What is schizophrenia?
Schizophrenia is a severe mental disorder which is characterized by a wide range of unusual behaviors: hearing voices (hallucinations) and distorted or false perception, often bizarre beliefs. They are unable to distinguish between reality and imaginative events. These unusual experiences seem real to the person whereas others assume that the person is lost in their own world.
Owing to the signs of schizophrenia, a person with the illness is likely to interpret reality in a way that seems abnormal to others. They may believe that others are trying to control them or harm them, and may feel compelled to act in ways to protect themselves that appear inexplicable to others – for instance, keeping all doors and windows closed to protect the family from the neighbors’ attempts to kill or harm them.
Persons with schizophrenia are not aware of the changes in their behavior. They may not accept that they are behaving differently. This is because for them, the lines between external and internal reality are blurred and they are unable to differentiate between the two. This lack of insight makes them withdraw from family and friends, and refuse medical support.
What schizophrenia is not
For most of us, the term ‘schizophrenia’ conjures up images of a person with unkempt appearance, disheveled hair and torn clothes; a person who is unable to control his or her actions and whose behavior is unpredictable and violent; someone who communicates with UFOs, or acts as if possessed. Movies have depicted persons with schizophrenia as eccentric geniuses or deranged and aggressive people who need to be locked up in a mental asylum for the rest of their lives.
In India, the common stereotype of a person with schizophrenia is being a crazy, out-of-control psychopath who is a threat to himself and others around him. Doctors say that the media portrayals of this disorder is not correct.
How does schizophrenia occur?
The onset of schizophrenia usually occurs between puberty and early adulthood. It is a condition that develops gradually, often over a period of weeks to months. Symptoms in the early stages of schizophrenia may be similar to other mental health issues: adjustment problems, depression or anxiety.
In the initial stages of the illness, the person may show ‘negative symptoms’ such as remaining aloof and withdrawn, preferring to stay away from friends and family. They may lose interest in daily activities and hobbies they enjoyed earlier, and ignore personal grooming or hygiene, even if they were very particular about it before. Their behavior changes too – they may smile or laugh to themselves for no apparent reason.
If not detected and treated, the problem may become more severe and the person may turn aggressive verbally and physically.
Across the world, schizophrenia affects approximately one per cent of the population, and is observed in both men and women. The common age of onset is 15 to 25 years, though there are cases in which the disorder can develop in people beyond this age group as well.
What are the symptoms of schizophrenia?
A person with schizophrenia is not likely to behave strangely all the time. The symptoms can be unpredictable in when they appear and disappear, and the intensity of the unusual experience fluctuates. The most common symptoms are:
Hallucinations: Seeing or hearing people or things that do not exist. The person may also have the experience of tasting, touching or smelling something that isn’t there. Most people also report they hear voices speaking to them, commanding or abusing them.
Delusions: These are beliefs that can persist even after they have been proved to be false or unreasonable. Some people believe that someone they know is trying to control them or poison them; some may believe that someone is communicating with them through a secret code on television. The person may feel everyone is talking about him/her and may be very suspicious all the time. In rare cases, the person may believe that he or she is a celebrity or a historical figure.
Disorganized thinking: Sometimes, the person is unable to think clearly. Their talk appears illogical, irrelevant or disconnected and this makes no logical sense to people around them. The person may stop abruptly before finishing a sentence, give irrelevant answers to questions, or occasionally they make up their own nonsensical words.
The symptoms listed so far are referred to as ‘positive symptoms.’
Cognitive problems: The person's impaired thinking makes it difficult for them to focus on simple tasks for longer durations. They have trouble paying attention to what other people are saying, and may forget even to do simple routine tasks which most people take for granted. This usually results in their poor performance at studies or at work. This problem is seen in the early stages of illness but family and friends may fail to identify the problem due to lack of awareness about the illness.
Disruption of normal behavior: The person may tend to avoid spending time with others, instead they prefer being alone. They speak in a flat monotonous tone, often in monosyllables, and their facial expressions are mask-like, displaying little or no emotion.
What are psychosis and psychotic episodes?
The term psychosis is used frequently with reference to schizophrenia, and some other serious mental disorders. The word refers to a mental condition in which the person may lose touch with reality (being unable to differentiate between real and imaginative events). This affects their mood and behavior, causing them to be withdrawn or depressed. A person with schizophrenia experiences hallucinations and delusions that cause fear, suspicion, agitation, and depression.
A psychotic episode is an instance in which the person has strong delusions or hallucinations. The severity and frequency of these psychotic episodes may vary from one person to another. The person may also remain entirely unaffected or appear normal during other times.
Sometimes, the person may get very violent or aggressive and be a physical threat to themselves or others. In such cases, the hospital allows caregivers to admit the person against his or her will with a Magistrate’s order.
Contact a doctor if you think the situation is getting out of control and you are concerned about the safety of the patient and his or her family.
What causes schizophrenia?
Medical researchers have not been able to find the exact causes of schizophrenia. Research now tells us that the disorder is linked to abnormalities in the structure of the brain. There are also some factors that are believed to put a person at a greater risk of developing schizophrenia:
Genetic factors: Having a parent or sibling with schizophrenia puts the person at increased risk
A chemical imbalance in the brain
Problems during pregnancy: The child may develop schizophrenia if the mother does not receive proper nutrition, or is exposed to viral illnesses during pregnancy
Extreme stress and overuse of drugs and alcohol can worsen any existing symptoms of schizophrenia.
How is schizophrenia diagnosed?
There is no single test for diagnosing schizophrenia. Due to the range of different symptoms that may be seen in the patient, the psychiatrist makes a diagnosis after a thorough clinical examination. As part of the examination the psychiatrist tries and unravels the changes in their behaviour and biological functions (sleeplessness, lack of interest in eating or socialising). Information about the deviations in the patient’s behaviour is also collected from the family or caregivers.
A person is diagnosed with schizophrenia only if he or she has exhibited a combination of the above mentioned symptoms for at least a month.
If you suspect someone you know has schizophrenia, it is best to consult a doctor. There are other mental health disorders such as addiction, bipolar disorder and depression that can be confused with schizophrenia because they also may cause delusions, hallucinations, and social withdrawal. Only a psychiatrist will be able to accurately diagnose whether the person has schizophrenia, or is suffering from another disorder.
Getting treatment for schizophrenia
Though there is no known cure for schizophrenia, there are several treatments that can help the person live his or her life independently. Schizophrenia is a chronic disorder and needs management, just like diabetes or blood pressure.
The goal of treatment is not only to control symptoms, but also to ensure that the person is able to lead a functional life.
“The rule of thumb is that one-third of people with schizophrenia get back to normal functioning; one-third of them return to a level of functioning that is just below normal, and are able to cope. The remaining one-third need more assistance to lead a functional life. No one can predict when exactly a patient will return to a normal level of functioning. The key lies in early diagnosis: the earlier you identify the problem and get a diagnosis, and the more scrupulously you follow the treatment, the greater are the chances of good outcome. Sticking to the treatment plan is the key to recovery,” says psychiatrist Dr S Kalyanasundaram, MD, CEO of the Richmond Fellowship Society (Bangalore branch).
Antipsychotic drugs and ECT
Depending on the symptoms and progress of the disorder, the doctor may prescribe a combination of drugs, therapy and rehabilitation. The prescribed drugs are called antipsychotic drugs that help in reducing positive symptoms such as hallucinations, delusions and paranoia. In some cases, the psychiatrist may prescribe Electro Convulsive Therapy (ECT).
“There are a lot of myths about anti-psychotic drugs and their side effects. Any medicine is bound to have certain side effect. But the anti-psychotic drugs used today have more desirable effects and minimal side effects – the patient may experience rigidity, stiffness or shivering. We do prescribe drugs, when necessary, to manage the side effects too,” says Dr Laxmi V Pandit, professor at KIMS, Bangalore.
Contrary to popular belief, ECT is a safe procedure when performed by trained professionals. “This is the safest therapy we can give to patients who are acutely disturbed, or are not responding to medication. The therapy is performed under anesthesia. It is mild and can relieve the positive symptoms, and does not cause any distress to the patient,” says Dr Pandit.
The management of schizophrenia requires a holistic approach, of which medicine is just one aspect. The caregivers’ support and structured rehabilitation also play a vital role in aiding recovery.
Caring for someone with schizophrenia
Caring for a loved one who has schizophrenia can be very challenging. It can be shocking and disheartening to see your loved one’s odd and unpredictable behavior. Caregivers – particularly parents – are very likely to have feelings of grief and guilt when they learn of the diagnosis. Common reactions include: “Why me?” “Where did I go wrong?” “Am I a bad parent?”
If you suspect that a loved one has schizophrenia, observe the changes in their behavior and give the doctor complete information. Speak to the doctor and get a thorough understanding of the diagnosis. If you need support to overcome your shock, grief or guilt, ask your doctor about a support group or counselor in your area. It will be easier for you to take care of the patient if you are correctly informed, and have received support for what you’re going through.
Doctors say that expressed emotion plays a huge role in the person's recovery. The person can, whether consciously or subconsciously, pick up emotional cues from the way the family is dealing with the illness. They are likely to recover sooner when then family provides support and care. If the family criticizes the person or blames him or her for the illness, the person may have to struggle harder for recovery, and a person who is recovering may suffer a relapse.
As a caregiver, it is important to remember that the person may not have an insight into the symptoms – they do not know or understand why their behavior is not normal. Their brain is sending them signals that make them believe that the hallucinations and delusions are real experiences. This makes the person resist treatment as they believe that there’s nothing wrong with them. They do not know that they are mentally ill. Some caregivers, out of concern for their loved one, may tell the person that the delusions are not true, and force them to seek help. This isolates the person from the caregivers and may increase the fear and paranoia caused by the delusions. You can help your loved one by:
Asking them about their experiences (hallucinations, delusions).
Acknowledging that the experience is true for them, and that it disturbs them (instead of denying their beliefs).
Encouraging and supporting the person to take decisions related to treatment.
Maintaining a record of the person’s symptoms and medication because the person is unable to recall or convey the relevant information, and doctors rely on the family to gather information.
Speaking to other family members about your concern, and discussing how you can support each other while the person undergoes treatment.
Speaking to a counselor or joining a local group to seek emotional support for your loved one, and for you. Schizophrenia can cause immense stress and grief to the caregivers too. Paying attention to your own needs will help you take better care of the person.
Watching the person for signs of relapse (your doctor can help you with a comprehensive list) so that you can get help before a psychotic episode occurs. Research has shown that a relapse can hamper the person's wellbeing, and can make recovery much harder, in addition to causing some adverse changes in the brain.