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Schizophrenia

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Schizophrenia



Introduction 

Schizophrenia is a long-term mental health condition that causes a range of different psychological symptoms, including:



hallucinations – hearing or seeing things that do not exist



delusions – unusual beliefs not based on reality that often contradict the evidence



muddled thoughts based on hallucinations or delusions



changes in behaviour



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

Why does schizophrenia happen?

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

It is thought certain things make you more vulnerable to developing schizophrenia, and certain situations can trigger the condition.

Who is affected?

Schizophrenia is one of the most common serious mental health conditions. About 1 in 100 people will experience schizophrenia in their lifetime, with many continuing to lead normal lives.

Schizophrenia is most often diagnosed between the ages of 15 and 35. Men and women are affected equally.

There is no single test for schizophrenia. It is most often diagnosed after an assessment by a mental health care professional, such as a psychiatrist.

It is important that schizophrenia is diagnosed as early as possible, as the chances of recovery improve the earlier it is treated.

How is schizophrenia treated?

Schizophrenia is usually treated with a combination of medication and therapy appropriate to each individual. In most cases, this will be antipsychotic medicines and cognitive behavioural therapy (CBT).

People with schizophrenia will usually receive help from a community mental health team (CMHT), which will offer day-to-day support and treatment.

Many people recover from schizophrenia, although they may have periods when symptoms return (relapses). Support and treatment can help reduce the impact the condition has on your life.

Living with schizophrenia

If schizophrenia is well managed, it is possible to reduce the chances of severe relapses. This can include:



recognising the signs of an acute episode



taking medication as prescribed



talking to others about the condition



There are many charities and support groups offering help and advice on living with schizophrenia. Most people find it comforting talking to others with a similar condition.



Misconceptions about schizophrenia

Split personality

It is commonly thought people with schizophrenia have a split personality, acting perfectly normally one minute and irrationally or bizarrely the next – this is not true.

Violent behaviour

Some people mistakenly equate schizophrenia with violent behaviour, but people with the condition are rarely dangerous.

Any violent behaviour is usually sparked off by illegal drugs or alcohol, which is the same for people who don't have schizophrenia.

Symptoms of schizophrenia 

Changes in thinking and behaviour are the most obvious signs of schizophrenia, but people can experience symptoms in different ways.

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



positive symptoms – represent a change in behaviour or thoughts, such as hallucinations or delusions



negative symptoms – represent a withdrawal or lack of function that you would usually expect to see in a healthy person; for example, people with schizophrenia often appear emotionless, flat and apathetic



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

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

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

Positive symptoms of schizophrenia

Hallucinations

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

Hallucinations are very real to the person experiencing them, even though people around them cannot hear the voices or experience the sensations.

Research using brain-scanning equipment shows changes in the speech area in the brains of people with schizophrenia when they hear voices. These studies show the experience of hearing voices as a real one, as if the brain mistakes thoughts for real voices.

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

Delusions

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

Some people develop a delusional idea to explain a hallucination they are having. For example, if they have heard voices describing their actions, they may have a delusion that someone is monitoring their actions.

Someone experiencing a paranoid delusion may believe they are being harassed or persecuted. They may believe they are being chased, followed, watched, plotted against or poisoned, often by a family member or friend.

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

Confused thoughts (thought disorder)

People experiencing psychosis often have trouble keeping track of their thoughts and conversations. Some people find it hard to concentrate and will drift from one idea to another. They may have trouble reading newspaper articles or watching a TV programme.

People sometimes describe their thoughts as "misty" or "hazy" when this is happening to them. Thoughts and speech may become jumbled or confused, making conversation difficult and hard for other people to understand.

Changes in behaviour and thoughts

A person's behaviour may become more disorganised and unpredictable, and their appearance or dress may seem unusual to others. People with schizophrenia may behave inappropriately or become extremely agitated and shout or swear for no reason.

Some people describe their thoughts as being controlled by someone else, that their thoughts are not their own, or that thoughts have been planted in their mind by someone else.

Another recognised feeling is that thoughts are disappearing, as though someone is removing them from their mind. Some people feel their body is being taken over and someone else is directing their movements and actions.

Negative symptoms of schizophrenia

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

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

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



losing interest and motivation in life and activities, including relationships and sex 



lack of concentration, not wanting to leave the house, and changes in sleeping patterns 



being less likely to initiate conversations and feeling uncomfortable with people, or feeling there is nothing to say



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


Psychosis

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

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

Causes of schizophrenia 

The exact causes of schizophrenia are unknown, but research suggests that a combination of physical, genetic, psychological and environmental factors can make people more likely to develop the condition.

Current thinking is that some people may be prone to schizophrenia, and a stressful or emotional life event might trigger a psychotic episode. However, it's not known why some people develop symptoms while others don't.

 

Increased risk

Things that increase the chances of schizophrenia developing include:

Genetics

Schizophrenia tends to run in families, but no one gene is thought to be responsible. It's more likely that different combinations of genes make people more vulnerable to the condition. However, having these genes doesn't necessarily mean you will develop schizophrenia.

Evidence the disorder is partly inherited comes from studies of twins. Identical twins share the same genes. In identical twins, if one twin develops schizophrenia, the other twin has a one in two chance of developing it too. This is true even if they are raised separately. 

In non-identical twins, who have different genetic make-ups, when one twin develops schizophrenia, the other only has a one in seven chance of developing the condition.

While this is higher than in the general population (where the chance is about 1 in a 100), it suggests genes are not the only factor influencing the development of schizophrenia.

Brain development

Studies of people with schizophrenia have shown there are subtle differences in the structure of their brains. These changes aren't seen in everyone with schizophrenia and can occur in people who don't have a mental illness. But they suggest schizophrenia may partly be a disorder of the brain.

Neurotransmitters

These are chemicals that carry messages between brain cells. There is a connection between neurotransmitters and schizophrenia because drugs that alter the levels of neurotransmitters in the brain are known to relieve some of the symptoms of schizophrenia. 

Research suggests schizophrenia may be caused by a change in the level of two neurotransmitters: dopamine and serotonin. Some studies indicate an imbalance between the two may be the basis of the problem. Others have found a change in the body's sensitivity to the neurotransmitters is part of the cause of schizophrenia.

Pregnancy and birth complications

Research has shown that people who develop schizophrenia are more likely to have experienced complications before and during their birth, such as a low birth weight, premature labour, or a lack of oxygen (asphyxia) during birth. It may be that these things have a subtle effect on brain development.

Triggers

Triggers are things that can cause schizophrenia to develop in people who are at risk. These include:

Stress

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

Drug abuse

Drugs do not directly cause schizophrenia, but studies have shown drug misuse increases the risk of developing schizophrenia or a similar illness.

Certain drugs, particularly cannabis, cocaine, LSD or amphetamines, may trigger symptoms of schizophrenia in people who are susceptible. Using amphetamines or cocaine can lead to psychosis and can cause a relapse in people recovering from an earlier episode.

Three major studies have shown teenagers under 15 who use cannabis regularly, especially "skunk" and other more potent forms of the drug, are up to four times more likely to develop schizophrenia by the age of 26.

Want to know more?



Mind: mental health effects of street drugs



Mind: what causes schizophrenia?



Rethink Mental Illness: causes of schizophrenia



Royal College of Psychiatrists: cannabis and mental health



 

Diagnosing schizophrenia 

There is no single test for schizophrenia. The condition is usually diagnosed after assessment by a specialist in mental health.

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

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

Community mental health team (CMHT)

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

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

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

To make a diagnosis, most mental healthcare professionals use a diagnostic checklist. Schizophrenia can usually be diagnosed if:



you have experienced one or more of the following symptoms most of the time for a month – delusions, hallucinations, hearing voices, incoherent speech or negative symptoms, such as a flattening of emotions



your symptoms have had a significant impact on your ability to work, study or perform daily tasks



all other possible causes, such as recreational drug use or bipolar disorder, have been ruled out



Related illnesses

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

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



bipolar disorder (manic depression) – people with bipolar disorder swing from periods of mania (elevated moods and extremely active, excited behaviour) to periods of deep depression; some people also hear voices or experience other kinds of hallucinations, or may have delusions



schizoaffective disorder – this is often described as a form of schizophrenia because its symptoms are similar to schizophrenia and bipolar disorder, but schizoaffective disorder is a mental illness in its own right; it may occur just once in a person's life or recur intermittently, often when triggered by stress.



You should also be assessed for post-traumatic stress disorder and other conditions, such as depression, anxiety and substance misuse. 

Getting help for someone else

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

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

If someone is having an acute schizophrenic episode for the first time, it may be necessary for a friend, relative or other loved one to persuade them to visit their GP.

In the case of a rapidly worsening schizophrenic episode, you may need to go to the accident and emergency (A&E) department, where a duty psychiatrist will be available.

If a person who is having an acute schizophrenic episode refuses to seek help, their nearest relative can request that a mental health assessment is carried out. The social services department of your local authority can advise how to do this.

In severe cases of schizophrenia, people can be compulsorily detained in hospital for assessment and treatment under the Mental Health Act (2007).

After diagnosis

If you or a friend or relative are diagnosed with schizophrenia, you may feel anxious about what will happen. You may be worried about the stigma attached to the condition, or feel frightened and withdrawn.

It is important to remember that a diagnosis can be a positive step towards getting good, straightforward information about the illness and the kinds of treatment and services available.


Diagnosing children and young people

Schizophrenia accounts for nearly a quarter of all psychiatric admissions in children and young people aged 10 to 18 years.

Children and young people with a first episode of schizophrenia should be referred urgently to a specialist mental health service. This should be either CAMHS (up to 17 years) or an early intervention service (14 years or over) that includes a consultant psychiatrist with training in child and adolescent mental health.

 

Treating schizophrenia 

Schizophrenia is usually treated with an individually tailored combination of therapy and medication.

Good schizophrenia care

The National Institute for Health and Clinical Excellence (NICE) has produced guidelines outlining how people with schizophrenia should be cared for.

NICE recommends anyone providing treatment and care for people with schizophrenia should:



work in partnership with people with schizophrenia and their carers



offer help, treatment and care in an atmosphere of hope and optimism



take time to build supportive and empathic relationships as an essential part of care



In July 2012, the government launched a new mental health implementation framework to help ensure the No Health Without Mental Health strategy, which aims to improve mental health and wellbeing, becomes reality.

Community mental health teams hide


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

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



social workers



community mental health nurses – a nurse with specialist training in mental health conditions



occupational therapists



pharmacists



counsellors and psychotherapists 



psychologists and psychiatrists – the psychiatrist is usually the senior clinician in the team



After your first episode of schizophrenia, you should initially be referred to an early intervention team. These specialist teams provide treatment and support, and are usually made up of psychiatrists, psychologists, mental health nurses, social workers and support workers.

 

Living with schizophrenia 

Most people with schizophrenia make a recovery, although many will experience the occasional return of symptoms (relapses).

With support and treatment, you may be able to manage your condition so it doesn't have a big impact on your life.

Spotting the signs of an acute schizophrenic episode

Learning to recognise the signs that you are becoming unwell can help you manage your illness. These can include losing your appetite, feeling anxious or stressed, or having disturbed sleep.

You may also notice some milder symptoms developing, such as feeling suspicious or fearful, worrying about people's motives, hearing voices quietly occasionally, or finding concentration difficult.

You may also want to ask someone you trust to tell you if they notice your behaviour changing.

Recognising the initial signs of an acute schizophrenic episode can be useful, as it may be prevented through the use of antipsychotic medicines and extra support.

If you have another acute episode of schizophrenia, your written care plan should be followed, particularly any advance statement or crisis plan. Your care plan will include the likely signs of a developing relapse and the steps to take, including emergency contact numbers.

Avoiding drugs and alcohol

While alcohol and drugs may provide short-term relief from your symptoms, they are likely to make your symptoms worse in the long run.

Alcohol can cause depression and psychosis, while illegal drugs may make your schizophrenia worse. Drugs and alcohol can also react badly with antipsychotic medicines.

If you are currently using drugs or alcohol and finding it hard to stop, ask your care co-ordinator or GP for help.

Taking your medication

It is important to take your medication as prescribed, even if you start to feel better. Continuous medication can help prevent relapses. If you have questions or concerns about medication you are taking, or any side effects, talk to your GP or care co-ordinator.

It may also be useful to read the information leaflet that comes with the medication about possible interactions with other drugs or supplements.

It is worth checking with your healthcare team if you plan to take any over-the-counter remedies, such as painkillers, or any nutritional supplements. This is because these can sometimes interfere with your medication.

Regular reviews

As part of the care programme approach, you will be in contact with your healthcare team regularly. A good relationship with the team means you can easily discuss your symptoms or concerns. The more the team knows, the more it can help you.

Self care

Self care is an integral part of daily life. It means you take responsibility for your own health and wellbeing with support from those involved in your care.

It includes things you do each day to stay fit, maintain good physical and mental health, prevent illness or accidents, and effectively deal with minor ailments and long-term conditions.

People living with long-term conditions can benefit enormously if they have support for self care. They can live longer, have less pain, anxiety, depression and fatigue, have a better quality of life, and are more active and independent.

Want to know more?



What is self care?




Healthy living hide



Keep healthy

As well as monitoring your mental health, your healthcare team and GP should monitor your physical health.

A healthy lifestyle, including a balanced diet with lots of fruits and vegetables and regular exercise, is good for you and can reduce your risk of developing cardiovascular disease or diabetes. You should also try to avoid too much stress and get a proper amount of sleep.

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

Stop smoking

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

Stopping smoking has clear physical health benefits but it has also been shown to improve the mental health of people with schizophrenia.

If you take antipsychotic medicines and want to stop smoking it's very important that you talk to your GP and/or psychiatrist before you stop as the dosage of your prescription drugs may need to be monitored and the amount you have to take could be reduced.

Want to know more?



Healthy eating



Rethink Mental Illness: wellbeing and physical health



Royal College of Psychiatrists: smoking and mental health




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Schizophrenia