Schizophrenia among us

I met a young man recently in a setting having nothing to do with psychiatry or mental health. He politely introduced himself and tried to learn the names of the others around him. He seemed socially awkward but inoffensive, and after I left I didn’t give the encounter much thought. However, I learned that soon thereafter he showed increasingly odd behavior. He talked to himself, breached social boundaries, and acted aggressively for no apparent reason. Others had to keep an eye on him, and eventually he was escorted peacefully off the premises.

The possible causes of such behavior are myriad: brain injury, psychotropic drugs, medical illnesses such as delirium or thyroid disease, and many others. One possible cause is mental illness, specifically schizophrenia. Schizophrenia is surprisingly common, affecting over 1% of the total population. As with many other disorders, schizophrenia can be mild or severe. Only a small minority of sufferers are institutionalized; the great majority live in society with everyone else. The class of medications called neuroleptics (anti-psychotics) have helped to make this possible, although some people with mild schizophrenia can function without medication.

I do not know whether the young man I met has schizophrenia. It would be presumptuous of me to attempt to diagnose someone I met only briefly in a social setting. But our meeting did spark some thoughts about the symptoms and deficits of this disorder.

A major hallmark of schizophrenia is auditory hallucinations (voices). When people “talk to themselves,” particularly if they do so without regard to others noticing, it may be in response to hallucinated voices. The voices can be ignored for a while if they are not too severe. At the other extreme, if insistent voices command the person to hurt himself or others, this is a very serious situation that usually requires hospitalization. Medications are often helpful in quieting auditory hallucinations.

(Thanks to cellphones, particularly those with wireless headsets, people seen “talking to themselves” could simply be on the phone.  More than once I’ve passed someone on the sidewalk and assumed one of these scenarios, only to realize seconds later it was the other.)

Delusions are also prevalent in schizophrenia, as well as in other disorders such as delusional disorder and manic psychosis. Medications help with delusions too, but not as quickly as with hallucinations.

There are also “negative symptoms” in schizophrenia which include lack of emotional expression and a decreased ability to initiate action or speech. These are more resistant to medication, although the “atypical” neuroleptics available for the past 15 years are of some benefit.

More subtle are the “thought process” changes in schizophrenia, and these are what came to my mind regarding the young man I met. Classically, schizophrenic thought is described as concrete. The ability to think abstractly, metaphorically, and symbolically is impaired. For example, in psychiatric evaluations patients are sometimes asked to interpret a proverb such as, “People in glass houses shouldn’t throw stones.” While most healthy individuals understand this is not literally about glass houses, many with schizophrenia will say something like, “because the glass will break.” Likewise, people with schizophrenia often cannot understand jokes or indirect references in the speech of others.

It is a sad and isolated existence to be cut off from so much human interaction, unable to share in common emotional experience.  Much of the meaning and flavor of life is contained therein.  This is not to say that people with schizophrenia cannot lead productive and meaningful lives.  They can, but it’s hard.  My “up close and personal” encounter with someone possibly suffering these challenges reminded me that compassion, not fear or disdain, is the most apt response to the tragedy of schizophrenia.

4 comments to Schizophrenia among us

  • Catrenia

    Can bipolar escalate to schizophrenia?

    • The short answer is no. They’re two different things: People with bipolar disorder usually connect well to others, but people with schizophrenia have an inability to connect well. Schizophrenia classically produces obvious symptoms starting around age 20, while bipolar disorder has a wider range of onset. Bipolar disorder produces extreme moods and affect (expressed emotion) while schizophrenia produces flattened or blunted affect. They both run in families, but they tend to run in different families.

      On the other hand… the DSM-4 has a diagnostic category called schizoaffective disorder for people who seem in-between. And sometimes schizophrenia comes along with a lot of agitation, which makes it look like mania. And both can produce psychotic symptoms, like auditory hallucinations (voices) and delusions. There are some psychiatrists who believe these disorders lie on a continuum or spectrum. I personally do not think so, and therefore I would say that bipolar disorder cannot escalate to schizophrenia.

  • i have a “situation” where i am rooming with my daughter, sharing a house for economic purposes…she has this “friend” that just by observing his behavior, is borderline schizophrenic and i say that because he is experiences both auditory hallucinations and is delusional. i haven’t continued reading the “manic psychosis” link in your reply dr. stephen and maybe i ought to before i try to make a completely amateuristic diagnostic statement about him but is there a characteristic of schizophrenia that covers “episodes” of violence and escalated outbursts that come in waves? like every 2 days or so? i only recently started recording these “episodes” because i fear for my daughter’s safety and for his own safety too. We live in california and i was wondering if there is any way or anything that i can do to help this person in getting a medical evaluation instead of the only other option we have and that’s a nine one one call for intervention by law enforcement. i don’t think law enforcement intervention is the answer because the way the system works he’ll only be incarcerated for a night or so and upon release could get even more violent dut to the going to jail thing. do you get my drift? the bottom line is this man neeeds help and 911 ain’t cutting it. he needs to be “5150” -ed …how do i do that? i’m only a concerned roommate/mom…

    • Although auditory hallucinations and delusions are common signs of schizophrenia, they can occur for other reasons too. Manic psychosis (now called bipolar disorder with psychotic features) is one possibility. But with outbursts that “come in waves” every two days or so, other possibilities are more likely. For example, drug use. Amphetamine psychosis looks very much like a primary psychiatric disorder, except it may come and go quickly. Hallucinogens create hallucinations by definition. Even severe alcoholism can eventually lead to hallucinations and delusions. Various kinds of brain injury and seizures could also do this. In short, it is impossible to diagnose this person’s problem without an in-person evaluation.

      How to get that evaluation is a hard question. If you or your daughter could convince him to see a psychiatrist voluntarily, that would be best of course. The only way in California to have him evaluated involuntarily is with a 5150, a 3-day psychiatric hold. Unless he is already connected with mental health services, you will probably need to call 911 for that, and he will only be held if he is judged to be dangerous to himself (suicidal), dangerous to others, or “gravely disabled” (unable to provide food, clothing, and shelter for himself). Many people who suffer hallucinations and delusions do not meet 5150 criteria, and therefore can refuse evaluation. If you or your daughter feel unsafe, please avoid this person, and call 911 if he persists.

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