Understanding Schizophrenia

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Understanding Schizophrenia

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Involving the Family

How to Prevent Relapse

Early Warning Signs of Relapse

Some Final Words

What's Covered on This Web Page?

This web page explains what is known about the symptoms of schizophrenia and about some of the possible causes of the illness. It also discusses the treatments for schizophrenia and how to get the most from them. The more you can get out of your treatment, the more likely it will be that you can control your symptoms instead of having your symptoms control you. The better your symptoms are under control, the better you'll be able to get on with your life.

What Are the Symptoms of Schizophrenia?

Doctors often sort the symptoms of schizophrenia into groups. There are three kinds of symptoms that you should learn to recognize:

Positive symptoms
Negative symptoms
Cognitive symptoms

When deciding if a patient has schizophrenia, doctors consider these three kinds of symptoms. Also, these symptoms can often be helped by medications and rehabilitation therapies.

Some examples of these symptoms are provided in the sections below. You may recognize some of them. Some might not relate to you. Keep in mind that no two people are exactly alike. The same goes for symptoms of schizophrenia. Someone with schizophrenia can have positive symptoms, negative symptoms, and cognitive symptoms all at once. Or, someone can have mostly one kind of symptom and not much of the others. No two people will have exactly the same symptoms.

Positive Symptoms

The symptoms that are most commonly connected with schizophrenia are called positive or psychotic symptoms. Positive symptoms are distortions in perception and thinking that are found in people with schizophrenia but not usually in other people. These symptoms are not called "positive" because they are good. They are called positive because they are added to everyday experiences. Two examples of positive symptoms are delusions and hallucinations.

Delusions are false ideas that the person believes in strongly. There are many different kinds of delusions. Examples of some delusions that people with schizophrenia have are:

The idea that ordinary things have special meanings just for them ("referential delusions"). Some people with schizophrenia believe that events around them are directly connected to them. For example, they may think the weatherman on the TV news is sending them special messages.
The idea that they are being persecuted ("paranoid delusions"). People with these kinds of delusions believe that they are being harassed or are in danger. They have these fears even though there isn't any proof backing up their beliefs. Often, people with paranoid delusions live in constant fear and anxiety. For example, they may be afraid to eat anything that isn't sealed because they believe that people are trying to poison them.
The idea that something is very wrong with their bodies ("somatic delusions"). Some people may believe that there is something physically wrong with their bodies, even when they are healthy and the doctor can't find anything wrong. For example, they may believe that their hearts have been taken out and replaced with computer-operated machines.

Hallucinations are perceptions or sensations that the person experiences but that others do not. They are almost like what happens in dreams, but they occur when the person is alert and awake. The different kinds of hallucinations are:

Auditory hallucinations: hearing voices or sounds that other people don't hear. The voices often say mean or insulting things. "I hear the voices of my high school classmates laughing at me and telling me I'm stupid.then they tell me I should hurt myself."
Visual hallucinations: seeing things other people don't see. Like auditory hallucinations, they can be nonspecific flashes or images, or they can be fully formed visions of people, animals, or objects. "The face of my doctor turned into the devil!"
Hallucinations involving feeling or smelling things: Touch (tactile) hallucinations include the sensation that something is on your skin (often insects.) Smell (olfactory) hallucinations are often sensations of unpleasant odors. These are somewhat less common than auditory or visual hallucinations, but they can happen.

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Negative Symptoms

Some symptoms of schizophrenia have to do with things that should be there, but are missing. For example, people want to have friends, or want to be active. Negative symptoms may take those normal things away. Negative symptoms mean lost motivation or functioning. Negative symptoms take away the person's interests, motivation, and abilities. Some examples of negative symptoms are listed below.

Not showing emotion ("flat affect"): the person doesn't show feelings. People with flat affect don't laugh at jokes, or don't look sad if they hear about the death of a friend. Maybe they experience emotions somewhere deep inside, but the emotions aren't shown outside.
Lack of motivation ("apathy"): the person doesn't feel like doing anything and has very low energy. An example might be someone who stays in bed all day even if he or she is not sleepy. The person doesn't feel like doing anything or going anywhere. This can be very frustrating for families because it looks like "laziness" or "not trying hard enough."
Not experiencing pleasure ("anhedonia"): the person doesn't feel pleasure. Instead, he or she feels nothing-kind of like having emotional anesthesia. For example, someone with anhedonia won't have favorite activities or TV shows and just is not interested in trying to have fun.
No social interests ("asociality"): the person isn't interested in having friends or social relationships. It's not shyness or depression-it's just that the person wants to be alone.

A cautionary note about negative symptoms. There are other problems that can look just like negative symptoms, but are caused by something else. For example, some people withdraw from others when they're trying to cope with their positive symptoms. This kind of withdrawal can look just like a negative symptom, but it's really a reaction to the positive symptoms. Another example is that the neurologic side effects of some of the antipsychotic medications can also resemble a negative symptom. The bottom line is to make sure you ask the doctor about whether the negative symptoms could be caused by something else.

Cognitive Symptoms

Cognitive symptoms include problems with concentration, attention, and learning. Doctors use the word "cognitive" because it is a medical word for thinking. Schizophrenia can make it harder to think clearly. But, this is NOT the same as having a low IQ. The cognitive problems that happen in schizophrenia are like a kind of learning disability. And, just like people with learning disabilities, you can have cognitive problems from schizophrenia and still be very smart.

Some examples of cognitive symptoms that happen in schizophrenia are:

Trouble concentrating: having a hard time paying attention, focusing, and concentrating. Examples: You can't pay attention long enough to follow a story on TV, read a book, or carry on a conversation; you can't keep your mind on anything for very long.
Trouble learning new information: having a really hard time learning new information or new skills. Examples: You study something over and over again but you just don't seem to get it; you want to learn to do something but you can't seem to get it right.
Trouble planning and thinking things through: having a hard time thinking ahead, making a plan, or deciding what steps need to be taken to get something done. Examples: You want to cook a meal for a friend but you have trouble figuring out all the things you need to do so you can make it happen; you decide you want to go back to school but you can't figure out where to start or what needs to be done.

A cautionary note about making a diagnosis. For a doctor to make a diagnosis of schizophrenia, the person has to have had some positive symptoms for a few weeks sometime in his or her life. And, the positive symptoms cannot be better explained by some other problem, such as ongoing problems with street drugs. Keep in mind that all of the symptoms of schizophrenia can happen in other conditions, such as other psychiatric disorders or substance abuse problems. Only a qualified doctor should make a diagnosis based on the person's medical and psychiatric histories.

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Watch Out for Depression

This web page does not cover all of the symptoms of schizophrenia. But one special kind of mood symptom is important to know about. It is called "postpsychotic depression." This means that the depression comes—or gets worse-soon after the positive symptoms get better. Even though the person has fewer symptoms of schizophrenia, he or she can get severely depressed. The depression shows up as feelings of hopelessness. Sometimes the depression gets so bad that the person becomes suicidal. The lesson here is that patients, family members, and doctors need to watch for postpsychotic depression, even if the patient seems to be getting better. If suicidal feelings come up during this time, they should be taken very seriously and the person should go for a psychiatric evaluation right away.

How Can Schizophrenia Affect Functioning?

The symptoms of schizophrenia can make it harder for people to do the things they once could. When the symptoms are severe, some people have trouble taking care of everyday tasks ("activities of daily living").

Positive symptoms, such as hallucinations (hearing voices or seeing things that are not there), are very distracting and can get in the way of doing a job or doing schoolwork. People with schizophrenia may also have delusions that people are trying to hurt them. Such fears may make it very difficult to be with other people.

Negative symptoms can also make it extremely hard for people with schizophrenia to carry on their daily activities. These individuals may feel that there is just no point in doing anything. They may not have the energy to even try. Things that they used to enjoy no longer interest them. Negative symptoms may make it difficult to participate in and enjoy social relationships. In some cases people with schizophrenia just give up trying to be part of the world and stay home doing very little most of the time.

Cognitive problems can make it harder to learn new skills. These problems can make it harder to concentrate or pay attention, so it can be difficult to go to school. People with cognitive difficulties may need to get extra help to keep up with new learning and new information. The good news is that a lot more is known these days about how to evaluate cognitive problems, and how to help people work around their specific learning problems.

When Does Schizophrenia Begin?

If you or someone you care about has been diagnosed with schizophrenia, you may feel that you are the only person facing this illness. But you are not alone. About 1 out of 100 people get schizophrenia. About 3 million people in the United States have schizophrenia.

The first symptoms of schizophrenia usually appear between the late teens and the mid-30s, but they can also start earlier or later in life. Most of the time, symptoms develop gradually, with the earliest signs of the illness appearing years before psychotic symptoms actually show up. Some early signs of schizophrenia can include:

Becoming more and more isolated from friends and family
Poor sleep habits, especially sleeping during the day and staying up all night
Acting strangely, almost like a different person
Doing worse in school

One thing to understand is that it is much easier to look back and realize there were problems. When these symptoms first happen, they often seem like a phase, and the hope is that the person will just grow out of it. It's important not to blame yourself or others if a lot of time passed between the first symptoms and finally getting help.

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What Causes Schizophrenia?

Many scientists who have studied this question believe that schizophrenia is a biological illness that involves chemical imbalances in the brain. These chemicals are called neurotransmitters. "Neuro" refers to the brain and a "transmitter" carries messages within the brain and the rest of the nervous system. Therefore, neurotransmitters are the chemicals that carry messages within our brains. One such neurotransmitter is dopamine. Dopamine is involved in many different kinds of activities in our brains and may play an important role in producing psychotic symptoms.

The importance of dopamine in psychotic symptoms is clear from the fact that medications that are used to treat psychotic symptoms affect dopamine to some degree. Scientists believe that other brain chemicals, such as serotonin, may also be involved in psychotic symptoms.

Some people who get schizophrenia are born with a susceptibility to getting the illness. Sometimes that susceptibility is genetic, meaning it runs in families. As with many diseases, a person's chances of developing schizophrenia increase if one has a relative with the illness. For example, if a person has a sister, brother, or parent with schizophrenia, the chances of getting it are about 10%. If there is no family history of schizophrenia, then there is only a 1.5% chance of getting it. If a person has an identical twin who has schizophrenia, the chances of developing the illness go up to about 30%.

Although genes play a role in schizophrenia, most people who get schizophrenia do not have anyone in their family with schizophrenia. For them, the illness has other causes that are not completely understood. What is known is that there are certain changes in brain chemistry that happen in schizophrenia.

The most important thing to know about schizophrenia is that it is a brain disease. Schizophrenia is not caused by bad parenting. It is not caused by emotional hardships in childhood. It is not caused by experimenting with street drugs as a teenager. Schizophrenia isn't anyone's fault.

What Is the Path of Schizophrenia?

Some people with schizophrenia have psychotic symptoms that go on for a long time. Other people have episodes of psychotic symptoms, sprinkled with periods during which the symptoms are under control. When a person has an episode of the illness, positive symptoms get worse. Sometimes things get out of control and hospitalization is needed to keep everyone safe.

You should know that no one can tell who will do well or who will do badly. But many doctors believe that the newer medications have improved the outlook for people with schizophrenia. You should also know that starting treatment quickly and getting symptoms under control as early as possible can improve the chances of a good long-term outcome.

How Is Schizophrenia Diagnosed?

There are currently no blood or other medical tests that can help make the diagnosis of schizophrenia. Schizophrenia also cannot be diagnosed based on the presence of just a single symptom. Rather, the diagnosis is based on a pattern of signs and symptoms that are present for a time. Signs are indications of the illness that other people can observe. For example, a person with schizophrenia may be seen talking to him- or herself. Symptoms are the internal experiences other people cannot see. Unless people report the symptoms they are having, others may not know the symptoms are there. For example, a person with schizophrenia may hear voices but other people may not realize what is happening.

To make the diagnosis of schizophrenia, a mental health professional, usually a psychiatrist, conducts a careful interview and performs a physical examination. The doctor does this to find out if the person has any physical problems that could cause symptoms that resemble schizophrenia. The final diagnosis of schizophrenia should not be made until the doctor is sure that a physical condition is not causing the symptoms.

How Is Schizophrenia Treated?

Antipsychotic Medications

People with schizophrenia almost always need medication to control their psychotic symptoms. The medications that are used to treat schizophrenia are called antipsychotic medications. The word "antipsychotic" means something that blocks or stops psychotic symptoms. Antipsychotic medications help control the hallucinations, delusions, and some of the thinking problems that are part of the illness. Antipsychotic medications affect the brain chemicals that are imbalanced and causing psychotic symptoms.

It is important to remember that people often need to try several different types of antipsychotic medications before they find the medication, or combination of medications, that works best for them. A person should not get discouraged or give up if the first medication does not work. There are many others that might help.

There are two kinds of antipsychotic medications conventional—antipsychotics and atypical antipsychotics.

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Conventional Antipsychotics
The conventional antipsychotics have been around for a long time. The oldest one (Thorazine® [chlorpromazine]) has been used since the 1950s. These medications help correct problems in brain chemistry by blocking some of the effects of dopamine in the brain. Some other conventional antipsychotics are Haldol® (haloperidol), Loxitane® (loxapine), and Trilafon® (perphenazine). Although the conventional antipsychotics are good at controlling the positive symptoms of schizophrenia, they are more likely to cause movement side effects, such as shaking (tremor) or stiffness (rigidity). These movement side effects, which are called extra-pyramidal symptoms (EPS), can be a serious problem. Because of these side effects, doctors generally recommend using one of the newer antipsychotic medications first.

Atypical Antipsychotics
The treatment of schizophrenia has been greatly improved by a group of newer antipsychotics that are often called atypical antipsychotics. These medications are called atypical because they work in a different way from the conventional antipsychotics. The atypical antipsychotics work on two different chemical messengers in the brain. They work on dopamine, just like the conventional antipsychotics, but they also work on serotonin. These newer medications generally help improve psychotic symptoms as much as the conventional antipsychotics. They also are less likely to cause the movement side effects that can be a problem with the conventional antipsychotics. The atypical antipsychotics may also be more helpful for negative symptoms (e.g., lack of energy and interest, social withdrawal) and cognitive symptoms (e.g., problems with paying attention, concentrating, and remembering) than the conventional antipsychotics.

There are five atypical antipsychotics available now: Clozaril® (clozapine), Geodon™ (ziprasidone), Risperdal® (risperidone), Seroquel® (quetiapine), and Zyprexa® (olanzapine). Although they are all in the category of atypical, they're not all the same.

Clozapine was the first atypical antipsychotic introduced. It is generally used to help people who have not responded well to several other antipsychotics. But, clozapine has some serious side effects that the other medications don't have, and people taking clozapine need to have ongoing blood tests. The bottom line is that although clozapine can be an effective antipsychotic treatment for schizophrenia, doctors usually try other atypical antipsychotics first because they may be safer and easier to use than clozapine.

Therapy and Rehabilitation

In addition to medications, certain kinds of talk therapies and rehabilitation programs can help people with schizophrenia get better. Learning as much as possible about the illness and how it is treated is the first step in getting control of it. As people recover from their psychotic symptoms, they are usually ready to learn more about their illness and how to prevent relapse. Also, the more family members know about the illness, the more they are able to understand what their loved one is going through and can help monitor symptoms and medications.

As they get better, people with schizophrenia often benefit from counseling, which provides emotional support and helps them learn to cope with their illness. Other people with schizophrenia (peer support groups) can provide companionship, encouragement, and advice. Peer support groups often play a valuable role in the recovery process.

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Assistance and Support

Society has made many improvements in support for physically handicapped people, such as wheelchair ramps and designated parking spaces. People with psychiatric disabilities also need extra support for their condition. Schizophrenia is often disabling, and many people who have schizophrenia cannot work, or have trouble with transportation, housing, or just making ends meet.

People with schizophrenia often need help in finding ways to pay for their medications, in getting disability income, food stamps, and supported housing. When they are especially ill, they may need help with everyday activities such as cooking, shopping, grooming, laundry, and managing their money. Sometimes people with schizophrenia are reluctant to get this support, perhaps because of embarrassment or pride. But, getting this support is just as much a part of treatment as medication or talk therapy.

Why Is Treatment So Important?

It is very important to diagnose schizophrenia and begin medication and other treatments as soon as possible for a number of reasons. Studies have shown that the earlier a correct diagnosis is made and effective treatment started, the better the outcome is likely to be. It appears that the longer schizophrenia goes untreated, the harder it gets to treat all of the symptoms.

Remember, having bad symptoms will interfere with being able to get back to "having a life" and achieving life goals. The more school the person misses, the further behind he or she becomes. The longer a person is out of work, the harder it is to get back into a job again. Getting treatment right away can help people get back on their feet quicker and get back to their school or their job sooner.

How Can Treatment Help the Person Function Better?

Antipsychotic medications can decrease positive symptoms (hallucinations and delusions) or at least make them less bothersome to the individual. Positive symptoms often start to improve fairly quickly after the person starts taking an antipsychotic medication. When their positive symptoms improve, people with schizophrenia may be able to complete their schooling, get a job, and live independently. Antipsychotic medications (particularly the newer, atypical medications) can help with the negative, cognitive, and depressive symptoms.

It is important to remember that improvements on medication can happen slowly. If someone has been ill for a long time, it will take a while to get back to previous activities. It can be frustrating to wait. When people with schizophrenia start to feel better because of the medication they are taking, they often feel in a hurry to "make up for lost time." But, it is better not to try to move too fast, since too much stress can increase the chances of getting sick again (relapse).

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The Importance of Following the Treatment Program

To manage schizophrenia successfully, the person and the treatment team must work together on several tasks. The first job of the treatment team is to help the person get better. The first step is to recognize the symptoms and make a diagnosis. Once the diagnosis is made, the doctor must work with the person to find a treatment program that will help control the person's symptoms while causing the fewest side effects.

The second job is to help keep the person better. Schizophrenia is a chronic illness (this means it lasts many years), and people with schizophrenia are likely to have new bouts of illness (relapse). The antipsychotic medications used to treat schizophrenia not only reduce the symptoms of the illness (make people better) but also help to prevent relapse. But, of course, medications can only do this if the person takes them exactly as told by the doctor. One of the most common reasons for relapse in schizophrenia is that the person has stopped taking his or her medications correctly. Staying on medication and continuing to see the doctor is called compliance.

Many people with schizophrenia do not realize that they have an illness and need treatment-this is part of their illness. It is hard for people to agree to take their medications if they do not believe that they are having symptoms or suffering from an illness. In some ways, it may be even more difficult for people to continue taking their medications once they begin to feel better. People often find it harder to take a medication to prevent symptoms.

Not taking medication as prescribed (non-compliance) is a very common problem for people with schizophrenia. But taking antipsychotic medication is the single most important thing to getting better and staying better.

Getting the Most Out of Medication

Antipsychotic medications are very effective for most people. The good news is that there are more medication choices today than ever before. This makes it more likely that you can find a medication that's right for you. That means it works well for your symptoms and doesn't have bad side effects. Here are some tips you can use to get the most out of your antipsychotic medications and to stay on them.

Controlling Symptoms

The first step is to get better control of your symptoms. When people have fewer symptoms, there is a better chance that they will be well enough to understand the need to take their medications. So the first thing to do is to tell the doctor what's really going on! Many people are embarrassed to tell their doctors about their symptoms. Some people are worried that the doctor won't respect them if they mention their positive symptoms. But, it's the doctor's job to help you control your symptoms. If you don't tell the doctor, he or she won't be able to adjust your medications properly. Sometimes it can be as simple as making a dosage adjustment. The same goes for telling the doctor if you've stopped your medication. It can be very hard to tell the truth, but to help you with your symptoms, you need to tell the doctor if you've stopped your medication.

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Controlling Side Effects

The second step is to work with the doctor to lessen side effects. When people are asked why they stopped taking their medications, they often mention the side effects as one of the biggest reasons. You should tell the doctor about the side effects that are bothering you. If you want to stop the medication because of those side effects, don't keep it a secret! Tell your doctor. Don't stop your medication on your own without first talking to your doctor. You might get withdrawal side effects from stopping your medication, and those can be a big problem. Most important, many side effects can be treated, and the chances are good that your doctor can do something about them. Some of the more common side effects of antipsychotics may include:

Feeling tired and sedated
Stiffness and/or a heavy feeling in the muscles of the arms and legs
Hand tremors
Tongue or mouth movements that can't be controlled
Feeling restless or having trouble sitting still
Lower sex drive
Feeling sad
Putting on weight

Simplifying the Medication Program

The third step is to work with the doctor to simplify the treatment program. The more complicated the medication schedule, the greater the chance it will not be followed. It is often difficult to remember to take medications regularly and as prescribed by the doctor. The goal is to find a medication and dosing schedule that can treat symptoms with as few side effects as possible.

In some cases, the doctor may recommend that the person receive a periodic injection of an antipsychotic medication. The benefit of the periodic injection is that it makes it easier for people to take their medication. The problem with the periodic injection is that only a few medications currently come in this form in the United States.

Involving the Family

The fourth step is to think about involving your family in your illness and treatment. It has been shown that people who receive support from their families are more likely to stay with the treatment. People who live with their families are also more likely to stay with treatment than people who are living in an unsupervised setting.

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How to Prevent Relapse

After someone with schizophrenia begins to respond to treatment and feel better, it is important to take steps to prevent relapse (getting sick again). There are a number of things that can be done to reduce the chances of relapse:

Stay on the medication. This is the most important way to stay well. The biggest cause of relapse is stopping medication. If side effects are a problem or the medication doesn't really seem to be controlling the symptoms, the person should let the doctor know right away and not wait until a full-blown relapse develops. Family members may notice problems with side effects and symptoms before the person does and the doctor should be contacted.

Work with the treatment team and keep them informed. The treatment team depends on individuals and their families for information about how things are going. It is important to try to keep appointments and call the doctor's office between appointments if new problems develop. It is never a good idea to stop medications and just wait for the next appointment.

Learn as much as possible about the illness. Once people begin to recover from the severe psychotic symptoms of the illness, they are better able to learn more about their illness, how to deal with it, and how to prevent relapses. Individuals and their families may want to contact the National Alliance for the Mentally Ill at 800-950-NAMI (800-950-6264) about taking one of their Family-to-Family Education courses or they can ask their doctor for more information. Another patient advocacy and support group is the National Mental Health Association. Their phone number is 800-969-NMHA (800-969-6642). Their nationwide branches provide programs geared to the specific needs of their communities. Their programs include support groups, rehabilitation, socialization, housing services, and more.

Reduce stress. People with schizophrenia are very sensitive to stress. Although they may often feel like they need to hurry to make up for lost time, trying to take on too much at once may cause symptoms to get worse and lead to a relapse. It is best not to make too many changes at once. For example, people with schizophrenia shouldn't try to move into a new apartment, start a course in college, and take on a part-time job all at the same time. The chances of success are better by going slowly and taking smaller steps.

Ask for special help if needed. People with schizophrenia often need help learning how to hold a job, dealing with other people, managing their money, and dealing with other aspects of daily living. The treatment team can suggest training and counseling that may help in all these areas and make it easier to get the person's life back on track.

Early Warning Signs of Relapse

No one can guarantee that you will never suffer a relapse, so it's important to recognize the warning signs. Certain types of problems often signal a relapse. Everyone is different, and each person may have his or her own early warning signs. When early warning signs happen, they can alert you and the doctor to possible danger ahead. Some common early warning signs of relapse are listed below:

Having trouble sleeping
Feeling anxious, worried, or afraid but not being able to figure out why
Having problems thinking clearly, remembering things, or concentrating
Losing interest in people or activities
Feeling cranky or irritable for no real reason

Often families and friends are very important people to get involved in reviewing the early warning signs. That's because these signs of possible relapse can come out of the blue. Chances are good that they'll happen between doctor appointments. Families who are in closer contact with the patient can call the doctor or therapist between sessions if they see early warning signs come up.

Some Final Words

Schizophrenia is a lifelong illness that affects many people. Although there is currently no known cure for schizophrenia, antipsychotic medications can help to control the symptoms. These medications form the cornerstone to all of the other ways a person can fight schizophrenia symptoms. Staying on medication is therefore the key to managing schizophrenia. Eventually it is the key to getting back to other parts of your life. It is also important to learn all you can about the illness. The more you know about schizophrenia and how it is treated, the more you can help yourself do better and learn how to control your symptoms.

Today, new medications and therapies are offering new hope to those who have schizophrenia. These treatments have helped many people overcome their symptoms and have often allowed them to go back to living a life that wasn't possible with the older treatments.

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Source: The Pfizer Health Library, Understanding Schizophrenia

Knowledge is power. The more you know about your health, the more power you have to take control of it and to improve your quality of life. The Pfizer Health Library offers information on many health-related issues and conditions.

The information provided on this web page is of a general nature and for educational purposes only. It is not intended to replace discussions with your health care provider.

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