A Better Command Hallucination

The other night a colleague and I were reflecting on some of the people we have worked with who have the bizarre, fun variety of psychosis and started brainstorming "wouldn't it be nice if" treatments. File the following under "why not?" Or delusional optimism.

An inspiring advocate for people living with schizophrenia, Dr. Fred Frese, who has lived with the disorder for several decades,  provides one of my favorite descriptions of different types of psychosis by comparing  them to different types of drunk. There are angry violent drunks, sad crying drunks, quiet withdrawn drunks, functional productive drunks, and (best?) of all, fun dancing drunks.  Unlike intoxication, schizophrenia does not wear off, and the goal of most providers is to eliminate the symptoms.  This is not always the primary goal of the patient. It is important to keep that in mind before labeling a patient as non-compliant.

Hearing a running commentary of behavior, judgements, and commands to act out anything from mundane to harmful behaviors is hard to fathom if you do not experience it for yourself.  While schizophrenia is often referred to as the cancer of mental illness, the good news about the paranoid type is that it is the most treatable. The bad news is that it is paranoid schizophrenia and debatable the most difficult one to live with. While treatment options are improving, the older medication therapies either give you parkinsonian-like side effects including drooling, involuntary movement, and shuffling gait, while the newer ones  make you fat, tired, stupid, and impotent. In addition to these expected side effects, other cumbersome factors may include cost, drug-drug interactions, regular blood monitoring, altering multiple lifestyle factors to prevent toxicity or ineffectiveness, or life-threatening adverse reactions. Oh, and more often than not, patients experience residual symptoms, or "breakthrough" psychosis. It is a high cost of doing business and I get why many folks would rather suffer the disease than the treatment.

So I got to thinking, maybe we are on the wrong track. Instead of elimination of voices through dopamine blockades in the prefrontal cortex, maybe what we need are to change the content of the delusions to something more health promoting.  What if we could trigger the positive self talk areas of the brain, particularly the Broca or Wernicke regions, to create a better hallucination? Instead of hearing "your worthless" or "they are all against you" or "jump off the bridge,"  they could be replaced with "do 30 minutes on the treadmill," or "check that nutrition label for trans fats," or "get home by 10 so you can get your beauty rest!" Who would need Weight Watchers and a personal trainer with voices like that?!

Though I am sure if we did had that ability through medication, advertisers would find a way to have the voices promote their products.

So on second thought, maybe not.