- ‘Positive’ and ‘negative’ symptoms
- Who develops schizophrenia?
- When people first become unwell
- Treatment and support
- Peer support and self-management
- Physical health problems
- A new name for schizophrenia?
Those with a schizophrenia diagnosis will experience psychosis symptoms – hallucinations, delusions and confused thoughts. Professional mental health workers often describe such symptoms as the ‘positive symptoms’ of schizophrenia.
When these symptoms occur, the person is described as having a psychotic ‘episode’. During an episode of psychosis, people won’t necessarily feel unwell and they won’t realise or think that they have a problem with their mental health. Professional mental health workers refer to this thinking as a ‘lack of insight.’ Consequently, people experiencing psychosis might not want to seek treatment or help.
Between psychotic episodes, people with a schizophrenia diagnosis might also experience ‘cognitive symptoms’ or ‘negative symptoms’ as described by mental health workers. This means that they lose motivation to carry out their usual tasks and don’t have much energy. People lose interest in their loved ones, friends and even the activities that they have enjoyed previously. They might lose interest in their appearance and isolate themselves socially. They make also experience problems with concentration and memory loss. Getting up in the morning will be a chore in itself so studying and working are often impossible.
What’s more, those with a schizophrenia diagnosis will often have depression and anxiety.
It’s important to remember that the symptoms and experiences of each person will be different and will last for different amounts of time. Some people will only have a short illness with one psychotic episode. Other people will experience multiple episodes of psychosis over a sustained length of time. Some people will have cognitive or negative symptoms in between psychotic episodes or after a single psychotic episode that could last months or years.
Schizophrenia can arise at any age. For men, the most common time to become unwell is in the late teenage years or the early 20s. Women, on the other hand, usually develop the illness when they are marginally older, in the late 20s. There are a few people that develop schizophrenia as they reach middle age or above.
Anyone is susceptible to schizophrenia but if your parents have had the illness, you are slightly more likely to have it too. Genes do play a part in schizophrenia and its onset but it is important to note that are many factors that contribute to the illness and not one single cause. Also, if one family member has schizophrenia, it is not inevitable that the other family members will develop it too.
There was some research carried out in England between the year 1950 and the year 2009, which showed that every year, 4 in 1,000 people had psychosis symptoms as a part of mental illness. Schizophrenia is widely recognised as the most common serious mental illness of its type.
Oftentimes schizophrenia will have a sudden onset with acute and frightening psychotic episodes.
A first psychotic episode, however, is often preceded by a ‘prodromal period’. This is a time when changes occur in a person’s behaviour.
During this prodromal period, people are usually anxious or depressed. It might be difficult to remember things and it is common to have concentration difficulties. People might stop socialising, you might see them acting uncharacteristically with less interest in their hobbies, work or studies. They will often not care about how they look and will withdraw themselves from social situations, preferring to be alone.
It is also possible to observe symptoms that resemble psychosis during this period – occasional hearing of voices or being paranoid or suspicious. Nevertheless, not all people who have these types of experiences end up having a psychotic episode.
A large number of those who experience the first episode of psychosis will get better again with treatment. Some will improve but might have more episodes or continue experiencing cognitive or negative symptoms.
Research shows that early psychosis treatments lead to a better recovery. Those who don’t seek medical help at the first sign or symptoms might improve at a slower rate or might not get better completely and therefore be at risk of a future relapse.
When people start to become unwell, it won’t always be obvious whether or not they have schizophrenia or a different serious mental health illness that has psychosis as a symptom. For example, it could be schizoaffective disorder or bipolar disorder. This is why people aren’t always given a diagnosis after their first psychotic episode.
It can also happen that a diagnosis changes in response to symptoms experienced at particular times.
Schizophrenia has different ‘sub-types’, which are determined by the symptoms that are the most prominent. The sub-type that is the most common is ‘paranoid schizophrenia’. With this diagnosis, the person mostly has delusions and paranoia. There are other schizophrenia sub-types but these aren’t diagnosed often.
Psychiatrists use two guides to diagnose a patient. One is the ICD – the International Classification of Diseases. This contains a chapter dedicated to psychiatric illnesses and is a guide published by the WHO (World Health Organisation). There is a section entitled ‘Schizophrenia, schizotypal and delusional disorders’ that describes diagnosis of schizophrenia sub-types.
The second guide is the DSM – the Diagnostic and Statistical Manual of Mental Disorders. This is an American Psychiatric Association publication. This was last updated in May 2013 and it actually
The quicker treatment is received for a psychotic episode, the more likely a recovery will happen.
The clinical guidelines published by NICE (National Institute for Health Care and Excellence) in 2014 about how to treat schizophrenia recommends that all first experiences of psychosis are to be assessed immediately with support and treatment offered by a team specialising in early intervention.
A person who has a subsequent psychotic episode might be offered support and treatment for another specialist team for mental health – a home treatment or crisis resolution team, for example.
It is sometimes the case that those experiencing psychosis symptoms will be hospitalised for treatment. Schizophrenia’s ‘positive’ symptoms are treated with antipsychotic medication. This either diminishes the symptoms or gets rid of them entirely. The recommendation by NICE is that people undergo a check of their physical health before taking any antipsychotics and a discussion needs to take place about medication side effects. People usually start on a low dose that can be increased. They will be monitored thoroughly during the first 12 weeks.
It has to be said, however, that for some people, antipsychotic drugs won’t work. When this happens, the illness might be called ‘refractory’ or ‘treatment-resistant’ schizophrenia.
The recommendation by NICE is that clozapine (an antipsychotic drug) can be prescribed to those who have not had success with two other medications. This drug has the ability to suppress psychotic symptoms for those who have not got better with different antipsychotic medications. When prescribed clozapine, patients need to have blood tests regularly as this drug can cause damage to white blood cells.
When a person has had a psychotic episode, they will be advised to take medication for a while afterwards. If people stop taking antipsychotic medication too soon, it is possible for symptoms to return. Some will need to take their antipsychotics for years or for their whole life but not everyone with a schizophrenia diagnosis will have to do this. People should speak to their mental health support worker before stopping their medication and will be advised to come off it gradually.
Currently, there is no medication that treats the cognitive and ‘negative’ symptoms of psychosis effectively (slow thinking, apathy, lack of motivation and attention, memory problems and difficulty interacting in everyday situations with others). CBT (cognitive behaviour therapy) for psychosis can help improve a person’s symptoms as well as other talking therapies. The recommendation by NICE is that people with schizophrenia are offered CBT and family therapy. Mental health professionals are also recommended to offer things like art therapies where available.
If a person with schizophrenia suffers anxiety and depression, they might also be given a prescription for anti-anxiety medication or antidepressants. It is possible that someone with schizophrenia is taking a large number of medications for their different symptoms or even to counteract the unpleasant side effects of their antipsychotic medications.
Carers and family members should play a part in the planning of care and support unless the individual says that they do not want them to.
When a person has recovered from a psychotic episode, they will probably continue to get support from a community-based team or an early intervention team. It might be that they are referred back to their GP for the continuation of care. If a person relapses, a GP won’t prescribe antipsychotics, they should always refer the patient back to specialists.
It is also recommended by NICE that mental health professionals consider ‘peer support’ to patients by someone who has experienced symptoms of psychosis in the past or has a schizophrenia diagnosis who has received peer support training. As an alternative, an offer to take part in a ‘self-management programme’ is a consideration. Both self-management and peer support have the aim of helping people to understand their diagnosis and symptoms, treatment and medication and recovery. They can also access support in staying well and how to seek help in a crisis.
You are more likely to develop physical health problems when you have a schizophrenia diagnosis. These include high blood pressure, weight gain, diabetes and heart disease.
The cause of these problems is due to lifestyle changes because of the symptoms. Research shows that those with a schizophrenia diagnosis (as well as other serious mental health conditions) tend not to look after themselves very well. They are more likely to eat unhealthily and smoke and less likely to exercise regularly.
Using antipsychotics in the long term can also lead to a gain in weight and an increased risk of diabetes and cardiovascular disease.
Research shows that these health problems are contributing factors to premature death. People with schizophrenia or another serious mental health problem have a lower life expectancy when compared with the national average. It is worth noting that some of these early deaths are also due to suicide).
NICE recommends people to have a physical health check before starting antipsychotics. They should also be monitored regularly during the first three months to check for physical changes.
Subsequently, GPs will check people’s physical health annually if they have a schizophrenia diagnosis. This will include a check of blood pressure, weight, cholesterol levels and blood sugar levels. Treatment will be given as necessary and advice about exercise and healthy eating should be offered.
There is a charity called Rethink Mental Illness which has created a ‘Physical Health Check’ that is designed to support mental health professionals to meet the physical health needs of their patients. There is a free questionnaire for people with schizophrenia, their family members and mental health workers available on the charity’s website.
Some people with experience of schizophrenia and researchers believe that the illness should be renamed. This is because ‘schizophrenia’ comes with stigma and discriminatory attitudes. The word was first used 100 years ago when the only thing that was known about the illness was its symptoms. Thus, the work is now unsuitable considering our better scientific understanding of contributing factors to getting the illness.
In 2002, the Japanese Society of Psychiatry and Neurology changed their terminology. The illness now goes by the name of ‘Togo ShitchoSho’ (integration disorder). Its previous name was ‘SeishinBunretsuByo’ (mind spilt disease). This change occurred in order to express the disorder’s complexity and avoid stigma.
Another suggested replacement was made by Jim van Os, a psychiatry professor at Utrecht University (The Netherlands) is ‘salience syndrome’.
Members of Anoiksis, a Dutch organisation, have suggested PSS – ‘psychosis susceptibility syndrome’ and are campaigning for it to be adopted.