VOL: 98, ISSUE: 38, PAGE NO: 32
Peter Chadwick, PhD, CPsychol, is lecturer in psychology, faculty of continuing education, Birkbeck College, and the Open UniversityPeter Chadwick, PhD, CPsychol, is lecturer in psychology, faculty of continuing education, Birkbeck College, and the Open University
There are strong elements of mystery and puzzlement about the psychotic mind that almost inevitably alienate doctors, nurses and social workers when a person with a serious mental illness comes into their care. I was diagnosed as having a schizoaffective psychotic episode in 1979 and aim to demystify some of these elements using insights from my case and those of people close to me who have had similar experiences.
I hope that a first-hand account of what it is like to experience a psychotic episode will help health care professionals to empathise with this client group as greater understanding will benefit the treatment and recovery processes associated with psychosis.
Although it is a jargonistic term, 'existential fragility' is a phrase that can mean a lot to people with a diagnosis of schizophrenia. I remember feeling this fragility. I often saw myself as 'a hole in space', insubstantial and not really 'there'. I used to be pleasantly surprised when cars stopped for me at zebra crossings because it proved that I existed. They could see me. I also remember that when I did a lot of weightlifting it helped me feel more 'solid'. It was as if I had greater presence.
This notion of fragility is alien to most people, but mental health nurses would do well to bear it in mind. The feeling is intensified if nurses talk over a patient's head as if they are not there. Being accidentally bumped into also reinforces it, as does dismissive behaviour or people forgetting things you have said.
When people are not really sure whether or not they exist they can come to regard careless, cruel or disinterested behaviour on the part of others as 'just what you would expect'. Most people would get angry if they were treated as though they did not exist, but a person with schizophrenia might not. Alternatively, he or she might be outraged because they are so sick of it.
Strategies to minimise stimulation
People with schizophrenia often say they feel overloaded with stimulation and are easily distracted. They may keep themselves to themselves or walk along the pavement with their heads down. They may prefer to be awake at night, when things are quiet, or to live permanently behind drawn curtains, even when it is sunny. They may prefer a pet to a person as a companion and generally restrict their interaction with the world. All this reduces stimulation.
The impact of everything seems three or four times stronger in the mind of a person with schizophrenia. Although some experiences can be pleasantly vivid and may even have a touch of magic about them, others are overwhelming. Motorcycles roaring past are ear-splitting, police sirens can be mind-blasting and even a dog barking can be seriously disturbing. One way in which people with schizophrenia deal with this is by living in their own (egocentric) world and keeping their attention very narrowly focused.
A person with schizophrenia has to use strategies to deal with how iridescent everything is but will never quite share another person's perspective or wavelength. This is partly because they cannot focus outside their own intense, preoccupying and distracting experiences. For the person with schizophrenia, the shouts and screams of children at a public swimming pool signal danger and threat rather than happiness and joyfulness; the wave machine is not fun but a potential killer. The bias is always in a negative direction and leans towards self-protection in a bewildering world. There is a constant, morbid fear of unfortunate consequences because anything could happen.
The problems of attention that have been mentioned can make a person with schizophrenia misunderstand or misinterpret everyday social interactions because his or her mind is not steady, calm or fully responsive to other people's concerns. The world, therefore, is always surprising, jolting, unpredictable, dangerous and frightening. Abuse need not be involved, even if it is sometimes a factor, to make a person fearful in this way.
But while people with schizophrenia may feel assailed on all sides, they are also assailed from within. For this client group, the boundary between self and other and the boundary between the unconscious and the conscious are more blurred and permeable than in the 'normal' person. This can give people who experience psychotic episodes greater access to the preconscious mind, which can result in enhanced creativity.
The permeability of the boundary between self and other can make people with schizophrenia feel 'eaten into', 'drained out' or 'taken over' by others, particularly if they are with them for long periods. A person with schizophrenia may also feel, after a long conversation, that they have taken on the other person's face or voice, especially if that person is talkative or overwhelming.
In extreme instances, this type of situation can bring on hallucinations or obsessive images. One way to deal with this is to have a social life made up of casual contacts. People with schizophrenia seem to prefer this and can be greatly disturbed by romantic relationships because they are so much more involving. Intense socialising may only be possible when the person is much stronger and when his or her boundaries are firmer.
At the opposite extreme, another consequence is that people without well-defined boundaries can try to 'merge' with other people and be overly demanding of their time and effort. This can result in health care professionals feeling pestered, invaded and destabilised. The psychologist Carl Rogers once had a disturbing experience of this kind with a patient and, for a time, feared for his own sanity. Establishing boundaries is essential when communicating with people with schizophrenia.
The difficulty people with schizophrenia have in demarcating and segmenting their experiences is similar to the problems they have with boundaries. In the thoughts of a person with schizophrenia, everything seems to merge.
However, this is also a feature of a mystical state. I remember being in Sweden on a research fellowship in the early 1970s and being prevented from writing up three years of research into single, separate papers as what I had discovered all seemed to be one great interconnected conflagration. I felt that I had to write either about everything at once - which is impossible - or about nothing at all. The only solution I could find was to create a monograph of coded and thematically labelled, but basically disconnected, paragraphs. I wrote pages of little snippets. I could not construct a smooth narrative.
After years of feeling on a different wavelength from the bulk of the human race, it is not surprising that delusional and paranoid fears take seed. Creativity is often a buffer against this, because if people feel that they are contributing creatively to the human endeavour it gives them a bond with society. It puts their experiences to some productive use, making them feel useful, helping to maintain self-esteem and keeping threatening, paranoid ideas at bay.
But even this can go wrong, particularly if that creativity falters or there is a genuine reason to feel rejected and persecuted. The sad fact is that people who are prone to schizophrenia do upset others. I did, and it is quite easy to think 'revenge is due and deserved'.
When in a delusional mood, a person with schizophrenia will feel that forces are gathering, gossip is going around, plans are being made and moves against them are gaining momentum. They will feel that 'something' is going on. The trigger for actual psychosis can be a coincidence, a delusional perception or a genuine threat.
All manner of things can trigger psychosis but the individual has to be primed for these incidents to dislodge his or her mental stability. Obscure statements heard on the radio can trigger a psychotic episode because the person is ready for them. They are like a key that fits into and turns a ready-made lock.
Strange though it may seem, delusional moods are worse than delusion. When the delusion crystallises, the person feels with a sense of relief: 'Ah, now I know what is going on.' The uncertainty is over and is replaced by the comfort of certainty. This 'comfort of certainty' is one of the reasons that delusions are so difficult to shift.
I have written previously on how a psychotic episode affects thinking (Chadwick, 1997; 2000; 2001). Schizophrenia does not mean 'split personality' in the sense of dual personality. It means 'fragmented mind', in which the individual experiences a looseness of association.
People with schizophrenia often use the word 'loosening' or 'feeling fragile' when they feel that they might be in danger of relapsing. For example, on receiving an airmail letter from a friend living abroad one woman started to feel that her friend could hear what she was thinking via the letter she had received. This is an example of loosening. Associations come too easily and too quickly, generating 'crazy connections'. Something of great emotional importance usually initiates this. In the example given, the friend was the woman's former lover who had moved abroad to live with someone else.
External locus of control
The term 'external locus of control' is another jargonistic phrase used in psychology but it is significant in understanding schizophrenia, particularly the paranoid mind. External locus of control relates to the feeling of a person's life being controlled by an outside force.
It is easy for people who feel threatened to think that other people are colluding against them. Ascribing great powers to external agents (for example, using advanced technology or great cunning) makes it easier for the person with schizophrenia to interpret almost anything that happens or is said as 'significant' or 'meaningful' and to see them as persecutory acts.
The external locus of control is what gives all manner of trivia, from the arrangement of milk bottles to things said on the radio, so much meaning. People may even feel that their thoughts are being controlled or monitored by external agents, which accounts for descriptions of thought insertion and thought broadcasting.
The experiences of people with schizophrenia exist on a continuum with normal functioning. Schizophrenia, creativity and spiritual experience are all intimately connected. This continuum model is a far greater antidote to stigma than seeing people with schizophrenia as categorically different from the rest of humanity because of their diagnosis.
Thinking in this way about the condition can help health professionals to realise that people with schizophrenia are kith and kin with the rest of the population and that they have abilities that can be used to enhance the future of our world.