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In Transition

Schizophrenia - Are We on the Same Bus?

by

Dr. Peter Melgaard Thompson

At the heart of what we are lies two intersecting concepts: how we see ourselves and how we relate to the world around us. These concepts are dependent on shared beliefs. I know who I am. The world (or that group that cares) knows who I am. In fact we agree on most things, e.g. the color of the sky, to say hello when we see people we know, etc. What happens if either the world or I disagree on the shared beliefs (this does not suggest that we cannot disagree on minor issues such as salary and who is responsible for the household chores)? Well, I for one would be very unhappy. My family would also be unhappy and the world would wonder what to do with me. Now let me magnify the disagreement to the point that I experience an entire body of events that the world around me cannot hear, see, touch or smell. The unhappiness increases exponentially and the world's confusion will reach such a state that, well, the people around me will throw up their hands and call it an illness. Schizophrenia is an illness that in its severe form robs the victim of both sense of self and connectiveness to the world. Of all the mental illnesses only this one can steal one's humanity.

Most times I say things like this, the response is "gee (well they do not actually say gee any more), thanks for the metaphysical session, but what are you saying"? Another way of saying all this is that schizophrenia is a group of illnesses with unknown causes that affects the brain. The changes in the brain (neuronal proteins, cell types) cause a wide range of symptoms that interfere with how we get along in life. The evidence of pathology in schizophrenia is both overwhelming and elusive. Without going into detail, brain areas that are responsible for emotions and thinking (frontal and limbic lobes) are altered.

The symptoms of schizophrenia impact how we think (cognition), what we think (positive symptoms) and what we do not think (negative symptoms). Positive symptoms are the most recognizable part of schizophrenia, but are not a prerequisite. These symptoms are the psychosis and range from bizarre thinking (not just odd, but way off base) to delusions and perception problems to hallucinations. The most common delusions are persecutory or paranoid. "They" (replace they with anyone you are frightened of) are after me, plotting against me. During WWII it was the Japanese or Germans. In the cold war it was the Russians and the CIA and now it's the terrorists. Also in the last 30 years, aliens have remained popular. I cannot prove that aliens do not fly around the world and try to control me, but for the life of me I sure cannot figure out why they would want to. As such, I am not going to spend any time thinking about it and so far this has worked out. Now if you have schizophrenia and this was the subject of your delusion you could not stop thinking about it. There are many other themes for delusions - in fact anything is fair game.

When I saw the movie Spiderman recently, it reminded me of a patient who truly thought he was Spiderman. Now on some level you might think this is funny. However, for this individual and his family it was horrible. He was sad because no one believed him. Because he was preoccupied with voices and delusions he was unable to work or keep an apartment. His family was devastated, he did not fit in, and they worried about him because he was unable to care for himself. In many situations the behaviors are so bizarre the family and the person with schizophrenia cannot function together. As in this case, my patient lived in a shelter and spent a great deal of time in the hospital, estranged from his family. Additionally, this individual also heard voices when no one else could. He thought that God was talking to him. At other times the devil would speak to him and call him incredibly obscene, hurtful names. Sometimes God and the devil would fight it out. Just hearing about this sounds terrifying; it is hard to image actually experiencing it.

In some cases the hallucinations and delusions are severe enough that all of reality is distorted. If the thoughts are self-persecutory, the patient may try to protect him or herself and become aggressive with disruptive behaviors. For example, if the person thinks a family member is trying to poison him, he may strike out first (not unlike lots of governments, but reality is often indistinguishable from fantasy). Or if he thinks the devil has invaded a family member, he may take bizarre actions to save him. Needless to say these thoughts disrupt life and can at times be dangerous to self or others. These types of psychosis are common in schizophrenia; fortunately only rarely do they lead to violence. Over reacting only worsens the situation by isolating family from the loved one. On the other hand if there is a history of violence, then the only prudent course is a cautious one.

In contrast to the illusions that often occur with people who are delirious, hallucinations can occur with any of the senses and are absent of external stimulation. Here external stimuli are misinterpreted, e.g. hearing angels singing when in the hospital and receiving large amounts of medication (a misinterpretation of background hospital noise). Auditory hallucinations are the most common in schizophrenia but these individuals can also feel bugs crawling on their skin or see things that no one else can see. The hallucinations do not occur by themselves but occur with other symptoms such as difficulty with organized thinking, disorganized speech and the loss of motivation.

This is more than the teenage puberty loss of motivation (which is really a shift in motivating objects); this is a major loss (avolition). Schizophrenics lose their motivation to interact with loved ones, work, school and life as we know it. Individuals with schizophrenia may also have a poverty of speech (alogia) and flattening of the affect. Affect is the outward expression and range of emotion. This group of symptoms is collectively called negative symptoms. These core mental abilities allow us to become emotionally involved with other people and show the world we are paying attention and are involved. When you say hello to the mail person, mother, father or significant other, you have an expression on your face. The person in reply says hello to you and has an expression on his or her face. Together the verbal and non-verbal communication says that I see you and that we are both here in this place. In schizophrenia this mental function is lost. Metaphorically, on the bus of life we either do not recognize them or they do not recognize us.

I hope I have begun to show you that schizophrenia is a serious illness affecting the brain. In its severe form it is devastating. The devastation occurs not only to the person who is afflicted but to family as well. The first major difficulty dealing with this illness is recognizing that an illness is present. The second difficulty is not being embarrassed or shamed about getting help. The third difficulty is treatment, but good news, bad news on treatment next time.