SOCIALIZATION FACTOR (PART 1)

MAJOR MENTAL ILLNESSES WITH INHIBITION OF SOCIALIZATION-AND THE
BENEFIT OF ATYPICAL ANTIPSYCHOTICS

“NEGATIVE SYMPTOMS” OF SCHIZOPHRENIA and AUTISTIC SOCIAL WITHDRAWAL are two common examples of the brain’s capacity to have inhibited socialization. They are commonly seen symptoms; they persist for years; they cause extremes of functional disability; and they have been difficult to understand and difficult to treat. Recently there has been progress in treatment, and this has provided us a better understanding of the nature of the brain’s function in socialization behavior.

1-A1) NEGATIVE SYMPTOMS OF SCHIZOPHRENIA, Negative symptoms are the most specific and most persistent symptoms of schizophrenia. They are defined as follows:
“ Restrictions in emotional expression, fluency and productivity of thought and speech” (DSM IV: The American Psychiatric Association Press, Washington, 1994, Page 275).
They are called “negative symptoms” since they represent a lack or loss of normal behavior – thus producing a negative in the patient’s life. The original medications which helped schizophrenia, such as Haldol, are now called typical antipsychotics. They lowered psychotic delusions and hallucinations but were not often helpful in treating negative symptoms. However, they sometimes were; in the mid-fifties a Life magazine article described the successful use of the first antipsychotic, chlorpromazine/ Thorazine. One of the patients at a mental hospital in Traverse City, Michigan told of the effect of the treatment.

Case One
This patient stated that he had wanted to ask about the results of a ball game, but could not until he had received the Thorazine.
This case demonstrates the principle:
[1] That there can be normal socialization drives functioning in individuals with symptoms of serious mental illness, but they may not be able to be expressed to the outside world.

1- A2) ATYPICAL ANTIPSYCHOTICS” AS “PRO-SOCIALIZATION” MEDICINES IN SCHIZOPHRENIA.

Starting in the 1980’s a different class of medications was developed called the “Atypical Antipsychotics.” These medication helped schizophrenic patients have more natural tendency toward socialization and conversation. Though not able to bring about complete cures in many individuals, they represented a great improvement in the treatment of one of the most devastating mental illnesses. Far more schizophrenic patients were able to resume normal life routines.
A-3) EARLY EXPERIENCE WITH EXCESSIVE “PRO-SOCIALIZATION”. Clozapine/ Clozaril was the first atypical antipsychotic medication, but it had so many difficult side effects that it was used sparingly. Though it increased socialization somewhat, its major benefits over the previous typicals was its lack of movement side effects, its better treatment of psychosis, its benefit in lowering violence, and its ability to stabilize manic mood in Bipolar Disorder.
In the early 1990’S, a second atypical antipsychotic risperidone/ Risperdal was marketed. It was more socially activating as illustrated by a case presented at the time.

Case Two
A 40 year-old man had chronic Bipolar Disorder and was successfully treated with clozapine/ Clozaril to stop his cycles of mania. When risperidone/ Risperdal became available, he was switched from clozapine/ Clozaril to lower various side effects. However, the man began to display the intrusive, uninhibited behavior that he had formerly shown when manic. The rest of the patients in his treatment group complained about this behavior, and he was switched back to clozapine/ Clozaril. However, he could no longer stand the dullness caused by the clozapine/ Clozaril. His clinician then gave him a mixture of lower doses of both drugs – accomplishing balance of appropriate socialization with adequate social inhibition.
This case demonstrates several principles
[2]- That different medications have different abilities to enhance socialization.
[3]- That it is possible for medications to encourage inappropriate, disinhibited socialization .
[4]- That mania may represent a loosening of the natural regulation of socialization impulses.

1-B1) THE SOCIAL WITHDRAWAL SYMPTOMS OF AUTISM. Among the social withdrawal symptoms of Autism are the following. “ Delay in or the lack of development of spoken language—impairment in use of non-verbal behaviors (eye-to-eye contact etc.) --- lack of spontaneous seeking to share—lack of make believe or social imitative play.”
(DSM IV: The American Psychiatric Association Press, Washington, 1994, Page 66)

1-B2) AUTISM VERSUS SCHIZOPHRENIA. Autism differs from schizophrenia especially in the age of onset. Whereas Schizophrenia occurs mostly after the age of 15, autism begins either from birth or within the very early years before much individualized brain maturation has occurred. The brain of the schizophrenic individual had a number of years of apparently normal social experiences; that of the autistic individual did not. Though not called negative symptoms, the social withdrawal symptoms seen in Autism have many similarities to those seen in Schizophrenia. They both have limited speech – especially conversational speech; both have forms of self-stimulating behaviors; both have diminished emotional expression of caring towards others; both tend to be very much oriented to self-concerns. Medications which benefit one generally benefit the other.

1-B3) PRO-SOCIALIZING EFFECT OF ATYPICAL ANTIPSYCHOTICS IN AUTISM. Beneficial effects in autism may be nearly instantaneous as illustrated by the two examples given in the autism section of this web site.

Case Three
A 25 year old highly autistic individual who had Bipolar Disorder was mood stable on a complicated medication regime but still highly involved in autistic self-stimulation. In 1994, after 4 days of being on risperidone/ Risperdal at the dose of 1.0 mg a day, he came up to his mother and spontaneously hugged her for the first time.

Case Four
A 5-year-old girl with considerable autistic behaviors who normally spent her time running her hand along the wall, began moving into the play area of her day school and tolerating the presence of her school mates within a week of starting on 1/40 mg of risperidone/ Risperdal a day.
These cases demonstrate the following principles:
[5]- That there exists a drive for socialization in individuals while they are demonstrating autistic behavior.
[6]- That this socialization drive can suddenly be turned on to allow expression.
[7]- That low doses of appropriate medication can effect socialization changes.

1-C) EVIDENCE OF INHIBITION OF THE SOCIALIZATION FACTOR IN NON-AUTISTIC, NON-SCHIZOPHRENIC INDIVIDUALS—E.G. SOCIAL PHOBIA.
Atypical Antipsychotics also have demonstrated the ability to treat “ordinary” disorders such as the following cases of poor socialization and of “Social Phobia.”

Case Five
Seven year old boy, only obvious symptom was rare rage reaction, but mother noted him to be isolationist. For example, he would get his ice cream at the Dairy Queen, climb into the back of the pick-up, and march up and down alone like a sentry. When placed on1/8 mg risperidone/ Risperdal, he then got his ice cream, climbed into the truck bed, but soon knocked on window at his mother asking her to join him—so they could talk.

Case Six
In the early 90’s a 30-year-old male was seen for “refractory depression”. He stayed in his room, talked little, had a dull emotional reactivity but had no hallucinations or delusions. However, he became quite verbally and socially functional when placed on 150 mg clozapine/ Clozaril a day.

Case Seven
A forty-year old man never could stand in a line longer than 5 people. On 0.25 mg risperidone/ Risperdal, he went into the bank, didn’t bother counting the line, and was nearly to the front when he realized he had spent the whole time talking to the stranger in front of him.
There is an interesting feature of case 7:
He did not tolerate the dose of risperidone/ Risperdal being raised to 0.5 mg/d because he became socially intrusive—e.g. he cornered his landlord and spent 30 minutes complaining about everything he could think was wrong with the apartment complex.
These cases demonstrate the following principles
[8]- That various symptoms can result from having inhibited socialization.
[9]- That atypical antipsychotics can increase the capacity for socialization for individuals who are not schizophrenic.
[10]- That drugs with pro-socialization effects may cause an unacceptable over- stimulation of socialization drive.