Medical Director Cygnet Hospital Ealing, 22 Corfton Rd, Ealing
London W5 2HT
The Priory Hospital, Priory Lane, Roehampton, London SW15 5JJ
And: 51 Sloane St, London, SW1X 9SW
And: 19 Cliveden Place, Sloane Square, London, SW1W 8HD
Schizophrenia is the name given to a group of illnesses that have a number of shared features, but also considerable variations, especially with regard to course and outcome. Attempts to subdivide them into recognisable separate illnesses have not been particularly successful. The diagnosis is not, as a result, a good predictor of future course of illness nor of response to treatment.
Schizophrenia is usually associated in the public mind with the phrase “split personality” which is misleading. Like all psychiatric illnesses it is defined by the symptoms and signs.
The illnesses that fall under the term “Schizophrenia” usually first start to occur in early adulthood, from late teens to early thirties, with the most common age of onset being in the early twenties.
The symptoms of schizophrenia are usually divided for descriptive purposes into positive and negative. Most patients with schizophrenia will have some but not all of the positive symptoms during an acute phase of the illness. In quiescent phases (periods of remission) patients may not have any positive symptoms or they may remain unstated and in the background. Negative symptoms are likely to develop progressively during the course of the illness and after many years may come to dominate the clinical picture.
Delusions are fixed beliefs in things that are not real or true and which cannot be understood from a persons background or religious beliefs. These false beliefs are often persecutory and frightening, and may be quite bizarre. A typical example might be that there is a conspiracy of people, quite possibly including real friends, that wish to do the person some harm. Attempting to challenge the ill person with logic has no effect on these beliefs. With time they tend to become more complicated, new false beliefs growing on the back of old ones.
Ideas or delusions of reference are terms that describes how sufferers connect external events to themselves in a way that is not real. An example might be someone watching a television soap opera that was dealing with a character losing their job believing that the programme in some way refers to them self. The patient may believe that the programme makers have special knowledge of them. These abnormal connections may be made in all sorts of strange ways and are not necessarily connected to the person themselves. They might see a red car parked outside the house and believe that it is part of a conspiracy to spy on them. The abnormal belief may spread to involve other thoughts and beliefs.
Passivity feelings occur when patients feel that people or things outside of themselves influence their thoughts or actions. These influences may even take control of their will or movements so they do not feel on their own. The term also refers to the feeling that things such as x-rays, radio beams and telepathic thoughts etc. are being put into their bodies.
Auditory Hallucinations are voices, that are heard by the sufferer, that don’t exist. These voices are usually indistinguishable from normal voices so that the person is unable to recognise that they are not real. At first they often occur when the person is alone and may appear to come from outside a lavatory door or through a window, the person speaking therefore remaining unseen. Once the illness has become more established they may just be there, not necessarily coming from anywhere, and will be accepted as “normal”. They may be recognised as those of acquaintances or friends or they may be those of strangers. There is usually more than one voice talking about the person in the third person, referring to the patient as “he” or “she”. The nature of the conversation is generally critical, personal and unpleasant. A typical example would be two or more people saying something like “she is a dirty person” or “he is a homosexual”. Occasionally the voices say things that indicate they are spying on the person or reading their thoughts. They might then say “he is getting out of his chair” or “he doesn’t want to go out” or something else that is descriptive of the person’s thoughts or actions at that moment.
In the background to the more florid symptoms of schizophrenia, there will also be evidence of a gradual change to the personality.
Ambition and drive seem to diminish so that sufferers fail to achieve their hoped for potential. Their lives tend to be less successful compared with the expectations that were there before the illness developed. Even when working at simple jobs they show a tendency to turn up late or take days off. They no longer make the necessary commitment to be successful.
The same sense of detachment and lack of commitment also affects their personal relationships. The consequence is usually a gradual drifting away from friends and the lack of drive means that new friendships are less often developed. Slowly, there is the tendency for increasing isolation. Sufferers are seldom driven to make the type of commitment that leads to marriage and often remain single and alone, although marriage is more common amongst female sufferers who marry young as the usual age of onset is slightly later at 28yrs.
Those who suffer from the worst negative symptoms can become generally apathetic to a wide range of issues, drop out of conventional life and are at risk of drifting slowly towards vagrancy, hence the importance of early treatment and family and social support.
During an acute phase, but seldom in other circumstances, someone with schizophrenia may be thought disordered. This term describes a disordering of the form of thoughts that is experienced by an observer as meandering speech. Answers to questions seem to drift past the point. Sometimes the person loses track of their thoughts in mid flow and speech just seizes up. Sometimes there may be abrupt changes in direction in the flow of conversation so that their speech can seem puzzling and disjointed.
In its most extreme form, the speech pattern can be bizarre and irrelevant with new words being made up (neologisms). The strange use of words and grammar fail to convey meaning clearly.
Changes in mood frequently accompany the changing stages of this illness. It is common to find that a patient who is about to relapse into an acute phase of the illness will first become more anxious and tense.
During an acute chaotic phases it is common to find some evidence of elation and excessive activity, although this is not as severe as that occurring in a hypomanic illness. The most typical change of mood at this stage is a strange disconnection between what is happening and the accompanying feelings. For example, apparently sad events may produce indifference or even giggling. This symptom, which psychiatrists call inappropriate affect is responsible for the concept of split personality and is the result of a split between a sufferer’s logic and their emotions.
As the more florid episode settles down, some patients have a tendency to periods of depression. This is characterised by them feeling gloomy and unmotivated, wanting to sit around and do nothing. They may feel worthless and feel that life is not worth living. If the symptoms are severe they may feel actively suicidal. Associated with these feelings may also exist the typical features of a true depressive illness, anxiety and tension and a range of physical changes to sleep pattern, appetite and sexual function.
When severe, the acute symptoms of schizophrenia are terrifying for the sufferer to experience. The symptoms create a world that is alien, threatening and that feels out of control. No one around them seems able to connect with what they are experiencing so they feel completely alone. Sufferers may become frightened and withdrawn and unable to care for themselves partly because they feel increasingly out of contact with the world outside their fantasy.
Behaviour becomes unpredictable because they live in a world that is not obeying the normal rules. For example, hearing something from an hallucination (that is not of course heard by anyone else) leads them to say or do things that to anyone else seems to have no cause or justification. Such an isolated and frightening existence can be enough to drive them to harming themselves. In rare instances a feeling about being attacked can lead to violence usually in some misguided attempt to use attack as the best form of defence.
As discussed at the beginning, there is a lot of variation in course and development of this illness because schizophrenia may not be a single illness.
The most usual course of the illness is that of episodes of acute illness followed by longer periods of relative improvement. Not all patients will relapse following a single episode of acute psychosis, but there is a high risk of it. The frequency of relapse and the speed of development and severity of the negative symptoms is very variable.
It is only after a period of at least two years that a pattern can be seen to develop that will give some indication of the future.
Those who will do best often have the most florid and alarming onset, and may have quite a lot of mood disturbance, becoming elated or depressed with the illness. They may relapse only occasionally and preserve most of their personality for many years. Other patients may be affected only by a single set of abnormal beliefs, however complicated, that respond to treatment or are able to remain in the patient’s background allowing them to live comparatively normal lives.
Those who have more severe illnesses often are unable to recognise themselves as ill and relapse frequently. They often comply poorly with medication and have difficulty leading normal lives, holding down jobs or maintaining good relationships.
There are many problems for those who live with an affected family member.
A major difficulty is living and coping with the recurrences of the acute phases of the illness. These cause unpredictable behaviour although each relapse is usually fairly similar to a previous one. It is true, for example, that if during previous breakdowns there has never been a suggestion of violence, then violence will be unlikely in any future episodes. Acute phases of the illness can be extremely disruptive and frightening for everyone. It is usually the case that sufferers lose insight during a relapse, so that they are unable to recognise that they are ill. In such a state it is hard to persuade them to accept the treatment they so clearly need and they may continue to deteriorate until they are unwell enough for treatment to be imposed on them under the Mental Health Act. In an acute phase of illness, most patients will need admission to hospital.
When the patient is first allowed home after an admission for an acute episode they are likely to need considerable support from those around them. Many are quite depressed during this phase of recovery. Often they are unmotivated and may have side effects from medication to add to their woes. It may help them to attend a day hospital or day centre that can provide structure to their lives. There may be some specific therapies that can help them to start mixing with other people again. They often lack confidence and find it difficult to carry out normal activities such as shopping, reading, watching TV etc. They may need encouragement to attend properly to personal hygiene and need to be accompanied on their first steps outside the home.
As the illness progresses the negative symptoms gradually become more of a problem. Finding and keeping a job, or developing some other purpose in life, often becomes the major difficulty.
Sufferers often come to need some form of assisted living in places where there is support such as a hostel or some form of sheltered accommodation.
Families can play a vital role but it can be a frustrating one. There can often seem an unending need to pick up the pieces and start again after a crisis or failure.
Sufferers with Schizophrenia often ignore their physical health. Many smoke a lot and may fail to notice early symptoms and signs of illness. Family members can play a useful role by trying to have a heightened awareness of this problem and by encouraging regular contact with the GP.
It is usually best to avoid being critical or trying to tell the patient that he is wrong about things. Occasionally there may be opportunities when you can help him to consider the possibility that his belief or experience may not be real.
The overall aim is to support the sufferers independence and attempt to enhance their quality of life whilst recognising and trying to avoid the potential for further crises.
We don’t know what causes this illness at present. It seems likely that it doesn’t have a single cause but that several different causes may lead it to develop. Most people consider schizophrenia to be more like a physical illness than a type of learned behaviour or an illness that can be understood in purely psychological terms. There is now strong evidence of structural changes in the brain that differentiate them from non-sufferers.
The incidence of Schizophrenia worldwide is around 1 in 100 and is remarkably consistent in different countries. There is good evidence that suggests that it is more common in those whose immediate family have other family members with the illness. This is probably the result of one or more genetic factors. It is approximately true that if a person has a close family member with this illness, a parent or sibling, then the risk is increased to about 1 in 10 for them to develop the illness. Most people who develop Schizophrenia have no family history of the disorder.
The conclusion must be that although a change in the genes may well be responsible, these are not necessarily inherited and in this sense hereditability is a weak influence.
In the past it has been fashionable to blame most mental illnesses on upbringing and early experience. This is one of the legacies of a time when all psychiatric conditions were thought understandable in terms of analytic theories. Those theories of cause don’t seem to fit the observed facts about Schizophrenia and there is therefore no real evidence to support them.
Parents usually blame themselves for any health or behavioural problems that may develop in their children, whatever their age. It is natural therefore that parents automatically blame themselves and feel guilty when their child becomes unwell. They are liable to question all aspects of the past from details of the pregnancy and birth onwards through childhood. Doing so does not help to provide them with an understanding of the cause of this illness.
There is considerable research going on into the possible causes of Schizophrenia.
There are two pieces of relevant accepted knowledge. Firstly there appear to be some small but real differences in structure between the brains of sufferers and those of a matched healthy population. These differences are not large or reliable enough to form the basis of tests for the illness but the finding is probably a true one. Because of these findings much research has been focused on the idea that the brain may not have developed quite normally either because of problems in the womb or perhaps because of minimal brain damage inflicted at the time of the birth.
It is also known that Schizophrenia is more likely to occur in children born in winter or early spring. The seasonal link has made people wonder if some viral or bacterial infection during pregnancy might have a damaging effect. This is because such infections are more common during winter months.
All these ideas are at the research stage and we hope that these research efforts will provide answers in the future.
The trigger of an episode should not be confused with its causes. Triggers may cause the illness to arise at a particular time but without them the illness would probably develop at a later date. The importance is that that those things that trigger the first episode of illness are likely to be the same things that may well trigger subsequent relapses. Management of the illness sensibly includes their identification and avoidance.
There are a number of different common triggers.
Illicit drugs, especially LSD and similar hallucinogenic drugs, are the most potent triggers of all. After a single psychotic episode avoidance of all illicit drugs is an absolute priority. Even Cannabis, which is often regarded as fairly harmless, can be a very significant trigger. Because it is so much more commonly taken it is a more frequent trigger than other drugs.
There is a strong case to be made for saying that after a psychotic episode it would be sensible to stop drinking alcohol altogether. Most people don’t heed to this advice.
Alcohol does not mix well with any medications used in the treatment of Schizophrenia, whether in an acute episode or later in the prevention of relapse. The best advice, apart from stopping, is to drink little, avoid spirits, avoid drinking every day and to try to keep to a maximum of two drinks per day.
If alcohol does seem to trigger a relapse in an individual’s case, then it must be avoided.
High stress periods of life are associated with the increased likelihood of developing every illness, mental and physical. Even moving house can precipitate relapse in some people.
It is difficult to modify this in a useful way because different things are stressful to different people. Also there is no way of leading a normal life and avoiding stress altogether. It is not even certain that a life of no stress is the most healthy sort to aim for. Exploring issues of stress management and trying to find sensible ways of achieving a balance is a normal part of therapy aimed at relapse prevention.
There is a lot of variation in the ways that normal family members communicate and relate to each other in different families. Some are used to having rows regularly and often shout or get angry with each other; others are quieter and avoid obvious conflicts. In some families the members are quick to criticise, in others criticism is restricted and they say something pleasant or remain silent.
Research has shown that patients who live in an environment where criticism is minimal have a lower risk of relapse and that certain sorts of therapy can be helpful in families in that regard.
Family therapy to help a family reduce expressed emotions, especially of a critical or angry nature, is a treatment process that can help to reduce relapse.
The onset of an acute phase of the illness almost always presents management problems. Generally the symptoms appear over a period of a few weeks but, in line with the diagnostic variations, this prodromal period can vary from a few days to a few months. The most frequently experienced build up is gradually over weeks and it is sometimes difficult to decide when and how to achieve treatment for someone who has no realisation that they are ill. The earlier treatment begins the better the outcome.
Early intervention achieved by persuasion is best but not all sufferers are able to retain enough insight into their illness for this to be possible. While the patient is in remission, one roles of the doctor, as well as the relatives, is to create the most positive relationship possible so that it will survive a more difficult period of psychosis should this arise. If persuasion fails then admission will almost certainly be compulsory under the Mental Health Act.
Admission to hospital under section of the Mental Health Act will normally be initiated by the GP in consultation with hospital staff. The formalities are achieved by two doctors and a social worker.
Effective treatment of an acute psychotic phase of illness is mainly about giving and taking medication. In general, the medication falls into a few groups.
Antipsychotic or neuroleptic drugs can be of older or newer, atypical, varieties. The effect of all drugs is a balance for the person taking them. This is a balance between the beneficial effects of reducing unwanted symptoms of illness and detrimental unwanted side effects. Older types of medication suit some people better than the newer. They tend to be somewhat sedative, which may be useful at times, and they are likely to cause the development of tremors and sometimes of other unwanted muscle movements. These side effects can often be minimised by careful handling of the dose and by giving anticholinergic drugs such as Procyclidine.
The newer, atypical, drugs are less sedative and much less likely to produce a movement disorder. For these reasons, they are generally favoured as the drugs of first choice and many patients prefer them.
It should be remembered that individuals vary and the illness is not a simple, discrete entity. It sometimes takes some time to find which of the different medications provide the most benefit and least side effects.
Once the acute phase is passed medication will be reduced and may often also be simplified, reducing perhaps to a single drug at reduced dosage. The minimum dose compatible with continuing good health is largely a matter of trial and error, and depends on careful and slow reduction of the dose with regular assessment of both benefits and side effects of the particular medication. A few sufferers will be able to stop medication and remain well either for long periods or indefinitely. Most will not and it will become clear that continuing medication is needed for the long term. Almost all patients will be advised to remain on medication for a year or longer after a single episode, in an attempt to minimise the risk of relapse.
An acute phase of Schizophrenia is often associated with excitement and over arousal. Combined with a lack of insight, this can make management at the start of treatment difficult. Sufferers may need to be sedated when they first come into hospital and this is usually achieved by giving, together with the neuroleptic, a Valium like compound, often Lorazepam.
As discussed above, a phase of depression may accompany Schizophrenia. These phases may be severe enough to require treatment with antidepressant medication. There is a broad choice of drugs available many of which are highly effective.
Because of the overlap between Schizophrenia, Schizoaffective disorder and Bipolar Disorder, it is not uncommon for some patients to make use of mood stabilising drugs as an additional help in relapse prevention. These include Lithium and Depakote.
Once the acute episode has subsided there are other courses of treatment, that don’t involve medication, that may assist in reducing the symptoms, regaining insight and preventing relapse.
These are both treatments based on talking and there are considerable similarities and overlap between them.
Counselling is the more immediate treatment. It can be of quite short duration, sometimes of as few as 10 sessions. It normally focuses on the immediate problems that a patient may present with such as coping with day-to-day issues and any damage to relationships that the illness has caused. It can also help to sort out the experience of illness and separate what was real from what was delusory. It can be used to support and encourage the relearning of life skills and the rebuilding of confidence enabling a return to normal life.
More classical psychotherapy depends partly on the development of the relationship between therapist and patient and the use of that relationship to understand and change behaviour at an emotional rather than a logical level. Perhaps because of the difficulty that people with Schizophrenia have in making deep relationships, it’s benefit in this illness is limited. It is more helpful for those who have a well preserved personality.
This form of therapy is aimed at changing symptoms and has become more popular over the past few years. Although the research is not faultless, it does appear that it can help someone with this illness to reduce symptoms, especially if medication has failed to control them adequately.
Cognitive therapy uses a number of different techniques that can be learned. These focus on the automatic repetitive ways that lead us to make negative assumptions. These are hopefully both identified, challenged and changed during the treatment.
Living with a schizophrenic through an acute breakdown is an extremely stressful experience. It can easily damage relationships and the fear of a further episode tends to lead to an increase of anxiety in the future. Most families will benefit from family work aimed at support, education and the management of any interpersonal difficulties that may have arisen. Family work may take place with or without the ill person, depending on that person’s ability to cope with any stress that may result from treatment.
Following the remarks made earlier about High Expressed emotion, it is clear that families can sometimes help to reduce the likelihood of relapse by modifying their own ways of communicating with each other and with the sufferer. Therapy, that requires special techniques, is often focused on helping the family to manage conflict without using extremes of emotion
There are a number of supporting organisations that may be available in a local area:-
These may be available and are usually organised by volunteers. They can be identified through the GP, social worker, community psychiatric nurse or the local mental health team.
The National association for mental health is a charitable organisation that is well known as it runs a number of high profile campaigns that are often in the press. It can put carers in touch with a network of supporters and has a range of other services which include drop-in centres, legal help and education.
National Telephone: 0845 660 163
London Telephone: 020 8522 1728
Website: www.mind.org.uk
Address: MIND, Granta House, 15-19 Broadway, London, E15 4BQ
Rethink is the new operating name for the National Schizophrenia Fellowship. It has a network of community self-help groups run by carers and provides a range of services including training courses and several types of support projects. The website has a great deal of information and links that are to do with all forms of severe mental illness.
Telephone: 020 8974 6814 (weekdays 10am - 3pm) the national advice service.
Website: www.rethink.org
Address: 28 Castle Street, Kingston-upon-Thames, Surrey KT1 1SS
Also Head Office: 30 Tabernacle St London EC2A 4DD
Tel 0845 456 0455 and Fx 0207 330 9102
Has a website: www.nsfscot.org.uk
This organisation has the aims of raising the public profile of the problems associated with Schizophrenia, providing information and support, and funding research.
SANE has a telephone crisis line SANELINE 0845 767 8000.
Open 12.00 pm to 2.00 am
Website: www.sane.org.uk
Dr Rowan's Secretary is stationed in the Priory Hospital, Roehampton.
Direct line Telephone Number: (0044) or (0) 208 392 4211
Fax: (0044) or (0) 208 876 4015
Email peter.rowan@psychiatrist4u.co.uk