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Schizophrenia: A Speculative Consideration of the Extreme Cases: A Highly Tentative Meditation
Shameless plug: I have been thinking about this subject for a long time, and wrote a short story concerning schizophrenia; its a kind of horror-suspense story. If you're interested, its called "I Must Kill The Gnomes."
We're not talking about "multiple personality disorder" and we're not talking about "paranoid" schizophrenia. As I see it, the "paranoid" tag is oxymoronic in relationship with what I see as the cognitive personality disorder of schizophenia.
I think the best way to get into this is to refer to a story I heard, years ago, on a public radio program called "This American Life." This American Life is a public radio program broadcast out of WBEZ in Chicago. It turns up on the NPR stations, in my area, on the weekends----93.9 FM/820 AM. The show is hosted by Ira Glass.
What they do, each week, is to present a theme for consideration, and tell one, two, three, or even four stories concerning that theme, and this, of course, gives us "This American Life." There was an episode called "Desperate Measures," which aired on April 15, 2004.
"Act One" was called Hasta La Vista, Arnie (Yes, meaning Arnold Schwarzenegger).
Hasta La Vista, Arnie
Scott Miller was a young, green medical/psychiatry student working at an unnamed hospital. A patient who insisted that he was "The Terminator," kept staging escapes for some of the other patients. "The Terminator" claimed that he was there to rescue "John Connor."
The patient had been one hundred percent stuck in his fantasy without a break, which, according to Scott Miller, is somewhat unusual. He said that usually such people have short-circuiting ruptures with the fantasy, in which they remember who they are, briefly, before submerging back into the fantasy. That did not happen with "The Terminator." There was no short-circuiting rupture with the fantasy in which he even briefly recalled who he really was.
The staff responded to the crisis by increasing the patient's medication and reasoning with him, explaining to the "Terminator" why he shouldn't be acting this way and how disruptive his behavior was---to no avail, of course.
Our young resident, Scott Miller, was intrigued with this situation. He had also remembered a psychiatrist called Milton Erickson, who had a reputation for treating difficult cases in unorthodox but effective ways. For instance, one man had been hospitalized for decades. He claimed to be Jesus Christ.
Dr. Erickson invited the man to his office and asked him if he was, indeed, Jesus Christ. The man said that he was. Erickson said, "You're a carpenter?" Again, the man answered in the affirmative. Dr. Erickson therefore put him to work making bookshelves at the hospital. Within a short period of time the man was released and working professionally as a carpenter.
One day when Scott Miller went in to work, he found "The Terminator" stripped down to his underwear, secured in a padded room. The patient still believed that he was the Terminator and the medication and reasoning had not brought about the slightest improvement.
Miller asked to speak to the man. He engaged the patient in conversation along lines which, of course, acknowledged the fantasy. At one point Miller said to the patient, "Are you really the Terminator, or are you Arnold Schwarzenegger?"
The patient was astonished. "How did you know?" he asked. Notice: The patient had adopted a false identity which was meant to conceal another false identity. Anyway, they chat for a little while, with Miller exclaiming about what a classic American rags-to-riches story that "Arnold" had lived.
Then Miller said that he had a new acting role for him to play, but that he wasn't quite sure "Arnold" was up to it. The patient confidently assured Miller that whatever acting role he had in mind, he, "Arnold Schwarzenegger" could indeed execute it.
Miller said that the role---presumably for an imaginary film project he was imaginarily (I just invented the word 'imaginarily') producing---was that of a mental patient. He said that in order for "Arnold" to prepare for that role, he was going to have to leave the padded room, behave himself, engage with the people who were "pretending" to be the hospital staff (presumably they were also actors researching their roles), talk about his feelings, participate in occupational therapy, and so forth.
As Miller recalls, the patient agreed to take up the challenge and was released five or six days later. The strange thing was that the "Arnold" was "in-role" so much that he "forgot" that he was Arnold Schwarzenegger.
This story is instructive in several dimensions. First of all, we get a good, workable answer to the question: What is schizophrenia?
The answer is that it is a cognitive disorder in which a person, to a greater or lesser degree, gets lost (and I emphasize the term 'lost') in the world of imagination; and, to a greater or lesser degree, has trouble finding his way back to reality on his own.
All of us, during the course of our lives, spend everyday constantly weaving in and out of the world of imagination. But the vast majority of us, those deemed 'neurotypical,' manage to do so without getting stuck in the imaginary realm. Our functioning in the real world is in no way impeded by making these constant, mental round trips between the real world and the imaginary world.
For example, suppose you and I are sitting at a cafe, chatting over cake and coffee, and so on. Suppose I catch the smell of freshly baked pecan pie. This smell triggers, in me, memories of when I had been a boy thirty years ago, and our family would visit my paternal grandparents in Kansas. Grand ma baked the best pecan pie!
Now, I can allow myself to be transported, somewhat, in this way, to cast my reflections back to those times WITHOUT losing my grip on the present reality, which is the fact of you and me sitting in this cafe thirty years later. I am not going to start acting like the ten-year old I had been when I visited my grandparents in Kansas. This is because I am remembering (for our purposes 'imagining' is actually a better word) and I KNOW that I am imagining.
If I were to slip into a schizophrenic episode, I would, perhaps, start acting like the ten-year old boy I had once been while visiting my grandparents in Kansas; and, very importantly, I will FORGET that I am imagining---just as the clinical patients "The Terminator" and "Jesus Christ" forgot that they were imagining.
Out of whimsy I might imagine that these walls are made of vanilla ice cream. But I know that I am imagining, so I am not going to take a spoon and try to eat the walls.
From the story related to us by Scott Miller, we understand that the most obvious way to treat a schizophrenic, someone who is LOST in the world of imagination, is---absurd as it may sound---by helping the person having a schizophrenic episode to get un-lost in the world of imagination, and lead him back to the world of reality. Furthermore, it would appear (and I stress the word 'appear') that the way to do this--get a person who is lost in the world of imagination 'un-lost'---is to use elements of the fantasy itself as a road back to reality. Recall the psychiatrist who treated the man who had been convinced he was Jesus Christ, by having the patient make bookshelves for the hospital (Jesus was a carpenter, remember). The carpentry was the connecting bridge between the fantasy of a Christ identity and the real world.
Scott Miller took the road of the acting craft to lead "The Terminator (aka Arnold Schwarzenegger)" back to reality. Miller challenged the acting professionalism of the patient. In this way, I suppose, the patient was asked to "pretend" to be... himself, until such time as the supposed pretense became genuine.
It seems to me that what follows from all of this is the hopeless ineffectiveness of drugs for treatment of schizophrenia. A drug is an inanimate object, and as such, cannot provide the intelligent interaction, which seems to be needed, to help a person suffering from a schizophrenic episode become un-lost in the world of imagination and find his way back to reality. I would imagine that, at best, what a drug can do is suppress, in a patient, what we might call explosive or disruptive behavior, and thus, hopefully, prevent him from hurting himself and others, which, of course, is no small thing.
But in terms of effectiveness, it is surely the case that a drug cannot eliminate the fantasy. In fact, its not hard to see why the use of drugs might engender resentment on the part of the patient. What the drugs would do is somewhat immobilize the ability of the patient to either creatively engage with the alternate world he is lost in, if it is wonderful, or defend himself from its dangers, if his alternate world is a perilous place. And then there comes a point when the body develops an immunity to the medication, as seemed to have happened with "Jesus Christ" and "The Terminator."
Obviously, not everyone who experiences schizophrenic episodes are lucky enough to have them in the presence of people like Dr. Milton Erickson (the man who ordered "Jesus Christ" to build bookshelves for the hospital) and Scott Miller. As far as I know, it may also be the case that not every person afflicted with schizophrenia has such a straightforward, easily identifiable fantasy life such as simply self-identifying as "The Terminator" and "Jesus Christ." A person with schizophrenia may get internally lost (I mean LOST) in several kinds of fantasies, either related and overlapping or separate and individually distinct.
Nevertheless, such people are LOST and need intervention of a certain kind to become un-lost and make their way back to reality.
I am simply going to play Nostradamus and predict that the ultimate answer will involve extremely sophisticated artificial intelligence. It seems to me that what a person with schizophrenia needs is an implant, perhaps something in nanotechnology, which would act as a kind of cognitive/behavioral GPS. It should be a powerful computer that is programmed with knowledge of all human myths, religions, fables, fairy stories, legends, etc. This device should be able to think creatively in order to stop a person from getting LOST in his imagination to the detriment of his real world functionality.
When the person is getting lost in his mind, the device should be able to figure out what kind of fantasy (or its variation) the person is stuck in, and plot a road map for his return to reality. In other words, I'm saying that the treatment of schizophrenia, I think, will ultimately depend on artificial intelligence to do, on an ongoing basis, what Scott Miller did for "The Terminator" and Milton Erickson did for "Jesus Christ."
Shameless plug #2: I also wrote a six-part novella that has some elements of schizophrenia in the story. Its called "Circus Madness," if you're interested.
Schizophrenia vs. Dissociative Disorder
I have seen a few essays that compare and contrast schizophrenia and dissociative disorder. Its important to remember that schizophrenia is a condition in which someone gets 'lost' in his imagination and cannot find his way back to reality on his own. His immersion into this alternate world of his imagination does bring on behavioral changes (not personality changes) and he seeks to engage with this alternate world in the way that seems appropriate to him.
A clue to what dissociative disorder is all about is contained in the very term---dis-sociative; in other words there is dis-association going on. To associate means to identify with something or somebody. If someone seeks dissociation, to dis-associate, he is seeking to sever identification with something, to disavow any connection with it.
Someone with dissociative disorder seeks to disavow any connection with an aspect of his personality that he is not comfortable with. Indeed, this basic idea is presented for us by Wikipedia. We are given five basic forms of dissociative disorder. But the basic definition of dissociative disorder provided is as follows: Dissociative disorders can be can be defined as a condition that involves disruptions or breakdowns of memory, awareness, identity and/or perception. People with dissociative disorders use dissociation, a defense mechanism, pathologically and involuntarily. Dissociative disorders are thought to primarily be caused by psychological trauma.
The point is that someone with a dissociative disorder is trying, in some way, to escape himself. This is NOT the issue with schizophrenia.
Thank you so much for reading.