Now, continuing with my previous post, Szasz classified schizophrenia as an illness fabricated by the psychiatry community whereas dementia for him was a legitimate medical illness. Schizophrenia is clinically defined as “a mental disorder characterized by abnormalities in the perception or expression of reality.” The latest issue of the American Journal of Psychiatry (Sep 2009) has a nice article on a woman, recently recovered from schizophrenia. She raises an interesting question of why some patients, including her, deny they have mental illness “in the face of flagrant symptoms”. Three reasons seemed to bolster her denial.

1. Many around her also led a chaotic life with false beliefs, but they managed it better than her. This is drawing comfort from a generalization whose results the patient is unable to handle, when other have had.

2. Mental illnesses don’t have a telltale physiological deficit like lumps in breast cancer patients. But all tumors are not malignant; so a benign lump is like having schizophrenia, when others say it is harmful. So she denied mental illness.

3. She chose beliefs she held, despite no ‘good evidence’ for their existence. As she puts it: “The illness was not something happening to me, but something I was ‘doing.’” This in any case is a delusion, quite common among schizophrenics.

Strangely, she reveals that these three reasons were annulled by first getting a dose of “new drug, olanzapine, that cleared her thoughts and mind in a way the earlier drugs hadn’t.” This made her realize that others had clear minds that she didn’t. So the first reason stands deleted. This led her to think that there are different kinds of schizophrenia. So characterizing schizophrenia as a benign lump was invalid. She says she may have a more benign version but she was cared and got to know that schizophrenia was impairing unlike the benign tumor. That nearly cancels the second reason.

Then, the third reason was erased when she knew that she could still do something that she didn’t want to. Tapping a toe was thought to be a side effect of the drug she took, but she could stop tapping when she wanted to. This realization is what medical practitioners should seriously think about and what a cognitive behavioral therapy is meant to do: let patients rediscover that they can do something that they thought they cannot. Confront a stranger, even if you think they are plotting to kill you.

Her conclusion is quite insightful. Let me quote her verbatim:

Narcissistic injury, I think, is what fuels most denial, whether or not there is a lesion involved… Getting past the need for denial is mostly a result of good therapy or other psychosocial intervention. (The importance of psychosocial approaches is of interest given recent efforts to focus on biology and—more important—to take the psychology out of lack of insight.) (pp.973)

And she lastly says clinicians have to patiently listen to the patient’s reasoning, however false it may be, and discover the treatment from it.