Schizophrenia is perhaps the
most painful and least understood of all mental illnesses, although
there is increasing reason to be hopeful for those with this disease.
I describe it as painful because it often strikes, without warning,
young adults just at the point where their lives look full of promise;
and its exact nature, cause, and treatment remain the subject of
great disagreement.
When I worked in a storefront
clinic Dave walked in one day, a new face. Dressed in an expensive
overcoat, obviously bright and well educated, Dave was about 22,
living in a flophouse and eating at the Salvation Army. All he would
say was that he wanted someone to talk to; I saw him for a few weeks
while he rambled in a vague, abstract way about wanting to make
friends and find a career. He seemed very anxious. He avoided all
my questions about how he got to his present state, what he was
doing to take care of himself, in fact anything that would give
me a clue about him as a person. Still he seemed desperate for contact
and someone to trust. He refused to see our psychiatrist when I
suggested some medication might help him relax.
After a weekend Dave came in
in a different state, laughing and excited. I didn't have to worry
about him anymore, he said, because he'd heard from his father.
His father couldn't let his presence be known directly because he
was an important figure in the CIA. But there were signs encoded
in the graffiti in our neighborhood that Dave felt were messages
from his father, reassuring Dave that he was being watched over.
I had seen Dave change from
what is known as the residual phase of schizophrenia, characterized
by negative symptoms -- social impairment, poverty of thought --
to the acute phase. In the acute phase, patients experience the
symptoms that are popularly thought to be characteristic of the
disease. These are delusions, or false beliefs, a distorted interpretation
of reality; inappropriate affect, or an emotional state that is
obviously not justified by objective reality; and hallucinations,
or false perceptions, typically hearing a voice or voices. Dave
was not hallucinating yet, though later he did believe that he heard
the voice of God.
There are often thought to
be two typical courses for schizophrenia. In one, a young person
appears socially, emotionally, and intellectually normal until there
is a sudden, acute episode (a "break"). Once the acute symptoms
are brought under control, and medication can help greatly with
this, the patient is left with the negative symptoms of the residual
phase, which are more difficult to treat. Usually the person is
left at a deteriorated level of functioning and may stay there for
the remainder of his or her adult life. The other course has an
even more pessimistic outlook. Some of the negative symptoms develop
in childhood or adolescence, so the young person is experienced
as "odd" by others. There is a gradual deterioration in functioning.
Once an acute stage is reached, medication may again be helpful
with the active symptoms but the prognosis is very guarded,.partly
because the patient had never made a good social adjustment to begin
with.
I had not seen Dave's first
break but his fifth or sixth. It came out that he had been hospitalized
first at age 19 and had been in and out of hospitals and community
residences ever since. His father was dead and he had no family
left in Chicago. The best I could do for him was to get him on a
plane for his sister in California, who was caring and concerned
and willing to get him the best care she could out there.
A few months ago I had the
immense pleasure of hearing from a young woman who showed me what
kind of progress has been made with the Daves of the world in the
last few years. Like Dave, she had had a sudden and dramatic break
and was in an acute psychotic state for some time. Her family got
her into an active treatment program that first of all taught her
that she had a disease that she was going to have to learn to live
with. They taught her to monitor her own medication to help control
the acute symptoms. They emphasized social skills, work, exercise,
and cognitive control of feelings and behavior to counteract the
negative symptoms. This young woman was speaking to a committee
of state representatives considering cuts in the mental health budget.
She spoke clearly and coherently, with great emotion which was,
however, perfectly appropriate to the situation. No one would have
suspected her condition if she had not chosen to reveal it.
I couldn't help thinking of
Dave. The prognosis is much better today for the young person in
the early stages of schizophrenia. Unfortunately there are not nearly
enough good treatment programs around, nor do most physicians or
the general public know how to find one when it's needed. The Mental
Health Association or the state Department of Mental Health are
the best places to start looking.