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IMAGINE A YOUNG man, if you will. Let’s call him Mike. He is a 22-year-old apprentice electrician who lives with his parents.
Mike normally enjoys soccer and has a few pints with friends at the weekends. He smokes cannabis at least weekly and has used cocaine a handful of times since his teenage years.
In recent months, his supervisor has noticed him becoming increasingly unreliable. He sometimes fails to turn up for work; at other times, he doesn’t finish jobs. His parents have noticed he is more withdrawn, spending more time at home, usually in his bedroom, sometimes appearing preoccupied or perplexed. They wonder if it is low mood and bring him to see the family GP.
It transpires that Mike has been avoiding work because he believes the American and Russian intelligence services can access his thoughts through the electrical wiring he routinely encounters. He is suspicious of vans in the local area, thinking he is being followed and is at risk of being kidnapped.
Mike also believes foreign intelligence officers can read his mind and are communicating with him through the television, radio and in graffiti on the walls of the locality. He hears their voices telling him, sometimes quite relentlessly, to hide fuses or sabotage electrical circuits. He finds the whole experience very frightening.
Mike’s symptoms are typical of a first episode of psychosis. One in every 33–50 babies born will experience some form of psychosis during their lifetime, yet it remains largely misunderstood in society.
Psychosis is a collection of symptoms affecting what a person perceives, believes and thinks, and how they behave. It can occur for a number of reasons, of which schizophrenia is just one. For example, people who become markedly depressed or manic (like in the context of bipolar disorder) can develop psychotic symptoms temporarily. So too can people using street drugs like cannabis, cocaine or hallucinogens, or people with certain physical illnesses or injuries.
Up to half of all psychoses are accounted for by schizophrenia, a more enduring mental illness involving psychotic symptoms that relapse and remit over time. Importantly, schizophrenia has nothing to do with the “split personality” described in Robert Louis Stevenson’s Strange Case of Dr Jekyll and Mr Hyde. The fact that so many people still believe this myth only adds to the stigma.
The symptoms are fourfold, and include hallucinations (hearing or seeing things that aren’t there), delusions (fervently believing things you don’t normally believe); and thought disorder (mixed up thinking that makes it hard to communicate). These first three clusters are called “positive symptoms” (things that are there when they shouldn’t be). The fourth cluster involves “negative symptoms” (things that aren’t there when they should be), specifically talking less, lack of motivation, social withdrawal, dropping out of school, higher education or employment, and so forth. Schizophrenia usually presents for the first time between the ages of 15 and 35 (a little earlier in men than in women).
Tomorrow is World Schizophrenia and Psychosis Awareness Day, which falls on 24 May each year. It was originally the brainchild of the National Schizophrenia Foundation (NSF), a US-based not-for-profit organisation which aims to support individuals affected by schizophrenia and similar disorders through the dissemination of information and the development of support groups.
According to the NSF, 24 May 1792 was when the French physician Dr Philippe Pinel first removed chains from hitherto-badly-treated psychiatric patients in the Bicệtre Hospital outside Paris.
Pinel is noted as an early pioneer in the provision of humane care and treatment for people with mental illness. He saw the value in careful listening, observing behaviour and thoughtful note-taking, with diagnoses based on cross-referencing the natural history of illness with the patient’s own lived experience of symptoms and events. Empathy, compassion and understanding were the order of the day. In due course, this paved the way for modern psychiatry.
There is no “one big thing” that causes schizophrenia, but rather lots of small and medium-sized risk factors. It’s often termed the “stress-vulnerability model”.
Vulnerability factors include genetics and while there is no single gene that specifically codes for the presence or absence of schizophrenia, it is an illness that tends to run in some families. Still, if both your parents or your identical twin have schizophrenia, your chances of getting it are only around 45%.
If just one parent or an ordinary sibling has it, your chances are 10-12%. Some pregnancy- and birth-related complications can slightly increase the risk of a child growing up to develop schizophrenia, while there are other neurological, cognitive, behavioural and developmental abnormalities (so called “soft signs”) that are slightly more common in children who grow up to develop the illness. But these signs are also common in many children who do not, so it’s important to remember they do not predict the illness.
It should also be noted that schizophrenia correlates to a degree with urban upbringing, childhood trauma, social marginalisation and migration. But by far the biggest modifiable risk factor is the use of street drugs such as cannabis. At this stage, there is strong scientific evidence that a significant proportion of people who develop schizophrenia might have avoided it if they had never used cannabis.
Semi-synthetic cannabinoids such as HHC (hexahydrocannabinol) should be viewed as equally dangerous. In my own practice, I have recently seen first-hand quite a number of people with severe psychosis on foot of taking HHC. Thankfully, Department of Health officials are currently drafting legislation to classify HHC as a Schedule 1 controlled substance under the Misuse of Drugs legislative framework.
But it must still be said that the increased risk of developing schizophrenia rarely seems to make it into the public debate about legalising cannabinoids, synthetic or otherwise. Of course, other street drugs such as heroin, cocaine, hallucinogens, amphetamines and various party pills can also bring about a substance-induced psychosis.
So, how does Mike recover? First, his GP refers him to a psychiatric service, and he is assessed by a multidisciplinary team. He is diagnosed with first-episode psychosis and prescribed an antipsychotic medication.
This works mostly by reducing the activity of a neurochemical in the brain called dopamine. Any side effects are proactively managed. He makes the decision to avoid all street drugs, including cannabis, from now on. He is offered cognitive behavioural therapy, which helps him to understand his recent thinking, challenge unhelpful beliefs and develop coping strategies to reduce distress.
Mike is also offered occupational therapy and access to vocational rehabilitation to manage his negative symptoms and guide his way back to education, employment and a full life generally. His parents are offered support through the team’s social worker, particularly with a view to preventing relapse or knowing how to seek help should relapse occur. Families are often the best resource people with psychosis have – even if they don’t realise it at first. Voluntary organisations like Shine and the Hearing Voices Network can also help.
There are always arguments for greater funding for services for this kind of mental illness. And of course, the more research into this area, the better for all patients. It’s also so important to remember that recovery from psychosis is possible if the right steps are taken.
Dr Stephen McWilliams is a consultant psychiatrist at St John of God University Hospital, Stillorgan, Co Dublin, where he is clinical lead of their Psychosis Programme. He is a clinical associate professor at the School of Medicine, University College Dublin, and an honorary clinical senior lecturer at RCSI University of Medicine and Health Sciences. @McWilliamsMD.
If you have been affected by any of the issues mentioned in this article, you can reach out for support through the following helplines. These organisations also put people in touch with long-term supports:
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