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Schizophrenia

 

Schizophrenia is a long-term mental health condition that causes a range of different psychological symptoms. These include:

  • hallucinations - hearing or seeing things that do not exist
  • delusions - unusual beliefs that are not based on reality and often contradict the evidence
  • muddled thoughts based on the hallucinations or delusions
  • changes in behaviour

Doctors describe schizophrenia as a psychotic illness. This means that sometimes a person may not be able to distinguish their own thoughts and ideas from reality.

The exact cause of schizophrenia is unknown. However, most experts believe that the condition is caused by a combination of genetic and environmental factors.

How common is schizophrenia?

Schizophrenia is one of the most common serious mental health conditions. According to Shine, an organisation which supports people with mental ill health in Ireland, there are about 3900 people in Ireland living with schizophrenia . Men and women are equally affected by the condition.

In men, schizophrenia usually begins between the ages of 15 and 30. In women, schizophrenia usually occurs later, beginning between the ages of 25 and 30.

Misconceptions about schizophrenia

Schizophrenia is often poorly understood and many people have misconceptions about it. Two of the most common misconceptions about schizophrenia are:

  • People with schizophrenia have a split or dual personality.
  • People with schizophrenia are violent.

Split personality

It is commonly thought that people with schizophrenia have a split personality, acting perfectly normally one minute and irrationally or bizarrely the next. However, this is not true. Although the term schizophrenia is a Greek word that means 'split mind', the term was first used long before the condition was properly understood.

It would be more accurate to say that people with schizophrenia have a mind that can experience episodes of dysfunction and disorder.

Violent crime

Most studies confirm that there is a link between violence and schizophrenia. However, the media tend to exaggerate this, with acts of violence committed by people with schizophrenia getting a great deal of high-profile media coverage. This gives the impression that such acts happen frequently when they are in fact very rare.

The reality is that violent crime is more likely to be linked to alcohol or other substance misuse than to schizophrenia. A person with schizophrenia is far more likely to be the victim of violent crime than the instigator.

Changes in thinking and behaviour are the most obvious symptoms of schizophrenia. People experience schizophrenia and its symptoms in different ways.

The earlier the symptoms are identified and treatment is started, the better the outlook.

The symptoms of schizophrenia are usually classified into one of two categories: positive or negative.

  • Positive symptoms represent a change in behaviour or thoughts, such as hallucinations or delusions.
  • Negative symptoms represent a withdrawal or lack of function that you would usually expect to see in a healthy person. For example, people with schizophrenia often appear emotionless, flat and apathetic.

The illness may develop slowly. The first signs of schizophrenia, such as becoming socially withdrawn and unresponsive or experiencing changes in sleeping patterns, can be hard to identify. Because the first symptoms often develop during adolescence, the changes can be mistaken for an adolescent 'phase'.

People often have episodes of acute schizophrenia, during which their positive symptoms are particularly severe, followed by periods where they experience few or no positive symptoms.

Positive symptoms of schizophrenia

Hallucinations

A hallucination occurs when a person experiences a sensation when there is nothing or nobody there to account for it. A hallucination can involve any of the senses, but the most common is hearing voices.

Although other people cannot hear the voices or experience the sensations, they seem real to the person experiencing them. Research using brain-scanning equipment has shown that there are changes in the speech area of the brain in people with schizophrenia when they hear voices. These studies show that the experience of hearing voices is a real one, as if the brain mistakes thoughts for real voices.

Some people describe the voices they hear as friendly and pleasant, but more often they are rude, critical, abusive or just annoying. The voices might describe activities taking place, discuss the hearer's thoughts and behaviour, give instructions or talk directly to the person. Voices may come from different places or they may come from one place in particular, such as the television.

Delusions

A delusion is a belief that is held with complete conviction, even though it is based on a mistaken, strange or unrealistic view. It may affect the way people behave. Delusions can begin suddenly or may develop over a period of weeks or months.

Some people develop a delusional idea to explain a hallucination they are having. For example, if they have heard voices describing their actions, they may have a delusion that a secret agent is monitoring their actions. Someone experiencing a paranoid delusion may believe that they are being harassed or persecuted. They may believe they are being chased, followed, watched, plotted against or poisoned, often by a family member or friend.

Some people who experience delusions find different meanings in everyday events or occurrences. They may believe that people on TV or in newspaper articles are communicating messages to them alone, or that there are hidden messages in the colours of cars passing in the street.

Confused thoughts (thought disorder)

People experiencing psychosis often have trouble keeping track of their thoughts and conversations. Some people find it hard to concentrate and will drift from one idea to another. They may have trouble reading newspaper articles or watching a TV programme. People sometimes describe their thoughts as 'misty' or 'hazy' when this is happening to them. Thoughts and speech may become jumbled or confused, making conversation difficult and hard for other people to understand.

Changes in behaviour and thoughts

Behaviour may become more disorganised and unpredictable, and appearance or dress may seem unusual to other people. People with schizophrenia may behave inappropriately or become extremely agitated and shout or swear for no reason.

Some people feel that their thoughts are being controlled by someone else, that their thoughts are not theirs, or that the thoughts have been planted in their mind by someone else. Another recognised feeling is that thoughts are disappearing, as though someone is removing them from their mind. Some people feel that their body is being taken over and someone else is directing their movements and action

Negative symptoms of schizophrenia

The negative symptoms of schizophrenia can often appear several years before somebody experiences their first acute schizophrenic episode. These initial negative symptoms are often referred to as the prodromal period of schizophrenia.

Symptoms during the prodromal period usually begin gradually and then slowly get worse. They include becoming more socially withdrawn and experiencing an increasing lack of care about your appearance and personal hygiene.

It can be difficult to tell whether the symptoms are part of the development of schizophrenia or caused by something else. Negative symptoms experienced by people living with schizophrenia include:

  • losing interest and motivation in life and activities, including relationships and sex 
  • lack of concentration, not wanting to leave the house and changes in sleeping patterns 
  • being less likely to initiate conversations and feeling uncomfortable with people, or feeling that there is nothing to say

The negative symptoms of schizophrenia can often lead to relationship problems with friends and family because they can sometimes be mistaken for deliberate laziness or rudeness.

A first acute episode of psychosis can be very difficult to cope with, both for the person who is ill and for their family and friends.

Drastic changes in behaviour may occur, and the person can become upset, anxious, confused, angry or suspicious of those around them. They may not think that they need help, and it can be very hard to persuade them to visit a doctor.

It is difficult to identify the causes of schizophrenia, but research suggests that several physical, genetic, psychological and environmental factors interact and make people more likely to develop the condition. Current thinking is that some people may be prone to schizophrenia, but sometimes a stressful or emotional life event might trigger a psychotic episode. However, it is not known why some people develop symptoms while others do not.

There are some risk factors for schizophrenia that you cannot change. These include:

Genetics

Schizophrenia tends to run in families, but no individual gene is responsible. It is more likely that different combinations of genes might make people more vulnerable to the condition. However, having these genes does not necessarily mean that you will develop schizophrenia.

Evidence that the disorder is partly inherited comes from studies of identical twins brought up separately. They were compared with non-identical twins raised separately, as well as with the general public. For identical twins raised separately, if one twin develops schizophrenia, the other twin has a one in two chance of developing it. In non-identical twins, who share only half of each other's genetic make-up, when one twin develops schizophrenia, the other twin has a one in seven chance of developing the condition.

While this is higher than in the general population (where the chance is about one in a 100), it suggests that genes are not the only factor influencing the development of schizophrenia.

Brain development

Many studies of people with schizophrenia have shown that there are subtle differences in the structure of their brains or small changes in the distribution or number of brain cells. These changes are not seen in everyone with schizophrenia and they can occur in people who do not have a mental illness, but they suggest that schizophrenia may partly be a disorder of the brain.

Neurotransmitters

These are the chemicals that carry messages between brain cells. There is a connection between neurotransmitters and schizophrenia because drugs that alter the levels of neurotransmitters in the brain are known to relieve some of the symptoms of schizophrenia. Research suggests that schizophrenia may be caused by a change in the level of two neurotransmitters, dopamine and serotonin. Some studies indicate that an imbalance between the two may be the basis of the problem. Others have found that a change in the body's sensitivity to the neurotransmitters is part of the cause of schizophrenia.

Infection

There is some evidence from research that certain viral infections, including the polio virus and the flu virus, may play a role in the development of schizophrenia.

Pregnancy and birth complications

Although the effect of pregnancy and birth complications is very small, research has shown that the following conditions may make a person more likely to develop schizophrenia in later life:

  • bleeding during pregnancy, gestational diabetes or pre-eclampsia
  • abnormal growth of a baby while in the womb, including low birth weight or reduced head circumference
  • exposure to a virus while in the womb
  • complications during birth, such as a lack of oxygen (asphyxia) and emergency caesarean section

Head injury

Traumatic head injury, such as the kind sustained in a fall or a traffic accident, may make people more likely to develop schizophrenia, but it is not known why this happens. Research has also suggested that head injuries during childhood could lead to the development of schizophrenia in people who are already prone to it. 

Triggers

There are some known triggers for schizophrenia.

Stress

The main psychological triggers of schizophrenia are stressful life events, such as a bereavement, losing your job or home, a divorce or the end of a relationship, or physical, sexual, emotional or racial abuse. These kinds of experiences, though stressful, do not cause schizophrenia, but can trigger its development in someone who is already vulnerable to it.

Drug abuse

Drugs do not directly cause schizophrenia, but studies have shown that drug misuse increases the risk of developing schizophrenia or a similar illness. Certain drugs, particularly cannabis, cocaine, LSD or amphetamines, may trigger some of the symptoms of schizophrenia, especially in people who are susceptible. Using amphetamines or cocaine can lead to psychosis and can cause a relapse in people who are recovering from an earlier episode. Three major studies have shown that teenagers under 15 who use cannabis regularly, especially 'skunk' and other more potent forms of the drug, are up to four times more likely to develop schizophrenia by the age of 26.

 

If you are concerned that you may be developing symptoms of schizophrenia, see your GP as soon as possible. The earlier schizophrenia is treated, the more successful the outcome tends to be.

Your GP will ask you about your symptoms and check that they are not the result of other causes, such as recreational drug use.

Community mental health team (CMHT)

If a diagnosis of schizophrenia is suspected, your GP will probably refer you to your local community mental health team (CMHT).

CMHTs are made up of different mental health professionals who support people with complex mental health conditions.

A member of the CMHT team, usually a psychologist or psychiatrist, will carry out a more detailed assessment of your symptoms. They will also want to know about your personal history and current circumstances.

There is no single test for schizophrenia. Most mental healthcare professionals use a 'diagnostic checklist', where the presence of certain symptoms and signs indicate that a person has schizophrenia.

Schizophrenia can usually be diagnosed if:

  • You have at least two of the following symptoms: delusions, hallucinations, disordered thoughts or behaviour or the presence of negative symptoms, such as a flattening of emotions.
  • Your symptoms have had a significant impact on your ability to work, study or perform daily tasks.
  • You have experienced symptoms for more than six months.
  • All other possible causes, such as recreational drug use or depression, have been ruled out.

Getting help for someone else

Due to their delusional thought patterns, people with schizophrenia may be reluctant to visit their GP if they believe there is nothing wrong with them.

It is likely that someone who has had acute schizophrenic episodes in the past will have been assigned a care co-ordinator. If this is the case, contact the person's care co-ordinator to express your concerns.

If someone is having an acute schizophrenic episode for the first time, it may be necessary for a friend, relative or other loved one to persuade them to visit their GP. In the case of a rapidly worsening schizophrenic episode, you may need to go to the accident and emergency (A&E) department where a duty psychiatrist will be available.

If a person who is having an acute schizophrenic episode refuses to seek help and it is believed that they present a risk to themselves or others, their nearest relative can request that a mental health assessment is carried out.

Your GP or your local community mental health team can advise you about how to do this.

In severe cases of schizophrenia, people can be compulsorily detained in hospital for assessment and treatment under the Mental Health Act (2001).

After diagnosis

If you (or a friend or relative) are diagnosed with schizophrenia, you may feel anxious about what will happen. You may be worried about the stigma attached to the condition, or feel frightened and withdrawn. It is important to remember that a diagnosis can be a positive step towards getting good, straightforward information about the illness and the kinds of treatment and services available.

Sometimes, it might not be clear whether someone has schizophrenia. If you have other symptoms at the same time, a psychiatrist may have reason to believe that you have a related mental illness.

There are several related mental illnesses that are similar to schizophrenia. Your psychiatrist will ask you how your illness has affected you so that they can confidently confirm that you have schizophrenia and not another mental illness, such as:

  • Bipolar disorder (manic depression). People with bipolar disorder swing from periods of mania (elevated moods and extremely active, excited behaviour) to periods of deep depression. But between the episodes of depression and mania, there can be stable moods. Some people with bipolar disorder also hear voices or experience other kinds of hallucinations or may have delusions.
  • Schizoaffective disorder. Schizoaffective disorder is often described as a form of schizophrenia because its symptoms are similar to schizophrenia and bipolar disorder. But schizoaffective disorder is a mental illness in its own right. It may occur just once in a person's life or may recur intermittently, often when triggered by stress.

Community mental health teams

Most people with schizophrenia are treated by community mental health teams (CMHTs). The goal of the CMHT is to provide you with day-to-day support and treatment while ensuring you have as much independence as possible.

A CMHT can be made up of and provide access to:

  • social workers
  • community mental health nurses (a nurse with specialist training in mental health conditions)
  • counsellors and psychotherapists 
  • psychologists and psychiatrists (the psychiatrist is usually the senior clinician in the team)

Care programme approach (CPA)

People with complex mental health conditions, such as schizophrenia, are usually entered into a treatment process known as a care programme approach (CPA). A CPA is essentially a way of ensuring that you receive the right treatment for your needs.

There are four stages to a CPA.

  • Assessment - your health and social needs are assessed.
  • Care plan - a care plan is created to meet your health and social needs.
  • Appointment of a care co-ordinator - a care co-ordinator, sometimes known as a keyworker, is usually a social worker or nurse and is your first point of contact with other members of the CMHT.
  • Reviews - your treatment will be regularly reviewed and, if needed, changes to the care plan can be agreed.

Not everyone uses the CPA. Some people may be cared for by their GP and others may be under the care of a specialist.

You will work together with your healthcare team to develop a care plan. Your care co-ordinator will be responsible for making sure that all members of your healthcare team, including your GP, have a copy of your care plan. The care plan may involve an advance statement or crisis plan, which can be followed in an emergency.

Treatment for schizophrenia

Treatment for schizophrenia usually involves a combination of antipsychotic medicines and psychological therapies.

People who have serious psychotic symptoms as a result of an acute schizophrenic episode may require a more intensive level of care than a CMHT can provide.

Voluntary and compulsory detention

More serious, acute schizophrenic episodes may require admission to a psychiatric ward at a hospital or clinic. You can admit yourself voluntarily to hospital if your psychiatrist agrees that it is necessary.

People can also be compulsorily detained at a hospital under the Mental Health Act (2001)) which was fully implemented in 2006. However, this is rare. It is only possible for someone to be compulsorily detained at a hospital if they have a severe mental disorder, such as schizophrenia, and if detention is necessary:

  • in the interests of the person's own health
  • in the interests of the person's own safety
  • to protect others

People with schizophrenia who are compulsorily detained may need to be kept in locked wards.

All people being treated in hospital will stay only as long as is absolutely necessary to receive appropriate treatment and arrange aftercare.

A Mental Health Tribunal will regularly review your case and your progress.You have a right to have a legal representave appointed by the Mental Health Commission at the Tribunal.The Mental Health Commission is completely independent of the mental health hospital. Once they feel that you are no longer a danger to yourself and others, you will be able to be discharged from hospital. However, your care team may recommend that you remain in hospital voluntarily.

Antipsychotics

Antipsychotics are usually recommended as the initial treatment for the symptoms of an acute schizophrenic episode. Antipsychotics work by blocking the effect of the chemical dopamine on the brain.

Antipsychotics can usually reduce feelings of anxiety or aggression within a few hours of use, but they may take several days or weeks to reduce other symptoms, such as hallucinations or delusional thoughts.

Antipsychotics can be taken orally (as a pill) or given as an injection. Several 'slow release' antipsychotics are available. These require you to have one injection every two to four weeks.

You may only need to take antipsychotics until your acute schizophrenic episode has passed. However, most people take medication for one or two years after their first psychotic episode to prevent further acute schizophrenic episodes occurring and for longer if the illness is recurrent.

There are two main types of antipsychotics:

  • Typical antipsychotics are the first generation of antipsychotics that were developed during the 1950s.
  • Atypical antipsychotics are a newer generation of antipsychotics that were developed during the 1990s.

Atypical antipsychotics are usually recommended as a first choice because of the sorts of side effects associated with their use. However, they are not suitable or effective for everyone.

Both typical and atypical antipsychotics can cause side effects, although not everyone will experience them and their severity will differ from person to person.

The side effects of typical antipsychotics include:

  • shaking
  • trembling
  • muscle twitches
  • muscle spasms

Side effects of both typical and atypical antipsychotics include:

  • drowsiness 
  • weight gain, particularly with some atypical antipsychotics
  • blurred vision
  • constipation
  • lack of sex drive
  • dry mouth

Tell your care co-ordinator or GP if your side effects become severe. There may be an alternative antipsychotic that you can take or additional medicines that will help you deal with the side effects.

Do not stop taking your antipsychotics without first consulting your care co-ordinator, psychiatrist or GP. If you do, you could have a relapse of symptoms.

Want to know more?

Psychological treatment

Psychological treatment, such as cognitive behavioural therapy (CBT) or family therapy, can help people with schizophrenia cope better with the symptoms of hallucinations or delusions.

Psychological treatments can also help treat some of the negative symptoms of schizophrenia, such as apathy or a lack of enjoyment.

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) is based on the idea that most unwanted thinking patterns and emotional and behavioural reactions are learned over a long period of time.

The aim of CBT is to help you identify the thinking patterns that are causing you to have unwanted feelings and behaviour, and learn to replace this thinking with more realistic and useful thoughts.

For example, you may be taught to recognise examples of delusional thinking in yourself. You may then receive help and advice about how to avoid acting on these thoughts.

Most people will require 8-20 sessions of CBT over the space of 6-12 months. CBT sessions usually last for about an hour.

Your GP or care co-ordinator should be able to arrange a referral to a CBT therapist.

Family therapy

Many people with schizophrenia rely on family members for their care and support. While most family members are happy to help, caring for somebody with schizophrenia can place a strain on any family.

Family therapy is a way of helping you and your family cope better with your condition.

Family therapy involves a series of informal meetings that take place over a period of around six months. Meetings may include:

  • discussing information about schizophrenia
  • exploring ways of supporting somebody with schizophrenia
  • deciding how to solve practical problems that can be caused by the symptoms of schizophrenia

If you think you and your family could benefit from family therapy, speak to your care co-ordinator or GP.

Arts therapy

Arts therapies are designed to promote creative expression. Working with an arts therapist in a small group or individually can allow you to express your experiences with schizophrenia. Some people find that expressing things in a non-verbal way through the arts can provide a new experience of schizophrenia and help them develop new ways of relating to others.

Arts therapies have been shown to alleviate the negative symptoms of schizophrenia in some people.

 

Healthy living

Keep healthy

As well as monitoring your mental health, your healthcare team and GP should monitor your physical health. A healthy lifestyle, including a balanced diet with lots of fruits and vegetables and regular exercise, is good for you and can reduce your risk of developing cardiovascular disease or diabetes.

Avoid too much stress and get a proper amount of sleep.

You should have a check-up at least once a year to monitor your risk of developing cardiovascular disease or diabetes. This will include recording your weight, checking your blood pressure and any appropriate blood tests.

Stop smoking

Rates of smoking in people with schizophrenia are three times higher than in the general population. If you are a smoker, you are at a higher risk of developing cancer, heart disease and stroke.

Stopping smoking has both short- and long-term health benefits. Research has shown that you are up to four times more likely to quit smoking if you use smoking cessation support as well as stop-smoking medicines, such as patches, gum or inhalators. Ask your doctor about this or go to www.quit.ie the HSE quit smoking website

Who is available to help me?

In the course of your treatment for schizophrenia, you will be involved with many different services. Some are accessed through referral from your GP, others through your local authority. These services may include the following:

  • Community mental health teams (CMHTs) provide the main part of local specialist mental health services and offer assessment, treatment and social care to people living with schizophrenia and other mental illnesses.
  • Early intervention teams provide early identification and treatment for people with the first symptoms of psychosis. Your GP may be able to refer you directly to an early intervention team. 
  • Crisis services allow people to be treated at home, instead of in hospital, for an acute episode of illness. They are specialist mental health teams that help with crises that occur outside normal office hours.
  • Acute day hospitals are an alternative to inpatient care in a hospital, where you can visit every day or as often as necessary.
  • Advocates are trained and experienced workers who help people communicate their needs or wishes, get impartial information, and represent their views to other people. Advocates can be based in your hospital or mental health support groups, or you can find an independent advocate to act on your behalf, if you wish.

 

 

Talk to others

Many people find it helpful to meet other people with the same experiences for mutual support and to share ideas. It is also an important reminder that you are not alone.

Charities and support groups allow individuals and families to share experiences and coping strategies, campaign for better services and provide support. Useful charities, support groups and associations include:

Other places that offer support to people with schizophrenia and other mental illnesses include:

Day centres

Even if you do not have a job or are unable to work, it is still important to go out and do everyday things and provide a structure to your week. Many people regularly go to a day hospital, day centre or community mental health centre. These offer a range of activities that enable you to get active again and spend some time in the company of other people.

 

What can family, friends and partners do to help?

Friends, relatives and partners have a vital role in helping people with schizophrenia recover and make a relapse less likely. It is very important not to blame the person with schizophrenia or tell them to "pull themselves together", or to blame other people. When dealing with a friend or loved one's mental illness, it is important to stay positive and supportive.

As well as supporting the person with schizophrenia, you may want to get support to cope with your own feelings. Several voluntary organisations provide help and support for carers.

Friends and family should try to understand what schizophrenia is, how it affects people, and how best they can help. They can provide emotional and practical support, and can encourage people to seek appropriate support and treatment. As part of the treatment, you may be offered family therapy. This can provide information and support for the person with schizophrenia and their family.

Friends and family can play a major role by monitoring the person's mental state, watching out for any signs of relapse, encouraging them to take their medication and attend medical appointments.

If you are the nearest relative of a person who has schizophrenia, you have certain rights that can be used to protect the patient's interests. These include requesting that the local social services authority ask an approved mental health professional to consider whether the person with schizophrenia should be detained in hospital.

 

Depression and suicide

Many people with schizophrenia experience periods of depression. Do not ignore these symptoms. If depression is not treated, it can worsen and lead to suicidal thoughts.

A recent review in the Journal of Psychopharmacology found about 1 in 20 people with schizophrenia will commit suicide.

If you have been feeling particularly down over the last month and no longer take pleasure in the things you used to enjoy, you may be depressed. See your GP for advice and treatment.

Immediately report any suicidal thoughts to your GP or care co-ordinator.

The warning signs of suicide

The warning signs that people with depression and schizophrenia may be considering suicide include:

  • making final arrangements, such as giving away possessions, making a will or saying goodbye to friends
  • talking about death or suicide. This may be a direct statement such as, "I wish I was dead," although depressed people will often talk about the subject indirectly, using phrases such as "I think that dead people must be happier than us" or "Wouldn't it be nice to go to sleep and never wake up?"
  • self-harm, such as cutting their arms or legs or burning themselves with cigarettes
  • a sudden lifting of mood, which could mean that a person has decided to commit suicide and feels better because of their decision

Helping a suicidal friend or relative

If you see any of these warning signs:

  • Get professional help for the person, such as from a crisis resolution team (CRT) or the duty psychiatrist at your local A&E department.
  • Let them know that they are not alone and that you care about them.
  • Offer your support in finding other solutions to their problems.

If you feel that there is an immediate danger of the person committing suicide, stay with them or have someone else stay with them and remove all available means of suicide, such as sharp objects and medicati


Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z.