Schizophrenia

Medical Code: SGM-FS-009
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Condition: Schizophrenia

Prevalence: 2.2 million in US

Layman’s Definition: A problem with wiring in parts of the brain that interpret information, causing the person to persistently see and/or hear (usually scary) things that are not there and/or to imagine they are under special threats or have unusual special abilities     

Typical Age of Symptom Onset: 15-25 years in males; 25-35 years in females

Primary Symptoms: Auditory and/or visual hallucinations, often (but not always) of a frightening character. Inward focusing of thoughts. Lack of engagement with the world and with other people. Repetitive, often ritualistic behavior, intended to ward off danger. The severity of these symptoms may vary but tends to decrease later in life.

Secondary Symptoms: A person with schizophrenia may appear emotionally flat, showing little response to events that would normally be expected to elicit smiles, frowns, or other signs of emotion. Feelings of anxiety and/or an inability to “turn off” internal voices may keep the person from being able to get enough sleep. Because of their focus on their internal battles, people with schizophrenia may neglect various aspects of their personal care and health and fail to take routine precautions against robbery, mugging, etc. They are therefore more likely to appear disheveled and to become ill from a range of conditions or to be victims of crimes.

Although general intelligence and creativity are not usually affected, the energy required to deal with the internal struggles associated with schizophrenia may cause school or work performance to suffer. Some individuals with untreated schizophrenia may attempt to quiet their voices or ease their anxiety by consuming alcohol or illegal drugs, creating a risk for addiction and making diagnosis and treatment of the underlying condition more difficult. Individuals experiencing delusions of a strongly paranoid character may react violently to imagined threats.

Some medications used to treat hallucinations (antipsychotics/neuroleptics) can increase the risk of developing a neurological condition that causes repetitive, involuntary, purposeless movements such as lip smacking, grimacing, tongue movements, or excessive blinking, all aspects of Tardive Dyskinesia. This condition also develops in some individuals with schizophrenia who have not taken these drugs.

In order to determine whether the symptoms indicate that medication levels are too high or too low, it’s important to distinguish between the abnormal involuntary behaviors of Tardive Dyskinesia and the odd but intentional repetitive actions used by individuals with schizophrenia to ward off danger. The risk of Tardive Dyskinesia seems to be higher with some of the older medications. Newer medications have not been in use long enough to fully evaluate long term safety issues.

Cause(s)/Risk Factor(s): The cause of schizophrenia is unknown but genetics and maternal exposure to certain infections during pregnancy are strongly implicated. The waxing and waning of symptoms and general reduction in symptoms in later life suggests a possible autoimmune component to the disease (similar to Multiple Sclerosis). Electrical recordings of brain activity in people with schizophrenia taken at rest suggest that hallucinations may be caused by the brain over-interpreting and trying to ascribe meaning to what is essentially background noise in their vison and hearing systems. Rather than filtering out this noise, the mind may imagine that it hears within it the whispers of angels or the muttering of demons.   

Standard Treatment(s):  Antipsychotic medications are typically prescribed to reduce hallucinations.

Anti-anxiety medications are often prescribed to help control the sense of fear caused by the hallucinations, which are rarely completely eliminated by antipsychotic medications.

Sedatives may be prescribed for a short period of time for individuals who have been unable to sleep for several days due to fear and anxiety caused by their hallucinations.

Additional medications are sometimes prescribed to reduce the risk of a specific side effect (Tardive Dyskinesia) which can occur when taking certain antipsychotic drugs.

It’s important to understand what each medication is for, so that if one of them causes side effects, that can be discontinued. But generally, any mediation taken to control these symptoms should be continued at least until the problem drug is out of the person’s system. In addition, a person should talk to their doctor before stopping the use of these medications; it’s often advisable to step down one’s dosages over several days. Alternatively, the doctor may prescribe medications to relieve nausea or other symptoms of abrupt medication withdrawal.     

People with schizophrenia are often hospitalized for a period of time after a first episode of the illness in order to reduce the risk of self-harm and monitor the person’s health while their doctors work to identify the best drug or drug combination for the patient.

If the condition is detected early, however, and if the person has a good support system, it may be possible to treat the person entirely on an outpatient basis. In such cases, however, it may take longer to identify the best medication and dosage, as the doctor may want to raise medication levels more slowly if the person is not under close medical supervision.

Each person’s body responds differently to medication, and therefore it is difficult to know what will work best for any individual. Several different kinds, dosages, or combinations of medications may need to be tested before effective relief of symptoms is achieved without unacceptable side effects.

Often people with severe schizophrenia symptoms are treated initially with older medications, even though they are known to have undesirable side effects. Such drugs are chosen because they act much more quickly than some of the newer medications that often require several weeks of usage before they become fully effective. Rapid control of the worst symptoms can be important if the person is highly agitated and/or at risk of harming themselves or others. If the patient is relatively calm and is not showing signs of violent intent towards themselves or others, slower-acting medications with fewer side effects are generally preferred.

Cognitive behavioral therapy is usually recommended to help the person with schizophrenia learn to distinguish between real events and thoughts that are caused by his/her disease as well as to learn how to mask some of their internal struggles and make their condition less apparent to others. Acting “normal” even when the patient doesn’t entirely feel normal can help them fit in and avoid stigmatization or bullying.

Although many individuals with schizophrenia are able to return to a normal level of functioning after treatment, symptoms are rarely completely and permanently eliminated. Ongoing therapy is generally recommended to monitor the person’s condition and adjust medications or develop new coping strategies as needed. Establishing a relationship of trust between doctor and patient is considered to be very important to assure that individuals with schizophrenia will obtain prompt treatment for any worsening symptoms. A long-term relationship with a doctor also increases the chances of quickly identifying and minimizing medication side effects.

It’s not clear how many individuals with schizophrenia will have their symptoms well controlled over the long term and how many will have more serious problems. Individuals with poorly controlled schizophrenia tend to get the most attention, as their behavior can be very disturbing to others. However, individuals with well-controlled schizophrenia tend to keep their diagnosis to themselves, at least until they have retired and no longer face job discrimination.

Studies following groups of schizophrenia patients for several years after an initial diagnosis have generally found that people who receive treatment soon after the appearance of their first symptoms tend to do better than those for whom treatment is delayed. Likewise, patients will do better if they have good support systems. They need people in their lives who will take notice if they show signs of worsening illness, people they trust enough to follow their advice to seek additional help. Individuals who are treated with both medication and ongoing cognitive therapy generally do better than those who use only one type of therapy or have no consistent medical care. Individuals are more likely to stay on their medication and see their therapist regularly if their concerns about issues such as medication side effects are taken seriously and promptly addressed.     

For a better understanding of treatment strategies for individuals with schizophrenia see: http://psychcentral.com/disorders/schizophrenia

For more detailed information about the symptoms and treatments for schizophrenia including different subtypes of the condition, see: http://www.minddisorders.com/Py-Z/Schizophrenia.html

For a better understanding of an important potential side effect of medications used to treat schizophrenia, see: Fact Sheet Tardive Dyskinesia

For a better understanding of drug dosing challenges, see: Pharmacokinetics for Beginners.

For advice for dealing with insurance agencies, locating appropriate treatment providers, communicating with others about your conditions, or to locate support groups for individuals with Schizophrenia or their families ,see: https://www.nami.org/Find-Support

For a self-screening test for schizophrenia, see: http://www.ementalhealth.ca/index.php?m=survey&ID=6 or PRIME Schizophrenia Self-Test

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