Central  South  Dakota Medical News
The Clinical View
by P.E. Hoffsten, M.D.
7/18/2002

THE MYSTERY OF SCHIZOPHRENIA

    Schizophrenia is a mental illness with an estimated incidence in our population of nearly 1%. The hallmark of thus disease is the presence of hallucinations that leaves the affected individual unable to tell the difference between what is real and what is not.

       As an exercise, think back to what you had for breakfast this morning. Like many people maybe it was nothing but if you ate something, think about it long enough to remember some detail about the nature of the food that you ate. Was it eggs, bacon and toast or sausage or cereal or fruit? Was it fresh fruit or canned fruit or frozen fruit? Take the time to remember what you can about your breakfast.

       Now as the second part of the exercise, imagine that you awakened and your butler brought you breakfast in bed. On the tray were the most delicious fresh raspberries that you had ever seen. There was your favorite cereal, coffee if you wanted it, a glass of fresh-squeezed orange juice and your favorite order of pancakes, french toast or a waffle with whipped cream and a cherry on top. It was served with very beautiful plates, fine silverware, a large linen napkin,  those things that were supposed to be cold, were cold, and those things that were supposed to be warm  were  warm.  Your coffee or hot chocolate was just the right temperature and you enjoyed the entire meal.

       Well, I didn't get a breakfast like that this morning either but I can tell the difference between that imagined breakfast and what I actually had. I am not sure how I do that but normal individuals are able to tell the difference between reality and imagination. If you watch television, you have seen that lawyers can mess with your mind and witnesses sometimes have trouble telling the difference between what they did see and what they didn't see. But normally day in and day out, normal people are able to tell the difference between reality and those things that are not real or imagined.

       The nature of a schizophrenic is that they have trouble telling the difference between reality and those things that are not real. They hear voices or noises that other people don't hear. They have visions and see things that other people don't see and the major problem is that the schizophrenic has great difficulty telling the difference between those things that are real and those things are not real. If you have not had the opportunity to this time, I would highly recommend the academy award winning movie "A Beautiful Mind" as a vivid example of the schizophrenic's world.

       Characteristically, schizophrenia tends to present at times when the stress of change in your life becomes increased. It is as though the individual can manage their mind until stress reaches a certain critical level and then they are no longer able to compensate and separate reality from unreality. It most commonly presents between the ages of 15 and 35 and presentations can be dramatic.

       My most vivid memory of a presentation was a patient who called me frantically at 11:00 pm at night wanting me to come to the hospital to see his 18 year old son who had just started college.  My patient (the father) had gone to the movies with his wife and came home to find the living room couch in flames, the room full of smoke and his son squirting charcoal lighter fluid onto the couch fanning the flames. The son had heard voices coming from the couch. and had interpreted them as being devils that were in the couch. The son felt that the only method of getting the devils out of the couch was to set it on fire and that is what he did. The part I remember most vividly about this incident, when I met the son in emergency room, was the father's anger at his son and the son simply not understanding why his dad was so angry. The newly diagnosed schizophrenic son had acted in perfect faith to deal the perceived evil. Eventually, getting the father to accept the fact that his son was mentally ill and not a common vandal was a difficult task.

       Before 1950, there were approximately two million individuals in mental institutions in this country because of our society's perception that “these people needed to be locked up”. Since then, medications have become available with new ones developing in the past several years having very low side effects and rendering the schizophrenic individual able to live in society without the need for an institution. Some schizophrenics may still need substantial support and supervision ,but more than 90% of all schizophrenics in this country are not in institutions.

       The problem of schizophrenia is really much more complex than this brief presentation can elucidate. First, schizophrenia is probably not one disease but instead has multiple causes that create an individual we call schizophrenic. Thus, a single drug to treat all patients is probably not a realistic expectation. Secondly. there are both positive symptoms of schizophrenia such as the hallucinations mentioned above.  In this sense “positive” is used to denote things the schizophrenic adds from their senses.   But there are also what are called a negative symptoms of schizophrenia which include the affected individual's tendency to be "a loner", have a depressed mood, and have a terrible time making decisions. Some researchers on schizophrenia feel that the positive and negative symptoms of schizophrenia mean that it is really at least two different diseases.

       Where as one might think that treatment of schizophrenia requires very specialized care, in fact, most schizophrenics are treated by general practitioners of medicine in the community.To my knowledge, there are only two psychiatrists that come to the Pierre/central South Dakota area, there are at least one thousand schizophrenics in this central South Dakota area with a population of one hundred thousand people. Thus, the practitioners at your local clinics ate aware of the problems of schizophrenia and how to help the individual with the condition in addition to helping their family and friends support the schizophrenic individual.  Both the diagnosis and the treatment for this condition begin and end in the local clinic.  Specialty care from a psychiatrist is infrequent and primarily supportive.

       As a closing note, anyone who has ever dealt with this condition always asks, “What in  the world causes this problem?” and the answer is we don’t know.  There are lots of clues but the mystery is not solved yet