The Internal Experience of Schizophrenia

Delusions and Hallucinations

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It’s difficult for a person who isn’t ill to understand the internal experience of schizophrenia. When people describe experiences to one another, they assume a shared understanding of what it feels like to think and to perceive the world with our senses. We expect that we can talk about what we are thinking, without having to describe the ways in which our brains connect different pieces of sensory information and memory to make a thought.

In someone with schizophrenia, the most basic processes of perceiving and thinking are affected by the illness. Every individual with the illness will have a unique experience of the world, but there are common themes. One way to try to understand them is to look at the experience of each of the basic symptoms of schizophrenia. An individual’s experience, of course, won’t be broken into these neat categories.

Although disconnected from reality as most people know it, people experiencing psychosis also experience true sadness or depression (as opposed to or in addition to negative symptoms, discussed below). Psychiatrist Amy Koreen found that this depression lifts when the psychosis is relieved by antipsychotic medications, without antidepressants.

Research like this underscores the fact that people with schizophrenia truly suffer from their illness. Their sadness is a natural response to being trapped in a terrifying and isolating situation.

A stunning first-person account of schizophrenia, “Autobiography of a Schizophrenic Girl” describes very clearly the sadness and loneliness the young author felt when gripped by psychosis.

What’s It Like to Have Delusions?

To have a delusion is to be obsessed with an idea, and to have absolute certainty that the idea is correct.

A person’s thinking may be clear in other ways, with an otherwise logical ability to reason starting with the absolute conviction of the incorrect premise.

Delusional ideas have a lot of power to preoccupy someone’s thoughts. Sometimes people with delusions can convince others that their delusions are true. This happens most often when the delusion is in the realm of common human experience, like an unfaithful spouse or a boss who’s “out to get me.” Some delusions are clearly recognized as abnormal, like when someone is convinced they’re a famous person or that their thoughts are being controlled by aliens.

Even after responding well to antipsychotic medications, a person may continue to believe their delusions are true. However, they may have developed an insight that other people think the ideas are probably delusions. Psychologists might call this a meta-awareness of the symptom, or an awareness that exists above the level of the symptom itself.

What’s It Like to Have Hallucinations?

Hallucinations and delusions can go hand-in-hand.

For example, hearing voices speaking to you from the radio is a hallucination. Being absolutely convinced that the voices are real and the things they tell you are true has a component of delusion. It is possible to experience hallucinations while being aware that they aren’t real. As with delusions, this would require a meta-awareness of the unreality of what appears to be a real experience.

We human beings usually rely on our perceptions to tell us what’s real. We’re unaware that different people experience the same situation differently because usually those small differences don’t come up in conversation. For example, someone can go their entire life without knowing they’re color blind because they don’t know what they’ve never experienced.

Likewise, at a party, an outgoing person may perceive friendly, receptive faces, while a shy person may perceive the same faces as being indifferent or even critical. Both of these perceptions are within the realm of normal human experience, and neither is pathological.

A person with schizophrenia, however, may actually hear people saying things that are critical or insulting when those conversations aren’t actually taking place. That would be a type of auditory hallucination.

Visual hallucinations can take many forms as well. A person with schizophrenia may find their attention drawn to one particular person’s face, notice that the teeth are very white, and then perceive the mouth and teeth growing to fill the room. This perceptual distortion would feel just like a real visual perception, and the person may believe it actually to be occurring. If they're frightened by the perception they might try to hide their fear, or they might cry out or run away.

Some people have persistent visual hallucinations, such as small children or animals that frequently appear or follow them around. They may even hold open doors for these hallucinations to pass through when they leave a room.

What’s It Like to Have Disorganized Speech or Behavior?

The process that disrupts the normal operations of the brain also disrupts the process by which the brain monitors its own operation. . To use an engineering analogy, a psychotic brain can’t trouble shoot its own errors, because the trouble shooting tools are malfunctioning too.

People experiencing disorganized speech are often aware that their thoughts and words aren’t communicating the things they intend.

However, they typically don’t understand why. They may earnestly try to communicate their thoughts in nonsensical, stream-of-consciousness language, and be frustrated when the other person doesn’t understand, or that the words aren’t coming out right. On the other hand, they may seem to be unaware that the listener doesn’t understand them.

There are many kinds of disorganized behavior. For example, someone may move their empty hands as if they’re knitting, or occasionally make an apparently meaningless hand gesture or body posture. They usually seem unaware of these motions.

Other forms or disorganized behavior can be quite dramatic. For example, a person may remove all his or her clothing in an inappropriate place. At the time the person does this, they seem to believe the behavior is entirely reasonable and usually don’t expect to generate an unusual response.

Disorganized public behaviors often result in contact with the law.

More and more legal jurisdictions are recognizing mental illness and referring people for psychiatric evaluation. However, there are still far too many mentally ill people in jails and even prisons for nothing more than disruptive, disorganized behavior.

Healthy people also perform bizarre and socially unusual behaviors.

Otherwise relatively normal people might take off their clothes at a football game, start a pillow fight in a public square, or wear bizarre dress. The difference is that these people are aware the behavior is unusual, and are looking for the attention they attract. This kind of behavior is not unusual among high-spirited teenagers and young adults.

What’s It Like to Have Negative Symptoms?

People with schizophrenia have a particularly difficult time recognizing negative symptoms as being symptoms of an illness or even abnormal. In this way, the experience can be like that of certain kinds of depression.

The person doesn’t express emotions or expresses them only mildly, even when confronted angrily, or in a dangerous situation. The person may also fail to find significant pleasure in things that were once delightful (this is called anhedonia).

A person experiencing negative symptoms has little energy or motivation, and the person's mental energy and acuity is often also depressed. Because the mind itself feels fuzzy or dull, there’s little perception that it’s possible to feel differently, and little memory of a time when one felt differently.

Many people who have experienced depression will understand this feeling of being in a mental fog.

Real People, Real Emotions, Real Lives

Samuel Keith, MD, editor of the America Journal of Psychiatry, expressed the plight of a person with schizophrenia very well:
Real people with real feelings get schizophrenia. One should never underestimate the depth of their pain, even though the illness itself may diminish their ability to convey it…. As one of my own patients told me, “Whatever this is that I have, I feel like I’m a caterpillar in a cocoon, and I’m never going to get the chance to be a butterfly.”

Schizophrenia is a progressive illness, and treatment with antipsychotic medications stops or slows the progression of the disease. Diagnosis and treatment with antipsychotic medications early in the illness, optimally within the first six months of symptoms, has the greatest potential to reduce the severity of a person’s illness for the rest of that person’s life. It is absolutely essential for people to get help, and insist on an evaluation by a psychiatrist, when psychotic symptoms occur.

Sources:

Chovel, I. The Experience of Schizophrenia: Ian Chovil’s Homepage. http://www.chovil.com/

Keith, S. Understanding the Experience of Schizophrenia. American Journal of Psychiatry. 150:11, November 1993. pp.1616-1617.

Koreen, A., Siris, S, Chakos, M,. Alvir, J., Mayerhoff, D. and Lieberman, J. Depression in First-Episode Schizophrenia. American Journal of Psychiatry 150:11, November 1993. pp. 1643 - 1648.

Sechehay, M. and Conroy, F. Autobiography of a Schizophrenic Girl: The True Story of “Renee.” Translated by Grace Rubin-Rabson. New York: Penguin Books. 1968.

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