The label of schizophrenia has a chilling ring. It carries with it the suggestion of a wrecked and wretched life. It is also a diagnosis that is notoriously difficult to shed. For this reason, the diagnosis of schizophrenia should not be applied lightly and not without a thorough understanding of the patient’s family and wider circumstances.
Tragically, however, schizophrenia is sometimes confused with psychological problems like severe anxiety or depression that are understandable reactions to disturbing life situations like loneliness, isolation, and/or family issues. This was the case with a young man I have been seeing in therapy for a little more than a year whom I will call “Alan.” Alan was referred to me by a psychiatric hospital.
He had been hospitalized for a week after several episodes of hearing voices, following four years of outpatient psychiatric treatment for depression. Alan had a history of psychiatric drugs which included Wellbutrin, Zoloft, Xanax, and finally Risperdal. None of the medications had helped him for long. He grew more depressed and finally had a psychotic episode. Alan was now taking 30 mg. of Zyprexa which the psychiatrist at the hospital had prescribed for him.
After two sessions of family therapy with Alan and his parents, I decided to work with Alan individually in weekly sessions. He was an exceptionally intelligent young man, and I soon found out that his main passion in life was music. After high school, Alan began studying at a music conservatory near his parent’s house, but he had dropped out after a year. Alan explained to me that he had experienced intolerable anxiety when he had to play his violin in front of his teachers and classmates: he felt like everyone was “judging” his performance.
After leaving the conservatory, Alan became increasingly isolated. His high school friends were all living out of town, and he had not made friends at the conservatory. He spent hours alone in his room practicing violin, and had little contact with anyone besides his parents. He grew more and more depressed, and began seeing a psychiatrist. The psychiatrist prescribed the medications for his depression and anxiety without any form of talk therapy.
The first milestone in Alan’s therapy with me came after four months, when he started driving himself to sessions. Because he had been in a serious car accident when he had first started hearing voices, Alan was reluctant to drive the half hour from his parent’s house to my office. His mother therefore drove him to sessions and read in the waiting room or did errands until the session was over.
In the early months, sometimes Alan was visibly shaking with anxiety at the beginning of our meetings. The shaking slowly disappeared as he became more comfortable with me and figured out that I was not interested in judging or labeling him. I treated him as a normal human being. I also asked his parents to treat him as a normal person. His father, a very intelligent man, thought that was a good idea. “A self-fulfilling prophecy,” he said. I nodded.
Along with dealing with his issues with his parents, I encouraged Alan to talk about music in our sessions. After about five months, I now and then caught a glimpse of his considerable sense of humor. He would say things deadpan and I would take him seriously—until I realized that he was putting me on. Then we would both laugh. His humor was often aimed at the outpatient program which the hospital had recommended for him. He felt uncomfortable in the group therapy and had panic attacks when the group leader called on him. Eventually, after a family meeting in my office in which his parents expressed concern, Alan quit the outpatient program, which was quite expensive, and began attending a free series of NAMI meetings. He didn’t feel that the meetings helped him, but he had perfect attendance.
Leaving the outpatient program meant finding a psychiatrist to manage Alan’s meds. He was still taking 30 mg of Zyprexa daily. His parents found a psychiatrist through their family doctor, and asked him to collaborate with me on Alan’s therapy. I was shocked when the psychiatrist made a diagnosis of “schizophrenia” after meeting with Alan for a single session and taking a history from his parents. Was Alan behaving very differently in the psychiatrist’s office than he was in mine? My diagnosis for Alan was anxiety with panic attacks, both of which had been steadily decreasing over the past nine months. His psychotic episode, I believed, was a brief reactive psychosis and it had not recurred. I strongly disagreed with the schizophrenia diagnosis and urged the psychiatrist to wean Alan from the Zyprexa. The psychiatrist balked at first, but as he got to know Alan better he reluctantly began gradually decreasing the dosages.
Today Alan is down to 5 mg. of Zyprexa. In three weeks he will be off it completely. Since he has been on lower doses of the meds, Alan has been looking more natural, more “there” as he phrased it. “I don’t feel ‘zombied out’ any more!” And it’s true. When he was heavily medicated, Alan seemed like a sedated zombie. He rarely laughed. These days he is dressing better and looking healthier, and a little more light flickers in his blue eyes. His sense of humor has emerged in full force. Now and then I ask him if he has heard any voices lately. Once he replied, “I’m hearing the score from Zero Dark Thirty.” When I gave him a quizzical look, he reassured me: “I bought it after I saw the movie” Last week when I asked about voices, he quipped with a deadpan expression, “Just one.” We laughed heartily.