Schizophrenia is a chronic and severe mental disorder that affects how a person thinks, feels, and behaves. People with schizophrenia may seem like they have lost touch with reality and display a wide range of symptoms, including hallucinations, delusions, disorganized thinking and speech, abnormal motor behavior, and negative symptoms like apathy and withdrawal. A key question surrounding schizophrenia is whether people with this condition are in control of their actions and behaviors. This article will examine the evidence on both sides of this debate.
What is schizophrenia?
Schizophrenia is a complex psychiatric disorder that affects about 1% of the population worldwide. It typically emerges in the late teens to early 20s and often persists throughout life. Schizophrenia has a strong genetic component and likely involves dysfunction in brain systems involving dopamine and glutamate. The symptoms of schizophrenia are usually categorized as:
– Positive symptoms – Psychotic behaviors not seen in healthy people. This includes hallucinations, delusions, thought disorders, and movement disorders.
– Negative symptoms – Deficits of normal emotional and behavioral states. This includes reduced motivation, reduced speech, flat emotional expression, and social withdrawal.
– Cognitive symptoms – Impairments in executive functioning, working memory, and attention.
While antipsychotic medications and psychosocial treatments can help manage the symptoms, there is currently no cure for schizophrenia.
Arguments that schizophrenics are NOT fully in control
There are several reasons why many argue that people with schizophrenia are not fully in control of their behaviors:
Brain abnormalities
Decades of research have shown that schizophrenia is associated with structural and functional abnormalities in the brain, particularly in regions involved in regulation of cognition, emotion, and behavior. This includes:
– Reduced gray matter volume in the frontal and temporal lobes
– Enlarged ventricles
– Dysfunction in dopamine signaling pathways
– Abnormalities in networks involving the prefrontal cortex
These widespread brain changes imply that schizophrenics have diminished control over their thoughts, feelings, and actions.
Positive symptoms
The positive symptoms of schizophrenia like hallucinations, delusions, and disorganized thinking and speech are seen as evidence that people with schizophrenia have an impaired sense of reality.
For example, auditory hallucinations where someone hears voices commanding them to act represent a loss of control over one’s perceptions and behaviors. Delusions also cause people with schizophrenia to act on false beliefs not based in reality.
Cognitive deficits
Many people with schizophrenia have deficits in cognition that affect their judgment, decision-making, and impulse control. These include:
– Poor working memory and inability to retain information
– Impaired attention and cognitive control
– Difficulty with planning and problem solving
With these cognitive deficits, schizophrenics may have trouble regulating their behaviors appropriately.
Lack of insight
A majority of people with schizophrenia have reduced awareness or denial of their illness, also known as poor insight. They may not believe they have an illness or need treatment. This lack of insight means they are less likely to monitor their behaviors and symptoms effectively.
Arguments that schizophrenics ARE in control
On the other side of the debate, some argue that despite their illness, people with schizophrenia still have agency and control over their actions:
Many can live independently
While schizophrenia is a chronic condition, many people with the disorder can still live independently and function in society with proper treatment. They are able to work, go to school, maintain relationships, and avoid hospitalization. This level of functioning implies an ability to control one’s behavior.
Symptoms vary over time
The positive and negative symptoms of schizophrenia fluctuate over time. During periods of remission when symptoms are less severe, people with schizophrenia often have greater self-control. This suggests control is possible at least some of the time.
Violence is not usually a feature
Despite public misconceptions linking mental illness and violence, people with schizophrenia are far more likely to be victims of violence than perpetrators. Only a small fraction of violence in society can be attributed to schizophrenia. Most people with this condition are not prone to violence when receiving proper treatment and support.
Schizophrenics can make rational decisions
Even during acute phases of schizophrenia, people retain the ability to make some rational decisions and exert control, albeit in a more limited capacity. For example, someone experiencing auditory hallucinations may still choose to take medication to quiet the voices. Their control is diminished but not abolished entirely.
Stigma overstates lack of control
Some argue that stigma around mental illness leads society to overstate the lack of behavioral control in conditions like schizophrenia. In reality, many people with schizophrenia have greater self-control than commonly believed.
Factors that influence control in schizophrenia
Whether a person with schizophrenia is able to control their behaviors likely depends on several factors, including:
Adherence to medication
Antipsychotic medications are one of the main treatments for schizophrenia. When taken consistently, they can reduce psychotic symptoms and allow for greater behavioral control. Non-adherence or stopping medication often precedes loss of control or hospitalization.
Substance abuse
Many people with schizophrenia have co-occurring substance abuse disorders involving drugs or alcohol. Intoxication and withdrawal from substances diminishes self-control and judgment in schizophrenia.
Presence of stressors
Stressful circumstances and events can worsen symptoms and impair control in schizophrenia. Examples include loss of housing, relationship problems, trauma, or lack of community support.
Degree of family support
People with schizophrenia who have involved family members supporting treatment plans often have better control than those lacking such social support. Family can help monitor symptoms and behaviors.
Access to treatment resources
Access to healthcare services, psychosocial treatments, housing assistance, and vocational rehabilitation can improve control by managing symptoms. People with more resources have better control.
Stage and severity of illness
Schizophrenia symptoms are usually most severe in the initial acute psychotic episode. With treatment and time, symptoms can improve, allowing for greater control over thoughts and behaviors in later stages.
How the legal system views control in schizophrenia
Views on whether people with schizophrenia are in control of criminal behaviors have important implications in the legal system. In many jurisdictions, the defense of not guilty by reason of insanity (NGRI) can be used if mental illness prevented a defendant from understanding right from wrong or controlling criminal conduct.
Landmark court cases
There have been several influential court cases involving schizophrenia and control:
M’Naghten case (1843) – This British case led to the widespread adoption of the M’Naghten rule, judging whether the defendant knew right from wrong during the crime. This remains the legal standard in about half of U.S. states.
Durham v United States (1954) – This U.S. appellate case established the Durham rule, which acquitted defendants if mental illness was the direct cause of criminal behavior. However, this was later struck down for being overly broad.
United States v. Lyons (1984) – This federal court case affirmed that psychosis alone does not qualify someone for an insanity defense under the M’Naghten standard. Loss of control must be proven.
Insanity defense statistics
The insanity defense is raised in less than 1% of felony cases, and only succeeds in about 25% of those. About 70% of insanity defenses involve schizophrenia or other psychotic disorders.
| Year | Insanity defenses | Successful verdicts |
|---|---|---|
| 2001 | 8,672 | 1,042 |
| 2002 | 9,158 | 1,021 |
| 2003 | 8,439 | 964 |
While schizophrenia itself does not absolve criminal responsibility, the defense argues the defendant’s ability to control behavior was sufficiently impaired. The circumstances of each case are heavily weighed.
Treatment recommendations to improve control
For people with schizophrenia struggling with control over their behaviors and actions, several treatment approaches may help:
Medication and medication compliance
Antipsychotic medication is essential for controlling the positive symptoms of schizophrenia like hallucinations and delusions. Long-acting injectable formulations can improve compliance over oral medications. Closely monitored compliance can prevent symptomatic relapse.
Psychosocial treatments
Treatments like cognitive behavioral therapy (CBT), social skills training, and cognitive remediation therapy can improve functioning and teach coping strategies. Family therapy can also help provide external support.
Supportive employment and housing
Assisted employment programs and supported housing provide stability and structure needed for better behavioral control. These services prevent homelessness and loss of purpose which can worsen control.
Substance abuse treatment
Integrated treatment for co-occurring substance abuse can eliminate substance-induced impairment of control. This may involve behavioral therapies and 12-step programs.
Crisis intervention plans
Developing an emergency plan for when symptoms escalate provides a sense of control. Identifying early warning signs, when to seek help, and listing coping strategies can improve control during crises.
Conclusion
In summary, whether people with schizophrenia have control over their actions is a complex issue. Schizophrenia profoundly impacts thoughts, emotions, and behaviors, suggesting a loss of control. However, the illness is heterogeneous in its presentation. While control is diminished, personal agency is not completely erased, especially with proper treatment and support. For the legal system, each case must be evaluated on its facts to determine if control was sufficiently impaired to qualify an insanity defense. With comprehensive and sustained treatment, many people with schizophrenia can achieve remission of symptoms and greater self-control. More research is still needed to fully disentangle issues of voluntary behavior versus illness-induced lack of control in this challenging disorder.