Allan Schwartz, LCSW, Ph.D. was in private practice for more than thirty years. He is a Licensed Clinical Social Worker in the states
A mental health worker recently wrote to me seeking information about the auditory hallucinations experienced by people diagnosed with schizophrenia and some of the other psychotic disorders. In writing a response it occurred to me that this is a fascinating topic that can be difficult for people to fully understand.
During the late 80’s and 90’s I spent a lot of time working in psychiatric day hospitals and continuing day treatment programs with people suffering from severe, chronic schizophrenic disorders. I came to respect and understand these people as the wonderful individuals they are. I also came to understand that they are not all wonderful people but, instead, are just people who, underneath their mental illness are good, not so good and fairly obnoxious people, just like everyone else.
The things that frighten, fascinate and confuse people about the psychotic disorders, such as schizophrenia, are those symptoms referred to as hallucinations and delusions. The average person tends to mistakenly believe that hallucinations and delusions are just weird ways of thinking. Therefore, let’s define terms and understand what a person with schizophrenia really experiences.Hallucinations are bizarre symptoms that can affect any and all of the five senses. In other words, people can have hallucinatory experiences that affect hearing, tasking, smelling, seeing and feeling. By far the most common type of hallucination is the one that affects hearing. These are called auditory hallucinations and usually come in the form of hearing voices. In cold reality, there is no other person there but the patient hears either one or more people talking. The patient can respond to these voices by speaking to them and by even doing what the voices urge them to do.
There is a subtlety that eludes most people in attempting to understand hallucinations and it is this:
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Patients do not believe they are hearing voices. Patients do not imagine they are hearing voices. Instead, patients know they are hearing voices for the simple reason that they are hearing voices.
Early in our training many of us made the mistake of asking patients in the hospital psychiatric emergency room if they were hearing voices of people who are not there. Some of us thought the patients were lying when they told us that they were not hearing voices, whether of someone there or not there. You see, for these patients, they were not hearing voices but were carrying on conversations with someone else. Again, these patients were not imagining a conversation but were really, really having a conversation. Therefore, they were not "hearing voices" but were being spoken to. The same applies to each of the other types of hallucinations affecting each of the other sense organs.
Delusions are bizarre and distorted ways of thinking that usually fit with the types of hallucinations being experienced. The most common type of delusion is what is referred to as paranoid delusional thinking. In this, the patient has an elaborate way of thinking having to do with others plotting against him. I have actually heard one patient discuss with full conviction or belief that the FBI was following him in order to carry out his execution. Behind this delusion was a complex type of thinking as to the reasons why the FBI was out to "get him."
Delusions are firmly believed and no amount of logic or discourse will shake a patient’s belief in his or her delusional beliefs. In fact, with the use of anti psychotic medications hallucinations will often vanish while the delusions remain.
Recovery from the symptoms of schizophrenia depends upon many factors. Most people respond well to anti psychotic medications but some do not and remain with their symptoms. A lot seems to depend upon nature of the psychotic illness and the extent to which brain cells have been affected. A lot also depends upon when the onset of these illnesses began. Most commonly, the symptoms of schizophrenia begin during late adolescence or into the early 20 s. For those patients there is an advantage that stems from the later onset of the illness in that they can remember a time when they did not experience hallucinations and delusions. However, some people begin childhood with schizophrenia and are experiencing hallucinations from the beginning of their lives. Therefore, they have nothing to compare their hallucinatory experiences to and cannot remember a time when they did not hear voices. The later onset of the illness improves the chances that a patient will understand that their hallucinations are in their head and, therefore not real. This improves the chances for recovery.
Very often hallucinations are experienced as frightening because voices are not saying nice things and are often either threatening or accusatory of other people. I have known a few cases in which hallucinations were not threatening and were even friendly in nature. While this is rare it can and does happen. I knew of one patient from many years ago who responded well to medication and was at peace with his illness finding the voices to be non threatening and able to be at the day hospital without any tension or discomfort.
In order that the reader fully understand what these patients cope with it is important to mention the fact that the psychotic medications have side effects that are very uncomfortable. Everything from extreme tiredness to hand shaking, tremors and drooling can result from these medications which are one reason why compliance is sometimes difficult. There is one medication which is particularly effective but carries a risk of developing a fatal blood disease. Weekly blood tests must be taken to keep these patients safe. That medication is used sparingly, usually for people who do not respond to any of the other medications.
One final point to make is that even patients who respond well to medications and greatly improve in their ability to function must keep their levels as low as possible or run the risk of relapse.
There is still a lot that is not known about the human brain and why it malfunctions as in cases where people experience schizophrenia. It has been said that someday we will know that schizophrenia is not one illness but is an umbrella term for many different types and varieties of the illness.
Your comments and questions are welcome and encouraged
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