I was a big fan of the Lord of the Rings movies a few years ago, so much so that when the Extended Cut DVDs became available, not only did I watch the even longer versions of the movies several times, I also probably watched all the behind the scenes bonus features as well. Like I said, I was a big fan. One of these bonus features was on the remarkable creation of the CGI character Gollum, the creature who had been in the possession of the One Ring and was corrupted by its evil influence. When talking about this character, director Peter Jackson described him as “schizophrenic” because of the two battling personalities within him, Smeagol and Gollum, which was illustrated during a memorable scene where the two sides of this character have a conversation with each other. I remember cringing inside by his use of the word “schizophrenic” because I was in the middle of my Psychiatry residency at that time, and my experience engaging with people suffering from Schizophrenia was nothing like this inaccurate description by this famous director describing a pivotal character in this wildly popular film. What also irked me was that I already knew that this error by Peter Jackson was pretty typical, in that many people use the word “schizophrenic” to describe a person they believe either has “multiple personalities” or as a description of their inconsistencies of behavior or thinking. Around the same time, a member of the band NSYNC, during the heyday of their popularity, released a solo album entitled Schizophrenic, as a reflection of the diverse styles of music on the album. To make matters worse, the album cover featured J.C. Chasez wearing a straight jacket. I think at the time, my reaction was more than just a cringe. Not a big fan. So the most popular movie in the world and the most popular band in the world, both getting it wrong. But no one really cared, which is really the problem. Not enough people care. As we’ll see here, Schizophrenia is the problem of a disconnected mind. Disconnected from within, and disconnected from people. The former is due to the illness. The latter is a product of society. We can do better with both.
Despite my strong personal feelings, the longstanding misconceptions about Schizophrenia are understandable, in that the word translated from its Greek roots means “a split mind.” However, in its original description by Eugen Bleuler who coined the word “schizophrenia” in the early 1900’s, the splitting of the mind he was describing was not between multiple personalities residing within one individual, but between the typical differentiated functions of the human brain: personality, thinking, memory, and perception. 100 years later, this description remains an accurate way to describe what Schizophrenia truly is, a chronic state of dysfunction relating to the disconnect between the normally integrated parts of our mind.
A model of “health” proposed by Daniel Siegel, founder of the field of Interpersonal Neurobiology, a multidisciplinary scientific field of research and application (aka “Relationship Science”) is summarized by the concept of integration – differentiated parts of the human mind connected and functioning synergistically and in harmony. When our minds are not integrated, we are in states of rigidity or chaos. These less than optimal states are experienced by all of us at least temporarily, such as times in our normal lives where our emotions may get the best of us, or our judgment is clouded by bias. These states of rigidity or chaos may also be chronic, reflected in states of illness, which include Psychiatric conditions like Depression, Bipolar Disorder, Anxiety Disorders, or Schizophrenia. In particular, Schizophrenia represents this dis-integration of mental functioning, leading to a life of chaos, consistent with Bleuler’s original descriptions of a “splitting of mind.”
The symptoms of Schizophrenia are a result of the mental changes at the onset of the illness (usually in the early 20’s for men, late 20’s for women) coupled with a person’s challenges in differentiating what is happening in the real world compared to what is happening within their own disconnected mind. This causes an impairment in judgment that leads to increasing difficulties in leading a functioning, capable life. What makes this so hard is that these false experiences in their mind are perceived as being as real as if they were truly happening. For example, when a person who has auditory hallucinations is monitored in a brain scanner, the parts of the brain that are typically activated when we process a real conversation are also being activated when they are “hearing voices.” In other words, their brains register the false voices in identical fashion as real voices. A common thought distortion observed in Schizophrenia has to do with making associations that aren’t actually true. For instance, there may be a belief that messages are being specifically directed at them through a TV show or billboard. Observations about random people acting in odd ways are perceived to be part of a conspiracy to make their life difficult. The challenge here is that these loose associations are also experienced in their brain in the same way that we might feel when we have an “a ha!” moment of understanding – a combination of an idea making sense and feeling right, in the context of something meaningful. And in the same way that these moments of profound insight give us a sense of certainty and conviction to make changes in our behavior, these false insights in Schizophrenia create the same kind of motivation to change how a person acts as well. What we might see as paranoid behavior is actually the logical behavior of anyone who believes with certainty that they are being persecuted. The problem with Schizophrenia is that these false beliefs are formed because they are experienced as being real.
In addition to the distortions in thinking and perception are negative changes in emotional expression, motivation, and social engagement. These are called the “negative symptoms” of Schizophrenia because they represent a “lack of” emotion, drive, and connection. In a previous series, A “Whole Brain” Theory On Human Motivation, I’ve talked about the interconnectivity between emotions, motivation, and relationships and how they lead towards healthiness (click here to read more). Then unsurprisingly, as all three of these domains are restricted in Schizophrenia we can understand how the disability in this condition is not completely due to hallucinations or distortions in thinking, but also from the cost of these negative symptoms. Prior to the first medications becoming available to treat the positive symptoms of Schizophrenia in the 1950’s, the consensus of experts as to what constituted the core and pervasive symptoms of the illness were in fact tied to these changes in emotion, drive, and withdrawal. As the first antipsychotic medications started being prescribed, a shift regarding the defining characteristics of the illness occurred, focusing more on the “positive symptoms” that these medications were effective at treating – hallucinations and distortions in thinking.
As we’ve reached the limits of efficacy with these medications, especially because decades of use have shown that they aren’t particularly helpful for the negative symptoms of Schizophrenia, there’s been a recent growing openness to alternative treatments. These include non-medication interventions focusing on changing self-defeating beliefs, improving emotional and social competency, and supporting occupational and social skills training. Many of these interventions have been shown to not only be helpful with symptoms (positive and negative), but more importantly to improve quality of life. I’ve talked about some of these in more detail in a previous article, also sharing my own experience in practice where a humanistic approach has allowed people with Schizophrenia to live lives of substance and meaning – restoring optimism, supporting self-worth, and creating relationships as a “treatment” for Schizophrenia. Click here to read more.
It’s important to change our understanding as a society of what Schizophrenia is, because misinformation and stigma have disconnected people suffering from this illness, and this isolation contributes to their worsening symptoms and deteriorating life course. Even though Schizophrenia affects less than 1% of the population, they are disproportionately overrepresented in the most marginalized sects of society (the poor, the disabled, the chronically ill, the homeless, and the incarcerated) compounding the probability of living a life in isolation. In addition, they have a high lifetime probability of also struggling with addiction, depression, and chronic medical illnesses – all contributing to a life expectancy that is 10 to 25 years shorter than the norm. Despite popular opinion, people with Schizophrenia as a whole are not any more prone to violence than the general population, though they are more likely to be victims of violence. Treatment for the whole spectrum of illness is effective and can help people with Schizophrenia to live healthy and meaningful lives. But this type of help is not readily available to all and so requires a greater willingness from all people to support their long-term needs of autonomy, competency, and relationships – the same universal human needs in all of us. In doing so, not only can we help individuals, we all benefit as we improve the parts of our society that are the most costly and where people struggle the most. However, this type of growth can only happen if we change our minds about Schizophrenia and what we believe is possible and worthwhile for these individuals. To keep it simple, we can all start by seeing each other first and foremost as people, and recognize that in engaging and in connecting we will make a difference in their wellbeing as well as ours.
No Simple Answers 