The symptoms of schizophrenia are manifold, and present in such a variety of combinations and severities that it is impossible to describe a ‘typical case’ of schizophrenia.
The so-called 'positive symptoms' of schizophrenia consist of psychotic phenomena (hallucinations and delusions), which are usually as real to the schizophrenia sufferer as they are unreal to everybody else. Positive symptoms are usually considered to be the hallmark of schizophrenia, and are often most prominent in the early stages of the illness. They can be provoked or aggravated by stressful situations, such as succumbing to a physical illness, breaking off a relationship, or leaving home to go to university.
Psychiatrists define a hallucination as ‘a sense perception that arises in the absence of a stimulus’. Hallucinations involve hearing, seeing, smelling, tasting, or feeling things that are not actually there. The most common hallucinations in schizophrenia are auditory hallucinations—hallucinations of sounds and voices. Voices can either speak to the schizophrenia sufferer (second-person, ‘you’ voices) or about him (third-person, ‘he’ voices). Voices can be highly distressing, especially if they involve threats or abuse, or if they are loud and incessant. (Carers might begin to experience something of the distress of hearing voices by turning on both the radio and the television at the same time, both at full volume, and then trying to hold a normal conversation.) On the other hand, some voices—such as the voices of old acquaintances, dead ancestors, or ‘guardian angels’—can be a source of comfort and reassurance rather than of distress.
Delusions are defined as ‘strongly held beliefs that are not amenable to logic or persuasion and that are out of keeping with their holder’s background’. Although delusions need not necessarily be false, the process by which they are arrived at is usually bizarre and illogical. In schizophrenia, delusions are most often of being persecuted or controlled, although they can also follow a number of other themes.
Positive symptoms correspond to the general public’s idea of ‘madness’, and people with prominent hallucinations or delusions may evoke fear and anxiety in others. Such feelings are often reinforced by selective reporting by the media of the rare headline tragedies involving people with (usually untreated) mental illness. The reality is that the vast majority of schizophrenia sufferers are no more likely than the average person to pose a risk to others, but far more likely than the average person to pose a risk to themselves. For example, they may neglect their safety and personal care, or they may leave themselves open to emotional, physical, or financial exploitation.
How can the schizophrenia sufferer best deal with positive symptoms?
For obvious reasons, there is little that a schizophrenia sufferer can do to address his or her delusions (other than engaging with mental healthcare services in general and with therapy in particular). However, there are a number of measures that he or she can take to reduce or altogether eliminate voices. These measures include,
• Keeping a diary of the voices to help identify and avoid the situations in which they arise
• Finding a trusted person with whom to discuss the voices
• Focussing attention on a distraction activity such as reading, gardening, singing, or listening to music
• Talking back at the voices: challenging them and asking them to go away. If out in public, the schizophrenia sufferer can avoid attracting attention to him- or herself by talking into a mobile phone
• Managing levels of stress and anxiety
• Taking medication as prescribed, especially antipsychotic medication
• Avoiding drugs and alcohol
How can carers best deal with positive symptoms?
Positive symptoms can be very distressing, both to the schizophrenia sufferer and to his or her carers. Carers often find themselves challenging the schizophrenia sufferer’s hallucinations and delusions, partly out of a desire to relieve his or her suffering, and partly out of understandable feelings of fear and helplessness. Unfortunately this can be counterproductive, because it can alienate the schizophrenia sufferer from his or her carers at the very time that he or she needs them most. Difficult though this may be, carers should not lose sight of the fact that positive symptoms are as real to the schizophrenia sufferer as they are unreal to everybody else.
A more helpful course of action for carers is to recognize that the schizophrenia sufferer’s hallucinations and delusions are real and important to him or her, whilst making it clear that they do not personally share in them. For example,
Person: The aliens are telling me that they are going to abduct me tonight.
Carer: That sounds terribly frightening.
P: I’ve never felt so frightened in all my life.
C: I can understand that you feel frightened, although I myself can’t hear the aliens you speak of.
P: You mean, you can’t hear them?
C: No, not at all. Have you tried ignoring them?
P: If I listen to my iPod they don’t seem so loud, and I feel a bit more calm.
C: What about when we talk together, like now?
P: That’s very helpful too.
Neel Burton is author of Living with Schizophrenia.