Schizophrenia for Writers - Her Problems Are All In Her Head

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English: Image showing brain areas more active in controls than in schizophrenia patients during a working memory task during a fMRI study. Two brain slices are shown. (Photo credit: Wikipedia)

In several of the books that I have read recently, schizophrenia has played a key role in the stalking and attacking of the stories' heroines. The volatility and changeability seen in the villains mental health make for interesting plot twists.  

When I worked as an emergency interventionist for the courts, I had a few clients who were diagnosed with schizophrenia. They were all non-compliant with their medications for varying reasons. This made some of my clients very scary individuals - but not all.

Schizophrenics do not all have voices in their heads telling them to "Kill her! Stab her! Hurt her!" Indeed, people with schizophrenia are not all violent towards others or themselves. But schizophrenia is fluid and changes in symptoms should be expected. This means that one never knows if the schizophrenic with whom they are interacting is safe or not.

If you are writing a plot line in any genre that includes someone driven by mental health issues, here is some information to help you develop a character with schizophrenia.

Characteristics of schizophrenia  include: 
* Delusions
* Hallucinations
* Disorganized speech and behavior, symptoms that cause social or occupational dysfunction.

Diagnosis can only be assessed after  symptoms have been 
* Present for six month
* Include at least one month of active symptoms.
   Video Quick Study (1:48) real footage of a mental health schizophrenic breakdown
   Link Quick Study (7:04)  Aileen Wuornos killed seven men and was executed. Look at her eyes.
   You can see the sclera  (whites of her eyes) all the way around. This is a KEY SIGN of high stress.
   

English: A schizophrenic patient at the Glore Psychiatric Museum made this piece of cloth and it gives us a peek into her mind.  (Photo credit: Wikipedia)

Schizophrenia symptoms are typically separated into 2 categories:

Positive symptoms: 

(Photo credit: Wikipedia)

* Extra feelings or behaviors that are usually not present.
* Delusions - believing that what other people are 
   saying is not true  - often leading to paranoia.
   This is the person who wraps their room in aluminum
    foil so the microwaves can't effect them,
    or thinks that the government has put tracking devices
    under their skin.

* Hallucinations - Hearing, seeing, tasting, feeling, or
   smelling things that others do not experience.
   

   So for example, one of my clients presented with a
   friend who happened to be a dragon. This dragon

   would fly around the ceiling. She didn't like to stand up
   in her house and would often duck down and drag

   me with her because the dragon was flying around and trying to hit her with its wings. On occasion, the

   dragon would become angry and frighten her; she would take all of her medications at once to make

   the dragon leave her alone. She'd call me to tell me - then we had to have her stomach pumped. She

   was very sweet and in my experience never caused harm to anyone else, but she was tormented by the

   images - no sounds - just the very-real-to-her image of the dragon.

   Video Study (14:00) TED Talk about a woman's  experience with auditory hallucinations. She was not
   violent or suffering - but this is her story of medical intervention.
   Video Quick Study (6:36) a first person view of various hallucinations - very interesting.
   Audio Quick Study (3:38) auditory hallucination simulation
   Video Quick Study (9:53) schizophrenia simulation
   

* Disorganized speech and behavior
   Video Quick Link (9:22) four patients experiences various symptoms of schizophrenia talking. 
  

Messages covering the windows of a house from a patient with schizophrenia. (Photo credit: Wikipedia)

Negative symptoms: A lack of behaviors or feelings that usually are present, such as:
* Losing interest in everyday activities, like bathing, grooming, or getting dressed. Many of our homeless

   have this attribute.
* Feeling out of touch with other people, family, or friends
* Apathy - Lack of feeling or emotion.
* Having little emotion or inappropriate feelings in certain situations
* Having less ability to experience pleasure

Notice that many of the NEGATIVE symptoms mimic depression. LINK to Depression for Writers 
I was recently listening to the blogger/writer from a blog I read who was speaking on NPR. She was diagnosed with depression and was discussing her episode. She said that her anti-depressants were helping. But to my ear, boy did she sound like she was exhibiting negative signs of schizophrenia. She described her utter lack of emotion. The only piece that prevented her suicide was the idea that her husband would find her body. This was the only feeling she could conjure up. Depression and schizophrenia diagnoses often overlap. 

weird place! tries to reproduce what it's like to have Schizophrenia. Don't stay in there too long. (Photo credit: Wikipedia)

* Schizophrenia affects different people differently and
   symptoms can vary from person to person.

* Some people may have many symptoms, while others
   may only have a few.
* Men diagnosed with schizophrenia usually start to
   show symptoms between their late teens and early
   20s.
* Women usually develop symptoms during their
    mid-20s to early 30s. LINK

It used to be that schizophrenia had sub-types like paranoid schizophrenic, but in the the new DSM V (the psychiatric bible) these have been done away with because the illness is so fluid and changeable that these specifications were not helpful to the treatment. They are now noted as displayed symptoms.

Want to see this article in action?
Check out this Fiona Quinn novel Chaos Is Come Again

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Criminal Psych 101: Information for Writers

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 (Photo credit: Wikipedia)

I have a masters degree in rehabilitation counseling, which means that I worked with people who had mental health issues created by or exacerbated by physical health issues. For example, I had a family whose father was electrocuted while working in the hospital. Because he was on site, doctors were able to save his life. However, he had a complete personality change and became prone to fits of physically-abusive rage. These were aspects that could not be changed, but the family had to deal with.

When I was practicing, I was a court ordered interventionist for families at risk. My population had at least one family member who was involved in the penal system AND displayed serious mental health concerns in the family including homicidal and/or suicidal ideations, and sexually deviant behaviors, among others. 

The following are some things that I think writers might find helpful when constructing their plot lines. I will also offer, that if you have a specific question, you can leave it below, and I will do my best to help.

One of the main things that I want to point out is that clients who are seeing a mental health provider because they want to improve their lives and someone who is court ordered to work with a mental health provider are different. 

Clinical:

* There of their own volition

* Generally honest and working hard to make improvements

* Client's privacy is protected under the law

* End goal is to become a better/happier person

Judicial orders:

* There against their will

* Typically uncooperative and uninterested in progress

* Information gleaned in the therapeutic setting does NOT fall under the same

   patient confidentiality laws

* Client is aware that the information can/will be part of their trial or other legal

   procedure (such as parole hearing)

* Client frequently tries to manipulate the mental health worker to influence their

   testimony and outcome.

So, I dealt with a lot of deception. The two main false presentations were malingering and defensiveness.

MALINGERING - the client pretends to have a mental health issue. Usually they do this to avoid being prosecuted. Malingering runs in cycles closely copying those stories that are found in the news. Clients usually didn't make up symptoms by doing research (in my client case load). Psych disorders and medical disorders tend to be fashionable - right now bi-polar is a big diagnosis. I personally know people who have been given this designation and are medicated for it when I am very clear this is not their issue. I am not digressing - I am pointing out that even clinicians, when not paying attention, can fall into this habit as well.  But if a client presented with PTSD, I would pay very close attention to their symptoms because PTSD is so prevalent in the news right now.
VIDEO QUICK STUDY (2:50)
AUDIO QUICK STUDY (2:38)

How could I pick out a malingerer? 

* VERY dramatic. Really pushing the envelope on wacked-out (yes, the clinically

  correct word) behaviors. So if your character is malingering, look up the

  symptom list in the DSM V (Should be in your library) and then magnify these

  behaviors.

* They drop the symptoms from time to time especially if they don't think anyone is

   watching. It's hard to maintain fake symptoms for long stretches of time. It's like

   constantly telling a lie; the brain is very engaged and becomes tired.

And then just to cloud things a bit, there is pseudo-malingering. That's when someone with a mental health issue pretends to have a different mental health issue because they think that will get them off the hook. Ex. Someone who is a psychopath presenting with PTSD symptoms. The mental health worker has to decide which symptoms are true and which feigned. It's a mess! But would make a GREAT PLOT TWIST!

DEFENSIVENESS - You can read this as the opposite of malingering. It's when a client, with OBVIOUS mental health issues, tries to present as stable. I had a client once who was trying to keep custody of her children. She was diagnosed schizophrenic, was non-compliant with her meds, and suicidal. When she went before the judge, she thought that the best way to keep her children in the home with her was to lie. (She was successful in keeping her six children, and the end result was catastrophic for the kids, I'm sorry to say.)

Now, while I am a counselor, typically the two titles seen in the legal system are:

Forensic Psychologists and Forensic Psychiatrists.

Forensic Psychologists 

* Have masters or PhD in psychology

* Can do psych testing

* Can offer expert testimony

* Can provide treatment and evaluation of progress  CANNOT prescribe

   medications

* Can attempt to establish a motivation in a crime

   Was it do to a substance abuse issue?

   Was it do to something that had happened to that person in the past?

   Was it do to a mental health disorder such as PTSD or Schizophrenia?

Forensic Psychiatrists

Regions of the brain affected by PTSD and stress. (Photo credit: Wikipedia)

* Have medical degrees and residency in

   psychiatry

* Can do everything that a psychologist

   can do

* Can prescribe medications

* Can decide if the client is a danger to

   self and community leading to an

   involuntary mental health hospital stay

* Can establish if the crime was based

   on a medical issue - one such issue that

   is coming up in the news lately are the

   brain injuries sustained in football,

   and tumors growing on the brain.

  Video Quick Study - Brain Injuries and Depression (1:25)

Counselors, Psychologists, and Psychiatrists all:

ASSESS - evaluating people using psychological tests

Mental health workers do NOT get to make a judgement. They are only offering their expert opinions. For example, I could not declare someone insane and have someone placed in a medical facility involuntarily. I would present my information and the judge would rule about the sanity/capacity of the client.

Testing is used to help the courts understand the person being assessed

Test Examples:

General personality inventories Myers-Briggs

Beck Depression Inventory 

Rorschache Test Video Link to original test (9:05)

Weschler Memory Scale

Weschler Adult Intelligence Test Video Information Link (13:38)

Robert Hare's Psychopathy Checklist Animated List - Link (2:43)

Rogers Criminal Responsibility Assessment Scales Informational Link

 (Photo credit: Wikipedia)

Psychiatrists can add physical exams:

Blood work

Toxicology reports

Electroencephalograms

Cat Scans

TREAT - psychotherapy like talk therapy, art therapy, music therapy,

 behavior modification

Video Quick Study - Mental Health and Prison  (6:36)

TESTIFY

* Civil - family members of custody, guardianship, JD, medical do-not resuscitate,

   disability and loss in workers comp cases and social security cases

* Criminal - 

   Ability to stand trial

   Competency

   Sentencing

   Treatment of incarcerated criminals

One of the things that Forensic Mental Health Workers are trying to decide upon is competency. Someone could have been legally insane at the time of the crime. That does NOT mean that they are insane now. So the assessment looks at what was the mental health capacity in the

* past

* present - what is their mental health standing now? 

   Can s/he give testimony? 

   Stand trial? 

   Can this client understand what is going on? 

   Can they participate in their defense?

It's during the trial that the judge would decide the level of sanity during the crime. Only about 1% of cases attempts an insanity plea. 1 in 1,000 are considered insane.

(Photo credit: Wikipedia)

Guilty but Insane:

M'NAGHTEN RULE - 

If the defendant did not or could not understand what he or she was doing, or they knew it was wrong, at the time of the crime, they are considered not guilty by reason of insanity.

VIDEO QUICK STUDY (3:33)

* Mens Rea - Guilty mind 

  VIDEOQUICK STUDY (7:48)

  You can't have a crime WITHOUT  mens rea and if you are
   criminally insane you CANNOT have mens rea and therefore you CANNOT
   be guilty

* Actus Reus volitional and conscious and/or omission to act. Ones mental
  state  can effect actus reus.

  Sleep walking disorder

  Car accident with stroke

  You don't owe the duty to go to someone's aid if they are imperil (unless by
   contract/law/or relationship)

  VIDEO QUICK STUDY (5:25) go to 1:30 to start.

  

Guilty but Mentally Ill:

After John Hinkley shot at Reagan the courts developed a new designation. Guilty but Mentally Ill happens when the suspect knew what he was doing was wrong BUT could not help or stop the actions because of his mental health status.

Diminished Capacity - you had the intent to commit the crime but had a mental reason for not being held completely responsible. VIDEO QUICK STUDY (:48)

See how this article influenced my plot lines in my novella MINE and my novel CHAOS IS COME AGAIN.

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Thank you so much for stopping by. And thank you for your support. When you buy my books, you make it possible for me to continue to bring you helpful articles and keep ThrillWriting free and accessible to all.