Psychiatry & Psychotherapy Podcast - Schizophrenia in Film and History

Episode Date: May 16, 2019

What is schizophrenia? It is a psychotic disorder that typically results in hallucinations and delusions, leaving a person with impeded daily functioning. The word schizophrenia translates roughly as the "splitting of the mind," and comes from the Greek roots schizein ( "to split") and phren- ( "mind").   The onset of the disease typically occurs in young adulthood; for males, around 21 years of age, for females, around 25 years of age.   We don't know exactly what causes schizophrenia. There are certain predictors for it, and as I discussed the basics and pharmacology a previous podcast, frequent marijuana use can increase the risk of a psychotic or schizophrenic illness to about 4 times what it would be without THC use. History of schizophrenia Sometimes, in ancient literature, it can be difficult to distinguish between the different psychotic disorders, but as far as we know, the oldest available description of an illness resembling schizophrenia is thought to have existed in in the Ebers papyrus from Egypt, around 1550 BC. Throughout history, in groups with religious beliefs, the misunderstanding of the psychopathologies caused people to paint those with mental health disorders as receiving divine punishments. This theme of divine punishment continues today in some parts of the world. It wasn't until Emil Kraeplin, a german psychiatrist (1856-1926) that schizophrenia was suggested to be more biological and genetic in origin. In around 1887, Kraeplin differentiated what we call schizophrenia today from other forms of psychosis. At that time he described schizophrenia as dementia of early life. In 1911, Eugen Bleuler introduced schizophrenia as a word in a lecture at a psychiatric conference in Berlin (Kuhn, 2004). Bleuler also identified the positive and negative symptoms of schizophrenia which we use today. Kurt Schneider, a german psychiatrist, coined the difference between endogenous depression and reactive depression. He also improved the diagnosis of schizophrenia by creating a list of psychotic symptoms typical in schizophrenia that were termed "first rank symptoms."   His list was: Auditory hallucinations Thought insertion Thought broadcasting Thought withdrawal Passivity experiences Primary delusions Delusional perception (the belief that a normative perception has a certain significance) Sigmund Freud furthered the research, believing that psychiatric illnesses may result from unconscious conflicts originating in childhood. His work eventually affected how the psychiatric world and society generally viewed the disease. The history and lack of understanding of the disease is a dark history, and it is still deeply stigmatized, but psychiatry has made massive leaps in understanding schizophrenia and changing how it is viewed in modern society. Nazi germany, the United States, and other Scandinavian countries (Allen, 1997) used to sterilize individuals with schizophrenia. In the Action T4 program in Nazi Germany, there was involuntary euthanasia of the mentally unwell, including people with schizophrenia. The euthanasia started in 1939, and officially discontinued in 1941 but didn't actual stop until military defeat of Nazi Germany in 1945 (Lifton, 1988). Dr. Karl Brandt and the chancellery chief Philipp Bouhler expanded the authority for doctors so they could grant anyone considered incurable a mercy killing. In reading about this event, it seems that This caused approximately 200,000 deaths. In the 1970's, psychiatrists Robins and Guze introduced new criteria for deciding on the validity of a diagnostic category (Kendell, 2003). By the 1980's, so much was understood about the disease that the DSM (Diagnostic and Statistical Manual of Mental Disorders) was revised. Now, schizophrenia is ranked by World Health Organization as one of the top 10 illnesses contributing to global burden of disease (Murray, 1996). Unfortunately, it is still largely stigmatized, leading to an increased schizophrenia in the homeless population, some estimates showing up to 20% vs the less than 1% incidence in the US average population. In conclusion On the podcast episode, we discuss the media's portrayal of schizophrenia. Although media paints mentally ill as often violent, on average people with mental illness only cause 5% of violent episodes. This is just one example of how the stigma is furthered. The more we understand about this disorder—what causes it, how we can help, how we can provide therapy and medicate and treat patients—the better. Getting rid of the stigma by learning the history and also moving beyond preconceived ideas to the newest science will also help de-isolate people with schizophrenia and help support them in communities, giving them a chance at a normal, healthy life. By listening to this episode, you can earn 0.75 Psychiatry CME Credits. Link to blog. Link to YouTube video. Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder    

Hello and welcome to the psychiatry and psychotherapy podcast, with over 32,000 mental health professionals listening every episode. Why? Because we need to stick together to survive the mental health field. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. Welcome back to the podcast. I am here with Ariana Cunningham, a now PGY1 psychiatry resident. She did the micro-expression series with me. She's on my research team. She'll be an awesome. author on one of the papers that I'm coming out with in the next couple months. And in this episode, we are going to be going through schizophrenia. It's going to be an overview. We're going to dive into some of the history, diagnostic stuff. We're going to go through treatment, both medications and

psychotherapy. But we want to start off talking about schizophrenia and pop culture. Yeah, because I think this is how for most people who maybe don't have a family member or, you know, someone in their vicinity who's going through this, this is really the first introduction is how it's portrayed in film. Yeah. And that's the case for me, like beautiful minds that that film was the first time that I even knew that schizophrenia was a thing as a kiddo. I think that was the case for myself as well. Yeah.

That particular movie, too? Yeah, this particular movie. So we're going to talk a little bit about the movie. and then what we're going to do is if you're on my YouTube or my Instagram, we'll also post basically a separate dialogue that we're going to have about the movie. We're going to show clips. We're going to break down the certain symptoms that are in the clips. And kind of like I've been doing, I've started this thing recently on my Instagram and YouTube where I'm putting up popular clips of movies and then talking about it from the psychological perspective. and with an emphasis on teaching empathy, microexpression, connection,

with the idea of trying to make it fun. So one of the things I noticed I came out with my app, Emotion Connection, you know, teaches micro expressions. But it's really hard to do. Yeah. Like it's really hard to get someone to sit down and spend, you know, 10, 20 hours to be able to master it. Versus sitting down to watch 10, 20 hours of Game of Thrones. Easy to do.

Yeah. So hopefully, you know, I'm trying to produce two of these a week. Hopefully that continues. And within a year, if someone all of a sudden finds it and binges on it, hopefully their empathy, psychological mindedness, even like there's one clip we did where I talk about arguments, how to fight fair. So yeah, I'll put a link in the show notes to the YouTube page and to my Instagram page as always. Yeah. And be ready for this to come out where we go through each clip. But tell me a little bit about the movie and the character and some of the things that were jumped out.

And there's going to be a spoiler alert here. Yeah. So if you haven't seen this film, maybe. Maybe pause it right now. Go watch it. Go watch it. And then come back. Because it is a great film.

So this is the one. It came out in 2001. It's based on a real life person who was diagnosed with schizophrenia. There's got to say there's a lot of commentary and backstories and people critiquing like, was this a true diagnosis? but for the sake of how it's represented in the film, this is a portrayal in popular culture that's really formative to a lot of people's understanding of what schizophrenia is, what it looks like, what the symptoms are.

So it's based on the life of this brilliant mathematician, John Forbes Nash Jr. It's also based off of a novel that was written about his life. And there's definitely some differences between the novel and the film itself. I haven't fully finished it, but I think it's like, it's an interesting read. It's also a great movie. Whatever your camp is, just go for it.

But definitely jump into that. And it outlines basically the story of this guy in the film coming into university. And then you start to kind of see things little by little go wrong. And then partway through the film, you have an aha moment with the character. I don't want to know. How far should we go into spoiler alerts here? I think we should just go full spoiler alert because it's like, yeah, we should do. Yeah. So in this guy's like life progression of coming into university, he's a little bit socially off. He says like his teacher once told him he got two helpings of brain and half a helping of heart and all these sorts of differences in how he struggles to connect with people are really portrayed. But then the real like well bang moment comes when you realize that some of these friendships and characters you're introduced to as the viewer are actually visual hallucinations of his. Not real people.

I think there's a really important, the first important thing is that there is a pro-drome for schizophrenia where people are a little bit more, they're more socially withdrawn, they don't have as many close friendships or they don't have as many romantic relationships, which is often a question I ask when I'm trying to discern is this person's schizophrenia. It's like, what was this guy as an adolescent, early adulthood? Yeah, so it has some of that. He's a little bit off. And sometimes it can almost look a little. Asperger's or autistic. Yeah, and that's where some of the, yeah, there's a lot of commentary around this film from the psychiatric community kind of saying like, is this really a good way to portray it?

And that's something we'll definitely dive into. But I think certain aspects, like you said, with that social awkwardness, like the opening of the film, he's like sitting in the back of the room, not really relating to people in attempts to joke and make friends. He ends up kind of being offensive without meaning. to. And that's not something I see in a lot of the schizophrenic patients I treat. So that would be, there's a difference between a little social withdrawal compared to like being unnecessarily offensive. Yeah. Yeah. And rubbing people the wrong way, kind of rough edges, which is definitely emphasized in the film a lot.

And, you know, that's fun. I mean, it's Hollywood. Yeah. It makes it interesting. Yeah. And the other thing that comes to my mind is with that is we have to take into account his intellect and how that changes the nature of his delusions and his perceptions because this guy's intellect is like off the chart. Yeah. And so the detail and the complexity of the delusions will be almost akin to that complex. So that's one thing I've found with different patients I've treated is the more highly educated, the higher educated, higher IQ,

they're making connections with things that it can really draw you in. Oh, yeah. And you can be all of a sudden like, well, wait a minute, like, are we in this conspiracy? Yeah. Are we in this sort of thing? And there's a certain like eloquence

and there's just a few patient interactions I've had. I come away being like, I just feel like they were dropping like profound reflections. And definitely they are not able to function in society in the same way if this is true schizophrenia, but there's a degree. Yeah, it's just really fascinating about how this disease manifests in different people.

Yeah, and whereas like someone who's more average IQ or whatnot, when they talk about the delusions, it's a little bit more identifiable to me. But reflecting back on some of my early patients, I almost got pulled in to a couple of them. Like one guy saying his parents tortured him and, you know, all these things. things and I was like in my mind I was like well maybe it's true yeah these parents were really abusive but then as the story came out more and more like parts of the narrative were just impossible to happen like my parents kept me up for 10 days straight tied mood of chair you know tortured me in these different ways and the more and more he told me the more and more I thought okay this is there's

something about this that's just impossible yeah and that's something that comes in the film is because it's this character and the real life person behind the character that's portrayed in the film is involved in helping, like, crack codes when it comes to in a wartime measures and looking for patterns and things, but it goes beyond what he was asked to do in a job and into a conspiracy that is confabulated. And a lot of people around him are unsure what to believe until the secrecy is kind of pulled away around his measures. So, yeah, like you said, it's just, it's interesting. Connecting the unconnectable.

Yeah. Some of them really try to connect all sorts of things that are unconnectable. Like one schizophrenic man that I knew that was off meds was telling me about how he flew overseas and he was in this parade and he noticed that God was communicating them directly to go to this hut and he went to this hut and he met this man and he had this three-hour conversation about fish and he knew that it was important to like, you know, therefore, you know, go get on a boat. And so he got on a boat in this Asian country and he stayed on the boat for three weeks and worked with this team fishing, you know. And it was like all these sort of like felt directed.

And the more I listened to him, you know, and I knew that this guy had been on Clausoril and he had been on some other psych meds before. And I was like, you know, this guy probably like, it's really fascinating. How he's connecting all these things and feeling guided, but how because he's very, very smart. Like I was in a group listening to this guy. Like multiple people were kind of bought into this in an interesting way. Okay, go on a little bit about the movie. It's so interesting. Yeah, so I think something that really stuck out to me, because I was reading different sources about and looking at the examples of how schizophrenia is portrayed in predominantly film.

I think that was my main focus is that there's kind of these two narratives of either. being violent or a genius. And that's really like the predominant portrayals we have. And I think both of those things actually are brought out in the film. In his genius, like we were talking, like at baseline before he had any of this dysfunction of the disease, he was a brilliant person. He ended up winning the Nobel Prize later on, like really, really incredible as far as his lifetime achievements. But there is also these elements that they bring out of hallucinations. And I mean, this is something to talk about too is in the film. It's purely visual hallucinations. There's no auditory hallucinations. And statistically from what I was kind of researching is that that may not be like

the most common. Like what we're seeing in him isn't what you would expect to see in most people with the disease state. Yeah, usually it's auditory hallucinations, delusions, and negative symptoms. Yeah. Whereas for him, it was really predominant positive symptoms in the visual hallucination along with the paranoia. And then in terms of kind of some violence, he was less violent towards others. There's a few instances where he's trying to engage with the visual hallucination, like these other, quote, people. And he ends up accidentally harming, you know, his family, his wife and baby in those measures. But he's also engaging in self-harm because he has this fear that, like, there was something implanted in his arm, a chip that can be red.

And he's trying to, like, dig it out of his skin. And some of those things that I don't know really. really how, yeah, if that's like a really accurate portrayal. Granted, this is Hollywood, certain things are kind of almost amped up for the drama, I guess you could say. Yeah, and it's unfortunate that people think that in general, you know, when anything violent happens, they're like, oh, this person had mental illness. That's just not the case.

The majority of violence is not mental illness. Like the vast majority is not mental illness. There is a slight increase in violence in someone who's having. their first psychotic episode. But overall, you know, it's not like people with schizophrenia are more violent than the average person. Yeah. So, you know, I think it's somewhere around 95% of people who do violent acts are not suffering

from a primary mental illness. Yeah. I think that's important to hold on too because I think even in this film, like once his disease is more known and you see the interactions of his friends around him and how that interaction is so different and guarded in any sense is that. And just how disruptive that is towards becoming more functional in society again. There's an incredible stigma on mental illness and schizophrenia in particular. And it's so much so that I tell my patients who are schizophrenic or high functioning,

who are on meds doing great, I say, hey, you may not want to tell people your diagnosis until you can really trust that person. Yeah. Because people don't know what to do with that information. People just have no schema, no framework to put it. No, absolutely. A few other, in case anyone out there is like watch these other films, there's Benny and June, which came out in 1993, a film called Snake Pit in 1948, one called Nightbreed in 1990. And that was kind of one of those very violent emphasized as far as the portrayal.

It's where, like, the doctor ends up giving this patient with a diagnosis drugs and is ordering him to kill him. to kill various people. Another film called Santa Sanger in 1989. Like this, this violent, I guess, kind of storyline really has been portrayed a lot in film. And it gets understandable maybe why we have certain biases, just given what's been exposed to and what stories we've seen. Yes, I think that's kind of a, definitely in the clips we can explore that more because the visuals of it are pretty impactful for those who have seen. the film. Yeah, so, you know, I'd really appreciate it. Go check out the YouTube, subscribe, or check on my Instagram. That's where they'll be posted. And probably a week or two weeks

after we post this podcast, but we'll see. Maybe they can come out at the same time. So let's get on to schizophrenia in general. So typically, they occur in young adulthood. On average, you know, the male who's 21, the female who's 25. And that's another commentary. as far as like how we introduced this, is that the character John Nash is apparently in his 30s kind of when all of this started. Granted, he's not alive today. This is historical report, but there's just, yeah,

further things kind of in film that we need to refocus in on what the statistics actually show or the true picture. Yeah, yeah. And so one thing is, it's if you have a schizophrenic patient who's having their first onset of schizophrenia in their 50s or 60s, I would really question that diagnosis. I would really question it.

So lifetime prevalence? 0.3 to 0.66%. And causes are complex? Super complex. There's still a lot of debate about, you know, what could be. There are some things that we've found as far as associations for earlier onset and different things like that that we'll chat about. But it really is, to a large degree, something we just don't fully understand.

understand. Yeah. And I would say with that, like for the people who say like, oh, there's no evidence of biological aspects of mental illness. Well, there's probably like hundreds of studies. So be careful to say that. There's just so many, it's so complex. And there's, I think schizophrenia could be a final common pathway for multiple, for multiple priming events and genetic events that have, you know, and epigenetic events. So another really interesting thing that I posted in previous episode on marijuana was that frequent marijuana use can increase the risk of a psychotic or schizophrenic illness about four times of what it would be otherwise. So that's very concerning. And I think that's very strong evidence. So there's many things that can sort of prime or lead to or be a part of. Do you want to say any more about that?

No, I think the next fit that we're getting into, for me personally, this is my favorite. Even as we look at like, why do we hold certain beliefs or biases that we do now and getting into the history and seeing how the understanding of mental illness at large, but specifically schizophrenia, this for me gets me going. Let's do it. So we're going to go all the way back. The earliest recorded kind of description of an illness resembling schizophrenia is found. in 1550 BC in what's called the Ebers papyrus in Egypt. So this is like our first, if we can kind of put it thumbtacks along historical time point. This is the first time that we have something kind of as a description down,

that people were observing this behavior. It was observed enough that there was a pattern and kind of a thought formulation around this. And then it's pretty good to understand, too, even in current day understanding, that if we go back, there is really this understanding that psychopathologies were stemming from divine punishment. I think nowadays there's more generally an understanding that things have biochemical bases, that there are genetics at play, and less of a like your dad did something and a god is angry at him and the firstborn son is blighted by this. I think that really changes how we view people who are suffering from these.

And then as far as this whole divine punishment thing, if we look in Greek mythology or even like the Judeo-Christian biblical texts, we can see like King Saul and First Samuel in the Bible that he goes mad after he angers God. And somebody has to play the harp to keep him calm. And in 1563, there is a book called what translates to the deception of demons, which is the first thing, 1563 BC that proposes that this might be from something that's as far as like a natural cause

and not just demon possession or spiritual warfare or divine punishment. So I know that's a whole lot as far as what formulates how you look at things now, but it's interesting to kind of rewind back and see that that's really a predominant thought process that's been in society going way back. Well, there's still a lot. I get I get DMs in my Instagram from. people overseas that still are questioning like, hey, is this person possessed or, you know. And I think in America, by and large, we don't think in those terms as much anymore,

but there certainly are people who do think in those terms. And interestingly, I was just asked on a DM by this one guy who's working in Turkey about, you know, he sees a lot of people who are going psychotic. believing that they're Jesus, believing that they're, you know, Muhammad, believing that they're, you know, some sort of spiritual figure or that some sort of spiritual figure

is angry at them and that they're possessed with the demon and cursed. And he was asking, like, what's up with that? And, you know, the thing is, is that often the culture that you're in will help govern the type of delusions and psychosis that you have. So for example, I had a patient who was really into the brother's caramuzoff

going through her PhD. She was at a university setting, got psychotic, and believed that she was a character connected with Alyosha. So it's like she was in that world. That was what was meditating or she was meditating about like day and night as she was working on her PhD. And so when she got psychotic, that got pulled into the psychosis, right? And in the same way I hear about people over you know, in the Middle East, who is a very strong Islamic culture, who, you know, themes of Muhammad and Quran and are pulled into it. And so there's often spiritual themes that kind of come into it. So that's, it's still very present. I mean, you go into the psychiatric hospital, and there's probably two patients right there that are still thinking in those terms, like,

I'm possessed, I have a demon that's persecuting me. Or even family members who might have a stronger reliance on that explanatory model as opposed to a more like biological genetic and that informs how they help as a support system and encouraging medication compliance or not if they feel like it is something that can be fixed through non-spiritual interventions, you know? Yeah, I had a medical student who was going through, his sister was going psychotic and the family was deeply religious and didn't want any medications. They wanted to, they continue to want to take her spiritual practices, it's very clear schizophrenia to me. And so sometimes those kind of like the things that are helpful for people by and large, you know,

dealing with realities of the world, spirituality helps a lot of people. Sometimes it can get in the way of getting the treatment that's needed. Yeah. And sometimes I'll put it into spiritual terms for the family. Like, hey, you know, there's a common grace that we can experience through medications, you know. or through good psychotherapy. Yeah. And understanding that this has been around for a long time, this thought process is helpful

in how you speak to them, kind of like what you're saying is like just knowing the different thought groups out there when it comes to explanatory models. Yeah. The next kind of pincushion that we have here in the timeline comes from Emil Kreppelin. He's a German psychiatrist, 1856 to 1926, kind of his time frame there. And he was the person that suggested in this sort of shift that I think we're seeing, in some academic circles, at least to be more biological and genetic in origin. The cool thing about him, because really like schizophrenia itself is a tough thing to parse away from other presentations that look similar, is that he differentiated what we call schizophrenia today from other types of psychosis. There was a term that we used that was dementia preozox.

I'm not sure how to pronounce that, but it was essentially like dementia of early life versus manic depression. And he kind of helped parse those apart because what he saw as schizophrenia as being an irreversible cognitive functional loss, he was able to differentiate that from what we would consider in like a mania, which might be more episodic in nature. And that's helpful, I think, for anyone out there is that when you have someone who presents, you know, let's say they're seeing things or hearing things or they're. you know, expressing things, you're like, this is strongly paranoid, this isn't founded in reality, to look at the time frame and find out, when did this start? Is this slowly progressive and worsening for years? Has this come and gone months at a time? Is this acute? Is this substance related? Like, he was really the father as far as understanding that that was a core part of making this diagnosis. Just so impressive to look back and be like, well done, psychiatric forefathers.

Just good observations. Good, yeah. And so for bipolar, you know, usually the person will be ramping up for several weeks without sleep, you know, feeling like they're on a special mission, talking fast, racing thoughts, and their sleep goes down maybe to three hours a night to two hours a night where they're not sleeping at all. And then somewhere deep in there, they get psychotic. Now, you could have personality disorder and also get psychotic. And so you could be borderline personality disorder and have these sort of what they're called quasi-psychotic episodes where they're hearing things,

persecutory voices telling them bad things about themselves. Whereas, you know, maybe when you're not in kind of a dissociative stress state, you can kind of have the social veneer and not feel those intrusive negative voices. And then there's also delirium. Delirium is, you know, usually later in life, but if you have enough hits to the system, I think you can make almost any person psychotic.

And in this sort of state, you know, people will see visual hallucinations often. They'll, you know, grandma who's having a urinary tract infection will be seeing things, hearing things. And it can be very distressing for the family. Oh, yeah. In hospital settings when I've seen that and people say like, this is not my fill in the blank mom, grandma, wife and just how heartbreaking that is to see such a drastic personhood change in front of you. Yeah. So it's Sensorium. So when I make the assessment, I'm looking at the trajectory, the pathway to the psychosis,

the things around the psychosis, are there drugs involved? You know, meth presents a little bit of a different picture of psychosis. You know, in the height of meth use, you can get psychotic. You can hear things, see things, get paranoid. And then, you know, when you stop the meth, usually most of it goes away. some persists, and that can be very distressing. And, you know, like, I mean, if you watch movies, people on meth, they're like duct taping cardboard to their windows and they're ducking, you know, and isolating and doing all sorts of

things. So, yeah, it's important to get a clear history, and sometimes the family is very necessary for this. Yeah. But it's important because you want to know, is this something that's progressively, you're you know, is this, is a person progressing into this? Is it an acute thing from drugs or some medical issue? Or is it, you know, part of a manic episode?

You're going to treat each of those people very differently. Oh, totally differently. So that's really, I don't know, it's just pretty fascinating to look back and see, like, who was the first person who identified that. So that was kind of Emil Crepline around 1887 to 1903, that sort of time window there when he made that differentiation. The next big player as far as our understanding of schizophrenia, what we call schizophrenia today, is Eugene Bliller.

Breuer. Oh, my pronunciation is horrible. How does you say it again? Brewer. Brewer? Something. Somebody will look that up and correct us later. But he was the person, and I love finding out, like, origin of the actual word.

He's the person who introduced the term. schizophrenia at a lecture that he was giving at a psychiatric conference in Berlin. So the actual word itself kind of roughly translates to splitting of the mind. Skuytsin means like to split friend mind itself. And this is cool. Like those are the Greek roots, but it also introduced what colors schizophrenia, even now today with the fact that that, how the name comes out, its actual origin and translation really makes it sound like multiple personality disorder, like splitting of the mind. So that was something that actually kind of there was like some confusion when you look

over the historical documents between things because this was the word that he introduced for it. Granted, this was further clarified by the next players in the game like Kurt Schneider, who was another German psychiatrist, his time frame 1887 to 1967. he coined some different phrases or terms to help us further clarify, like, what's going on. He improved the diagnosis of schizophrenia essentially by creating a list of what he considered to be first-ranked symptoms or, like, things that are typified in the disease course itself. So things that we've already talked about that you see in the character of John Nash,

like hallucinations, thought insertion, thought broadcasting, thought withdrawal, passivity experience. experiences, the delusions themselves, delusional perception. Wait, define thought withdrawal? Thought withdrawal. So this is, I had to look this up. This is when someone experiences that they're having thoughts removed from their perception by another person or influence. I think that's good to put side by side with thought broadcasting, which is where you believe

that your thoughts, instead of being taken away from you, are being inserted into, like, if you're having a thought that you feel that the TV is displaying it, maybe you can clarify. Thought broadcasting is like other people can read your thoughts, know your thoughts. Thought withdraw is you're having the thoughts removed. Like if I were having it, I would be having my thoughts removed by another person. So another person would be influencing me pulling out my thoughts. And then that passivity experience is sort of the sense that someone else is controlling your actions, your body movements, your sensations. And I think I've seen a few of these on inpatient psychiatric units,

especially the thought broadcasting and the passivity experience. But it's, yeah, so this is kind of the first guy who really made a list instead of this vague, like people who are acting abnormal. He was like, sit down. These are first-ranked symptoms. When we see these things, especially in clumps together, we really need to be putting this on the table as a possible explanation. And he essentially was like, we want to diagnose the form of the behaviors instead of the content of the behavior. So it used to be that anyone who was, let's say, having weird thoughts about the church was clumped together, weird thoughts about the human body and its experience was clumped together,

paranoid thoughts about their family members were clumped together. And now they're like, no, no, no, instead of that, let's put them together by the types of things that they're having. So he was a big player as far as that goes. The next guy that we have up is Sigmund Freud. Maybe a few of you have heard of him, 1856 to 1939. He is someone that more so just kind of influences the general conception of mental illness at large. He wasn't as much specifically with schizophrenia from what I found, but just his perception of how early life and unconscious conflicts can influence things,

I think that that was definitely worth to mention when we talk about our society's perception of mental illness and schizophrenia. Yeah, I mean, we could go on about fluid for a while. But a lot of who he treated were not the severely, severely mentally ill. And that's important for our conception of the, types of patients he treated. Now, if you look at someone like Evelyn Sacks, who is a lawyer at USC, she wrote a book called The Center Cannot Hold. I read that. That was interesting. I actually have a signed copy of the book. And I heard her talk when I was at the psychoanalytic

Institute for two years. She gave in talk there because she's very into how important psychoanalysis was for her in particular and her journey and having that close relationship with another human being through the struggles. So she is a great case study on the integration of good psychotherapy and more of the psychoanalytic psychotherapy. Okay, keep going. That's cool. Okay, so the next thing that I think is really worthwhile in mentioning is once we hit, we've kind of gone through these people who are helpful in noticing that these behaviors might be a diagnosis, making arguments for, you know, as we look back historically, what the source or causative factors might be, if this is natural, biochemical, or spiritual in nature.

Moving forward, it's really, really important to note that in the 20th century around when Nazi Germany was in place, that there was a lot going on in the psychiatric world and with people who had mental illness. And I think a really big thing that happened was what we call, or what was called the Action T4 program, which was the involuntary euthanasia of the mentally unwell. So this started in 1939. It was officially discontinued in 1941, but it didn't actually stop until 1945. And I'll post up the articles if you want to read more about this, but it's just pretty heartbreaking. There's in this Action T4 program an estimated 200,000 deaths that occurred.

And something I just want to read a quick quote here is Dr. Carl Brunt and the Chancellor Chief Philip Boyler. This is a quote here, are charged with a responsibility for expanding authority of physicians so that patients considered incurable can be granted a mercy killing. Kind of in reading documents around this, though, it kind of looks like the inclusion criteria were not strict and oftentimes the economic status or productivity level of the individual in question might have played more of a role in that criteria. Yeah, just to, I think it's important to address where society has maybe really done a horrible job of taking care of people with this diagnosis.

Horrible. And we're talking about an estimated 200,000 deaths. 200,000 in this program that only spanned really from 1939 to 1945 is when it asked. actually ended. And it was even interesting that the order for when this came out was backdated to the day that World War II began so that it would appear to be a wartime measure, even though it actually was implemented later on. I mean, there was, I think it's important to state there was like the Roman Catholic Church. There were some documents and protests, some physicians protested, including some psychiatrists, but overall, like this was even in the phrasing of it to expand the

authority of physicians and just, I don't know, maybe a moment for us to kind of reflect on truly what a vulnerable position it is in society if you have this and that you might lack a voice when it comes to. Oh, absolutely. And, you know, the other thing that comes to my mind is that in most big studies, the compliance rate is very, very low towards the actual treatment. And so people who really need, really need the medications often don't get them. Yeah. And so, for example, like, I think the rate is about, you know, 0.6 in the general population, whereas in the homeless population, it's like 20%. And so you have this incredible need for the people with the most severe mental illness to get treatment. But even in the county

program like how hard is it you have to go to a walk in clinic okay that could be 20 miles away from you from where you live and transportation is an issue and then you have to wait for five to six hours sometimes to be seen or it may take four hours you know if you're just walking in and in that time all the stimulus may be so distressing that you'll just leave yeah so this is where like act teams, teams that go in to where the people live. And I'm looking on sort of doing some of this stuff as well, where I live partnering with different people. And I'm putting up a YouTube video of a recent talk I gave on homelessness,

empathy, and connection, and the importance of that. And one of the big things is that, you know, the most sort of at-risk populations will not get treatment because they're so isolated. In part of the delusions and the paranoia, they lose all connections with everyone. Yeah. You know, really, I think there's some studies that show kind of one of the main prognostic influencers is just your support system. And if you have, let's say, you know, a family that's invested in keeping you safe and well

and setting you up and also helping with accountability when it comes to appointments and follow-up and medications. Yeah. I had a patient on the inpatient unit who he was set up and his main thing is like, I have an apartment. My parents like help me out. I get some monetary compensation for the diagnosis, but that his life is really just consistent of like staying in his apartment and playing video games.

And as long as he doesn't leave, he won't get in any trouble because it's interaction. with humans that always seem to go awry and then he's brought in by the police and, you know, kind of his life is very small, but that's how he can maintain a certain level of independence is by secluding himself. And it seems like a tough catch-22. And so one of the things that we've, I've started discussing one of my best friends out here, he works full-time with the homeless in the city that I live in. And so he's on the street.

he literally knows 100 or so homeless people by name, knows their stories, knows a lot about them. And it's taken years to develop those relationships. And so we've been in dialogue about like, what is the biggest need that these people have? And for him, his conclusion is relationship. Yeah. And it could be something small,

like just giving your attention, you know, repetitively to someone over the course of a year or two. That's how he's built these relationships. but there's so much paranoia. The system is against me. All of this stuff leads to extreme isolation. And then there's the stress of being on the street, which is another really ongoing, unrelenting stress,

and there's really no safe haven. And also the rates of trauma are so much higher. The rates of previous trauma before homelessness are so much higher. Often a lot of the people who are homeless who are raised in the foster care system, So there's a lot of these stresses that lead someone down this road to homelessness. And so it's something we're talking about more, I think, in upcoming episodes like, how do we address this as mental health providers?

And even as you mentioned, because there's World Health Organization releases every now and then some really helpful statistics. And one of the more recent estimates is, I know we mentioned earlier, 0.3 to 0.66 is kind of the U.S. average as far as the rates of schizophrenia in the general population, but within the population of people experiencing homelessness, the estimates are up to about 20%. So yeah, just what you were saying there is that this is really a, it's a tough situation because that's the exact position where you lack all those support and structures that help with a good prognosis and outcome and, you know, long-term longevity there. Yeah, so I think what we'll do is we'll stop this episode, actually.

Maybe let's summarize some of the big takeaways from this episode that we want. And then in part two, why don't we jump into clinical manifestations and start to go through treatment? Can I get into like the nitty gritty. Nitty gritty of things, yeah. One of the big things that I think is a takeaway from here is the importance of connection, is the importance of empathy for this group. And I hope that we're humanizing and sort of decreasing some of the fears. Like violence is not, although it's big in the movies, it's not that big in real life. Yeah.

Like these patients are not incredibly violent people. There's so many factors that lead to someone down this pathway that it's not like a moral failure. Yeah. I think that's really important to emphasize because even if that's something you hold deep within and don't consciously process, maybe introducing an alternative explanation would really soften how you interact with them or how you greet someone if you notice them. Yeah.

And then what we'll be going through in the subsequent episodes is how we can have empathy, like how we can be with someone who might have psychotic symptoms in a way that doesn't co-author the delusion but actually can be present with the distress in the delusion. Yeah, I think something, really wise that I think it was one of my attendings who I've worked with that they say even if

the content of what they're saying is completely non-factual, not based in reality, there is no fill in the blank organization or person following them, that their emotional distress from that perception is real and tangible and factual and in front of you. No matter what their explanation is or what their delusions are, their emotional experience in the midst of that is there. Yeah, and I think one of the other big takeaways is, is that the age at which onset this occurs at usually is a younger age. Yeah.

And that this has been talked about throughout history. So it's not just like a culturally constructed notion of what something is. And there's a pattern. There's a constellation. social withdrawal early on in adolescence and then, you know, auditory hallucinations and delusions and negative symptoms. And so in the next episode, we'll get more into the details of what those are, what those look like.

What those are. And we'll go from there. So, Ariana, thank you so much. Thank you. And we're just going to pause and record episode number two right now. So if this has been helpful for you, Let me know, jump onto my social media. We'll post all of these notes on my resource library.

If you've got in it before, just recheck your email and just go straight there. And we will also be looking forward to some video highlights from this series. And in this series, I'm really hoping to go through some of the major diagnoses in the future and go through kind of the history and the pop culture stuff, but then also dive into what you need to know to be able to treat this population. So, there we go.