Schizophrenia - Questions And Answers

Schizophrenia - Questions And Answers

National Institute of Mental Health


U.S. Department of Health and Human Services
Public Health Service
Alcohol, Drug Abuse, and Mental Health Administration

Prepared by
Schizophrenia Research Branch
David Shore, M.D., Editor
Division of Clinical Research

Forward

We expect that nearly 3 million Americans will develop schizophrenia during the course of their lives, and about 100,000 schizophrenic patients are in public mental hospitals on any given day. The treatments available for schizophrenia, while very important in relieving at least some of the suffering for many of the people affected, are not yet preventing the common pattern of repeated relapse with chronic disabilities in social and occupational functioning. Schizophrenia remains poorly understood and largely feared by the public.

This booklet addresses five main questions about schizophrenia: What is it? What causes it? How is it treated? How can other people help? What is the outlook? Accurate information may help to remove misconceptions and thereby reduce the fear, shame, and hopelessness that are too often associated with the disorder.

SHERVERT H. FRAZIER, M.D. Director National Institute of Mental Health

 
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What Is It?

Schizophrenia is a term used to describe a complex, extremely puzzling condition - the most chronic and disabling of the major mental illnesses. Schizophrenia may be one disorder, or it may be many disorders, with different causes. Because of the disorder's complexity, few generalizations hold true for all people who are diagnosed as schizophrenic.

With the sudden onset of severe psychotic symptoms, the individual is said to be experiencing acute schizophrenia. "Psychotic" means out of touch with reality, or unable to separate real from unreal experiences. Some people have only one such psychotic episode; others have many episodes during a lifetime but lead relatively normal lives during the interim periods. The individual with chronic (continuous or recurring) schizophrenia often does not fully recover normal functioning and typically requires long-term treatment, generally including medication, to control the symptoms. Some chronic schizophrenic patients may never be able to function without assistance of one sort or another.

Approximately 1 percent of the population develop schizophrenia during their lives. This disorder affects men and women with equal frequency, and the information in this booklet is equally applicable to both. The first psychotic symptoms of schizophrenia are often seen in the teens or twenties in men and in the twenties or early thirties in women. Less obvious symptoms, such as social isolation or withdrawal or unusual speech, thinking, or behavior may precede and/or follow the psychotic symptoms.

Sometimes people have psychotic symptoms due to undetected medical disorders. For this reason, a medical history should be taken and a physical examination and laboratory tests should be done during hospitalization to rule out other causes of the symptoms before concluding that a person has schizophrenia.

The World of People With Schizophrenia

UNUSUAL REALITIES: Just as "normal" individuals view the world from their own perspectives, schizophrenic people, too, have their own perceptions of reality. Their view of the world, however, is often strikingly different from the usual reality seen and shared by those around them.

Living in a world that can appear distorted, changeable, and lacking the reliable landmarks we all use to anchor ourselves to reality, a person with schizophrenia may feel anxious and confused. This person may seem distant, detached, or preoccupied, and may even sit as rigidly as a stone, not moving for hours and not uttering a sound. Or he or she may move about constantly, always occupied, wide awake, vigilant, and alert. A schizophrenic person may exhibit very different kinds of behavior at different times.

HALLUCINATIONS: The world of a schizophrenic individual may be filled with hallucinations; a person actually may sense things that in reality do not exist, such as hearing voices telling the person to do certain things, seeing people or objects that are not really there, or feeling invisible fingers touching his or her body. These hallucinations may be quite frightening. Hearing voices that other people don't hear is the most common type of hallucination in schizophrenia. Such voices may describe the patient's activities, carry on a conversation, warn of impending dangers, or tell the person what to do.

DELUSIONS: Delusions are false personal beliefs that are not subject to reason or contradictory evidence and are not part of the person's culture. They are common symptoms of schizophrenia and can involve themes of persecution or grandeur, for example. Sometimes delusions in schizophrenia are quite bizarre - for instance, believing that a neighbor is controlling the schizophrenic individual's behavior with magnetic waves, or that people on television are directing special messages specifically at him or her, or are broadcasting the individual's thoughts aloud to other people. Delusions of persecution, which are common in paranoid schizophrenia, are false and irrational beliefs that a person is being cheated, harassed, poisoned, or conspired against. The patient may believe that he or she, or a member of the family or other group, is the focus of this imagined persecution.

DISORDERED THINKING: Often the schizophrenic person's thinking is affected by the disorder. The person may endure many hours of not being able to "think straight." Thoughts may come and go so rapidly that it is not possible to "catch them." The person may not be able to concentrate on one thought for very long and may be easily distracted, unable to focus attention.

The person with schizophrenia may not be able to sort out what is relevant and what is not relevant to a situation. The person may be unable to connect thoughts into logical sequences, as thoughts may become disorganized and fragmented. Jumping from topic to topic in a way that is totally confusing to others may result.

This lack of logical continuity of thought, termed "thought disorder," can make conversation very difficult and contribute to social isolation. If people cannot make sense of what an individual is saying, they are likely to become uncomfortable and tend to leave that person alone.

EMOTIONAL EXPRESSION: People with schizophrenia sometimes exhibit what is called "inappropriate affect." This means showing emotion that is inconsistent with the person's speech or thoughts. For example, a schizophrenic person may say that he or she is being persecuted by demons and then laugh. This should not be confused with the behavior of normal individuals when, for instance, they giggle nervously after a minor accident.

Often people with schizophrenia show "blunted" or "flat" affect. This refers to a severe reduction in emotional expressiveness. A schizophrenic person may not show the signs of normal emotion, perhaps using a monotonous tone of voice and diminished facial expression.

Some people with symptoms of schizophrenia also exhibit prolonged extremes of elation or depression, and it is important to determine whether such a patient is schizophrenic, or actually has a bipolar (manic-depressive) disorder or major depressive disorder. Persons who cannot be clearly categorized are sometimes diagnosed as having a schizoaffective disorder.

NORMAL VERSUS ABNORMAL: At times, normal individuals may feel, think, or act in ways that resemble schizophrenia. Often normal people are unable to think straight. They can be made extremely anxious, for example, speaking in front of groups so that they could feel confused, be unable to pull their thoughts together, and forget what they had intended to say.

Just as normal people may occasionally do strange things, many schizophrenic people often think, feel, and act in a normal fashion. Unless in the midst of an extremely disorganized state, a schizophrenic person will have some sense of common reality, for instance, knowing that most people eat three times each day and sleep at night. Being out of touch with reality (which is one way to describe the psychotic symptoms of schizophrenia) does not mean that an individual is living totally in another world. Rather, there are certain aspects of this individual's world that are not shared by others and that seem to have no real basis. Hearing a voice of warning that on one else can hear is not an experience shared by most people and is clearly a distortion of reality, but it is only a distortion of one part of reality. A schizophrenic person may, therefore, appear quite normal much of the time.

Schizophrenia Is Not "Split Personality"

There is a common notion that schizophrenia is the same as "split personality" - a Dr. Jekyll - Mr. Hyde switch in character. This is not an accurate description of schizophrenia. In fact, split or multiple personality is an entirely different disorder that is really quite rare.

Is Schizophrenia a New Disease?

Although the term "schizophrenia" was not used until the early 20th century, the disorder has existed for a great many years and has been found in all types of societies.

In Western society, "madness" or "insanity" was not generally regarded as a health problem until the early 19th century. At that time, a movement to offer more humane treatment to the mentally ill made it impossible for them to receive more scientific, medical treatment. The mentally ill were unchained, released from prisons, and given more appropriate care. Several categories of mental disease were subsequently identified. By the early 20th century, schizophrenia had been distinguished from manic-depressive illness, and subcategories had been described. In 1911, Dr. Eugen Bleuler, a Swiss psychiatrist, first used the term "the group of schizophrenias." Despite disagreement among scientists as to precisely what conditions should or should not be included in this group, the term has been commonly used since then.

Can Children Be Schizophrenic?

Children over the age of 5 can develop schizophrenia, but it is very rare before adolescence. Moreover, research is needed to clarify the relationship of schizophrenia occurring in childhood to that occurring in adolescence and adulthood. Although some people who later develop schizophrenia may have seemed different from other children at an early age, the psychotic symptoms of schizophrenia (for example, hallucinations, delusions, and incoherence) are rarely seen in children.

Are People With Schizophrenia Likely To Be Violent?

Although news and entertainment media tend to link mental illness and criminal violence, studies tell us that if we set aside those persons with a record of criminal violence before hospitalization, mentally ill persons as a whole are probably no more prone to criminal violence than the general public. Studies are underway to refine our understanding of the different forms of mental illness to learn whether some groups are more prone to violence than others.

Certainly most schizophrenic individuals are not violent; more typically, they prefer to withdraw and be left alone. Some acutely disturbed patients may become physically violent, but such outbursts have become relatively infrequent following the introduction of more effective treatment programs, including the use of antipsychotic medications. There is general agreement that most violent crimes are not committed by schizophrenic persons, and that most schizophrenic persons do not commit violent crimes.

What About Suicide?

Suicide is a potential danger in those who have schizophrenia. If an individual tries to commit suicide or expresses plans to do so, he or she should receive immediate professional help. People with schizophrenia appear to have a higher rate of suicide than the general population. Unfortunately, the prediction of suicide in schizophrenic patients may be especially difficult.

What Causes Schizophrenia?

There is no known single cause of schizophrenia. As discussed later, it appears that genetic factors produce a vulnerability to schizophrenia, with environmental factors contributing to different degrees in different individuals. Just as each individual's personality is the result of an interplay of cultural, psychological, biological, and genetic factors, a disorganization of the personality, as in schizophrenia, may result from an interplay of many factors. Scientists do not agree on a particular formula that is necessary to produce the disorder. No specific gene has yet been found; no biochemical defect has been proven responsible; and no specific stressful event seems sufficient, by itself, to produce schizophrenia.

Is Schizophrenia Inherited?

It has long been known that schizophrenia runs in families. The close relatives of schizophrenia patients are more likely to develop schizophrenia than those who are not related to someone with schizophrenia. The children of a schizophrenic parent, for example, each have about a 10 percent chance of developing schizophrenia. By comparison, the risk of schizophrenia in the general population is about 1 percent.

Over the past 25 years, two types of increasingly sophisticated studies have demonstrated the importance of a genetic factor in the development of schizophrenia. One group of studies examined the occurrence of schizophrenia in identical and fraternal twins; the other group compared adoptive and biological families.

Recent studies of twins have confirmed the basic findings of earlier, scientifically less rigorous studies. Identical twins (who are genetically alike) generally have a higher rate of "concordance" for schizophrenia than fraternal twins (who are no more genetically alike than ordinary siblings). "Concordance" occurs when both members of a twin pair develop schizophrenia. Although studies of twins provide convincing evidence of an inherited factor in schizophrenia, the fact that concordance for schizophrenia among identical twins is only 40 to 60 percent suggests that some type of environmental factor or factors also must be involved.

A second major group of studies looked at adopted children to examine the effects of heredity and environment. In Denmark, an exhaustive investigation of the mental health of adopted-away children of schizophrenic parents was conducted. These children were compared with adopted children whose biological parents had no history of mental illness. A comparison was also made of the rates of mental disorder among the biological relatives of two groups of adoptees - one known to be schizophrenic and the other without a history of mental illness. Findings of adoption studies have indicated that being biologically related to a schizophrenic person increased the risk for schizophrenia, even when the related individuals have had little or no personal contact.

These studies indicate that schizophrenia has some hereditary basis, but the exact extent of this genetic influence needs further exploration. Most scientists agree that what may be inherited is a vulnerability or predisposition to the disorder - an inherited potential that, given a certain set of factors, can lead to schizophrenia. This predisposition may be due to an enzyme defect or some other biochemical abnormality, a subtle neurological deficit, or some other factor or combination of factors.

We do not yet understand how the genetic predisposition is transmitted and cannot predict accurately whether a given person will or will not develop the disorder. In some people, a genetic factor may be crucial for the development of the disorder; in others, it may be relatively unimportant.

Are The Parents at Fault?

Most schizophrenia researchers now agree that parents do not cause schizophrenia. In past decades, there was a tendency for some mental health workers to blame parents for their children's disorder. Today, this attitude is generally seen as both inaccurate and counterproductive. Mental health workers now commonly try to enlist family members' aid in the therapeutic program and also show a heightened sensitivity to the very real feelings of burden and isolation many families experience in their attempts to care for a schizophrenic family member.

Is Schizophrenia Caused by a Chemical Defect?

Although no neurochemical cause has yet been firmly established for schizophrenia, basic knowledge about brain chemistry and its link to schizophrenia is expanding rapidly. Neurotransmitters - substances that allow communication between nerve cells - have long been thought to be involved in the development of schizophrenia. It is likely that the disorder is associated with some imbalance of the complex, interrelated chemical systems of the brain. Although we have no definite answers, this area of schizophrenia research is very active and exciting.

Is Schizophrenia Caused by a Physical Abnormality in the Brain?

Interest in this research question has been stimulated by the development of CAT scans (Computerized Axial Tomography) - a kind of x-ray technique for visualizing the structures of living brains. Some studies using this technique suggest that schizophrenic patients are more likely to have abnormal brain structures (for example, enlargement of the cavities in the interior of the brain) than are normal persons of the same age. It should be emphasized that some of the abnormalities reported are quite subtle. These abnormalities have been found neither to be characteristic of all schizophrenic patients nor to occur only in individuals with schizophrenia.

A more recent development is the PET (Positron Emission Tomography) scan. In contrast to the CAT scan, which produces images of brain structures, the PET scan is a way of measuring the metabolic activity of specific areas of the brain, including areas deep within the brain. Only very preliminary research has been done with the PET scan in schizophrenia, but this new technique, used in conjunction with other types of scans, promises to provide important information about the structure and function of the living brain.

Other special imaging studies that may increase our understanding of schizophrenia include MRI, rCBF, and computerized EEF measures. MRI stands for magnetic resonance imaging, a technique involving precise measurements of brain structures based on the effects of a magnetic field on different substances in the brain. This technique has sometimes been referred to as nuclear magnetic resonance (NMR) imaging. In rCBF, or regional cerebral blood flow, a radioactive gas is inhaled, and the rate of disappearance of this substance from different areas of the brain gives information about the relative activity of brain regions during various mental activities. The computerized EEG (electroencephalogram) is a kind of brain wave test that maps electrical responses of the brain as it reacts to different stimuli. All of these imaging techniques are being used for research. They are not new forms of treatment.

How Is It Treated?

Since schizophrenia may not be a single condition and its causes are not yet known, current treatment methods are based on both clinical research and experience. These approaches are chosen on the basis of their ability to reduce schizophrenic symptoms and lessen the chances that symptoms will return. A number of treatments and treatment combinations have been found to be helpful, and more are being developed.

What About Antipsychotic Drugs?

Antipsychotic medications (also called neuroleptics) have been available since the mid-1950's. They have greatly improved the outlook for individual patients. These medications reduce the psychotic symptoms of schizophrenia and usually allow the patient to function more effectively and appropriately. Antipsychotic drugs are the best treatment now available, but they do not "cure" schizophrenia or ensure that there will be no further psychotic episodes. The choice and dosage of medication can be made only by a qualified physician who is well trained in the medical treatment of mental disorders. The dosage of medication is individualized for each patient, since patients may vary a great deal in the amount of drug needed to reduce symptoms without producing troublesome side effects.

Antipsychotic drugs are very effective in treating certain schizophrenic symptoms (for example, hallucinations and delusions). A large majority of schizophrenic patients, however, are not helped very much by such medications and a few do not seem to need them. It is difficult to predict which patients will fall into these two groups and to distinguish them from the large majority of patients who do benefit from treatment with antipsychotic drugs.

Sometimes patients and families become worried about the antipsychotic medications used to treat schizophrenia. In addition to concern about side effects (discussed elsewhere in this pamphlet), there may be worries that such drugs may lead to addiction. Antipsychotic medications, however, do not produce a "high" (euphoria) or a strong physical dependence, as some other drugs do.

Another misconception about antipsychotic drugs is that they act as a kind of mind control. Antipsychotic drugs do not control a person's thoughts; instead, they often help the patient to tell the difference between psychotic symptoms and the real world. These medications may diminish hallucinations, agitation, confusion, distortions, and delusions, allowing the schizophrenic individual to make decisions more rationally. Schizophrenia itself may seem to take control of the patient's mind and personality, and antipsychotic drugs can help to free the patient from his or her symptoms and allow the patient to think more clearly and make better informed decisions. While some patients taking these medications may experience sedation or diminished expressiveness, antipsychotic medications used in appropriate dosage for the treatment of schizophrenia are not chemical restraints. Frequently, with careful monitoring, the dosage of the medication can be reduced to provide relief from undesirable effects. There is now a trend in psychiatry that favors finding and using the lowest dosage that allows the schizophrenic person to function without a return of psychosis.

How Long Should Schizophrenic Patients Take Antipsychotic Drugs?

Antipsychotic drugs also reduce the risk of future psychotic episodes in recovered patients. With continued drug treatment, about 40 percent of recovered will suffer relapses within 2 years of discharge from a hospital. Still, this figure compares favorably with the 80 percent relapse rate when medication is discontinued. In most cases, it would not be accurate to say that continued drug treatment prevents relapses; rather, it reduces their frequency. The treatment of severe psychotic symptoms generally requires higher dosages than those used for maintenance treatment. If symptoms reappear with a lower dosage, a temporary increase in dosage may prevent a full-blown relapse.

Some patients may deny that they need medication and may discontinue antipsychotic drugs on their own or based on someone else's advice. This typically increases the risk of relapse (although symptoms may not reappear right away). It can be very difficult to convince certain schizophrenic people that they continue to need medication, particularly since some may feel better at first. For patients who are unreliable in taking antipsychotic drugs, a long-acting injectable form may be appropriate. Schizophrenic patients should not discontinue antipsychotic drugs without medical advice and monitoring.

What About Side Effects?

Antipsychotic drugs, like virtually all medications, have unwanted effects along with their beneficial effects. During the early phases of drug treatment, patients may be troubled by side effects such as drowsiness, restlessness, muscle spasms, tremor, dry mouth, or blurring of vision. Most of these can be corrected by lowering the dosage or can be controlled by other medications. Different patients have different treatment responses and side effects to various antipsychotic drugs. A patient may do better with one drug than another.

The long-term side effects of antipsychotic drugs may pose a considerably more serious problem. Tardive dyskinesia (TD) is a disorder characterized by involuntary movements most often affecting the mouth, lips, and tongue, and sometimes the trunk or other parts of the body. It generally occurs in about 15 to 20 percent of patients who have been receiving antipsychotic drugs for many years, but TD can occur in patients who have been treated with these drugs for shorter periods of time. In most cases, the symptoms of TD are mild, and the patient may be unaware of the movements.

The risk-benefit issue in any kind of treatment for schizophrenia is an extremely important consideration. In this context, the risk of TD - as frightening as it is - must be carefully weighed against the risk of repeated breakdowns that can terribly disrupt patient's efforts to reestablish themselves at school, at work, at home, and in the community. For patients who develop TD, the use of medications must be reevaluated. Recent research suggests, however, that TD, once considered irreversible, often improves even when patients continue to receive antipsychotic medications.

What About Psychosocial Treatments?

Antipsychotic drugs have proven to be crucial in relieving psychotic schizophrenic symptoms such as hallucinations, delusions, and incoherence, but do not consistently relieve all the symptoms of the disorder. Even when schizophrenic patients are relatively free of psychotic symptoms, many still have extraordinary difficulty establishing and maintaining relationships with others. Moreover, because schizophrenic patients frequently become ill during the critical trade-learning or career-forming years of life (ages 18 to 35), they are less likely to complete the training required for skilled work. As a result, many schizophrenic patients not only suffer thinking and emotional difficulties, but they lack social and work skills as well.

It is with these psychological, social, and occupational problems that psychosocial treatments help most. In general, psychosocial approaches have limited value for acutely psychotic patients (those who are out of touch with reality or have prominent hallucinations or delusions), but may be useful for those with less severe symptoms or those whose psychotic symptoms are under control. Numerous forms of psychosocial therapy are available for patients with schizophrenia, and most focus on improving the patient's functioning as a social being - whether in the hospital or community, at home or on the job. Some of these approaches are described here. Unfortunately, the availability of different forms of treatment varies greatly from place to place.

REHABILITATION: Broadly defined, rehabilitation includes a wide array of nonmedical interventions for those with schizophrenia. Rehabilitation programs emphasize social and vocational training to help patients and former patients overcome difficulties in these areas. Programs may include vocational counseling, job training, problem-solving and money management skills, use of public transportation, and social skills training. These approaches are important for the success of the community-centered treatment of schizophrenia, because they provide discharged patients with the skills necessary to lead productive lives outside the sheltered confines of a mental hospital.

INDIVIDUAL PSYCHOTHERAPY: Individual psychotherapy involves regularly scheduled talks between the patient and a mental health professional such as a psychiatrist, psychologist, psychiatric social worker, or nurse. These talks may focus on current or past problems, experiences, thoughts, feelings, or relationships. By sharing their experiences with a trained, emphatic person and by talking about their world with someone outside it, schizophrenic individuals may gradually come to understand more about themselves and their problems. They can also learn to sort out the real from the unreal and distorted.

Recent studies tend to indicate that supportive, reality-oriented therapy is generally of more benefit to schizophrenic outpatients than more probing psychoanalytic or insight-oriented psychotherapy. In one large-scale study, patients given psychotherapy oriented toward reality adaptation and practical interpersonal skills generally did as well or better than patients given more frequent and intensive insight-oriented therapy.

FAMILY THERAPY: As usually practiced, family therapy involves the patient, the parents or spouse, and a therapist. Brothers and sisters, children, and other relatives may also be included. The purposes vary. Meeting in a family group can enable various family members and the therapist to understand each other's viewpoints. It also can help with treatment planning (such as discharge from the hospital) and enlisting the aid of family members in the therapeutic program. Family therapy can also provide a way for the therapist to offer the family needed support and understanding in a time of crisis.

Very often, patients are discharged from the hospital to their families' care, so it is important that family members have a clear understanding of schizophrenia and are aware of the difficulties and problems associated with the illness. It is also helpful for family members to understand the ways of minimizing the chance of future breakdowns and to be aware of the different kinds of outpatient and family services that are available in the period after hospitalization.

GROUP THERAPY: Group therapy sessions usually involve a small number of patients (for example, 6-12) and one or two trained therapists. Here, the focus is on learning from the experiences of others, testing out one person's perceptions against those of others, and correcting distortions and maladaptive interpersonal behavior by means of feedback from other members of the group. This form of therapy may be most helpful after symptoms have subsided somewhat and patients have emerged from the acute psychotic phase of the illness, since psychotic patients are often too disturbed or disorganized to participate. Later, when patients are beginning to recover, participation in group therapy will often be helpful in preparing them to cope with community life.

SELF-HELP GROUPS: Another kind of group that is becoming increasingly common is the self-help group. Although not led by a professional therapist, the groups are therapeutic because members - usually ex-patients or the family members of people with schizophrenia - provide continuing mutual support as well as comfort in knowing that they are not alone in the problems they face. These groups also serve other important functions. Families working together can more effectively serve as advocates for needed research and hospital and community treatment programs. Ex-patients as a group may be better able to dispel stigma and draw public attention to such abuses as discrimination against the formerly mentally ill.

Family and peer support and advocacy groups are now very active and provide useful information and assistance for patients and families of patients with schizophrenia and other mental disorders.

The National Alliance for the Mentally Ill is composed exclusively of family groups, with 550 of them as of the end of 1985 and adding about 150 to 200 new groups each year. The National Mental Health Association, the nation's oldest and largest nongovernmental citizen's voluntary organization, is concerned with all aspects of mental disorders and mental health. The National Mental Health Consumer's Association, a network of self-help organizations across the country, now has about 150 affiliates and operates a Self-Help Clearinghouse. These groups can be contacted at the following addresses:

The National Alliance for the Mentally Ill
1901 North Fort Myer Drive, Suite 500
Arlington, Virginia 22209
703/524-7600

National Mental Health Association
1021 Prince Street
Alexandria, Virginia 22314-2971
703/684-7722

The National Mental Health Consumers' Association
311 South Juniper Street, Room 902
Philadelphia, Pennsylvania 19107
215/735-2465

Residential Care

Prolonged hospitalization is now very much less common than it was 20 or 30 years ago, when approximately 300,000 schizophrenic patients were residents of State and county mental institutions. Despite this trend, a minority of patients still seem to require long-term inpatient care. For most patients, prolonged hospital stays are not recommended because they increase dependence on institutional care and result in a loss of social contacts with family, acquaintances, and the community. Short-term residential care in well-staffed facilities can give patients needed relief from stressful situations, provide a protective atmosphere for the troubled patient, allow restarting or adjustment of medication, and reduce pressure on the family.

Many schizophrenic persons can benefit from partial hospitalization (day care or night care), from outpatient treatment (going to a clinic or office regularly for individual, group, or occupational therapy), or from living in a halfway house (designed to aid patients in bridging the gap between 24-hour hospitalization and independent living in the community).

What About Other Forms of Treatment?

ELECTROCONVULSIVE THERAPY (ECT) AND INSULIN COMA: These two forms of treatment are rarely used today in the treatment of schizophrenia. In particular situations, however, electroconvulsive therapy may be useful. It can be of help, for example, if a severe depression occurs in the course of a schizophrenic episode. Insulin coma treatment is virtually never used now because of the availability of other effective treatment methods that have fewer potentially serious complications.

PSYCHOSURGERY: Lobotomy, a brain operation formerly used in some patients with severe chronic schizophrenia, now is performed only under extremely rare circumstances. This is because of the serious, irreversible personality changes that the surgery may produce and the fact that far better results are generally attained from less drastic and hazardous procedures.

LARGE DOSES OF VITAMINS: Good physical hygiene, including a nourishing diet and proper exercise, is important to good health. Well-controlled studies have shown that the addition of large doses of vitamins to standard therapy regimens does NOT significantly improve the treatment of schizophrenia. Also, although vitamins have been thought to be relatively harmless, reports of side effects raise the possibility that these substances may have detrimental consequences when used in very high doses. Reliance on high-dose vitamins as a treatment for schizophrenia is not scientifically justified and does have risks.

HEMODIALYSIS: Preliminary reports that some schizophrenic patients appeared to improve following hemodialysis, a blood-cleansing treatment used in certain kidney disorders, attracted a great deal of attention. However, several more recent controlled scientific studies have reported that the procedure has no beneficial effect on the symptoms of schizophrenia. The weight of scientific evidence now indicates that hemodialysis is NOT useful in the treatment of schizophrenia.

How Can Other People Help?

A patient's support system may come from several sources, including the family, a professional residential or day program provider, shelter operators, friends or roommates, professional case managers, churches and synagogues, and others. Because the majority of patients live with their families, the following discussion frequently uses the term "family." However, this should not be taken to imply that families ought to be the primary support system.

There are numerous situations in which patients with schizophrenia can be helped by people in their support systems. First of all, for patients who do not recognize that they are ill, family or friends may need to take an active role in having them seen and evaluated by a professional. Often, a schizophrenic person will resist treatment, believing that delusions or hallucinations are real and that psychiatric help is not needed. Since laws regarding involuntary commitment have become very strict, families and community organizations may be frustrated in their attempts to see that a severely mentally ill individual gets needed help. These laws vary from State to State, but generally people who are dangerous to themselves or others due to a mental disorder can be taken by the police for emergency psychiatric evaluation and, if necessary, hospitalization. In some cases, a member of a local community mental health center can evaluate an individual's illness at home if he or she will not voluntarily go in for treatment.

Sometimes only the family or others close to the patient will be aware of strange behavior or ideas that the patient has expressed. Since schizophrenic patients may not volunteer such information during an examination, family members or friends should ask to speak with the person evaluating the patient so that all relevant information can be taken into account.

Seeing that a schizophrenic patient continues to get treatment after hospitalization is also important. Patients may discontinue medications or stop going for followup treatment - often leading to a return of psychotic symptoms. Encouraging and assisting the patient to continue treatment can be very important to recovery. Without treatment, some schizophrenic patients become so psychotic and disorganized that they cannot care for their basic needs, such as food, clothing, and shelter. All too often people with severe mental illnesses such as schizophrenia wind up on the streets or in jails, where they rarely receive the kinds of treatment they need.

Those close to people with schizophrenia are often unsure of how to respond when patients make statements that seem strange or are clearly false. The schizophrenic patient's bizarre beliefs or hallucinations seem quite real - they are not just "imaginary fantasies." Instead of going along with a patient's delusions, family members or friends can tell the patient that they do not see things the same way or do not agree with his or her conclusions, while acknowledging that things may seem that way to the patient.

It may also be useful for those who know the patient well to keep a record of what types of symptoms have appeared, what medications (including dosage) have been taken, and what effects various treatments have had. By knowing what symptoms have been present before, family members may know better what to look for in the future. Families may even be able to identify some "early warning signs" of potential relapses (such as increased withdrawal or changes in sleep patterns) better and earlier than the patients themselves. Return of the psychosis may thus be detected early and treatment may prevent a full-blown relapse. Also, by knowing which medications have helped and which have caused troublesome side effects in the past, the family can help those treating the patient to find the best treatment more quickly.

In addition to involvement in seeking help, family, friends, and peer groups can provide support and encourage the person with schizophrenia to regain his or her abilities. It is important that goals be attainable, since a patient who feels pressured and/or repeatedly criticized by others will probably experience this as a stress that may lead to a worsening of symptoms. Like anyone else, people with schizophrenia need to know when they are doing things right. A positive approach may be helpful and perhaps more effective in the long run than criticism, and this advice applies to all those who interact with the patient.

A common question raised by family and friends concerns "street drugs." Since some people who take street drugs may show symptoms similar to those typical of schizophrenia, people with schizophrenia may be accused of being "high on drugs." To help understand the cause of the patient's behavior, blood or urine samples can be tested for street drugs at many hospitals or physician's offices. While most researchers do not believe that schizophrenic patients develop their symptoms because of drug use, people who have schizophrenia often have particularly bad reactions to certain street drugs. Stimulants (such as amphetamines or cocaine) may cause major problems for schizophrenic patients, as may drugs like PCP or marijuana. In fact, some patients experience a worsening of their schizophrenic symptoms when they are taking such drugs. Schizophrenic patients may also abuse alcohol or other drugs for delusional reasons or in an attempt to lessen their symptoms. This can cause additional problems requiring multiple treatment approaches. Such patients may be helped by a combination of therapies such as medication, rehabilitation, psychotherapy, or Alcoholics Anonymous or other substance abuse programs.

What Is The Outlook?

The outlook for people with schizophrenia has improved over the last 25 years. Although no totally effective therapy has yet been devised, it is important to remember that many schizophrenic patients improve enough to lead independent, satisfying lives. As we learn more about the causes and treatment of schizophrenia, we should be able to help more schizophrenic patients achieve successful outcomes.

Studies that have followed schizophrenic patients for long periods, from the first breakdown to old age, reveal that a wide range of outcomes is possible. A review of almost 2,000 patients' life histories suggests that 25 percent achieve full recovery, 50 percent recover at least partially, and 25 percent require long-term care. When large groups of patients are studied, certain factors tend to be associated with a better outcome - for example, a pre-illness history of normal social, school, and work adjustment. Our current state of knowledge, however, does not allow for a sufficiently accurate prediction of long-term outcome.

The development of a variety of treatment methods and facilities is of crucial importance because schizophrenic patients vary greatly in their needs for treatment. In particular, better alternatives are needed to fill the gap between the relatively nonintensive treatment offered in outpatient clinics and the highly regulated treatment (including 24-hour supervision) provided in hospitals. With a variety of facilities available, mental health professionals will be better able to tailor treatment to the different needs of individual patients. Some patients require constant care and attention, while others need a place to learn how to function more independently without constant supervision.

Given the complexity of schizophrenia, the major questions about this disorder - its cause or causes, prevention, and treatment - are unlikely to be resolved in the near future. The public should beware of those offering "the cure" for (or "the cause" of) schizophrenia. Such claims can provoke unrealistic expectations that, when unfulfilled, lead to further disappointment. Although progress has been made toward a better understanding of schizophrenia, there is an urgent need for a more rigorous and broad-based program of basic and clinical research. Research on schizophrenia has benefitted greatly from recent basic scientific discoveries, and we hope that a better understanding of neurobiological and psychosocial factors in schizophrenia will be achieved in the next decade.

To Subscribe to the SCHIZOPHRENIA BULLETIN

The SCHIZOPHRENIA BULLETIN is a quarterly journal prepared by the Schizophrenia Research Branch of the National Institute of Mental Health. Intended as a forum for the multidisciplinary exchange of information about schizophrenia, the BULLETIN is the only periodical exclusively devoted to the exploration of this severe and puzzling disorder.

Frequently, an issue of the BULLETIN focuses on one critical topic. Themes of past issues, for example, have been the role of heredity in schizophrenia, psychosocial approaches to treatment, biological factors in the disorder, subtypes of schizophrenia, childhood psychoses, community support systems, stress and social networks, prognosis and long-term outcome, advances in diagnostic procedures, and research on individuals at high risk for the development of schizophrenia.

The BULLETIN publishes articles on all facets of schizophrenia research and treatment. Special emphasis is placed on the publication of detailed state-of-the-art reviews of critical areas in the study of schizophrenia. Although the BULLETIN wishes to encourage a variety of subscribers, most articles published in the journal are primarily directed to the scientific community.

The subscription price, covering four issues per year, is $16.00 domestic and $20.00 foreign. The single copy price is $4.75 domestic and $5.94 foreign. This price was in effect at time of printing. Prices are subject to change. We urge those intending to subscribe to complete the subscription form as soon as possible. Your check or money order should be made payable and mailed, together with your order form, to the Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402.

Acknowledgements

We greatly appreciate the assistance of those whose reviews and suggestions contributed to this report: Shervert H. Frazier, M.D., Frank J. Sullivan, Ph.D., Darrel A. Regier, M.D., M.P.H., Jack D. Burke, Jr., M.D., M.P.H., Samuel J. Keith, M.D., Nina R. Schooler, Ph.D., Seymour Kety, M.D., Joseph H. Autry, III, M.D., Julius Segal, Ph.D., Richard J. Wyatt, M.D., Irma Lann, M.Ed., A Hussain Tuma, Ph.D., Lorraine Torres, Elaine Pearl, Susan Matthews, Barbara Bruner, Camille Frezzo, Marilyn Sargent, Helen M. Lejnar, Bette Runck, and Joan Abell, all from the National Institute of Mental Health; Mildred K. Lehman, Alcohol, Drug Abuse, and Mental Health Administration; Bettie Payne of the National Mental Health Association; Charles Miles, M.D., Agnes Hatfield, Ph.D., James W. Howe, Richard T. Greer, Laurie Flynn, Maryellen Walsh, Jane Myers, and Peggy Straw, all from the National Alliance for the Mentally Ill; E. Fuller Torrey, M.D.; Nancy Domenici; William T. Carpenter, Jr., M.D. of the University of Maryland at Baltimore; Magda Campbell, M.D. of the New York University Medical Center; and representatives of the National Mental Health Consumer's Association, American Psychiatric Association, American Psychological Association, National Association of Social Workers, and the American Sociological Association.

Portions of this booklet were contributed by Ann Reifman, Ph.D., and Loren R. Mosher, M.D. (first edition), and Sherry Buchsbaum (first revision).

DHHS Publication No. (ADM) 86-1457
Library of Congress Catalog Card Number 86-600530

Single copies are available at no charge from the Public Inquiries Branch, National Institute of Mental Health, Room 15C-05, 5600 Fishers Lane, Rockville, MD 20857.

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