What would you say if I told you about a woman who’s really strange? Here’s more about her:
She’s really weird. Everybody knows she’s weird…I don’t like her. I never really liked her. We don’t talk much. I haven’t talked to her in person — I’ve talked to her on the phone — but I haven’t talked to her in person for ages, because she doesn’t like me like I don’t like her…she’s really strange.
What would you say to that, then?
Would you say, “OK” and change the subject? How do you think I would feel if you did? This is the kind of difficulty that some severe forms of mental illness can cause.
For example, a man who’s schizophrenic might be caught up in his own world much of the time, but visit the real world fleetingly — enough to seem almost normal. He might hear voices that we don’t hear. He might see people that we don’t see. The voices and the people are likely to be distracting for him, at the very least, and they might even be threatening or demanding.
When you talk to someone who is severely ill in this way, it’s not immediately apparent what’s wrong. He seems to be taking part in the conversation in a limited way, but he doesn’t seem to be actually present in the conversation as a functioning person. As you talk to him, there’s a feeling that you can’t quite put your finger on — a feeling that what you’re saying isn’t sinking in.
If you tell him about a woman you know who’s really strange, he might just say “OK” and change the subject, leaving you feeling that what you say doesn’t really matter to him.
There might be clues that indicate he’s being distracted by his own thoughts.
For example, his body language might be inappropriately defensive. He might sit with his legs crossed, his body turned away from you, and his arm across his body. It’s a small thing in itself, but one that can play its part in helping you to understand what’s going on.
He might make inappropriate movements. For example, he might suddenly look as if he’s going to stand up, or turn away from you unexpectedly.
His facial expressions might be strange. He might be unable to make eye contact, or show facial expressions that seem unrelated to what’s being said.
The flow of the conversation might be unnatural. For example, he might constantly change the subject, rarely responding to what you have just said. Or he might respond to you in a way that actually dismisses what you have just said.
These could be defensive strategies on his part, preventing the things you are saying from influencing him and his world. A fairly typical thought in a man who suffers from paranoid schizophrenia might be that other people can control his mind directly, and someone who has these thoughts understandably takes steps to prevent his mind being controlled by others.
Other factors preventing the normal flow of conversation are lack of empathy, which is his inability to interpret other people’s feelings, and lack of affect, which is his inability to express his own feelings in ways that other people can interpret.
Seeing is believing
To see examples of these behaviours, you can watch the video here: Anthony and his brother…
The man at the left seems to be part of the conversation, yet at the same time not part of the conversation. His posture is defensive, at one point very near the start (time: 0:12) he lurches forward as if he’s going to get up, and later on (5:56) he suddenly turns away, perhaps to cough, but without any explanation.
His facial expressions do not completely match what he is saying. Look closely at his expressions (1:03) when he asks “And how much time does that actually involve?” And again, though less pronounced, in his next question (1:14).
He constantly disrupts the flow of the conversation by changing the subject, and he gives the speaker no indication (apart from occasional nods and grunts) that he understands what is being said.
This is particularly obvious when he’s been told something distressing by the speaker. Look how he sits stony faced when the speaker says with feeling (3:00) “I’m so frustrated that I can’t get some answers…” And at the end of that long statement (3:44) he just changes the subject again: “Mmm-hmm, OK. Are the any other problems or issues…”
We hear at length (from 4:11) how Anthony is very isolated and doesn’t go out, but he responds as if none of this was said: “Staying on that note, would you say that Anthony is well integrated into society?” He has just been told in great detail that Anthony is not well integrated into society.
This odd behaviour continues in the later part of the video, after the first speaker has gone. He says to Anthony (7:12), “Hi, Anthony, I’ve just been speaking with your brother…” But Anthony has been sitting there from the start!
Anthony’s remarks about his brother’s wife being a really strange woman are at 10:24, and the response he gets is, “OK. Can I just ask about…”
What this is about
In fact this video is part of a badly thought-out training package for nurses created at Birmingham City University. The apparently dysfunctional man is meant to portray a nurse, and Anthony is mean to portray a patient.
The whole package is based around a book, Fundamentals of Mental Health Nursing, and the publishers make a sample chapter available online. It’s as bad as the video in its own way.
For example (p72 in the book, p4 in the chapter):
Anthony has developed tardive dyskinesia and this makes him pull odd facial expressions. He also has a degree of akasthisia and he is often restless.
Why is tardive dyskinesia in bold type? Because it’s a technical term, presumably. So why is akasthisia not in bold type? Because no one edited the book, presumably. Also, the second sentence there makes it seem that Anthony has akasthisia and Anthony is also often restless. But akasthisia means restless. Whoever wrote that sentence was confused, and whoever reads it will be confused too.
By the way, if you watch Anthony closely in the video he does not have evident tardive dyskinesia — there’s no sign at all of the facial tics that you would expect. And he is not restless either — he sits immobile in his chair throughout. Someone with akasthisia would be on the move, or at least shifting constantly in his seat, wanting to get up. Anthony does exhibit repetitive movements of his hands and legs, which seem to be simply anxiety because they become more severe when he is doing the talking. Drug-induced automatic movements would not have changed when he became the centre of attention.
On the same page there’s a section headed ’Typical medication’ in quotes. Why the quotes? Because no one edited the book, presumably. The bigger problem here is that the term ‘typical’ is a technical term in pharmacology. Is there any explanation of that? No.
Then there’s this drivel:
A ‘depot’ is an intramuscular injection, the effects of which usually last between two and four weeks, the advantage of this being that people don’t have to remember to take lots of tablets… Unfortunately, this kind of medication has a range of unpleasant side effects and long-term problems…
No, depot injections don’t have those unpleasant side effects and long-term problems. It’s antipsychotic drugs that have the side effects and problems, no matter whether they are delivered by depot or not. Again, whoever wrote this is confused.
Antipsychotic drugs are also known as neuroleptics, but that very common term for them does not appear anywhere in the chapter.
Finally, at the bottom of the page, there’s a table captioned ‘Typical medication’. Unfortunately the technical term ‘typical’, which the authors forgot to define in the body of the text, does not apply to the last drug in the list, Risperidone, which is atypical.
So it seems to me that parts of this book are just a mess. Badly written, badly edited, and with dire supporting materials, it looks set to make a lot of mental nurses very confused, and their patients very unhappy.