Putting the science in fiction - Dan Koboldt, Chuck Wendig 2018
Schizophrenia
The brain is wider than the sky
By Jonathan Peeples
Schizophrenia is probably the most difficult psychiatric condition to write about because there’s so much we don’t understand. Though we’ve made tremendous strides in recent years, we still don’t know exactly what causes it or why it may affect one person and not another. Genetic studies have suggested that what we call schizophrenia probably represents several distinct disorders, each with its own set of symptoms that may respond very differently to medication. In addition to the numerous uncertainties, it’s also incredibly challenging for a writer to accurately present the thought process of someone who has the disease.
There’s no way for me to capture all of the complexities of schizophrenia in this chapter. Research studies often yield conflicting findings, and leading academics may disagree on anything from causative factors (e.g., adolescent marijuana use) to treatment efficacy (e.g., whether clozapine really statistically separates from the rest of the antipsychotics).
The condition is further confused by its portrayal in film and literature. Sometimes a work may explicitly state that a person has schizophrenia (Sylvia Nasar’s A Beautiful Mind [Simon & Schuster, 1998]), but often the viewer assumes that any time a character is a psychotic murderer with seven personalities, he has schizophrenia. That’s just not the case.
I want to use this chapter to describe what schizophrenia may look like, rather than talking about its biological basis (which is imperfectly understood). The most important thing that I want to convey is that the patients I’ve worked with are not “schizophrenics.” One patient wanted to become a great tennis player. Another spent eight hours a day writing books. I’ve met with a business owner, a thrift store worker, a college student, a musician, a custodian at Wendy’s, and a sculptor. Schizophrenia is a tough illness, and they were all fighters. Don’t use schizophrenia as a cheap plot device. People with schizophrenia are complex—with hopes, dreams, goals, and desires. Whatever you do, please don’t lose sight of that.
Is schizophrenia having multiple personalities?
Definitely not. I’ve heard many people use the two interchangeably, but they’re totally different disorders. The idea of “multiple personalities” is most similar to a condition called dissociative identity disorder (DID) in which a person has two or more distinct personality states. DID is much rarer than schizophrenia.
Is psychosis always schizophrenia?
No. In fact, “psychosis” can be seen in a number of different situations. Severe depression or mania can have psychotic features. Hallucinations are present in a variety of conditions. Sudden-onset hallucinations and behavioral changes are more suggestive of substance use or medical problems (e.g., delirium, brain tumors) than primary psychotic disorders. You can also see hallucinations in alcohol withdrawal, various dementias, and as side effects to some medications. It’s important to rule out medical causes of psychosis before giving a diagnosis of schizophrenia.
Hallucinations are often reported by people with personality disorders and can be a manifestation of primitive coping mechanisms. There are also various internal and external incentives to having a diagnosis of schizophrenia such as disability payments, seeking inpatient hospitalization to avoid being homeless, and taking on a “sick” role. There are probably hundreds of thousands of people in the United States who are unnecessarily subjected to the damaging side effects of antipsychotics due to inaccurate diagnoses.
Who gets schizophrenia?
A commonly cited number for the prevalence of schizophrenia is 1 percent, though there’s some variation across countries. It’s not entirely clear what causes this variation, but some of it may be due to inconsistent diagnostic procedures and different exposures to risk factors.
Schizophrenia has a usual onset of early twenties in men and late twenties in women. Late-onset schizophrenia (over age forty) is much more common in women than men, though its features are different than typical schizophrenia and may have a different biological basis.
There are definite genetic links to schizophrenia, though many people with the illness have no family history. If a person with schizophrenia has an identical twin, that twin has about a 50 percent likelihood of having schizophrenia as well. This shows that while there’s certainly a genetic component, other factors are at play. Increased paternal age, hypoxia (lack of oxygen) during birth, and early marijuana use are thought to be contributing factors.
What does schizophrenia look like?
As mentioned earlier, schizophrenia likely represents several distinct disorders that we group together based on clusters of symptoms such as delusions, hallucinations, disorganized thinking, disorganized motor behavior, and negative symptoms. Not everyone with schizophrenia has all of these symptoms, but they must have some of them to get the diagnosis.
Delusions
Delusions are fixed beliefs that don’t change even when someone is presented with conflicting evidence. There are many types of delusions. I’ve seen patients who were convinced that certain criminal organizations were trying to kill them. One patient was severely distressed because she believed she’d given a little boy AIDS through a blood transfusion. Patients may believe that famous people are in love with them. I’ve seen two instances of a rare condition called a Cotard delusion where the patients believed they were dead, though neither had schizophrenia (one had bipolar disorder and the other had major depressive disorder).
Hallucinations
Hallucinations are perception-like experiences that occur without an external cause. As I’ve mentioned earlier, hallucinations can be seen in a variety of mental and physical conditions. Hallucinations during alcohol withdrawal, substance intoxication, and medical illness are often visual, but auditory hallucinations are more common in psychotic disorders, like schizophrenia. Though auditory and visual are the most common types of hallucinations, hallucinations can occur in any sensory modality (e.g., tactile, olfactory).
Disorganized Thinking
Disorganized thinking really stands out during the diagnostic interview. The patient may jump from one subject to the next without any clear connection between the two topics. Sometimes the patient is so disorganized that even his words don’t fit together to make a coherent sentence. It’s important to check for substance use because people who are intoxicated on certain drugs can present very similarly.
Disorganized or Abnormal Motor Behavior
Abnormal motor behavior can present in different ways, but I want to focus on something called catatonia. Catatonia can be seen in a number of medical and mental disorders, including schizophrenia. Presentations of catatonia can be very different, but you may see catalepsy (rigid, fixed posturing held against gravity), waxy flexibility (slight, even resistance to positioning by the examiner), mutism, posturing, echolalia (mimicking another’s speech), and echopraxia (mimicking another’s movements). Though catatonia is often thought of as having a lack of motor activity, people can also be in a state of over-activity with repetitive, purposeless movements. Treatment usually involves benzodiazepines, though electroconvulsive therapy can be used for resistant cases. It’s also important to identify and treat the underlying cause.
Negative Symptoms
Negative symptoms are especially prominent in schizophrenia and can manifest in a number of ways. People with schizophrenia often show diminished emotional expression on their faces, which can be described as a “flat” or “blunted” affect. They may also seem less motivated and display decreased engagement in self-initiated purposeful activities. Negative symptoms are some of the most difficult features to treat.
Schizophrenia spectrum timelines and diagnostics
There are several psychotic disorders that fall under the schizophrenia spectrum, but the ones I want to discuss are brief psychotic disorder, schizophreniform disorder, schizophrenia, and schizoaffective disorder. These disorders are organized by different timelines of symptoms because chronicity of psychosis has implications for long-term prognosis. The longer a person is psychotic, the lower the chance is that she will have a complete recovery.
· BRIEF PSYCHOTIC DISORDER occurs when someone experiences one of the psychotic symptoms described earlier for longer than one day but less than one month.
· SCHIZOPHRENIFORM DISORDER is diagnosed when someone experiences two (or more) of the psychotic symptoms described earlier for at least one month but less than six months. If a person is only experiencing delusions and no other psychotic symptoms, she can be diagnosed with delusional disorder instead.
· SCHIZOPHRENIA is similar to schizophreniform disorder, but the symptoms must have been present for at least six months. Sometimes a person may have only had full-blown psychosis for one month, but if he’s shown a gradual decline in functioning for more than six months, he can still be diagnosed with schizophrenia.
· SCHIZOAFFECTIVE DISORDER is diagnosed when someone meets the criteria for schizophrenia but also has a major mood episode (e.g., major depressive episode, manic episode). It’s important for the delusions or hallucinations to exist outside of the mood episode, otherwise the person may be experiencing psychotic features related to severe depression or mania, not schizophrenia. I have patients who come in all the time saying they have “bipolar schizophrenia.” Though it’s a commonly used phrase, it’s not a diagnosis. The correct term is schizoaffective disorder, bipolar type.
Wrapping up
Above all else, I encourage writers to respect the individual with the illness and to create characters who are real people with real hopes and dreams. People who have schizophrenia often feel that they’re alone or not heard, and authors should do whatever it takes to retain their humanity.