Schizophrenia
WHAT IS SCHIZOPHRENIA?
Schizophrenia is a disorder characterized by severely disorganized thoughts, emotions, and behaviors.1, 2 The word “schizophrenia” means “split mind,” and originally the disorder was given this name to call attention to the divided thought processes of the people affected by it.3
Unfortunately, over the years, many people have confused schizophrenia with dissociative identity disorder, a mental health problem in which people report having multiple personalities. This is not accurate; people with schizophrenia don’t have multiple personalities. Rather, they suffer from a collection of different kinds of problems that make it very difficult to function at home, at work, and in other social situations. And yet, despite these various problems with their thought processes, many people with schizophrenia are of average or above average intelligence.4
Most people suffering with schizophrenia experience some kind of hallucination. Hallucinations are visual, auditory, or other sensory events that only the person can perceive. Hallucinations might include seeing people or things that aren’t really there, hearing voices that others can’t hear, or smelling scents that don’t really exist. These hallucinations might happen frequently, and they are often very disturbing.
Another common experience in schizophrenia is delusional thinking. A delusion is a strongly held but mistaken, belief. For example, some people with schizophrenia have delusions of reference, which means they mistakenly think that common experiences have a special meaning for them. For example, a man might think that the television newscaster is talking directly to him, or a woman might believe that someone is sending her secret messages in the newspaper. Other people with schizophrenia have delusions of persecution, meaning they think that other people are looking to do them harm. For example, a woman might think she’s being followed by a secret government organization, or a man might think that someone other than himself is controlling his thoughts.
Most likely, the person struggling with schizophrenia also suffers from other serious problems with his or her thought processes. Typically, problems occur when these people try to think of words they want to use, try to remember information, or try to maintain their focus on something.5 These problems with thought processes often lead to problems in speaking, which are noticed by other people. The person might have difficulty focusing on one topic and instead switch from one subject to another very quickly and frequently. This often makes people with schizophrenia difficult to understand.
Most people with schizophrenia also suffer from some kind of severe behavior difficulty. This could mean having problems doing regular daily activities, like eating and bathing. Or perhaps the person can’t control his or her impulses and as a result behaves in unpredictable and inappropriate ways, like screaming at people in public. In more extreme cases of schizophrenia, a person might be unable to move and appear to be rigid, like a statue; or, conversely, the person might engage in some type of strange but constant motion. This is called catatonia.
Another problem commonly associated with schizophrenia is difficulties interacting with others. Some people with schizophrenia appear to have an expressionless face and often seem unable to display their emotions, while others display emotions that are quite different from what would be expected, like laughing during a serious conversation. Other common problems include an inability to participate in social or work activities, or to enjoy activities that provided entertainment before the person became ill with the disorder.
A diagnosis of schizophrenia would be made after a person had been struggling with these problems for a period of at least six months. Symptoms that last less than six months are more accurately diagnosed as schizophreniform disorder. In addition, some people suffer with a combination of schizophrenic and depressive symptoms known as schizoaffective disorder. In addition to the above symptoms, they also experience symptoms common to depressive episodes.
In a study that tried to identify the early warning signs of schizophrenia, certain problems were frequently reported by people who later developed the disorder.6 These early problems included hallucinations, becoming exceptionally suspicious of others, experiencing changes in sleep patterns, feeling very anxious, experiencing problems with thinking, becoming excessively angry, developing delusions, and experiencing depression. In additional studies, the sudden development of very strange behaviors also preceded onset of schizophrenia.7-9 However, this development by itself isn’t enough to predict the onset of the disorder.
ARE THERE OTHER PROBLEMS RELATED TO SCHIZOPHRENIA?
In addition to the severe problems associated with schizophrenia itself, as many as 50 percent of the people with the disorder have additional health problems.10 Among the most common is cigarette smoking. It’s estimated that up to 90 percent of people with schizophrenia smoke heavily,1 making them vulnerable to many related health problems. People with schizophrenia also have a greater risk for developing diabetes.11 In addition, many of them suffer with depression, obsessive-compulsive disorder, drug or alcohol addictions, anxiety, social phobia, or panic attacks.12-14
The greatest health risk associated with schizophrenia, however, is suicide. Suicide is the number one cause of premature death for people with schizophrenia.15 Nearly 50 percent of people with schizophrenia will attempt to end their lives.16 For these reasons, it’s extremely important to seek immediate professional help for someone struggling with schizophrenia or related symptoms.
Besides affecting individuals and families, schizophrenia also has a wide-ranging social impact. Many people with schizophrenia who lack family or social support become homeless and live on the streets17 or end up in jail due to vagrancy.18 In fact, it’s believed that one-third of the estimated 350,000 to 1 million homeless people in the United States suffer from a severe mental disorder, and often it’s schizophrenia.18, 19
WHO IS AFFECTED BY SCHIZOPHRENIA?
Schizophrenia is one of humankind’s most serious health problems. In 1990, it was estimated that schizophrenia was the ninth leading cause of disability in the entire world,20 trailing problems such as depression, accidents, alcohol use, and heart disease. On the whole, schizophrenia affects approximately 1 percent of the world’s population,21-23 a statistic that translates into almost three million people in the United States alone.24
Men have a slightly greater risk of developing schizophrenia than women.25 Typically, people develop schizophrenia between their late teenage years and their early thirties, with men developing the disorder a little earlier in life than women.1
WHAT CAUSES SCHIZOPHRENIA?
Unfortunately, in the mid-twentieth century, many parents were mistakenly blamed for the development of schizophrenia in their children. Some theories suggested that a cold child-rearing style could cause schizophrenia. This is not true. Although the exact causes of the disorder are unknown, it’s now generally agreed that schizophrenia is a brain disorder caused by biological factors, not by environmental or social risk factors.2 However, environmental factors such as stress can trigger the onset of the disorder or make it worse.26
Statistics indicate that schizophrenia is an inheritable illness. A person’s chances of developing the disorder increase from 1 percent to 13 percent if one parent has schizophrenia,27 and the risk is higher if it’s the person’s mother who has the disorder, rather than the father.1 This suggests that genetic factors can create a vulnerability to developing the disorder, and these factors can be passed on to later generations.21
The leading theory about schizophrenia is that it’s caused by high levels of dopamine, a neurotransmitter produced in the brain.28 Some researchers believe that an inheritable genetic code produces an ineffective nerve receptor in the brain, which disrupts the transmission of dopamine.29
Other possible causes of schizophrenia have been identified using brain-imaging techniques, such as magnetic resonance imaging (MRI). Some researchers have observed that certain areas of the brain are sometimes smaller than expected in people with schizophrenia.30-32 However, the differences are sometimes as small as 2 percent,33 the results aren’t always the same for men and women,34 and sometimes such results are found only in 25 to 30 percent of the people observed.5
WHAT TREATMENTS ARE EFFECTIVE FOR SCHIZOPHRENIA?
Since schizophrenia is a biological illness, just like cancer and diabetes, the most important first treatment is medication.2 Some commonly used medications include risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), clozapine (Clozaril), and aripiprazole (Abilify).2, 35 The good news is that these medications can be very effective at treating many of the symptoms of schizophrenia, and since they were first introduced in the mid-twentieth century, they have been greatly improved. However, the unfortunate news is that these medications need to be taken regularly for the person’s entire life. Right now, this is the best treatment for schizophrenia. This may seem unfair and burdensome, but the truth is that people who don’t take medication to treat their schizophrenia lead very unhealthy, unfulfilling lives.
Making this situation even more complicated is the fact that all of these medications have side effects. Some of them, like clozapine (Clozaril), have severe side effects that require monitoring with weekly blood tests.35 Nevertheless, despite these complications, medication is still the best treatment for controlling the symptoms of schizophrenia and reducing the person’s chances of having a severe schizophrenic episode in the future.26
Once people begin taking medication for schizophrenia, it’s critically important that they continue taking it. Stopping the use of medication without the advice and supervision of a medical professional is never a safe decision, no matter how good the person might feel when he or she makes that decision.
After people have begun medication, psychological treatments can help them control the symptoms of schizophrenia.2, 36 Unfortunately, many people with schizophrenia do stop taking their medications despite being advised not to.37 One of the main goals of psychotherapy, therefore, is to help people with schizophrenia adhere to their medication regimen.
Specific types of psychotherapy, such as family therapy,38 can educate the person’s family members about the disorder and help to create a more positive environment in which the person can live. Studies have shown that family therapy can help prevent relapse, lessen readmissions to hospitals, and help the person continue taking his or her medications.39
Cognitive behavioral therapy, in both individual and group settings, has also proven to be an effective treatment.24, 40, 41 Cognitive behavioral therapy for schizophrenia is designed to help the person relieve stress, understand the nature of the disorder, evaluate hallucinations and delusions, adhere to the medication schedule, and prevent relapse.42 In studies comparing the use of cognitive behavioral therapy with and without medication, people who used cognitive behavioral therapy with medication experienced fewer symptoms of schizophrenia and fewer relapses.43-47
In two small studies, acceptance and commitment therapy has also been an effective treatment when used in conjunction with medication.48, 49 In both studies, the patients receiving this treatment were rehospitalized less frequently for their symptoms, reported greater overall improvements, and were able to cope with their hallucinations with less distress.
Other kinds of treatments have also been successful at providing specific skills training to people with schizophrenia, such as social skills training50 and supportive work training.51 Social skills training is very effective for helping people learn to communicate more effectively and have more socially fulfilling lives.52 Its goal is to build communication skills and socializing skills, along with skills that can help the person cope with everyday problems, like managing medical appointments. Supportive work training is designed to place people with schizophrenia in a fulfilling job and provide them with the support they need to maintain that job and succeed in the workplace.
For people with more severe forms of schizophrenia, a residential facility or a community-based care program may be an alternative to hospitalization. One such program, assertive community treatment, offers the support of a team of health care workers twenty-four hours a day. It has been shown to reduce hospitalizations and to help patients improve the use of the health care services available to them.53, 54
COGNITIVE BEHAVIORAL THERAPY FOR SCHIZOPHRENIA
Cognitive behavioral therapy (CBT) is a form of treatment that combines elements of both cognitive therapy and behavior therapy. Cognitive therapy examines the way people’s thoughts about themselves, others, and the world affect their mental health. Behavior therapy investigates the way people’s actions influence their own lives and their interactions with others. By combining the two, CBT examines the way people can change their thoughts and behaviors in order to improve their lives.
The CBT treatment for schizophrenia often involves working with the person’s family, but it can also be helpful when used only with the individual who is struggling with the disorder. However, it must be restated that the initial and most important treatment for schizophrenia is medication; psychological treatments can only be helpful after people with schizophrenia have been stabilized on medication.
Also, it’s very important to recognize that this illness is not easily treatable without the help of a professional mental health care professional. Although suggestions for self-help material appear below, these should only be used in conjunction with professional treatment.
COGNITIVE BEHAVIORAL FAMILY THERAPY
The goal of cognitive behavioral family therapy is to focus on the way a person’s family communicates and behaves with one another. Researchers have observed that people with schizophrenia who live with their family have lower relapse rates when the family has lower amounts of family stress and conflict.55, 56 In particular, researchers have found that families with a great deal of expressed emotion are particularly difficult for people with schizophrenia.57 These families often communicate with each other in critical, hostile ways and don’t respect each family member’s right to privacy.
In light of this research, cognitive behavioral family therapy often focuses on three goals:58
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Educate the patient and the patient’s family about schizophrenia
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Manage the stress level in the family
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Set goals to create a healthier family environment
1. Educate the Patient and the Patient’s Family About Schizophrenia
It’s very important for the person and the person’s family to understand the basic nature and causes of schizophrenia (as highlighted above). It’s also very important for everyone involved to understand the nature of this particular CBT treatment and the demands it will put on the family. The goal of the treatment is not to make the illness go away. Rather, the goal is to restructure the way the family relates to one another in order to create a healthier environment for everyone. This treatment is very interactive and requires the person and his or her family to do work outside of the therapy session. (Click here for information on cognitive behavioral family therapy.)
2. Manage the Stress Level in the Family
In this second step, the person and his or her family are taught specific stress management and communication skills that can help reduce the overall stress level in the family. In particular, each person in the family is asked to observe how his or her reactions and communication style affect the family member with schizophrenia, so that specific interventions can be made.
The techniques introduced at this stage of treatment might include general stress reduction techniques, such as muscle relaxation and breathing skills; problem-solving skills; and communication skills. (Click here for information on stress reduction skills, problem-solving skills, and communication skills.)
3. Set Goals to Create a Healthier Family Environment
Finally, the last step of the cognitive behavioral family treatment for schizophrenia involves assessing all family members for specific changes they would like to make in their own lives. For example, the mother might want more time alone to socialize with friends, while a sibling might want to get involved with athletics. It’s also important that the person with schizophrenia make a list of goals. Then, when each person has made his or her list, the family should collaboratively help each other make the necessary changes. It’s usually helpful for everyone to begin making the changes in a slow, graded manner, beginning with the easiest changes first. For the person with schizophrenia, it’s also helpful for the family to increase his or her independent functioning in a graded way. For example, if the person wanted to start taking a class, it might be helpful to have a family member to accompany him or her to the first few classes, and then slowly increase the person’s level of independence. (Click here for information on setting goals with the family.)
INDIVIDUAL COGNITIVE BEHAVIORAL THERAPY
The techniques used in individual cognitive behavioral therapy for people with schizophrenia are similar to those used in cognitive behavioral family therapy. Often, people with schizophrenia benefit from individual CBT after family CBT (if the person is living with his or her family) and the use of medication.59, 60
Individual cognitive behavioral therapy for schizophrenia often focuses on three goals:61
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Educate the patient
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Address the person’s cognitive functioning
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Challenge delusional thoughts
1. Educate the Patient
Again, the first step of treatment is to educate the person about the nature and causes of schizophrenia, as well as the nature of the individual CBT treatment. One of the main goals of this step is to engage the person in the treatment. Schizophrenia is a very disabling illness, and it takes a large commitment of time and energy to begin addressing it.
2. Address the Person’s Cognitive Functioning
This second step of the treatment involves addressing the prominent hallucinations and reacting to them in a different way. Hallucinations of any kind are very disturbing, and often they appear very real to the person experiencing them. As a result, the person sometimes attributes the hallucination to an outside force, rather than to the misfiring of neurons in the brain. For example, a person who hallucinates voices might belief that spirits or demons are commanding him or her to do something, instead of recognizing that these are symptoms of an illness.
One of the challenges of individual cognitive behavioral therapy is to help the person respond to these hallucinations in a different way. This can help reduce both the frequency of the hallucinations and the distress related to them. The first step is to help the person recognize when the hallucinations are starting, so that he or she can learn to address them as soon as possible. Next, the person is taught to cope with the hallucinations in a different way. This includes recognizing that they are products of the person’s brain, not some other entity. And instead of responding with old habits, such as talking back to the voices, the person is helped to switch his or her attention to something else, like coping statements or more positive thoughts or images.
3. Challenge Delusional Thoughts
The final step of individual CBT for schizophrenia is to help the person challenge his or her delusional thoughts. This can be done by looking for evidence that supports and contradicts the person’s delusions, as well as by running small experiments that challenge the delusion. For example, the person who believes that he or she can’t go to public parks for fear of being kidnapped might find ways to challenge this belief in a safe, stepwise manner. This might include first going to the park with a group of friends, then going with one friend, then going with a friend at a distance, and so on. This step of the treatment often proceeds very slowly, and the person should not be rushed to change his or her thinking.
ACCEPTANCE AND COMMITMENT THERAPY
Acceptance and commitment therapy (ACT) incorporates elements of behavior therapy, meditation and mindfulness practices, and scientific research on how humans learn.
ACT is based on the principle that many psychological problems are caused by efforts to control, avoid, or get rid of emotions and thoughts that are undesirable. Often, people try to get rid of feelings and thoughts that make them sad or anxious, just as they get rid of other things they don’t want, such as old clothes. However, as ACT points out, feelings and thoughts can’t be controlled. And for the person with schizophrenia, hallucinations and delusions also can’t be controlled. A person can’t throw them out like an unwanted pair of shoes. In fact, the harder a person tries to control his or her thoughts and feelings, the more powerful they often become and the longer they stick around.
In the two small studies that utilized ACT in the treatment of schizophrenia, participants were taught to accept their thoughts without struggling against them, and to work toward achieving valued goals, such as independent living.48, 49 In both studies, the patients receiving this treatment were rehospitalized less frequently for their symptoms, reported greater overall improvements, and were able to cope with their hallucinations in less distressing ways. (Click here for information about acceptance and commitment therapy.)
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REFERENCES FOR SCHIZOPHRENIA
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58. Mueser, K. T., and S. M. Glynn. 1999. Behavioral Family Therapy for Psychiatric Disorders. Oakland, CA: New Harbinger Publications.
59. Tarrier, N., L. Yusupoff, C. Kinney, E. McCarthy, A. Gledhill, G. Haddock, et al. 1998. A randomised controlled trial of intensive cognitive behaviour therapy for chronic schizophrenia. British Medical Journal 317: 303-307.
60. Pilling, S., P. Bebbington, E. Kuipers, P. Garety, J. Geddes, G. Orbach, et al. 2002. Psychological treatments in schizophrenia: Meta-analysis of family intervention and cognitive behaviour therapy. Psychological Medicine 32: 763-782.
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