Understanding Schizophrenia:
A GUIDE FOR PEOPLE WITH
SCHIZOPHRENIA
AND THEIR
FAMILIES
Source: NARSAD RESEARCH
WHAT IS SCHIZOPHRENIA?
Schizophrenia is a serious
brain disorder. It is a disease that makes it difficult for a person to tell
the difference between real and unreal experiences, to think logically, to have
normal emotional responses to others, and to behave normally in social
situations. People with schizophrenia may also have difficulty in remembering,
talking, and behaving appropriately.
Schizophrenia can be very draining on both the people with schizophrenia and
their families. People with schizophrenia often have difficulty functioning in
society; they cannot work or go to school. Family members often have to help
out financially and make sure that medicine is taken.
Schizophrenia is not a “split personality.” It also is
not caused by bad upbringing, personal weakness, or laziness. Schizophrenia is
a disease with a physical cause, like cancer or heart disease.
In addition, schizophrenia is a very costly illness. In
the United States, it costs as much as $48 billion each year. This total
includes the costs of medical treatment, Social Security payments, and wages
lost because of illness for every person with the disease.
There is no cure for schizophrenia today, but proper
treatment can usually control the symptoms. With treatment, most people with
schizophrenia can lead productive and fulfilling lives- working, living with
their families, and enjoying friendships.
WHO GETS SCHIZOPHRENIA?
Schizophrenia is one of the
most common mental illnesses. About 1% of the world population has
schizophrenia. In the United States, there are about 2.5 million people with this
disease. Schizophrenia is the cause of more hospitalizations than almost any
other illness.
Schizophrenia most commonly begins between the ages of 15
and 25. Although it strikes men and women equally, the symptoms may appear
later in women than in men. Very rarely, the symptoms of schizophrenia can appear
before the age of 12. Such childhood
schizophrenia has a more chronic disease course and involves poor early
language development.
WHAT ARE THE SYMPTONMS
OF SCHIZOPHRENIA?
People with schizophrenia can
have a variety of symptoms. Sometimes, these symptoms come on suddenly.
Usually, though, the illness develops slowly over months, even years. At first,
the symptoms may not be noticed or may be confused with those of other
conditions. For example, people with schizophrenia may feel tense, be unable to
concentrate, or have trouble sleeping. They often become increasingly isolated
and withdrawn as their grip with reality loosens. They do not make or keep
friends. They may stop caring about the way they look. Dropping out of school
or doing badly at work are other early signs of schizophrenia.
As the illness progresses, symptoms of psychosis develop. The person starts to act strangely
and talk nonsensically. People with schizophrenia may
develop hallucinations; that is, they
may see, feel, smell or hear things that are not really there. They may have
physical symptoms, like frowning or unusual movements, and may stand or sit in
strange positions. Some people become almost motionless. Others move around
constantly.
The severity of symptoms varies from one person to
another. The symptoms also tend to worsen and improve. When the symptoms are
improved, the person may appear to behave relatively normally, but usually
there will be repeated episodes of the illness (relapses) that will cause symptoms to reappear.
The symptoms of schizophrenia usually fall into two large
categories: positive and negative symptoms. Positive symptoms
include paranoia, auditory hallucinations, and bizarre behavior. Negative
symptoms
include the lack of initiative and inability to relate to
others that often results in persons with schizophrenia withdrawing from
society. Some symptoms of schizophrenia, together with their medical names, are
shown in the box.
|
Common Symptoms of Schizophrenia |
|
POSITIVE (abnormal thoughts and perceptions) |
|
·
Disordered
thinking: Thoughts “jump”
between completely unrelated topics or may be “blocked.” The person may talk
nonsense, make up words, or replace words with sounds and
rhymes.
·
·
Hallucinations: Hearing, seeing, or feeling things that are not
there. People with schizophrenia may hear voices that may comment on their
behavior or give them commands. |
|
NEGATIVE (loss or decrease of normal functions) |
|
·
Blunted (or flat) affect: Lacking awareness of other people’s feelings. The
person does not show feelings or emotions on the face. The face looks “blank”
compared with the face of someone without ·
Avolition: Lacking energy, spontaneity, initiative. ·
Anhedonia: Lacking pleasure or interest in activities that
were once enjoyable. ·
Attention
deficit:
Difficulty in concentrating. |
HOW IS SCHIZOPHRENIA DIAGNOSED?
Because other diseases can
also cause symptoms of psychosis,
psychiatrists ( medical doctors who specialize in the treatment of mental
illnesses) should make the final diagnosis. The diagnosis is made based on a
thorough psychiatric interview of the person and family members. As yet, there
are no medical tests for schizophrenia.
There are also disorders that may be related to
schizophrenia. These include schizotypal
personality disorder, which is a
milder form of schizophrenia, and
schizoaffective disorder, in which schizophrenia is accompanied by
inappropriate “highs” (mania) or
depression.
DEPRESSION, SUICIDE, AND SCHIZOPHRENIA
Depression is a real danger
in people with schizophrenia. A person with schizophrenia is especially likely
to have attacks of severe depression in the time between psychotic episodes.
About two of every ten people with schizophrenia try to
commit suicide, and about half of them succeed... In fact, suicide is the
number one cause of death for young people with schizophrenia.
The reason? In rare cases, people act under the influence
of delusions or hallucinations, such as hearing voices. But suicide is usually
the result of depression that occurs when people with schizophrenia are
thinking relatively clearly and have some understanding of their illness.
WHAT CAUSES SCHIZOPHRENIA?
Schizophrenia is a complex
and puzzling illness. Even the experts are not sure exactly what causes it.
Some doctors think that the brain may not be able to process information
correctly. In the next section, we will discuss some of the structural and
chemical abnormalities that cause the brains of people with schizophrenia to
get overloaded by too much information from the outside
world. People without schizophrenia usually filter our unneeded information:
for example, the sound of a dog barking next door. People with schizophrenia, however,
cannot always filter out this extra information.
Heredity
One possible cause of
schizophrenia may be heredity, or genetics. Experts think that some people
inherit a tendency to schizophrenia.
In fact, the disorder tends to “run” in families, but only among blood
relatives.
People who have family members with schizophrenia may be
more likely to get the disease themselves. 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 Schizophrenia Developing |
|
General population 1% |
|
Brother or sister
has schizophrenia 8% |
|
One parent has
schizophrenia 12% |
|
Fraternal twin has
schizophrenia 14% |
|
Both parents have
schizophrenia 39% |
|
Identical twin has
schizophrenia 47% |
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.
Environment
Some researchers believe that
events in a person’s environment trigger schizophrenia. Some studies have shown
that influenza infection or improper nutrition during pregnancy and
complications during birth may increase the risk that the baby will develop
schizophrenia latter in life.
Many researchers believe schizophrenia is likely caused
by a complex combination of genetic and environmental factors. Certain people
are born with a tendency to develop the disease. But the disease only appears
if these people are exposed to unusual stresses or traumas.
WHAT HAPPENS IN THE BRAIN IN SCHIZOPHRENIA?
People with schizophrenia may
have a chemical imbalance in the brain. They may be either very sensitive to or
produce too much of a substance called dopamine.
Dopamine is one of several brain chemicals (neurotransmitters)
that allow nerve cells to send messages to each other. Researchers have found
several types of dopamine receptors in
different parts of the brain. Other neurotransmitters and their receptors also
may be affected in people with schizophrenia.
Researchers have used modern techniques to show the
differences between the brains of people with schizophrenia and those of
mentally healthy people. Specialized tests that produce images (scans) of the inside of the brain show
differences in the size and shape of certain brain structures in people with
schizophrenia compared with those of mentally healthy people. For example, in
people with schizophrenia, there is enlargement of the fluid-filled cavities of
the brain called ventricles. Similarly,
there is a decrease in the size of the part called the hippopcampus. Other tests have shown that in the brains of people
with schizophrenia there is less activity in the prefrontal cortex, the part of the brain that governs thought and
higher mental functions.
HOW IS SCHIZOPHRENIA TREATED?
Schizophrenia is usually
treated with antipsychotic medication. Some people with schizophrenia also
benefit from counseling and rehabilitation. They may need to go to the hospital
during an acute attack. The goal of treatment is to reduce symptoms during
acute attacks and to help prevent relapses. At this time, there is no cure for
schizophrenia.
Antipsychotic Medications
Antipsychotic medications
(often called neuroleptics) are very
effective in controlling the symptoms of schizophrenia. These medications first
became available in the mid-1950s. They have greatly improved the lives of
thousands of people. Before that time, people with schizophrenia spent most of
their lives in crowded hospitals. With antipsychotic medication, however, many
people with schizophrenia are able to live in the outside world.
Because each person with schizophrenia has a unique mix
of symptoms, no single medication works best for all people. The ideal
medication for one person may not be the best choice for another. Although
antipsychotic medications do not cure the disease, they can reduce
hallucinations and delusions and help people with schizophrenia regain their
grip on reality. Medication also reduces the risk of the symptoms returning. If
the person does have a relapse of symptoms, medications may make the symptoms
less severe.
Unfortunately, many people with schizophrenia do not take
the medications they need. Understanding the importance of medication to
control schizophrenia is important for patients, family members, and the
community.
Counseling and Rehabilitation
People with schizophrenia can
have a hard time communicating with other people and carrying out ordinary tasks.
This is true even when the positive symptoms are reduced. Counseling and rehabilitation
can help people with schizophrenia build the skills they need to function
outside the sheltered setting of a hospital. However, these treatments are not
very helpful during acute attacks.
Rehabilitation programs may help people with
schizophrenia develop skills needed for ordinary life (money management,
cooking, and personal grooming, for example). They may also prepare the person
to go or return to work. Individual psychotherapy
(sometimes called talk therapy) may
help persons with schizophrenia learn to sort out the real fromorm
the unreal. Group therapy may help them learn to get along with others.
Self-help groups may help persons with schizophrenia (and family members) feel
that others share their problems.
Family therapy can also be very helpful. Family members
often help care for people with schizophrenia. It is important that caregivers
understand the disease and its treatment. Families and other people in the
community need to provide support for persons with schizophrenia coming out of
the hospital. Family members are also taught to watch for signs of relapse.
This helps them make sure that the person gets medical help and takes the medications
that prevent symptoms from returning.
WHAT DO ANTIPSYCHOTIC MEDICATIONS DO?
Antipsychotic medications
work by changing the balance of chemicals in the brain. There are two major
types of antipsychotics: traditional antipsychotics
and newer antipsychotics.
Traditional Antipsychotics
The traditional antipsychotic
medications control the positive symptoms (hallucinations, delusions,
confusion) of schizophrenia very effectively. Researchers believe that part of
this effect may be explained by the way these medications affect the brain
chemical dopamine. This group of medications seems
to block dopamine type 2 receptors from taking up the information carried by
dopamine. Dopamine regulates many normal body functions, including movement,
emotions, behavior, and appetite. Many of these functions are affected in
people with schizophrenia. Some researchers think that the positive symptoms of
schizophrenia-delusions, hallucinations, and confusion-may be caused by too
much dopamine in the brain (or very sensitive dopamine receptors).
Even though typical antipsychotics do much good, many
persons with schizophrenia stop taking them. They stop for two reasons.
First, these medications may have unpleasant side
effects, especially at higher doses. Some side effects, such as dry mouth,
blurred vision, constipation, and dizziness (which are called anticholinergic effects), and drowsiness
are not serious. These side effects usually disappear a few weeks after the
person starts treatment. More serious side effects cause trouble with muscle
control. Because they also block receptors in the part of the brain that
controls muscle movement, these medications may cause movement disorders, or
extrapyramidal side effects (EPS).
More than 60% of people who take traditional antipsychotics experience some
form of EPS. They may have muscle spasms or cramps in the head and neck (dystonia), or they may fidget or pace
restlessly (akathisia). Some may
develop symptoms like those affecting people with Parkinson’s disease. These
effects include tremors and shuffling of the feet. About one third of people
who take traditional antipsychotics will develop facial tics, thrusting and
rolling of the tongue, lip licking, panting, and grimacing (tardive dyskinesia).
Second, these medications do not improve the negative
symptoms of schizophrenia (such as depression and emotional withdrawal). This
is probably because brain chemicals other than dopamine control the negative
symptoms.
Newer Antipsychotics
The newer antipsychotics are
also effective in treating the positive symptoms of schizophrenia. This group
of medications may also be effective against the negative symptoms.
These newer antipsychotics do not seem to cause as many
problems with muscle control. This may be because, in addition to dopamine,
they block another neurochemical, called serotonin.
Also, they are selective: they
work only on the part of the brain that causes the psychotic symptoms but not
on the part that controls normal muscle movement.
One newer antipsychotic is clozapine (Sandoz Pharmaceiutical
Corp.). It is more selective for serotonin receptors and dopamine subtype
receptors other than dopamine type 2 receptors. Clozapine is very effective in
treating psychotic symptoms without causing EPS. However, because it blocks
many receptors, in the brain other than just dopamine and serotonin receptors, clozapine
tends to cause sedation and the anticholinergic effects of the traditional
antipsychotics-dry mouth, blurred vision, constipation, and dizziness. In a
small number of people, clozapine also causes a large weight gain, seizures,
and considerable drooling. Clozapine has also been known to cause a significant
reduction ion the
number of infection-fighting white cells in the blood. Because of this, people
taking this medication must have blood test taken once a week.
Another newer antiphotic is risperidone (Janssen Pharmaceel Inc.). It is believed to block
both dopamine type 2 and serotonin type 2 receptors and relieves both the
positive and negative symptoms of schizophrenia. Risperidone has a reduced risk
of EPS, anticholinergic effects, and sedation. It is safer than colzapine but
tends to cause EPS at higher doses.
Approved by the FDA in late 1996, olanzapine (Eli Lilly and Co.) is similar to clozapine. It is
effective against both positive and negative symptoms and causes very little
EPS. Because, like clozapine, olanzapine blocks many more
receptors in the brain than just dopamine and serotonin receptors, , olanzapineclospine
can cause some sedation and anticholinergic effects.
Newest
Generation of Antipsychotics
It is hoped that the
development of the newest generation of antipsychotics will prove to be a great
help to people with schizophrenia, providing better control of symptoms with
fewer side effects. Quetiapine and sertindole are awaiting FDA approval in
mid-1997. Ziprasidone filed for FDA approval in March of 1997.
Quetiapine
(Zeneca Pharmaceuticals) blocks a variety of receptors but is more selective
for serotonin type 2 receptors than dopamine type 2 receptors. It is also more
selective for receptors in the part of the brain responsible for psychotic
symptoms and has minimal effect on muscle tone. Quetiapine is also effective
against both positive and negative symptoms. Quetiapine showed no difference in
EPS and prolactin levels compared to placebo in controlled clinical trials
across all dosage ranges. Side effects which may be seen include drowsiness and
orthostatic hypotension.
Sertindole (Abbott
Laboratories) is different from clozapine; it is selective for fewer receptors-
primarily dopamine type 2 and serotonin type 2 receptors. It is effective
against both positive and negative symptoms of schizophrenia without causing
EPS, sedation, or anticholinergic effects. In a few patients, sertindole has
caused nasal congestion, and some men have had decreased ejaculatory volume,
but this was generally accompanied by normal sexual desire and function.
Ziprasidone
(Pfizer Labs Division) is a strong blocker of serotonin type 2a receptors and a
moderate blocker of dopamine type 2 receptors. It also blocks serotonin type 2c
and type 1d receptors but stimulates serotonin type 1a receptors. Because of
its effects on other receptors, ziprasidone causes less low blood pressure and
sedation than traditional antipsychotics.
WHEN CAN MEDICATIONS BE
STOPPED?
Schizophrenia is usually a
lifelong disease, like diabetes or high blood pressure. Most people with
schizophrenia will probably need special medical care and medication for the
rest of their lives. Antipychotic medications do not cure schizophrenia. They
only control the symptoms of the disease.
When people with schizophrenia stop taking their
medication, they may have a relapse.
That is, symptoms of an acute attack appear again. Most people who stop taking
their medication will have a relapse within 1 year. It is very important that
people with schizophrenia continue to take their medication to prevent new
attacks.
A few people continue to have psychotic attacks even when
they take their medications. Their symptoms are probably less severe, however.
Sometimes increasing the dose of the medication can stop a relapse.
HOW CAN RELAPSES BE
PREVENTED?
The best way to prevent
relapses is to continue to take the prescribed medication. People with
schizophrenia may stop taking their medication for several reasons.
Side effects are one of the most important reasons that
people with schizophrenia stop taking their medication. It is hard for people
to put up with unpleasant side effect for months or years. It is especially
hard when the person feels well. It is very important to find the medication (and
the dose) that controls symptoms without causing side effects.
Convenience is also important. Some medications need to
be taken two, three, or even four times a day. Others may be taken just once a
day. People are more likely to remember to take a medication once a day than
several times a day. Some people prefer to get injections every month of
long-lasting medication (depot medication).
Taking medications regularly is the best way to prevent
repeated illness and hospitalization.
For more information contact
The
Alliance for the Mentally Ill
NAMI of
Greater Chicago
1536 West Chicago Avenue
Chicago, IL 60622
(312)
563-0445
Fax 312-563-0467