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Schizophrenia and Psychosis

Schizophrenia Information & Treatment Introduction
By Michael Bengston, M.D.

Throughout recorded history, the disorder we now know as schizophrenia has been a source of bewilderment. Those suffering from the illness once were thought to be possessed by demons and were feared, tormented, exiled or locked up forever. In spite of advances in the understanding of its causes, course and treatment, schizophrenia continues to confound both health professionals and the public. It is easier for the average person to cope with the idea of cancer than it is to understand the odd behavior, hallucinations or strange ideas of the person with schizophrenia. As with many mental disorders, the causes of schizophrenia are poorly understood. Friends and family commonly are shocked, afraid or angry when they learn of the diagnosis. People often imagine a person with schizophrenia as being more violent or out-of-control than a person who has another kind of serious mental illness. But these kinds of prejudices and misperceptions can be readily corrected. Expectations become more realistic as schizophrenia is better understood as a disorder that requires ongoing -often lifetime -- treatment. Demystification of the illness, along with recent insights from neuroscience and neuropsychology, gives new hope for finding more effective treatments for an illness that previously carried a grave prognosis. Schizophrenia is characterized by a broad range of unusual behavior that cause profound disruption in the lives of people suffering from the condition, as well as in the lives of the people around them. Schizophrenia strikes without regard to gender, race, social class or culture.

Delusions & Hallucinations Are Common in Schizophrenia

One of the most obvious kinds of impairment caused by schizophrenia involves how a person thinks. The individual can lose much of the ability to rationally evaluate his or her surroundings and interactions with others. They often believe things that are untrue, and may have difficulty accepting what they see as "true" reality. Schizophrenia most often includes hallucinations and/or delusions, which reflect distortions in the perception and interpretation of reality. The resulting behaviors may seem bizarre to the casual observer, even though they may be consistent with the schizophrenic's abnormal perceptions and beliefs. For instance, someone with schizophrenia may act in an extremely paranoid manner -- purchasing multiple locks for their doors, always checking behind them as they walk in public, refusing to talk on the phone. Without context, these behaviors may seem irrational or illogical. But to someone with schizophrenia, these behaviors may reflect a reasonable reaction their false beliefs that others are out to get them or lock them up. Nearly one-third of those diagnosed with schizophrenia will attempt suicide. About 10 percent of those with the diagnosis will commit suicide within 20 years of the beginning of the disorder. Patients with schizophrenia are not likely to share their suicidal intentions with others, making life-saving interventions more difficult. The risk of depression needs special mention due to the high rate of suicide in these patients. The most significant risk of suicide in schizophrenia is among males under 30 who have some symptoms of depression and a relatively recent hospital discharge. Other risks include imagined voices directing the patient toward self-harm (auditory command hallucinations) and intense false beliefs (delusions). The relationship of schizophrenia to substance abuse is significant. Due to impairments in insight and judgment, people with schizophrenia may be less able to judge and control the temptations and resulting difficulties associated with drug or alcohol abuse. In addition, it is not uncommon for people suffering from this disorder to try to "self-medicate" their otherwise debilitating symptoms with mind-altering drugs. The abuse of such substances, most commonly nicotine, alcohol, cocaine and marijuana, impedes treatment and recovery.

The Onset of Schizophrenia

The onset of schizophrenia in most people is a gradual deterioration that occurs in early adulthood -- usually in a person's early 20s. Loved ones and friends may spot early warning signs long before the primary symptoms of schizophrenia occur. During this initial pre-onset phase, a person may seem without goals in their life, becoming increasingly eccentric and unmotivated. They may isolate themselves and remove themselves from family situations and friends. They may stop engaging in other activities that they also used to enjoy, such as hobbies or volunteering. Warning signs that may indicate someone is heading toward an episode of schizophrenia include:

Social isolation and withdrawal Irrational, bizarre or odd statements or beliefs Increased paranoia or questioning others' motivations Becoming more emotionless Hostility or suspiciousness Increasing reliance on drugs or alcohol (in an attempt to self-medicate) Lack of motivation Speaking in a strange manner unlike themselves Inappropriate laughter Insomnia or oversleeping Deterioration in their personal appearance and hygiene

While there is no guarantee that one or more of these symptoms will lead to schizophrenia, a number of them occurring together should be cause for concern, especially if it appears that the individual is getting worse over time. This is the ideal time to act to help the person (even if it turns out not to be schizophrenia).

Schizophrenia Symptoms
Schizophrenia is a mental disorder that is characterized by at least 2of the following symptoms, for at least one month:

Delusions Hallucinations Disorganized speech (e.g., frequent derailment or incoherence) Grossly disorganized or catatonic behavior A set of three negative symptoms (a "flattening" of one's emotions, alogia, avolition; see below)

Only one of the above symptoms is required to make the diagnosis of schizophrenia if the person's delusions are bizarre or if the hallucinations consist of a voice keeping up a running commentary on the person's behavior or thoughts, or two or more voices conversing with each other.

Positive Symptoms Delusions

Hallucinations Disorganized thinking Agitation

Negative Symptoms Affective flattening - The person's range of emotional expression is clearly diminished; poor eye contract; reduced body language

Alogia - A poverty of speech, such as brief, empty replies Avolition Inability to initiate and persist in goal-directed activities (such as school or work)

Although the above symptoms must be present for at least one (1) month, there also needs to be continuous signs of the disturbance that persist for at least six (6) months. During this period, the signs of the disorder may be present in a milder form, for instance as just odd beliefs or unusual perceptual experiences. During this 6 month period, at least two of the above criteria must be met, or only the criteria of Negative Symptoms must be present -- if even just in milder form. For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset of the symptoms (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement). Schizoaffective Disorder and Mood Disorder With Psychotic Features have been considered as alternative explanations for the symptoms and have been ruled out. The disturbance must also not be due to the direct physiological effects of use or abuse of a substance (e.g., alcohol, drugs, medications) or a general medical condition.

If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated).

Different Types of Schizophrenia:

You'll learn more about the different types of schizophrenia in the next section. However, briefly, they are:

Paranoid schizophrenia -- a person feels extremely suspicious, persecuted, grandiose, or experiences a combination of these emotions. Disorganized schizophrenia -- a person is often incoherent but may not have delusions. Catatonic schizophrenia -- a person is withdrawn, mute, negative and often assumes very unusual postures. Residual schizophrenia -- a person is no longer delusion or hallucinating, but has no motivation or interest in life. These symptoms can be most devastating.

The kinds of symptoms that are utilized to make a diagnosis ofschizophrenia differ between affected people and may change from one year to the next within the same person as the disease progresses. Different subtypes of schizophrenia are defined according to the most significant and predominant characteristics present in each person at each point in time. The result is that one person may be diagnosed with different subtypes over the course of his illness.

Schizophrenia: Paranoid Subtype

The defining feature of the paranoid subtype (also known as paranoid schizophrenia) is the presence of auditory hallucinations or prominent delusional thoughts about persecution or conspiracy. However, people with this subtype may be more functional in their ability to work and engage in relationships than people with other subtypes of schizophrenia. The reasons are not entirely clear, but may partly reflect that people suffering from this subtype often do not exhibit symptoms until later in life and have achieved a higher level of functioning before the onset of their illness. People with the paranoid subtype may appear to lead fairly normal lives by successful management of their disorder.

Paranoid schizophrenia is the most common subtype.

People diagnosed with the paranoid subtype may not appear odd or unusual and may not readily discuss the symptoms of their illness. Typically, the hallucinations and delusions revolve around some characteristic theme, and this theme often remains fairly consistent over time. A persons temperaments and general behaviors often are related to the content of the disturbance of thought. For example, people who believe that they are being persecuted unjustly may be easily angered and become hostile. Often, paranoid schizophrenics will come to the attention of mental health professionals only when there has been some major stress in their life that has caused an increase in their symptoms. At that point, sufferers may recognize the need for outside help or act in a fashion to bring attention to themselves. Since there may be no observable features, the evaluation requires sufferers to be somewhat open to discussing their thoughts. If there is a significant degree of suspiciousness or paranoia present, people may be very reluctant to discuss these issues with a stranger. There is a broad spectrum to the nature and severity of symptoms that may be present at any one time. When symptoms are in a phase of exacerbation or worsening, there may be some disorganization of the thought processes. At this time, people may have more trouble than usual remembering recent events, speaking coherently or generally behaving in an organized, rational manner. While these features are more characteristic of other subtypes, they can be present to differing degrees in people with the paranoid subtype, depending upon the current state of their illness. Supportive friends or family members often may be needed at such times to help the symptomatic person get professional help.

Schizophrenia: Disorganized Subtype

As the name implies, this subtypes predominant feature is disorganization of the thought processes. As a rule, hallucinations and delusions are less pronounced, although there may be some evidence of these symptoms. These people may have significant impairments in their ability to maintain the activities of daily living. Even the more routine tasks, such as dressing, bathing or brushing teeth, can be significantly impaired or lost. Often, there is impairment in the emotional processes of the individual. For example, these people may appear emotionally unstable, or their emotions may not seem appropriate to the context of the situation. They may fail to show ordinary emotional responses in situations that evoke such responses in healthy people. Mental

health professionals refer to this particular symptom as blunted or flat affect. Additionally, these people may have an inappropriately jocular or giddy appearance, as in the case of a patient who chuckles inappropriately through a funeral service or other solemn occasion. People diagnosed with this subtype also may have significant impairment in their ability to communicate effectively. At times, their speech can become virtually incomprehensible, due to disorganized thinking. In such cases, speech is characterized by problems with the utilization and ordering of words in conversational sentences, rather than with difficulties of enunciation or articulation. In the past, the term hebephrenic has been used to describe this subtype.

Schizophrenia: Catatonic Subtype

The predominant clinical features seen in the catatonic subtype involve disturbances in movement. Affected people may exhibit a dramatic reduction in activity, to the point that voluntary movement stops, as in catatonic stupor. Alternatively, activity can dramatically increase, a state known as catatonic excitement. Other disturbances of movement can be present with this subtype. Actions that appear relatively purposeless but are repetitively performed, also known as stereotypic behavior, may occur, often to the exclusion of involvement in any productive activity. Patients may exhibit an immobility or resistance to any attempt to change how they appear. They may maintain a pose in which someone places them, sometimes for extended periods of time. This symptom sometimes is referred to as waxy flexibility. Some patients show considerable physical strength in resistance to repositioning attempts, even though they appear to be uncomfortable to most people. Affected people may voluntarily assume unusual body positions, or manifest unusual facial contortions or limb movements. This set of symptoms sometimes is confused with another disorder called tardive dyskinesia, which mimics some of these same, odd behaviors. Other symptoms associated with the catatonic subtype include an almost parrot-like repeating of what another person is saying (echolalia) or mimicking the movements of another person (echopraxia). Echolalia and echopraxia also are seen in Tourettes Syndrome.

Schizophrenia: Undifferentiated Subtype

The undifferentiated subtype is diagnosed when people have symptoms of schizophrenia that are not sufficiently formed or specific enough to permit classification of the illness into one of the other subtypes. The symptoms of any one person can fluctuate at different points in time, resulting in uncertainty as to the correct subtype classification. Other people will exhibit symptoms that are remarkably stable over time but still may not fit one of the typical subtype pictures. In either instance, diagnosis of the undifferentiated subtype may best describe the mixed clinical syndrome.

Schizophrenia: Residual Subtype

This subtype is diagnosed when the patient no longer displays prominent symptoms. In such cases, the schizophrenic symptoms generally have lessened in severity. Hallucinations, delusions or idiosyncratic behaviors may still be present, but their manifestations are significantly diminished in comparison to the acute phase of the illness. Just as the symptoms of schizophrenia are diverse, so are its ramifications. Different kinds of impairment affect each patients life to varying degrees. Some people require custodial care in state institutions, while others are gainfully employed and can maintain an active family life. However, the majority of patients are at neither of these extremes. Most will have a waxing and waning course marked with some hospitalizations and some assistance from outside support sources. People having a higher level of functioning before the start of their illness typically have a better outcome. In general, better outcomes are associated with brief episodes of symptoms worsening followed by a return to normal functioning. Women have a better prognosis for higher functioning than men, as do patients with no apparent structural abnormalities of the brain. In contrast, a poorer prognosis is indicated by a gradual or insidious onset, beginning in childhood or adolescence; structural brain abnormalities, as seen on imaging studies; and failure to return to prior levels of functioning after acute episodes.

What Causes Schizophrenia?

The causes of schizophrenia, like all mental disorders, are not completely understood or known at this time. There is no known single cause of schizophrenia. Many diseases, such as heart disease, result from an interplay of genetic, behavioral and other factors, and this may be the case for schizophrenia as well. Scientists do not yet understand all of the factors necessary to produce, but all the tools of modern biomedical research are being used to search for genes, critical moments in brain development, and other factors that may lead to the illness.

Can Schizophrenia Be Inherited?

It has been long understood that schizophrenia runs in families. People who have a close relative with schizophrenia are more likely to develop the disorder than are people who have no relatives with the illness. A child whose parent has schizophrenia has about a 10 percent chance of developing schizophrenia themselves. A monozygotic (identical) twin of a person with schizophrenia has the highest risk a 40 to 65 percent chance of developing the illness. People who have second-degree relatives (aunts, uncles, grandparents, or cousins) with the disease also develop schizophrenia more often than the general population. By comparison, the risk of schizophrenia in the general population is about 1 percent. Scientists are continuing to study and better understand the genetic factors related to schizophrenia. 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. In addition, factors such as prenatal difficulties like intrauterine starvation or viral infections, perinatal complications, and various nonspecific stressors, seem to influence the development of schizophrenia. However, it is not yet understood how the genetic predisposition is transmitted, and it cannot yet be accurately predicted whether a given person will or will not develop the disorder. 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. 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.

Is Schizophrenia Caused by a Chemical Defect in the Brain?

Basic knowledge about brain chemistry and its link to schizophrenia is expanding rapidly. Neurotransmitters, substances that allow communication between nerve cells, have long been thought to be involved in the development of schizophrenia. It is likely, although not yet certain, that the disorder is associated with some imbalance of the complex, interrelated chemical systems of the brain, perhaps involving the neurotransmitters dopamine and glutamate.

Is Schizophrenia Caused by a Physical Abnormality in the Brain?

There have been dramatic advances in neuroimaging technology that permit scientists to study brain structure and function in living individuals. Many studies of people with schizophrenia have found abnormalities in brain structure. In some small but potentially important 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. It should be emphasized that these abnormalities are quite subtle and are not characteristic of all people with schizophrenia, nor do they occur only in individuals with this illness. Microscopic studies of brain tissue after death have also shown small changes in distribution or number of brain cells in people with schizophrenia. It appears that many (but probably not all) of these changes are present before an individual becomes ill, and schizophrenia may be, in part, a disorder in development of the brain.

Developmental neurobiologists have found that schizophrenia may be a developmental disorder resulting when neurons form inappropriate connections during fetal development. These errors may lie dormant until puberty, when changes in the brain that occur normally during this critical stage of maturation interact adversely with the faulty connections. This research has spurred efforts to identify prenatal factors that may have some bearing on the apparent developmental abnormality. In other studies, investigators using brain-imaging techniques have found evidence of early biochemical changes that may precede the onset of disease symptoms, prompting examination of the neural circuits that are most likely to be involved in producing those symptoms. Meanwhile, scientists working at the molecular level are exploring the genetic basis for abnormalities in brain development and in the neurotransmitter systems regulating brain function.

Overview of Treatment for Schizophrenia

By MICHAEL BENGSTON, M.D.

Most people who have schizophrenia do not experience a complete remission of symptoms. However, this disorder can be managed by a combination of psychosocial therapies and medications. A psychiatrist, who attends to the biological or medical needs of the patient, directs the treatment of schizophrenia. Social workers and other mental health professionals devise and supervise a plan to address the socialization and educational components of the treatment. Difficulties in social skills are addressed by involvement in group treatment and planned group activities that include appropriate behavioral interaction and conversational topics. To be better able to cope with day-to-day living, the patient learns or re-learns more productive, acceptable behavior. Other aspects of treatment deal with personal care, living skills, managing money and other practical matters. In many areas, people who have schizophrenia are able to receive assistance from local community mental health facilities and possibly qualify for a case manager. A case manager is someone who helps to ensure that the patient can get to appointments and group activities, monitors the progress of the patient and helps him apply for other available assistance. The case manager may become a very important resource for the schizophrenic patient, especially for cases in which there is no family member available to become involved. The case manager may come to serve as the patients major advocate in dealing with landlords, social service agencies and utility companies. The case manager is trained to know local, state and federal programs that may be accessed to meet the particular needs of each client. The specific programs available at community mental health facilities differ from one facility to another, but most offer some helpful programs. The importance of involvement in regular activities cannot be overemphasized. This part of the treatment addresses the social and interactional skills that are necessary for everyday life. When these services are provided in an environment that the patient views as safe and nonthreatening, the opportunity exists for the patient to develop greater trust in others. Such treatment can help the patient to re-integrate into society more comfortably. While not all schizophrenic patients will require the services of a case manager, the vast majority are encouraged to follow a psychosocial treatment plan as well as the medical and drug plan supervised by their physician.

Schizophrenia Treatment
By John M. Grohol, Psy.D.

Table of Contents

Introduction Psychotherapy Medications Coping Guidelines For The Family Self-Help

Introduction
Schizophrenia usually first appears in a person during their late teens or throughout their twenties. It affects more men than women, and is considered a life-long condition which rarely is "cured," but rather treated. The primary treatment for schizophrenia and similar thought disorders is medication. Unfortunately, compliance with a medication regimen is often one of the largest problems associated with the ongoing treatment of schizophrenia. Because people who live with this disorder often go off of their medication during periods

throughout their lives, the repercussions of this loss of treatment are acutely felt not only by the individual, but by their family and friends as well. Successful treatment of schizophrenia, therefore, depends upon a life-long regimen of both drug and psychosocial, support therapies. While the medication helps control the psychosis associated with schizophrenia (e.g., the delusions and hallucinations), it cannot help the person find a job, learn to be effective in social relationships, increase the individual's coping skills, and help them learn to communicate and work well with others. Poverty, homelessness, and unemployment are often associated with this disorder, but they don't have to be. If the individual finds appropriate treatment and sticks with it, a person with schizophrenia can lead a happy and successful life. But the initial recovery from the first symptoms of schizophrenia can be an extremely lonely experience. Individuals coping with the onset of schizophrenia for the first time in their lives require all the support that their families, friends, and communities can provide. With such support, determination, and understanding, someone who has schizophrenia can learn to cope and live with it for their entire life. But stability with this disorder means complying with the treatment plan set up between the person and their therapist or doctor, and maintaining the balance provided for by the medication and therapy. A sudden stopping of treatment will most often lead to a relapse of the symptoms associated with schizophrenia and then a gradual recovery as treatment is reinstated.

Psychotherapy
Psychotherapy is not the treatment of choice for someone with schizophrenia. Used as an adjunct to a good medication plan, however, psychotherapy can help maintain the individual on their medication, learn needed social skills, and support the person's weekly goals and activities in their community. This may include advice, reassurance, education, modeling, limit setting, and reality testing with the therapist. Encouragement in setting small goals and reaching them can often be helpful. People with schizophrenia often have a difficult time performing ordinary life skills such as cooking and personal grooming as well as communicating with others in the family and at work. Therapy or rehabilitation therapy can help a person regain the confidence to take care of themselves and live a fuller life. Group therapy, combined with drugs, produces somewhat better results than drug treatment alone, particularly with schizophrenic outpatients. Positive results are more likely to be obtained when group therapy focuses on real-life plans, problems, and relationships; on social and work roles and interaction; on cooperation with drug therapy and discussion of its side effects; or on some practical recreational or work activity. This supportive group therapy can be especially helpful in decreasing social isolation and increasing reality testing (Long, 1996). Family therapy can significantly decrease relapse rates for the schizophrenic family member. In high-stress families, schizophrenic patients given standard aftercare relapse 50-60% of the time in the first year out of hospital. Supportive family therapy can reduce this relapse rate to below 10 percent. This therapy encourages the family to convene a family meeting whenever an issue arises, in order to discuss and specify the exact nature of the problem, to list and consider alternative solutions, and to select and implement the consensual best solution. (Long, 1996).

Medications
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 antianxiety medication. One of the biggest challenges of treatment is that many people don't keep taking the medications prescribed for the disorder. After the first year of treatment, most people will discontinue their use of medications, especially ones where the side effects are difficult to tolerate. As a recent National Institute of Mental Health Study indicated, regardless of the drug, three-quarters of all patients stop taking their medications. They stopped the schizophrenia medications either because they did not make them better or they had intolerable side effects. The discontinuation rates remained high when they were switched to a new drug, but patients stayed on clozapine about 11 months, compared with only three months for Seroquel, Risperdal or Zyprexa, which are far more heavily marketed -- and dominate sales. Because of findings such as this, it's generally recommended that someone with schizophrenia begin their treatment with a drug such asclozapine (clozapine is often significantly cheaper than other antipsychotic medications). Clozapine (also known as clozaril) has been shown to be more effective than many newer antipsychotics as well. 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. Traditional antipsychotics effectively control the hallucinations, delusions, and confusion of schizophrenia. This type of antipsychotic drug, such as haloperidol, chlorpromazine, and fluphenazine, has been available since the mid-1950s. These drugs primarily block dopamine receptors and are effective in treating the "positive" symptoms of schizophrenia. 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. Mild side effects: dry mouth, blurred vision, constipation, drowsiness and dizziness. These side affects usually disappear a few weeks after the person starts treatment.

More serious side effects: trouble with muscle control, muscle spasms or cramps in the head and neck, fidgeting or pacing, tremors and shuffling of the feet (much like those affecting people with Parkinson's disease). Side effects due to prolonged use of traditional antipsychotic medications: facial ticks, thrusting and rolling of the tongue, lip licking, panting and grimacing. There are many newer antipsychotic medications available since the 1990's, including Seroquel, Risperdal, Zyprexa and Clozaril. Some of these medications may work on both the serotonin and dopamine receptors, thereby treating both the "positive" and "negative"symptoms of schizophrenia. Other newer antipsychotics are referred to as atypical antipsychotics, because of how they affect the dopamine receptors in the brain. These newer medications may be more effective in treating a broader range of symptoms of schizophrenia, and some have fewer side effects than traditional antipsychotics. Learn more about the atypical antipsychotics used to help treat schizophrenia.

Coping Guidelines For The Family

1. 2. 3. 4. 5. 6. 7. Establish a daily routine for the patient to follow. Help the patient stay on the medication. Keep the lines of communication open about problems or fears the patient may have. Understand that caring for the patient can be emotionally and physically exhausting. Take time for yourself. Keep your communications simple and brief when speaking with the patient. Be patient and calm. Ask for help if you need it; join a support group.

Self-Help
Self-help methods for the treatment of this disorder are often overlooked by the medical profession because very few professionals are involved in them. Adjunctive community support groups in concurrence with psychotherapy is 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. Another use of self-help is for the family members of someone who lives with schizophrenia. The stress and hardships causes of having a loved one with this disorder are often overwhelming and difficult to cope with for a family. Family members should use a support group within their community to share common experiences and learn about ways to best deal with their frustrations, feelings of helplessness, and anger.

Living with Schizophrenia

By MARGARITA TARTAKOVSKY, M.S.

Page: 1 2 3 4View All

Your daughter has schizophrenia, I told the woman. Oh, my God, anything but that, she replied. Why couldnt she have leukemia or some other disease instead? But if she had leukemia she might die, I pointed out. Schizophrenia is a much more treatable disease. The woman looked sadly at me, then down at the floor. She spoke softly. I would still prefer that my daughter had leukemia.

This book is a product of a thousand such conversations, writes research psychiatrist and schizophrenia specialist E. Fuller Torrey, M.D., in Surviving Schizophrenia: A Manual for Families, Patients And Providers. Getting a diagnosis of schizophrenia can be devastating. Families and patients alike think theres no hope. What follows may be shock, shame and confusion. But schizophrenia isnt a death sentence or an inevitable descent into psychosis and violence, as some movies and shows would have you believe. Even though it may be terrifying, receiving a proper diagnosis is a good thing: Its one step closer to the right treatment. Earlier treatment and shorter duration of untreated psychosis is associated with better treatment response, less likelihood of relapse and better clinical outcome, said Sandra De Silva, Ph.D, psychosocial treatment codirector and outreach director at the Staglin Music Festival Center for the Assessment and Prevention of Prodromal States (CAPPS) at UCLA, departments of psychology and psychiatry. Heres a look at what effective treatment for schizophrenia entails, how you can manage the disorder and what to do if you notice early warning signs.

Early Diagnosis of Schizophrenia

Schizophrenia rarely occurs unexpectedly. Instead, it produces a gradual decline in functioning. There are usually early warning signs, referred to as the prodrome, which last one to three years, which provide the perfect place to intervene. Early symptoms are the same as in psychotic illnesses, but they are experienced at a milder, subthreshold level, De Silva said. The key symptoms to look for are suspiciousness, unusual thoughts, changes in sensory experience (hearing, seeing, feeling, tasting or smelling things that others dont experience), disorganized communication (difficulty getting to the point, rambling, illogical reasoning) and grandiosity (unrealistic ideas of abilities or talents), according to De Silva. Just one of these symptoms is the greatest predictor of psychosis to date greater than having a parent with schizophrenia, she said. In fact, according to recent research, 35 percent of individuals who presented with one of these symptoms developed psychosis within 2.5 years. Substance use, such as alcohol and marijuana, also has been shown to boost risk.

Early Intervention for Schizophrenia

So what can you do if you think your loved one is showing these early signs? There are various prodromal clinics in the U.S. and some abroad that offer services usually including regular evaluations and treatment for at-risk youth and their families. At De Silvas clinic, CAPPS, individuals from 12 to 25 years old get a diagnostic screening, assessments and case management at no charge. Early treatment aims to reduce the risk of developing schizophrenia, delay its onset (which research shows has a better prognosis), decrease severity after onset and improve outcomes in all areas, De Silva said.

Treatment of Schizophrenia
The longer an illness is left untreated, the greater the disruption to the persons ability to study, work, make friends and interact comfortably with others, De Silva said. A combination of treatments is best for individuals with schizophrenia. Medication is the mainstay of treatment, used to minimize hallucinations, help the individual think more clearly, focus on reality and sleep better, according to Dawn Velligan, Ph.D, professor and co-director of the Division of Schizophrenia and Related Disorders at the Department of Psychiatry, UT Health Science Center at San Antonio . However, decades of research have shown that psychosocial treatments are also important in improving symptoms and quality of life, she added.

Living with Schizophrenia

By MARGARITA TARTAKOVSKY, M.S.

Page: 1 2 3 4View All Team-based care also is pivotal. A treatment team may include a psychiatrist, licensed therapist and case manager. There are many other professionals who may help, including psychiatric nurses, vocational therapists and rehabilitation therapists. When building a team, Robert E. Drake, M.D., Ph.D, professor of psychiatry and of community and family medicine at Dartmouth Medical School, suggests keeping in mind people who will:

Serve as the primary contact person to help patients navigate through the system Help patients achieve functional goals (e.g., finding an apartment and job) Ensure patients get good medical care, understand medication options and learn to use them appropriately Treat co-occurring problems. Substance abuse is the most common co-occurring disorder in individuals with schizophrenia, but physical health conditions also may be present. Try to find the appropriate professional to treat the co-occurring issues. When looking for a psychiatrist, search out professionals who specialize in schizophrenia. Ask other families or professionals, like your primary care physician, write Irene S. Levine, Ph.D, and Jerome Levine, M.D., in Schizophrenia for Dummies. You can find families at the National Alliance for the Mentally Ill (NAMI) by checking out your local affiliate. Also, check with the psychiatry or psychology department of a local university or medical school. Visit two to three different providers and ask them about available resources, their outcomes, their team (i.e., do they have a typical team of

professionals they work with? How do they put together a team?) and what they can do for you, Dr. Drake said.

Psychosocial Treatments for Schizophrenia

Because mental illnesses are compounded by a cascade of personal losses including friendships, work opportunities and a place to call home effective treatment requires addressing the needs of the whole person and listening to their hopes and dreams, Irene Levine said. Helpful treatments may include the following:

Cognitive Remediation/Related Treatments. While hallucinations and delusions can be devastating, it is thecognitive decline problems with memory, attention, problem solving, processing information that complicates daily life. Because medication doesnt treat problems with attention, concentration and memory, treatments that address these issues are vital. Cognitive remediation strives to strengthen patients cognitive skills, helping them pay attention, remember, process information and plan better, Velligan said. This is usually done with cognitive exercises and compensatory behaviors (things like checklists that help individuals compensate for memory loss). For instance, Demian Rose, M.D., Ph.D, medical director of the University of California, San Francisco PART Program and director of the UCSF Early Psychosis Clinic, and his research team have developed a cognitive training software package thats shown good results. Velligan and colleagues use environmental supports tools that help manage the day-to-day, like checklists, signs, pill boxes and alarms in their program, Cognitive Adaptation Training, to bypass cognitive impairments and help with taking medication, grooming, housekeeping, managing money and participating in leisure activities.

Family psychoeducation. Families may be confused about schizophrenia and what they can do to help their loved one. Supportive families can be a godsend for people with schizophrenia. They function as de facto case managers, filling in the gaps of the fragmented system that exists in many communities, Irene Levine said. Family psychoeducation gives families an accurate understanding of schizophrenia and teaches them how to help. Individual psychotherapy. This can take many forms, such as a cognitive-behavioral approach. Dr. Rose recommends individual therapy for various reasons. For one, by the time most individuals have been diagnosed with schizophrenia, they have many problems with relationships. Also, individual therapy gives patients a better understanding of their own symptoms. I see so much suffering and misunderstanding purely because no one has told (patients) whats going on, Dr. Rose said. Cognitive-behavioral therapy (CBT). Though using CBT to treat schizophrenia is fairly new, research has shown that it holds promise, according to Dr. Rose. In addition to grasping their symptoms, CBT helps individuals set goals, form new ways of relating to people, examine and challenge persistent beliefs and cope with hallucinations. Supported employment. This program helps individuals find a job based on preferences and abilities and usually assists with training and any issues that may come up on the job. For ideas on what questions to ask, this handbook (in PDF format) offers a detailed questionnaire.

Medication for Schizophrenia

One of the most important advances in the treatment of schizophreniaover the last half century has been the discovery of antipsychoticmedications that reduce the troubling symptoms of the disorder and give people the chance to live normal lives, Irene Levine, also a psychologist, said. Unfortunately, there are many misconceptions about medication and stigma attached to taking medications for a mental disorder as compared to taking them for physical problems, she added. However, medications form the foundation on which the recovery process is built, Velligan said. With good medication on board, individuals can turn their attention to improving their quality of life and attaining their recovery goals. Are some medications better than others? According to Levine, the second generation antipsychotics are no better or worse than the first generation. Almost all antipsychotics have similar efficacy. The main difference is in the side effects: The older drugs give rise to movement disorders, while the newer ones set the stage for weight gain and metabolic side effects. (For more on antipsychotic medications, see here and here.) Finding the right medication or combination of medications is a complex and highly individual process. Its often a balancing act between making sure the patient experiences benefits and doesnt experience intolerable side effects. Just like blood pressure or cholesterol-lowering drugs, medications for schizophrenia may have to be changed, increased, decreased and tinkered with for optimal results, Irene Levine said. Still, patients may get frustrated and want to stop taking their medication. Many clinicians use too low or too high a dose, or combine many medications at once in the absence of any evidence for a clear benefit, which can worsen schizophrenia and side effects, Dr. Rose said.

Tips for Taking Medication

When taking medication, keep the following in mind:

Become an active participant. Watching your treatment or the treatment of a loved one on the sidelines doesnt help anyone. Taking an active role leads to more successful treatment. Educate yourself. Whether you or your loved one has schizophrenia, educate yourself about the various drugs and potential side effects, Irene Levine said. Invest the time in learning everything you can about these medications. But, if you come across personal experiences (whether the accounts concern pharmacological or psychosocial treatments), keep in mind that this is an idiosyncratic experience, Dr. Drake said. So dont rule out a certain medication or treatment because of negative information but do raise the concerns to your provider and do more research. Be sure its a partnership. Because finding the best balance is already a hard process, not having a provider you trust can make it even harder, Dr. Drake said. Make sure that your provider welcomes a collaborative relationship with patients. Create a medication list. Keep an updated list of your medications handy. Your list should include all medications taken, the length of time they were taken, the dose and the adverse effects, Dr. Torrey writes in Surviving Schizophrenia. Create a wish list. Another excellent tip from Dr. Torrey: Write out a list of things you wish you could do but that schizophrenia prevents you from doing. What did you do prior to your illness that you wish you could do again? On your list, you might write read a book, go into a crowded room without panicking, hold a job at least half-time, have a boyfriend, Dr. Torrey writes. Essentially, this list includes goals youd like to attain with the help of medication and other treatments. The list serves as a reminder of why youre taking medication and why youre open to trying new medications to improve symptoms, he writes. Take medication as prescribed. Do you forget to take your medication? You dont want (the prescribing physician) to raise the dose because you forgot to take the pills half the time, Velligan said. Have you decided to stop taking them altogether? Speak up. Maybe youve stopped taking your medication because it just doesnt feel right. Maybe youre experiencing bothersome side effects. Communicate with doctors on an ongoing basis to make sure that the medications are safe and effective, Levine said. Consumers and doctors constantly need to evaluate medication regimens and weigh the pros and cons of any treatment. Create reminders. No one is very good at remembering to take every dose of medication, Velligan said. To stay on track, find reminders that work for you. Velligan suggests pill containers, voice alarms, signs and checklists.

Schizophrenia and Substance Abuse

Almost 50 percent of individuals with schizophrenia suffer from substance abuse, such as alcohol and nicotine. Research has shown that patients with dual diagnoses are more susceptible to severe symptoms, higher rates of hospitalization, illness, violence, victimization, homelessness, medication noncompliance and poor response to medication. Conventional antipsychotics dont seem to help; research shows that individuals with dual diagnoses seem to have a tougher course than those without substance abuse (see Green, Drake, Brunette & Noordsy, 2007). Integrated Dual Disorder Treatment (IDDT) is one option. It treats both disorders simultaneously and has been shown to be highly effective. Unfortunately it isnt readily available. If youre having issues with substance use or suspect your loved one is, talk to your primary provider about getting a proper evaluation and treatment services.

Minimizing Relapse
A relapse occurs when symptoms worsen or reappear. Here are some ways you can reduce your risk of relapse:

Stay on medication. Medication is the cornerstone of treatment, and discontinuing use without informing your physician is dangerous. Talk to the team. Ask your psychiatrist, case manager, therapist and other providers youre working with how to avoid a relapse. They should have many preventative tips. Be aware of warning signs. Watch out for general warning signs, unique-to-you precursors and changes in sleeping and eating patterns. For instance, bad relationships may trigger a relapse for one person, whereas excessive sleep and desire for isolation do for another. If a relapse happens, know what to do. Talk with your providers about the best ways to manage a relapse should it happen. Stay in regular contact with clinicians. Others will usually pick up on the warning signs before you do, so even when symptoms are in remission and function is good, stay in contact, Dr. Rose said. Stay in contact with your support system. Stress is a risk factor for relapse. Dr. Rose suggested staying involved with loved ones as much as possible.

Disclosing Your Diagnosis

Should you tell others about your diagnosis? According to Velligan, you may want to tell close family and friends, who can participate in groups that provide education about the illness and how to help their (loved one) manage symptoms. Telling employers is an individual decision. Velligan suggested informing employers in a supported employment program, because the employer will be more willing to work with the employment specialists to help you improve your job performance.

This is a time of great hope for individuals with schizophrenia, said Velligan. There are many new medication treatments and psychosocial treatments that work to improve a broad range of outcomes. References Green, A.I., Drake, R.E., Brunette, M.F., & Noordsy, D.L. (2007). Schizophrenia and co-occurring substance use disorder. The American Journal of Psychiatry, 164, 402-408.

Helpful Hints about Schizophrenia for Family Members and Others

By BRIAN SMITH, MS

People with schizophrenia often encounter challenges when it comes to their friends and family. Family often try and cope with someone who has schizophrenia for a period of time, but can become frustrated by their seeming lack of progress in treatment or staying in treatment altogether. A familys emotional support may wane, and some families cut off all contact with their schizophrenic son, daughter or sibling. Friends can also not understand a person with schizophrenias experiences, and quickly lose interest in continuing the friendship when a person with schizophrenia deteriorates or drops out of treatment. The most common complaint amongst friends and family members of a person with schizophrenia is not understanding how to help them, or give them continued, long-term support that help keeps them from becoming homeless or unemployed. A persons support system may come from several sources, including the family, a professional residential or day program provider, shelter operators, friends or roommates, professional case managers, churches and synagogues, and others. Because many patients live with their families, the following 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 numerous situations in which people with schizophrenia may need help from people in their family or community. Often, a person with schizophrenia will resist treatment, believing that delusions or hallucinations are real and that psychiatric help is not required. At times, family or friends may need to take an active role in having them seen and evaluated by a professional. The issue of civil rights may enter into an attempt to provide treatment to someone with schizophrenia. Laws protecting patients from involuntary commitment have become very strict, and families and community organizations may be frustrated in their efforts to see that a severely mentally ill individual gets needed help. These laws vary from state to state; generally, when people are dangerous to themselves or others due to a mental disorder, the police can assist in getting them an emergency psychiatric evaluation and, if necessary, hospitalization. In some places, staff from a local community mental health center can evaluate an individuals illness at home if he or she will not voluntarily go in for treatment.

6 Tips to Help Family Members and Friends

1. The closest family member or friend should speak-up and be an advocate for the person with schizophrenia. Sometimes only the family or others close to the person with schizophrenia will be aware of strange behavior or ideas that the person has expressed. Since patients may not volunteer such information during an examination, family members or friends should ask to speak with the person evaluating the patient so that all relevant information can be taken into account. 2. Ensure ongoing compliance with treatment, especially when released from inpatient care. Ensuring that a person with schizophrenia continues to get treatment after hospitalization is also important. A patient may discontinuemedications or stop going for follow-up treatment, often leading to a return of psychotic symptoms. 3. Offer strong emotional encouragement and support for continuing treatment. Encouraging the person to continue treatment and assisting him or her in the treatment process can positively influence recovery. Without treatment, some people with schizophrenia become so psychotic and disorganized that they cannot care for their basic needs, such as food, clothing and shelter. All too often, people with severe mental illnesses such as schizophrenia end up on the streets or in jails, where they rarely receive the kinds of treatment they need. 4. Know how to respond to bizarre statements or beliefs.

Those close to people with schizophrenia are often unsure of how to respond when patients make statements that seem strange or are clearly false. For the individual with schizophrenia, the bizarre beliefs or hallucinations seem quite real they are not just imaginary fantasies. Instead of going along with a persons delusions, family members or friends can tell the person that they do not see things the same way or do not agree with his or her conclusions, while acknowledging that things may appear otherwise to the patient. It is very important not to challenge the persons beliefs or delusions. They are very real to the person who experiences them, and theres little point in arguing with them about the delusions or false beliefs. Instead, move the conversation along to areas or topics where you both agree upon. 5. Keep a record. It may also be useful for those who know the person with schizophrenia well to keep a record of what types of symptoms have appeared, what medications (including dosage) have been taken, and what effects various treatments have had. By knowing what symptoms have been present before, family members may know better what to look for in the future. Families may even be able to identify some early warning signs of potential relapses, such as increased withdrawal or changes in sleep patterns, even better and earlier than the patients themselves. Thus, return of psychosis may be detected early and treatment may prevent a full-blown relapse. Also, by knowing which medications have helped and which have caused troublesome side effects in the past, the family can help those treating the patient to find the best treatment more quickly. 6. Help the person set attainable, simple goals in his or her life. In addition to involvement in seeking help, family, friends and peer groups can provide support and encourage the person with schizophrenia to regain his or her abilities. It is important that goals be attainable, since a patient who feels pressured or repeatedly criticized by others will probably experience stress that may lead to a worsening of symptoms. Like anyone else, people with schizophrenia need to know when they are doing things right. A positive approach may be helpful and perhaps more effective in the long run than criticism. This advice applies to everyone who interacts with the person.