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by Lawrence A. Slager, M.S.W., A.C.S.W.
Imagine you have just awakened from a nightmare so real it took a few
moments to realize it was just a dream. You are confused and frightened
from misperceptions of sight or sound. Then relief sweeps over you as
you sort reality from unreality.
Contrast your relief with what it would be like if the nightmare continued
after you woke up. Add hearing voices others do not hear. Pretend you
think a tragedy will strike a loved one unless you carry out certain actions
others misunderstand. Or you are convinced you have discovered the key
to the universe. You have a mission to persuade others of ideas that seem
strangely unintelligible to all those around you.
This gives you some idea of what the person suffering from schizophrenia
experiences during the most intensely disturbing phase of the illness.
It is like a nightmare, but daylight brings no relief.
Probably the most challenging problem mental health professionals face
is caring for and treating those with schizophrenia. Schizophrenia is
one of the least understood and most frightening of mental illnesses.
One out of every 100 Americans will be afflicted by the disease during
his or her lifetime. Each year, another 100,000 Americans are diagnosed
with this disabling condition. Most typically, the first episode of major
symptoms occurs during young adulthood, between ages 18 and 25.
Added to the tragedy of the schizophrenic disease is the stigma people
afflicted and their families bear. For centuries, people have misunderstood
schizophrenia. Our limited understanding-together with myths and misconceptions
fed by sensational news reports-encourages a mystical perspective on this
disease.
Many people think schizophrenia means a person will be violent or have
a split personality. Believing they may have contributed to the development
of the illness, families often feel devastated.
In fact, schizophrenia is a brain disease that develops from causes we
only vaguely understand. Research does not prove that poor family relationships
cause it. Neither does stress cause this perplexing disease. Some schizophrenics
may be violent during the most disturbing part of their illness because
their misconceptions make them frightened. However, overall they have
less history of violence than the general population of well people. People
suffering from multiple or split personalities have a condition different
from schizophrenia.
What we have learned is that schizophrenia is a disease related to the
structure and function of the human brain. The brain of the schizophrenic
person sometimes looks different and usually works in a different way
than the non-schizophrenic brain.
Schizophrenics know the meaning of intense psychological pain during
episodes of "psychosis." Psychosis is when they have a problem knowing
what is real and what is not. Reality and unreality blur. During this
"psychotic breakdown," they may be preoccupied with strange sounds and
voices called "auditory hallucinations." These voices are usually unpleasant.
They often blame the person for real or imagined misdeeds.
Sights and sounds people ordinarily wouldn't notice take on an ominous
meaning for acutely ill schizophrenics. They may feel threatened by otherwise
trusted family members. They may have grandiose and irrational thoughts
that make them act in ways that are confusing and outlandish to others.
Sometimes the schizophrenic thinks he or she can control other people's
minds due to a special telepathic power. Their sense of identity and place
blur. Body boundaries dissolve.
One of my patients wrote:
I think I am going crazy or the world is getting goofy...I don't know
what's going wrong...I don't think it is a pill thing. It is just that
somebody's insides collapsed on them. I think all the contents are spilling
out. I don't know how to hold my insides in. I've got to pull my head
together. Is it like Humpty Dumpty? Everything is like nothing and then
it is like the hurricane hitting the window. It takes you by surprise
every time. Too much of the world is leaking in. If a person can just
hold themselves together, maybe it will go away. I don't know what to
do. Fear comes creeping up my bones and makes my bones go soft.
To understand the breakdown a schizophrenic experiences, think of a filter
in people's minds. When the filter malfunctions, all kinds of extra and
overwhelming sensations flood in. These cause thoughts to be too stimulated
and disorganized.
Because patients feel these thoughts are bombarding them, sometimes it
helps them to be by themselves during periods of particular difficulty.
When the filter's balance is threatened, it is often therapeutic for them
to spend extra time alone and away from the busyness and hubbub of large
group activities.
One patient wrote:
The mind must have a filter that functions without our conscious thought,
sorting stimuli and allowing only those relevant to the situation at
hand to disturb consciousness. And this filter must be working at maximum
efficiency at all times, particularly when we require a high degree
of concentration. What had happened to me...was a breakdown in the filter
and a hodgepodge of unrelated stimuli was distracting me from things
which should have had my undivided attention. By the time I was admitted
to the hospital, I had reached a stage of 'wakefulness' in which the
brilliance of light on a window sill or the color of blue in the sky
would be so important it could make me cry. I had very little ability
to sort the relevant from the irrelevant. The filter had broken down.
Completely unrelated events became intricately connected in my mind.
The person experiencing an acute episode of schizophrenia needs a situation
that gives protection. It is a relief to a patient to have a predictable
routine with less social stimulation. The patient needs a safe place where
someone gently and firmly can point out what is real. It is important
to a patient when we say, "I understand how frightened (or confused or
angry or tense) these thoughts make you feel right now, but we are committed
to helping you stay safe."
When patients are out of touch with reality and preoccupied with unreality,
they feel reassured when someone they trust offers a glimmer of reality.
A hospitalized patient expressed it like this:
It feels safer in the hospital. There are some people around you that
seem to know what they are doing and don't get shook up if you think
it's the end of the world...It can be good, too, to go to the hospital
if you are getting upset and you are all alone. If you live alone, there
is nobody with whom you can check out your fears. If suddenly the world
seems depopulated, it might be too frightening to go check it out for
yourself. Also, when time does funny things, like stretching into eternity,
if you live alone you can have trouble bringing it back to real time,
but the routine in a hospital can help keep time in a regular framework.
Because recent knowledge shows schizophrenia is a brain disease, we rely
on medication as the base for treatment. The proper dose of medication
helps correct the imbalance in the brain chemistry while it lessens the
medications' unwanted side effects.
Patients often want to avoid taking medication. They hope that by talking
out their problems in individual psychotherapy, they can "heal" their
inner conflicts so they don't have a recurrence of their intense disturbance.
While this is true for many psychological problems, schizophrenia does
not go away as the result of our talking therapies. In fact, exposing
personal conflicts and hurts without using corrective medication may actually
make the seriously ill person's psychological pain and confusion worse.
Medication is the first and most effective treatment for the acutely disabling
symptoms of confusion, fear, and misperception.
Although some patients experience remission after brief treatment and
have few symptoms the rest of their lives, most continue to be bothered
by occasional episodes of more intense disturbance. Typically, the afflicted
person will swing between recognizing the illness and denying it.
Most patients are eager to believe there is nothing wrong with them that
some minor adjustment in life's circumstances could not correct. It is
especially hard for young adults to face the prospect of a long-term illness
of their minds. No one wants to accept the possibility of more episodes
of intense disturbance.
An important principle supporting treatment is developing relationships
of trust with each patient. This enables mental health professionals and
patients to talk openly about all aspects of the disease. There are many
sensitive issues about the disease that can only be discussed and resolved
within a relationship of trust, acceptance, and respect. Individual psychotherapy
and small group discussions encourage the patient's understanding of the
disease. Understanding the illness also means being able to identify early
signs of impending relapse.
Although stress does not cause the disease, periods of remission between
episodes last longer if people manage the stress in their lives. Another
goal is helping patients learn ways to reduce stress both for them and
their families. Small group discussions encourage patients to learn strategies
for managing stress.
Treatment for patients with schizophrenia usually avoids activities that
require them to express intense feelings. Instead, patients work with
small groups on tasks like cooking or art projects. Patients develop new
skills and leisure interests. Gradually, we see their span of concentration
and mental focus expand. Some typical group therapies include preparing
and eating a meal or a recreational activity like bowling or discussing
finding a job.
Schizophrenia-like arthritis, diabetes, and many other physical diseases-cannot
be cured by current treatment. Instead, we think of a gradual process
of recovery and rehabilitation. Occasional and temporary setbacks often
mark this process. Living with the disease requires extraordinary patience
and courage from both the afflicted people and their family members. The
unknown and unpredictable aspects of the disease can cause nearly unbearable
sadness and anger.
Sometimes patients' wish to deny the disease thwarts treatment efforts.
They hope that by forgetting its existence, schizophrenia will go away.
They sometimes stop taking their medication or build up false hopes. Sometimes
they blame other circumstances so they can temporarily look away from
the disease.
Our challenge and our hope is to achieve a partnership with patient,
family, and mental health worker. Together, we work toward a growing success
in managing the disease and experiencing steady progress toward a life
of meaning and purpose. A patient reflects this spirit:
As of yet, I still have a long road ahead of me. There is much that
I don't understand about schizophrenia, but I realize I am not alone
in my lack of knowledge about the illness. Slowly I am learning to accept
the limitations of my illness, and I feel that I am beginning to make
more constructive choices than I have in the past. Life puts various
limitations on each person, but within those limitations there is always
the freedom to make certain choices...
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