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What Is Schizophrenia?
This is a major psychiatric condition characterised by changes in the way a person thinks, perceives, behaves and/or the way they emotionally respond to themselves, other people and the world around them. It has a devastating effect on the person and their family. It is not one illness with a set of symptoms that all people diagnosed with schizophrenia share. People may have a different set of symptoms and still get the same diagnosis of schizophrenia (see subtypes below). It is a psychotic disorder that usually requires medication for varying amounts of time. Some people have one episode and never experience one again. For others it is a life long (chronic) condition for which medication is necessary and periods of hospital care are required. After recovering from an acute episode of psychosis there can be difficulty getting back to normal activities including relationships, school, work and enjoying life. Support from family and friends, treatment and professional help are really important with this mental health problem. WHAT IT IS NOT:
Signs & Symptoms of Schizophrenia Early Warning Signs
People whose family members have schizophrenia developed the following list of warning signs. Many behaviours described are within the range of normal responses to situations. Yet families sense, even when symptoms are mild, that behaviour is "unusual"; that the person is "not the same." The number and severity of these symptoms differ from person to person, although almost everyone mentions "noticeable social withdrawal."
• Deterioration of personal hygiene Symptoms of Schizophrenia
Schizophrenia affects different people in different ways. Not everybody will experience the same symptoms, nor are they always to the same degree. Two types of symptoms are distinguished in schizophrenia – they are classified as positive and negative symptoms.
There are numerous signs and symptoms that are characteristic of schizophrenia, however, the expression of these symptoms varies greatly from one individual to another. No one symptom is common to all people. As such, diagnosis and treatment must always be tailored to the individual's unique experience of schizophrenia. The symptoms of schizophrenia are often divided into two groups: • Positive symptoms, for example, hallucinations and delusions It has also been proposed that disorganised symptoms (for example, disorganised speech and disorganised behaviour) constitute a third group, separate from the positive/negative groups. Positive Symptoms The positive symptoms of schizophrenia (also referred to as 'psychotic' symptoms) reflect an excess or distortion of normal functioning. Delusions They may revolve around persecutory, religious, grandiose, somatic or referential themes. For example, a person experiencing delusions may believe they are being spied on, tormented, followed or tricked (persecutory). Or they may believe gestures, comments, passages from books, television and other environmental cues are directed specifically at them (referential). Delusions may be bizarre (believing your thoughts have been removed by an outside force) or realistic (believing you are being followed by the police). Delusions will occur during some stage of the disorder in ninety percent of people who experience schizophrenia.
Hallucinations Hallucinations can occur in any of the five senses but the most common are auditory. These are usually experienced as voices which are perceived as distinct from the person's own thoughts. For example, the person may hear voices repeating or mimicking their thoughts, arguing, commenting on their actions (often in a critical manner) or telling them what to do (command hallucinations). Hallucinations of any form occur in over 70 per cent of people who experience psychotic illnesses. Auditory hallucinations occur in approximately 50 per cent of people with schizophrenia, while visual hallucinations occur in 15 per cent. Disorganised Thinking This is usually expressed through abnormal spoken language. For example, the person's conversation jumps erratically from one topic to another, new words may be created, the grammatical structure of language breaks down and speech may greatly speed up or slow down. Disorganised Behaviour This can be manifested in a variety of ways and is the result of the underlying brain dysfunction. A person with schizophrenia may, for example, aimlessly wander, display child-like silliness or become unpredictable. They may display behaviour that is considered inappropriate according to usual social norms, such as wearing many layers on a hot day, muttering aloud in public or inappropriately shouting or swearing. Disorganised behaviour can lead to problems in conducting the activities of daily living such as organising meals and maintaining hygiene. It may be difficult to link disorganised behaviour in adolescents as being a sign of early psychosis as teenagers are often intrinsically disorganised. Catatonic Behaviour This refers to states of muscular rigidity and immobility, stupor and negativism, or to states of wild excitement. The person may hold fixed or bizarre bodily postures for extended periods of time and resist any effort to be moved. The incidence of catatonic behaviour is very rare in developed countries (Cutting, 1996). Negative Symptoms Positive symptoms refer to an increased amount or distortion of normal behaviour. Negative symptoms refer to a decreased degree of otherwise normal behaviour. The negative symptoms of schizophrenia (also referred to as 'deficit' symptoms) reflect a loss of normal functioning. Withdrawal, Loss of Motivation and Ambivalence (Avolition) This may involve lack of energy, apathy or seeming absence of interest in what were usually routine activities. People experiencing avolition may be inattentive to grooming, personal hygiene, have difficulty making decisions and have difficulty persisting at work, school or household chores. Loss of Feeling or an Inability to Experience Pleasure (Anhedonia) This may manifest itself through having a lack of interest in social or recreational activities or through failure to develop close relationships. It may mean that the simple pleasures of life, like appreciating a beautiful sunset, being no longer enjoyed. Poverty of Speech (Alogia) The person's amount of speech is greatly reduced and tends to be vague or repetitious. People showing signs of alogia may be slow in responding to questions or not respond at all. Flat Presentation (Affective Flattening) This can be indicated by unchanging facial expressions, poor or no eye contact, reduced body language and decreased spontaneous movements. A person experiencing affective flattening may stare vacantly into space and speak in a flat, toneless voice. Flat affect refers to the outward expression of emotion and not the inner experience. Some people with schizophrenia experience negative symptoms prior to and after and acute episode of the illness. However, the negative symptoms are difficult to assess because they may be caused by a variety of other factors such as medication side effects, mood disorders or the demoralisation often felt as a consequence of a mental illness. It is also possible a person may have schizophrenia but be symptom-free. The symptoms may only emerge during an acute episode. Cognitive Impairments Although not part of diagnostic criteria, cognitive dysfunction is often present in people with schizophrenia. A large body of research demonstrates schizophrenia is associated with cognitive impairments including problems with attention, concentration and memory.
Types of Schizophrenia Subtypes Paranoid Type People with the paranoid type stand out because of their delusions or hallucinations, at the same time, their cognitive skills and affect are relatively intact. They generally do not have disorganised speech or flat affect, and they typically have a better prognosis than people with other forms of schizophrenia. A person experiences hallucinations and delusions, while their thinking and emotions remain relatively intact. The hallucinations and delusions tend to centre around a particular theme. Thus they usually don’t have the thought disorder or flat affect. Disorganised Type These people show marked disruption in their speech and behaviour, they also show flat or inappropriate affect, such as laughing in a silly way at the wrong times. A person experiences thought disorder, disorganised speech, flat affect and their behaviour is altered. This type of schizophrenia is usually observed at a younger age, it tends to be chronic and the person is not likely to improve as much as with the other subtypes. If hallucinations and delusions are experienced they tend to be disorganised without a theme. Catatonic Type In addition to the unusual responses of remaining in fixed positions, engaging in excessive activity and being oppositional by remaining rigid, individuals with catatonic type sometimes display odd mannerisms with their bodies and faces, including grimacing. They may repeat the words or movements of others. This is a fairly rare type – it is thought that medication treats these symptoms so well that it is rarely seen anymore. Undifferentiated Type People who do not neatly fit into these subtypes are classified as having an undifferentiated type of schizophrenia. Residual Type A group that have recovered from episodes and no longer experience the psychotic phase but have some remaining delusions, hallucinations or negative symptoms.
Schizophreniform Disorder Some people experience the symptoms of schizophrenia for a few months only; they can usually resume normal lives. The symptoms sometimes disappear as the result of successful treatment, but often for reasons unknown. Schizoaffective Disorder People who have symptoms of schizophrenia and who also exhibit characteristics of mood disorders are classified with schizoaffective disorder. Delusional Disorder The major feature is a persistent belief that is contrary to reality, in the absence of other characteristics of schizophrenia. Eg. A person believing their co-workers are poisoning them. Brief Psychotic Disorder Characterised by the presence of one or more positive symptoms such as delusions, hallucinations or disorganized speech or behaviour within a month. Shared Psychotic Disorder Relatively little is known about shared psychotic disorder, the condition in which an individual develops delusions simply as a result of a close relationship with a delusional individual.
What Causes Schizophrenia?
The causes of schizophrenia are not fully understood. Some theorise that a viral infection in a baby’s brain before it is born contributes to schizophrenia. Others attribute it to an imbalance of certain brain chemicals; differences in the structure of certain parts of the brain; or a genetic component – a gene for schizophrenia. Some people may be born with a tendency towards developing schizophrenia and certain things - for example, stress, a traumatic event or use of drugs such as marijuana, LSD or speed - can trigger their first episode.
Genetics Twin, family and adoptions studies suggest that genetic factors play an important role in the development of schizophrenia. For example, the child of one parent with schizophrenia has about a 10 per cent chance of developing schizophrenia; if both parents have schizophrenia, the risk is increased to 40 per cent. Environment Possible environmental factors include obstetric complications such as exposure to influenza during pregnancy or nutritional deprivation during pregnancy. It has also been suggested that stress and trauma can lead to the emergence of schizophrenia. Family factors causing stress may affect the course of the illness but there is no convincing evidence that they have a causative role. Neuro developmental Factors The research in this area investigates the possibility that individuals who develop schizophrenia in early adult life have suffered some from of cerebral maldevelopment in utero. That is, they experience a disorder in the development of their brain while in the womb. Drug Misuse Although contentious, some research suggests that substance misuse is related to the development of schizophrenia. It is likely that substance misuse may precipitate or worsen the symptoms and interfere in the treatment of a person with schizophrenia. Biochemical Factors Certain biochemical imbalances in the brain are believed to be involved in the cause of schizophrenia. Neurotransmitters (the substances that allow communication between nerve cells) have long been thought to be involved in the development of schizophrenia.
Risk Factors:
Schizophrenia can affect anyone regardless of gender, ethnicity, culture, sexuality, class, intelligence or level of education. On average 1 in every 100 people will develop schizophrenia at some stage in their lives. 75% of new cases of schizophrenia occur amongst adolescents.
Statistics • Schizophrenia is the most severe of the mental illnesses and can affect all spheres of life, including perception, thought, judgement, mood, drive and ultimately, personality.
Myths about Schizophrenia:
a. Schizophrenia is a split personality People with schizophrenia have only ONE personality. The word 'schizophrenia' comes from the Greek word meaning 'split' and this is perhaps where the confusion started. However, schizophrenia is a split from reality rather than a split in personality. b. People with schizophrenia are violent People with schizophrenia are NOT developmentally delayed. This myth has its basis in the treatment programs in the 1960s. During this period, people with a developmental delay and people with a mental illness were placed in asylums together and this is probably where the confusion arose d. People with schizophrenia have a lower than average intelligence. People with schizophrenia do NOT have a lower than average intelligence level. As with any population, there is a variation, but this is not a characteristic of the illness.
Treatment/Therapy:
Treatment can do a lot to reduce or even eliminate symptoms and should include a combination of medication, emotional and social support. Social Support - Having support from family and friends is very important so you feel less isolated and alone. With support you are likely to be better able to deal with your symptoms. Counselling - Supportive counselling can also help deal with the emotions you may experience if diagnosed with schizophrenia.
Medication - Anti-psychotic drugs have dramatically changed the treatment of schizophrenia. These drugs are not addictive and work by correcting the chemical imbalances in the brain. Anti-psychotic drugs are taken daily in tablet form or liquid injection. Since Schizophrenia appears to be a combination of a thought disorder, mood disorder, and anxiety disorder, the medical management of schizophrenia often requires a combination of antipsychotic, antidepressant, and anti-anxiety medication. Antipsychotic medications help to normalize the biochemical imbalances that cause schizophrenia. They are also important in reducing the likelihood of relapse. There are two major types of antipsychotics, traditional and new antipsychotics. Side effects for antipsychotics may cause a patient to stop taking them. However, it is important to talk with your doctor before making any changes in medication since many side effects can be controlled. Be sure to weigh the risks against the potential benefits that antipsychotic drugs can provide.
Things to remember about medications: • Medication is not considered a sole treatment. The best outcome for people who experience schizophrenia is achieved when medication treatments are viewed as one part of the Individual Service Plan. Cognitive-behavioural therapy (CBT) Cognitive behavioural therapy (CBT) is concerned with the influence of beliefs, thoughts and self-statements on behaviour. CBT for the symptoms of schizophrenia aims to heighten awareness of the inconsistency of delusions and to develop practical coping mechanisms for persistent symptoms. The results of recent publications of the first randomised controlled trials on cognitive behavioural therapy for schizophrenia are encouraging. Behavioural therapies Behavioural therapies for people with schizophrenia are designed to encourage appropriate and functional behaviour, particularly for those living in institutional settings. The behavioural management approach is particularly effective for people with long-term schizophrenia who may need encouragement to become involved in activities. As schizophrenia is a disorder that often has profound effects on motivation, individually tailored behavioural contracts to help people meet their goals in rehabilitation programs can be very useful. Social and living skills training Social and living skills training is an effective means of enabling individuals with schizophrenia to learn a variety of skills necessary for interacting socially and living independently. The techniques used in skills training are modelling, role-playing, feedback, and independent task performance. Social and living skills training can be used with individuals and with groups and provides opportunities for people to: • Acquire skills they have not been able to develop due to particular life circumstances; Vocational training and rehabilitation Work has the potential to be a ‘normalising’ experience and to provide benefits such as enhanced personal satisfaction, increased self-esteem, additional income, financial independence, social interaction and recreational and companionship opportunities. Most importantly, it is frequently identified as a goal of people with schizophrenia. Any person with schizophrenia who expresses an interest in having employment, either competitive or otherwise, or who may benefit from employment, should receive vocational services.
The medical profession often overlooks self-help methods for the treatment of this disorder because very few professionals are involved in them. Community support groups in concurrence with other behavioural therapies are usually beneficial to most people who suffer from schizophrenia. Caution should be utilized, however, if the person's symptoms aren't under control of a medication. People with this disorder often have a difficult time in social situations, therefore a support group should not be considered as an initial treatment option. As the person progresses in treatment, a support group may be a useful option to help the person make the transition back into daily social life. What To Do In A Crisis? Most families reported that a crisis or psychotic episode - that is, a severe break with reality - occurred a few months to a year after they began to notice unusual behaviour. Some said, however, that the crisis occurred with little or no warning. During a crisis episode, your relative will exhibit some or all of the following symptoms: hallucinations, delusions, thought disorder, and disturbances in behaviour and emotions. Families who have been through these psychotic episodes warn that no amount of preparation can fully protect you from the shock, panic, and sickening dread you will feel when your relative enters this stage of schizophrenia. Understand also that your relative may be as terrified as you are by what is happening: "voices" may be giving life-threatening commands; snakes may be crawling on the window; poisonous fumes may be filling the room. You must get medical help for your relative as quickly as possible, and this could mean hospitalisation. If your relative has been receiving medical help, phone the doctor or psychiatrist immediately. Ask which hospital you should go to and for advice about what to do • DO'S - Try to remain as calm as possible. Decrease other distractions; turn off the television, radio, etc. If other people are present, ask them to leave the room. Talk one at a time. Try saying, "let's sit down and talk," or "let's sit down and be quiet." Speak slowly and clearly in a normal voice. Make statements about the behaviour you are observing: "You are afraid/angry/confused. Please tell me what is making you afraid, etc." Avoid patronizing, authoritative statements such as "you are acting like a child," or "you'll do as I say, young lady." Repeat questions or statements when necessary, using the same words each time. Don't rephrase the question in the hope that this will make it clearer. Allow your relative to have personal "space" in the room. Don't stand over him or her or get too close. Understand that too much emotion on your part can upset your relative further. • DON'TS - Don't shout. If your relative appears not to be listening to you, it may be because other "voices" are louder. Don't criticize. Your relative cannot be reasoned with at this point. Don't challenge your relative into acting out. Avoid continuous eye contact. Don't block the doorway. Don't argue with other people about what to do. Importantly, keep a list of emergency contact numbers in case of a crisis situation. Calling the police (‘000’) and/or the Mental Health Crisis Teams is essential. To get the details of your local mental health crisis team, see the “Living In Your Community” section of the white pages, or contact your local community health centre. • Go slow. Recovery takes time. Rest is important. Things will get better eventually. In the meantime, get to know all about schizophrenia.
Diet change strategies: The best place to get quality supplements is from a natural healthcare provider. There are dozens of supplements marketed on supermarket shelves today, but many of these do not receive standardization. It is important if you decide to use supplements that you get the best quality supplement possible. • Black Cohosh – This may affect one’s hormones, which may be one cause for symptoms of some mental health disorders. • Damiana – Often used to help lessen depression, but may cause mania in people with bipolar disorder. • Ginseng – May help provide more energy to people who feel fatigue during depressive states. • Gotu Kola – May help address symptoms of anxiety. • St. John’s Wort – One of the most popular of herbal supplements supported with scientific research that may help lessen mild depression. Again, one should use with caution and can interact with other medications including antidepressants.
Vitamin & Nutrient Associations
If you suffer from mental health disorders, it is important you eat well to nourish your body. Deficiencies of vitamins and minerals can contribute to your symptoms. Deficiencies of vitamins and minerals in anyone can contribute to symptoms including anxiety, depression and poor health. A good quality multivitamin is a good start, especially if you do not have a history of eating well. Even if you do eat well, not all people absorb the vitamins and nutrients from their foods completely, so a multivitamin may help correct any shortages. Many therapists recommend patients with bipolar disorder take extra B vitamins because these vitamins may affect our moods. A deficiency in vitamin B of any type may result in symptoms of depression or anxiety. B vitamins are also often recommended to people to help lessen fatigue. For most, B vitamins help energize the body. There are many forms of B vitamins, so your best bet is a complex tablet containing all the B vitamins. For your information, here is a breakdown of the B vitamins by category. • B-1 – Also known as “Thiamin.” This may impact anxiety, irritability and improve blood circulation in the brain and body. • B-6 – Also known as “Pyridoxine.” This B vitamin may help reduce irritability. Doctors sometimes recommend it to patients with premenstrual irritability and agitation. You can take too much however, so be sure you consult with your doctor. • B-12 – This vitamin helps convert what you eat into fuel for your body. It is most helpful for reducing drowsiness. • Folic Acid – Important for preserving the body’s systems and biochemical balance. Careful however, as this supplement may interact with some of the more commonly prescribed mood stabilizers including Depakene. Other vitamins that may prove helpful may include vitamin E, which may combat the risk of seizures often associated with the use of traditional medication therapies. Here are some other supplements and nutrients that may prove useful for combating the symptoms of mental health disorders. • SAMe (pronounced Sammy) – This supplement may affect levels of dopamine and serotonin in the brain, but carries with it a risk of mania. • Tyrosine – Often used in combination with B vitamins, this amino acid is a precursor to dopamine and norepinephrine, important neurotransmitters in the body. What this means is your body needs tyrosine to make norepinephrine and dopamine. • GABA – May help relieve some symptoms including anxiety, insomnia, racing thoughts and tension in patients with bipolar or related disorders. • Essential Fatty Acids – Essential fatty acids are important for our entire body to work properly. They nourish the brain and may help reduce symptoms of depression. You can get essential fatty acids by eating more fatty fishes and flax seed or by taking an Omega 3 supplement. Some healthcare providers recommend as much as 5,000 I.U. or more for patients with severe depression. Be sure you check in with your doctor. Most over-the-counter supplements contain only 1,000 I.U. per serving. • Lecithin – This substance may help stabilize mood swings. If you plan to use this supplement, you should do so while working with a natural health care provider. • Calcium – Calcium is a mineral our bodies need for proper neurotransmitter production. Look for a supplement with calcium and magnesium to heighten the effects. A lack in magnesium can often lead to insomnia and anxiety. • Zinc – This important and often ignored mineral is often lacking in many people’s diet. It can help combat colds and may help reduce some symptoms of depression or other mental disorders. Remember, as with herbal supplementation you should embark on vitamin and nutritional therapy under a skilled practitioner’s guidance. Even when we try to eat well, we're disadvantaged. The nutritional content of most food has been compromised over the years, not only by deficient soils and modern production, transportation, storage and processing methods, but also by the enormous amounts of chemical and artificial substances added to promote growth, storage life, taste and appearance. It's for this reason that more and more medical authorities are advocating the use of vitamin and mineral supplements. However, finding them in the right combination can be both confusing and costly. You may find benefit from our information on detoxification as well as a bit about detoxing because of change of diet Most mental health disorders are complex and often misunderstood, that affects millions of people every year. It is important that patients understand their disorder is one that they can live with, and even learn to enjoy life with. There are many misconceptions surrounding mental health disorders. There are times when a patient’s symptoms may become very serious. In cases like this it is critical a person seek professional care and guidance. A mental health disorder can manifest in many different ways. It can for example, manifest as a mild disorder with mild mood swings, or a major mood disorder with swings that are very extreme. There are many approaches to treating a mental disorder. A patient should always work with a competent doctor or other healthcare provider they can rely and trust on in times of need. Also important to one’s health is his or her ability to build a supportive wellness team. Your wellness team can help you during the tough times, offering support and helping you make critical decisions when you may not be up to it. The most important step a patient can take, the one that will ultimately lead to their success and fulfillment, is to take a proactive role in their recovery and in their care. To do this, you must first embrace and accept the fact that you have a mental health disorder. Once you do this, life gets a lot easier. You can then help manage your disorder by working actively with each member of your wellness team as well as with members of your family and your healthcare team to create an action plan that allows you to live a happy, healthy life. Many people live with mental health disorders. Your job is to learn to not only live with, but also learn to enjoy life with bipolar disorder or any serious ailment. Congratulations on taking a step in the right direction, one that will lead to your long-term recovery and happiness. We wish you well in your search for solutions to this Schizophrenia problem and your movement towards better health in all areas. More Resources available about Schizophrenia : If the tension gets too much for us to cope with, however, it can cause us to "break down" emotionally or mentally, that is, not be able to carry on our lives in health. At these times, we may need to ask for help or support while we adjust. Many people live with disability, including physical illness or mental illness, and cope in a healthy way. The challenge for all of us is to search out new ways to cope. WHERE TO GET HELP
• Schizophrenia Fellowship on 02 9879 2600
www.sfnsw.webcentral.com.au - Schizophrenia Fellowship of NSW www.schizophrenia.ca - Schizophrenia Canada www.schizophrenia.com - Support and Education Centre www.mentalhelp.net - Mental Help Net www.mentalhealth.com - Internet Mental Health www.schizophrenia.co.uk - UK based Schizophrenia site
Reading List Mueser K.& Gingerich S. COPING WITH SCHIZOPHRENIA . New Harbinger publications 1994 Durand & Barlow ABNORMAL PSYCHOLOGY Brooks Cole Publishing USA 1997 Carer’s Handbook: Caring For Someone Who Has A Psychiatric Disability (1996; contact Schizophrenia Fellowship of Victoria, ph 03 9482 4199) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (1994, American Psychiatric Association) How to Live With a Mentally Ill Person: A Handbook of Day-to-Day Strategies by Christine Adamec (1996; John Wiley & Sons) Living Well With Schizophrenia: A book full of great ideas for people living with schizophrenia by Sandra Miller, Walter Culture, Mark Cruickshank & Maxie Ashton (1997;contact Schizophrenia Fellowship of South Australia, ph 08 8221 5160) MIMS Annual (Australian Edition) (monograph reference of therapeutic pharmaceuticals) (1998; MediMedia - 1800 800 629 - alternatively, your library may have a copy, or ask your GP/psychiatrist) Schizophrenia: The Facts (SANE Australia - 1800 688 382) Surviving Schizophrenia by Marge Overs (1994; Gore & Osment publishers) The SANE Guide for Brothers and Sisters: A guide for siblings of people living with a mental illness (SANE Australia - ph 1800 688 382) The SANE Guide for Consumers: A resource for people living with a mental illness (SANE Australia - ph 1800 688 382) The SANE Guide to Psychosis: What is Psychosis? A guide in everyday language (SANE Australia - ph 1800 688 382) The SANE Guide to Treatments: A guide to treatments for people seriously affected by mental illness (SANE Australia - 1800 688 382) Understanding and Coping With Schizophrenia: 14 Principles for the Relatives by Ken Alexander (1991; Schwartz & Wilkinson publishers) When Someone You Love Has a Mental Illness: A Handbook for Family, Friends and Caregivers by Rebecca Woolis (1992; Putnam publishers) With A Little Help: Choosing and Assessing Mental Health Therapists by Deborah Saltman (1996; Choice Books)
Disclaimer: The information provided is to be used for educational purposes only. It should not be used as a substitute for seeking professional care in the diagnosis and treatment of mental health disorders. Information may be reproduced with an acknowledgement to the Mental Health Association NSW. This, and other fact sheets are available for download from www.mentalhealth.asn.au. This fact sheet was last updated in Winter, 2002.
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