Coping with Schizophrenia

Kevin Gournay

• Publisher: Sheldon Press
• Year: 2014
• Print ISBN: 9781847092649
• eBook ISBN: 9781847092656
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

Schizophrenia is traditionally difficult to define and commonly misunderstood, but involves problems differentiating inner experiences and perceptions to everyday external reality. This book provides up-to-date information about changing views on schizophrenia and how it can be treated. As well as exploring classic symptoms such as hallucinations and hearing voices, it provides strong practical suggestions for dealing with the mental and emotional distress involved. Topics include: History of name and diagnostic categories; Myths and facts about schizophrenia; Medication; Therapy (especially CBT); Professional help; Diet and exercise; Social support; Work and leisure; Dealing with stress in the family; Stigma, discrimination and educating the public.

Part 1

SIGNS, SYMPTOMS AND DIAGNOSIS

1

What is schizophrenia?

History

The word schizophrenia was first used by the psychiatrist Eugen Bleuler just over one hundred years ago. The word, literally translated from the Greek, means ‘splitting of the mind’, hence the incorrect belief among many that people with schizophrenia have a ‘split personality’. This was not Bleuler’s intent and, even then, he realized that schizophrenia was a highly complex condition involving personality, thinking, memory and perception.

Before that, others realized that schizophrenia was different from dementia, intellectual disabilities and the common mental health problems such as depression and anxiety, and that it appears in many shapes and forms. Over the years there have been various attempts to classify schizophrenia. The current classifications can be found in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) and the World Health Organization’s International Classification of Diseases, revision 10 (ICD-10). The classifications used now are still controversial and international experts disagree with one another. However, what seems to be clear is that schizophrenia is probably best thought of as an ‘umbrella’ term to describe a number of conditions that may manifest themselves in quite different ways and require differing approaches to treatment and care.

Signs, symptoms and diagnosis

Over the years there have been a number of controversies about diagnosis. Thirty years ago, many psychiatrists disagreed about whether a particular individual had schizophrenia. It was also true to say that the diagnosis was often made after the individual had spent many years in contact with mental health professionals without their problems being recognized. Although the situation is now far from perfect, mental health professionals across the world are now in much greater agreement about what constitutes a schizophrenic illness. Of considerable importance, many countries now have programmes dedicated to improving diagnosis, so that treatments may begin earlier in the disease. There is certainly accumulating evidence that early intervention is beneficial for long-term outcomes.

Schizophrenia presents in various forms or subtypes, and even within the subtypes there is considerable variation between individuals. Broadly speaking, one of the most accepted ways of looking at signs and symptoms is to divide and classify them as positive, negative and cognitive. When professionals talk about ‘positive’ symptoms they do not mean symptoms that are helpful or provide a benefit, they are referring to psychological experiences that are added to or exaggerated in someone’s personality. ‘Negative’ refers to symptoms that are deficits or reductions of normal emotional responses. ‘Cognitive’ refers to how we think and process information. Examples of some of the symptoms of schizophrenia and how they are classified are given in Table 1.

Table 1 Symptoms of schizophrenia

Type of symptom	Symptom
Positive	Delusions
	Hallucinations
	Behavioural changes
Negative	Apathy
	Blunting of emotions
	Incongruity of emotions/responses
	Reduction in speech
	Social withdrawal
	Reduction in social performance
Cognitive	Problems with working memory
	Poor executive functioning
	Inability to sustain attention

It is worth noting that people with schizophrenia commonly have other mental health problems. It is important that these are identified and appropriately treated; it is sadly all too common to see with people with schizophrenia experiencing various anxieties, fears and phobias that are not being addressed by mental health professionals (see ‘Other mental health problems’ in this chapter).

Positive symptoms

Delusions

There are a number of definitions of a delusion. Indeed, if one looks at the books written about schizophrenia, some authors have written literally thousands of words in their attempt to tell us what delusions are. One definition that we prefer is simple: a false belief that is impervious to reason or logic and has no evidence to support it. However, the issue of context needs to be taken into account when applying this definition. One obvious example is that of spiritual and religious beliefs. Many religious beliefs appear to have little or no hard evidence to support them and are regarded as a matter of faith. It would therefore be ridiculous to regard all people of faith as delusional. Likewise, there are certain beliefs held within certain cultures that appear to others not within that culture to be irrational and illogical and also without any evidence base. What might therefore distinguish a delusion from a religious or cultural belief? This perhaps might best be explained by an example:

Peter is a 24-year-old man who grew up in a village in Somerset. He attended the local Church of England service every Sunday morning with his family and went to a church school. Throughout his childhood and adolescence Peter took part in a number of Christian activities and was always proud to say that he was a committed Christian. At 18 years of age he left home to go to university, where he studied physics and obtained a good degree. While at university he joined the Society of Christian Students, where he often discussed how he approached what appeared to be an incompatibility between hard science and faith. Indeed, Peter left university saying that the more he learned about the universe, the stronger his faith had actually become.

Shortly after leaving university, Peter encountered a number of significant life stresses, including the sudden death of his mother. He gradually became more withdrawn and depressed, and although he continued to work he did little else – even neglecting to attend his usual Sunday service. After a while Peter told his father that the reason for his withdrawal was his belief that there were people watching him and that he would need to wait until they told him what to do with his life. It also seemed clear that Peter believed that those watching him had told him that if he continued to go to church ‘something bad’ would happen to his father and the rest of his family. Peter eventually went to an accident and emergency department in a state of panic because he felt that ‘these people’ were pursuing him. The hospital represented a place of safety. He was referred to the duty mental health nurse, who spoke to Peter for about an hour and a half. She found that Peter’s beliefs about ‘these people’ were completely fixed and despite reassurance that he would be safe he continued to feel under very serious threat.

Following a short admission to hospital and treatment with medication and cognitive behavioural therapy (see Chapter 8) Peter eventually made a good recovery from his illness, which was diagnosed as schizophrenia. Several months later, when he had returned to normal function and resumed going to church and, indeed, was making plans to get married to his long-term girlfriend, he told his community psychiatric nurse that he remembered how he was at the height of his illness and how everything had seemed like a bad dream. He was also able to say that he was, at the time, completely convinced that others were in some way controlling him and that nothing that anyone could have said or done would have convinced him otherwise. He said that obtaining insight into his illness and understanding that his convictions were part of that illness took him several months. These beliefs, which he now recognized as delusions, did not simply go away. They very slowly diminished in strength and intensity until they were no longer present.

Hallucinations

Hallucinations are best defined as sensory experiences for which there is no external stimulus. All five senses – taste, sight, touch, smell and hearing – can be affected. It is worth emphasizing that hallucinations are not necessarily a sign of mental illness and there is a wide variety of research that shows that hallucinations occur in many people who are in good mental health. Indeed, we have all probably experienced hallucinations – just before sleep or on waking up (hypnagogic or hypnopompic hallucinations, respectively). They may also occur under extremes of stress and tiredness.

The most common form of hallucination in schizophrenia is hearing voices. These sometimes take the form of a commentary on what the person is doing or what is happening around them and at other times may come in the form of commands. Sometimes the voices are pleasant in tone or content but they can be critical, and very distressing as a result. Many people with schizophrenia realize that the voices are not real but are part of their illness, while others perceive them to be real and if they are particularly critical, serve to compound the person’s distress. It is therefore very important that the professionals or family members around a person with schizophrenia take the time and trouble to understand the nature and content of the voices. As we will see later, an understanding of the voices is the first step in developing a coping strategy.

Thoughts and thinking problems

One feature of some but not all cases of schizophrenia is thought disorders and problems of thinking. All of us have problems with thinking, every day of our lives. Just recall those occasions when your mind ‘goes blank’ or where you lose your concentration – or simply when your mind suddenly jumps from one topic to another. Some people experience more of these problems than others. However, for most of us these problems of thoughts and thinking do not interfere with our everyday lives and pose no real problems in our interaction with others. In schizophrenia, problems of thinking may be very prominent and cause great disruption of all aspects of life.

The main problem for the affected person sometimes concerns attention and concentration. These problems are often connected with the great distraction caused by hallucinations, or by the preoccupation with a delusional idea. People with schizophrenia can experience thought blocking, where a train of thinking suddenly stops. The individual may then pause and continue with a train of thought on a completely different subject. American psychiatrist Dr Nancy Andreasen has catalogued some of the thought problems encountered in schizophrenia:

Derailment Wandering off of the point during the free flow of conversation.

Tangentiality Answering questions that are off the point.

Incoherence Breakdown of the relationships of words within a sentence so that the sentence no longer makes sense.

Loss of goal Failure to reach a conclusion or achieve a point.

Dr Andreasen also describes unusual uses of language – for example, people with schizophrenia often invent new words (neologisms) to describe a particular, novel experience.

Changes in behaviour

Delusions and hallucinations may lead to behavioural changes. However, behaviour such as agitation and overactivity may occur without any apparent connection to delusions or hallucinations. The overactivity seen in some types of schizophrenia can lead to exhaustion, weight loss and sometimes serious physical illness.

Among the other behavioural changes seen in schizophrenia are increases in fluid drinking and food intake. Although these may be connected with the side effects of medication (some medications cause an increase in appetite) they should be investigated by the patient’s GP.

Negative symptoms

Apathy

One of the changes that family members often observe in the early stages of the illness is a change in interest and enthusiasm for pastimes and hobbies that have previously given great enjoyment. The person will often describe ‘losing interest’.

Blunting of emotions

Some people with schizophrenia experience ‘blunting’ of emotions and lack of emotional response to events that would normally make the person sad, happy or excited.

Incongruity of emotions

This describes the way in which some people with schizophrenia react inappropriately in their mood and reactions to external events. For example, on hearing news of a family member who has died or suffered serious illness, a person with schizophrenia may react by laughing or giggling. Likewise, quite ordinary interactions may lead to outbursts of anger or irritability.

Reduction in speech

This may be an early sign of the illness but is common at any stage. It is sometimes difficult to keep a conversation going because the person shows what is often described as ‘impoverished’ speech or verbal responses.

Social withdrawal

People with schizophrenia will often withdraw from interactions with other people and can often become extremely reclusive. Even if they find themselves in social situations they will withdraw and be uncommunicative.

Reduction in social performance

An early sign of schizophrenia may be a change in social performance. Thus, a person who has previously performed well socially begins to show poor social skills. This may be demonstrated in problems at work or with peers in social groups at college or university.

Cognitive symptoms

In addition to the impact positive symptoms and thought disorder have on concentration and thinking, further cognitive impairments often interfere with a person’s ability to lead a productive and independent life. These symptoms are usually present before the onset of the illness and before a person receives treatment.

Problems with working memory

The ability to use information immediately after reading or hearing something, and making decisions based on that information, is often impaired in people with schizophrenia.

Poor executive functioning

Executive functions include the capacity to formulate goals, to plan, organize and carry out a particular behaviour fully and effectively, and to monitor and self-correct behaviour. Doing simple tasks such as shopping for groceries or following a recipe can often be difficult. Being able to make choices when more than one option is presented can also present difficulty. Because poor executive functioning may lead to difficulties in censoring thoughts and behaviour, the person may talk out loud inappropriately in social situations.

Proble...

Table of contents

• Foreword
• Acknowledgements
• Note to the reader
• Introduction
• Part 1: Signs, symptoms and diagnosis
• Part 2: Treatment
• Part 3: Further help
• Part 4: Physical health in schizophrenia
• Conclusion
• Useful contacts
• References
• Search terms