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Hearing Voices and Paranoid Delusions: Inside a Schizophrenic Brain
Now and then we've all thought we heard someone calling our name, or noticed a strange coincidence. But for people with schizophrenia, these can take on a much more nefarious quality. Dr. Vikaas Sohal walks us through what it feels like to be inside a schizophrenic brain.
Dr. Vikaas Sohal is Assistant Professor of Psychiatry at UC San Francisco. His research has focused for years on cognition and functioning. He has written extensively on aging in schizophrenia, functional impairments in severe mental illness, the cognitive effects of typical and atypical antipsychotics, as well as studying the effects of cognitive enhancing agents in various conditions, including schizophrenia, dementia, affective disorders, and traumatic brain injury. Dr. Sohal is also a board certified psychiatrist and continues to see outpatients approximately one half day each week. He directs an annual conference on cognition that is an official satellite of the International Congress on Schizophrenia Research and the Schizophrenia International Research Society.
Dr. Sohal earned his A.B. in Applied Mathematics from Harvard University, his M.A.St. in Mathematics from Cambridge, and his MD, PhD from Stanford University. He completed his graduate work in the lab of John Huguenard, then stayed at Stanford to complete his psychiatry residency and a postdoctoral fellowship in the lab of Karl Deisseroth.
Vikaas Sohal: Many of us often have the experience of thinking we heard someone calling our name and then realizing that wasn't really the case, and we just move on, and we forget about it. Sometimes we notice coincidences, like, "Oh, there were a couple of cars on the street," and again, we pay no attention to it. But for someone with schizophrenia, these experiences take on a vastly different kind of feeling. So you might notice, "Oh, there were three red cars on the street," and instead of just forgetting about it, you start thinking, "Well, why were there three red cars on the street? Maybe it has something to do with me. Maybe these people are actually coming to monitor me or do something that would harm me," and you start working through some kind of plot or conspiracy related to that coincidence that you noticed.
The symptoms that people are most familiar with in schizophrenia are often hearing voices or having paranoid delusions and paranoid thoughts. We now know that, in addition to those kinds of symptoms, many people with schizophrenia have trouble focusing, paying attention, and remembering things. Many people talk about hearing voices and mean different things. Sometimes people will say, "Oh, yeah, when I'm thinking about what to do, I hear a voice in my head that tells me this would be the right thing to do, or this would be the wrong thing to do, or that gives me an idea." And when individuals with schizophrenia talk about hearing voices, they describe it very, very differently. It's really a voice, that they can't tell the difference between that voice and a voice coming from a person sitting right next to them in a room. And it sounds absolutely real. It sounds loud. Sometimes it's so loud that they can't stop paying attention to it. And sometimes the voices are just calling their name, but sometimes the voices are saying much more complicated things. Sometimes they're giving them commands, telling them what to do. Sometimes they're commenting on what they're doing, often in a negative or derogatory way.
It comes as no surprise that the brain is a complicated place. There's information flying all over the brain, and the brain has to get that information to the right place and decide what to do with it. We think that, perhaps, in schizophrenia some of the problems come because information isn't getting to the right place, or, sometimes when information does get to the right place, the brain doesn't know what it should pay attention to and what it should ignore. This is really important. In our everyday lives, we might hear a car alarm in the background, and we have to know not to pay attention to that, but we might also hear a baby crying in the background, and that probably is something that we need to pay attention to. And so, if your brain's not able to act as an executive and say, "This is what's important and this is what's not important," it becomes very difficult to sort through those everyday situations in ways that are really important for living and holding down a job or managing your life.
Seeing things — visual hallucinations, are more uncommon in schizophrenia. They do sometimes happen, and sometimes they take the form of people seeing ghosts or seeing people who aren't really in the room. Sometimes they look at a picture and they see something more than what the picture shows, often something with nefarious intent. Those are the kinds of experiences that individuals with schizophrenia will sometimes describe. Some people have them; some people don't. Even for people who have them, they can come and go at times. But these other symptoms that we now understand better and are starting to recognize more, they're much more fundamental to the disease, and they're much harder to deal with. And those are the symptoms like having trouble paying attention, having trouble remembering information, and having trouble being able to organize your activities and switch from one activity to another activity. These are things which individuals with schizophrenia start to find are harder than they were before they became ill. So, all of a sudden, they have trouble paying attention in class. They have trouble focusing on what they're reading. They have trouble doing jobs that require them to switch between one kind of thing and another kind of thing quickly. And that obviously stands in the way of people being able to live their lives to the fullest, being able to work, being able to manage their household, being able to manage their families and family relationships. And so those symptoms, what we often call "cognitive" symptoms, symptoms related to attention, and memory, and concentration, and focus. They're really one of our biggest challenges right now in schizophrenia.
Now and then, we've all thought we heard someone calling our name, or noticed a strange coincidence. But for people with schizophrenia, these can take on a much more nefarious quality. Dr. Vikaas Sohal walks us through what it feels like to be inside a schizophrenic brain.
Study findings<p>For the study, <a href="https://link.springer.com/article/10.1007/s11606-020-05970-4" target="_blank">published in the Journal of General Internal Medicine</a><em>, </em>Flentje and her team evaluated survey responses from nearly 2,300 individuals who identified as being in the lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community. Most of the participants were white, while nearly 19 percent identified as a racial or ethnic minority. Multiple genders were represented with cisgender women (27.2 percent) and men (24.6 percent) making up a majority of the participants. Sixty-three percent had been assigned female at birth. For the most part, participants identified their sexual orientations as queer (40.3 percent), gay (36.5 percent), and bisexual (30.3 percent).</p><p>The JGIM study participants were recruited from the 18,000-participant <a href="https://pridestudy.org/" target="_blank">PRIDE Study</a> (Population Research in Identity and Disparities for Equality), which is the first large-scale, long-term national study focusing on American adults who identify as LGBTQ+. It conducts annual questionnaires to understand factors related to health and disease in this population. </p><p>Participants filled out an annual questionnaire (starting in June 2019) and a COVID-19 impact survey this past spring. Flentje noted that on an individual level, some people may not have experienced a big change in anxiety or depression levels, but for others there was. Overall, depression increased by a <a href="https://patient.info/doctor/patient-health-questionnaire-phq-9" target="_blank">PHQ-9 score</a> of 1.21, putting it at 8.31 on average. Anxiety went up by a <a href="https://www.mdcalc.com/gad-7-general-anxiety-disorder-7" target="_blank">GAD-7</a> score of 3.11 to an average of 8.89. Interestingly, the average PHQ-9 scores for those who screened positive for depression at the first 2019 survey decreased by 1.08. Those who screened negative for depression saw their PHQ-9 scores increase by 2.17 on average. As for anxiety, researchers detected no GAD-7 change among the study participants who screened positive for anxiety in the first survey, but did see an overall increase of 3.93 among those who had initially been evaluated as negative for the disorder. </p>
Risks among gender and sexual minorities<span style="display:block;position:relative;padding-top:56.25%;" class="rm-shortcode" data-rm-shortcode-id="fc3fd1ae68b77bbbf58a6995638d6d65"><iframe type="lazy-iframe" data-runner-src="https://www.youtube.com/embed/EnUqDjCqg0A?rel=0" width="100%" height="auto" frameborder="0" scrolling="no" style="position:absolute;top:0;left:0;width:100%;height:100%;"></iframe></span><p>The LGBTQ+ community is a vulnerable population to mental health concerns because of their fear of stigmatization and previous discriminatory experiences.</p> <p>Previous research by the Human Rights Campaign has found "that LGBTQ Americans are more likely than the <a href="https://medicalxpress.com/tags/general+population/" target="_blank">general population</a> to live in poverty and lack access to adequate medical care, paid <a href="https://medicalxpress.com/tags/medical+leave/" target="_blank">medical leave</a>, and basic necessities during the pandemic," said researcher Tari Hanneman, director of the health and aging program at the campaign.</p> <p>"Therefore, it is not surprising to see this increase in anxiety and depression among this population," Hanneman said in the release. "This study highlights the need for <a href="https://medicalxpress.com/tags/health+care+professionals/" target="_blank">health care professionals</a> to support, affirm and provide <a href="https://medicalxpress.com/tags/critical+care/" target="_blank">critical care</a> for the LGBTQ community to manage and maintain their mental health, as well as their physical health, during this pandemic."</p>
What should health care providers do?<p>The authors of the study recommend that health care providers check in with LGBTQ+ patients about stress and screen for mood and anxiety disorders in members of that community—even among those with no prior history of anxiety or depression.</p><p>As cases of COVID-19 continue to mount, the sustained social distancing, potential isolation, economic precariousness, and personal illness, grief, and loss are bound to have increased and varied impacts on mental health. Effective treatments may include individual therapy and medications as well as more large-scale coronavirus support programs like peer-led groups and mindfulness practices. </p><p>"It will be important to find out what happens over time and to identify who is most at risk, so we can be sure to roll out public health interventions to support the mental health of our communities in the best and most effective ways," said Flentje.</p>
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