Schizophrenia is a severe mental disorder marked by abnormalities in various areas of functioning. It is known as a psychotic disorder, which typically involves delusions, hallucinations and disorganized thinking. Schizophrenia can also impair motor behavior, motivation and emotional expression, while interfering with interpersonal and occupational functioning and self-care.
Schizophrenia is a chronic and debilitating disorder that requires intensive and collaborative treatment, and is frequently accompanied by high rates of suicide, substance abuse and other serious health conditions. This article will explore schizophrenia as an insidious clinical disorder, its features and symptoms, and the various approaches to treatment.
What is Schizophrenia?
The term schizophrenia literally means “split mind” because of the presence of fragmented thinking and disorganized speech noted in the disorder. But this should not be confused with having a “split personality” or any other type of mental phenomenon. Schizophrenia is a complicated psychiatric disorder, but understanding its symptoms and the experiences common to people with the disorder can increase understanding, compassion and accurate treatment and care for those individuals and their loved-ones.
Although there may be various influences in the development of schizophrenia, the predominant causal factor of schizophrenia appears to be genetic in origin. That is to say, it is passed down through family hereditary lines. People with the genetic markers for schizophrenia would be at much greater risk of suffering its symptoms compared to those who don’t have those particular genes. There is evidence of some environmental factors in the development of the disorder, but the classic expression of schizophrenia likely requires the genetic predisposition.
Sometimes people can develop other forms of psychosis, and may do so even without underlying genetic factors, such as those suffering from extreme episodes of psychological trauma. But it is frequently noted that people with schizophrenia can have family members with a history of the disorder or perhaps another serious mental illness.
It appears that genetics influence how the brain develops in a person, and in schizophrenia, this may indeed affect the person’s eventual ability to interpret their own thoughts and feelings, as well as the perception of the world around them. Because of these genetic factors, one could say that people with schizophrenia have had the disorder their whole lives.
However, the actual symptoms that are most recognizable usually present themselves anywhere from adolescence to early adulthood, although prepubescent children may also be diagnosed with schizophrenia. It’s rare to see someone develop their first signs of schizophrenia past their mid-30’s.
Older people showing the first signs of what looks like schizophrenia are usually tested for other causes, such as neurological disease, alcohol or drug involvement, or severe responses to traumatic stress. In fact, these other possible causes should be ruled out in anyone of any age prior to diagnosing schizophrenia.
It’s important to note that no one is at fault for having schizophrenia in their lives—neither the patient or any family member, including parents. Certainly, life challenges, hormonal changes, and sometimes trauma can bring out hidden symptoms or worsen existing ones. But other people don’t make people schizophrenic. It’s far more about the genetic makeup of the individual.
Symptoms of Schizophrenia
The symptoms of schizophrenia are divided into “positive” and “negative” symptoms. The use of these terms does not imply good or bad, but are used in a medical sense to reflect an excess or distortion of functioning (positive symptoms), or reduction or loss in functioning (negative symptoms).
The positive symptoms of schizophrenia include hallucinations, delusions, disorganized speech and grossly disorganized or catatonic behavior. The negative symptoms involve the restriction or absence of appropriate emotional expression, fluency of thought and speech, and in the initiation of appropriate or productive behavior.
For schizophrenia to be diagnosed, two or more symptoms must be present over a significant portion of time and at least one positive symptom of hallucinations, delusions, or disorganized speech must be present. The diagnosis of schizophrenia also requires a persistent reduction in overall functioning and self-care.
In fact, it’s not unusual for someone to be a rather high-functioning individual at first, then show evidence of decline in school, work, relationships, usual activities, and personal responsibilities. Schizophrenia is a progressive mental illness with little chance of improvement or reversal of symptoms without treatment. The diagnosis itself requires at least six months of continuous signs of the disorder, unless interrupted by early treatment intervention.
Hallucinations – Positive Symptom of Schizophrenia
People with schizophrenia can experience hallucinations from any perceptual dimension, including auditory, visual, tactile (touch), somatic (bodily) or gustatory (taste/smell). The most common type of schizophrenic hallucination is auditory, and in particular, hearing voices that are not actually present.
These voices and similar kinds of auditory hallucinations are not the same as what many people would describe as an “inner voice,” such as when we might have an internal dialogue with ourselves. In that instance, we are aware that it is us, and we use our familiar language and communication process in such things as personal decision making, thinking aloud or simple daydreaming.
Auditory hallucinations in schizophrenia are often experienced as if others are speaking to the individual, either as separate entities outside the body or invading the body from within, particularly in the head. These voices may be command-oriented in which they tell the person what to do, or can be giving a running commentary on the individual or the situation around them, including people they may encounter.
They can be more than one voice and often be in dialogue with each other about the person and his or her situation. They can also be critical of the person; but some people with schizophrenia may say that the voices can be helpful or comforting. And sometimes the voices are simply gibberish or indiscernible.
Along with voices, people with schizophrenia can hear frightening sounds or just their name being called, causing them fear or a sense that they are being beckoned by some outside force.
Delusions – Positive Symptom of Schizophrenia
Schizophrenic delusions can encompass a range of false ideas, but they usually involve the individual as the center of the delusional belief. The most common of these are paranoid delusions, which involve ideas that others are watching, monitoring or persecuting the person. They often feel as if others are thinking or talking about them, or supplanting their ideas or reading their minds.
Others who are objects of their delusions can include those who are familiar to them, or involve complete strangers. These delusions may also include the sense that they are receiving special messages planted into their minds in some way, or from what they witness through outside sources, such as the television or other media.
Delusions always involve false beliefs, but can be divided between bizarre and non-bizarre types. Delusions that are non-bizarre reflect situations that can actually happen in life, though they are not provably happening to that individual.
An example of a non-bizarre delusion would be someone falsely believing that the police are surveilling them. It is considered “non-bizarre” because the police do surveil certain suspected people.
A bizarre delusion involves something that does not occur in reality, such as someone believing that space aliens inserted microchips in their brain while asleep. People with schizophrenia can have either type of delusion, or a mixture of both over time.
In the early development of symptoms, known as the prodromal phase of schizophrenia, the individual may struggle to accept the validity of the first presence of hallucinations and delusions. But as symptoms progress, the individual can become increasingly convinced that these experiences reflect something mysteriously surreal or a hidden truth that requires further acknowledgement or understanding.
They might either feel a sense of surrender to their hallucinations and delusions, or embark on a confusing, entangled and sometimes even dangerous hunt to uncover the perceived purpose of these troubling experiences. They may even feel a need to follow-through on the perceived commands they are experiencing.
As delusions and hallucinations intensify, so does the mistrust of others around the individual, including loved-ones and those interested in helping them. People ensconced in their schizophrenic delusions frequently incorporate others into their false beliefs, especially the more paranoid ones. This is especially true when someone tries to convince the person with schizophrenia that what they’re experiencing isn’t real. They may then be seen by the person with schizophrenia as a co-conspirator—directly or indirectly—in the plot to control or injure them.
Disorganized Speech Patterns – Positive Symptom of Schizophrenia
It’s not unusual for people with schizophrenia to present disorganized speech patterns that can be tangential, disrupted or incoherent. At times, schizophrenic speech may be described as “word salad.” This disorganization can further extend to various aspects of basic functioning. They can become so overwhelmed by their internal experiences that they neglect personal hygiene, nutrition, finances, relationships, and other typical life responsibilities.
If for example, they believe that television shows are actually speaking coded messages to them, they may fixate on the TV for hours, attempting to process and decode those “messages” to the detriment of all other daily activities. Although some people with schizophrenia can be highly engaging and even charismatic personalities, the increasing intensity of their inner disturbances often result in social isolation and withdrawal from typical social norms.
In some, this may also manifest in catatonic behavior. A person with schizophrenia can at times become physically stiff, immovable, or assume unusual postures for extended periods of time.
While the positive symptoms of schizophrenia often receive greater attention, the disorder’s negative symptoms frequently present some of the most significant challenges over the course of the illness. These symptoms generally involve the reduction or absence of emotional, verbal and non-verbal expression, and behaviors related to motivation and interest.
Disturbance of Affect – Negative Symptom of Schizophrenia
People with schizophrenia often have a disturbance of affect, which is the physical expression of emotion or acknowledgement of a current situation, mostly presented in culturally common facial expressions. Affect that appears inappropriate, incongruent or simply bizarre is not uncommon, and further reflects a loss in one’s sense of connection to reality.
People with schizophrenia may suddenly laugh or giggle uncontrollably for no apparent reason, or stare blankly for protracted periods of time. Their affect is often noted to be flat, blunted or odd, and they may sound monotonic or mutter without any animation or appropriate modulation in their speech patterns.
Along with the disorganization of speech noted as a positive symptom, there can often be a poverty of speech, which is a negative symptom that reflects a lack of desire to communicate in a socially appropriate fashion. But the observation that someone with schizophrenia is simply “spaced out” is likely a mistaken one.
Often, people with schizophrenia who appear disconnected with their environment may still be listening to others and assessing the situation around them, albeit in a fractured manner.
Lack or Absence of Motivation and Interest – Negative Symptom
Additionally, negative schizophrenic symptoms include the lack or absence of motivation and interest, including activities once pursued or enjoyed by the individual before the prodromal phase began. People with schizophrenia will often avoid goal-oriented activities that are sufficiently useful in their daily life and what would be necessary for long-term success.
Instead, they may become stunted in their personal growth, pursuing instead the apparent directives of their delusions or hallucinations, if doing anything at all. They may also present anhedonia, which also describes the absences of pleasurable activities common to daily human experience, such as entertainment, romance and sex.
Schizophrenia vs Depression
Negative symptoms should not be confused with symptoms associated with major depression or other mental disorders that reflect a decrease of functioning. While people with schizophrenia can certainly become depressed, the aggregated symptoms of schizophrenia reflect a primary disorder of thinking instead of a primary disorder of mood.
For example, people with severe mood disorders, such as bipolar disorder, can have the psychotic symptoms of hallucinations and delusions when they are in the worst mood episodes of the disorders. However, these psychotic symptoms generally retreat when the mood episodes subside, and therefore are considered episodic in the person’s daily life.
In schizophrenia, symptoms do not come and go according to mood, but are generally pervasive over extended periods of time no matter what else may be happening in the person’s life. This distinction is particularly important in understanding the depth of schizophrenic symptoms in those individuals, the common experiences of people suffering from schizophrenia, and how treatment is constructed, both from the medical and psychological points of view.
Suicide is highly prevalent in schizophrenia. About 5-6% of people with the disorder die by suicide, while many more will attempt it or at least have persistent thoughts of suicide. This fact makes it all the more important to understand the complexities and experiences of people suffering from schizophrenia, even if they do not show the typical signs of depression associated with suicidal thoughts or intent.
At times, some people with schizophrenia can become violent towards others, especially in domestic confrontations. But unfortunately, due to the stigma of mental illness, too many people believe that someone with schizophrenia is an automatic threat to society. This is simply not true, and such misbegotten beliefs can present more danger to the individual with schizophrenia than anyone else.
Treatments for Schizophrenia
The treatment for schizophrenia ultimately involves a collaborative approach among various mental health providers and services that address the different areas of dysfunction. Typically, people with schizophrenia require treatment from:
- Psychiatrist – provides medical evaluation and treatment services
- Clinical Psychologist – provides additional assessment tools,
- Psychotherapist – provides psychotherapy in the individual, family and/or group modalities
In addition, they will need psychosocial rehabilitation services from any number of qualified professionals to improve functioning and insure ongoing health and safety. This certainly appears to be a tall order, and in fact, comprehensive treatment services for people with schizophrenia can be difficult to establish and maintain for several reasons. But understanding those needs can help make the process more seamless and effective in both the immediate sense and for long-term success.
For those who may need ongoing care or are at risk of being unhoused or hospitalized frequently, assertive community treatment may be a good option.
Assessment of Schizophrenia
The treatment process for schizophrenia begins with proper assessment, which often accompanies crisis intervention for patient and family. Not always will someone present for a clinical evaluation at the first signs of trouble. But as it is with all medical and psychological problems, early detection and intervention can offer the best results. Having said that, schizophrenic symptoms can first present with other problems, such as substance abuse or changes in school or work functioning, or any other issues that would draw more initial attention.
In more advanced cases, people with schizophrenia may push back on attempts by family or professionals to seek and accept treatment, fearing the motives of those who actually want to help or that the treatment may actually harm them. Especially if their paranoid delusions or hallucinations are warning them against such things. Often, a suicidal or other related crisis will result in hospitalization, which may be the first attempt at the assessment and treatment for schizophrenia.
But since the movement of deinstitutionalization during the 1970’s and 80’s, most care for schizophrenia is meant to be provided in the community on an outpatient basis. So even when people are hospitalized with schizophrenic symptoms, the short-term goal is to release them for follow-up care elsewhere, unless their disorder is so advanced that they present a grave level of disability.
Medication for Schizophrenia
Treatment typically requires antipsychotic medications, along with other medications to help improve functioning. Antipsychotic medications have been called neuroleptics or major tranquilizers. They are divided into the older, first-generation medicines known as typical antipsychotics, and the newer, second-generation medicines known as atypical antipsychotics.
Both kinds can be effective in the reduction and management of positive symptoms, particularly with hallucinations and disorganized thinking. Unfortunately, there are less robust levels of effectiveness with negative symptoms.
The main difference in these medications has often to do with their respective side effects. Generally, the atypical antipsychotics have fewer or simply more manageable side effects compared to the older medications. These side effects can include what is known as extrapyramidal signs, which include tremors, slurred speech, tongue protrusions, muscle dystonia and anxiety. Drugs used for Parkinson’s disease can also be used to control these side effects.
Another common side effect to the antipsychotics is what is known as the metabolic syndrome. These medications are often correlated with weight gain and the development of diabetes and high cholesterol. Regular monitoring for these conditions is required when the medications are used.
Patients sometimes complain that antipsychotic medications may make them feel tired or sluggish, and they may actually miss some of the mental acuity not disturbed by hallucinations. Psychiatrists who treat schizophrenia are familiar with these side effects and understand how to approach dosage requirements and changes in med variety to find the best treatment path.
Some of the medications are available in long-acting injectable formulations for patients who struggle with taking a medication daily.
While there are a few competing theories on what is happening in the brain that explains schizophrenia from a neurological point of view, it seems clear that antipsychotic medications essentially affect the brain’s dopamine system. Dopamine is one of the chemicals in the brain that, if overactive, can lead to increased agitation and reduced organization of perception and thought. Antipsychotics help to stabilize this activity, and thus can improve schizophrenic symptoms.
Doctors can use other psychiatric medications often in tandem with antipsychotics to likewise improve related symptoms, including depression and anxiety, to round out an effective treatment profile.
Some with Schizophrenia Can Be Resistant to Medication
Given how effective these medications can be, why do people with schizophrenia often avoid them? There may be different reasons, but remember that people with delusional thinking and/or hallucinations that can comment about immediate events or command a person in their actions can find this whole medication thing very threatening.
In fact, a doctor could be explaining how a medication can help them while the patient is hearing a voice tell them that the doctor is not there to help but actually trying to poison them. Additionally, anyone who recommended or supported that patient to seek psychiatric help may now be viewed with the same suspicion.
So while medications are needed to reduce and manage these symptoms before various therapies can be most effective in the long-term, it’s also important for people entering this often scary and disorienting experience to have treatment professionals work with them to improve feelings of trust, even as forces within offer resistance.
It’s vital for people with schizophrenia to have a team of experts in schizophrenia help them face those frightening forces without judgment or reproach. Instead of just telling them, “Those voices in your head aren’t real,” the communication is more, “I’d like to know more about the voices and how you feel about them.”
Essentially, mental health professionals trained in the treatment of schizophrenia will often try to go with patients into their experiences, rather than simply try to invalidate them, which could validate the paranoia instead. By creating this “journey together,” patients and their doctors and therapists can begin to explore feelings that are often hidden, repressed or blunted within the individual, and develop a sense of trust as an antidote to paranoid thoughts and commands.
Living and Coping with Schizophrenia
During the initial phase of treatment, medications and psychotherapy ideally work together to improve symptoms and functioning. It’s also good, when appropriate, to involve specific family members, such as parents for young or single people, and spouses, partners or caregivers for older people.
Family education and understanding is important in stressing that no one is at fault in the cause and development of the schizophrenic disorder, but loved-ones can play an important role in ongoing care. Moreover, family members will likely need support and perhaps their own therapy due to the emotion strain that the consequences of schizophrenia has caused in their lives.
Because schizophrenia can threaten so many different areas of life, different therapies beyond medication and psychotherapy are necessary for long-term success. These treatments can include various forms of occupational and recreational therapies, nutritional and self-care guidance, and for many, concurrent substance abuse treatment. Tobacco addiction, weight gain, diabetes and other chronic conditions often require attention along with schizophrenic symptoms. The importance of a team-approach to schizophrenia care cannot be overstated.
In particular, addressing substance abuse is critical, as many people with schizophrenia self-medicate, instead of only using prescribed medications to treat their symptoms. While they may experience relief with certain drugs, the wrong substances can exacerbate psychotic symptoms overall, and place individuals who abuse substances at greater risk for poor outcomes and consequences.
It is also critical for many to gain access to greater community and social services. Unfortunately, many people with schizophrenia “fall through the cracks” of contemporary society, and become severely disabled, jobless or homeless. Unifying treatment professionals, responsible family members, and community resources offer people with schizophrenia the best opportunities for lifelong success.
While this mental disorder can be pernicious in so many ways, many people with schizophrenia go on to enjoy accomplishments through various creative and vocational pursuits, along with fulfilling relationships. It is likely among all of them that they will need to maintain a treatment regime through their lifespan, along with novel approaches to meet life challenges.
