Q & A: Expressed Emotion and Schizophrenia

A reader writes:

I have a friend, let's call him X, who refuses to communicate with me now because I keep telling him he should be on medication to help him with his paranoia. I'm pretty sure X hears voices and he also is quite sure that Jesus speaks to him personally. He won't go to therapy. Any advice or insight would be welcome. Thanks!

First of all, you can't put yourself in the place of a trained mental health professional.

Be that as it may, I think from your letter that you recognize that X may suffer from schizophrenia, a disorder that drastically affects cognitive functioning. You budding therapists out there may know by now that that means we don't do any rational cognitive therapy in this case.* What it means in plain English for everyone else is that you don't try to reason with a person who has difficulty reasoning, as is often characteristic of persons with schizophrenia.

You can and should contact X's family, tell them of your suspicions, ask them to help X get help. You said he is high functioning, so they may be in denial and may have little control over X and his compliance to treatment. But you never know until you ask.

As a friend you can remain supportive and caring. That may seem like no big deal, but it is a tremendous deal, and it translates into avoiding "expressed emotion," and telling others to do that as well.

"Expressed emotion" in this context is anger. People with schizophrenia are extremely sensitive to stress, and conflict/anger is stressful. We protect loved ones who suffer from this disorder by avoiding any criticism, sarcasm, argument, loud noises, yelling, even angry facial expressions, decisions, demands, bad news when in their presence.

You can also ask X what he's thinking. If he says voices speak to him and to no one else, then ask him what the voices are saying. If the words he's hearing in his head scare or stress him, he might confide in you. It might be a relief to tell you about them. He might get to a point where he really wants help. He's scared. Then you're there to take him in to see a psychiatrist. Skip right to a medical doctor with a person who has schizophrenia if at all possible.

Being supportive and non-conflictual is the best way to help someone who says they don't want help. Persons who suffer from mental illness who are mistrustful of the health care system have a right to be afraid. It is terrifying to them. They have to trust you or someone else, like a physician or a therapist, to the degree that they will confide their fear before there is a possibility of lowering resistance. If a sick person is in enough psychic pain, he might reach out for relief.

You may be that person who gets to hear how bad it really is for X. Then it is in your court to somehow reel him in. Until he's there, meaning until X really is in tremendous psychic pain and is willing to talk about it, all you'll get is denial and social withdrawal.

You want him to get help before he hurts himself or someone else. Not every person with schizophrenia is dangerous, but that's not your call to make. So if you really are friends with X or someone with this disorder, without seeming too invasive, hearing the thoughts is pretty important, and attending to them without being conflictual or demanding is the objective.

You want to ask him directly (gently) if he ever feels like hurting himself or anyone else. In that case, you really have some convincing to do, and might have to bring in either the police or a mental health professional who will help you bring him to a hospital. Sometimes the police are actually well-trained for this kind of thing.

And good luck.

*Studies have shown, according to F.D., that cognitive therapies are used successfully as an adjunct when drug therapies have successfully stabilized patients with schizophrenia.

Friends, if you have any other suggestions, by all means comment below. But...
I'm not encyclopedic, certainly, and don't pretend to know everything. I just want to be helpful generally, not to advise in particular cases. These are merely guidelines. Please consult appropriate mental health and legal professionals with problems when you think they might help.

TherapyDoc

Head spin

That story in WSJ on Chuck Mahoney did that, triggered me, maybe it triggered some of you, too. For me it was less the outrage about nobody saving Chuck's life than it was the sadness I felt for his parents and his brother. Elizabeth Bernstein wrote:

About once a week, the elder Mr. Mahoney opens the closet and buries his head in a sweatshirt that belonged to his son, trying to detect the fading scent.

I read the story on Saturday, looked up from my newspaper, stared through an open window to the backyard and tranced back over thirty years ago, saw myself putting on my brother's clothes, picking out a jacket (way too big for me), burying my head in it. My mother found me and I turned to her, This is mine, okay?

I almost started my post (3-24-07) on Chuck Mahoney like this: If you're easily triggered, meaning if you get depressed and stay depressed for a long time and can't bring yourself out of it, YOU MIGHT NOT WANT TO READ THIS.

So Elizabeth Bernstein's article made me. . . pause. For quite awhile. A good four hours, and my brother didn't kill himself. Journalists can do that to you. This blog is journalistic in that way too, sometimes. Maybe now.

Emotionally manipulative-- intentionally. I'll let you in on a little secret. You already know it, probably. Feeling badly for most of us, soaking up a little sadness, relating to the pain of others or even feeling our very own pain isn't so bad. In fact, it's a good stretch. Almost sublime. Expands our sensory perception of reality.

In my world view if a day goes by and I haven't squirted out at least one tear then I've been out of touch with reality, the suffering around me. It's around you, too, of course.

There are triggers and there are triggers, and there are the triggered and there are the triggered. My warning on that post would have been to those individuals who wouldn't bounce back within the hour or the day. The warning would have been for people who could really lose their cognitive functioning and maybe wouldn't be able to work for a couple of days after that. It can happen.

Being unable to function when depressed means there's no capacity to think. That's why making decisions is so hard. When a person can't "think straight" then there can be an added feeling of panic. That's why you'll sometimes describe to me waking up with a horrific fear, crippling fear mixed with tears and sadness, all interwoven at the same time, severe, severe panic and pain. And you haven't even started your day! You haven't brushed your teeth yet!

Not a nice disorder, depression.

So therapydocs tell people who suffer from it to avoid triggers. Although in some types of depression (probably the severe one I just described above) triggers may have nothing whatsoever to do with the onset, meaning an episode can seemingly come from out of the air.

Bi-polar disorder can be this way, although bi-polars can be triggered too. They will usually cycle, however, and there are seasons and months that are more likely to be more severe in one direction or another. They jump around on the continuum below in every which way with no say so in the matter. Usually it's physiology is all.Sometimes that depression on the left can hit like a ton of bricks with no warning.

For most other types of depression, however, like adjustment disorders, the onset is a little slower, and things do get gradually more and more gray and horrible.

We tell patients recovering from depressions of all kinds to avoid stimuli that they know will make them sad, the thoughts that will stick with them, affect their thinking, send them back down again.

Here's my short list of how to avoid triggers that can either cause an episode or make it difficult to recover:

don't read the newspaper
don't watch t.v. (unless you're sure it's comedy)
don't follow the war
don't go to funerals or wakes unless you KNOW you'll be okay
don't talk to people who upset you
that might mean, don't answer the phone or the doorbell
do protect yourself from stress of all kinds
do try to live in a bubble (although you can't, really, but try)
do make your own emotionally safe, restful environment (don't accept visitors, don't do extra community work to make people happy until you're really better)

that's basically what being in the hospital is like, you know, protective

And of course, my advice is based upon empirical data vis a vis the things that trigger psychotic reactions Let's segue there because it's so interesting.

The psychotic fear, depression and paranoia of schizophrenia and schizo-affective disorder can be triggered by something called expressed emotion.

Expressed emotion is really anger/criticism expressed at anyone at all by anyone within the family or on the job. Families who have a member who suffers from schizophrenia are taught to keep the anger and the criticism, ANY anger/criticism to anyone to a minimum.

Best to lose it entirely from the family's range of emotions.

That's the best thing you can do for a mentally ill person in your family. Be really gentle and nice all of the time. That will reduce your vulnerable family member's screaming anxiety and depressive outbursts.

Now. I think we could take a leap, here. Maybe, just maybe, if anger and criticism are bad for people with severe mental disorders, then perhaps they're also bad for the rest of us?

Hmmm.


Copyright 2007, TherapyDoc

Bi-polar Disorder: Not everyone has it, actually

Bipolar Disorder, Manic-Depressive Illness

The diagnosis of the year.

Never before have so many patients told me they think their partner, brother, sister, mother, in-law, uncle, first cousin once removed, just about everyone or anyone they know is for sure bi-polar.

It's good that there's so much awareness of the disorder, perhaps due to the media, especially talk shows that cater to the therapy-craving public, sensationalizing mental illness. But I feel there has to be more clarification, a little polish here, for the benefit of those who never had the chance to go to grad school.

The bi in bipolar refers to the two poles of the disorder, ends of a continuum. Symptoms of these end-points range from manic, as in spending much more than one has to spend, driving too fast, craving sex all the time and not being 17, to depressive, often wishing you could dig yourself out of a deep, dark, pit and sleeping most of the day and night. Having features of only mania or only depression, one is uni-polar, not bi-polar.

I know that Reymundo Sanchez, the Latin King who wrote My Bloody Life and The Unmaking of a Latin King 'fesses up to the disorder at the end of his books (it won't spoil them knowing this) which speaks to the necessity for public education and early diagnosis. Several high profile people have owned having Bipolar Disorder.

We use the word disorder, fyi, not disease. Disease has been out of favor for at least 25 years. Now we say, bipolar, as opposed to manic-depressive, too. These terms are less-stigmatizing, is the thinking. Not everyone feels this way, certainly not Kay Redfield Jamison, who prefers Manic-Depressive Illness. A must-see is this psychiatrist's story, her personal journey, in the video below.

Biographies and public disclosures from famous personalities who suffered from this difficult emotional life include*:

Lionel Aldridge
Hans Christian Andersen, writer
Ned Beatty, actor
Robert Boorstin, writer, assistant to Pres. Clinton,
Arthur Benson, writer
E F Benson, writer
William Blake (1757-1827), poet
Ralph Blakelock, artist
Napoleon Bonaparte (1769-1821), general
Tadeusz Borowski
Art Buchwald, writer, humorist
Tim Burton, artist, movie director
Robert Campeau, financier (Canada)
Drew Carey, actor
Jim Carrey, actor
Dick Cavett, writer, media personality
C.E. Chaffin, writer, poet
Agatha Christie, mystery writer
Winston Churchill, 1874-1965- British Prm Mnstr
John Clare, poet
Rosemary Clooney, singer
Garnet Coleman, legislator (Texas)
Francis Ford Coppola, director
Patricia Cornwell, writer
Richard Dadd
John Daly, athlete (golf)
John Davidson, poet
Edward Dayes, artist
Ray Davies, musician
Emily Dickinson
Kitty Dukakis, former First Lady of Massachusetts
Patty Duke (Anna Duke Pearce), actor, writer
Thomas Eagleton, lawyer, former U.S. Senator
T S Eliot, poet
Ralph Waldo Emerson, essayist
Robert Evans, film producer
Carrie Fisher, writer, actor
Edward FitzGerald
Robert Frost
F Scott Fitzgerald, author
Larry Flynt, magazine publisher
Connie Francis, actor, musician
Sigmund Freud, physician
Cary Grant, actor
Kaye Gibbons, writer
Shecky Greene, comedian, actor
Linda Hamilton, actor
Kristin Hersh, musician
Victor Hugo, poet
Jack London, author
Robert Lowell, poet
Marilyn Monroe, actress
Mozart, composer
Jay Marvin, radio personality, writer
Cara Kahn, mtv's 'real world'
Kevin McDonald, comedian, actor
Kristy McNichol, actor
Dimitri Mihalas, scientist
Kate Millett, writer, artist
Buzz Aldrin, astronaut
Spike Milligan, comic actor, writer
John Mulheren, financier (U.S.)
Robert Munsch, writer
Napoleon, general
Ilie Nastase, athlete (tennis), politician
Isaac Newton, scientist
Margo Orum, writer
Nicola Pagett, actor
J C Penney
Plato, philosopher, according to Aristotle
Edgar Allen Poe, author
Jimmie Piersall, athlete, sports announcer
Charley Pride, musician
Mac Rebennack (Dr. John), musician
Jeannie C. Riley, musician
Phil Graham, owner, Washington Post
Graham Greene, writer
Peter Gregg, team owner and manager, race car driver
Abbie Hoffman, writer, political activist
Lynn Rivers, U.S. Congress
Francesco Scavullo, artist, photographer
Lori Schiller, writer, educator
Frances Sherwood, writer
Scott Simmie, writer, journalist
Alonzo Spellman, athlete (football)
Muffin Spencer-Devlin, athlete (pro golf)
Gordon Sumner (Sting), musician, composer
St Francis
St John
St Theresa
Rod Steiger, film maker
Robert Louis Stevenson
Liz Taylor, actor
J.M.W. Turner
Mark Twain, author
Alfred, Lord Tennyson, poet
Ted Turner, entrepreneur, media giant
Jean-Claude Van Damme, athlete, actor
Vincent van Gogh
Mark Vonnegut, doctor, writer
Sol Wachtler, judge, writer
Tom Waits, musician, composer
Walt Whitman, poet
Tennessee Williams, author
Brian Wilson, musician (Beach Boys), composer, arranger
Jonathan Winters, comedian, actor, writer, artist
Luther Wright, athlete (basketball)
Margot Kidder, actor
Robert E Lee, soldier
Bill Liechtenstein, producer (TV & radio)
Abraham Lincoln (1809-1865), US President
Daniel Johnston, musician
Samuel Johnson, poet
Burgess Meredith, 1908-1997, actor, director
Kay Redfield Jamison, psychologist, writer

There must be thousands more. I'm always suspicious when a powerful actor gains a lot of weight that this poor soul is on lithium, a wonderful discovery that has helped millions, but tends to increase the appetite, preferable to the destructive impact of mania and depression to oneself, family, and friends. No one likes it, or wants to take it in a manic state. Mania is addictive, becomes an addiction to the substances in one's own brain.

Yet, with such distinguished company, who wouldn't want to have this disorder? I know a physician who taught medical school who outright admitted to it, when I was a young person, in his first lecture. So is it romantic? Cool? Do we want this?

Not exactly. It isn't a romantic disorder; it's a difficult one that can wreak havoc on a person's life, especially if one’s presentation reaches the extreme poles of either depression or mania. One in five are vulnerable to suicide.

The good news is that the medications we have now are amazing and have made life not only tolerable, but often pretty darn good, although finding the right cocktail can be trying. Psycho-education, which this blog aspires to, enables individual, families and friends to cope when it's known that someone is suffering from Bipolar Disorder.

There are two kinds, and I'll focus on Bipolar I in this post. Bipolar II is primarily depression with manic episodes few and far between.

It helps to look at the illness as a very fluid, changing cluster of symptoms that range from one pole to another on a continuum. Pretend the continuum is a baton, the thing they twirl in marching bands. At one end of the baton is depression, and at the other is mania. The ends are extreme and flag the disorder.

The depressive end of the continuum is so vegetative, so depressed, that a person sleeps most of the day and still doesn’t feel good. Everything is an effort, everything hopeless, despairing. Thinking a chore, reading impossible, the memory effusive. The manic end of the baton is hyper-attentive, so awake, so incredibly, alive, that one feels omnipotent. (This is a place akin to that in which some have religious identifications with deities, but it isn't the only condition that can manifest itself this way).

The manic pole is characterized with no empathy. People at both ends of the baton are likely to be completely out of touch with the feelings of others, and this is especially evident at the manic pole. Under mania people need no sleep, we’re not talking like, they get 3-4 hours a night, they get none. They can get very testy, too, irritable, even shoot people without reason, certainly bark at them and abuse them.

So, this is not a good disorder, okay? It is not a romantic condition. Lucky for all of us, it is treatable. Unfortunately, when mania does not present as irritability, when it presents as ecstasy and omnipotence, the rest of us may suffer to the individual’s lack of empathy, but the patient is feeling no pain, does not want treatment, and will be non-compliant about medication.

Anyway, although symptoms and behaviors at the two poles are extreme, there's a wide continuum of emotional life between them. The baton, by the way, can get pretty long in higher functioning individuals with the disorder.

In our hyper-caffeinated world, I have to say that it is my personal feeling that many people who think they have this illness don't. Cut out your caffeine and alcohol consumption for a month and then look at your symptoms before you look at the symptoms of the disorder and say, "Hey, that's me!"

The catch is, of course, Cut out your caffeine and alcohol consumption. Who wants to do that? Just a thought, something to consider.

Diagnosis requires careful assessment and a history, and it won't matter all that much if a person's had a Single Episode, or a Most Recent Episode Unspecified, for example. If you or someone you know has this disorder you should get help and let a professional fine-tune your basic diagnosis.

Labeling someone is unctuous, undesirable, and there is a movement against it within the psychiatric community, certainly the social work community. But if someone has Bipolar I Disorder, the first step really isn’t to talk about feelings or to treat the family. It is medical intervention, meaning medication.

Then there's much more to do, even when an individual is on the right meds, for there are triggers, it seems. We used think people cycle, still do. But stress hurries the cycle along, "triggers" both manic and depressive episodes, complicating the natural cycling of emotions along the baton. Anger, especially, (discussed as expressed emotion, in the literature) is toxic.

This makes a case, of course, for psychotherapy, family therapy, and behavioral therapy. Beware if someone you know has a major disorder and is only taking meds.

Copyright 2006, TherapyDoc

*See Actors and Actresses with Bipolar Disorder and Bipolar Disorder and Public Personalities, this list is direct from their websites, perhaps not even true, my disclaimer. If you read through the list, however, you might think, Maybe so! This explains the genius!

But just to keep you honest, the disorder is confused with others, and the assessment is complicated. The most readable of the books on the subject (okay, I confess, I haven't read them all) An Unquiet Mind, by Kaye Redfield Jamison (Johns Hopkins School of Medicine).

Here she is:



Here are a few of the differential diagnoses, compliments of Depression Alliance.
Mood Disorder Due to a General Medical Condition.
Substance-Induced Mood Disorder.
Major Depressive Disorder.
Dysthymic Disorder.
Bipolar II Disorder.
Cyclothymic Disorder.
Schizoaffective Disorder.
Schizophrenia.
Delusional Disorder