Schizophrenia

What Is Schizophrenia?

Schizophrenia is a chronic, severe, and disabling brain disorder that has affected people throughout history.

People with the disorder may hear voices other people don't hear. They may believe other people are reading their minds, controlling their thoughts, or plotting to harm them. This can terrify people with the illness and make them withdrawn or extremely agitated.

People with schizophrenia may not make sense when they talk. They may sit for hours without moving or talking. Sometimes people with schizophrenia seem perfectly fine until they talk about what they are really thinking.

Families and society are affected by schizophrenia too. Many people with schizophrenia have difficulty holding a job or caring for themselves, so they rely on others for help.

Treatment helps relieve many symptoms of schizophrenia, but most people who have the disorder cope with symptoms throughout their lives. However, many people with schizophrenia can lead rewarding and meaningful lives in their communities. Researchers are developing more effective medications and using new research tools to understand the causes of schizophrenia. In the years to come, this work may help prevent and better treat the illness.

The different types of schizophrenia

·       Paranoid schizophrenia -- a person feels extremely suspicious, persecuted, or grandiose, or experiences a combination of these emotions.

·       Disorganized schizophrenia -- a person is often incoherent in speech and thought, but may not have delusions.

·       Catatonic schizophrenia -- a person is withdrawn, mute, negative and often assumes very unusual body positions.

·       Residual schizophrenia -- a person is no longer experiencing delusions or hallucinations, but has no motivation or interest in life.

·       Schizoaffective disorder--a person has symptoms of both schizophrenia and a major mood disorder such as depression.

Causes

Experts think schizophrenia is caused by several factors.

Genes and environment. Scientists have long known that schizophrenia runs in families. The illness occurs in 1 percent of the general population, but it occurs in 10 percent of people who have a first-degree relative with the disorder, such as a parent, brother, or sister. People who have second-degree relatives (aunts, uncles, grandparents, or cousins) with the disease also develop schizophrenia more often than the general population. The risk is highest for an identical twin of a person with schizophrenia. He or she has a 40 to 65 percent chance of developing the disorder.

We inherit our genes from both parents. Scientists believe several genes are associated with an increased risk of schizophrenia, but that no gene causes the disease by itself. In fact, recent research has found that people with schizophrenia tend to have higher rates of rare genetic mutations. These genetic differences involve hundreds of different genes and probably disrupt brain development.

Other recent studies suggest that schizophrenia may result in part when a certain gene that is key to making important brain chemicals malfunctions. This problem may affect the part of the brain involved in developing higher functioning skills. Research into this gene is ongoing, so it is not yet possible to use the genetic information to predict who will develop the disease.

Despite this, tests that scan a person's genes can be bought without a prescription or a health professional's advice. Ads for the tests suggest that with a saliva sample, a company can determine if a client is at risk for developing specific diseases, including schizophrenia. However, scientists don't yet know all of the gene variations that contribute to schizophrenia. Those that are known raise the risk only by very small amounts. Therefore, these "genome scans" are unlikely to provide a complete picture of a person's risk for developing a mental disorder like schizophrenia.

In addition, it probably takes more than genes to cause the disorder. Scientists think interactions between genes and the environment are necessary for schizophrenia to develop. Many environmental factors may be involved, such as exposure to viruses or malnutrition before birth, problems during birth, and other not yet known psychosocial factors.

Different brain chemistry and structure. Scientists think that an imbalance in the complex, interrelated chemical reactions of the brain involving the neurotransmitters dopamine and glutamate, and possibly others, plays a role in schizophrenia. Neurotransmitters are substances that allow brain cells to communicate with each other. Scientists are learning more about brain chemistry and its link to schizophrenia.

Also, in small ways the brains of people with schizophrenia look different than those of healthy people. For example, fluid-filled cavities at the center of the brain, called ventricles, are larger in some people with schizophrenia. The brains of people with the illness also tend to have less gray matter, and some areas of the brain may have less or more activity.

Studies of brain tissue after death also have revealed differences in the brains of people with schizophrenia. Scientists found small changes in the distribution or characteristics of brain cells that likely occurred before birth. Some experts think problems during brain development before birth may lead to faulty connections. The problem may not show up in a person until puberty. The brain undergoes major changes during puberty, and these changes could trigger psychotic symptoms. Scientists have learned a lot about schizophrenia, but more research is needed to help explain how it develops.

Who Is At Risk?

About 1% of Americans have this illness.

Schizophrenia affects men and women equally. It occurs at similar rates in all ethnic groups around the world. Symptoms such as hallucinations and delusions usually start between ages 16 and 30. Men tend to experience symptoms a little earlier than women. Most of the time, people do not get schizophrenia after age 45. Schizophrenia rarely occurs in children, but awareness of childhood-onset schizophrenia is increasing.

It can be difficult to diagnose schizophrenia in teens. This is because the first signs can include a change of friends, a drop in grades, sleep problems, and irritability—behaviors that are common among teens. A combination of factors can predict schizophrenia in up to 80% of youth who are at high risk of developing the illness. These factors include isolating oneself and withdrawing from others, an increase in unusual thoughts and suspicions, and a family history of psychosis. In young people who develop the disease, this stage of the disorder is called the "prodromal" period.

Signs & Symptoms

The symptoms of schizophrenia fall into three broad categories: positive symptoms, negative symptoms, and cognitive symptoms.

Positive symptoms

Positive symptoms are psychotic behaviors not seen in healthy people. People with positive symptoms often "lose touch" with reality. These symptoms can come and go. Sometimes they are severe and at other times hardly noticeable, depending on whether the individual is receiving treatment. They include the following:

Hallucinations are things a person sees, hears, smells, or feels that no one else can see, hear, smell, or feel. "Voices" are the most common type of hallucination in schizophrenia. Many people with the disorder hear voices. The voices may talk to the person about his or her behavior, order the person to do things, or warn the person of danger. Sometimes the voices talk to each other. People with schizophrenia may hear voices for a long time before family and friends notice the problem.

Other types of hallucinations include seeing people or objects that are not there, smelling odors that no one else detects, and feeling things like invisible fingers touching their bodies when no one is near.

Delusions are false beliefs that are not part of the person's culture and do not change. The person believes delusions even after other people prove that the beliefs are not true or logical. People with schizophrenia can have delusions that seem bizarre, such as believing that neighbors can control their behavior with magnetic waves. They may also believe that people on television are directing special messages to them, or that radio stations are broadcasting their thoughts aloud to others. Sometimes they believe they are someone else, such as a famous historical figure. They may have paranoid delusions and believe that others are trying to harm them, such as by cheating, harassing, poisoning, spying on, or plotting against them or the people they care about. These beliefs are called "delusions of persecution."

Thought disorders are unusual or dysfunctional ways of thinking. One form of thought disorder is called "disorganized thinking." This is when a person has trouble organizing his or her thoughts or connecting them logically. They may talk in a garbled way that is hard to understand. Another form is called "thought blocking." This is when a person stops speaking abruptly in the middle of a thought. When asked why he or she stopped talking, the person may say that it felt as if the thought had been taken out of his or her head. Finally, a person with a thought disorder might make up meaningless words, or "neologisms."

Movement disorders may appear as agitated body movements. A person with a movement disorder may repeat certain motions over and over. In the other extreme, a person may become catatonic. Catatonia is a state in which a person does not move and does not respond to others. Catatonia is rare today, but it was more common when treatment for schizophrenia was not available.

Negative symptoms

Negative symptoms are associated with disruptions to normal emotions and behaviors. These symptoms are harder to recognize as part of the disorder and can be mistaken for depression or other conditions. These symptoms include the following:

• "Flat affect" (a person's face does not move or he or she talks in a dull or monotonous voice)
• Lack of pleasure in everyday life
• Lack of ability to begin and sustain planned activities
• Speaking little, even when forced to interact.

People with negative symptoms need help with everyday tasks. They often neglect basic personal hygiene. This may make them seem lazy or unwilling to help themselves, but the problems are symptoms caused by the schizophrenia.

Cognitive symptoms

Cognitive symptoms are subtle. Like negative symptoms, cognitive symptoms may be difficult to recognize as part of the disorder. Often, they are detected only when other tests are performed. Cognitive symptoms include the following:

• Poor "executive functioning" (the ability to understand information and use it to make decisions)
• Trouble focusing or paying attention
• Problems with "working memory" (the ability to use information immediately after learning it).

Cognitive symptoms often make it hard to lead a normal life and earn a living. They can cause great emotional distress.

Behaviors that are early warning signs of schizophrenia include:

·       Hearing or seeing something that isn’t there

·       A constant feeling of being watched

·       Peculiar or nonsensical way of speaking or writing

·       Strange body positioning

·       Feeling indifferent to very important situations

·       Deterioration of academic or work performance

·       A change in personal hygiene and appearance

·       A change in personality

·       Increasing withdrawal from social situations

·       Irrational, angry or fearful response to loved ones

·       Inability to sleep or concentrate

·       Inappropriate or bizarre behavior

·       Extreme preoccupation with religion or the occult

Prognosis:

While no cure for schizophrenia exists, many people with this illness can lead productive and fulfilling lives with the proper treatment. Recovery is possible through a variety of services, including medication and rehabilitation programs. Rehabilitation can help a person recover the confidence and skills needed to live a productive and independent life in the community.

SPECIFIC TESTS, MEDICATION, TREATMENT

Schizophrenia, just like any other illness, requires the understanding of Doctors and others around the effected individual.  This disease can be difficult for friends and family members to understand and cope with.  Schizophrenia is a lifelong condition and requires a correct diagnosis and early treatment of the illness is best. People with Schizophrenia need the help and support of those around them, as this is a very difficult disease to live with. When a diagnosis is made, Doctors may begin a variety of different medications or treatments to help manage the condition. Even when the symptoms have subsided, treatment is still necessary.  Schizophrenia, being a lifelong condition, is not cured but treated.

            Treatment of schizophrenia is primarily treated through medication. Medications are used to treat and control the psychosis associated with schizophrenia (delusions, hallucinations etc.). Unfortunately, a life-long drug regimen is hard to maintain and often gets neglected. This makes the ongoing treatment of schizophrenia difficult. Because of this, it is often necessary and successful when medications are used in conjunction with psychosocial support therapy. Psychosocial support therapy can be useful in helping the individual learn how to cope with his/her disease, find a job and have meaningful relationships with others in the home and community. For extreme conditions or severe symptoms, hospitalization may be necessary in order to ensure safety and to provide basic necessities such as food and hygiene.

Specific Tests

            There is no one specific test done to diagnose schizophrenia. When a doctor suspects that a patient has schizophrenia, medical and psychiatric histories are requested, the patient may undergo a series of laboratory tests. These lab tests can include blood tests (this may help rule out other conditions), screenings for drugs or alcohol, or an imaging study such as an MRI or CT scan.  Doctors will also observe the patients mental status by looking at and evaluating the patient’s demeanor, appearance and asking about thoughts, moods, delusions, hallucinations, substance abuse etc.

            Current research is ongoing, however, to find a reliable test to help diagnose schizophrenia. These include blood tests for schizophrenia, special IQ tests, eye tracking, brain imaging and smell tests (http://schizophrenia.com/diag.php#). These tests are in their infancy and are not widely used.

            The diagnostic criteria for schizophrenia from the DSM-IV are:

SCHIZOPHRENIA

Two or more symptoms, each present for a significant portion of time during a 1

month period

o Delusions

o Hallucinations

o Disorganized speech

o Grossly disorganized or catatonic behavior

o Negative symptoms

Social/occupational dysfunction

Continuous signs of disturbance persist for at least 6 months

Schizophrenia Subtypes

PARANOID TYPE

o Preoccupation with one or more delusions or frequent auditory

hallucinations

o None of the following are present: disorganized speech, disorganized

or catatonic behavior, flat or inappropriate affect

DISORGANIZED TYPE

o Disorganized speech, disorganized behavior, and flat or inappropriate

affect are prominent

CATATONIC TYPE

o Dominated by at least 2 of the following

Motoric immobility as evidenced by catalepsy (including waxy

flexibility) or stupor

Excessive motor activity

Extreme negativism (motiveless resistance to instruction or

maintenance of rigid posture) or mutism

Peculiarities of voluntary movement

Echolalia or echopraxia

RESIDUAL TYPE

o Absence of prominent delusions, hallucinations, disorganized speech,

and grossly disorganized or catatonic behavior

o Continuing evidence of the disturbance as indicated by the presence of

negative symptoms or 2 or more symptoms in an attenuated form

UNDIFFERENTIATED TYPE

If an individual suspects that they may have schizophrenia, they can take an online test to see if they have any symptoms commonly associated with schizophrenia or a related disorder

Important note: This test does not diagnose, treat or prevent schizophrenia or any other mental health issue in any way.

Yale University PRIME Screening Test

For accurate results, you must be entirely honest in your response to all twelve questions in this test. The test can be scored at the web site where you downloaded this screening test from (http://www.schizophrenia.com/sztest/). To complete the test, circle the response listed below the statement that best represents your level of agreement with the prior statement.

1. I think that I have felt that there are odd or unusual things going on that I can’t explain.

Definitely disagree

Somewhat disagree

Slightly disagree

Not sure

Slightly agree

Somewhat agree

Definitely agree

2. I think that I might be able to predict the future.

Definitely disagree

Somewhat disagree

Slightly disagree

Not sure

Slightly agree

Somewhat agree

Definitely agree

3. I may have felt that there could possibly be something interrupting or controlling my thoughts, feelings, or actions.

Definitely disagree

Somewhat disagree

Slightly disagree

Not sure

Slightly agree

Somewhat agree

Definitely agree

4. I have had the experience of doing something differently because of my superstitions.

Definitely disagree

Somewhat disagree

Slightly disagree

Not sure

Slightly agree

Somewhat agree

Definitely agree

5. I think that I may get confused at times whether something I experience or perceive may be real or may be just part of my imagination or dreams.

Definitely disagree

Somewhat disagree

Slightly disagree

Not sure

Slightly agree

Somewhat agree

Definitely agree

6. I have thought that it might be possible that other people can read my mind, or that I can read other’s minds.

Definitely disagree

Somewhat disagree

Slightly disagree

Not sure

Slightly agree

Somewhat agree

Definitely agree

7. I wonder if people may be planning to hurt me or even may be about to hurt me.

Definitely disagree

Somewhat disagree

Slightly disagree

Not sure

Slightly agree

Somewhat agree

Definitely agree

8. I believe that I have special natural or supernatural gifts beyond my talents and natural strengths.

Definitely disagree

Somewhat disagree

Slightly disagree

Not sure

Slightly agree

Somewhat agree

Definitely agree

9. I think I might feel like my mind is “playing tricks” on me.

Definitely disagree

Somewhat disagree

Slightly disagree

Not sure

Slightly agree

Somewhat agree

Definitely agree

10. I have had the experience of hearing faint or clear sounds of people or a person mumbling or talking when there is no one near me.

Definitely disagree

Somewhat disagree

Slightly disagree

Not sure

Slightly agree

Somewhat agree

Definitely agree

11. I think that I may hear my own thoughts being said out loud.

Definitely disagree

Somewhat disagree

Slightly disagree

Not sure

Slightly agree

Somewhat agree

Definitely agree

12. I have been concerned that I might be “going crazy”.

Definitely disagree

Somewhat disagree

Slightly disagree

Not sure

Slightly agree

Somewhat agree

Definitely agree

Medications

Medications to treat schizophrenia have long been in use and have been successful in their treatments of individuals with schizophrenia. There are two types of medications: atypical antipsychotics and conventional, or typical, antipsychotics.

            Atypical Antipsychotics: these are newer medications, many of which were introduced in the 1990’s, and are usually preferred because of the lower risk of debilitating side effects. These can include:

·      Aripiprazole (Abilify)

·      Clozapine (Clozaril)

·      Olanzapine (Zyprexa)

·      Paliperidone (Invega)

·      Quetiapine (Seroquel)

·      Risperidone (Risperdal)

·      Ziprasidone (Geodon)

Side effects of these medications can include weight gain, which can bring a risk of diabetes, rapid heartbeat, menstrual problems, sensitivity to the sun, and skin rashes.

These newer drugs are generally tolerated better by the patients than were the older drugs. These antipsychotic drugs can be effective at treating specific symptoms, such as hallucinations, but be rather ineffective in treating others, such as reduced motivation, depression and emotional expressiveness.

Conventional, or typical antipsychotics: These are generally the older medications introduced as early as the 1950’s. These drugs are used less because of the greater risk of serious side effects, some of which are similar to the effects of schizophrenia itself. These medications can include:

·      Haloperidol (Haldol)

·      Chlorpromazine (Thorazine)

·      Fluphenazine

·      Perphenazine

Side effects of antipsychotics

Some people have side effects when they start taking these medications. Most side effects go away after a few days and often can be managed successfully. People who are taking antipsychotics should not drive until they adjust to their new medication. Side effects of many antipsychotics include: dry mouth, blurred vision, low white blood cell count, fever, constipation and movement disorders such as stiffness, other side effects may include:

• Drowsiness
• Dizziness when changing positions
• Blurred vision
• Rapid heartbeat
• Sensitivity to the sun
• Skin rashes
• Menstrual problems for women.

Atypical antipsychotic medications can cause major weight gain and changes in a person's metabolism. This may increase a person's risk of getting diabetes and high cholesterol. A person's weight, glucose levels, and lipid levels should be monitored regularly by a doctor while taking an atypical antipsychotic medication.

Typical antipsychotic medications can cause side effects related to physical movement, such as:

• Rigidity
• Persistent muscle spasms
• Tremors
• Restlessness.

Long-term use of typical antipsychotic medications may lead to a condition called tardive dyskinesia (TD). TD causes muscle movements a person can't control. The movements commonly happen around the mouth. TD can range from mild to severe, and in some people the problem cannot be cured. Sometimes people with TD recover partially or fully after they stop taking the medication.

TD happens to fewer people who take the atypical antipsychotics, but some people may still get TD. People who think that they might have TD should check with their doctor before stopping their medication.

Psychosocial Therapy

            Psychosocial therapy is also an important part of treating schizophrenia.  Psychosocial therapy is most beneficial when used to help the patient once they are somewhat stabilized from their medication. Different forms of Psychosocial therapy can help patients deal with everyday challenges associated with schizophrenia such as difficulty communicating, work, keeping up relationships and self care.  Patients who regularly take part in psychotherapy are more likely to continue taking their medication and less likely to have a severe episode, have a relapse or be hospitalized. Psychotherapy can help the patient to better understand the disease and how to live with the disorder. Different forms of psychosocial therapy can include:

·      Family Education: People with schizophrenia are often under the care of their families. It is important for the family of the patient to be aware of challenges, symptoms, medications and other important issues relating to schizophrenia. Families can be an important part of helping the patient to cope with their disease and can be useful in developing problem solving skills

·      Self-help groups: self-help groups are becoming more common, this can be a great source of peer support and comfort. Professional therapists do not have to be involved.

·      Illness management skills: People with schizophrenia can be their own best resource in managing their schizophrenia. Patients can learn about schizophrenia and about useful treatments. Once this is done, they can take a more active role in managing their schizophrenia. They can better watch for warning signs of a relapse and learn how to respond which can help prevent further relapses.

·      Cognitive behavioral therapy (CBT): CBT is a type of therapy that focuses on thinking and behavior. CBT helps patients with symptoms that do not go away easily, even when they take medication. Therapists can teach patients how to test the reality of their thoughts and perceptions, how to ignore or not listen to their hallucinations and overall symptoms. CBT can also help reduce the severity of symptoms and reduce the risk of a relapse.

·      Hospitalization: Some patients with severe symptoms may require hospitalization. Hospitalization is necessary to treat severe delusions or hallucinations, an inability to care for ones self or suicidal thoughts. Hospitalization can be essential to help protect the patient from him/herself.

Potential Problems

            Schizophrenia can be difficult to treat because of some of the following:

·      The patient may not believe that they are ill or need any medication

·      The patient’s thinking is too disorganized and they may forget essential elements of their treatment.

·      The side effects of their medication can cause them to not want to continue taking them.

·      Substance abuse can interfere with the effectiveness of treatments.

Types of services that help a person with schizophrenia include:

·       Case management helps people access services, financial assistance, treatment and other resources.

·       Psychosocial Rehabilitation Programs are programs that help people regain skills such as: employment, cooking, cleaning, budgeting, shopping, socializing, problem solving, and stress management.

·       Self-help groups provide on-going support and information to persons with serious mental illness by individuals who experience mental illness themselves.

·       Drop-in centers are places where individuals with mental illness can socialize and/or receive informal support and services on an as-needed basis.

·       Housing programs offer a range of support and supervision from 24 hour supervised living to drop-in support as needed.

·       Employment programs assist individuals in finding employment and/or gaining the skills necessary to re-enter the workforce.

·       Therapy/Counseling includes different forms of “talk”therapy, both individual and group, that can help both the patient and family members to better understand the illness and share their concerns.

·       Crisis Services include 24 hour hotlines, after hours counseling, residential placement and in-patient hospitalization.

TR IMPLICATIONS

Therapeutic Recreation

            Schizophrenia is a serious and complicated disease. A CTRS helping a patient with schizophrenia must understand all aspects of schizophrenia in order to be able to help the patient most effectively.

            Therapeutic recreation is important in order to help manage the symptoms associated with schizophrenia.  Patients with schizophrenia experience a variety of symptoms that can affect different areas of their lives such as social skills, work, hygiene, daily living skills, or recreation and leisure skills. Undergoing therapeutic recreation can help to:

·      Aid the patient in sharing his/her thoughts more easily

·      Improve relationships

·      Find enjoyable activities to participate in during free time

·      Learn new skills and also for rehab purposes

·      Improve his/her self-image and improve their overall quality of life

·      Help learn skills that would be beneficial at work, home or school

·      Learn coping strategies

·      Find meaning in life, which can help people avoid indulging in their delusions

·      Find common surroundings, which can help a person distinguish what is real and what is not

·      Learn how to make individual and group decisions.

            TR Suggestions

·      Be aware of any and all medications the patient is on and know the side effects. If your patient is on a medication that makes them sensitive to the sun, you would not want to take them out on a boating trip!

·      Be aware of their family support situation and encourage positive family interaction. Encourage family support.

·      Support groups/peer support. It is good for patients to know that they are not alone. These groups can help them feel accepted and help improve self image.

·      Can take part in either active or passive activities. Active activities can include exercise and sports, while passive activities can be as simple as playing a board game or having a simple discussion. Both activities can help improve conversation and social skills, problem solving and decision-making. They can also reduce the frequency of negative thoughts and depression.

·      Always get to know your patient as well as you can, within reason, and get to know their strengths and weaknesses

Therapeutic recreation can provide great learning opportunities for those affected by schizophrenia. It can help reduce or alleviate symptoms and can improve physical, emotional and mental health status. Individuals with schizophrenia must learn appropriate and acceptable social skills in order to function properly outside of an institution and on their own. Therapeutic recreation can provide the outlet to help learn those appropriate social skills. Without this, individuals with schizophrenia may not be productive citizens or be able to contribute, as they would like to

            Researchers do recognize active forms of TR to be effective modalities in the treatment and prevention of mental illness. An active lifestyle leads to a healthier lifestyle and promotes greater well-being. While the benefits of TR have been found to be beneficial, there are few studies that have been done that address specific types of TR or specific activities and how they affect specific behaviors of the patient.

RESOURCES

·      National Alliance for the Mentally Ill (NAMI)

Colonial Place Three

2107 Wilson Blvd. Suite 200

Arlington, VA 22201-3042

Phone: 1-800-950-NAMI or (703) 524-7600

http://www.nami.org

·      National Mental Health Association (NMHA)

2000 N. Beauregard St., 6^th floor

Alexandria, VA 22314-2971

Phone: 1-800-969-6942 or (701) 685-7722

http://www.nmha.org

·      National Mental Health Consumers’ Self-Help Clearinghouse

1211 Chestnut St., Suite 1207

Philadelphia, PA 19107

Phone: 1-800-553-4539 or (215) 751-1810

http://www.mhselfhelp.org

·      National Alliance for Research on Schizophrenia and Depression (NARSAD)

60 Cutter Mill Rd., Suite 404

Great Neck, NY 11021

Phone: (516) 829-0091

http://www.narsad.org

·      National Institute of Mental Health (NIMH)

Science Writing, Press, and Dissemination Branch

6001 Executive Blvd., Room 8184, MSC 9663

Bethesda, MD 20892-9663

Phone: (301) 443-4513

http://www.nimh.nih.gov

·      Utah State Hospital

1300 E. Center St.

Provo, UT 84604

Phone: (801) 344-4400

Fax: (801)344-4225

Email: jgierisch@utah.gov