Schizophrenia is much misunderstood. In his 1911 textbook, the leading Swiss psychiatrist, Eugen Bleuler, used the term to describe the splitting of the psychological functions. Bleuler considered that the key features of schizophrenia were “Ambivalence, Autism, impaired Associations, and flattened Affect”. Such language meant that all sorts of shy oddballs could be categorised as schizophrenic, and the antipsychiatry movement of the 1960s and 1970s exposed its lack of definition. Mistaken assumptions about a “split mind” had already given it a popular Jekyll & Hyde fearsomeness, reinforced by films such as Alfred Hitchcock’s Psycho.
Reliable criteria have now been established in which forms of hallucination, delusions, thought disorder and passivity experience (the feeling that you are controlled by an outside agency) are dominant themes. These “positive” symptoms (add-ons to the normal mind) are allied to “negative” ones such as loss of feelings, social withdrawal and limited speech, and the diagnosis is now very reliable. Take 100 psychiatrists and over 90 per cent will agree on a case, rather better than the agreement sometimes seen among surgeons trying to diagnose a painful abdomen.
Schizophrenia’s bad reputation persists, however, even though sufferers are more likely to be victims of violence than to perpetrate it. Routine risk assessments are required if someone is getting unwell.
We went to visit Mrs T on a cold morning because she had stopped taking her depot injections. Given every two to four weeks, these are rather elegant biochemically, the injection dissolving naturally and giving a steady release of medication. After missing one or two, patients start to become unwell again, so often don’t equate the actual timing of stopping the injection with relapse. Mrs T wasn’t causing a nuisance, but the neighbours upstairs had phoned, because of the noise.
Her son let us in, and the outward signs of illness were apparent. The floor was sticky, there was a fetid smell, my eyes watered, and Mrs T was smiling but oddly dressed with a smear of lipstick on her face. She had done her best to look good for us, and offered tea (politely declined). The problem was that she heard screams all night from the children upstairs who were being tortured by electricity. She could hear the bedsprings creaking, and the children followed her around wherever she moved in her flat. They talked through her TV, and she couldn’t think straight. She was scared and upset, and had lost her cat.
Mrs T was not a split personality, and she wouldn’t have harmed a fly. After two months in hospital she was clean and tidy, apologetic, and back on injections. She talked sense and after a visit from the cleaning squad (and a community care grant to get some more furniture) she even went back to her flat. We put her on a Community Treatment Order (CTO). This meant she would have to go on taking her medication and see us, or could be taken back to hospital.
Unfortunately the latest research into CTOs has shown that 36 per cent of patients relapse within the first year of discharge from hospital, whether or not under the conditions of a CTO. Nevertheless, many doctors feel that it is only the CTO that keeps some patients well. Social research in schizophrenia always tends to divide opinion. That’s why it’s so interesting and keeps being misunderstood.
Trevor Turner is a consultant psychiatrist working in east London. Some details have been changed to protect identity