Sunday, August 30, 2009

The Epistemology of Paranoid Schizophrenia

Note: All details, including names, ages, and specific descriptions of conversations with staff or patients have been considerably changed. Sorry, I know that reality blogging is more fun than fake medical encounters. Additionally, the discussion exclusively concerns people with relatively mild or well-controlled schizophrenic symptoms, with whom I can easily engage in conversation.

When the psychiatry resident asked for an update on Tracy, I glibly responded, "Still very delusional. Thinks the CIA is after her."

"She's not delusional!" the doctor corrected. "The CIA or the FBI or whatever agency really is after her. Tracy used to threaten killing former President Bush numerous times. During her last hospitalization, I had to argue with the authorities for hours, to convince them that she's safe for discharge." Thus, my near-designation on my patient's record as possessing this delusion, or a "fixed, false belief," that is not "widely held within the context of the individual's cultural or religious group" was in error. Tracy's paranoia was based on truth.

The interesting part, however, of working with schizophrenic patients is generally not figuring out what is false; Patients have spoken of receiving commands from their televisions to overthrow the "vitamin pill industry," and of obtaining classified information that their true parents are Liza Minnelli and Bobby Fisher. Many patients insist that a doctor or nurse can gain remote access to the contents of their brains, via some transhumanistic, genetic link-protocol of sorts. False belief, check.

Determining what falls under cultural norms can be a bit trickier. One patient, David, believes that he and fellow schizophrenics have powers in the "sixth dimension," on an "etherical, astral, plane," a belief that I'd brand as delusional, if I 1) Knew what it meant, curvilinear coordinates not being my forte and 2) The International Headquarters of the Theosophy Society weren't right in my hometown, flagging this as a possible local cultural or religious belief.

The main challenge in assessing delusions, however, lies mainly in determining which are considered "fixed," or intransigent to reason and the passage of time. A binary "yes" or "no" to describe the "fixedness" of a belief is inadequate. Many patients come to the hospital voluntarily, desperate to rid themselves of fearsome beliefs or voices that they know, at least in part, aren't true. Thus, they demand anti-psychotics that deny the pleasure of dopamine, and beg for mood-stabilizing drugs that inhibit norepinephrine-fueled arousal. And those are just some of the intended effects. Side effects include dystonia, neuroepileptic malignant syndrome, the frog-tongued gestures of tardive dyskinesia, and the rabbit-mouthed oscillations of EPS. Patients are often desperate to "unlearn" their beliefs, and hope to foster distrust of the voices in their head, which so distrust everyone around them.

Tom, one of my fellow medical students, asks patients an interesting question: "What do you think is the percent probability that your belief is true, and what is the percent probability that it isn't true?" Lillian, who's convinced that President Obama promised her $1 million, so long as she refrains from eating, (the Cult of the Presidency is the only thing both alive and well in the psych ward) said "About 5% of me thinks it's true, and 95% of me thinks it's not true." Five percent is not terribly much. I'm sure there are plenty of beliefs I maintain with a similar level of certainty that would confer me with at least an Axis II diagnosis, if someone could scan my brain for the latest Bayesian updates. Which leads me to wonder if percentages and predictions can adequately capture the credos that serve as the foundation for diagnosing paranoid schizophrenia.

For those of us with homo economicus pretensions, such stated probabilities may even persuade us that schizophrenic biases are simply standard deviants from very irrational mean population thought content. Indeed, critics of psychiatry often insist that people are deemed psychotic, simply because their delusions don't conform to what all the cool kids are fabricating this season. In this view, once norms change (like they did when the medical professions stopped labeling homosexuality as a disease), many schizophrenics will be considered as peers among the unhinged masses, with all our opioidic (agonistic and antagonistic both), nonsensical beliefs unleashed.

Perhaps we can focus on a more qualitative approach to evaluating "fixedness." After all, numbers don't seem to work with a patient named Mark, who contemplates (at least after he's taken his meds) of the instructions he "receives" from the devil via rap songs on the radio, "they're sometimes real...I don't know... it's so hard to separate in my head." Perhaps, we can ask an Isaac Levi-inspired series of questions, checking off what David considers "serious possibilities," out of a "potential corpora of knowledge and evidence." I can ask David, "Do you think that it's physically possible for you to hear the devil speaking to you, and only you, from the radio? Logically possible? Technologically possible? Psychologically possible?

Defenders of psychiatric designations counter their critics by noting that virtually every DSM-IV diagnosis, including schizophrenia, must involve significant impairment in occupational or social functioning. Apparently, in 2003, 20% of Americans affirmed to pollsters that an HIV vaccine already exists, but is being kept a secret. And yet, I don't see many people staging the proper revolt that such a conspiracy, if actually true, would merit. Aberrant thought content alone is not the rate-limiting-step to being diagnosed as schizophrenic. Many people have negative thoughts about the vitamin pill industry, but only Sally (who has Schizoaffective Disorder, Bipolar Type) embraced her mission by roaming in the streets, "recruiting" fellow revolutionaries (i.e. passing cars), and propelling Los Angelenos into traffic-induced hysterics.

So for paranoid schizophrenics who maintain only 5% certainty about their delusions, perhaps they simply act upon this glimmer of confidence more often than others, like the "Deal or No Deal" folks who, knowing basic math, still reject the banker's actuarially outlandish offer, because, what if the million is in my box? According to polls, many Americans claim that our current president is a foreigner, and is thus ineligible for his elected position, according to our country's most sacred national document. Then we go off to do our laundry and water our lawns. However, there are always those few that can't eat, sleep, or tweet, while harboring such persistent ideations of conspiracy.

A behaviorist might say that, Bayesian self-reports not-withstanding, patients' actions exclusively measure their convictions. Skinnerians will believe our stated fidelity to untruth when they see it! All the rest perhaps just falls under the purview of "symbolic belief." In other words, you may take pride in widely professing that Obama is an alien, but watch your shame when a behaviorist calls you out on your pretense! My humble suggestion: To stay out of the psych ward, you're better off holding certain beliefs as insincerely as possible.