Damaging perceptions of schizophrenia

MEDICAL MATTERS: Confounding stereotypes of 'split personalities'

THE FIRST person I came across with acute schizophrenia was my own age. I was in my penultimate year in medical school; he was an engineering student who had been admitted to the ward the night before. I was asked to meet him with a view to “presenting” him to the team I was attached to.

Quiet and shy, he consented to my taking his history; initially I wondered why he was in the psychiatric unit, but a pattern of altered thinking slowly emerged. Eventually he shared his primary delusion: that he was Christ and he had returned to earth to try to get younger people to return to their faith.

He was quietly convinced of this “fact”. For many weeks he stuck to his belief, one of the features of a delusion, which is defined as a fixed idiosyncratic belief unusual in the culture to which the person belongs. For me, despite my book knowledge of the illness, the vocalisation of his delusion seemed unreal and, I have to say, unsettling.

Over the following two months I met other patients with delusions and it became easier to accept the depth of faith that some had in the most bizarre beliefs. Along with hallucinations, delusions defy logic and may lead to public fear of people with schizophrenia. Sensationalist media reporting has fed the myth that people with schizophrenia are dangerous, facilitated in some way by having a “split personality”. In fact, violence is rare among sufferers.

I have looked after many people with schizophrenia since that first encounter. Those with the chronic form of the disease tend to have reduced motivation and diminished emotional expression. This may lead to sufferers becoming indifferent to social contact and emotional interaction. In psychiatry, these are referred to as “negative” symptoms as opposed to the “positive” ones such as hallucinations, disordered thought processes and delusions.

Once successfully treated, some people actually miss their delusions. Delusions of grandeur are not uncommon; in one case, a man who thought he had special powers and had been chosen to save the world felt bereft to the point that life as an ordinary person living in a homeless shelter had lost its purpose. Another patient described how the voices he was hearing were nice to him and now that they had gone he felt lonely without them.

However, many delusions are disabling. One woman wakes up every morning believing she is being called to a child protection trial and spends the day writing down the evidence she will give in court. She had an abusive childhood and so her delusions may be her way of working through her past. In another case, a woman has a fear of being attacked from behind and so will not sit with her back to any window; she won’t travel in the front seat of a car for the same reason.

Hypochondriacal delusions, especially those associated with de-personalisation and a loss of identity, can be especially disabling. And paranoid delusions usually centre on a conviction that the person is someone of great importance and, because of that, is being persecuted, despised and rejected.

But the treatment of schizophrenia and other disorders that cause delusions has moved on in leaps and bounds. The latest anti-

psychotic medications have less disabling side effects and seem to combine an ability to dampen down hallucinations and delusions while simultaneously encouraging social interaction and emotional expression. Probably the most effective intervention is that of a good team of nurses, occupational therapists and social workers, whose ongoing involvement with the patient engenders a sense of care, trust and some degree of acceptance.

A lot of people get to a point where medication manages their symptoms and they can live independently or in supported living arrangements. Lots of people have jobs, or volunteer. Lots have relationships. I came across a young man recently who is thinking about using online dating to find a partner. He has decided to openly state on his profile that he has schizophrenia. He reckons people are open about being alcoholics or drug addicts in recovery, or having an eating disorder. How right he is.