Rethinking and Redressing Misconceptions of Schizophrenia
Popular culture is rife with depictions of mentally ill people as villains or lesser unpredictable cogs liable to unleash havoc or render considerable harm to some unsuspecting victim. I find this perplexing. In my experience, the villain in a psychological thriller is often a person with antisocial personality disorder. These are termed psychopaths or sociopaths. Pray do not forget the impersonal notoriety and brutality of Hannibal Lecter, Francis Dollarhyde or Jamie Gumm. They are villains in Thomas Harris’ novels who were as apathetic and misanthropic as they were vicious. They may also be someone psychotic, schizophrenia proving a neat fit justifying the character’s ulterior motives.
Schizophrenia is a mental illness experienced by a small segment of the population. It is a widely known mental illnesses. The Diagnostic and Statistical Manual of Mental Disorders (DSM V) classifies it as part of the spectrum of psychotic disorders. Its onset is in the early to mid-twenties in males and late twenties in females.
An Unfair Portrayal
I often wonder why schizophrenic individuals are portrayed in fiction as devious and unpredictable, basing their ‘heinous’ acts on illusory beliefs. “Movies are made to make money,” Dr. Henry Holcomb, a psychiatrist who sees schizophrenic patients at MedPsych Inc. says, “they are not documentaries, do not set out to display certain archetypes that are the normal abnormal or normal schizophrenic.”
I share culpability. I admired Heath Ledger’s ‘Joker,’ the antagonist in Christopher Nolan’s critically acclaimed film “The Dark Knight.” It tacitly mentioned his diagnosis as a paranoid schizophrenic. Curiously, none of his actions seemed the workings of such nor were any symptoms depicted. It didn’t stop there; John Nash’s visual hallucinations depicted in the Ron Howard-directed biopic were so enchanting that anyone could easily be spellbound and forget the anguish and despair he must have suffered.
The public often seems awed and overtly cautious when disordered individuals speak to themselves or some unseen party or act erratically. They seldom present any definitive danger. Still, the very psychotic symptoms that stir the public’s curiosity cause their aversion. In a 2004 study investigating stigmatization, subjects were tested on their attitudes and emotional disposition towards a theoretical paradigm of a schizophrenic individual. To evaluate the public’s “social closeness” to the affected, it also assessed public opinion of psychosis. It seemed the more a public member was informed about mental illness, the more “social distance” they placed between themselves and psychotic individuals. However, in Thomas Insel’s opinion, the “negative symptoms (loss of will, anhedonia, poverty of thought) and cognitive deficits (reduced working memory, poor cognitive control) are core features of the disorder that account for much of the long-term morbidity […].”
Through the Looking Glass
The Human Reflection Staring Back
“The voices are gone. My thoughts are hollow; there is only emptiness now,” said Thomas Hurst when I asked how he had been feeling for the past month. “I guess the medication is working. But I am still unwell. I feel depressed and have no energy to wake up or even shower.” Thomas, my friend of two years, had survived his first psychotic episode yet had not emerged unscathed. He clearly was not out of the woods. I was perplexed. Why would a diagnosed paranoid schizophrenic individual experience low mood? Was the depression comorbid? I later learned that there was far more to the illness than imagining things and hearing voices. Though unapparent then, Thomas was experiencing several inclusive symptoms within the symptom spectrum of schizophrenia.
Schizophrenia is considered to have positive and negative symptoms. Positive symptoms are not normally present with ordinary function. By contrast, negative symptoms are a loss of a function normally present in a physiologically intact brain. As per the DSM V, positive symptoms include psychosis either as delusions (bizarre thinking and beliefs) and hallucinations (“perception-like experiences that occur without an external stimulus”), disorganized thinking and speech. Negative symptoms include diminished facial expression in expressing emotions, avolition (a persistent lack of motivation to act), limited eye contact, reduced amount of speaking and a reduced receptiveness to pleasure. Despite this caveat, it is evident that delusions and hallucinations continue catching the notice, fancy, and dread of the populace.
Thomas and I had immediately hit it off when we first met. He was amicable yet noticeably peculiar. He was earnest and sincere to levels that social etiquette forbade. I couldn’t help but take to him. As fate or circumstance would have it, we suffered from two different mental illnesses yet experienced psychosis in common. During our interaction, it appeared his experiences were far more tumultuous than mine. “Three unruly men live inside my head, giving me a running commentary about each other and myself,” he said once, “I haven’t time to my own thoughts. It’s always loud and chaotic.” Antipsychotics were a temporary solution or more aptly a glaringly inadequate part of it.
When his psychosis subsided, his negative symptoms became prominent. He had low motivation and was taciturn, heavily disinclined to speak or be engaged in conversation. “Often times anhedonia (the loss of pleasure) and avolition are mistaken in schizophrenic individuals as depression and deflated motivation,” says Emily Mendez, a fourth year MD/PhD student at the University of Texas school of medicine at Houston, where her study focus is in psychiatric genetics.
The Truth(s) about Schizophrenia
Positive symptoms diminish over time. “Symptoms like word salad, bizarre gestures, posturing, catatonia, unusual ritualistic behaviors change over time to being less dramatic, less conspicuous,” Dr. Holcomb adds. With these diminishing or managed by antipsychotics, negative symptoms become prominent. These are more difficult to treat.
“In general, most therapists are reluctant to tend to schizophrenic individuals because most established forms of psychotherapy do not adequately treat their symptoms,” says Dr. Ling Wu, a psychotherapist also affiliated with MedPsych Inc.
“Cognitive Behavioral Therapy is limited in treating symptoms,” Mendez continues, “but it rarely helps with negative symptomatology.” In fact, only one consensus treatment is prescribed in practice. “With predominantly negative symptoms, patients are likely to be placed on Clozapine, an antipsychotic. It works somewhat but presents a lot of side effects and isn’t preferable,” Mendez adds. I then attempt a mental tally of how many prescriptions treat positive versus negative symptoms. Were it not so tragic, it would seem a farce.
Why then is it so difficult to ameliorate negative symptoms? “It involves targeting systems for reward mechanisms which have common neurocircuitry that give rise to positive symptoms, making them difficult to treat,” says Professor Akira Sawa, a psychiatrist and faculty member at the Johns Hopkins school of medicine. “Schizophrenia is basically too much dopamine in certain brain circuits and too little in others. Depleting dopamine with antipsychotics means not enough in separate circuits to enhance motivation or even drive the experience for pleasure.”
The last I heard of Thomas, he had experienced his fourth psychotic break, lost his employment and moved back in with his parents. The psychosis was reined in with some effort, but dejection and misery took center stage. In our last conversation three years ago, his voice seemed a monotone drone; he was the least bit invested.
“Intrusive thoughts of a repetitive and controlling nature are especially common in schizophrenia,” Dr. Holcomb says in conclusion, “but it is the loss of motivation coupled with diminished sociability, anhedonia and emotional aridity that is most challenging.”