An Anecdote Describing the Treatment of One Case of Schizophrenia
Although my research group in Saskatchewan in 1951 was the first group in North America to use the double-blind prospective placebo controlled trials, when we showed that adding vitamin B-3 to the current treatment of acute schizophrenia, doubled the 2 year natural recovery rate from 35 to 75%, I was also among the first to discover that this is an expensive, usually useless research technique, loved mostly by administrators, government agencies, and editors of some journals. As I have written elsewhere, it is the ideal method for groups with a lot of money and little imagination.
The classical clinical method has served us well for many years and was effective in introducing new and useful treatments. The blind adherence to double blind methodology has merely made it more difficult to introduce new treatments. I can't think of a single new departure into a new treatment paradigm that originated with the double-blind methodology, except, of course, our first use of the double-blind to introduce megavitamin therapy. In fact, the use of 1-dopa for the treatment of Parkinsonism was killed by the double blind controlled experiments, and was resurrected by the usual clinical open studies done by good clinicians. Yet our own double blind trials were totally ignored for political reasons.
The clinical method is to describe patients accurately and honestly, to apply the treatment, and to report honestly the outcome. All this modern talk about `outcome evaluation of treatment' means nothing more than a return to what has been our traditional method all along. Basic to the clinical method, introduced by Sir Thomas Sydenham over 350 years ago, is the anecdote. This is not something to be derided and criticized. It is the essence of medicine, for this is how one doctor learns from another. After all, the modern double blind methods simply consists of an array of anecdotes arranged according to some statistical trick, except that in some modern therapeutic papers the patient has vanished so far that all one reads about are chi squares and probability values.
One aches to know what kind of patients were treated, were they human or animals, how did they like the treatment, and what was the outcome? The greatest clinicians, like Sir William Osier, wrote excellent anecdotes. I will therefore revert back to the method I have never forgotten, i.e. to record anecdotes where real flesh and blood patients are treated by live physicians.
My favorite anecdotes are about schizophrenic patients, but they are not nearly as good as accounts written by recovered patients. Several hundred books have been written, usually after they have recovered, occasionally while they are still sick. A recent book I recommend was written by Mark Vonnegut, The Eden Express. See also "A Letter to Rob" by Mark Vonnegut.( 1) There he described his descent into schizophrenia and his recovery. Even more recent is the book, Rickie, written by Dr. F. Flach with Recollections by Rickie Flach Hartman.( 2)
I will write about recovered patients because orthodox psychiatrists seldom see cured schizophrenic patients. I wonder if they have ever really seen one. The psychiatric dictionaries do not even define the word `cure'; obviously there is no need to define what is never seen.
On July 13, 1978, I received a letter from a physician from eastern Canada who wrote, "The above named patient has been suffering from chronic paranoid schizophrenia for many years. Since his teens he was treated at the ------ Hospital on numerous occasions. He has been seen by at least five psychiatrists with little success. On occasion he has been so psychotic that he required being placed in therapeutic quiet for long periods of time. He was extremely delusional, his delusions being of a religious nature, grandiose and paranoid. He often hallucinated for periods of weeks at a time. He received all forms of therapy, including massive doses of psychotropic drugs plus ElectroConvulsive Treatment.
"On his last admission in 1976 I treated him. Eventually it was possible to discharge him on a dose of thioridazine 450 mg daily. I commenced seeing him September 1976 for weekly psychotherapy. He was able to function outside the hospital but was still quite psychotic. At his father's request I commenced megavitamin therapy. Patient has shown a marked improvement since. His father, a professional person, had been reading about megavitamin therapy and has asked me to request a consultation."
The physician sent along some of his hospital records. The patient, J, was first admitted May 18, 1967, on certificate. He had been restless for six months, and about five days before admission became severely psychotic. The first few days he refused to get up unless the bishop or the Pope was called so he could tell him a secret. He said, "I am God's child, Doc, and He is going to take me away. He is bigger and better than your God." He was given 14 electroconvulsive treatments (ECT), and was better on discharge, August 1, 1967.
He was admitted for the third time February 6, 1973, and discharged June 20, 1973. The chart showed he had completed grade 12 but had always functioned at a borderline level. He was diagnosed schizophrenia, undifferentiated type. On admission he was started on ECT, and given large doses of chlorpromazine, later changed to thioridazine 800 mg daily. He was discharged improved.
I saw him in Victoria on February 19, 1979. He was then 28 years old and had been sick for 13 years. He was better but not well. He told me that he had never been normal, that he had suffered from recurrent episodes of depression all his life. After his third discharge he remained on medication.
In 1976 he was started on a megavitamin program by a psychiatrist. Not being familiar with the treatment he promptly took J off all his medication. It takes at least two months before the vitamin program can begin to work, and during this time it is essential that tranquilizer support be maintained if it is already providing some support. He promptly relapsed. He was then started back on medication by his family physician who referred him to me.
I think that the mental state is the most important part of the clinical examination. I follow Dr. Karl Menninger's( 3) method for examining the mental state as outlined in his little book of over 45 years ago. He looked at the three main ways of describing the functioning of the brain: perception, thinking and mood.
The patient told me he believed that people were looking at him all the time, although the feeling had eased recently. Lights bothered him, and when he was upset he felt unreal. His thought processes had improved and he was not as paranoid as he had been in the past. He still believed that people were talking about him and at times plotting against him. But he had regained his insight and realized that in spite of these strong feelings they were not true. At times these thoughts ran out of control. Often he would forget what he was thinking about or talking about for a few seconds. Not surprisingly, his concentration was not good and his memory was faulty. The hallmarks of schizophrenia are the combination of perceptual changes and thought disorder. Depression is usually present. His episodes of depression had become less severe. He was still very tired and slept too much.
I administered two perceptual tests I had developed with Humphry Osmond many years ago. These simple card-sort tests facilitate uncovering perceptual and thought disorder symptoms and signs. The cards (or a questionnaire) are handed to the patient with simple instructions. They are scored in a few minutes. Izik and I developed a software program for using the HOD.( 4) With both tests, HOD( 5) and EWI,( 6) he scored high, i.e. within the schizophrenic range. These tests are used by physicians and chiropractors but ignored by psychiatrists. In my opinion they are very useful diagnostic tests. In April 1996, while I was in London presenting orthomolecular psychiatry to the Institute of Optimum Nutrition, I was called by Dr. Nancy Dunne from Dublin. She reminded me she had been using the HOD test for over 20 years. Whenever she found a high scoring patient she would refer them to a psychiatrist, and so far not one had disagreed with the HOD diagnosis. Dr. Max Vogel, a veteran orthomol ecular physician has been using it with great success, and treating schizophrenic patients very successfully for over 25 years.
I discussed the diagnosis with this patient, pointing out that in my opinion it was a biochemical disease. I use the term schizophrenia, but try to remove its stigma by discussing its biochemical nature, that it creates mental symptoms and therefore can be confused with a mental disease, and that it is treatable by finding out the best nutrition and the optimum doses of the important anti-schizophrenic nutrients. I usually discuss the prognosis, estimating about how long it will take before they will recover.
His dietary and clinical history did not indicate he had food allergies. I suggested he clean up his nutrition by avoiding all junk food -- any food preparation which contains added simple sugars. Since most foods containing added sugar also contain other additives and preservatives, this simple advice -- easily given, harder to follow -- will remove perhaps 90% of all the junk from the diet.
I recommended he take niacinamide 1 gram three times daily, pyridoxine 250 mg daily, zinc sulfate 220 mg daily, and to continue with ascorbic acid 1 gram three times daily, B-forte 1 tablet three times daily, halibut liver oil capsules 1 three times daily, and continue with his thioridazine 450 mg daily. I add the nutrient component to any medication the patient is already taking if it has been helpful in controlling symptoms. There is ample time later on to remove the drugs as the patient improves. I am not tempted to try new drugs just because they are new. I then sent his physician in Eastern Canada my consultation report.
May 22, 1980, his doctor wrote to me again and said since the patient came back, "...I saw [him] more or less continuously in psychotherapy...until August 1979. Patient reported that he was feeling very good and in June 1979 we reduced his Mellaril from 150 mgs t.i.d. to [400 mg dally]....On the 28th of August I [noted that he was] beginning to make very good progress [and] had improved to the extent that he has obtained a permanent job.
"In October of 1979 I reported [he] has a full time job as a janitor and he loves it. He is mixing much better, he can talk to people. His thioridazine has been cut down to [300 mg daily]...13th March 1980...I noted [he was] beginning to relapse." He was very disturbed by his brother's illness. His brother had developed schizophrenia and was in hospital.
The physician increased his drug to 1200 mg and gave him 5 ECT. I agreed with the use of additional ECT. I have treated hundreds of patients since 1950 who would undoubtedly never have recovered if they had not been given the benefit of a series of ECT, including lawyers, doctors, teachers, labourers -- the station in life is immaterial. When used properly and sympathetically it can be life saving.
I saw this patient for the second time in Victoria, BC, in May, 1980. He told me that he had started hearing voices again and had become very paranoid even about his parents, but had improved since his series of ECT. I then advised him to adhere to the following program daily: niacin 3 grams, niacinamide 3 grams, ascorbic acid 6 grams, pyridoxine 250 rag, zinc sulfate 220 mg, B-forte, once daily, and to continue with his thioridazine 1000 mg daily.
His family was concerned about the possibility of preventing schizophrenia from appearing in other members. There were 10 siblings. I outlined a junk-free diet, B-complex 50's three daily for the well members. For those showing symptoms I added niacinamide 3 grams, ascorbic acid 3 grams, pyridoxine 150 mg and zinc sulfate 220 mg, all daily.
I saw him again in Montreal, in September 1985, with his girl friend. We met in Dr. William D. Hitching's office. Dr. Hitchings was one of the original orthomolecular psychiatrists who practiced in New York before moving to Montreal. The patient was normal.
He visited me for the last time September 1990 in Victoria. He had been on his job for 6 years as a civil servant and liked it. He earned over $20,000 per year and paid over $4,000 income tax annually. I also discussed with him a very slow decrease in drug dose, going down by 25 mg per month.
My criteria for normality or wellness include the following factors: ( 1) free of signs and symptoms, ( 2) getting on well with the family, ( 3) getting on well within the community, and ( 4) paying income tax.
Last year at a meeting in Vancouver Dr. Alan Brier, Chief, Unit of Pathophysiology and Treatment, Experimental Branch, National Institutes of Mental Health, Bethesda, Maryland, stated, "So 85% of all people with schizophrenia who are treated with neuroleptic drugs are deriving suboptimal benefits..." and later, "In the past our measures of outcome were relatively modest -- if the patients were stable, living in the community and not causing too much trouble we considered that to be a reasonably good outcome."
This was one of the few honest statements about outcome, and vastly different from those routinely reported by the psychiatrists who have promoted tranquilizer drugs so enthusiastically for the past forty years.
At this meeting it was reported that only 15% of all treated patients obtained a good response. Since this meant 85% of schizophrenics were refractory, the term refractory was redundant in the title of this symposium. Dr. Brier added that "40 to 60% of these refractory patients demonstrated a clinically meaningful (not defined) response beyond that achieved with traditional neuroleptics." In my own series I see many chronic patients. I now have under my care about 500 who are seen anywhere from once every few years to once each month. Very few are refractory patients.
Nowhere in this symposium is there any discussion of recovery, of being well, of being cured. No statement was made regarding the percentage of patients on tranquilizers who were able to work again. Thus, the tradition of psychiatry not to be aware of recovery is maintained, even with the advent of the modern, very expensive and toxic drugs such as clozapine, and the less expensive and safer resperidone.
January 29, 1993, I received a letter from J's mother who wrote, "My son, J has been to see you on three occasions. Thanks to your skill coupled with his doctor here, he has been able to lead a fairly normal life. He has held a job for 9 years -- with an excellent record. We feel this would not be so, without your help. For this he and the family will be forever grateful to you, and we are not hesitant to say where our help came from." Then she added that she, too, had been following the vitamin program and that this had contributed greatly to her good health.
In May 1989 J was seen by a psychiatrist in the east who had been in private practice in the west, and had moved east to take on a position with one of the hospitals and a university. He sent me a copy of his consultation report in which he concluded that the patient showed signs of residual schizophrenia, was slightly depressed, but was much improved over what he had been in the past. He suggested J continue with the program he was following and that he did not need any additional psychiatric treatment.
The following elements of any treatment program must be used to optimize the chances for recovery from any disease, especially for schizophrenia, these are: ( 1) hospitalization whenever required, with competent nursing staff and other ancillary personnel; ( 2) a competent and caring physician willing to put in the time required; ( 3) a family who provide continuing support and encouragement; and ( 4) the right medical treatment program.
Fortunately for J, he had all four. The first three components were present even before he was started on the orthomolecular program (originally called megavitamin therapy). He was in hospital on three different occasions and appears to have been treated well. He had a very good, caring physician with an open mind, willing to try anything which would not harm his patient and might help, and willing to stay by him long enough. With chronic patients I had found,( 7) that five to seven years of supervision on the program are required before there is a major move toward recovery. Very few doctors, including psychiatrists, are prepared to put that much time into the treatment of chronic patients. He had a devoted family willing to do everything in their power to help their psychotic son. But on tranquilizers alone or combined with ECT, he did not recover even though he was certainly much improved. It was only after he went onto a total vitamin and mineral program did he begin to enter the world of health.
His prognosis is very good as long as he continues to follow his program. He may need to readjust his medication now and then, or the doses of vitamins, and he may have to consult his doctors when he runs into difficulties. But this applies to any chronic disease, physical or mental. This patient's treatment program represents the orthomolecular treatment program, which is a combination of vitamins and minerals in optimum dosages, with whatever drug is essential to achieve control. When recovery is well underway, the dose of the drugs are gradually decreased until the level is so low it no longer is a hindrance to living and employment, and helps control the disease process. Doses of nutrients and drugs must be adjusted according to the clinical state of the patient. This requires the help of a physician who is familar with and not frightened of, vitamin therapy.
Every schizophrenic patient will cost the province or state he or she is in over 2 million dollars over their lifetime, estimated at 40 years. This includes hospitalization costs, welfare costs, medication, physicians' fees, legal costs, police costs and costs of incarceration, as well as loss of revenue -- taxes -- to the governments, because they can not be gainfully employed.
On tranquilizers alone it is impossible to get well. This is quite obvious if one accepts the truism that tranquilizers make normal people sick. If you don't believe this try it on yourself: take 3 mg of respiridone or 100 mg of clozapine. This is the heart of the tranquilizer dilemma which has been studiously avoided by psychiatrists, in the same way that many years ago they refused to believe that these drugs could cause tardive dyskinesia (t.d.).
The problem arises from two observations. The first is that tranquilizers do make schizophrenic patients better by reducing the intensity and frequency of symptoms and signs. I find them very useful for this reason. The second observation is that they make people who are normal, sick. They create the tranquilizer psychosis. The tranquilizer psychosis can be described as a syndrome of chronic fatigue, difficulty in concentration, indifference, apathy, lack of interest, decreased motivation, impotence and frigidity, and its accompanying neurological and other toxic effects such as t.d., blood dyscrasias, skin lesions, and obesity. Tranquilizers convert the original schizophrenic psychosis to the iatrogenic tranquilizer psychosis.
This is the situation. The psychosis becomes unbearable either to the patient or to society or to both, and treatment is initiated. The drugs rapidly reduce the intensity of the psychosis, which makes them desirable for their psychiatrists and for society, and in most cases for the patients as well. The path toward normality is started. But as the patient continues to improve, s/he approaches a dividing border where s/he is more normal than psychotic and begins to suffer the appearance of the tranquilizer psychosis. Eventually most of the original psychosis may be gone, but it will be replaced by the full intensity of the tranquilizer psychosis.
Psychiatrists try to deal with this by decreasing the amount of drug, and this will work for awhile. However, if the patient is still biochemically sick the psychosis will emerge once again. This is called a relapse. Thus the unhappy patient oscillates, like on a swing, between approaching the original psychosis or approaching the tranquilizer psychosis. There is no relief and this becomes the basis for the revolving door syndrome. In essence, patients prefer to be well which they cannot achieve, while psychiatrists realizing they can not make them well, prefer for them to have the tranquilizer psychosis. This is forced on the patients by the use of legal pressure and long-acting injectible tranquilizers.
The solution is simple. Use a treatment which will keep the patient well even after the original psychosis has been vanquished. This is where orthomolecular psychiatry plays its major role. By combining it with the drugs, the rapid action of the drugs is used to give the patient and family quick relief. As the drug is withdrawn, the nutritional treatment combined with the megadoses of vitamins B-3 and B-6 maintain the state of health. Patients no longer face the choice, should I be psychotic as I was, or should I be psychotic because of the drugs I have to take? Their new choice will be simple. Should I remain well on vitamins, or should I allow myself to get sick again by stopping my program?
J's family, by seeking additional help, by paying for his visits to Victoria, by discussing the new treatment with his physician, and by paying for his vitamins (these are not covered by drug plans even though tranquilizers are, no matter how costly), have, in fact, saved his sanity and his life. They have saved their province about 1.5 million dollars. For this they will receive no recognition or gratitude from their government, nor from the many psychiatrists who treated him unsuccessfully. The credit for J's recovery must be given to his family, to his physician, and lastly to the orthomolecular program his physician supervised so well and so carefully. Had his physician been more familiar with the program he would have done as well, and there would have been no need for J to come to Victoria.
I have selected this case because my personal role as a therapist has been minimal. I do not think three visits will have much of an impact on a chronic schizphrenic. In the past when psychiatrists found my patients well they were honest and admitted this, but then added -- the vitamins had nothing to with it: it was my personality. Gratifying perhaps, but totally wrong. Or they would fall back on an old favorite -- to deny the patient ever had been schizophrenic. This reminds me of the case of a bright student who had recovered from schizophrenia and had applied to Harvard Medical School. The admissions committee wanted him because he was intelligent and because he carried a famous name, but they had a policy of not admitting schizophrenic patients. They resolved this conflict by telling the candidate that since no schizophrenic had ever recovered, and since he had recovered, it was obvious he never had been schizophrenic; he was admitted to the school. He is still practicing m edicine.
A. Hoffer, PhD, MD
Suite 3 - 2727 Quadra Street
Victoria, British Columbia V8T 4E5
(1.) Vonnegut M. A Letter to Rob. J. Orthomolecular Psychiatry 2:667-71, 1973.
(2.) Rickie. With Recollections by Rickie Flack Hartman. Ballantine Books, New York, 1990.
(3.) He gave me the copy, signed, he had brought with him when he gave a week of seminars in Saskatchewan in 1951. It is an excellent little manual. I regret I have lost my copy and I suspect very few psychiatrists have ever seen it. I recommend it for its clarity and wisdom. His mental state is in agreement with the John Conolly definition published about 150 years ago.
(4.) This is described in http://www.islandnet.com Under Members Mall, Health and Medicine, Softtec Ent.HOD
(5.) Hoffer A, Kelm H & Osmond H: The Hoffer-Osmond Diagnostic Test. RE Krieger Pub Co. Huntington, New York, 1975. Available from Behavior Science Press, 3710 Resource Drive, Tuscaloosa, AL 35401-7059.
(6.) El Melegi AM & Osmond H.: A Manual for the Clinical Uses of the Experiential World Inventory. Intuition Press, PO Box 404, Keene, NH 03431.
(7.) Hoffer A: Common Questions on Schizophrenia and Their Answers. Keats Publishing, Inc., New Canaan, CT, 1988.
Hoffer A: Orthomolecular Medicine for Physicians. Keats Publishing, Inc., New Canaan, CT, 1989. Hoffer A: Chronic Schizophrenic Patients Treated Ten Years Or More. J. Orthomolecular Medicine, 9:7-37, 1994.
Hoffer A & Osmond H: How To Live With Schizophrenia. University Books, New York, NY, 1966. Also published by Johnson, London, 1966. Written by Fannie Kahan. New and Revised Edition, Citadel Press, New York, N.Y. 1992.
Townsend Letter for Doctors & Patients.
By A. Hoffer