Situational Schizophrenia

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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.

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12 COMMENTS

  1. Great to hear how Alan is progressing. Being diagnosed with ‘schizophrenia’ can sometimes be a life sentence, not because of the so-called ‘illness’ but because of the debilitating psychiatric treatment dictated by the stigmatising label. I’m so glad Alan is receiving appropriate help.

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  2. “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.” I’m flabbergasted. Should this be understood as: “schizophrenia” has got nothing to do with people’s life story? And if it is, how do you support this view of so-called “schizophrenia”? How do you explain the, compared to medical “treatment”, significantly better outcomes of approaches, like Open Dialogue, that do view and treat “schizophrenia” as psycho-social problems?

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    • Marian, Like other psychological problems, “schizophrenia” is intimately connected with a person’s life story or psycho-social context. Like severe depression, anxiety, or obsessions, schizophrenia is a reaction to painful or traumatic life circumstances and can be treated through a caring relationship with a skilled therapist. I couldn’t agree with you more.

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      • Marilyn, thanks for the clarification! I was in doubt, because in your first paragraph you write: “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.” (my italics) Of course, a truly “thorough understanding of the” person’s “family and wider circumstances” will in every case lead to the conclusion “complex/post-traumatic stress”, rather than “schizophrenia” or any other “mental illness”. But I’ve seen too many professionals claim to have investigated the person’s family and wider circumstances thoroughly, and still they arrived at “schizophrenia”, or some other “mental illness”, and when you write that “schizophrenia” shouldn’t be applied lightly, it came across as meaning the label actually should be applied in certain cases, just not too lightly.

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        • Hi Marian, I think you make a good point. It is very tempting when we see harm done to a particular person by the label “schizophrenia” to attempt to rescue the person from the label, saying “this person does not really have schizophrenia” leaving of course the implication that there are others who really can be accurately diagnosed as having a condition called schizophrenia that has nothing to do with their life history!
          The problem with this strategy is that it is unfair to all the other people so labeled, who also need to be protected from the presumption that they have an illness that has nothing to do with their life history, or their own creative attempts to deal with that history (which may have inadvertently made things worse) or with the efforts of others to “help” them (which also may have inadvertently made things worse.)

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          • I know your comments, Ron Unger, were addressed to Marian, and I hope you don’t mind me chipping in with my thoughts. This is something I have thought long and hard about. I agree with you that if a person is said to be ‘misdiagnosed with schizophrenia’, this can be seen to imply that others do have an illness called schizophrenia. I am not happy with this, even though I do sometimes say that I was misdiagnosed (for reasons I’ll try to explain).

            In my teens I was diagnosed and treated (in UK) for ‘chronic schizophrenia’ despite never having had the so-called ‘positive symptoms’ such as hearing voices, delusional beliefs, hallucinations and so on. My ‘symptoms’ were social withdrawal, flattening of affect, lack of interest (so-called ‘negative’ symptoms on which a diagnosis of the ‘simplex’ form of schizophrenia was based). There were situational reasons for my so-called ‘symptoms’ which, like for many with a schizophrenia diagnosis, were not taken into account. I was treated for five years with heavy neuroleptic medication. I’ve been fine since I managed to get myself off all the medication and leave the psychiatric system.

            Nowadays people (including the publishers promoting my memoir, psychiatrists and others who have read my book or know me) say that I was misdiagnosed with schizophrenia. I’m not happy with this for the reason you describe. I do believe that I never did have ‘schizophrenia’ – but does anyone? However, if I don’t say I was misdiagnosed, some people think I must then have recovered from schizophrenia. But this ‘recovery’ idea (and also the idea that an illness called schizophrenia does not exist, a view I lean towards), can lead to the dangerous implication that anyone diagnosed with schizophrenia should be able to come off their medication and build up a life for themselves, as I was able to do. Unfortunately some people can’t, though it doesn’t mean they are less ‘strong’ than me, or that they actually do have an illness called schizophrenia.

            Maybe I’m wrong to say I was ‘misdiagnosed’. But can you see my dilemma? I suppose every diagnosis of ‘schizophrenia’ is really a misdiagnosis and the schizophrenia label should be abolished. But, meanwhile, we ‘psychiatric system survivors’ have to struggle to express ourselves with inadequate terminology and hope people will understand what we mean.

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    • I don’t think it’s that ‘schizophrenia’ has got nothing to do with people’s life story. More like people’s life story has got nothing to do with ‘schizophrenia’, though of course a person’s life story can bring about the thoughts and behaviour that might lead to a person being given this diagnosis, wrongly in my opinion. Surely a person’s normal responses to traumatic events should not be given the label of ‘schizophrenia’. There are serious flaws in the psychiatric diagnostic process.

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      • I would like to thank all of you for your well-honed comments. I want to say something to clarify the context of my work.Unfortunately, in my daily work as a therapist I have to deal with psychiatrists who do believe that there is a biological disease called schizophrenia. If I had said to Alan’s psychiatrist “There is no such thing as schizophrenia so of course you are misdiagnosing him,” I would have lost credibility with him and would not have been able to influence him to take Alan off the meds. What I think in my own mind (and I have always agreed with Laing’s and Mosher’s view of schizophrenia),and what I have to say to protect my patients in my daily work, are sometimes very different. This article was intended to be about the dangers of misdiagnosis which in turn can lead to the wrong kind of treatment. I hope this helps. Thanks.

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  3. Marilyn:
    I am so glad that Alan has found a caring, thoughtful and competent therapist. One thing that worries me: he is on 5 Mgs of Zyprexa and will be off in 3 weeks. Please take a look at the “surviving antidepressants” website (it isn’t just about antidepressants…lots of info on neuroleptucs too). The last bits of medication withdrawal generally seem to require extremely slow tapering.
    All the best,
    Ed

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    • Ed, Thank you so much for your thoughtful comment and careful reading of my post. I will read the article you suggest and double check that the tapering of the drug is as slow as it should be. Actually, the psychiatrist has been tapering the meds extremely slowly.

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  4. I agree with Ed about the medication withdrawal. My son found it impossible to come off 2.5mg of zyprexa. He developed such withdrawal symptoms (extreme akathisia and total insomnia) that he was rehospitalised and moved onto Risperidone and than taken off it in about 10 weeks. Even then he went through hell and had to shave of slowly bits of a 1/2 mg tablet before he could come off the antipsychotic all together. Luckilly I had read Peter Breggin’s book warning of all the pitfalls. Otherwise he would have given up in dispair.

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