Away in the head


With the highest age group at risk falling neatly into the student population, Catriona Laverty looks at the many myths surrounding schizophrenia

At my very first psychiatry lecture, my lecturer gave my class a survey. In it we were asked to truthfully document our understanding about certain well-known psychiatric conditions. Comparing notes afterwards, it became clear that most of our class – despite being over halfway through a degree in medicine – had very little understanding of what the word ‘schizophrenia’ meant. Not only that, but a fair number of us had made the common mistake of equating schizophrenia with multiple personality disorders.

It’s a mistake very frequently made, but the illnesses are very separate entities, with one being rather common, and the other exceedingly rare. Sadly, the mistake is made with alarming frequency. Even in the course of writing this article, I’ve endured the standard jibes and quips, from being asked whether I was co-authoring with myself, to poems about ‘me and me’ having schizophrenia.

It’s no exaggeration to say that schizophrenia is one of the most misunderstood illnesses in the world. It’s also one of the most debilitating – and yet, there is very little coverage in the media. Mental illnesses have enjoyed somewhat of a glamourisation in the media of late – depression, in particular, has become widely acceptable and much talked-about – yet schizophrenia remains firmly sequestered behind the closed doors of GP surgeries and psychiatric facilities. So what is it about this illness that makes people so wary to talk about it?

It must start with all those misconceptions – the stigma surrounding schizophrenia is immense, and the myths and old wives’ tales prolific. But what is schizophrenia? To answer that question, I went back to my original source of knowledge on psychiatry – my tutor from my days in the UCD School of Medicine, Dr Seamus MacSuibhne, the man who handed out those fateful surveys – and indeed, re-issued them in our final lecture, to see if we had learned anything.

The word ‘schizophrenia’ is derived from the Greek for ‘splitting of the mind’ – so it’s not the public’s fault, he tells me, that so many misconceptions about split personalities abound. While the name dates back many years, psychiatrists now understand that those two illnesses are entirely different. So now, having left split and multiple personalities to the realms of television dramas, what is schizophrenia?

To understand scizophrenia, we must first understand psychosis. “Psychosis is essentially losing touch with reality,” says Seamus – most appropriately illustrated when people begin to suffer from delusions: “They may have false beliefs that have no basis in reality; these beliefs are not religious in nature.” People suffering from psychosis have a different sense of the world around them; they may misinterpret other people’s behaviour and intentions. Paranoia is a common feature. They may even begin to suffer from hallucinations – usually auditory.

But what does this mean to the layperson, exactly? My own first encounter with schizophrenia was during my psychiatric rotation as a medical student, when my partner and I were sent to interview a patient without being told their diagnosis. After 45 minutes, we were none the wiser as to what their condition might be – all we could say was that the person we talked to was a little, well… odd. The rhythm of their speech was completely disjointed, jumping from one topic to the next and onward – all the while producing fantastical reasons and ideas for why things had happened the way they had. Everyone in the patient’s life had been in on a ‘conspiracy’ – what the purpose of that conspiracy was, they didn’t know, but they were very certain it had played out that way. Trying to get further details, we were led down another path of fantasy. I am certain that should my partner or I ever be presented with a case of psychosis again, we won’t not recognise it.

Psychosis is a major factor in the diagnosis of schizophrenia – but they are not the same thing. Schizophrenia is just one cause of psychosis; other causes include severe depression, bipolar affective disorder, medications or medical illnesses, and drugs. Of particular interest is cannabis, the use of which at an early age has been found to double the risk of developing schizophrenia, and thus psychosis. The advent of Head Shops popping up around the country presents another risk.

So if psychosis is one symptom of schizophrenia, what are the others? According to MacSuibhne there are also ‘negative’ signs of schizophrenia, such as “social withdrawal, lack motivation and willingness to participate in social events.” To say that someone may be suffering from schizophrenia, some or all of these symptoms must be evident for a period of time (“at least a month” is a good indicator). Schizophrenia, he says, is a pervasive illness – its symptoms and signs are not intermittent, but a constant feature of someone’s personality during this time.

Although there’s no one cause that can be pinned down, there are several risk factors for developing the illness. “The biggest risk factor is probably family history,” says MacSuibhne; “there is a genetic link.” Other factors can play a part: there are traditionally higher rates of schizophrenia in people living in urban areas, compared with those in rural. There’s also an increased risk in people born under obstetrical complications.

The most worrying factor of all is the age of onset. Schizophrenia tends to develop in men at around the age of 20, while women have a mean onset age of 25. According to MacSuibhne, men also tend to have a worse prognosis than their female counterparts. Although previously more prevalent in lower socio-economic classes, more and more third-level students are presenting with symptoms of psychosis and schizophrenia. “There are theories about dislocation stress,” MacSuibhne explains. “When you go to college, you can go from a fairly settled environment to one where you’re living alone and you’re a bit more isolated, and you mightn’t have the same support network you might have had.” Students in third-level education therefore fall into the very age bracket that is most at risk – and yet, we know and are taught almost nothing about the illness.

One reason for this may be the media portrayal of people with schizophrenia as dangerous, criminal typecasts who should be feared rather than helped. MacSuibhne is quick to refute this image – “people with schizophrenia are at much more risk of being attacked than anything else” – adding that while there is an increased risk of someone being more aggressive during an active psychotic episode, the risk is “not as great as people think.” In an extreme example, research has shown that although the number of murders in the UK has dramatically increased in the last fifty years, the number linked with mental illness has stayed the same.

People with schizophrenia are perhaps of more harm to themselves than to others, and given the stigma attached to the condition, the increased risk of suicide among those affected is a major concern. Schizophrenia carries an eight to ten per cent lifetime risk of suicide –  higher than that of depression, and one of the highest of any mental illness. MacSuibhne explains that one reason for this is that when people recover from a first episode of psychosis, and gain a more balanced insight into their condition, they become embarassed or ashamed about the illness and find the fear of relapsing too great to bear.

People suffering from schizophrenia may also endure hallucinations where they believe they’re being told to harm themselves, or to entertain other negative thoughts. It’s strange, then, that so much emphasis is placed on talking about depressive episodes, while psychosis and schizophrenia are all but ignored.

So how is the condition to be managed and lived with? One of the biggest factors in determining the outcome and prognosis of schizophrenia is the duration of time between the first symptoms and the formal diagnosis. This Duration of Untreated Psychosis, or DUP, is the key area targeted by the Detect early intervention initiative in south Dublin and Wicklow. Dr Brian O’Donoghue is a psychiatrist assessor with the programme, which comprises a team of thirteen staff operating from Blackrock.

The idea behind Detect, O’Donoghue explains, is that people approaching their GPs with psychotic symptoms can be referred quickly and directly to the Detect team for a comprehensive psychiatric evaluation, thus minimising the DUP. Those requiring further treatment can then be referred to consultant psychiatrists for long-term care. Many patients are referred to Detect by their GPs when concerns are raised by a patient’s family and friends.

As well as reducing the DUP, Detect aim to educate patients about the “warning sides of relapse”, so that assistance can be sought quickly in the event of a subsequent episode. Detect take a holistic approach to the treatment of psychosis, encompassing drug treatments as well as therapy sessions and support services for family members.

Detect have succeeded in reducing the average DUP within their area from six months to two months – a result which also reduces the chances of people with psychosis needing hospitalisation. “More people are being treated in outpatients clinics, without the need for hospitalisation,” explains O’Donoghue. “The impact of reducing the DUP is that the symptoms aren’t as severe.” This, in turn, helps to reduce the associated risks of self-harm.

O’Donoghue is also keen to emphasise the importance of an early intervention service, given the average age of onset of schizophrenia: “It’s a crucial time in someone’s life, their late teens or early twenties – they’re starting higher education or establishing their career and life friendships.”

While the Detect pilot programme currently only operates in the St Vincent’s and Cluain Mhuire catchment areas of south Dublin and Newcastle, Co. Wicklow, O’Donoghue hopes that its success will prompt the HSE to roll it out nationwide. While acknowledging that such schemes are difficult to promote (“there’s a lot of stigma around mental illness… People are reluctant to come out and support these types of groups, and subsequently there’s less pressure on politicians”), he is positive about the future of the scheme as a nationwide service.

If you are worried about any of the issues presented above, contact the Student Health Service who can advise you on any concerns or put you in contact with the Detect programme or visit