Q & A: Catatonic Schizophrenia, Dismal Institutions, and Dreams

Q:I am writing a novel about a man suffering from catatonic schizophrenia. I believe this is not as common as it used to be. What time frame should I use as a setting? (I would prefer the sanitarium to be dark and dismal such as you find in "One Flew Over the Cuckoo's Nest")

The patient (while he is catatonic) dreams,and he believes these dreams are his real existence. Is this plausible?

A:Catagonic schizophrenia has become less common than it used to be, but it’s also being treated a lot better than it used to be.  In 1955, neuroleptic drugs (that is, antipsychotics) were developed, and they can make a huge difference in the life of someone with schizophrenia. 

There are several theories about what schizophrenia is and what causes it, but we do know several things.

1. There is a strong genetic basis for it.  Though identical twins (people who have exactly the same genes) don’t always both have it, if one twin develops it, the other twin has about a 50% chance of developing symptoms as well.  The mediating factor is stressors in one’s life – you have to have stressors to trigger any disorder.
2. Dopamine seems to be involved.  Dopamine is a neurotransmitter that has to do with movement, emotions, motivation, and addiction.  When you don’t have enough, you develop a disorder like Parkinson’s, where you have little control over movements; when you have too much, you can develop psychosis – hallucinations (hearing things, seeing things, feeling things that aren’t there) and delusions (unusual ideas with no basis in reality).
3. The ventricles in the brain (four small spaces that produce cerebrospinal fluid to cushion the brain and spinal cord) tend to get bigger due to tissue loss (ie deterioration of the area of the brain around them).

How Antipsychotics Work

Antipsychotics work as antagonists in the synapse (the place messages pass between neurons, aka nerve cells, in the brain); that is, they block the neural receptors all that extra dopamine would plug into to send the psychotic messages.

The early drugs, called typical antipsychotics, like haloperidol (trade name Haldol) were so potent and so heavily sedating they’re sometimes referred to as “major tranquilizers.”  (They’re also called classic neuroleptics” and  “conventional antipsychotics.”)  The point is, many patients looked pretty catatonic while they were taking them, even if the kind of schizophrenia they had wasn’t catatonic.  (This is why movies and TV shows always show people doped up in the mental hospitals, because that’s what used to happen.)

In the 1990s and early 2000s, atypical antipsychotics were introduced, and they’re far less sedating and have fewer side effects overall.  In particular, they’re less likely to cause extrapyramidal (extra-PYR-am-i-dal) side effects (shaking) and tardive dyskenesia (TAR-div dis-KIN-ee-seeya), which refers to involuntary movements of the lips and tongue.  (Tardive dyskenesia isn’t immediate, it appears over years, and is permanent.)  Olanzapine (Zyprexa) and Rispiradone (Rispirdol) in particular seem to be used a lot with outpatient clients these days.

So your character is even more likely to spend a lot of time in a catatonic state if he’s also being given a typical antipsychotic, which means prior to the 1990s.

When Were the Institutions Unpleasant?

What time frame should I use as a setting? (I would prefer the sanitarium to be dark and dismal such as you find in "One Flew Over the Cukoo's Nest")

The particularly unpleasant institutions were in place until about the 1970s; One Flew Over the Cuckoo’s Nest was actually important in forcing reforms.  If you want your character to be on the more sedating antipsychotics, you’d probably want to look at 1955-1970.  Anytime a drug is new, there’s more trial and error, so the earlier you set it, the less certain the doctors are to get the medications just right.

Ken Kesey, the author of Cuckoo’s Nest, was institutionalized for a mood disorder, and he did base the story on his experiences.

Electroconvulsive therapy (ECT) and lobotomies were also happening a lot up until around 1970, and they could cause catatonic symptoms as well, the latter in particular.  

(Lobotomies are no longer practiced; ECT is used in very rare circumstances, and the electrical current tends to be mild. The person is given a muscle relaxant and a sedative [so they don’t get anxious that they can’t move] so their bodies won’t shake during the treatment.  I always tell my students it’s kind of like rebooting the brain, and in someone who hasn’t had anything else work, it truly can be a lifesaver. Everyone I’ve heard about having it done through colleagues was thankful for it.)

Some state-run mental institutions are still, I’m sorry to say, unpleasant places to be.  They’re not so dark and dismal, but they’re pretty cold and institutional-looking.  They’re more likely to hourse people whose families either can’t or won’t take care of them, and there’s actually very little public money that goes into our mental health system.  They can be depressing places, with catatonic patients in the beds or staring at the walls, and since hygiene can be a problem for people who struggle with severe psychosis, the smell isn’t wonderful – you get that antiseptic-unwashed bodies-urine smell in some places.

Are People Who are Catatonic Conscious? Do They Dream?

The patient (while he is catatonic) dreams,and he believes these dreams are his real existence. Is this plausible?

One study in which researchers did interviews with people who had negative-symptom states (ie withdrawal, catatonia, etc.) and found that while “patients generally deny any diminishment of affect [feelings] and thinking, they do describe qualitative alterations of experience suggestive of hyperreflexivity [overactive or exaggerated responses] and diminished self-affection [affecting oneself and being affected by oneself].” (Sass, L. A., &  Parnas, J. (2001). Phenomenology of self-disturbances in schizophrenia: Some research findings and directions. Philosophy, Psychiatry, & Psychology, 8(4), 347-356.)

People suffering from a catatonic stupor are conscious, but they’re experiencing apathy (they just don’t care) and avolition (it’s just too much work to do anything). 

While in a stupor, some will display extreme negativism (not allowing someone else to move their limbs when they’re in a rigid posture, but there’s no motive or reason behind resistance) or mutism.  Others will display waxy flexibility (someone else can move them and “pose” them and they’ll stay as the person leaves them). 

They may also display echolalia (repeating a word they just heard over and over, like an echo), echopraxia (imitating people’s movements over and over, also like an echo).  In most cases, these behaviors aren’t voluntary or motivated by anything. 

Voluntary movements may lead to bizarre postures, or stereotyped (repetitive, often meaningless) movements, or extremely noticeable grimacing.

Delusions and hallucinations are the two most prominent symptoms of schizophrenia, so people do experience them during catatonia.  I don’t know that the brain is active enough to produce an entire ongoing, imaginary world, but some of the medications can produce strange dreams, and if you combined the schizophrenia with a tendency to overuse the fantasy defense mechanism, that would work.  (Especially because that defense mechanism can spill over into dreams.)

Fantasy (as a defense mechanism) is the tendency to retreat into an imaginary world to deal with anxiety.  Usually the person is trying to cope with unacceptable or unattainable desires.  That doesn’t necessarily have to be something strange; if you live in a family where you don’t get a lot of love, you might retreat into a fantasy world where you’re adored.

People tend to use a whole “toolbox” of defense mechanisms, but it’s not unusual for people to have favorites.  Defense mechanisms aren’t bad unless they’re putting you in danger (e.g. you deny that you could get an STD from unprotected sex and are less careful than you should be); in fact, we need them to function normally. (Being able to laugh at something embarrassing is a defense mechanism – humor!)

Families in which schizophrenia runs may display some odd behaviors anyways, which can put stress on the child and make him or her more likely to rely on defense mechanisms.  “Cognitive slippage,” for example, is more common in families with schizophrenia in the genes, even if the family members don’t meet the criteria for schizophrenia themselves.  Cognitive slippage is where lists and categories become too broad; for example, “name some colors” might lead to an answer like “purple, blue, green, orange, strawberries, bananas, celery, carrots, lemons, and pink.” 

Likewise, these types of families often experience downward drift, which means they “drift” down in to a lower socioeconomic status because their odd thought patterns keep them from functioning high enough to be middle or upper class.  Poverty is an enormous stressor, and many children would fantasize about all the things they can’t have.