1. What Is Schizophrenia?
Schizophrenia is a serious mental illness that affects 300,000 Canadians. Although it affects men and women with equal frequency, schizophrenia most often appears in men in their late teens or early twenties, while it appears in women in their late twenties or early thirties. Finding the causes for schizophrenia proves to be difficult as the cause and course of the illness is unique for each person.
Interfering with a person’s ability to think clearly, manage emotions, make decisions and relate to others, schizophrenia impairs a person’s ability to function to their potential when it is not treated. Unfortunately, no single, simple course of schizophrenia treatment exists. Research has linked schizophrenia to a multitude of possible causes, including aspects of brain chemistry and structure, as well as environmental causes.
Psychosis (psyche = mind, osis = illness) is defined as the experience of loss of contact with reality and usually involves hallucinations and delusions. Psychosis is a common symptom of schizophrenia. Learn more about psychosis, including first episodes, to gain more insight into this condition, including early intervention options.
2. Diagnosing Schizophrenia
There is no single laboratory or brain imaging test for schizophrenia. Schizophrenia treatment professionals must rule out multiple factors such as brain tumors and other medical conditions (as well as other psychiatric diagnoses such as bipolar disorder). At the same time, they must identify different kinds of symptoms that manifest in specific ways over certain periods of time. To make matters more complicated, the person in need of mental health help and treatment may be in such distress that they have a hard time communicating. It often takes a decade for people to be properly diagnosed with schizophrenia. A health care provider who evaluates the symptoms and the course of a person’s illness over six months or more can help ensure a correct diagnosis.
Since scientific knowledge is changing all the time, the diagnostic criteria may change as well. Schizophrenia has been categorized in several subtypes such as paranoid, catatonic, disorganized and undifferentiated, but these divisions may be phased out in favor of a syndrome model that includes multiple dimensions.
The Diagnostic and Statistical Manual of Mental Disorders (DSM), the book health care professionals use to diagnose mental illness, provides a set of common standards. The DSM often gets revised as new research develops, and a fifth edition is due out in 2013. Find out more about the DSM at www.dsm5.org.
The current DSM V lists the following as schizophrenia classification guidelines in patients if two or more occur persistently. However, delusions or hallucinations alone can often be enough to lead to a diagnosis of schizophrenia.
- Disorganized speech
- Disorganized or catatonic behavior
- Negative symptoms
Health care providers also look for social/occupational dysfunction in one or more areas:
- Work or school
- Interpersonal relations
- Self care
Health care providers look for duration of these symptoms in this pattern:
- Persist for at least six months
- Include symptoms from the symptoms above for at least one month – May include periods of prodromal (early signs) or residual symptoms or only symptoms from the social bullet section or two or more symptoms from the first section of bullets, with less intensity.
Health care providers make sure the following are not present:
- Sustained mood disorder symptoms during the episode
- The direct effects of substance use
- An underlying medical condition
- A pervasive developmental disorder (such as autism) unless prominent delusions or hallucinations are present.
According to current research, it is extremely important to identify schizophrenia as early as possible. Studies show that catching schizophrenia early can increase the chances of managing the illness and mental health recovery. If identified and treated early on, schizophrenia can be managed fairly well and the chances of subsequent psychotic episodes are greatly reduced. The DSM 5 manual of the American Psychiatric Association is at this time considering whether to include a diagnosis for early onset of symptoms consistent with this line of thinking.
3. The Symptoms of Schizophrenia
As you can see from the DSM criteria, no single symptom positively identifies schizophrenia. On top of that, an individual’s symptoms can change over time. The symptoms of schizophrenia are generally divided into three categories: positive, negative and cognitive symptoms.
Positive symptoms are also known as “psychotic” symptoms because the person has lost touch with reality in certain ways. The term “positive symptoms” refers to mental experiences that are “added on” to a person’s usual experience—typically these are hallucinations and delusions.
- Hallucinations cause a person to hear voices inside or outside their heads or, less commonly, see things that do not exist.
- Delusions occur when someone believes ideas that are clearly false, such as that people are reading their thoughts or that they can control other people’s minds.
Negative symptoms do not refer to negative thinking, but rather reflect symptoms that indicate reduction of a capacity, such as motivation. Negative symptoms often include emotional flatness or lack of expressiveness, an inability to start and follow through with activities, speech that is brief and lacks content and a lack of pleasure or interest in life. Difficulties with social cues and relationships are common. These symptoms challenge rehabilitation efforts, as work and school goals require motivation as well as social function. Negative symptoms can also be confused with clinical depression.
Cognitive symptoms pertain to thinking processes. People living with schizophrenia often struggle with executive functioning (prioritizing tasks), memory and organizing thoughts. Cognitive function is involved in many tasks of daily living—especially in work or school settings. A common cognitive deficit associated with this condition is anosognosia or “lack of insight”—when someone is not aware of having an illness. This difficulty in understanding is based in the brain—it is not a choice or psychological denial—and can make treating or working with people who live with schizophrenia much more challenging. I Am Not Sick, I Don’t Need Help, a book by Xavier Amador, Ph.D., is a great resource for dealing with this challenge.
Medications are crucial to symptom control within the schizophrenia treatment process, and other psychological strategies are also gaining acceptance to augment their impact. For example, a treatment called Cognitive Behavioral Therapy (CBT) is well-established as a useful strategy to help people actively manage their Hallucinations.
Researchers still don’t know exactly what causes schizophrenia, but they do know that the brains of people living with schizophrenia are different, as a group, from the brains of those who don’t live with the illness.
Research strongly suggests that schizophrenia has something to do with problems involving brain chemistry and brain structure and, like many other medical illnesses, is thought to be caused by a combination of problems, some inherited and others occurring during a person’s development. For example, some researchers think that schizophrenia may be triggered by a viral infection affecting the brain very early in life or by mild brain damage from complications during birth. Drug use can trigger underlying genetic vulnerability in a person. It is still premature to label schizophrenia as either a neurodevelopmental (impairment of the growth and development of the brain) or a neurodegenerative (progressive loss of structure or function of neurons) disorder, as both seem to be in play over the course of the illness. Scientists are working to understand if changes in the brain are present early in life and how much those changes worsen over time.
People can develop schizophrenia at any age. About 1 percent of the world’s population develops schizophrenia, meaning that out of all the people born today, one in 100 will develop the disorder by the time they reach age 55. About 75 percent of people living with the illness develop it between the ages of 16- 40; women typically have a later onset than men. Children can also be diagnosed with schizophrenia, though this is quite rare before the age of 12. New cases are uncommon after age 40.
Extensive and intensive molecular genetic research programs continue to generate hope that specific combinations of genes will provide an answer to the riddle of what causes schizophrenia and other psychoses. Just like in the early stages of cancer and diabetes research, more time and innovative research are needed to learn more about this complex disorder.
5. Schizophrenia Treatment and Mental Health Recovery
Schizophrenia treatment requires an all-encompassing approach, and it is important to develop a plan of care that is tailored to each person’s needs. Mental health care providers and the individual needing mental health help should work together to craft this plan.
Finding the right medication is one important aspect of symptom management, but other services are also needed in order to promote mental health recovery. Rehabilitation strategies involving work, school and relationship goals are also essential and need to be addressed in creating a plan of care. Peer support— learning from someone who has “been there”—is a growing area of the field and can also provide employment opportunities for people needing mental health help. See the mental health resources section for peer support group information.
The fact that schizophrenia occurs in all cultures means that schizophrenia treatment options should account for these differences in cultural context. Most people living with schizophrenia can manage their conditions with the interventions listed in this section. Long-term research demonstrates that, over time, individuals living with schizophrenia often do better in terms of coping with their symptoms, maximizing their functioning while minimizing their relapses. Mental health recovery is possible for most, though it is important to remember that some people have more trouble when it comes to managing their symptoms. Although many effective schizophrenia treatments options exist, more research is needed to promote greater understanding, more effective treatments and a potential cure for schizophrenia and other mental illnesses.
A cure for schizophrenia has not yet been found, but mental health recovery is possible as most people’s symptoms can be improved with medication. The primary medications for schizophrenia, called antipsychotics or neuroleptics, help relieve the hallucinations, delusions and, to a lesser extent, the thinking problems people can experience. These medications are thought to work by correcting an imbalance in the chemicals that help brain cells communicate with each other.
The first generation of antipsychotic medications were introduced in the 1950s. These earlier medications, now called conventional, or typical, antipsychotics, often have side effects of restless motion (called akathisia), Parkinson-like symptoms (e.g., stiffness, dry mouth, sedation) and can cause a disabling, embarrassing and untreatable movement disorder called tardive dyskinesia.
There is a second-generation of antipsychotic (SGA) drugs called atypical antipsychotics, so called because they do not cause most of the movement problems noted above. SGAs appear to have a relatively lower risk of causing tardive dyskinesia, the movement disorder that is the most troubling problem with conventional antipsychotic medications. In some cases, switching to clozapine may provide some relief for tardive dyskinesia. If movement disorders are a concern, individuals should speak with a health care provider.
Clozapine (Clozaril) was the first atypical antipsychotic in the United States and it has demonstrated a clear advantage over the other medications for difficult-to-treat symptoms. Clozapine is often a very effective medication, particularly for people who have not responded well to at least two other antipsychotic medication trials (a trial requires adequate dose and duration). A drawback is that it requires blood monitoring to check for— and prevent—a very rare adverse effect: a decrease in white blood cells which increases the risk for infection. Clozapine appears to reduce the symptoms of schizophrenia in some people, but it is hard on the body and may lead to weight gain, diabetes and other medical conditions. Clozapine has also been shown to reduce suicide risks for individuals living with schizophrenia. Clozapine has complex risks and benefits.
Other atypical medications do not require blood monitoring. However, they all can cause important, yet largely preventable, side effects: weight gain and metabolic syndrome, which is increased triglycerides and risk of diabetes or cardiac disease. Clozapine and olanzapine have the highest risk of these problems; ziprazidone and aripiprazole have the lowest.
7. Psychosocial Rehabilitation
Like all people, individuals living with schizophrenia typically have important goals for themselves in the areas of relationships, work and living. Psychiatric rehabilitation strategies are designed to enable people to compensate for, or eliminate, the environmental and interpersonal barriers as well as the functional deficits created by this illness. The field of psychosocial rehabilitation helps people successfully live in independent housing, pursue education, find jobs and improve social interaction.
ACT, or PACT, known as Assertive Community Treatment, is an evidence-based, service-delivery model that provides comprehensive, locally based treatment to people living with serious mental illness such as schizophrenia. Available 24 hours a day, seven days a week, ACT professionals meet people where they live, providing at-home and in-community support at whatever level is needed. Professionals work with individuals living with mental illness to address problems proactively, helping to make sure that crises do not happen, ensure medications are being properly taken and assist in helping individuals meet the routine challenges of daily life, which is an important part of mental health recovery.
8. Medical Care and Wellness
People living with schizophrenia are subject to many medical risks and typically receive poor medical care and mental health help. High rates of smoking (which may have positive impacts on memory for some but very bad health effects overall) and co-occurring alcohol and drug problems can endanger an individual’s health and jeopardize mental health recovery. Risks of obesity and diabetes related to some of the medications noted above are also of significant concern. Research shows that monitoring is often not adequate for these metabolic side effects. Learning how to better manage your own health— becoming a self advocate—is very important.
Better and more integrated care is essential for people living with schizophrenia. Diet, exercise and other supplements play a big role in managing health. There is interest in the potential of omega-3 fatty acids (found in fish oil) to improve brain health and outcomes for individuals living with mental illness. Ask your doctor about the latest research on this evolving area of the field and how these can be integrated in your schizophrenia treatment
9. Schizophrenia and Co-occurring Disorders
When someone is living with schizophrenia and another medical or psychiatric condition (known as a co-occurring disorder), it is important that all aspects of care are coordinated, especially medications. It is not uncommon for people living with schizophrenia to experience depression, although it may be difficult to distinguish depression (low mood) from the negative symptoms that affect someone’s ability to display emotion. Symptoms of depression in addition to the existing symptoms of schizophrenia may significantly add to a person’s distress and increase the likelihood of suicide. It is important to discuss any possible symptoms of depression with a health professional and examine antidepressants, such as Selective Serotonin Reuptake Inhibitors (SSRIs) that may be safely added to the current schizophrenia treatment.
About 25 percent of people living with schizophrenia also have a substance abuse disorder, frequently called a dual diagnosis. While it may seem like a way to escape from the distressing experiences associated with the illness, substance abuse can make schizophrenia treatment less effective or make people in need of mental health help less likely to follow their treatment plan. Drugs like marijuana and stimulants such as amphetamines or cocaine may make symptoms worse. Marijuana use, in particular, is thought to have a correlation with the onset of schizophrenia, perhaps triggering the illness in those with a genetic predisposition. Traditional 12- step programs, such as Narcotics Anonymous and Alcoholics Anonymous, can be effective for some people living with schizophrenia, while others do better with treatment specialized for the needs of individuals living with a dual-diagnosis.
10. Therapy and Cognitive Aspects
Within schizophrenia treatment medication is an important way to reduce symptoms, but some studies have shown that people living with schizophrenia can also benefit from changing their approach to symptom management. In particular, Cognitive Behavioral Therapy (CBT) has been shown to be an effective part of a treatment plan for some people living with schizophrenia, and it is widely used in the United Kingdom. CBT, which is becoming more widely available in the U.S., engages the individual who needs mental health help, in developing proactive coping strategies for persistent symptoms.
Many people report that it is beneficial to have someone to discuss their experiences with. Talk therapy is a helpful tool in learning how to better manage mental illness. Peer support groups like WRAP (Wellness Recovery Action Plan) encourage involvement in mental health recovery by working on social skills with others. The Illness Management Recovery (IMR) model is an evidence-based approach that emphasizes setting goals and acquiring skills to meet those goals. The clubhouse recovery model promoted by the International Center for Clubhouse Development (ICCD) helps individuals move towards mental health recovery by providing a safe place to socialize and work. See the resources section for more information.
Complimentary and Alternative Medicine (CAM) refers to practices that are not part of standard care. However, respecting a person’s culture and personal choice in managing his or her illness should be a top priority. Meditation, acupuncture or other alternative approaches can be beneficial when it comes to managing personal wellbeing.
In the beginning, schizophrenia may completely alter a person’s way of life, affecting daily functional tasks from personal hygiene to eating well and following medical treatment. Although new and better schizophrenia treatment options allow many people to return to more active lives, many people living with schizophrenia may need help over the long term with their basic needs, such as money, housing, food and clothing. One goal of mental health recovery is to promote as much independence as possible.
Mental health recovery is not a linear process. Setbacks and relapses can occur within the schizophrenia treatment process, so progress should be evaluated on each level separately. Perhaps someone is not making as rapid progress towards fulltime employment as he or she would like, but he or she has improved social skills by involvement with a church or overall health by keeping a regular exercise routine. A holistic view of wellness does not end with taking medication regularly. It’s about taking medicine to help get closer to other life goals.
11. The Social Aspects of Mental Illness
Living with mental illness means living within a society and all its specific cultural, economic and political factors. In addition to competent mental health care, people living with schizophrenia need strong social supports. Individuals and families should work together to create the best environment to management recovery.
While schizophrenia occurs in approximately 1 percent of any society’s population, some groups are more likely to be diagnosed with schizophrenia in the United States. African Canadians and Latinos are more prone to misdiagnosis, likely due to differing cultural or religious beliefs or language barriers. For anyone who has received a diagnosis of schizophrenia, it is important to look for a health care professional who understands a person’s cultural background and shares the same expectations for schizophrenia treatment.
13. Socializing and Bias
Social difficulties are one of the hallmarks of schizophrenia. Negative symptoms can make picking up on social cues challenging, which, further complicated by competing stimuli from positive symptoms, can make conversations more difficult, particularly with people who don’t know much about schizophrenia and the mental health recovery process. In addition, some people feel isolated because they are aware that others do not share their hallucinations or delusions.
There is bias around mental illness, and as many as 96 percent of individuals living with schizophrenia experience discrimination and mental disorders stigma-other people expecting negative things of them, or nothing at all, because of their illness. Prejudice can come from the outside and the inside of a person. A person might have negative experiences with potential employers rejecting their job applications, or they might be hindered by anxiety about these possible transactions.
Social skills training can be useful laboratory for finding appropriate ways to interpret and respond to social cues. This training can occur formally (in classes or therapy) or informally (within peer groups or a clubhouse setting) and it is an important step in mental health recovery. Volunteer opportunities or any other venue where an individual already has something in common with the other participants can offer a less risky environment for socializing.
Research suggests that as many as 70 percent of people living with schizophrenia would like to be engaged in competitive employment, but fewer than 15 percent are actually employed. People living with schizophrenia can find a sense of accomplishment and independence from working. In addition, it improves social skills rather than isolating an individual in need of mental health help, which tends to exacerbate negative symptoms. Research demonstrates that a supported employment model has better outcomes for a more safe and successful route to finding and keeping a job. Supported employment opportunities are scarce. Some clubhouses or hospitals also offer supported employment opportunities or referrals.
15. Families and Social Factors
For people living with schizophrenia, spirituality can be a source of comfort and strength during the schizophrenia treatment process. The most supportive congregations will be those that are aware of the medical nature and treatments for mental illness or are open to learning about them. People living with schizophrenia indicated that faith-based support was a top need and benefit in managing mental health recovery. It is important to include prayer in recovery management for people of faith.
Families who are educated about schizophrenia can offer strong support to their loved one and help reduce the likelihood of relapse. The key is to be in tune with what the person who needs mental health help is open to at any given time. For example, arguing with an individual about delusions creates distance and is usually ineffective. Empathizing with someone’s distress or success is more likely to foster more positive outcomes and help in the mental health recovery process.
One of the challenges of a caregiver is to find ways to provide mental health help, support and protect their loved one while allowing room for self reliance. Every family is different, but family structures tend to vary from culture to culture, with certain groups like Latinos tending to benefit from schizophrenia treatment solutions that involve the entire family. Over time and without support, some family caregivers can begin to experience anxiety or depression. Families can experience “caregiver burnout” and a sense that their challenges are not valued as much as those faced by caregivers of people with other illnesses. Families should also become educated about health privacy rules and the legal aspects of providing care for an adult living with schizophrenia who is too ill to understand the need for treatment. Psychiatric advance directives, which allow individuals to designate schizophrenia treatment and contact persons in case they are unable to make their own decisions, can be another tool.
Because of all of these levels on which the fight to regain wellbeing is fought, family members often find it helpful to keep a journal of all medications, medical visits, treatments and legal actions they have undertaken. Having this information handy can be helpful when switching providers or dealing with a crisis. For all of these reasons, family members should seek education and support for their own needs from groups specially designed for families.
16. Discovering the Truth about Schizophrenia
Because the illness may cause unusual, inappropriate and sometimes unpredictable and disorganized behavior, people who are not effectively treated are often shunned and the targets of social prejudice. The apparent erratic behavior is often caused by the delusions and hallucinations that are symptoms of schizophrenia. Along with medication, psychosocial rehabilitation and other community-based support can help those with schizophrenia go on to lead meaningful and satisfying lives. A lack of appropriate services devoted to individuals living with schizophrenia has left many improperly placed in jails and prisons without the help they need.
Schizophrenia is often mischaracterized as an untreatable disease associated with violent behavior and many untrue and unfortunate stereotypes have developed, which led to mental disorders stigma. Most individuals living with schizophrenia are not violent; risk of violence is associated primarily with factors such as psychotic symptoms or substance abuse. Even then, violent behavior is generally uncommon and the overall contribution of schizophrenia to violence in a community is small. When engaging in schizophrenia treatment, the illness is a manageable. The varying nature of each case though means that mental health recovery for every individual is different.
Like any other illness, schizophrenia can often have a profoundly negative effect on a person’s life, on their families and on their communities if not addressed. Suicide is a serious risk for those with schizophrenia, occurring at a much higher rate than the general population. However, the risk of suicide can be greatly reduced through the use of medication and psychiatric rehabilitation and mental health recovery-oriented services.
17. Fighting Mental Disorders Stigma: Dispelling Myths
There have been so many misconceptions about schizophrenia throughout history that it’s best to begin by looking at what schizophrenia isn’t.
MYTH: Schizophrenia is the same as “split” or “multiple personality.”
FACT: The origins of the word schizophrenia have contributed to this confusion. In an effort to describe the mismatch he observed between the feelings and thoughts of people experiencing this medical condition, Eugen Bleuler, a Swiss psychiatrist at the turn of the twentieth century, proposed the terms schizo (split) and phrene (mind) to capture this juxtaposition. Many people have confused this term with so called “split” or “multiple” personality (now called dissociative identity disorder), but there is no relation between the two conditions.
MYTH: Schizophrenia is caused by bad parenting or personal weakness.
FACT. Schizophrenia is a medical illness caused by a variety of factors including genetics, stress, substance use and trauma, among others.
MYTH: People living with schizophrenia are violent.
FACT: Almost all people living with schizophrenia are not dangerous when they are engaged in schizophrenia treatment, although the behavior of a person in need of such mental health help can be unsettling or unusual. Violence is a noteworthy risk for some people living with schizophrenia who are not in treatment and who also have co-occurring alcohol or drug use problems.
18. A Positive Outlook
Led primarily by real people living with schizophrenia, there is a changing assumption on what is possible for those living with the illness. Long viewed as an incurable illness, new data suggests that as many as 70 percent of people diagnosed with schizophrenia have positive outcomes when they receive appropriate treatment. With new research and expanding knowledge for the causes of schizophrenia, the outlook for those living with schizophrenia continues to improve.
(Adapted from “SCHIZOPHRENIA” published by the National Alliance on Mental Illness, 2011.)