• The more serious end of mental illness is often left out of the conversation

  • Dr Alice Feller explores the symptoms and treatment of more heavily stigmatised conditions like schizophrenia and bipolar disorder

Exploring schizophrenia

If you are so unlucky as to fall into that one percent of the world population who suffers from schizophrenia, it will start in your teens or your twenties. It usually begins slowly. You might see things or hear things that others don’t—a cat going by or noises on the roof. You might have unusual thoughts or delusional ideas—things you’ll recognise as odd. You might start to feel persecuted, or that you can’t trust your friends or your family. Or you might feel unusually important.

You might have trouble sleeping or difficulty concentrating, and this might lead to problems with school or work that you’ve never had before. You might have trouble making yourself understood, or following a conversation. You might find that even small things bother you in a way they never did before. Things that used to give you pleasure will often be less enjoyable, and you might spend much more time alone than you used to. People might tell you you’re acting strange, or that your hygiene has deteriorated. 

It’s important to note that none of these symptoms by itself means you have schizophrenia. But at this point you’ll know there’s something wrong; you’re not who you used to be. If someone offers help you’ll probably agree. You might learn that what you’ve been experiencing is something other than a psychotic illness, such as depression. But if what you’ve been experiencing is the early stage of schizophrenia and you get no medical help, you’ll most likely go on to full-blown psychosis. 

Psychosis is the loss of ability to tell the real from the unreal. You’ll begin to hear voices—auditory hallucinations—and the voices will sound as real as any other voices. You won’t see who’s speaking, but you’ll know there’s someone there, talking to you or about you. The voices can be vicious. If you’re a man who enjoys talking with children, the voices might call you a pedophile. If you’re a woman anxious to please others, the voices might say you give off a bad odour. When things aren’t going well for you, they will often advise suicide. Sometimes they’ll give you the method—“walk into traffic” or “hang yourself.” 

You might suffer from the feeling that a close family member has been replaced by an imposter or an alien. This delusion is brilliantly captured in the classic horror movie The Invasion of the Body Snatchers. In the 1956 version of the film, a woman realises that her husband has been replaced by a look-alike imposter. When she confides in a friend, explaining what’s happened, he brushes her off and advises her to "talk to someone". As the movie goes on, and more people turn into look-alike imposters, she realises that no one believes her and that in fact there’s a plot to isolate her and convince her she’s crazy. To the outside world, she appears paranoid and delusional, but she knows she’s not.

People who are lucky enough to receive good treatment at the beginning of the illness can often resume their normal lives. But those who don’t may end up living in the back room of their parents’ homes, or sometimes on the streets, or even behind bars.

Exploring bipolar disorder

If you are one of the three percent of the world population who develop bipolar disorder, it may begin with a profound depression, so deep sometimes that it’s hard to think or move or carry on with your life. Or it may begin with a manic episode, a slowly increasing excess of energy, leaving you unable to sleep but also inspiring you with a wealth of new ideas, boundless confidence and a feeling of joy. Unfortunately, this happy mood gives way to irritability, and then easy rage. You are apt to get into quarrels, or even physical confrontations. You might lose your job. Your family might eject you from the home, and the police might even be called.

Your normally good judgment is impaired and you might make impulsive decisions based on overconfidence or blinding infatuation. You might make rash business decisions that leave you bankrupt, or marry someone you barely know. Meanwhile, you are suffering from severe insomnia. Like many others you may try to use alcohol or other sedating substances in a desperate attempt to sleep.

It’s likely that you have lived a successful life up until these changes began. You might even have been mentally healthy into your fifties, and then suffered a first manic episode or a first severe depression. Bipolar disorder is cyclical, and in between episodes of illness you’ll continue for long stretches with your normally successful life. 

Treatment for schizophrenia and bipolar disorder

Treatment for each of these illnesses involves medication. For schizophrenia, we must use antipsychotic drugs. Most have some side effects for some people, therefore it’s important to work with a psychiatrist who meets with you frequently—every day if you’re in the hospital, and if not then once or twice a week until you’re stable. Together, you should work to find the most effective drug with the least side effects at the lowest dose. After that, you should continue to meet periodically to make sure you’re doing well. 

For treatment to work, your doctor should be part of a team of clinicians who collaborate to provide intensive care, which includes family involvement, long-term psychotherapy and vocational rehab to get you back to work or back to school. You should have this intensive team-based treatment for a couple of years, and then be able to touch base as needed. The most important part of this early intervention approach is to start early—ideally before psychosis develops, because after that it’s often hard to believe that you’re sick and need treatment. The longer the duration of untreated psychosis, the worse the prognosis. 

Bipolar disorder requires psychotherapy and medical treatment, but not with ongoing antipsychotic drugs. The usual medications are antidepressants if needed and mood stabilisers, such as lithium carbonate and valproate, an anticonvulsant also used to control seizures. Lithium can harm the kidneys if the blood level is too high, so it requires periodic blood draws, mostly in the beginning of treatment, to find the correct dosage. Ongoing side effects can include tremors and weight gain. Valproate needs the same sort of monitoring to determine the correct  blood level and can also cause weight gain and tremors, but much less so in the small doses used for bipolar disorder.

The important thing to keep in mind is that serious mental illness is treatable. We have the know-how, and everyone deserves the best possible mental health.

Dr Alice Feller is the author of American Madness

Further reading

Understanding paranoia and extreme mistrust

How EMDR helped me recover after a breakdown

Stigma and synaesthesia: My experience of bipolar disorder

From mania to post-traumatic growth: How therapy saved me

My experience of psychosis and tips for others