On the beautiful mind

The mind can be thought of as the subjective experience of our stream of consciousness. What happens when our mind tells us that we can see and hear things that aren’t there? What happens when we start to lose touch with reality? This is psychosis and one of the most debilitating psychotic disorders is schizophrenia. The film “A Beautiful Mind” offers us a glimpse of the devastating effects of schizophrenia and how a remarkable man rose to overcome it, eventually triumphant as he accepts a Nobel Prize.

It is the late 1940s, and John Forbes Nash, Jr (played by Russell Crowe), having won the prestigious Carnegie Prize for Mathematics, had just arrived at Princeton University as a graduate student. From the start, it appears that the introverted Nash is not a people person and is excruciatingly awkward with the opposite sex. Nevertheless, he confides in his newfound roommate Charles Herman.

Nash is not content with the mundane part of university life – classes, preferring to devote his time and energy into the completion of his thesis, which he hopes will be a masterpiece. He then finds the inspiration for his novel idea in a bar – as his friends fight over how to tackle a particular blonde. He calls his idea “governing dynamics” and it is now known as the Nash Equillibrium in his honour. Wikipedia summarizes this theory in a succinct manner:

Stated simply, Amy and Bill are in Nash equilibrium if Amy is making the best decision she can, taking into account Bill’s decision, and Bill is making the best decision he can, taking into account Amy’s decision.

With his graduate studies complete, Nash accepts a job at the Massachusetts Institute of Technology. However, he is preoccupied with cracking numbers that he sees in newspapers and magazines in his office, causing him to neglect his teaching responsibilities. Despite this, he was able to fall in love with and eventually marry his student Alicia Larde (played by Jennifer Connelly).

He then believes that he was recruited by the Department of Defense in the Pentagon to decipher Soviet communication codes which are placed in the mass media. There, he encounters a shady man in a top hat, William Parcher who is later revealed to be a Pentagon official. Nash accepts his covert assignment and receives an implant in his forearm from the Department of Defense which allegedly functions as a listening device. Nash becomes increasingly fearful, especially after he believes he was chased by Russian operatives. His paranoid behaviour (turning off the lights, suspicion of people outside his house) alarms his wife. On his return to Princeton, he sees Charles Herman and his niece Marcee who is a young girl. As Nash is about to deliver a lecture, he is brought involuntarily into a psychiatric hospital.

It is then revealed that Nash had been living alone all the while at Princeton. His roommate Charles, his niece and even William Parcher were all hallucinations. Nash even tries to dig out the implant in his forearm with his bare hands, but fails as no such device was planted in the first place. His covert assignment about thwarting Soviet communications was only an elaborate delusion.

Nash is then subjected to a series of insulin shock therapies (which are no longer used today) and started on antipsychotics. His symptoms seem to subside and he is subsequently discharged, but nevertheless, problems soon arise at home. As a result of his antipsychotics, Nash feels his mind has become slow and he struggles with his calculations. He also loses his libido which strains his relationship with his wife. Nash decides to stop taking his pills, hoarding them in a desk drawer instead. Predictably, his paranoid symptoms and hallucinations return.

Nash’s relapse is finally realized by his wife when she noticed he had almost drowned their infant son. He then sees and hears William Parcher instructing him to kill her. She calls for his psychiatrist, but ultimately decides to live with his condition. Nash begins to gain insight that his hallucinations, especially the young Marcee, “never seem to get old”. He then starts to ignore his hallucinations even though they continued to haunt him.

In his later years, it appears that Nash is taking the “newer antipsychotics”. He accepts a teaching position back in Princeton, and in 1994 wins the Nobel Prize in Economics for his in “governing dynamics”, also known as game theory.

So, how accurate is the portrayal of schizophrenia in this film? As far as psychiatry is concerned, the film depicts Nash as having hallucinations (perceiving something through your 5 senses when there is nothing there) that are concurrently auditory and visual. These are actually rare, and the real Nash only heard voices (auditory hallucinations are the most common type of hallucination in schizophrenia). He starts to have persecutory delusions (that the Soviet are out to get him) and delusions of reference (believing that there are special codes in the newspapers that only he can decipher). His behaviour becomes erratic and he withdraws socially. The hallucinations and delusions also affect his work and relationship with his wife.

As mentioned earlier, insulin shock therapy is no longer used today. It was once used to treat schizophrenia, by method of injecting large amounts of insulin to induce coma and seizures. This was phased out by the developlment of antipsychotics and electroconvulsive therapy. Typical antipsychotics such as Haloperidol are effective in treating the hallucinations and delusions of schizophrenia but do cause the cognitive impairment and sexual dysfunction depicted in the film. More commonly, they cause extrapyramidal side effects which are problems with muscle tone and coordination. Newer “atypical” antipsychotics are also used today and they have less extrapyramidal and cognitive side effects but can cause weight gain and lead to metabolic syndrome.

In real life, it appears that Nash never took the supposed “newer antipsychotics”, it was added because the screenwriters were worried that it could send the wrong message to the public on the medication compliance. In the past, schizophrenia was traditionally seen as a chronic deteriorating illness (Emil Kraepelin), but this view is now changing. It is now believed that up to 20% of schizophrenics who suffer from acute episodes recover completely. A further 20% have recurrent acute episodes and 40% have a chronic illness. With the advance of biopsychiatry, the prognosis of schizophrenia has improved. Furthermore, Nash most probably suffered from the paranoid schizophrenia subtype, with its relative absence of catatonic and negative symptoms. This is the subtype of schizophrenia with the best prognosis.

Finally, the impact of schizophrenia on the family is dramatically shown in the character of Alice Larde, Nash’s wife who has to live with the paranoia and abnormal behaviour of a schizophrenic. Although in the film she was portrayed as a supporting wife, the real Alicia Larde divorced Nash, only to remarry him when he won his Nobel Prize in 1994. That’s why supportive psychoeducation on schizophrenia and mental illness is crucial for the recovery of patients. Without good social support, schizophrenics are less likely to be compliant and more likely to relapse.

Mental illness is still seen as stigma in society which paralyzes its sufferers. I think that the film “A Beautiful Mind” is a rare film that is both powerful, inspirational and has great value in educating the public on mental illnesses such as schizophrenia in order to erode this stigma.

The rise of Caroline Wozniacki

Caroline Wozniacki is an enigma. She is one of two Danes in the top 500 of the WTA rankings – the other has a current rank that is 476 places lower than her. She is the youngest player in the top 10 by a longshot – her closest competitor by age is Jelena Jankovic who in tennis years is practically middle aged at 25. And this Monday, she will be the 20th woman and first Dane to ascend to the top of women’s tennis, the 3rd to do so without ever winning one of the four grand slams.

Born in Odense, Denmark to Polish immigrants, Wozniacki took up tennis at a young age, eventually winning matches against her family members who were sports enthusiasts (Her father played professional soccer in both Poland and Denmark while her mother was on the Polish national volleyball team). In 2004 she won the Osaka Mayor’s Cup at the age of 14. 2 years later she would clinch the Wimbledon Junior’s Title. She turned professional in 2005 and her steady rise caught the eye of fashion designer Stella McCartney. Last year, she was named as the global face of Adidas’ Stella McCartney tennis line.

It is ironic that the woman she replaced is 13 time Grand Slam winner Serena Williams, because in many aspects she is the Anti-Serena. On the court, Wozniacki prefers to frustrate her opponents with her formidable defence, and then wear them down (a style of play some tennis fans mockingly call “pushing”). Rather than blast winners from the baseline, she often wins points by forcing her opponents to make errors. Her detractors will decry the fact that Wozniacki has not won a grand slam title, while Serena who is nearly a decade older has swooped to 2 major victories this year. But rankings measure success over 365 days and grand slams do not tell the whole story. It is difficult to argue with the fact that Wozniacki has had a dominant year. She has won 5 singles titles this year – more than any other competitor and amassed a win loss record of 54-15. Serena on the other hand has played few tournaments this year and has battled with a freak foot injury she sustained at a Munich restaurant in July. As a result, she hasn’t set foot on a competitive court since Wimbledon. In short, the rankings are not just about majors, its about consistency.

For Wozniacki, she has little time to bask in the success of her number one ranking. Her next goal is to prove her critics wrong by winning a grand slam. For fans of women’s tennis it will be interesting to see what Wozniacki can achieve in the future, as she is still only 20 years old. Nevertheless, this could mark the breakthrough of a younger generation of tennis players who up till now have been overshadowed by the alternating dominance of the old guard of Williams sisters, Belgians and Russians. In September during the Pilot Pen Tournament, she expressed her desire to apply to Yale University “to study business or management”. There’s no question that Wozniacki is one of the brightest young stars in women’s tennis. But previous slamless number ones (Jankovic, Safina) have since struggled to maintain their form. Another former number one Ana Ivanovic saw her game collapse spectacularly after her 2008 French Open win. Will Wozniacki be here to stay?

Reflections on the 8th Inter-Medical Physiology Quiz 2010

At the end of September, I was fortunate enough to be chosen to participate in the 8th Inter-Medical Physiology Quiz this year at Balai Ungku Aziz, University Malaya. A record 41 teams made the trip this year from a diverse group of countries including Sri Lanka, Japan, China, Australia and Romania. The written quiz was absolutely gruelling – a high level of understanding of physiology concepts was needed. Subsequently we were ranked according to the results from the written test.

Quiz day was a test of wits and nerves. The organizers decided to be autonomically sympathetic by making each participant stand to deliver an answer – much like a spelling bee. No discussion between team members was allowed, and penalties were given for incorrect “steals” by the opposing teams. Aggressive teams risked penalties for a higher reward while defensive teams could progress by watching aggressive teams self-destruct. This year, University Malaya clinched the Prof A. Raman Challenge Trophy, defeating a resurgent team from the University of Colombo, Sri Lanka.

The organizing team did a good job as well – they spent a lot on freebies and our accommodation at the rusty Wisma Belia was surprisingly cozy. I was proud that our team reached the quarterfinals of the competition and we exceeded expectations by topping the group during the first round. I hoped that I managed to improve my grasp of physiology despite the limited amount of time spent on the subject in my pre-clinical years.