Schizophrenia 101: Schizophrenia and Psychosis

By Michael Bengston, M.D.

Throughout recorded history, the disease 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 are poorly understood. Friends and family commonly are shocked, afraid or angry when they learn of the diagnosis. Expectations become more realistic as schizophrenia is better understood as a brain disease that requires ongoing treatment. Demystification of the illness, along with recent insights from basic neuroscience, 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 behaviors that cause profound disruption in the lives of the patients suffering from the condition and in the lives of the people around them. Schizophrenia strikes without regard to gender, race, social class or culture.

One of the most important kinds of impairment caused by schizophrenia involves the person’s thought processes. The individual can lose much of the ability to rationally evaluate his surroundings and interactions with others. There can be hallucinations and 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.

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.

Schizophrenia 101: Schizophrenia and Substance Abuse

Substance abuse is a common concern of the family and friends of people with schizophrenia. Since some people who abuse drugs may show symptoms similar to those of schizophrenia, people with schizophrenia may be mistaken for people “high on drugs.”

While most researchers do not believe that substance abuse causes schizophrenia, people who have schizophrenia often abuse alcohol or drugs, and may have particularly bad reactions to certain drugs.

Substance abuse can reduce the effectiveness of treatment for schizophrenia. Stimulants (such as amphetamines or cocaine) may cause major problems for patients with schizophrenia, as may PCP or marijuana. In fact, some people experience a worsening of their schizophrenic symptoms when they are taking such drugs. Substance abuse also reduces the likelihood that patients will follow the treatment plans recommended by their doctors.

Schizophrenia and Nicotine

The most common form of substance use disorder in people with schizophrenia is nicotine dependence due to smoking. While the prevalence of smoking in the U.S. population is about 25 percent to 30 percent, the prevalence among people with schizophrenia is approximately three times as high.

Research has shown that the relationship between smoking and schizophrenia is complex. Although people with schizophrenia may smoke to self-medicate their symptoms, smoking has been found to interfere with the response to antipsychotic drugs. Several studies have found that schizophrenia patients who smoke need higher doses of antipsychotic medication.

Quitting smoking may be especially difficult for people with schizophrenia, because the symptoms of nicotine withdrawal may cause a temporary worsening of schizophrenia symptoms. However, smoking cessation strategies that include nicotine replacement methods may be effective. Doctors should carefully monitor medication dosage and response when patients with schizophrenia either start or stop smoking.

Source: National Institute of Mental Health

Schizophrenia 101: Schizophrenia and Violence

News and entertainment media tend to link mental illness and criminal violence; however, studies indicate that except for those persons with a record of criminal violence before becoming ill, and those with substance abuse or alcohol problems, people with schizophrenia are not especially prone to violence.

Most individuals with schizophrenia are not violent; more typically, they are withdrawn and prefer to be left alone. Most violent crimes are not committed by persons with schizophrenia, and most persons with schizophrenia do not commit violent crimes.

Substance abuse significantly raises the rate of violence in people with schizophrenia but also in people who do not have any mental illness. People with paranoid and psychotic symptoms, which can become worse if medications are discontinued, may also be at higher risk for violent behavior. When violence does occur, it is most frequently targeted at family members and friends, and more often takes place at home.

Source: National Institute of Mental Health

Schizophrenia 101: What Causes Schizophrenia?

There is no known single cause of schizophrenia. Many diseases, such as heart disease, result from 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 schizophrenia, 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.

Is It 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. This area of research is promising.

Is It Caused by a Physical Abnormality in the Brain?

There have been dramatic advances in neuro-imaging 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 (for example, enlargement of the fluid-filled cavities, called the ventricles, in the interior of the brain, and decreased size of certain brain regions) or function (for example, decreased metabolic activity in certain brain regions).

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 funded by the National Institute of Mental Health (NIMH) 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.

Do People Inherit Schizophrenia?

It has long been known that schizophrenia runs in families. However, schizophrenia is not passed on directly, like eye or hair color. Other conditions are necessary because other factors are involved. Otherwise, schizophrenia would always develop in both identical twins, since they have the same heredity.

Scientists are studying genetic factors in schizophrenia. It appears likely that multiple genes are involved in creating a predisposition to develop the disorder. 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.

Several regions of the human genome are being investigated to identify genes that may confer susceptibility for schizophrenia. The strongest evidence to date leads to chromosomes 13 and 6 but remains unconfirmed. Identification of specific genes involved in the development of schizophrenia will provide important clues into what goes wrong in the brain to produce and sustain the illness and will guide the development of new and better treatments. To learn more about the genetic basis for schizophrenia, the NIMH has established a Schizophrenia Genetics Initiative that is gathering data from a large number of families of people with the illness.

People who have a close blood relative with schizophrenia are more likely to develop the disorder than are people who have no relatives with the illness. If both biologic parents have schizophrenia, there is nearly a 40% chance that their child will get it, too. This happens even if the child is adopted and raised by mentally healthy adults. In people who have an identical twin with schizophrenia, the chance of schizophrenia developing is almost 50%.

In contrast, children whose biological parents are mentally healthy-even if their adoptive parents have schizophrenia-have about a 1% chance of getting the disease. That is about the same risk as for the general population shown in the chart.

Chances of Developing Schizophrenia

• General population: 1%
• Brother or sister has schizophrenia: 8%
• One parent has schizophrenia: 10-12%
• Fraternal twin has schizophrenia: 14%
• Both parents have schizophrenia: 39%
• Identical twin has schizophrenia: 47-50%

Sources:

NIMH (National Institute of Mental Health)

John M. Grohol, Psy.D.

Jim Haggerty, M.D.

Schizophrenia 101: For Family Members and Friends of a Schizophrenic

A patient’s 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.

Patients with schizophrenia may need help from people in their family or community in numerous situations. 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 enters into any attempts to provide treatment. 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 individual’s illness at home if he or she will not voluntarily go in for treatment.

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.

Ensuring that a person with schizophrenia continues to get treatment after hospitalization is also important. A patient may discontinue medications or stop going for follow-up treatment, often leading to a return of psychotic symptoms.

Encouraging the patient 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.

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 person’s 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 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 may. 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.

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.

Coping Guidelines for Family or Friends

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

Sources:

National Institute of Mental Health

John M. Grohol, Psy.D.

Schizophrenia 101: Treatment for Schizophrenia

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. Most patients do not experience a complete remission of symptoms. However, this disorder can be managed by a combination of psychosocial therapies and medications.

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.

Therapy

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.

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.

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 anti-psychotic, anti-depressant, and anti-anxiety 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 as Clozapine (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.

Anti-psychotic 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.

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. An adjunctive community support group 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.

Mental Health Professionals

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 patient’s 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.

Sources:

National Institute of Mental Health (NIMH)

Michael Bengston, M.D.

John M. Grohol, Psy.D

Schizophrenia 101: Symptoms of Schizophrenia

Schizophrenia is characterized by at least 2 of the following symptoms, for at least one month:

• Delusions
• Hallucinations
• Disorganized speech (e.g., frequent derailment or incoherence)
• Grossly disorganized or catatonic behavior
• Negative symptoms (e.g., a “flattening” of one’s emotions, alogia, avolition; see below)

(Only one symptom is required if delusions are bizarre or 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.)

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 (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement).

Schizoaffective Disorder and Bipolar 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, and 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:

• 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.

Positive Symptoms

• Delusions
• Hallucinations
• Disorganized thinking
• Agitation

Negative Symptoms

• Lack of drive or initiative
• Social withdrawal
• Apathy
• Emotional unresponsiveness

Source: www.about.com

Schizophrenia 101: Types of Schizophrenia

By Michael Bengston, M.D.

The kinds of symptoms that are utilized to make a diagnosis of schizophrenia 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.

Paranoid Subtype

The defining feature of the paranoid subtype 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.

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 person’s 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.

Disorganized Subtype

As the name implies, this subtype’s 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.

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 Tourette’s Syndrome.

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.

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 patient’s 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.

Schizophrenia 101: An Introduction to Schizophrenia

By Michael Bengston, M.D.

Throughout recorded history, the disease 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 are poorly understood. Friends and family commonly are shocked, afraid or angry when they learn of the diagnosis.

Expectations become more realistic as schizophrenia is better understood as a brain disease that requires ongoing treatment. Demystification of the illness, along with recent insights from basic neuroscience, gives new hope for finding more effective treatments for an illness that previously carried a grave prognosis.

Schizophrenia occurs in about 1 percent of the general U.S. population. That means that more than 3 million Americans suffer from the illness.

The disorder manifests itself in a broad range of unusual behaviors, which cause profound disruption in the lives of the patients suffering from the condition and in the lives of the people around them. Schizophrenia strikes without regard to gender, race, social class or culture.

One of the most important kinds of impairment caused by schizophrenia involves the person’s thought processes. The individual can lose much of the ability to rationally evaluate his surroundings and interactions with others.

There can be hallucinations and 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.

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 chronic abuse of cigarettes among schizophrenic patients is well-documented and probably related to the mind-altering effects of nicotine. Some researchers believe that nicotine affects brain chemical systems that are disrupted in schizophrenia; others speculate that nicotine counters some of the unwanted reactions to medications used to treat the disease.

It is not uncommon for people diagnosed with schizophrenia to die prematurely from other medical conditions, such as coronary artery disease and lung disease. It is unclear whether schizophrenic patients are genetically predisposed to these physical illnesses or whether such illnesses result from unhealthy lifestyles associated with schizophrenia.

Schizophrenia 101: Top 10 Signs of Schizophrenia

By John M. Grohol, Psy.D.

Schizophrenia is characterized by a broad range of unusual behaviors that cause profound disruption in the lives of the patients suffering from the condition and in the lives of the people around them. Schizophrenia strikes without regard to gender, race, social class or culture.

Not everyone who has schizophrenia experiences every symptom. Some people experience a few symptoms, some many. The severity of symptoms varies with individuals and also varies over time.

The top 10 signs of schizophrenia are:

1. Delusions (believing things that are not true)
2. Hallucinations (seeing or hearing things that are not there)
3. Disorganized thinking
4. Agitation
5. Disorganized speech (e.g., frequent derailment or incoherence)
6. Grossly disorganized or catatonic behavior
7. Lack of drive or initiative
8. Social withdrawal
9. Apathy
10. Emotional unresponsiveness

One of the most important kinds of impairment caused by schizophrenia involves the person’s thought processes. The individual can lose much of the ability to rationally evaluate his surroundings and interactions with others. There can be hallucinations and 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.

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