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Schizophrenia
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Definition
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Schizophrenia is a disabling, chronic, and severe mental illness that affects more than 2 million Americans age 18 and over. Symptoms include hearing internal voices, thinking that other people are reading one's mind, controlling one's thoughts, or plotting harm, which may leave a person feeling fearful and withdrawn. Their disorganized behavior can be perceived as incomprehensible or frightening.
Regardless of available treatments that can relieve many problems associated with the illness, most people with schizophrenia continue to suffer some symptoms throughout life. No more than one in five people recovers completely. Schizophrenia affects men and women equally and usually appears by late adolescence or early adulthood. Women may not display symptoms until their late 20s or early 30s.
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Symptoms
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The first signs of schizophrenia often appear as confusing, or even shocking, changes in behavior. Coping with the symptoms can be especially challenging for family members who remember how vital and present a person was before illness. The symptoms of schizophrenia are categorized into three groups: positive, negative, and disorganized. Positive symptoms refer to the presence of symptoms, such as hallucinations and delusions that should not be there. Negative symptoms indicate the absence of characteristics that are present in normal individuals: emotional expression, pleasure and normal speech patterns. Disorganized symptoms refer to difficulty in communicating with others, interpreting surroundings and feelings, and to their slow movements and repetitive gestures.
The sudden onset of severe psychotic symptoms is referred to as an "acute" phase of schizophrenia. "Psychosis" is a state of mental impairment marked by hallucinations, which are disturbances of sensory perception, and delusions, which result from an inability to separate real from unreal experiences. Other symptoms including social isolation or withdrawal, unusual speech, thinking, or behavior, may precede, be seen along with, or follow the psychotic symptoms.
Some people have only one such psychotic episode; others have many episodes over a lifetime, but lead relatively normal lives during the interim periods. "Chronic" schizophrenia refers to recurring patterns of illness from which a person often does not fully recover and typically requires long-term treatment to control symptoms.
Symptoms may include the presence of two or more of the following for at least one week:
Distorted Perceptions of Reality: Perceptions of reality that are strikingly different from the reality shared by others, which may leave sufferers feeling frightened, anxious, and confused. Due to these misperceptions, people with schizophrenia may experience sporadic bouts of seeming distant, detached, preoccupied, sitting rigidly for hours. Other times they may move about constantly, appearing wide-awake, vigilant, and alert.
Hallucinations and Illusions: Disturbances of perception that occur without connection to an appropriate source. They can be visual, tactile, gustatory, olfactory, and auditory. Voices may describe the patient's activities, carry on a conversation, warn of imminent dangers, or even give orders to the individual. Illusions occur when a sensory stimulus is present but incorrectly interpreted by the individual. For example, the sounds of crashing waves may be interpreted as gunfire.
Delusions: False personal beliefs that are unrelated to reason. Delusions may take on different themes. In a paranoid situation, a person may have delusions of persecution and think they are being cheated, harassed, conspired against, or poisoned. They also might have delusions of grandeur, in which they may believe they are famous or an important figure. A delusion might mean believing that a neighbor is controlling their behavior with magnetic waves or that people on television are directing special messages to them.
Thought Disorder Schizophrenia often affects a person's ability to think straight, and an inability to concentrate or focus attention.
People with schizophrenia may not be able to sort out what is relevant or not relevant to a situation. An inability to connect thoughts into logical sequences can make conversation very difficult and may encourage social isolation. If people cannot make sense of what an individual is saying, they are likely to become uncomfortable.
Emotional Expression
People with schizophrenia often show a "blunted" or "flat" affect which is a severe reduction in emotional expressiveness. Other symptoms may include a lack of normal emotion, speaking in monotone, diminished facial expressions, an extremely apathetic appearance, social withdrawal, and having nothing to say. Motivation can be greatly decreased, resulting in a person spending entire days with no activity, even neglecting hygiene.
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Causes
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There is no known single cause of schizophrenia. Many diseases result from the interplay of genetic, behavioral, and other factors which may be the case for schizophrenia as well. While scientists do not yet understand all of the factors that produce schizophrenia, researchers are working to determine the factors that may lead to the illness.
Schizophrenia runs in families and therefore might be an inherited illness. People who have a close relative with schizophrenia are more likely to develop the disorder. A child whose parent has schizophrenia has about a 10 percent chance compared to the risk in the general population of about 1 percent.
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Treatment
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Since schizophrenia may not be a single condition and its causes are not yet known, treatment methods are based on both clinical research and experience. These approaches are chosen on the basis of their ability to reduce the symptoms of schizophrenia and to lessen the chances that symptoms will return.
Hospitalization
Hospitalization is necessary during the acute phase of the illness. It is necessary when the patient is at risk because of serious suicidal thoughts or his unable to care for himself. Hospitalization is also necessary to treat delusions, hallucinations, or problems with drugs and alcohol.
Medication
Anti-psychotics have greatly improved the outlook for individual patients as they reduce the psychotic symptoms and usually allow the patient to function more effectively and appropriately. Antipsychotic drugs are currently the best treatment available, but they do not "cure" schizophrenia or ensure that there will be no further psychotic episodes. Only a qualified physician can make the choice and dosage of medication in the medical treatment of mental disorders. The dosage of medication is individualized for each patient; the amount of drug needed to reduce symptoms may vary.
The large majority of people with schizophrenia show substantial improvement when treated with antipsychotic drugs. Some patients, however, are not helped by the medications and a few do not seem to need them. It is difficult to predict which patients will fall into either group and to distinguish them from the large majority of patients who do benefit from treatment with antipsychotic drugs.
New antipsychotic drugs (atypical anti-psychotics) have been introduced since 1990. The first of these, clozapine, has proven more effective than other antipsychotics. There is the possibility of severe side effects—in particular a condition called agranulocytosis or loss of white blood cells that fight infection. Newer antipsychotic drugs, such as risperidone and olanzapine, are safer than the older drugs. Several additional antipsychotics are currently under development.
Antipsychotic drugs are often very effective in treating symptoms of schizophrenia, particularly hallucinations and delusions. However they may not be as helpful with other symptoms, such as reduced motivation and emotional expressiveness. Older antipsychotics (neuroleptics) such as haloperidol or chlorpromazine, may produce side effects that resemble symptoms that are more difficult to treat. Often, lowering the dose or switching to a different medicine may reduce these side effects. The newer medicines, including olanzapine, quetiapine, and risperidone, appear less likely to have this problem. Sometimes when people with the illness become depressed, other symptoms can appear to worsen. The symptoms may improve with the addition of an antidepressant medication.
Patients and families sometimes become worried about the antipsychotic medications used in treating this disease both in terms of side effects and possible addiction. However, antipsychotic medications do not produce euphoria or addictive behavior in people who take them.
Another misconception about antipsychotic drugs is that they act as a kind of mind control, or a chemical straitjacket. Antipsychotic drugs used at the appropriate dosage do not knock out people or take away their free will. While these medications can produce a sedative effect that can be useful when treatment is initiated, the utility of the drugs is not due to sedation but to their ability to diminish the hallucinations, agitation, confusion, and delusions of a psychotic episode. Thus, antipsychotic medications should eventually help an individual to deal with the world more rationally.
Medication Compliance
Antipsychotic medications reduce the risk of future psychotic episodes in patients who have recovered from an acute episode. But even with these drugs, some people may suffer relapses. Far higher relapse rates are seen when medication is discontinued. In most cases, it would not be accurate to say that continued drug treatment prevents relapses; rather, it reduces intensity and frequency. The treatment of severe psychotic symptoms generally requires higher dosages than those used for maintenance treatment. If symptoms reappear on a lower dosage, a temporary increase in dosage may prevent a full-blown relapse.
Relapse is more likely when antipsychotic medications are discontinued or taken irregularly so it is important that patients work with their doctors to stick to their treatment. It is often difficult for people with schizophrenia to adhere to a plan, but it can be made easier with the help of several strategies and can lead to improved quality of life.
There are a variety of reasons why people with schizophrenia may not adhere to treatment. Patients may not believe they are ill and may deny the need for medication, or they may have such disorganized thinking that they cannot remember to take their daily dose. Physicians may neglect to ask patients how often they are taking their medications, or they may be unwilling to accommodate a patient's request to change dosages or try a new treatment. Some patients report that side effects seem worse than the illness itself. Furthermore, substance abuse can interfere with treatment, leading patients to discontinue medications. When a complicated treatment plan is added to any of these factors, good adherence may become even more challenging.
Fortunately, there are many strategies that doctors, patients, and families can use to improve adherence and prevent worsening of the illness. Some antipsychotic medications, including haloperidol, fluphenazine, perphenazine, and others, are available in long-acting injectable forms that eliminate the need to take pills. A major goal of research on treatments for schizophrenia is to develop a wider variety of long-acting antipsychotics, especially the newer ones with milder side effects, which can be delivered through injection. Medication calendars or pillboxes labeled with the days of the week can help patients and caregivers with medications that have or have not been taken. Using electronic timers or taking medication with meals can help patients remember and adhere to dosing schedules. Also, family members can help patients take their medication. In addition, doctors can identify when pill taking is a problem and can work with patients to make adherence easier.
Side Effects of Medication
Antipsychotic drugs, like virtually all medications, have unwanted side effects. Short-term side effects include drowsiness, restlessness, muscle spasms, dry mouth, tremor, or blurred vision. Most of these can be corrected by lowering dosage or by using other medications. Different patients have different treatment responses, so one drug may be more helpful than another.
One long-term side effect may pose a more serious problem. Tardive dyskinesia (TD) is a disorder characterized by involuntary movements most often affecting the mouth, lips, and tongue, and sometimes other parts of the body. It occurs in 15 to 20 percent of patients receiving older antipsychotic drugs, but TD can also develop in patients who have been treated with these drugs for shorter periods of time.
Antipsychotic medications developed in recent years all appear to have a much lower risk of producing TD. The risk is not zero, however, and they can produce side effects such as weight gain. In addition, if given at too high of a dose, the newer medications may lead to problems such as social withdrawal and symptoms resembling Parkinson's. Nevertheless, the newer antipsychotics are a significant advance, and their optimal use in people with schizophrenia is a subject of current research.
Psychosocial Treatment
Antipsychotic drugs have proven very helpful in relieving the psychotic symptoms of schizophrenia—hallucinations, delusions, and incoherence—but are not consistent in relieving the behavioral symptoms of the disorder. Even when patients with schizophrenia are relatively free of psychotic symptoms, many still have huge difficulty with communication, motivation, self-care, and establishing and maintaining relationships. Moreover, because patients with schizophrenia frequently become ill during the critical career-forming years of life (ages 18 to 35), they are less likely to complete the training required for skilled work. As a result, many with the illness not only suffer thinking and emotional difficulties, but lack social and work skills as well.
Psychosocial treatments may help. While psychosocial approaches have limited value for acutely psychotic patients, they may be useful for patients with less severe symptoms. Various forms of psychosocial therapy are available; these focus on improving social functioning in a variety of settings. Some of these approaches are described here but their availability varies greatly from place to place.
Rehabilitation
Rehabilitation includes a wide array of non-medical interventions emphasizing social and vocational training to help patients and former patients overcome difficulties. Programs may include vocational counseling, job training, problem-solving, money management skills, use of public transportation, and social skills training.
Individual Psychotherapy
Individual psychotherapy involves regularly scheduled talks between the patient and a mental health professional. The sessions may focus on current or past problems, experiences, thoughts, feelings, or relationships. A positive relationship with a therapist gives the patient a reliable source of information, sympathy, encouragement, and hope, all of which are essential for managing the disease. The therapist can help patients better understand and adjust to living with schizophrenia by educating them about the causes, symptoms or problems they may having. However, psychotherapy is not a substitute for antipsychotic medication.
Family Education
Oftentimes patients with schizophrenia are discharged from the hospital into the care of their family, so it is important that family members understand the difficulties associated with the illness and learn ways to minimize the patient's chance of relapse by having an arsenal of coping strategies and problem-solving skills to manage their ill relative.
Self-Help Groups
Self-help groups are becoming increasingly common. Although not led by a professional therapist, these groups may be therapeutic because members provide continuing mutual support as well as comfort in knowing that they are not alone. Self-help groups may also serve other important functions. Families working together can more effectively serve as advocates for research and treatment.
Community Support
A patient's support system may come from several sources, including the family, a professional residential or day program provider, shelter operators, friends, roommates, case managers, churches and synagogues, and others. Because many patients live with their families, discussion frequently uses the term family. However, this should not be taken to imply that families ought to be the primary support system. There are many situations in which people with schizophrenia will need help from other people including getting treatment, legal advocacy/protection, and caregiving.
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Sources
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- National Alliance of Mental Illness
- National Institute of Mental Health
- US Department of Health and Human Services
- Archives of General Psychiatry
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Copyright © 2003-2010. Cognode, Inc.
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