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A student emailed me asking for some help on a school project he was undertaking about catatonic schizophrenia. Here's my reply:

Okay first off could you explain exactly what you do ... where you do it from and possibly your history in the business...

I initially trained as a registered general nurse and worked primarily in Accident and Emergency and then Neurology/Neurosurgery. I also work independently as a therapist. For this I trained as a hypnotherapist and then trained in neurolinguistic programming. I am not registered nor certified as a therapist, nor belong to any professional organisations. I work from an office at home, mostly on a one to one basis with clients with a variety of problems and difficulties. These range from depression, anxiety through to complex psychiatric problems. I also do a lot of consultancy and advisory work for people who are trapped within the psychiatric system, or undergoing tribunal or professional problems for speaking out about psychiatric practices. My therapeutic work began as I grew increasingly despondent about the quality of practice in psychiatry - I was appalled at how unskilled most of the staff were, who appeared to be more interested in "pet theories" than actually being able to make people better. As I became more outspoken and increasingly alienated from the establishment, more and more people began to approach me for help. I found that despite the trouble I was regularly in for my views and the negative image that was portrayed about me, there was a large number of people who felt the same way that I did and wanted help. This was how my private practice began.

Have you dealt with any catatonic schizophrenics? If yes, what have you observed?

One of the most interesting experiences about working with people in a state of schizophrenic catatonia is how "normal" people behave around them. NLP innovator Dr Richard Bandler comments that it is strange how everyone whispers when there is a catatonic in the room. I have certainly found this to be true. In one instance, with a young man who not infrequently slipped into catatonia, it was his mother's behaviour that interested me the most. When he was relatively "normal", his mother would fuss around him, constantly checking if he was ok, asking how he was feeling mentally etc etc. However, when he slipped into a catatonic state, she would behave and talk to him as though he were perfectly normal. Whilst this might seem strange it is in fact remarkably common. It's as if the mother (or whoever is dealing with the patient - I see staff behaving this way too) can only relate to the patient when he is ill. When he is well, they do not know how to relate to him. The nearest analogy I can think of is that of a teacher and student. In class, they both understand their relationship to each other. One is in charge, the other isn't. It's a complementary role that they both have equal contribution too. But what if that teacher comes to the students house, casually dressed, for dinner? It can be very confusing for the student because the dynamics of their relationship is altered by the change in context and his role has changed. It would be easy if the teacher maintains his role as "teacher", but what if he behaves just as he would when he isn't in his teaching role?

Also strange is that with catatonic schizophrenia, people tend to behave as though the catatonic shouldn't be disturbed. People whisper around them and speak in soft tones. Strangely, catatonic schizophrenics often get positioned in a wheelchair in front of the window. Maybe the staff think that they'll enjoy the view or something.

 

What's the craziest thing you have seen or witnessed in a mental institution?

Well, the staff seem to have the monopoly on all the crazy stuff. For example, who on earth thinks that plugging someone's brain into the electricity mains and giving them electroshock is a good thing? They used to think drilling holes in people's heads and scooping out parts of their brain was a good thing too, but now they just drug everybody. The dynamics within any psychiatric institution are pretty crazy. You'd have to be crazy to be there in the first place. If you weren't, I'm sure you'd soon become a little unhinged just to survive. "Fitting in", in any environment is important part of human survival. Strangely, most of the behaviours from patients that seem crazy are pretty intelligible when seen through the right filters. For example, I treated a lady who believed that she didn't have a head. Everyone else thought that she meant this literally. Well, I got to thinking that maybe she didn't mean it in the way that everyone thought she did. For example, we use metaphorical language every day. Some people are a pain in the neck and some will lose their mind. Others report experiencing "heartburn" for which they need to take a medicine. Of course, we all know that they don't really think that their hearts are on fire; we accept their words as a simple metaphor.

I think it was R.D. Laing that used the example of the patient who said he was "made of glass." Of course, a particular problem about being detained in a psychiatric institution where everyone thinks they can see straight through you is that nothing is ever private. People see everything you do and if you feel fragile enough, you might just shatter.

What's a daily routine for someone who has Catatonic schizophrenia or any type of schizophrenia?

Generally, they are given a bed bath, drugged, dumped in front of the window in their wheel chair. Every once in a while someone will empty the catheter bag, and if they remember, they'll adjust the position of the patient to prevent pressure sores. Maybe on the odd occasion, someone might try to coax the patient to talk or respond. Sometimes they'll cart him off and plug his brains into the electric socket to see if that will wake him up (electroshock). As far as I can tell, very little of what goes on inside mental institutions has any point. Much of it is just drudgery and routine, certainly nothing that might stimulate people to get well. If the catatonic remains in his stupor long enough, his stupor is regarded as normal, and people no longer notice the catatonia as an aberration.

Is there any such treatment for the disease?

I think it's a mistake to think of catatonia as a "disease" - catatonia refers to a behaviour, which can have many causes. It can be caused organically (such as *encephalitis), or psychiatrically. It is less fashionable these days; there are fewer catatonics than there was, say, 50 years ago. Primarily this is because of improvement in neurological diagnosis and treatment of neurological disease but also because the manifestation of psychiatric behaviours does follow a fashion. Post-traumatic stress is very fashionable today, so is teenage depression. Co-dependency isn't as popular now as it was in the 1980's and multiple personality disorder is seeing a revival since they renamed it to "dissociative identity disorder" and a few movies were made about it Catatonia doesn't receive much publicity these days, so it isn't within the popular psyche as much as other disorders.

Meanwhile, some things used to be treated as "psychiatric", but we now know we were wrong about them. For example the chronic neurological disease, multiple sclerosis, was dismissed as psychiatric for years until the plaques that occur in the brain were seen with the advent of improved brain scanning technology. We now know that multiple sclerosis is a serious medical disorder that behaves very much like a psychiatric disorder in many ways.

In order to wake up a genuine schizophrenic catatonic, the trick is to break through the schizophrenia to reach the person behind it. You'll need to raise their motivation level to break through and break out. Whispering, talking in softly, softly tones just won't cut it. Think metaphorically in terms of strapping them into the front of the biggest roller coaster you can think of. That might go someway to effecting a change.

And in your own words/observation - what do you think causes such a condition? (note I have changed the question from "disease" to "condition")

This is difficult to answer, because I think it erroneous to think of any human behaviour in terms of cause and effect relationships. I've always liked Gregory Bateson's reasoning when he suggested that if you kick a ball, you know where it's going to go, but if you kick a dog the results will not necessarily be predictable (paraphrased). I think a better reasoning might be to start with the question, what incentive, if any, does the catatonic have to wake up and come out of his stupor? As far as I can tell, in most psychiatric units I have been in, there is no incentive or motive whatsoever. Most have plenty of reasons to go catatonic, but knowing what these are isn't going to help anyone - they just allow us to build a protection of reasoning around the catatonic behaviour.

Having said all that, you might like to check out the Alan Parker movie, "Birdy" - great film about a Vietnam veteran who is in a catatonic stupor, starring Nicholas Cage and a great soundtrack by Peter Gabriel. The film explores the themes and background to catatonic schizophrenia and is still one of my most favourite movies.

Where would someone like my self go to, in case I had the disease?

Basically, you'd end up in a psychiatric facility somewhere with people whispering to you. I guess it might depend on which culture/society you lived in. Some might put you in a monastery and support you in your inner contemplation; others might start offering prayers to you. Others will lock you up and give you drugs and electric shocks. They might offer you "therapy" and get you to study in detail all the painful things that ever happened to you, in order to make you feel better about yourself - which if you think about it, focussing continuously on the bad isn't likely to lift one's spirits.

 

*You might like to look at Oliver Sacks work with the post-encephalic patients from the great epidemic in the 1920`s (??) that left a large number of people "frozen in time" - catatonic. He woke them up with a drug used in the treatment of Parkinson's disease called, levo-DOPA. This was recorded in Sacks' superb book, "Awakenings" and made into a mediocre film of the same name with Robert DeNiro. Another area that might be of interest to you was the epidemic of catatonia amongst heroin addicts, two of which have occurred in the last 10 years. Basically, a contaminant in the heroin left a large number of addicts neurologically affected and rendered into catatonia. Mostly the affected were in Scotland, UK and I believe New York, USA. I never followed up the story so am not aware if these victims went on to recover, die or stay the same.

I don't know if levo-DOPA (sometimes just called l-dopa) has ever been used in the "treatment" of "catatonic schizophrenia, but I wouldn't be surprised if it had. I am not aware of it being in current use. Conventional wisdom has it that schizophrenia arises as the result of a over sensitivity or excess in the neurotransmitter called "dopamine" - levo-dopa is the precursor to dopamine - so medical wisdom has it that the way to treat a schizophrenic is to give him drugs that lower dopamine levels in the brain, not raise them, which levo-DOPA will do.

On this point, it's worth noting that because they lower dopamine levels, the anti-psychotic drugs used to treat schizophrenia tend to cause symptoms of Parkinson's disease, a disease resulting in a deficiency of dopamine in the brain. Counter to this, some Parkinson's disease patients who are given levo-DOPA to raise their dopamine levels quickly develop hallucinations and sometimes other symptoms of schizophrenia. Parkinson's disease is a nasty condition and often has very strange manifestations, often with an alternating pattern of catatonia-agitation, with periods of relative normality in between. It is a physical condition of the brain, and demonstrates a marked interaction with the environment and thought processes. Sadly, owing to adaptation responses within the brain, levo-DOPA only has an effect for a limited period of time, and isn't a cure.

For trivia purposes: there was an X-Files episode based in a sanatorium for old people with dementia etc, many of whom were catatonic. Mulder and Sculley were called in when strange phenomena started to occur and previously catatonic patients started not only waking up and becoming mentally active, but started seeing dead people and long lost friends and relatives. Turns out, the janitor, an old mystical Indian type, was giving the patients an ancient recipe made out of the amanita mushrooms. What wasn't mentioned in the episode was that some of the amanita mushrooms contain chemicals that are directly related to drugs used in the treatment of Parkinson's disease, Amantidine and Muscarine - both have a tendency to cause hallucinations of long lost friends and relatives as a side effect. In folk medicine, small doses of some amanita mushrooms have been recommended daily as a brain tonic. It's a very risky business though, because some amanita mushrooms have a 100% fatality rate when ingested in even the smallest doses.