Schizophrenia: Coping With Delusions and Hallucinations

[Article revised on 4 May 2020.]

The symptoms of schizophrenia are manifold, and present in such a variety of combinations and severities that it is impossible to describe a "typical case" of schizophrenia.

Positive symptoms

The so-called "positive symptoms" of schizophrenia consist of psychotic phenomena (hallucinations and delusions), which are usually as real to the schizophrenia sufferer as they are unreal to everybody else.

Positive symptoms are usually considered to be the hallmark of schizophrenia and are often most prominent in the early stages of the illness. They can be provoked or aggravated by stressful situations, such as succumbing to a physical illness, breaking off a relationship, or leaving home to go to university.

Hallucinations

Psychiatrists define a hallucination as "a sense perception that arises in the absence of a stimulus." Hallucinations involve hearing, seeing, smelling, tasting, or feeling things that are not actually there.

The most common hallucinations in schizophrenia are auditory hallucinations—hallucinations of sounds and voices. Voices can either speak to the schizophrenia sufferer (second-person, "you" voices) or about him (third-person, "he" voices).

Voices can be highly distressing, especially if they involve threats or abuse, or if they are loud and incessant. (Carers might begin to experience something of the distress of hearing voices by turning on both the radio and the television at the same time, both at full volume, and then trying to hold a normal conversation.)

On the other hand, some voices—such as the voices of old acquaintances, dead ancestors, or "guardian angels"—can be a source of comfort and reassurance rather than of distress.

Delusions

Delusions are defined as "strongly held beliefs that are not amenable to logic or persuasion and that are out of keeping with their holder's background. Although delusions need not necessarily be false, the process by which they are arrived at is usually bizarre and illogical. In schizophrenia, delusions are most often of being persecuted or controlled, although they can also follow a number of other themes.

Positive symptoms correspond to the general public's idea of "madness," and people with prominent hallucinations or delusions may evoke fear and anxiety in others. Such feelings are often reinforced by selective reporting by the media of the rare headline tragedies involving people with (usually untreated) mental illness.

The reality is that the vast majority of schizophrenia sufferers are no more likely than the average person to pose a risk to others, but far more likely than the average person to pose a risk to themselves. For example, they may neglect their safety and personal care, or they may leave themselves open to emotional, physical, or financial exploitation.

How to deal with positive symptoms

For obvious reasons, there is little in the way of self-help that sufferers can do to address their delusions—other than, of course, engaging with their carers, care team, and treatment plan.

But there are some simple things that anyone can do to dampen, and maybe even banish, auditory hallucinations.

If you're assailed by voices, try out some or all of the following:

• Keep a diary of the voices to help identify and avoid the situations in which they arise.
• Identify a trusted person with whom to discuss the voices.
• Focus your attention on a distracting activity such as reading, singing, listening to music, gardening, or exercising.
• Talk back to the voices: Challenge them and insist that they go away.
• Manage your levels of stress and anxiety.
• Ensure that you are getting enough sleep.
• Avoid alcohol and recreational drugs.
• Take your medication as prescribed. If necessary, ask for a review of your medication.

Advice for carers

Psychotic symptoms can also be extremely distressing to carers.

Carers typically find themselves challenging their loved one's delusions and hallucinations, partly out of a desire to relieve their suffering, and partly out of understandable feelings of fear and helplessness. Unfortunately, this can be counterproductive, insofar as it can alienate the depression sufferer at the very time when they are most in need of care.

Difficult though this is, carers should remind themselves that their loved one's experiences are as real to them as they are unreal to everyone else.

A much more constructive/less confrontational approach for carers is to recognize that their loved one's psychotic symptoms are meaningful to them while making it clear that they themselves do not personally share in them.

For example:

"The devil told me that I'm to blame for everything that's happened."

"Are you hearing him now?"

"No, he's just stopped talking."

"What else did he say?"

"That I'm a very bad person and don't deserve to be looked after."

"Has he been telling you to harm yourself?"

"No, he hasn't, although I sometimes feel as though I should."

"Would you actually harm yourself?"

"No, no, of course not."

"Gosh, this all sounds terrifying. How are you feeling?"

"I've never felt so frightened in all my life."

"I feel your pain, although I myself have never heard the devil you speak of."

"Didn't you hear him earlier on?"

"No, not at all. I've never heard or seen him."

"What about all the evil spirits?"

"No, I haven't heard them either, not at all. Have you tried ignoring all these voices?"

"If I listen to my iPod they don't seem so loud, and I can actually hear myself think."

"What about when we talk together, like now?"

"Yes, that's very helpful too. I feel much less frightened now."

Neel Burton is the author of The Meaning of Madness and other books.