Deborah Danner and the Suffering of Schizophrenia

Sword of Damocles (1812), oil painting on canvas by Richard Westall. Ackland Museum, Chapel Hill, North Carolina, United States of America.

COMMENTARY

Opponents of psychiatry use 3 main strategies when discussing schizophrenia and other forms of psychotic illness: deny it, romanticize it, or trivialize it. Thus, a recent “white paper” by the British Psychological Society (“Understanding Psychosis and Schizophrenia”) blandly declared, “Many of us hear voices occasionally, or have fears or beliefs that those around us do not share.”¹ This shallow trivialization does scant justice to the nightmarish reality of psychosis, which is vividly detailed by Deborah Danner, a 66-year-old woman with self- described schizophrenia, who was shot to death in October by a New York City policeman.

The New York Times’ release of Ms. Danner’s eerily prescient 2012 essay, “Living With Schizophrenia,” gives the lie to the misleading narratives of antipsychiatry.²

In her essay, Ms. Danner described schizophrenia as “a curse,” with the only saving grace being “. . . it’s not a fatal disease.” (That’s true, although the rate of suicide among persons with schizophrenia is about 10 times that of the general population.³) For Ms. Danner, as for millions who suffer with schizophrenia and related disorders, her illness is like having “. . . the proverbial ‘Sword of Damocles’. . .” hanging over one’s head. She recounted memories of “roaming the streets of New York in the wee hours of the morning” with the intention of finding “. . . a public place to kill myself . . . .”

Ms. Danner lamented the lack of mental health training among police, and the plight of both incarcerated and homeless persons with severe mental illness. And far from regarding mental illness as a “myth,” Ms. Danner rightly noted, “Mental illness is just that, an illness, a treatable illness and most of the public needs to be educated about that fact.” Instead, many in the general public (including some of Ms. Danner’s employers) regard persons with schizophrenia as terribly dangerous or violent, leading to unwarranted discrimination.

Each instance of severe mental illness is a personal, familial, and societal tragedy.

To be sure, untreated psychotic illness, especially if complicated by substance abuse, does substantially increase the risk of violence toward oneself or others.⁴ However, schizophrenia by itself is only weakly associated with perpetration of violence, and when adequately treated, poses a very low risk of violence toward others.4 And, fortunately, suicide risk in schizophrenia can be significantly reduced with antipsychotic medication.⁵

Unfortunately, in the public perception, “. . . there remains a focus on violence perpetration [by those with mental illness] to the neglect of victimization” within this vulnerable population.6 Yet when personality disorder and comorbid substance abuse are taken out of the equation, persons with mental illness who live in the community are more likely to be victims than perpetrators of violence, at rates of victimization several times higher than that in the general population.⁶

Ms. Danner observed that “. . . generally speaking, those who don’t suffer [with mental illness] believe the worst of those of us who do. We’re treated with suspicion as liars . . . .” This is not surprising. The notion that people with schizophrenia are “liars” was actually propounded by one of psychiatry’s most famous critics, the late Dr. Thomas Szasz-who declared that mental illness is merely “a myth” or a “metaphorical” illness. But in his 1996 book, The Meaning of Mind, Szasz went even further, writing:

I believe viewing the schizophrenic as a liar would advance our understanding of schizophrenia. What does he lie about? Principally about his own anxieties, bewilderments, confusions, deficiencies and self-deception.⁷

Dr. Szasz, who was one of my professors during residency, had important things to say about protecting the civil liberties of persons with mental illness. But his view of schizophrenia as a self-inflicted form of lying has done great injury to those who suffer from this devastating illness. His position is also belied by scores of studies showing that persons with schizophrenia exhibit brain abnormalities at a significantly higher frequency than “normal” control subjects.^8-10

To her lasting credit, Ms. Danner stressed the importance of adequate treatment of mental illness, including the use of medication. She specifically noted that the “incarcerated mentally ill must be adequately treated and prepared with some sort of support system that will ‘take over’ their treatments, read medication schedules and [provide] therapy . . . .”

The Danner case in larger context

According to a recent report in the Columbus Dispatch, the number of people who receive mental health services in the US rose by 10% from 2009 to 2012, but funding to state mental health agencies was reduced by $4.35 billion. During this same period, another 4500 psychiatric hospital beds were cut nationally-and the number of inpatient beds has dropped by 75% since the 1970s.¹¹ We need to reverse these disastrous trends while educating law enforcement officers and the general public about the nature of severe psychiatric illnesses like schizophrenia.

It is easy to view the issue of severe psychiatric illness from an academic or theoretical standpoint. Yet each instance of severe mental illness is a personal, familial, and societal tragedy-which, in too many cases, leads to inadequate treatment, incarceration, or suicide. As regards the anguish of a family dealing with the psychotic illness of a loved one, there is no better testimony than that of Pete Earley, who has written movingly about his son’s psychotic illness-and how maddeningly difficult it has been to obtain appropriate treatment for him. I will let Mr. Earley speak for himself, in his foreword to the important new book, Committed:

Imagine your child, a loving and brilliant young art student in college. One morning, his friends deposit him on your doorstep and tell you that he is crazy. He is argumentative, refuses to eat or sleep, and is convinced that he needs to go immediately to the White House because God has given him a message for the President. Imagine watching him pace back and forth in front of the television with tin foil wrapped around his head to keep the Central Intelligence Agency from reading his thoughts. Imagine him being arrested because he has broken into a stranger’s house to take a bubble bath. Imagine listening to someone you love scream at you, call you the enemy, tell you that he hates you. Imagine watching your son hit his own head to clear the voices inside his mind, which are screaming at him, telling him that he will die if he steps out of a car, taunting him to hurt himself . . . Picture that and remember that this is your son. What would you do?¹²

Nothing will restore the life of Deborah Danner. But we can learn from her tragic story, and that of Pete Earley’s son. We can push back against those who deny, romanticize, or trivialize the painful reality of severe mental illness. And we can insist that our dysfunctional non-system of mental health care face its ethical obligations and provide adequate, timely, and affordable care to those who suffer with severe mental illness.

This article was originally posted on 11/7/2016 and has since been updated.

Note to readers: I will be taking a break for the next few months to work on some literary projects. Thanks to all for their interest and feedback. -Ron Pies, MD

For further reading:
Pies RW. Trivializing the Suffering of Psychosis. Psychiatric Times. December 22, 2014. http://www.psychiatrictimes.com/blogs/trivializing-suffering-psychosis. Accessed November 7, 2016.
Pierre J. Psychosis Sucks. Psychology Today. March 5, 2015. https://www.psychologytoday.com/blog/psych-unseen/201503/psychosis-sucks. Accessed November 7, 2016.
What Is AOT? Treatment Advocacy Center. http://www.treatmentadvocacycenter.org/storage/documents/aot-one-pager.pdf. Accessed November 7, 2016.

To our readers: As per our policy, we ask that comments be accompanied by your names and professional titles. Thank you. -The Editors.

References:

1. Cooke A (Ed). Understanding Psychosis and Schizophrenia. The British Psychological Society. http://www.bps.org.uk/networks-and-communities/member-microsite/division-clinical-psychology/understanding-psychosis-and-schizophrenia. Accessed November 7, 2016.

2. Danner D. Living With Schizophrenia. January 28, 2019. Posted by The New York Times, October 19, 2016. http://www.nytimes.com/interactive/2016/10/19/nyregion/document-Living-With-Schizophrenia-by-Deborah-Danner.html. Accessed November 7, 2016.

3. Baxter D, Appleby L. Case register study of suicide risk in mental disorders.
Br J Psychiatry. 1999;175:322-326.

4. Are People with Serious Mental Illness Who Are Not Being Treated
Dangerous? Treatment Advocacy Center. March 2014. http://www.treatmentadvocacycenter.org/storage/documents/violent-behavior-backgrounder.pdf. Accessed November 7, 2016.

5. Haukka J, Tiihonen J, Härkänen T, et al. Association between medication and risk of suicide, attempted suicide and death in nationwide cohort of suicidal patients with schizophrenia. Pharmacoepidemiol Drug Saf. 2008;17:686-96.

6. Desmarais SL, Van Dorn RA, Johnson KL, et al. Community violence perpetration and victimization among adults with mental illness. Am J Public Health. 2014;104:2342-2349.

7. Szasz TS: The Meaning of Mind: Language, Morality, and Neuroscience. Santa Barbara, CA: Praeger; 1996.

8. Bakhshi K, Chance SA. The neuropathology of schizophrenia: A selective review of past studies and emerging themes in brain structure and cytoarchitecture. Neuroscience. 2015;303:82-102.

9. Woo TU. Neurobiology of schizophrenia onset. Curr Top Behav Neurosci. 2014;16:267-295.

10. Iritani S. What happens in the brain of schizophrenia patients? An investigation from the viewpoint of neuropathology. Nagoya J Med Sci. 2013;75:11-28.

11. Johnson A, Candisky C. Mental-health system overwhelmed, underfunded. Columbus Dispatch. May 26, 2013. http://www.dispatch.com/content/stories/local/2013/05/26/overwhelmed-underfunded.html. Accessed November 7, 2016.

12. Earley P. Foreword. In: Miller D, Hanson A. Committed. The Battle Over Involuntary Psychiatric Care. Baltimore: Johns Hopkins University Press; 2016.