schizophrenia is often thought of as “split personality”. This is a misconception, as the person suffering from schizophrenia does not have more than one distinct personality as is seen in dissociative identity disorder (multiple personality disorder). Instead, they are characterized by having psychosis with, generally, two or more of the following: delusions, hallucinations (visual or auditory), disorganized speech (derailment of speech or incoherence), disorganized or catatonic behavior, or negative symptoms such as flattening of affect or lack of motivation.

Delusions may be grandiose, in which the person believes they have special powers, or may be bizarre in which they feel their parents are martians. Persecutory delusions are also common.

Hallucinations are reported by approximatey 75% of schizophrenics, with 90% being auditory, and 40% visual (There is some overlap as some sufferers have both auditory and visual). Auditory hallucinations may be voices that whisper to the person, command them to do things, comment on their actions, suggest courses of action. The voices may be from people they know (a dead relative) or strangers. Visual hallucinations can be bizarre and frightening, even threatening. They may see things such as snakes crawling from skulls, blood dripping from people, creatures coming from walls. Less common are tactile hallucinations in which the patient feels bugs and ants crawling over or under their skin.

From the beginning, the person with schizophrenia firmly believes in their delusions and hallucinations: they are real. After a time period in which they are very confused, they have a catharsis in which they are able to find their own “holy grail” that ties everything together for them that explains it all. However, this generally makes no sense to anyone else. This might be “The FBI is watching me and sending thoughts into my mind.” With increased therapy, medication management and over time, these statements begin to tone down “The FBI might be wathcing me and sending thoughts into my head” then “I’m not so sure about that FBI stuff”, and “Every so often I think the FBI is watching me. Isn’t that crazy?” and finally “I’ve learned no to pay attention to those ideas about the FBI. They just get me into trouble.” What this shows is not a complete remission of the thoughts. It shows a softening of the hallucination, which are still there, but to an extent to which they are more manageable.

Schizophrenia usually onsets during adolescence or early adulthood, with 1/4 of patients having an abrupt, active onset. The remainder have an acute onset after a slow decline in functioning that may include social withdrawal, impaired functioning, poor hygeine, flat affects, vague rambling speech, odd or magical thinking, ideas of reference, overvalued ideas, persecutory thoughts, and illusions, depersonalization, and derealization.

Schizophrenia is a chronic disease – there is no magic cure. However, it is characterized by periods of exacerbations and remissions. The first years are the worst, with active symptoms predominating and possible multiple hospitalizations. As the disease ages however, a more nonpsychotic state is reached with chronic symptoms of apathy, low energy levels, social withdrawal, and increased vulnerability to stress.. They may pick at imaginary objects or repeat words. Most schizophrenics report symptoms of depression at sometime during their illness, usually following an acute psychotic episode.

The major negative sequela of schizophrenia is suicide. approximately 20% of schizophrenics attempt suicide, and 10% are successful. It is generally during the depressive period immediately following an acute period when this occurs. 30% occur within 3 months after hospitalization and 50% within 6 months of hospitalization.

There are five subtypes of schizophrenia which may be noted: paranoid, disorganized, catatonic, undifferentiated, and residual. The paranoid type have prominent persecutory or gandiose delusions or hallucinations with similar content. They may be unfocused, angry, argumentative, violent and anxious. They assume people can’t be trusted and that anyone who likes them must be up to no good. They live a highly contained and structured existence. The disorganized type is characterized by prominent incoherence with flat, silly or inappropriate affect. The catatonic type, on the other hand, which is much rarer, is a case of psychomotor disturbance. They have a sudden onset, better prognosis, and more mood disorders. They can have either extreme motion on one end of the scale, or on the other end, and extreme resistance to movement. The undifferentiated type merely notes that they do not fit into the above categories. The residual type is used if chronic symptoms continue after an active phase ends.

Treatment is with traditional antipsychotics such as zyprexa and geodon. Therapy is used to stress reality testing initially, and later to explore stressors, and improve coping skills.

I offer a case history of a client, M, who is in his early 30’s who is diagnosed as schizoaffective-bipolar, non-medication compliant, abuses alcohol and street drugs. He has had “voices in my head since I was a teenager” “they always talk to me, tell me what to do in social situations, in conflicts, they are my guides.” Additionally, he has visual hallucinations that he admits to following at work, and he has been found talking to one of these, when it appeared he was talking to a wall. There are a large number of factors that come into play here. He was unmedicated and untreated by the medical community until he was in his mid-twenties. Before that time he was using a wide range of drugs, smoking and injecting, as well as alcohol. This was done as a form of self-medication. When he was finally diagnosed, he was addicted. Fighting his addiction and attempting to go onto medications was difficult, but he did it for a while. Then he dropped off the medications and went back to street drugs and drinking for one simple reason: when he was medicated, his voices went away. Without his voices, he lost all of his internal guides, the voices he had come to rely upon for support, to show him what to do, how to act for the past 10+ years. He was lost socially and emotionally without them. He felt that he had no effective coping skills without them. So, he reverted back.

I chose this case study as a simple example of a reason why a person would choose to continue to stay unmedicated in the case of schizophrenia (which means shattered personality, literally). Along with other mental illnesses, many times the known is more comfortable than the unknown and the work that would have to be put into changing the whole world-view that has been held for so many years.