7 (and more) facts about Schizophrenia

Many books, articles and blogs have discussed schizophrenia and often there are differences in terminology. As an ex-mental health nurse/ward manager and someone who has experienced a lengthy psychotic episode, this is my take on schizophrenia.

Schizophrenia can be separated into positive and negative symptoms. These are not positive and negative in the way you might think. A positive symptom is one that adds a behaviour, thought or feeling, whereas a negative symptom takes away a behaviour, thought or feeling.

Schizophrenia has five types of symptoms: hallucinations, delusions, disorganized speech, disorganized behaviour (the positive symptoms), and negative symptoms. However, the symptoms of schizophrenia vary dramatically from person to person, both in pattern and severity. Not every person with schizophrenia will have all the symptoms, and the symptoms of schizophrenia may also change over time.

Most people with schizophrenia are not violent. More typically, they prefer to withdraw and be left alone. In some cases, however, people with mental illness may engage in dangerous or violent behaviours that are generally a result of their psychosis and the resulting fear from feelings of being threatened in some way by their surroundings.

  1. Hallucinations

People with schizophrenia might hear (the most common hallucination), see, smell, taste or feel (the five senses) things no one else does i.e. hearing voices talking in the first person, to them or about them, they might see other people, animals, faces, things that we can’t see. One patient could smell sh*t everywhere he went, causing him to retch and another said he could taste tin or metal so someone was trying to poison him. He wouldn’t eat the hospital food or take the drinks. He’d only drink bottled water that he brought in from home. One patient felt like he had spiders crawling all over him and inside his body.

2. Delusions

A delusion is a firmly-held belief that a person has despite evidence that it isn’t true. Delusions are extremely common in schizophrenia, occurring in more than 90% of those who have the disorder. Often, these delusions involve illogical or bizarre ideas or fantasies, such as:

Delusions of control – Belief that your thoughts or actions are being controlled by outside, alien forces. Common delusions of control include thought broadcasting “My private thoughts are being transmitted to others so people can hear what I’m thinking”, thought insertion “Someone is planting thoughts in my head”, and thought withdrawal “The CIA is robbing me of my thoughts”.

Delusions of grandeur – Belief that you are a famous or important figure, such as Jesus Christ or Napoleon. One of our patients believed he wrote all Michael Jackson’s lyrics. Alternately, delusions of grandeur may involve the belief that you have unusual powers, such as the ability to fly.

Delusions of persecution – Belief that others, often a vague “they,” are out to get you. These persecutory delusions often involve bizarre ideas and plots e.g. “Martians are trying to poison me with radioactive particles delivered through my tap water” or “they’ve put a chip in my neck so they can follow me, they followed me to San Francisco once and had me deported back to the UK.” He had actually been deported once it was noticed he had been on Section 3 of the Mental Health Act 1983 as you cannot enter the States if you have been on Section 3*.

Delusions of reference – A neutral environmental event is believed to have a special and personal meaning. For example, you might believe a billboard or a person on TV is sending a message meant specifically for you.

3. Disorganised speech

People lose their train of thought during conversations, make loose associations of topics (jumping from one topic to another), and give answers to unrelated questions. They might make up words that only they know the meaning to (word salad), rhyme without noticing they’re doing it, and repeat the same things over and over again when trying to keep up a conversation.

4. Disorganised behaviour

Patients often have a very hard time functioning independently and this is easily seen in the difficulty they have in starting or finishing a task without help from other people. Mundane tasks such as taking a shower or cooking a simple meal become massive tasks. Patients start to lose independence and not being able to perform normal everyday activities and they start to lose routines to the point where they can be completely lost.

5. Negative symptoms include:

Blunted affect – reduced intensity and range of emotional expression including vocal, facial expression, body movement and hand gestures.

Alogia – decreased quantity of speech, reduced spontaneous speech and loss of conversational fluency.

Amotivation – lack of motivation i.e. in school, work, personal hygiene etc.

Anhedonia – inability to feel pleasure in normally pleasurable activities.

Asociality – lack of motivation to engage in social interaction and/or the preference for solitary activities

6. Suicide

Five to 6% of people with schizophrenia die by suicide, about 20% make suicide attempts on more than one occasion, and many more have significant suicidal thoughts. Suicidal behaviour can be in response to hallucinations and suicide risk remains high over the lifespan of individuals with schizophrenia.

7. Early warning signs of schizophrenia

In the early phase of schizophrenia, a person might seem reclusive, unmotivated, eccentric and emotionless to others. They might start to say odd things, isolate themselves, show a general indifference to life and begin neglecting their appearance. They may abandon activities or hobbies, and their performance at university, school or work can deteriorate.

8. The most common early warning signs include:

  • Odd or irrational statements; strange use of words or way of speaking
  • Depression, social withdrawal
  • Flat, expressionless gaze
  • Inability to cry or express joy or inappropriate laughter or crying
  • Oversleeping or insomnia; forgetful, unable to concentrate
  • Hostility or suspiciousness, extreme reaction to criticism
  • Deterioration of personal hygiene

If you are worried that odd or out of the ordinary behaviour is causing problems in your life or the life of a loved one, please seek medical advice. The earlier you get treatment, the better the prognosis.m

Is there anything else you would like to know about schizophrenia? Is there anything you think I’ve missed?

* Section 3 of the Mental Health Act is commonly known as “treatment order” it allows for the detention of the service user for treatment in the hospital-based on certain criteria and conditions being met.

For immigrants with a mental disorder or disability, seeking entry to the United States is not easy. U.S. immigration law imposes barriers to entry for persons with certain kinds of physical or mental illness, particularly when it appears that the chances of harm to persons or property are high or when an immigrant may likely have no financial support in the United States.

These barriers can be compounded by immigration officials who lack up-to-date scientific knowledge or who may unknowingly prejudice such cases. There are ways round these barriers and travellers must ensure they have the legal documents required for entry into the States (https://www.alllaw.com/articles/nolo/us-immigration/mental-illness-barrier.html )

First day nerves on placement on an acute in-patient ward

My first morning on an acute in-patient ward

Staff photo board on an acute inpatient
mental health ward

Beyond the door, people were milling about in all states of undress, one lady baring her breasts as she had a hospital gown on backwards and the ties were undone. Fortunately she had knickers on, albeit they were large white paper ones, which covered her modesty. Others had hospital-issue pyjamas bottoms on, some bare-chested and barefoot while some had on what looked like their own dressing gowns, clothing and footwear.

I could see more dusky coloured walls, on the left was old artwork, curling at the edges and hanging precariously with tattered tape. A large perspex covered board with photographs of unsmiley people and nametags, who appeared to be staff, hung on the right. Alongside, was a wonky shelf with welcome leaflets and other ward related information. Looked like someone had a fallout as they’d scribbled on the perspex over one particular nurse’s face.

Which one is the nurse?

Heart thudding and having pressed the buzzer to get in I watched as this guy, who looked like an all-American Quarterback sporting a huge white smile, sauntered lazily towards the door. He unlocked it with one of the keys from a large bunch and nodded me in then he locked the door behind me. I guessed that, because he had keys dangling from his belt, he was staff.

Other than the pyjamas, it was difficult to identify who was a patient and who was staff. Man mountain was wearing jeans, a sweatshirt and trainers. He introduced himself as Adeola and pointed me toward the nurses office where, because the door was locked, I stood for a few seconds, hoping one of the three people in there would let me in.

“Hello. You must be Nancy, our new student. Come in now, come sit. Moreblessings get up and give this wee lady a seat now, will ye?” A young Northern Irish guy also in jeans, t-shirt and trainers raced on “I’m Derry, that’s Moreblessings and there’s Abimbola, Nancy. Would ye like a wee cuppa tea Nancy, would ye? Give us a wee minute and we’ll get ye one, eh”? I loved him already and despite some humphs and tuts from Moreblessings, I knew I was going to like it here.

The office was tiny. There was a rickety desk with some stacked filing drawers, a telephone and some office paraphernalia on it, and two old swivel chairs. Two battered-looking four-drawer filing cabinets stood opposite each other, a formica top stretched along one side of the office and held a fax machine, photocopier and few loose files.

Above was a couple of  flimsy shelves holding lots of precariously balanced files and some nursing books. Dressed in a neat flowery jumper, a calf length skirt with thick black tights and flat black shoes, poor Moreblessings huffed and puffed her bulk out of the chair in the far corner, between the filing cabinets, to give up her seat. Derry slid into her empty chair, leaving his for me.

The troops arrived

Just at that, the office door burst open and in bungled two others, out of breath and laughing as they attempted to get their coats off in such a small space. “Yer late again Alison, Fadhili. Come on now. Hurry up.”

“Keep your hair on, I’ll just grab some coffee.” giggled Alison as she winked at me.
“You’ll just not. Come on. Some of these folks want to go home this morning.” said Derry. “Anyway, this is Nancy, our new student.” he added. Alison smiled and Fadhili nodded at me.

The heat from the six of us steamed up the office window and I was getting a rather icky whiff of body odour, badly covered up with strong but not unpleasant cologne. However, as Alison sat her neat bum on the table edge, she was closer to me and the sweet, floral scent that she wore helped mask the other smells. She too was wearing faded jeans with a striped shirt and trainers while Fadhili had on trousers, a shirt and tie and shiny black mock croc shoes.

Derry looked towards Abimbola who started to read out names from  a large whiteboard on the wall. “Helen, slept all night, no problems. Peter, he’s okay, just waiting to go home. Isaac, restless and sat in the day area most of the night.” He went on, discussing the twenty patients on the ward that morning. This was called handover and it happened at the beginning of each shift. It was brief and didn’t give me too much information, but enough to begin with as I had to memorise the staff names first.

Finished, Abimbola snatched up his coat and heaved his large frame through everyone and left the office, waving wearily as he went. It was like a mass exodus then, as everyone else made a mad dash too.

Was it still only 8 o’clock?

“Coffee Nancy?” I heard Derry say over his shoulder as he went next door to the kitchen so I followed him and said I’d have a coffee with milk. Out came the toaster, cereal and coffee mugs, clattering onto the stainless steel worktop and I watched as some staff helped themselves to breakfast. Derry just made two coffees and handed one to me saying “Do you smoke Nancy?” As I nodded he made eyes at me to follow him and we crossed the narrow hall to the smoking room.

We walked into the stench and a dark yellow fog that you get when there’s half a dozen smokers and no ventilation. The smoke stained windows were open but only half an inch, obviously so no one can escape. Several pairs of lifeless eyes turned towards us, though many remained staring blankly, either at the grubby windows or the soiled floor which was littered with fag ends, empty crisp packets, screwed up plastic cups and old cola tins.

Derry sat on one of the chairs, inviting me to sit next to him, and I hoped my fixed smile hid my disgust at the state of the stained chairs with their cigarette burns and other unidentifiable debris.

Still, I smiled around nervously and offered my introduction “Hi, I’m Nancy and I’m a new student on the ward.”
“Alright Nancy. I like students. You got a spare fag?”
Derry interrupted “Pete, the wee lass just started today. Leave her alone.”
“No it’s okay.” I said and offered the pack to Pete then watched as others eyed the box, willing me to offer them one too. I didn’t feel I had a choice so I was five ciggies down already, and it was just gone eight o’clock.

Medication. Medication. Medication.

At that, there was a loud rattling of the kitchen hatch going up and Moreblessings was yelling “Breakfast time, breakfast……” as she loped along the hall. “Time to move.” said Derry. “I’m your mentor for this placement Nancy, but bear with me and I’ll catch you up in a wee bit. I’m coordinating the shift today. Have a wee seat, chat to a few patients and see how you get on, eh?”

Moreblessings was still yelling and now Fadhili had joined in, “Medication,” he sang and I watched as he went down the hall, knocking on bedroom doors “Medication. Breakfast. Medication………” Patients trickled out from rooms, heading in various directions, some to the hatch between the kitchen and dining room for breakfast and others towards the queue for medication. One or two just flopped on chairs in the living area and gazed at the television.

I thought I’d be best in the kitchen helping with breakfast, as there wasn’t much I could offer on the medication side, being a new student. This also aided in putting a wide barrier between me and a slightly aggressive young female who was eyeing me up and down and glaring at me. However it didn’t protect me from the stale morning breath and unwashed bodies.

There was no queue as such and patients just leant over each other to reach for cereal, milk and sugar or the hot buttered toast, some burnt and some still white. Not sure if this was a defect with the toaster or the domestic, who was also busy handing out green plastic cups of hot water so that patients could add either tea or coffee. Drinks and cereal sloshed as patients shuffled to small tables in the dining area.

Soon, vacated tables had crumbs, slops and spills so I went round the other side of my barrier to wipe some of it up, but I practically flew back when Mandy, I learned, screamed, “Fucking lesbian. Stop fucking staring. You ugly white bitch.” This was the young lady who’d earlier on, had her nightgown on back to front. “Oh, ignore Mandy. She harmless really.” said Mrs Farrell, this tiny, sweet domestic lady in her Jamaican twang “She just having a bad morning.”

Meeting the patients

Breakfast was almost over and the last of the dawdlers were still in the queue for medication. I popped into the office to see that Derry had allocated patients to the four staff on duty; two qualified mental health nurses being Derry and Alison while Moreblessings and Fadhili were the  two nursing assistants. I had Supernumerary status which means that student nurses are additional to the clinical workforce and undertake a placement in clinical practice to learn, not as members of staff.*

I asked Derry what I could do to help as I was feeling a bit like a spare part and quite out of my depth, what with Mandy following me, cursing like a sailor on a drunken holiday! Derry said to just shadow one of the staff and not to worry about Mandy; she’ll be fine after some medication. Alright for you to say,  I thought as I bumped into Mandy when I backed out of the office and turned with a wobbly smile to say “Hi, I’m Nancy, a new student here. Is there anything I can I do to help you this morning Mandy?”

“Ah, you’re a student, I thought you was one of the Doctors, I ‘ate Doctors. Ask if I can have leave, will ya? It ain’t ward round today and that’s the only time you get to ask for leave, but I’m not fucking waiting ’til Wednesday. I need some clothes, look at me in this fucking dirty ‘ospital gear.” she ranted.

I asked where her clothes were, what did she come in with and whether we could perhaps find them together. “They ain’t here. Someone nicked them in the night. Jealousy, that’s what it is. Jealous cos I’m a model and I get given good gear to wear. And that’s why they nick it. Fucking poofs and lesbian, all of them. And the staff, they’re at it too. All of ’em” she rambled. I didn’t know what to think about her clothing. I offered to help find her clothes but she wandered off, still cursing and muttering. Quieter now though.

“Go and have a wee break Nancy, you deserve it.” Derry grinned.

*Nursing & Midwifery Council, 2014

Patients loved good student nurses

I really wasn’t looking forward to this placement because, not only did I dislike the area (East London) or the hospital, it was also a general male ward. And generally where you get all men, you get burps, farts, snot and phlegm, in no particular order. The first time I was asked to collect mucus made me gag just at the thought, but actually holding a sputum cup half-full with sticky green bodily fluid had me dry-retching and reaching for the ladies. I dreaded the day I had to hold male poo samples.

There was a lovely elderly chap called Derek on the ward, who had prostate cancer along with other age-related ailments. He used to smile and wink at me when he saw the disgust in my face screwed up but I realised I was being unprofessional and managed eventually to arrange my face into something likened to serenity.

Derek loved telling me stories about his life during the war and how, once home with his lovely young wife, they’d never spent a day apart. He also told me that his wife was on another ward down the corridor and he missed her terribly. I’m no Linda Carter (aka Wonder Woman) but before I went off shift that day, despite groans from other nursing staff, I managed to get Doris’ bed wheeled right next to Derek’s for the afternoon. I got to see why they never spent time apart; holding hands, whispering and giggling like teenagers and dipping custard creams into each other’s tea. It was humbling yet I felt proud that I was able to help in some small way.

The next morning Derek’s bed had been moved so I asked a male nurse where he was. With a nod and his eyes rolling upward, he said: “He’s gone upstairs.” When I asked why he replied flatly: “He’s dead!” I stopped by the ladies to dry my eyes before looking in on Doris and her family to pass on my condolences. When I heard the laughter, I wasn’t sure I was at the right curtains but Doris could see my shiny shoes and she called me in. The family wanted to thank me for the humanity shown the previous day and told me how much it had meant to both parents; they’d had their final chuckles and they were both at peace in their own way now.

Most patients love good students on the ward because they’re the only ones who sometimes have time to stop and chat, to ask patients about their needs and wants. While poor nurses are run ragged doing medication and ward rounds, writing notes, and updating no end of needless care plans while phones are ringing and everyone wants a piece of them.

Unfortunately, particularly in large cities like London, most patients have more problems than just the health issue they came in with. There are those who can’t speak or understand English and need interpreters, which comes at great cost to the hospital. They might also have housing and benefit needs or support when they are discharged. Nurses have to make hundreds of phone calls to the various support agencies and social services, taking them away from the very job they trained for; looking after patients.

Note to self: “Be who you are and say what you feel, because those who mind don’t matter, and those who matter don’t mind.”

Why I became a mental health nurse

The first eighteen months of our uni course included general nursing and students, along with the aforementioned pushers and shovers, made a mad dash for the announcement boards to see where we’d be placed for the next eight weeks. I got ‘Gynaecology & Urology’. This was back in the day when we still had mixed wards, which was shocking and probably embarrassing for the mainly females, due to the nature of the ward.

I was so excited that ridiculously early Monday morning, in my new blue and white striped uniform with my upside down watch and the obligatory shiny new black DM’s. The nurses were all welcoming and there was a nice friendly male nursing assistant, Phil, in his mid thirties, who was to show me around the ward.

Phil was a bit on the cheeky side and seemed to have a good relationships with both the nurses and the patients. Nevertheless, he was lazy and would habitually try to fob menial and yukky tasks onto gullible students like me. I quickly let him know that while I don’t mind sharing the load, I was also a mature student who needed to learn certain nursing skills as well as carry out his nursing assistant tasks.

A few weeks in, Phil was grinning when told me to remove a catheter from a male patient and that he’d be back in five minute to check. On his return I told him I’d completed the task and with eyes agog, mouth agape, he paled immediately, thinking that I’d followed his instructions. As students, we all knew, you didn’t carry out such tasks on your own if you’ve never done it before – so I didn’t. Having never carried out this procedure, how would I know you had to deflate the balloon before you removed the tube from the penis?

While we were in lectures at uni, we’d learned about all the different types of poo. There’s no such thing as a perfect poo – it comes in all shapes and sizes, colours and textures. The most surprising was fecal vomiting which was one type we were told, we’d probably never come across during our mental health nursing. Fecal vomiting is serious and can happen when a person has an obstruction (usually in the small bowels).

Anna was only forty-six and had both colon and bowel cancer which had now spread to the lymph nodes and she wasn’t expected to recover. She’d called me, looking very embarrassed, asking for the commode and as she was so weak, I had to help her onto it.

No sooner had Anna sat down, she requested the sick bowl sitting nearby. Too late, she furiously projectile vomited, propelling runny poo all over the bed and down her clothes. She was mortified and kept apologising as I stood behind her rubbing her back and saying “it’s okay, not to worry. You’re okay Sweetheart” while my eyes and nostrils were stinging and I was gagging silently. I really felt for Anna, I did. My heart so went out to her and I burst into tears. I was annoyed with myself for feeling so ‘icky’ about it all.

Although urology and gynae was mostly ‘icky’, fecal vomit was definitely the worst. Yet I still feel somewhat privileged to have been able to support a patient in some small way, during probably one of the worst times in her life.

I was sad to leave this placement because the staff were so lovely, always including me in their daily chats, sharing all the chocolates and laughing at me when they saw me heave at the sight of bodily fluids. General nursing definitely wasn’t for me!

However, I’d learned how to make hospital beds, empty bedpans and clean up shit as well as making gallons of coffee whilst at the same time, remembering to document patient care in their notes, to be signed off by qualified staff.

My shiny new dm’s were tested to their limits, having ran around the wards thousands of times, at breakneck speeds. My lovely blue and white uniform got tighter as I enjoyed the sweets and chocolates gifted by patients and the daily homemade cakes I’d taken in, to ‘bribe the nurses into liking me’. My upside down watch was used often, probably more often than normal I suppose, because I had to keep re-doing BP, pulse and resps – to ensure they were correct. I was terrified I’d make a mistake and someone would die because of me, in fact, I had nightmares!

I didn’t realise how much I’d miss the patients and the relationships we built during such a short period and the times we’d laughed and cried together. I felt so humbled by this experience, when these lovely people, despite their illness, pain or suffering, shared with me their life stories and their innermost fears and secrets, some of which they’ve never been able to talk about.

Note to self: “Listen to that inner voice of yours. It’s not you, but it’s for you.”
― Kiyo Giaozhi

My first 3 anxiety-ridden months at university studying to become a mental health nurse

I just wasn’t getting this studying lark. I foolishly thought I’d be learning about Mental Health nursing but we had so many seminars and lectures about all the oligies like sociology, biology, physiology and psychology, trotted out by bored lecturers using big words. By the time I’d figured out how to spell sternocleidomastoid*, the topic had moved on and my notes had more holes than Swiss cheese.

Another bugbear was the alarming amount of classes we had to endure each week in communication and interpersonal skills. People just have these, right? Hmm, the shoving and pushing together with the teeth clicking and tutting, rattling newspapers, talking or sleeping through lectures and being generally disruptive in class should have been enough of a clue.

It’s been said that there’s no such thing as a stupid question. Well, I beg to differ here because some students asked stupid questions, argh! with disturbing regularity. Just kill me already! ‘It says here to write my name in black ink, does that mean I can’t use a blue pen?’ And these same students managed to interrupt and disrupt lessons with their stupid questions, so much so, that the topics were cut short, meaning we had to go through the whole bloody lesson all over again in a few days.

Three months in and just before Christmas, we were given an essay to complete over the festive period, something like ‘How is my life is different since starting Uni.’ Ok, that sounds simple enough. Or it did, until I got it home and read how I had to write in an ‘academic’ manner, using references and to use ‘reflection in and on action.’ I’d only passed a few GSCSs some twenty years ago and, as far as I can remember, we didn’t use referencing and not one of them mentioned ‘reflection’ or ‘academic writing’.

I re-wrote this essay so many times, trying to sound clever and knowledgeable but ended up failing miserably and just feeling even more stupid. What, with this and the bubble gum blowing class disruptors, boredom, big words and stupid people, I was wondering if uni was the place for me.

However, what example would I have set for my sons had I not completed the essay and got a whopping seventy eight per cent as a result?

Note to self: “Character consists of what you do on the third and fourth (and fifth) tries.” – James A Michener

*One of two thick muscles running from the sternum and clavicle to the mastoid and occipital bone; turns head obliquely to the opposite side; when acting together they flex the neck and extend the head