Coping With Psychosis: Some Thoughts From a Psychologist With Paranoid Schizophrenia

In the early spring of 1966, I was hospitalized and diagnosed with paranoid schizophrenia. Over the course of the following decades, I recovered sufficiently to become a psychologist and devote virtually all of my professional life to caring and advocating for others whose disabilities are similar to my own. Although accounts of my adventures with relapse and recommended coping strategies have been published elsewhere (Frese, in press; Frese, 1997; Frese, 1994; Schwartz et al., 1997), this article focuses specifically on the mental process accompanying schizophrenia, which is traditionally termed disorganized thinking or formal thought disorder.

Due to the cognitive processes that are involved in disorganized thinking, those of us with schizophrenia may exhibit a tendency toward circumstantiality, meaning that in conversations we wander from the topic at hand, but we are generally able to return to the topic after our diversionary side-trips. As this mechanism progresses, however, we increasingly become unable to return to the topic, slipping off the track, exhibiting derailment, loose associations and tangentiality. If this phenomenon further exacerbates, we may find ourselves in states of linguistic disorganization, incoherence, or in the production of "word salad." This disorganized thinking has been argued by some to be "the single most important feature of schizophrenia" (American Psychiatric Association, 2000).

My experience suggests that a model based on the thinking of the philosopher Edmund Husserl, as described by Schwartz et al. (1997) and Spitzer (1997), can be particularly helpful in rendering an increased understanding and appreciation of this process. According to these authors, the disorganized thinking of schizophrenia can be conceptualized as a cognitive process of over-inclusion, or "an expansion of the horizon of meaning" (Schwartz et al., 1997). From time to time, often as a function of stress or excitement, our neurotransmitting mechanisms become increasingly active.

During these times, we begin to conceptually broaden, or overemphasize, the connectedness of words, as well as of other sounds and sights, in a non-linear, quasi-poetic, manner. Our thinking becomes dominated by metaphors. We have a heightened awareness of similarities in the sounds of words. We become particularly aware of rhyming, alliterations and other phonological relationships among words. Words and phrases are likely to engender thoughts of music and lines from songs. We are more likely to perceive amusing relationships among words, and between words and other stimuli. In more poetic terms, our mental processes become increasingly influenced by the muses. As a part of this phenomenon, we may also begin to perceive certain mystical or spiritual aspects of everyday situations. Sometimes these experiences can be quite moving, frightening and even life-altering.

If one's mental horizons are allowed to expand too far, there will be serious consequences. If not contained, this cognitive process can become quite disabling. Fortunately, modern medicines and other forms of treatment enable increasing numbers of us to avoid the worst of these consequences. The mind's tendency to expand its horizon of meaning can be kept in check. Our sensitivity to semantic and phonological relationships does not have to become so acute that we can no longer focus on the problems of everyday life.

The DSM-IV-TR states that "less severe disorganized thinking or speech may occur during the prodromal or residual periods of schizophrenia" (American Psychiatric Association, 2000). However the DSM-IV-TR does not make it clear that, even in recovery, our thought processes tend to be colored by the same mechanisms which, when intensified, can become disabling. Even with treatment, the cognitive processes of those of us with schizophrenia continue to be affected to some degree. Even when we are in a relatively normal state, our minds often continue to be subject to perceiving relationships of which others are unaware, relationships that affect our sense of reality and truth. Because we have this tendency to "listen to a different drummer," we often experience difficulties in communicating with our more "normal" friends. Sometimes others perceive what we say and do as strange or bizarre. Even while in recovery, we may still meet one or more of the DSM-IV-TR criteria for the three schizophrenia-spectrum personality disorders-paranoid, schizoid or schizotypal.

In conclusion, there has recently begun to appear in the literature a call for reconsideration concerning the disorganized thinking aspect of schizophrenia. Recognizing this process as a function of an expanded horizon of meaning may provide an improved vehicle for a better appreciation of the phenomenological world of people with schizophrenia. Such improved understanding could be valuable in assisting those of us with this condition to more easily integrate our social and vocational efforts into the activities of the everyday world.

Dr. Frese served as director of psychology at Western Reserve Psychiatric Hospital from 1980 to 1995. He is currently coordinator of the Summit County, Ohio, Recovery Project, and is First Vice President of the National Alliance for the Mentally Ill.