Because treatment occurs so late in the disease process when the presence of positive symptoms becomes obvious, researchers worldwide have been testing drugs, omega-3 supplements, and psychotherapy – with mixed results - taking on the challenges of early detection or even prevention of schizophrenia, perhaps in the prodromal phase. This phase involves an intensification of social difficulties and muted or fleeting psychotic symptoms, such as strange thoughts, odd perceptions, or hearing or seeing something that is not there. The hope is that early intervention efforts might alter the disease course in a way that would improve outcomes and prevent disability. However, preventing schizophrenia is still more dream than reality (Harvard Mental Health Letter - B, 2009, pp. 4-5).
Observational note for later discussion: John demonstrates a unique ability to see patterns with a pattern rising off the glass and synchronizing with patterns on Neilson’s tie. Perhaps this may be related to the characteristic of schizophrenia in which there is an assault on one’s senses and, therefore, when one sees something, it may look very bright, distorted in color or shape.
In time the scale does tip toward mental illness. John Nash has reached the age coupled with the conditions that surround a schizophrenic break. He has the stress of a new, unfamiliar and competitive environment. His social isolation becomes painfully apparent, i.e., his major competitor humiliates him by his inference that John can be mistaken for a waiter rather than a student of mathematics. John retreats to his room from that situation only to experience further isolation as he looks from his window at students on the outside interacting with one another. At this moment of high stress, a positive symptom of schizophrenia emerges, a hallucination.
According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, (DSM-IV-TR) (American Psychiatric Association, 2000, p.299), the symptoms that characterize schizophrenia fall into two groups:
Positive - an access or distortion of normal functions, such as, thinking and ideas (delusions), perception and sensations (hallucinations and illusions) and language and communication (disorganized or bizarre speech).
Negative - a deficit or loss in normal functioning, such as, the range and degree of emotions (flat affect), the fluency and productivity of thought and speech (alogia) and the initiation of goal-directed behavior (avolition).
A hallucination is a false sensory perception in the absence of a real external stimulus. It may be induced by emotional and other factors such as drugs, alcohol, and stress. It may occur in any of the senses, thus a person may experience seeing, hearing, touching, smelling and/or tasting something that does not exist (Kaplan and Sadock, 1991, p.202).
So, at a time of high stress from competition and social isolation, John experiences the friendship of Charles via auditory and visual hallucinations. This friendship/hallucination appears to help John survive as it eases John’s painful isolation and allows John some social moments and some social drinking, away from mathematics. John uses this opportunity to state to himself, through the image of Charles, that, “…I don’t like people much and they don’t like me.” Through the image of Charles, John, is able to say to himself that he will not find the “higher truth” in something as boring as mathematics.” In addition, a delusion of grandeur is emerging, i.e., he believes he is superior to the professors and the theorists to be studied in text books as he refers to them as “lesser mortals.”
A delusion is a false belief, based on incorrect inference about external reality, not consistent with an individual’s intelligence and cultural background that cannot be corrected or reasoned.
Delusions of grandeur are exaggerated ideas of one’s importance or identity (Kaplan and Sadock, 1991, p. 219).
A Challenge
John is seen on the campus grounds, without Charles, interacting with his peers. Time has passed and John has not attended classes. It also appears that his bizarre thinking has increased as a peer refers to John as “psycho,” and there is a bizarreness in John’s appearance as John is wearing sneakers, white socks and ill fitting pants as he sits next to his peers who all have leather shoes and stylish clothing. The stress of the competition is reinforced as Martin defeats John in a mathematical board game while also reminding John that two colleagues, Bender and Sol, have published a paper and Martin, himself, has two papers under review. The defeat causes John to rush away from his peers with a very obvious physical clumsiness.
The appearance of physical clumsiness may occur along with other changes like problems with attention and social withdrawal during, what was mentioned earlier as, the prodromal phase of the illness. This period occurs for some time prior to full-blown psychosis. Thus, John, like many other people with schizophrenia, appears to be ill for some time before his psychotic symptoms appear. Psychotic symptoms usually occur later in the disease process (Harvard Mental Health Letter - H, 2008, p. 1).
The Need to Focus
The newly reinforced stress leads John to hold up for two days in the library searching for an original idea and he begins to formulate his original idea. However, once again a high level of stress from competition and isolation trigger John’s hallucination of Charles, the playful friend. The hallucination of Charles allows John to take himself from the library to a social environment to eat, drink beer, play pool and be with his peers.
In this bar scene, in addition to John’s positive symptom experience of the hallucination of Charles, his negative symptoms of schizophrenia are apparent. There is a deficit in John’s fluency and productivity of thought and speech. Specifically, his peers tease him and send him to approach a woman at the bar. However, given his seriously impaired social interactions which he has communicated earlier in his own voice and in the voice of Charles, John approaches this as a mathematical problem, reminding his friends that his odds of success dramatically improve with each attempt. He approaches the woman but is unable to say a word. She breaks the ice and then John says, “I don’t exactly know what I’m required to say in order for you to have intercourse with me....” She, of course, slaps him and leaves. His friends have a good laugh but John is able to comfort himself via his hallucinatory friend, Charles.
John, although brilliant, does not attend classes and has not published any papers. It appears from an earlier conversation that John believes all he has is his mind. However, in this scene John is confronted with possible failure and loss of what he believes is his only asset, his mind. Professor Helinger tells John that he may not get a placement as he did not, “focus.” John’s inability to focus may be an alteration of cognition that is due to his schizophrenia.
Cognition refers to intelligence, memory, academic skills and the ability to use these skills. It is the ability to acquire knowledge, to plan, to make use of one’s perceptions and to reason out problems or difficulties. (Fischler and Booth, 1999, p. 2).
Cognitive impairment is recognized as an integral characteristic of schizophrenia with deficits appearing in tasks that require attention, verbal fluency, memory and executive functioning. These impairments are much more influential on social and vocational functioning and quality of life than are psychotic symptoms of the illness. (Tasman, Kay and Lieberman, 2003, p.242).
Following the high stress of this rejection by his professor and the confrontation of pending failure and loss, John’s symptoms of schizophrenia, negative, positive and cognitive, are invoked.
John’s ability to focus is impaired and he struggles, thinking if he faces the wall rather than the window, he’ll be better able to concentrate. At this point John’s stress reaches a summit and John bellows about, complaining of the expectation of, “…their requirements...to follow their
