Schizophrenia talk

Preface

While this article is done in the style of a research paper it should not be be mistaken for one. This paper represents my understanding and personal experiences with schizophrenia as of February 2005.

i. Introduction

Schizophrenia is often referred to as a neurobiological disorder¹ which is a way of saying that it is a disease of the brain which affects the mind. The term neurobiological disorder is probably better to use than mental illness when talking to those not familiar with diseases of the brain because most of the lay public who hear the term ‘mental illness’ think that it means that the illness is ‘all in your head’, or, for certain religious groups, possession. This paper will attempt to cover things that people with schizophrenia experience so that the reader or friend knows they are not alone, as well as to help you understand this illness and the hope that now exists.

I. The Experience of Schizophrenia

The following is an attempt to enumerate a large number of symptoms that schizophrenics experience. It cannot be complete because every individual has a different response to disease, but I hope this list will help. It is important to note that this is intended to give you a feel for what someone with schizophrenia experiences and not as a guide to diagnosis. The diagnostic criteria are very specific and can be found in the appendix (which is taken from https://www.mentalhealth.com/dis1/p21-ps01.html [Link dead 2021-12-06] and, in turn, from the Diagnostic and Statistical Manual IV (DSM-IV) – the official guide to diagnosing mental illness in Canada and the U.S.)

While many explanations of schizophrenia divide symptoms into so-called ‘positive’ and ’negative’ symptoms, this section of the paper will not use that terminology because it is about illuminating what schizophrenia feels like. In case you are wondering the ‘positive’/’negative’ terminology doesn’t mean good and bad symptoms, but rather that ‘positive’ symptoms are additions to reality (like hallucinations and brightened or muted colours), while ’negative’ symptoms subtract from reality (e.g. anhedonia and lack of motivation).

A. Disordered Thinking

• Racing thoughts²

Thoughts tumble out one after the other, seem to have no space in between each one, and can’t be stopped.

• Thinking in Tangents³

E.g. When talking about what I had for breakfast, I think of monkeys, then zoos, and then extinction of species. This author’s personal experience includes a time when ill, he tried to write an essay for English and couldn’t because his mind kept going on on tangents that had nothing to do with topic of the essay.

• Unable to connect thoughts in logical sequences⁴.
• Often speech is incoherent and illogical because thoughts are disorganized and fragmented⁵.

B. Delusions

These often overlap with paranoia and problems of reference.

• Special powers or role⁶
  • E.g. I am one of the prophets described in Revelations, or by thinking and moving my fingers a certain way I can go back in time.
• Fixed false belief⁷
  • A belief you can’t be argued out of.
  • and (usually) no one else will back you on it (that is, it may not be considered a delusion if it is a belief common to your culture or religion).
• Interpreting sensual information incorrectly⁸
  • E.g John Nash seeing latitude and longitude in the essentially random numbers of an encrypted message in A Beautiful Mind, because the
    numbers seemed to jump out of the soup of numbers.
• Conviction that random events are about self⁹
  • E.g. The theme of a movie was written based on your life.
  • Or, someone coughs which signals another person on the street, who crosses to avoid you.
• Partly because sounds, colours my be louder/brighter than usual and therefore have more significance¹⁰.
• Seeing significance in things that aren’t¹¹
  • E.g. Someone moves their hand up and down while walking and you think it’s a signal of some kind.
  • Or in a similar vein, believing that your hand movements are unconscious signals to some underground organization.
  • Or the fact that you had to wait for three red lights, and saw three bluebirds means there will be three feet of snow tonight.
• Believing that one has a medical illness (e.g. cancer or heart condition) that others know about but won’t tell you because they think they are protecting you¹².
• Feeling entire life is a movie¹³.
• Telepathy and mind control¹⁴.
• Thought broadcasting¹⁵.
• Sometimes a fixed belief, firmly believed for a day, then not, then again¹⁶.
• Feelings of thought insertion (someone putting thoughts in your head)¹⁷.

C. Hallucinations (Voices and/or Visual)

• Spectrum: overly acute senses to distortion of stimuli to full hallucinations¹⁸.
  • Distortion: hearing something other than was actually said, distinctly and not realizing it happened (except by other’s reaction)¹⁹.
• Usually unpleasant²⁰.
• Voices common but not required for schizophrenic diagnosis²¹.
• Voices may give commands that hearer feels compelled to obey²².
• Visual hallucinations without sound are usually not schizophrenia²³.
• Tactile hallucinations – feeling things that aren’t there²⁴.
• Also, smell and taste²⁵.

Problems of Reference & Paranoia

• These often overlap with delusions.
• Thinking others talking about self when one can’t hear what they’re saying²⁶.
• Believing what you’re doing is of great interest to anyone within sight²⁷.
  • E.g. Walking down the street you think everyone is noticing your hand movements.
• Belief that most people are plotting against you²⁸ (or for you, or that there are secret friends and foes).
• Belief that everyone is watching everything you do and continually commenting on it²⁹.
• Belief that radio/movies/TV shows have secret messages for you³⁰.

Other

• Disorganization & Poor Self-care³¹
• Difficulty interpreting input and responding appropriately³².
• Fear/anxiety/confusion (from symptoms)³³.
• Altered sense of self (e.g. A man thinking he was developing woman’s breasts)³⁴ (Note that this is in the absence of Gender Dysmorphia; a better example might be the sense that one has a dent in one’s skull when one’s skull is normal and not injured)
• Disturbance of Feeling (Emotion)
• Emotion may be inappropriate to situation or topic of discussion³⁵.
• Lack of emotion (flatness of affect) – may seem unable feel or show any emotion³⁶.
• Anhedonia – inability to feel pleasure, e.g. In what used to be favourite type of movie³⁷.
• Lack of motivation³⁸.
• Depression (partly because of symptoms and partly from actions while ill) ³⁹.
• Social Withdrawal/Social Phobia (partly due to paranoia etc, partly symptom itself)⁴⁰.
• Too much or too little sleep⁴¹.
• Blunted Pain – a rare symptom is lack of pain, e.g. From a perforated ulcer, fractured bone, or other major injury or disease which normally would be quite painful⁴².

Cause: Current Theories

Genetic

• This is the most prevalent theory⁴³.
• Inherited based on multiple genes (else would be more common)⁴⁴.
• Family history of mental illness is predictive (one parent = 10% chance) ⁴⁵.
• However even in identical twins, when one has schizophrenia, the finding that the other twin has schizophrenia only happens about 30% of the time ⁴⁶.
• Probably a combination of genes and something else⁴⁷.
• Suggestion that it’s a predisposition to schizophrenia, not the sole cause ⁴⁸.

Viral

• There is evidence to suggest that a viruses that affect the brain are at least part of the cause⁴⁹.
• This is not a hugely popular theory but is gaining converts⁵⁰.

Pregnant Mother

• This is also a fairly popular theory, in which it is suggested that something goes wrong with brain development during pregnancy, e.g. Due to malnourishment, or the mother having a virus during early pregnancy⁵¹.

Father’s Age

• Older fathers more likely to have a child who later develops schizophrenia⁵².
• This theory hasn’t had a lot of research yet.

Brain Structure

• For some reason brains of people with schizophrenia send information coming into the brain to different areas (at least partly) than those without it⁵³.
• This theory, however, is more about the specific mechanics of what happens, as you still need to explain, –why– the brain structure is different.

Neurotransmitters

• Unusual level of neurotransmitters, or the way they are handled e.g. Dopamine⁵⁴.
• Highly popular theory, and by many considered the main reason antipsychotics work (that is by restoring proper levels of dopamine and other neurotransmitters)⁵⁵.
• But, as with brain structure, why different chemical levels?

Immune system dysfunction

• Some research suggests that problems with the immune system may cause schizophrenia⁵⁶. However, it is not clear whether problems with the immune system in schizophrenics causes schizophrenia or whether it is the result of having schizophrenia, or even a result of medication.

Stress-Vulnerability

• Popular theory in many books, but not supported by research⁵⁷,⁵⁸. [Torrey95], [Temes02]
• If it were the case why not increase in schizophrenia during the great depression, WWII, in prisons, etc.⁵⁹
• Stress does, however, play a major role in determining when or if wellness is achieved.

Street Drugs

• Most evidence leads to the conclusion that street drug psychosis is not a cause of Schizophrenia ⁶⁰,⁶¹
• However, https://www.mentalhealth.com has a pointer to a study in the British Medical Journal that suggests that cannabis use increases the chances of becoming schizophrenic.

Treatment

Not psychotherapy only

• Insight-based psychotherapy (e.g. Freudian, Jungian), does not help or worsens schizophrenia⁶².
• Social support and therapy alone have little effect⁶³.

Medication alone

• If one is to choose a single treatment, medication is the most effective. However a combination is better. “… without medication you suffer tremendously. With medication you suffer much less.”⁶⁴.

Medication & Psychosocial

• Medication alone is quite effective, and medication plus social supports and therapy (but not insight-driven such as Freudian or Jungian psychotherapy) is even better, and can result in a return to a relatively normal life⁶⁵

Types of medication

• First Generation Anti-psychotics.
  • ~70% clearly improve, 25% improve minimally, 5% get worse⁶⁶.
  • Bad side effects, especially stiffness and tardive dyskinesia⁶⁷
  • 60% chance of not being re-hospitalized⁶⁸.
  • We really don’t know how they work – thought to be dopamine blocker, but according to -Surviving Schizophrenia 3ed-, research doesn’t support this as the means by which schizophrenia is treated. Remember though that we also don’t know how aspirin works⁶⁹.
  • Possible side effects include drowsiness, stiffness, dizziness, mild tremors, restlessness, akinesia (restlessness), sun sensitivity, sexual dysfunction, tardive dyskinesia (muscle tremors), dry mouth, blurred vision, constipation, acute dystonic reaction (An acute dystonic reaction consists of sustained, often painful muscular spasms, producing twisting abnormal postures), weight gain, menstrual changes, breast discharge, urinary retention, fast heart beat, fainting, seizures (rare), neuroleptic malignant syndrome (rare - The neuroleptic malignant syndrome (NMS) is a rare, but life-threatening, idiosyncratic reaction to a neuroleptic medication. The syndrome is characterized by fever, muscular rigidity, altered mental status, and autonomic dysfunction (failure of autonomous nervous system which keep heart beating and lungs breathing))⁷⁰
• A List of First Generation Antipsychotics
  • chlorpromazine (Thorazine)
  • thioridazine (Mellaril)
  • mesoridazine (Serentil)
  • fluphenazine (Prolixin, Permitil)
  • trifluoperazine (Stelazine and others)
  • perphenazine (Trilafon)
  • proclorperazine (Compazine)
  • thiothixene (Navane)
  • chlorprothixene (Taractan)
  • haloperidol (Haldol)
  • pimozide (Orap)
  • lixapine (Loxitane)
  • molindone (Moban)
  • clozapine (Clorazil) - But ‘atypical’ and more like the newer medications except a potentially fatal side effect which can be detected before it is a threat through the use of regular blood tests.
• New medications (atypical antipsychotics)
  • They are called ‘atypical’ because they affect different neurotransmitters than first generation antipsychotics, they work for on a large number of patients for whom first generation drugs aren’t effective⁷¹.
  • ‘atypical’ medications are also thought to be more effective on ’negative symptoms’ (that is symptoms like anhedonia and lack of motivation vs. symptoms like hallucinations which are called ‘positive’ because they are additions to sensory experience)⁷².
• A (Partial) List of Second Generation Medications
  • resperidone (Risperadal)
  • olanzapine (Zyprexa)
  • quetiapine (Seroquel)
  • ziprasidone (Geodone, Zeldon)
• Antipsychotics are not addictive, that is they have no ‘high’, no cravings, and no (or little) build up of tolerance to clinical effect (that is they continue to be effective on symptoms even when used for years). There are, however, withdrawal symptoms (headache, fatigue, etc) if antipsychotics are completely stopped instead of tapered off. This is likely to the patient’s body adapting to having the medication in their system.

What now?

Coping with continued symptoms and/or side effects

‘Positive’ Symptoms

• Reality Test: For example, if you’re not sure if something you’re thinking is reasonable or not, ask someone you trust if it is.
• Constructive Self-Talk: For example, If you tend to start worrying over a perceived plot or intended slight, tell yourself to analyze the situation to see of that is really a reasonable interpretation.
• Keep a journal (to unload)
• Talk about things that bother you with someone you trust, perhaps a team member, or a friend who understands.

‘Negative’ Symptoms

• Endure. Particularly if you have just started on medication be aware that it can take quite a while for it work, but there is hope. Also know just because the first or second medication doesn’t work, doesn’t mean that nothing will. It took this author many years of ups and downs to reach a comfortable place, but he is now happy and glad he endured.
• Use self-rewards when you accomplish something
• Break things into small manageable tasks
• Do things even if you don’t feel like it. It will at least use up time.
• Find the social groups for others with your illness, or other major mental illness, and attend (even when you don’t feel like it) - a shared burden is a lighter burden.

Work/School

• Are you ready? If you know you’re not, instead work on getting and staying well.
• If you think you are, plan how to do it. This will help you decide if you really are ready. If you can’t plan your return to school (e.g planning how to finance your education, filling out necessary paperwork, making a budget, and catching up on subjects you may not have touched on for years), you’re probably not ready to go back. Similarly, if you want to work and can’t focus or motivate yourself to plan a budget, how to deal with sick days, making a resume, and other such tasks, you might not be ready.
• Get help from your team, and any employment supports available to you. In Ontario, you are likely eligible for Employment Supports through the Ontario Disability Support Plan, and they will help you assess your readiness and help you get where you want to go.
• If you try and find you’re not ready after all, take a break, and when you think you’re ready, try again.
• Do be cautious of taking on too much at once. The author was determined to get his degree, and instead of getting well and then completing it, struggled on for ten years when it probably would have been less painful to take a break, get well, then carry on. He did complete his Bachelor/Baccalaureate nonetheless.

Other Topics

Self-care, Mornings, Stress, Depression, Alcohol, Social Life, Love Life

Appendix A

Diagnostic Criteria [DSM-IV]

• Characteristic symptoms:
• Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated):

1. delusions
2. hallucinations
3. disorganized speech (e.g., frequent derailment or incoherence)
4. grossly disorganized or catatonic behaviour
5. negative symptoms, i.e., affective flattening [flatness of emotion], algolia [poverty of speech], or avolition [lack of energy, spontaneity and initiative].

Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behaviour or thoughts, or two or more voices conversing with each other.

1. Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement).
2. Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).
3. Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either (1) no Major Depressive, Manic, or Mixed Episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.
4. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
5. Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated).

Diagnostic Criteria of Schizophrenia Subtypes

Paranoid Type

A type of Schizophrenia in which the following criteria are met:

1. Preoccupation with one or more delusions or frequent auditory
   hallucinations.
2. None of the following is prominent: disorganized speech, disorganized or catatonic behaviour, or flat or inappropriate affect.

Catatonic Type

A type of Schizophrenia in which the clinical picture is dominated by at least two of the following:

1. motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor
2. excessive motor activity [that is apparently purposeless and not influenced by external stimuli]
3. extreme negativism [an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved] or mutism
4. peculiarities of voluntary movement as evidenced by posturing [voluntary assumption of inappropriate or bizarre postures], stereotyped movements, prominent mannerisms, or prominent grimacing
5. echolalia [repeating the speech of another person in an involuntary and meaningless way] or echopraxia [imitation of movement]

Disorganized Type

A type of Schizophrenia in which the following criteria are met:

1. All of the following are prominent:

   1. disorganized speech
   2. disorganized behaviour
   3. flat or inappropriate affect

2. The criteria are not met for Catatonic Type.

Undifferentiated Type

A type of Schizophrenia in which symptoms that meet Criterion A are present, but the criteria are not met for the Paranoid, Disorganized, or Catatonic Type.

Residual Type

A type of Schizophrenia in which the following criteria are met:

1. Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behaviour.
2. There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms or two or more symptoms listed in Criterion A for Schizophrenia, present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

Differential Diagnosis

Psychotic Disorder Due to a General Medical Condition, delirium, or dementia; Substance-Induced Psychotic Disorder; Substance-Induced Delirium; Substance-Induced Persisting Dementia; Substance-Related Disorders; Mood Disorder With Psychotic Features; Schizoaffective Disorder; Depressive Disorder Not Otherwise Specified; Bipolar Disorder Not Otherwise Specified; Mood Disorder With Catatonic Features; Schizophreniform Disorder; Brief Psychotic Disorder; Delusional Disorder; Psychotic Disorder Not Otherwise Specified; Pervasive Developmental Disorders (e.g., Autistic Disorder); childhood presentations combining disorganized speech (from a Communication Disorder) and disorganized behaviour (from Attention-Deficit/ Hyperactivity Disorder); Schizotypal Personality Disorder; Schizoid Personality Disorder; Paranoid Personality Disorder

Bibliography

[DSM-IV] https://www.mentalhealth.com/dis1/p21-ps01.html [Link dead 2021-12-06] which is in turn, from the Diagnostic and Statistical Manual IV

[PE] Personal Experience of this author (Daniel F. Dickinson).

[SSC99] Schizophrenia Society of Canada Learning About Schizophrenia: Rays of Hope Schizophrenia Society of Canada (Toronto, 2002)

[Temes02] Roberta Temes, Ph.D Getting Your Life Back Together When You Have Schizophrenia New Harbinger Publications, Inc. (California, 2002)

[Torrey95] E. Fuller Torrey, M.D. Surviving Schizophrenia, Third Edition: A Manual for Families, Consumers and Providers Harper Collins Publishers Inc. (New York, 1995)