Courtesy of Godoy Medical Forensics
The police were called to a busy intersection of the city because a man was standing in traffic, shouting, and stopping cars. He was a white male in his early 20s with an unkempt appearance. When the police questioned him, he stated that he was an undercover FBI agent. He said that his job was to direct traffic and find terrorists. The police ordered him to get out of the road and he refused. He became combative when the officers tried to escort him. He was tased by one of the officers and fell, hitting his head on the street. He was unconscious and transported to the emergency room, where he was diagnosed with head trauma and admitted to the intensive care unit. Emergency room personnel recognized him and referred to him as a “frequent flyer” who had a diagnosis of schizophrenia and was admitted to the acute psychiatric unit on a regular basis. The case is likely to receive media attention and the community may state that the police officer acted inappropriately by using a Taser on an individual who was unarmed and mentally ill. A lawsuit may be filed against the police department by the family of the injured man, potentially leading to both criminal and civil proceedings.
Symptoms and Diagnosis
There is currently no diagnostic test for schizophrenia. The age of onset is usually between the late teens and early thirties. Diagnosis is based on an individual’s history and presenting symptoms. Positive, negative, and cognitive symptoms are identified. Positive symptoms are delusions and hallucinations. Sometimes, people confuse these two symptoms. A delusion is a belief that is not based in reality. In the scenario presented, the individual believed that he was an undercover FBI agent. Delusions often have themes involving religion, sex, or the government. An individual who has schizophrenia may have paranoid delusions—believing that a person or group will harm him or her. Hallucinations involve the senses. They can be auditory, visual, tactile, olfactory, or gustatory. The most common are auditory hallucinations, sometimes referred to as “voices.” An individual who is hearing voices may appear distracted, be slow to respond, or appear to be listening or laughing inappropriately. Initially, the voices can be comforting or amusing but this changes as the disease progresses. The voices can become very critical and derogatory.
Individuals with schizophrenia may sleep excessively or use alcohol or other substances to diminish the voices. Command hallucinations are the most serious and can be dangerous. The voices may command an individual to harm themselves or others. The person may feel that they must obey. It is helpful to ask someone who experiences auditory hallucinations if they are in control or the voices are in control. They will respond best to a low stimulation environment if experiencing psychotic symptoms. Examples would be low lighting, minimal people and a low noise level. Only one person should speak to the psychotic individual and requests should be direct and brief. Whispering and laughing can be misinterpreted and should be avoided. Orienting the individual to reality, such as using his or her name, is recommended. The focus when working with a person who has schizophrenia is to decrease anxiety and build trust.
The negative symptoms of schizophrenia involve a loss of function. Examples are a loss of verbal fluency, loss of energy and motivation, loss of the experience of pleasure, and loss of emotional expression. Personal hygiene and social skills may be lacking. These symptoms may seem less dramatic than positive symptoms but they are just as debilitating. When a person with schizophrenia is being interviewed, he or she may respond with one word answers and seem to have no expression on their face. This presentation could be mistaken for low intelligence or depression. Cognitive symptoms can involve memory and language deficits. The individual may be slow to process information. They may be slow to respond to questions. Individuals with schizophrenia may lack insight and awareness of their disorder. They may resist treatment for this reason. Social skills training, anxiety management, and education about the illness and medications is also helpful. Insight-oriented psychotherapy is less effective.
Medical Treatment Options
The primary treatment for schizophrenia is anti-psychotic medication. It can help individuals to manage their symptoms, but it is not a cure. The older anti-psychotic medications—called “first generation”—were effective for positive symptoms and had serious side effects. Some side effects, such as tardive dyskinesia can be irreversible. Neuroleptic malignant syndrome is a rare, but life-threatening, side effect. Examples of first generation anti-psychotics are: Thorazine, Haldol, Stelazine, and Prolixin. Haldol is still used in emergency situations because it can be given by injection and is fast acting. The older medications may be prescribed because of lower costs, but the newer anti-psychotic medications are generally considered safer and more effective. First prescribed in the 1990s, they are effective for both positive and negative symptoms. Geodon, Seroquel, Abilify, and Risperdal are examples. These newer medications—called “atypical” or “second generation”—can also cause significant side effects, but less frequently. There is a high risk for weight gain and type II diabetes with the newer medications. Compliance with treatment is often a problem for people who have schizophrenia. They may not have insight about their need for treatment as noted in the previous section. They are usually unable to maintain employment in jobs that have insurance benefits. When faced with a choice between medication and food, because of inadequate finances, they will choose food. Side effects—such as obesity, sedation or restlessness, dizziness, and sexual dysfunction—can discourage people from taking their medication. When individuals stop taking medication they experience symptoms that can lead to hospitalization or legal problems.