Distorted Perceptions of Reality

People with schizophrenia may have perceptions of reality that are strikingly different from the reality seen and shared by others around them. Living in a world distorted by hallucinations and delusions, individuals with schizophrenia may feel frightened, anxious, and confused.

In part because of the unusual realities they experience, people with schizophrenia may behave very differently at various times. Sometimes they may seem distant, detached, or preoccupied and may even sit as rigidly as a stone, not moving for hours or uttering a sound. Other times they may move about constantly - always occupied, appearing wide-awake, vigilant, and alert.

Hallucinations and Illusions

Hallucinations and illusions are disturbances of perception that are common in people suffering from schizophrenia. Hallucinations are perceptions that occur without connection to an appropriate source. Although hallucinations can occur in any sensory form - auditory (sound), visual (sight), tactile (touch), gustatory (taste), and olfactory (smell) - hearing voices that other people do not hear is the most common type of hallucination in schizophrenia. Voices may describe the patient's activities, carry on a conversation, warn of impending dangers, or even issue orders to the individual. Illusions, on the other hand, occur when a sensory stimulus is present but is incorrectly interpreted by the individual.

Delusions

Delusions are false personal beliefs that are not subject to reason or contradictory evidence and are not explained by a person's usual cultural concepts. Delusions may take on different themes. For example, patients suffering from paranoid-type schizophrenia symptoms - roughly one-third of people with schizophrenia - often have delusions of persecution, or false and irrational beliefs that they are being cheated, harassed, poisoned, or conspired against. These patients may believe that they, or a member of the family or someone close to them, are the focus of this persecution. In addition, delusions of grandeur, in which a person may believe he or she is a famous or important figure, may occur in schizophrenia. Sometimes the delusions experienced by people with schizophrenia are quite bizarre; for instance, believing that a neighbor is controlling their behavior with magnetic waves; that people on television are directing special messages to them; or that their thoughts are being broadcast aloud to others.

Disordered Thinking

Schizophrenia often affects a person's ability to "think straight." Thoughts may come and go rapidly; the person may not be able to concentrate on one thought for very long and may be easily distracted, unable to focus attention.

People with schizophrenia may not be able to sort out what is relevant and what is not relevant to a situation. The person may be unable to connect thoughts into logical sequences, with thoughts becoming disorganized and fragmented. This lack of logical continuity of thought, termed "thought disorder," can make conversation very difficult and may contribute to social isolation. If people cannot make sense of what an individual is saying, they are likely to become uncomfortable and tend to leave that person alone.

Emotional Expression

People with schizophrenia often show "blunted" or "flat" affect. This refers to a severe reduction in emotional expressiveness. A person with schizophrenia may not show the signs of normal emotion, perhaps may speak in a monotonous voice, have diminished facial expressions, and appear extremely apathetic. The person may withdraw socially, avoiding contact with others; and when forced to interact, he or she may have nothing to say, reflecting "impoverished thought." Motivation can be greatly decreased, as can interest in or enjoyment of life. In some severe cases, a person can spend entire days doing nothing at all, even neglecting basic hygiene. These problems with emotional expression and motivation, which may be extremely troubling to family members and friends, are symptoms of schizophrenia - not character flaws or personal weaknesses.

Normal Versus Abnormal

At times, normal individuals may feel, think, or act in ways that resemble schizophrenia. Normal people may sometimes be unable to "think straight." They may become extremely anxious, for example, when speaking in front of groups and may feel confused, be unable to pull their thoughts together and forget what they had intended to say. This is not schizophrenia. At the same time, people with schizophrenia do not always act abnormally. Indeed, some people with the illness can appear completely normal and be perfectly responsible, even while they experience hallucinations or delusions. An individual's behavior may change over time, becoming bizarre if medication is stopped and returning closer to normal when receiving appropriate schizophrenia treatment.

Schizophrenia is found all over the world. The severity of the symptoms of schizophrenia and long-lasting, chronic pattern of schizophrenia often cause a high degree of disability. Medications and other treatments for schizophrenia, when used regularly and as prescribed, can help reduce and control the distressing symptoms of this psychotic illness. However, some people are not greatly helped by available treatments or may prematurely discontinue antipsychotic medication treatment because of unpleasant side effects or other reasons. Even when treatment is effective, persisting consequences of the illness - lost opportunities, stigma, residual symptoms, and medication side effects - may be very troubling.

The first signs of schizophrenia often appear as confusing, or even shocking, changes in behavior. Coping with the symptoms of schizophrenia can be especially difficult for family members who remember how involved or vivacious a person was before they became ill. The sudden onset of severe psychotic symptoms is referred to as an "acute" phase of schizophrenia. "Psychosis," a common condition in schizophrenia, is a state of mental impairment marked by hallucinations, which are disturbances of sensory perception, and/or delusions, which are false yet strongly held personal beliefs that result from an inability to separate real from unreal experiences. Less obvious symptoms, such as social isolation or withdrawal, or unusual speech, thinking, or behavior, may precede, be seen along with, or follow the psychotic symptoms.

Some people have only one such psychotic episode; others have many episodes during a lifetime but lead relatively normal lives during the interim periods. However, the individual with "chronic" schizophrenia, or a continuous or recurring pattern of illness, often does not fully recover normal functioning and typically requires long-term treatment, generally including medication, to control the symptoms.

Basic knowledge about brain chemistry and its link to schizophrenia is expanding rapidly. Neurotransmitters, substances that allow communication between nerve cells, have long been thought to be involved in the development of schizophrenia. It is likely, although not yet certain, that the disorder is associated with some imbalance of the complex, interrelated chemical systems of the brain, perhaps involving the neurotransmitters dopamine and glutamate. This area of research is promising.

Is Schizophrenia Caused By A Physical Abnormality In The Brain?

There have been dramatic advances in neuroimaging technology that permit scientists to study brain structure and function in living individuals. Many studies of people with schizophrenia have found abnormalities in brain structure (for example, enlargement of the fluid-filled cavities, called the ventricles, in the interior of the brain, and decreased size of certain brain regions) or function (for example, decreased metabolic activity in certain brain regions). It should be emphasized that these abnormalities are quite subtle and are not characteristic of all people with schizophrenia, nor do they occur only in individuals with this illness. Microscopic studies of brain tissue after death have also shown small changes in distribution or number of brain cells in people with schizophrenia. It appears that many (but probably not all) of these changes are present before an individual becomes ill, and schizophrenia may be, in part, a disorder in the development of the brain.

Developmental neurobiologists funded by the National Institute of Mental Health (NIMH) have found that schizophrenia may be a developmental disorder resulting when neurons form inappropriate connections during fetal development. These errors may lie dormant until puberty when changes in the brain that occur normally during this critical stage of maturation interact adversely with the faulty connections. This research has spurred efforts to identify prenatal factors that may have some bearing on the apparent developmental abnormality.

In other studies, investigators using brain-imaging techniques have found evidence of early biochemical changes that may precede the onset of disease symptoms, prompting an examination of the neural circuits that are most likely to be involved in producing those symptoms. Meanwhile, scientists working at the molecular level are exploring the genetic basis for abnormalities in brain development and in the neurotransmitter systems regulating brain function.

Why I decided to publicly acknowledge my mental illness (schizoaffective disorder) and not keep my mental illness a secret.

There was a long time that I tried to keep my mental illness a secret, but I eventually decided to acknowledge it publicly. It was a difficult decision, but ultimately I have decided it is a better way to live. I can be open and honest, without feeling that I need to lie to protect myself. If there are negative consequences to speaking openly about my illness, I take a great deal of comfort in the inspiration that my writing has been to others who suffer.

I was moved to write this particular article today after I saw the movie A Beautiful Mind last night.

It is the story of John Forbes Nash, a brilliant mathematician who was struck down early in his career by severe schizophrenia. He suffered in obscurity for decades (tormented by hallucinations and paranoia) before he recovered in the early 90's. Dr. Nash was awarded the 1994 Nobel Prize in Economics for the pioneering work he did on Game Theory as his Ph.D. thesis in the early 1950's.

Throughout my life, I have always felt it important to speak out about the things that I believed in. That's why I posted John J. Chapman's Make a Bonfire of Your Reputations on my website after I first read it in The Cluetrain Manifesto.

However, I have not always been such an eloquent speaker. It took me a long time to learn to write well, and when I was young I was unable to speak convincingly at all. It has happened quite a few times that speaking out caused me trouble, and it was especially difficult to get anyone to listen during the times my illness made it difficult to organize my thoughts.

It is likely that you've heard or read the ramblings of a mentally ill person and written them off as inspired by delusions. But there is often truth behind even the most paranoid manifestoes, sometimes a terrible truth, if only you were able to decipher their real meaning.

I have found that getting people to listen to me doesn't require that I avoid embarrassing or forbidden topics, only that I discuss them eloquently enough that I gain my readers respect by the way I express my ideas. I'd like to suggest that you learn to write and speak well too, if you have something to say that you think others won't want to hear.

One of the reasons I used to work so hard to keep my illness a secret is that while in the grip of my symptoms I did a lot of things that I regret. Most people regarded me as a pretty weird guy in general, and having such a reputation to live down does not help when trying to establish a career in a competitive industry or in trying to find the affection of a loving woman. It might well happen that some who knew me when I was the most ill might post embarrassing comments in response to this article. It might also happen that potential consulting clients - or my current ones - read this and wonder about my competence.

It is a risk that I accept in order to live true to myself. While at times I am in the grip of insanity, I take full responsibility for everything I have ever done. The best defense that I have is to let my words speak on my behalf.

As Maggie Kuhn, the founder of the Gray Panthers said:

Stand before the people you fear and speak your mind - even if your voice shakes.

next: Living With Schizoaffective Disorder, Reading

Here's how the symptoms of  schizoaffective disorder appeared and how they impacted my life.

I have experienced various symptoms of mental illness for most of my life. Even as a young child, I had depression. I had my first manic episode when I was twenty, and at first thought it was a wonderful recovery after a year of severe depression. I was diagnosed as schizoaffective when I was 21. I'm 42 now, so I have lived with the diagnosis for 21 years. I expect (and have been emphatically told by my doctors) that I'm going to have to take medication for it for the rest of my life.

I have also had disturbed sleeping patterns as long as I can remember - one reason I'm a software consultant is that I can keep irregular hours. That's a primary reason why I went into software engineering at all when I left school - I did not think my sleeping habits would allow me to hold a real job for any length of time. Even with the flexibility most programmers have, I don't think the hours I keep now would be tolerated by many employers.

I left Caltech when my illness got really bad at the age of 20. I eventually transferred to U.C. Santa Cruz and finally managed to get my physics degree, but it took a long time and a great deal of difficulty to graduate. I had done well in my two years at Caltech, but to complete the last two years of classes at UCSC took me eight years. I had very mixed results, with my grades depending on my mood each quarter. While I did well in some classes (I successfully petitioned for credit in Optics) I received many poor grades and even failed a few classes.

next: Schizoaffective Disorder is a Poorly Understood Condition

Here's what to do if you think you are mentally ill plus help with choosing a psychotherapist.

If you feel you may be suffering from a mental illness, I urge you in the strongest terms to seek the advice of an experienced mental health professional - a psychologist or psychiatrist.

(Psychiatrists are medical doctors who specialize in mental illness. They have M.D. degrees and are licensed to prescribe medicine. Psychologists hold graduate degrees and practice "talk therapy".)

This is important for more reasons than to simply relieve your suffering.

As I said before if left untreated mental illness can cause permanent damage. Besides the kindling that occurs with untreated manic depression, there is the damage that bad decisions or the inability to maintain relationships can do to your life. If you get severely depressed, there is the danger of suicide. It is much easier to deal with a mental illness before you become desperately ill. Look at it this way: an office visit is much cheaper than a hospital stay.

Accurate diagnosis is important. It is difficult to diagnose many mental disorders, and if you're misdiagnosed you may not receive the treatment you need. It is common to mistake manic depression for schizophrenia and vice versa. Other illnesses that can be confused with manic depression include Attention Deficit Disorder and Borderline Personality Disorder.

There is the danger that antidepressants may cause one to become manic. An occurrence of even one manic episode in your lifetime is enough for a diagnosis of manic depression. I feel the history of every patient who receives antidepressants for the first time should be investigated to determine the danger that their medicine may cause mania. Although general practitioners - regular medical doctors - may legally prescribe antidepressants, I am strongly of the opinion that it is unethical for them to do so except in emergencies, as they do not have the training or experience to determine whether one might be manic-depressive.

Fooling Yourself With Self-Diagnosis

Do not engage in the self-deception of self-diagnosis. It is common for people to hear about illnesses of all sorts on Oprah or Donahue (or the Internet!) and to then fool themselves into thinking they share the diagnosis with the talk show guest. If you research an illness carefully enough before you consult a doctor, you can even fool him into agreeing with your diagnosis.

Failure to diagnose correctly can be life-threatening. A number of serious medical conditions cause disturbances in thought and affect, for example, stroke, brain injury as well as cancer of the brain, thyroid or adrenal gland. When the grandmother of Mindfulness author Ellen J. Langer complained to her doctor that a snake living in her head was giving her headaches, he diagnosed her as senile and refused to investigate further. It was only after her death that an autopsy found the brain tumor that killed her.

A mental disturbance can be caused by heavy metal poisoning - the Mad Hatter in Alice in Wonderland was inspired by real hat makers who were sickened by the mercury used in the manufacture of felt hats.

Drugs of abuse can cause mental disturbances that last long after the drug itself has worn off. Besides the damage that addiction can do to your life and that of your loved ones, drugs, including alcohol, can cause such things as paranoia, anxiety and depression.

It is common for people with psychiatric illnesses to "self-medicate", but this ultimately causes more problems than it solves. Besides the alcoholic drowning their sorrows with drink, I have heard that alcohol suppresses hallucinations for the schizophrenic. Many times I have been warned by my doctors of the tempting danger that drugs hold especially for the manic-depressive.

Neuroses can be caused by unresolved traumas early in life. For example childhood sexual abuse and violence, or living through times of famine and war. Having an addicted family member usually causes the entire family to behave in dysfunctional ways that leave lasting scars on everyone.

Perhaps you carry a terrible secret, a secret that you've never told anyone. Carrying the memory of childhood trauma continues to cause damage in adulthood far out of proportion to the original injury. Perhaps it is time to find someone you can trust to share your secret with. The injury you suffered can never be undone, but it is within your power to change how you live with it today.

Diagnosing Mental Illness

Mental illnesses can be mistaken as physiological ones: I have heard of a woman who was diagnosed and treated as epileptic when she was a young girl, then suffered for years because the medicine did not relieve her symptoms. It was only when she turned 16 and wanted to get a driver's license that further investigation found she really suffered from anxiety.

My diagnosis at Alhambra CPC included CAT scans of my head, blood and urine tests, an electroencephalogram and neurological tests to rule out such things as tumours and poisoning. A psychiatrist will usually do a thyroid panel before treating someone for manic depression. (There was another patient at Alhambra who arrived in a catatonic stupour and slowly awakened during our time there. It turned out that he had a physiological condition that caused the buildup of ammonia in his blood.)

However, there is no blood test for psychiatric illness; at best blood tests can rule out other physiological conditions. Tests such as Positron Emission Tomography can detect such things as the excessive metabolization of sugar in the right brain hemispheres of manic people, but PET scans are very expensive and so only commonly performed for research purposes.

Diagnosis of a mental disorder is made from the patient's history, observation of the patient's current behaviour, talking with the patient, and psychological diagnostic tests.

I had the Rorschach Inkblot Test, the Thematic Apperception Test, in which I explained what I thought to be happening in some pictures, and the Minnesota Multiphasic Personality Inventory in which I answered a lengthy questionnaire about my thoughts and feelings.

I also took an IQ test. Being manic I was feeling quite intelligent, so I was appalled to find that my score was off about 20 points from the two IQ tests that school psychologists had given me as a child. The psychologist who tested me in the hospital reassured me that my brain was not degenerating, but that psychosis caused a temporary decrease in intelligence. She said my intelligence would recover when the episode passed. However, she warned me that my intelligence would fail to recover fully if I had repeated manic episodes.

Need Help Paying for Mental Health Treatment?

If you don't have the money to pay for treatment you may still have options depending on where you live. Even in the United States, which does not have publicly funded health care for most illnesses, there are government-supported mental health clinics in many communities, as well as private non-profit clinics that charge their patients based on their ability to pay.

Many psychologists and psychiatrists offer sliding scales, where they charge lower-income patients less money. Not everyone offers this, so you have to call around.

Some psychiatric medications are expensive; treatment with clozapine for schizophrenia, for instance, costs thousands of dollars a year. The government might assist in the cost of your medicine and some drug companies offer "compassionate drug plans" in which qualifying patients receive their medicine free of charge directly from the drug company. In addition, the drug companies often give psychiatrists free advertising sample packs of drugs, which the psychiatrists then give to their patients who cannot afford to buy them.

next: Therapy for Treatment of Schizoaffective Disorder

Auditory hallucinations are a key sign of schizophrenia. Find out what it's like hearing voices and having a visual hallucination.

Yet it is in place to appeal to the fact that madness was accounted no shame nor disgrace by men of old who gave things their names; otherwise they would not have connected that greatest of arts, whereby the future is discerned, with this very word 'madness', and named it accordingly.
-- Plato Phaedrus

Auditory hallucinations are the key sign of schizophrenia. After the summer I was diagnosed, when I related my experience to a fellow UCSC student who studied psychology, he said that the fact that I heard voices by itself made some psychologists consider me schizophrenic.

Everyone has an inner voice that they talk to themselves with in their thoughts. Hearing voices is not like that. You can tell that your inner voice is your own thinking, that it's not something you're actually hearing someone saying. Auditory hallucinations sound like they're coming from "outside your head". Until you come to understand what they are, you cannot distinguish them from someone actually talking to you.

I haven't heard voices very much, but the few times I have is quite enough for me. While I was in the Intensive Care Unit at the Alhambra Community Psychiatric Center that summer of '85, I heard a woman shout my name - simply "Mike!" It was distant and echoey, so I thought she was shouting my name from down the hall, and I would go look for her and find no one.

Other people hear voices whose words express much more disturbing things. It is common for hallucinations to be harshly critical, to say that one is worthless or deserves to die. Sometimes their voices keep up a running commentary about what's going on. Sometimes the voices discuss the inner thoughts of the person who hears them, so they think everyone around can hear their private thoughts discussed aloud.

(One might or might not have a visual hallucination of someone actually doing the speaking - the voices are often disembodied, but for some reason that doesn't make them any less real to those who hear them. Usually, those who hear voices find some way to rationalize why the speech does not have a speaker, for example by believing that the sound is being projected to them over a distance via some kind of radio.)

The words I heard weren't disturbing in themselves. For the most part, all my voice ever said was "Mike!" But that was enough - it wasn't what the voice said, it was the intention that I knew to be behind it. I knew that the woman shouting my name was coming to kill me and I feared her like nothing I've ever feared.

When I was brought to Alhambra CPC, I was on a "72-hour hold". Basically, I was in for three days of observation, to allow myself to be studied by the staff to determine whether lengthier treatment was warranted. I had the understanding that if I just stayed cool for three days I would be out with no questions asked and so although I was profoundly manic, I stayed calm and behaved myself. Mostly I either watched TV with the other patients or tried to soothe myself by pacing up and down the hall.

But when my hold was up and I asked to leave, my psychiatrist came to tell me he wanted me to stay longer. When I protested that I'd met my obligation, he replied that if I didn't stay voluntarily he would commit me involuntarily. He said something was seriously wrong with me and we needed to deal with it.

He told me I'd been hallucinating. When I denied it, his response was to ask "Do you ever hear someone call your name, and you turn, and no one is there?" And yes, I realized he was right, and I didn't want that happening, so I agreed to stay voluntarily.

Hallucinations aren't always menacing. I understand some people find what they have to say familiar and comforting, even sweet. And, in fact, another voice I think I heard (I can't be sure) came when I was hanging out by the nurse's station in the ICU. I heard one of the nurses ask me an inconsequential question and I answered her only to be surprised to find her looking down at her desk, ignoring me. I think now she hadn't addressed me at all, that the question I heard was one of my voices speaking to me.

I became very determined that the voices were going to stop. They really bothered me. I worked hard to determine the difference between real people talking and my voices. After a while, I was able to find a difference, although a disturbing one - the voices were more convincing to me than what real people actually said. The concreteness of my hallucinations' apparent reality always struck me immediately, before I ever heard what they said.

Some of my other experiences are this way too: the conviction of their reality always strikes me before the actual experiences do. People have often told me I should just ignore them, but I haven't had that choice, by the time I can make the decision to ignore something I have already been frightened by it.

After a while, I decided I just wouldn't listen anymore. And after a short time, the voices stopped. It only took a few days. When I reported this to the hospital staff, they seemed quite surprised. They didn't seem to think I should be able to do that, to just make my hallucinations go away.

Still, the voices bothered me enough that for years afterwards, it startled me to hear anyone call my name when I didn't expect it, especially if someone I didn't know was calling someone else who happened to be named "Mike". For example, there was someone named Mike who worked on the night shift at the Safeway grocery store in Santa Cruz when I lived there, and it would frighten me when they would call his name on the public address system, asking him to come help at the cash register.

next: Schizoaffective Disorder and Dissociation

One out of three people is mentally ill. Ask two friends how they're doing. If they say they're OK, then you're it.

Mental illness is common in the entire world's population. However many people are unaware of the mentally ill who live among them because the stigma against mental illness forces those who suffer to keep it hidden. Many people who ought to be aware of it prefer to pretend it doesn't exist.

The most common mental illness is depression. It is so common that many are surprised to find out that it is considered a mental illness at all. About 25% of women and 12% of men experience depression at some time in their lives, and at any given moment about 5% are experiencing major depression. (The statistics I find vary depending on the source.)

Roughly 1.2% of the population is manic-depressive. You probably know more than a hundred people - the chances are great that you know someone who is manic-depressive. Or to look at it another way, according to K5's advertising demographics, our community has 27,000 registered users and is visited by 200,000 unique visitors each month. Thus we can expect that K5 has roughly 270 manic-depressive members and the site is viewed by about 2,000 manic-depressive readers each month.

A slightly smaller number of people have schizophrenia.

About one in two hundred people get schizoaffective disorder during their lives.

While homelessness is a significant problem for the mentally ill, most of us are not out sleeping on the streets or locked up in hospitals. Instead, we live and work in society just as you do. You will find the mentally ill among your friends, neighbors, coworkers, classmates, even your family. At a company where I was once employed, when I confided that I was manic-depressive to a coworker in our small workgroup, she replied that she was manic-depressive too.

next: Schizoaffective Disorder and Life on a Roller Coaster

Depression can often be treated quite effectively by drugs called antidepressants. Read about the effectiveness of antidepressants.

The Strange Pill

This leads me to another odd experience I have had a number of times. Depression can often be treated quite effectively by drugs called antidepressants. What these do is increase the concentration of neurotransmitters in one's nerve synapses, so signals flow more easily in one's brain. There are many different antidepressants that do this via several different mechanisms, but they all have the effect of boosting one of the neurotransmitters, either norepinephrine or serotonin. (Imbalances in the neurotransmitter dopamine cause the schizophrenic symptoms.)

The problem with antidepressants is that they take a long time to take effect, sometimes as long as a couple of months. It can be hard to keep up hope while waiting for the antidepressant to start working. At first, all one feels is the side effects - dry mouth ("cottonmouth"), sedation, difficulty in urinating. If you're well enough to be interested in sex, some antidepressants have such side effects as making it impossible to have orgasms.

My Strange Antidepressant Experience

But after a while, the desired effect begins to happen. And here is where I have the odd experiences: I don't feel anything at first, the antidepressants don't change my feelings or perceptions. Instead, when I take antidepressants, other people act differently towards me.

I find that people stop avoiding me, and eventually start to look directly at me and talk to me and want to be around me. After months with little or no human contact, complete strangers spontaneously start conversations with me. Women start to flirt with me where before they would have feared me.

This, of course, is a wonderful thing and my experience has often been that it is the behavior of others rather than the medicine that lifts my mood. But it is really strange to have others change their behavior because I'm taking a pill.

Of course, what really must be happening is that they are reacting to changes in my behavior, but these changes must be subtle indeed. If this is the case the behavioral changes must happen before there is any change in my own conscious thoughts and feelings, and when it starts to happen I cannot say that I've noticed anything different about my own behavior.

While the clinical effect of antidepressants is to stimulate the transmission of nerve impulses, the first outward sign of their effectiveness is that one's behavior changes without one having any conscious knowledge of it.

One friend who is also a consultant who suffers from depression had the following to say about my experiences with antidepressants:

I've had the almost identical experience--not just in how PEOPLE treat me, but how the entire WORLD works. For instance, when I'm not depressed, I start getting more work, good things come to me, events turn out more positively. These things COULDN'T be reacting to my improved mood because my clients, for example, may not have talked to me for months prior to calling and offering me work! And yet, it truly does seem that when my mood looks up, EVERYthing looks up. Very mysterious, but I do believe there's some kind of connection. I just don't understand what it is or how it works.

Some people object to taking psychiatric medications - I did until it became clear I would not survive without them, and even for some years afterwards, I wouldn't take them when I was feeling well. One reason people resist taking antidepressants is that they feel they would rather be depressed than to experience artificial happiness from a drug. But that's really not what's happening when you take antidepressants. Being depressed is as much a delusional state as believing oneself to be the Emperor of France. You may be quite surprised to hear that and I was too the first time I read a psychologist's statement that his patient suffered from the delusion that life was not worth living. But depressive thought really is delusional.

It's not clear what the ultimate cause of depression is, but its physiological effect is a shortage of neurotransmitters in the nerve synapses. This makes it difficult for nerve signals to be transmitted and has a dampening effect on much of your brain activity. Antidepressants increase the concentration of neurotransmitters back up to their normal levels so that nerve impulses can propagate successfully. What you experience when taking antidepressants is much closer to reality than what you experience while depressed.

next: A Risky Treatment

Achieving real change is a lengthy process. Find out how therapy helps and how to find the right therapist.

Q: How many psychologists does it take to change a light bulb?
A: Just one, but the light bulb has to want to change.

Early on, in the year before my diagnosis and for awhile afterwards, I saw a number of psychologists. (I had also seen one for awhile when I got really depressed in eighth grade, and had also seen a couple of school psychologists in elementary and junior high school, but didn't feel any of them helped much because I was such an unwilling patient.) I would typically seek a therapist out because I felt really bad, but after a few months I would feel better and stop going. Early on, I really disliked having anything to do with psychologists and wouldn't see one any more than I absolutely had to.

That's a pretty common phenomenon for therapy patients. It seems that many of the people who seek out therapists are not in a position to get better in any substantial way because they have no commitment to making any real change in their lives.

Achieving real change is a lengthy process and it is often painful. Seeing a therapist just until you feel better for awhile is not likely to effect meaningful change. And, in fact, for a bipolar person it's not likely that the therapist will have made any difference in such a short time - you could consult a brick wall for your depression for a few months and after awhile the inevitable bipolar cycle while make you feel better.

Time for Meaningful Change

There came a point, I think it was around the Spring of 1987, that I noticed that I always kept falling into the same hole and that I was not having any success in making my situation any better. I was on medication for much of the time since I was diagnosed and although it provided some relief, I did not feel that it did much to make my life substantially better either. The symptoms weren't so bad with the medication but I still experienced them and life just plain sucked in general.

I made a really important decision then. It's the sort of decision everyone needs to make if they're going to get anything out of therapy and is one of the more significant turning points in my life. I decided I was going to see a psychotherapist and stick with it and no matter what happened that I was going to keep going even if I felt better. I was going to keep going until I was able to effect meaningful, positive, lasting change in my life.

(Simply deciding to see a therapist for a long time is not enough. You have to decide that you're really going to change and face up to the work it will require and face the fear that it will arouse. Lots of people see therapists for years, even decades, and never get anything out of it beside a little temporary comfort. I know some people like this and I find them incredibly vexing. These people don't want to change and quite possibly will never change. They may even feel that they're good little therapy patients because they attend regular therapy for so long. However, they must be very frustrating to their therapists who spend years trying to get their patients to face themselves only to have every effort deftly deflected.)

Finding a Good Therapist

It's important to pick out a good therapist that you can work with effectively. I don't think nearly all therapists are all that enlightened - I'm sure almost all learn a lot of important theory in graduate school, but I don't think any amount of theory is going to make anyone an insightful human being.

Even if you find a therapist that's good in general, you may not personally be able to work with them. For that reason, it's best to shop around. And that's why it's best not to wait until you really need help to find a therapist - if you feel, as I did at first, that psychologists are only for crazy people, then likely you're not going to see one until you are crazy. When that happens it's hard to take the time to shop around and it's also much harder to pick up the pieces. If you think you're ever going to need to see a therapist, it's best to start when you're in a strong enough position emotionally to see one on your own terms.

At the time I made my fateful decision, I was getting by OK. I was desperately unhappy, but life was manageable. It was not like when I first saw a psychiatrist at Caltech, when I was ready to climb out of my own skin.

I got a very poor impression of the first therapist I saw. Her primary concern was whether I had the financial means to pay for her sessions. She was really quite shrill about the money and kept emphasizing that she did not offer a sliding scale. I had a good job at the time and would have had no problem paying her fee, but in the end decided she was just not someone I cared to be around.

The second therapist I saw was someone I rather liked. I'd responded to her ad in The Good Times offering New Age therapy. (Santa Cruz is a pretty New Age kind of place, one reason I decided to stay there after living in the urban Hell of Southern California.) She seemed like a pretty happy and enlightened woman and was quite pleasant to talk to. She seemed to like me at first too.

But when I explained my history to her - mania, depression, hallucinations, hospitalization and finally my diagnosis, she said she wasn't competent to deal with someone as troubled as I. She said I should consult with someone who specialized in challenging cases. I was really disappointed.

She gave me the names of several other psychologists. One of them was someone I'd seen at the County Mental Health department who I thought was competent enough but I didn't want to see anymore because I did not feel that she cared for me as a person. The next one on the list was the therapist I ended up sticking with.

All told, I saw my new therapist for thirteen years.

That's a lot of head-shrinking. I made a lot of changes during that time. Aside from my emotional growth, I got my career as a programmer started and built it up to eventually become a consultant, dated several women and eventually met and got engaged to the woman I am now married to. I also got my B.A. in Physics from UCSC and started (but unfortunately did not complete) graduate school.

Life certainly hasn't been easy for me as a consultant, especially since the economic downturn, but despite that, I've been doing well mentally and emotionally for quite some time and I credit that to my work with my therapist, not to any medicine I might take. The only professional help I require is a brief appointment with a doctor at the local mental health clinic every month or two to check my symptoms and adjust my medication.

Life's been pretty damn hard but I'm able to deal with it and despite the obstacles I face I am able to maintain my optimism most of the time. That's a far cry from my experience of 1987 when I had few external difficulties but could barely tolerate living through the day - despite medication.

Who is this miracle worker you ask? I'm sorry, I can't tell you, much as I'd like to. When I wrote my first web page about my illness, I had her read it and then asked her if she'd like me to give her name. She said she would rather her name be kept private. I would rather give her the credit she deserves, but I respect her feelings so I won't give her name.

Insights From Therapy

One of the main objectives of therapy is for one to develop insight into one's condition. I would like to discuss the many insights I found but I feel I could not discuss them adequately in the space I have here. I would like to discuss just one of them, as the key point I learned also applies to many other engineers and scientists. If you feel that you would like to know more than I can say in what follows, then I encourage you to read David Shapiro's book Neurotic Styles, especially the chapter on Obsessive Compulsive Style.

One day, after I had been seeing my therapist for about seven years, she said to me: "I think it's time" and handed me a photocopy of the Obsessive-Compulsive Style chapter of Shapiro's book. I took it home to read and found it nothing short of astounding. As I read it, I often burst out in hysterical laughter as I came across something that seemed deeply familiar from my own experience. I still find it very embarrassing to find a lifetime of experience so neatly summarized in a single chapter of a book that was published when I was one year old. I just had to read the whole book so I bought my own copy and have since read it several times.

Obsessive-compulsive style is distinguished from obsessive-compulsive disorder by being a personality trait rather than a psychiatric condition that can be treated with medication. It is characterized by, among other things, rigid thinking and distortion of the experience of autonomy.

Shapiro says:

The most conspicuous characteristic of the obsessive-compulsive's attention is its intense, sharp focus. These people are not vague in their attention. They concentrate, and particularly do they concentrate on detail. This is evident, for example, in the Rorschach test in their accumulation, frequently, of large numbers of small "detail-responses" and their precise delineation of them (small profiles of faces all along the edges of the inkblots, and the like), and the same affinity is easily observed in everyday life. Thus, these people are very often to be found among technicians; they are interested in, and at home with, technical details... But the obsessive-compulsive's attention, although sharp, is in certain respects markedly limited in both mobility and range. These people not only concentrate; they seem always to be concentrating. And some aspects of the world are simply not to be apprehended by a sharply focused and concentrated attention... These people seem unable to allow their attention simply to wander or passively permit it to be captured... It is not that they do not look or listen, but that they are looking or listening too hard for something else.

Shapiro goes on to describe the obsessive-compulsive's mode of activity:

The activity - one could just as well say the life - of these people is characterized by a more or less continuous experience of tense deliberateness, a sense of effort, and of trying.

Everything seems deliberate for them. Nothing is effortless... For the compulsive person, the quality of effort is present in every activity, whether it taxes his capacities or not.

The obsessive-compulsive lives out their lives according to a set of rules, regulations and expectations which he feels are externally imposed but in reality are of his own making. Shapiro says:

These people feel and function like driven, hardworking, automatons pressing themselves to fulfill unending duties, "responsibilities", and tasks that are, in their view, not chosen, but simply there.

One compulsive patient likened his whole life to a train that was running efficiently, fast, pulling a substantial load, but on a track laid out for it.

My therapist focused on my own rigid thinking starting very early in our work together. My experience now is that I have a sense of free will that I did not possess before I began seeing her. However obsessive-compulsive style is a trait that is so deeply ingrained in me that I don't think I can ever be completely free of it. However I find that being able to focus my attention so intensively is an advantage to my computer programming. I find that programming allows me to experience being obsessive-compulsive in a way that I find enjoyable, like taking a holiday to go back to a familiar place from my past.

next: The Reality Construction Kit