May 11, 2009

The first-person dimension of homeless Sacramentans suffering from Schizophrenia

"Disabilities and dysfunction process from having been shunned and denied access to needed opportunitites and networks of support."
~ the brothers Lysaker in Schizophrenia and the Fate of the Self

What is schizophrenia? How many are homeless Sacramentans?

Perhaps 15% of the Sacramento homeless population suffers from schizophrenia. The percentage is difficult to determine for many reasons that branch from both the fuzzy definition of the malady and that many people within the homeless community who have the illness (1) are in denial and are undiagnosed and (2) have the illness as a diagnosis only – the disability can be faked by people who are successful claimants of social security and other benefits.

What is schizophrenia? One webspace gives us this definition: The most chronic and disabling of the severe mental disorders. Typically develops in the late teens or early twenties. The overt symptoms are hallucinations (hearing voices, seeing visions), delusions (false beliefs about commonly held views of reality) and bizarre thought patterns. Another webspace adds this: Psychosis characterized by the breakdown of integrated personality functioning, withdrawal from reality, emotional blunting and distortion, and disturbances in thought and behavior

According to a study by Amador, et al, "Awareness of Illness in Schizophrenia and Schizoaffective and Mood Disorders" in the Oct 94 issue of General Psychiatry, between a third and two-thirds who have the malady deny or are unaware they have the mental illness.

According to Dr. Joseph Pierre's commentary in the Feb 2009 issue of Psychiatric Times, "What do you mean, I don't have schizophrenia?": my patients' world – and in the wake of the Contract With America Advancement Act of 1996 – a diagnosis of schizophrenia is one of the best ways to gain access to a disability income and other social services that are unavailable for those who "only" have a substance use disorder ... [M]y patients were far from relieved when I "took away" their schizophrenia diagnosis or an antipsychotic medication. On the contrary, their very existence was threatened.

Viewed from this perspective, I realized that malingering, if present, was often [caused by the medical establishment] – incentivized by increasingly restrictive criteria for disability incomes or access to care that characterize addiction as a lifestyle choice. I'd find myself thinking of Jean Valjean: given existing conditions, who wouldn't steal the loaf of bread as a simple act of survival?

Thus in homeless communities in America, there are many undiagnosed schizophrenics, and many with other problems but who get a schizophernia diagnosis but don't have the malady.

The number of homeless in Sacramento who are schizophrenic is approximately 420. But this educated guess could be off by a hundred or more, either up or down.

Blunted affect and diological self

The medications that schizophrenics take will relieve their hallucinations and delusions and bizarre thinking to great extent, but do little for the emotional blunting and withdrawl. Schizophrenics faithfully keeping up their medication regimen will be placid and unnoticed, but from their experience, they are alienated nothings.

From the book Schizophrenia and the Fate of the Self:
... blunted affect ... generally refers to a lack of emotional expression in inflection, expression and gesture. A person described as having blunted affect would show a limited range of emotions, perhaps appearing wooden or lifeless in the midst of a celebration or a time of sadness. In contrast to a drepressed person who might silently be consumed by pain, someone with flat affect would feel emptiness. If confronted with something painful, pleasurable, surprising, or disgusting a person with flat affect would show the same emotional response: nothing. ...

[As an example, one schizophrenic, Glass, describes his experience thus:] Glass tells us that he is in a cloudbank, suggesting a hazy, undifferentiated state within which direction is elusive. Moreover, none of the events wherein his life unfolds produces any particular effect in him, as if each self-world interaction were just more mist and vapor, including his own role therein.

When one becomes fully emotionally flat like this, it disrupts one's sense of self. You have nothing to animate your character. Internally, for the schizophrenic, there is nothing to stir him to converse with others. But the schizophrenic does suffer from a sense of "nothing," feeling as if he is barely there and fading away.

Without an animating self, there is a lack of volition. There is simply nothing to compel one to pursue any particular course of action in a day.

It should be of no surprise, then, that the most common cause of death for a person with schizophrenia is suicide.

Problems for schizophrenics who are unaware of their illness

From Schizophrenia and the Fate of the Self:
Imagine having a vague sense that one was faring less well than before, but maintaining the belief that the likely symptom of and thus key to one's diminishment was irrelevant to one's situation. Presuming one's assessment was mistaken, one would continue to fare poorly, and perhaps waste time addressing unrelated situations. This is precisely the kind of scenario we think occurs when people lack insight into, or an awareness of the symptoms associated with schizophrenia - the dialogical compromises they affect continue unabated. The point is not simply that such folk are unlikely to seek help, but also that their lack of awareness prevents the development of a meta-position, for example, self-as-ill, which could help them interpret and thus delimit the influence of the unusual experiences and/or beliefs they find themselves having.

Lack of insight into one's condition is also likely to intensify social alienation. Without a plausible account of one's trouble, it would be nearly impossible to talk to others about one's experiences and the difficulties that often surround them.

... If dialogical breakdowns lead to a sense of self as diminished, and particularly with regard to one's agency, awareness of illness could be overwhelming. ... one of our [the authors'] central claims is that sense of self derives from interanimating play of self-positions. As that play proves increasingly disordered, sense of self will suffer, finding little to hold onto besides its diminishment. ... the thought that one is nothing but diminishment can be devastating. So it may be that a refusal to see one's symptoms as sympoms allows one a sense of self that is disoriencted and diminished, but at least not the nothingness that seemed to loom on the edges of paranoia.

Sorry, kind readers, for posting such a big block of text, but what's written here is important, I think.

In layman's terms from what I glean from the above: People, generally, use a lot of their energy trying to cope with and cover up their deficits. But for the large number of schizophrenics who are undiagnosed and unaware of their mental illness, things are triply bad. They can lose the ability to have a meta-position with respect to their self. [A meta-position, as I understand it, is how you fluidly present yourself as your interactions with others change during the course of short-range spans of time.] Not having access to more-resolved meta-positions, schizophrenics can be prone to more delusional thinking, and that leads to greater social alienation.

The authors believe that successful, orderly and accepted "play" between the different selves we each have makes us "normal." A schizophrenic experiences a sense of failure in transactions with others, disorder and unacceptance. Thus, there is a downward spiral toward feelings of disorientation, alienation and "nothingness." At this stage, a schizophrenic person might experience himself as disembodied.

Psychosocial rehabilitation

In a final, very short few paragraphs at the end of their book, the brothers Lysaker write about "pychosocial rehabilitation." They suggest vocational programs for supported employment; peer support and guidance and case management.

Also, the brothers are keen on creating social situations for schizophrenic people that elicit and support self-positions such that sense of self is celebrated and stabalized.

Helpful links:

Glossary Of Schizophrenia Terminology
Schizophrenia and the Fate of the Self at amazon
Schizophrenia and the Fate of the Self at Oxford University Press

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