Understanding Schizophrenia

Schizophrenia is a serious mental disorder in which people lose the ability to interpret reality in a normal way. It is a disorder that affects a person's ability to think, feel and behave normally. Schizophrenia usually results in a combination of delusions, hallucinations, and mental disorientation that impairs thinking and behavior, this affects day to day functioning, and can be disabling.

Background:

Schizophrenia is named from the Greek words ‘schizein’ and ‘phren’ which mean

‘to split’ and ‘mind’, respectively. The early definition of schizophrenia literally translated to ‘the fragmentation of psychological functioning’. Hence, for schizophrenics, ‘the personality loses its unity’.

Schizophrenia is a psychotic disorder. This means that it is a disorder relating to the mind.?

SYMPTOMS AND DIAGNOSIS

Schizophrenia is marked by the following symptoms:

Positive Symptoms of Schizophrenia:

Positive symptoms are highly exaggerated perceptions, ideas, or actions. The person has trouble differentiating what’s real from what isn’t. "Positive" here means the presence (rather than absence) of symptoms. They can include:

Delusions

Delusions are erroneous beliefs. These beliefs are often misinterpreted. Schizophrenic individuals experience delusions which vary in terms of content, these are:

• Persecutory delusions - the belief that an individual is being made to suffer, tricked, ridiculed, or being spied upon.
• Referential delusions - the belief that certain comments, gestures, or passages from lyrics, newspapers or books are being directed towards the schizophrenic person.
• Delusions of grandeur - Belief that you are a famous or important figure, such as Lord Rama or Ashoka. It may also involve the belief that you have unusual powers, such as the ability to fly.??????????????????????????????????????????????????????????????????????????????????
• Delusions of control - Belief that outside or alien forces are controlling one's thoughts or actions. Common delusions of control include:? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? Thought broadcasting (“My private thoughts are being transmitted to others”).? ? ? ? ? ? ? ? Thought insertion (“Someone is planting thoughts in my head”) and,? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? Thought withdrawal (“The CBI is robbing me of my thoughts”).

Hallucinations

Delusions occur in the ‘mind’ but hallucinations depend on the five senses. Auditory hallucinations are most common. It involves hearing voices not belonging to the individual. Threatening voices as well as two or more voices ‘talking’ to each other are common.

Disorganized Thinking

Disorganized thinking for schizophrenics can have many forms like:?

• Loose associations or Derailment - Jumping from one topic to another.
• Tangentiality - Answers completely unrelated to the question may be provided by an individual.?
• Incoherence - This disorganization may be so severe that an individual cannot be comprehended or understood at all.

Disorganized Behavior

This is marked by problems when it comes to goal-directed behavior, manner of dressing, and catatonic behaviors. In this case, a schizophrenic individual may find it difficult to complete activities like bathing and dressing properly in order to go to school or to work, and may display agitated behavior even when no environmental triggers are present.

In terms of catatonic or disorganised behaviors, a schizophrenic individual may display any or all of the following:

? Catatonic stupor - being completely unaware of the environment

? Catatonic rigidity - resistance to be moved, and maintaining a rigid posture

? Catatonic negativism - resisting instructions or efforts to move or to be moved

? Catatonic posturing - assuming bizarre body postures

? Catatonic excitement - excessive movement or activity without stimulation

Important Notes:

• When assessing schizophrenia in relation to disorganized behavior, one must be careful to distinguish between simple, aimless movements from those that are spurred by delusional beliefs.
• In addition, the presence of catatonic symptoms does not immediately indicate schizophrenia. Note that these symptoms are also present in other disorders such as in Mood Disorders that have catatonic symptoms, Movement Disorders Induced by Medication and Catatonic Disorder due to a Medical Condition.

Negative Symptoms of Schizophrenia:

Negative symptoms refer to an absence or lack of normal mental function involving thinking, perception and behavior. You might notice:

? Affective flattening – a condition where a person’s face becomes immobile or

unresponsive, coupled with poor eye contact and reduced bodily language.

? Alogia - also called ‘poverty of speech’, it is characterized by a decrease in speech

fluency and productivity. (It is different from unwillingness to speak which requires a different clinical intervention altogether).

? Avolition - a condition characterized by an inability to engage in planned activities.

The associated negative symptoms for schizophrenia are:

? Anhedonia - the loss of pleasure or interest

? Dysphoric mood - which takes the form or anger, anxiety, or depression

The other associated features of schizophrenia are:

? Display of inappropriate affect

? Disturbances in sleep patterns

? Lack of interest to eat or refusing food (this is a consequence of an individual’s

delusions)

? Abnormal psychomotor activities such as rocking, pacing, and apathetic immobility

? Difficulty in concentrating, which is a consequence of the individual’s preoccupation

with his or her thoughts

? Some cognitive dysfunctions may manifest, although limited in nature

? Confusion, disorientation, and memory impairment, especially when the negative

symptoms are severe

? Depersonalization may happen which can progress to delusional levels

? Lack of insight

DIAGNOSIS

In order for schizophrenia to be diagnosed, an individual must meet certain requirements of symptoms as set by DSM – 5. The Diagnostic and Statistical Manual of Mental Disorders (DSM–5) is the result of effort by hundreds of international experts in all aspects of mental health for more than 10 years.?

There are five sets of criterions that need to be considered:

Criterion A. An individual must meet two of the five criterions set forth, and at least one of the first three:

? Delusions

? Hallucinations

? Disorganized thinking

? Disorganized (or catatonic) behavior

? Negative symptoms

Criterion B. There must be a deterioration in the individual from a previous level of functioning in areas of life such as self-care, social relations, and work.

Criterion C. Schizophrenic tendencies must be experienced by the individual for at least six months. Such duration should include a manifestation of the symptoms listed in Criterion A.

Criterion D. There must be a manifestation of a full manic or depressive syndrome in the individual as defined by Criteria A and B of the major manic or depressive episode.

Criterion E. The disorder must have been active before the age of 45.

Criterion F. The symptoms must not be due to mental retardation or any organic mental disorder.

In sum, the diagnosis of schizophrenia involves two things:?

• First is that the symptoms displayed must not be indicative of other mental disorders; and?
• Second, that the symptoms should not result from substance abuse, a medical condition or medication. For the former, other mental disorders must be ruled out before the finalization of the diagnosis.

CAUSES OF SCHIZOPHRENIA

• Schizophrenia, currently, has no definitive cause.
• Instead, according to experts, the development of schizophrenia in a person is a function of Risks and Triggers. Therefore, when exposed in suitable environments, or when subjected to certain triggers, those people who are predisposed to developing such a disorder are more likely to manifest symptoms.?

Let's take a look at the risks and the triggers that lead to the manifestation of schizophrenic symptoms.

RISKS

Genetics

• According to this hypothesis, schizophrenia runs in the blood, it is supported by

research on identical twins.?

• Even when raised in different environments, there's a 1 in 2 chance that a twin will develop schizophrenia if the other does. For fraternal twins, there's a 1 in 7 chance that one will develop schizophrenia if the other does.?

Research data suggests the following incidence rates:

? 9% in case of siblings.

? 14% in the case of children with one parent who has schizophrenia.

? 37% in the case of children whose both parents have schizophrenia.

Though there are other risk factors and triggers that need to be considered before a diagnosis is deemed final.

Brain Development

Studies are indicative of differences in the brain structure of those who are diagnosed with schizophrenia, although these differences are subtle. Overall, the findings have led to the contention that schizophrenia may partly be a brain development disorder.

Neurotransmitters

• According to researchers there is a connection between certain drugs and

schizophrenia.?

• Drugs designed to alter the levels of neurotransmitters in the brain were also found to relieve some of the symptoms of schizophrenia.?
• The neurotransmitters most closely related to schizophrenia are serotonin and dopamine. Neurotransmitters are “the messengers of the brain”; and serotonin and dopamine are only two of them.?
• Serotonin is responsible for communicating the feeling of happiness and well-being while dopamine controls the brain’s pleasure and rewards center.
• The levels of both neurotransmitters affect a person’s perceived reality and cause the manifestation of schizophrenic symptoms.

Pregnancy and Complications at Birth

• Research has also shown a correlation between schizophrenia and pregnancy complications.
• Complications during pregnancy such as premature birth, low birth weight, and asphyxia, or the lack of oxygen at birth were found in people who developed Schizophrenia.?
• Birth complications, collectively, can also affect the development of the

brain’s structure.

Note:

• The risk factors discussed above only show some of the possible causes of schizophrenia.?
• They cannot be considered as sole determinants in building a person’s disorder history. They should also not become the single-handed basis for planning treatment.?
• It is best to consult with a psychological professional for proper intervention if one suspects having schizophrenia.

TRIGGERS

‘Triggers’ represent the precursors to the development of schizophrenic symptoms and do not directly cause schizophrenia.

Stress

Emotionally-charged events usually cause high levels of stress. These include death and consequent bereavement, the loss of a home or a job, the end of a marriage or a relationship, and different forms of abuse such as physical, emotional, and sexual.

Drug Misuse and Abuse

• Certain drugs, like LSD, cocaine, marijuana, and other amphetamines have been proven to trigger schizophrenic symptoms to manifest among people who are susceptible.
• In the case of amphetamine use, consequent psychotic episodes with continued abuse can progress to full-blown schizophrenia.?
• Studies have also shown that individuals who have started abusing marijuana under age 15 are more likely to develop schizophrenia by the time they reach the age of 26.

Interventions

Schizophrenia requires lifelong intervention even when its symptoms have ceased to manifest. There is no cure for schizophrenia, though there are various types of interventions designed to help manage its symptoms.?

These are: medical and psychosocial therapy.

On top of these, hospitalization may also be required to ensure that the affected individual gets proper nutrition and enough sleep. Hospitalization ensures

safety of the individual, especially when the symptoms are severe and may be necessary in order to prevent the individual from neglecting physical hygiene.

Medical Intervention

Antipsychotic drugs are the most commonly used medications in managing

schizophrenic symptoms. Problems in the brain’s neurotransmitters can lead to the manifestation of schizophrenic symptoms, antipsychotic medications are administered in order to balance neurotransmitter levels, especially dopamine.?

A psychiatrist may try multiple antipsychotic drugs, and possibly a combination of them in order to determine which works best for a patient. At times, antipsychotic drugs

can also be combined with other types of drugs such as anti-anxiety medication, or

antidepressants.

These medicines have side effects so it's important that an individual discusses

what these are with the psychiatrist. Also, not all patients are always willing to take pills, some may prefer injections as the mode of administration.

Psychosocial Interventions

Psychosocial (psychological and social) interventions should be implemented along with?

medical treatment. The following are the types of interventions that may be implemented once the schizophrenic symptoms have subsided:

• Individual Psychotherapy

This helps the person to spot early warning signs of schizophrenic symptom relapse and also helps to realign the person’s thought processes with objective reality. Learning how to spot signs of a relapse shall help the individual to manage themselves until professional help becomes available. It also helps to normalize an individual’s thought processes, enabling them to recognize what’s real and what’s not.

• Cognitive Behavior Therapy

Also known as CBT, it is aimed at changing an individual’s thoughts and behavior. Delusions and hallucinations cause irrational thoughts. An individual can be taught how to manage such delusional and hallucinatory thoughts by undergoing CBT. It includes being aware of the triggers

and how to respond in order to minimize their effects.

• Cognitive Enhancement Therapy

Also known as CET and ‘cognitive remediation’, this approach teaches

individuals how to better identify social triggers that lead to psychotic episodes. Upon identifying triggers, the individuals are taught how to reorganize their thought processes, attention and memory. This therapy integrates computer-based training into the overall procedure.

• Family Therapy

Immediate family of a schizophrenic patient also needs support, and as such, the importance of going through family therapy cannot be understated. Some of the things that will be discussed during the therapy include coping strategies,

information about the disorder, strategies for dealing with a schizophrenic person, and also learning how to prevent emotional breakdowns. Family members should be aware that they partly play a role towards an affected member’s road to effective recovery. They must learn how to properly relate with a schizophrenic person.

• Social Skills Development

Upon being diagnosed with schizophrenia a person will notice changes in the way he or she relates to the people around them, as well as how they deal with the day to day demands of life. Though a small number of schizophrenics fully recover and get reintegrated into the society, it’s not usually the case for most. As schizophrenic symptoms are recurring, affected individuals need to learn to make adjustments in order to apply themselves adequately socially. They’ll be an active player in their daily routines by doing so.

• Vocational Training and Rehabilitation

Affected persons may find it difficult to keep their regular jobs because of the nature of the symptoms of schizophrenia. Which will be even more likely in case their jobs are stressful and demanding. There’s no telling about the recurrence and severity of an individual's symptoms, this may cause issues that can affect their employment. For these very reasons it is better if schizophrenic individuals work in jobs that are fit to their circumstances and their condition. Thus, the goal of vocational training and rehabilitation is to prepare them for the prospect of employment, finding employment, and staying in such employment. It’s also useful for individuals with schizophrenia to reach out to their communities.

This is especially true if their communities offer support programs for people affected by schizophrenia.

COMORBIDITY

‘Comorbidity’ is the ‘simultaneous presence’ or ‘co-occurrence’ of two or more chronic disorders in the same individual. Some schizophrenic symptoms are similar to other psychotic disorders due to which there's a high chance of comorbidity. This means that

a schizophrenic individual can develop other mental disorders, or that other mental disorders can lead to schizophrenia.

Based on research findings, the following disorders may coexist with

schizophrenia:

? Panic Disorder

? Post-Traumatic Stress Disorder

? Obsessive-Compulsive Disorder

? Depression

• The underlying concepts related to comorbidity are experiences, symptoms and habits.
• Other mental disorders have similar features, just like Schizophrenia, thereby sharing similar symptoms. It’s important for this reason to arrive at a definite diagnosis by performing different types of tests.
• An individual’s experiences also play a role in comorbidity. For example, an individual diagnosed with PTSD can develop a heightened sense of awareness or hypervigilance perceiving pending danger even when such danger isn’t really present. Such Hypervigilance, if it becomes severe, can cause delusions and hallucinations in a person.?
• Habits too can spur comorbidity. Research for Schizophrenia has found that those who develop the disorder often had a history of substance abuse.

Why Comorbidity Matters

Knowledge about comorbidity matters due to the following reasons:

• Comorbidity is high in mental disorders, it almost always happens

when the diagnosis is a mental disorder.

• It helps in making an accurate diagnosis. Thus, It must be taken into account when studying a case for the purpose of diagnosis. An incorrect diagnosis may be made if it is excluded from an individual’s overall assessment.
• Comorbidity helps with the prevention of the disease. For example, medical professionals, if an individual has anxiety symptoms, can help prevent the co-occurrence of other disorders by reducing drug medications in the intervention plan accordingly.
• Comorbidity helps in understanding a patient’s quality of progress. Studies

found that people having comorbid mental disorders respond poorly to treatment, the course of their disorder even worsened over time. Thus it can give clinical

insights as to how treatment should be structured for such people.

• It has a lot of implications in a treatment. For example, schizophrenia developed due to substance abuse may be treated by managing the substance abuse aspect itself.
• It gives insights into the relationship between the severity of symptoms and cause of habits and vice versa. For example, among individuals diagnosed with depression, there is a high level of alcohol consumption.

Living with a Schizophrenic

Remember the following points if you are a family member of someone who has been diagnosed with schizophrenia:

? You can’t cure your loved one’s condition no matter how hard you try. This applies to other types of disorders and diseases too, especially mental disorders.

? At times your loved one’s symptoms may seem to be getting worse, and there will be times when they might seem to improve.

? You might be giving too much of yourself into the helping relationship if a feeling of resentment is cropping up. There are times when you need to keep your distance.

? It will be hard to accept that your loved one is schizophrenic but you must remember that it’s equally hard for him or her to do the same.

? Making your other relatives accept that one of your loved ones is schizophrenic will be very hard. Acceptance by everyone in the family is ideal but it rarely happens.

? Attempting to reason with your loved one while he or she is having a psychotic episode won’t work. It is best to just be quiet and ensure that they don't inflict harm to themselves or to others.

? You may start to hate the person because of the symptoms that he or she is manifesting. But please remember this: the person is separate from the disorder. Hate the disorder if you have to but not the person.

? Similarly, the side effects of medication are separate from the person and the disorder. Recognize these side effects and respond to them as such.

? You should not blame anyone for your loved one’s disorder. While studies show that immediate family members are more likely to develop schizophrenia once it manifests in one member, they should not blame their parents, grandparents, or anyone else.

? Don’t neglect yourself in the process of helping your loved one cope with the disorder, you shouldn’t ignore your own needs or wants. Keep in mind that schizophrenic symptoms don’t really go away, so find time for you.

? Mental disorders carry a social stigma which stems from the lack of education, from misunderstanding, and from fear or apprehension. Understand that a mental disorder is nothing to be ashamed of, it exists, and it does affect people.

? Know your expectations and base them on facts. Build these expectations from the nature of the disease and what the doctor tells you. You shouldn’t over-expect nor should you expect for the worst to happen.?

? The success of individuals, or their response to treatment or interventions, varies. You should not compare your loved one’s progress with that of others. See if there’s something that you can do to help your loved one. Always consult with the doctor first for validation when doing something out of the recommended treatment plan.

? Family conflicts may arise. Don’t expect everyone in the family to be readily accepting of your loved one’s condition, to be agreeable with the treatment plan, to respond well to psychotic episodes, to be supportive of any decisions, and to fully understand the nature of schizophrenia - even if you do.

? As you deal with the disorder on your own, you will need support from medical institutions as well as other people around you. Letting out your feelings once in a while will help you de-stress by having some fun.

? Any conflicted relationship developed in response to your loved one’s condition may spill over into other relationships. Recognize the warning signs as you may re-enact the conflicted relationship without being aware of it.

? Do not set expectations, keep in mind that your loved one has limited capabilities now. Provide them with the support and encouragement they need in order to cope with the disorder.

? Remember that if you don’t take care of yourself, then you won’t be able to take care of others. Also, if you can’t help a schizophrenic, you can at least help others who are helping him or her.

? Don’t take it personally if your loved one lashes out at you. Strong reactions or emotions in schizophrenics are caused by their symptoms. It will be normal for you to react, but remember that reacting is different from responding.

? The mental disorder of your loves one is not a definite indication of their mental health.

? Try and learn more about schizophrenia and its comorbid disorders. Educating yourself will help you understand different ways in which you can help someone who is affected with the disorder.

When your family member has a psychotic episode, remember to not:

? Threaten them as it may cause harmful behavior.

? Shout, as your loved one may be ‘hearing’ other voices in his or her head.

? Criticize, as it doesn’t really do anything good to help your loved one.

? Squabble. Instead, follow your doctor’s advice on what to do in this situation.

? Bait the person. If he or she acts out his or her threats, you may not be ready for the consequences.

? Continuously touch or make eye contact, as it may prompt unwanted reactions.

? Comply with what your loved one says, if it does not cause harm to anyone. Doing so will give him or her a sense of control.

? Get angry or express irritation or frustration.

? Entertain any visitors. It’s actually more helpful if there are fewer people during the episode.

? Increase distractions in an attempt to calm the person. Instead, turn off any distractions like the TV or radio.

Instead, aim to:

? Be friendly and warm

? Be accommodating and accepting

? Be supportive and encouraging

? Be attentive and a good listener

? Be inclusive

? Be respectful

You can also lessen the likelihood of a relapse through the following:

? Creating a supportive and tolerant environment at home.

? Keeping the home atmosphere calm and stress-free.

? Giving your relative enough physical and psychological space.

? Limiting hostile behavior to discourage its progress in severity.

? Recognizing each stride towards developing more independence.

? Taking care of yourself.

? Staying with the present.

Communicating with a Schizophrenic

The external environment is often overwhelming for a schizophrenic. Effective communication is key to ‘calming’ them down. This is a skill that you will have to learn when you talk to a person with schizophrenia (or with any mental disorder).

Three elements of good communication are:

Knowing when to talk

• Don’t bring up something important to your loved one who is suffering from schizophrenia if you’re upset or overwhelmed with negative emotions.?
• You will need to compose yourself first just as you’d do when talking about something serious with another adult. You'll be able to focus and speak clearly when you’ve calmed down.

Knowing what to talk about

• You can’t talk about everything, especially not about problems related to the disorder. It may cause your loved one to become upset.?
• When talking about problems, prioritize which ones bothers you or your family members the most. Be very specific when bringing them up. For example, if the loved one plays loud music during the day or night, tell them calmly that you’d like them to not do that, and explain why.

Knowing how to talk

• Communicating can be done in two ways: verbal and non-verbal. You should consider both when you communicate.?
• Verbal communication is what you say, and non-verbal communication is the way you say it. So, when you communicate verbally, talk simple and be concise and specific.?
• Take note of your voice, your tone, posture, facial expression, and physical distance as you tell your loved one what you have to say. In most cases, how you say something is more important than what you say.

Conclusion

• The exact causes of schizophrenia aren't known. A combination of genetics, environment and altered brain chemistry and structure are known to play a role.
• Schizophrenia is characterized by thoughts or experiences that seem out of touch with reality, decreased participation in daily activities and disorganized speech or behavior. Difficulty with concentration and memory may also be present.
• Treatment is usually lifelong and involves a combination of medications, psychotherapy and coordinated speciality care services inclusive of but not limited to hospitalization / rehabilitation.

Ajitinder Sandhu