospect of patients with spinal injuries being able to seemlessly control robotic limbs or even entire body suits in the future has been raised. New BCI technologies have led to the development of a neuro-prosthetic device implant. These devices are planted in the area of the brain where intentions are made. Simply by thinking about moving their arms, participants have been able to move a robotic arm to help them with all kinds of tasks such as drinking from a bottle, performing a smooth hand-shaking gesture and playing rock, paper, scissors.
In the process of creating the neuro prosthetic device, scientists were focusing on gathering signals from the brains motor cortex. The motor cortex is where the brain generates the electrical signals that are sent down the spinal cord and control the contractions of every muscular movement. The replying neuro-prosthetics produced movements that were delayed and jerky; not the smooth and seemingly automatic gestures associated with natural movement. They then decided to move the implants into the ‘higher’ brain region, called the posterior parietal cortex (PPC), which gives rise to the intention of movement, rather than the details of how to execute. By decoding a person’s actual intentions, the scientists were able to get closer to achieving their goal.
The participants underwent surgery where they had a pair of small electrode arrays implanted in two parts of the PPC. Each four by four millimetre array contained 96 electrodes each recording the activity of single neurons. The arrays are connected by a cable to a system or computer processors that decode the brain’s intent and turn into movement of the robotic arm. The technology can be viewed in a video.
The implications of this research may change the lives of paralysed people across the world. By implanting two small chips into the PPC an individual may be able to control all kinds of technology, simply by thinking it. The next question is how far will the technology go and how quickly?
Mind Controlled Exoskeleton Suit That Allows Paraplegics To Walk
One bit of BCI technology that has received a lot of media attention is an exoskeleton that can be controlled by the user’s thoughts. In the opening ceremony of the 2014 Brazil World Cup, a paraplegic man walked and kicked a ball thanks to BCI technology. Neuroengineer Miguel Nicolelis led a group of 156 people from 25 different countries in a project that spanned 18 months, with the ultimate aim of creating an exoskeleton controlled by thought processes.
The mind controlled exoskeleton is built out of lightweight alloys and powered by hydraulics. It uses sensors to read the electrical activity of the brain which generates the motor commands that are usually downloaded onto the spinal cord. The motor planning is a result of electrical impulses in the brain, picked up by sensors and then converted into digital commands which are then sent to the exoskeleton. After spinal cord lesions the brain still sends these messages but the body can not receive them because of the break in the spine. Instead, the exoskeleton becomes the body, so the impulses do not go down the spines to the muscles instead they go to a computer which decodes them and sends them to the exoskeleton.
To use the skeleton, the person is helped into the suit and given a cap with sensors in that are fitted with electrodes. These signals are then passed to the computer in the backpack where they are read and decoded. An operators feet rest on plates, which also have sensors, that detect when contact is made with the ground. With each footfall a signal shoots up to a vibrating device sewn into the forearm of the weavers shirt. The device seems to fool the brain into thinking that the sensation came from their foot. In virtual reality simulations, patients felt like their legs were moving and touching something.
This technology may just put wheelchairs in museums, technology keeps on developing at incredible rates since the World Cup. Companies are starting to invest heavily in research of the exoskeleton, with the vision of being the first to create the technology that allows paraplegics to walk again. Nicolelis believe that the technology is ripe for turning into everyday devices to help paralysed patients. The system has been passed as safe to use. The exoskeleton has been fitted with multiple gyros to stop it from falling over during the balancing act of bipedal walking.
BCI advances are coming fast and thick at the moment, and show no signs of slowing. The days when amputees can fit a robotic arm in every morning as if they never lost a limb are upon us, and it will not be long until the technology spreads to more commercially driven products. The day when you can turn off the light just by thinking of it is almost here, and it’s an exciting time for science!