The nitty-gritties of schizophrenia

Last week I covered what schizophrenia looks using real-world experiences. This week, I’m going to dive into the disease on a more technical level. As per usual, none of this information is to be used to diagnose or treat anyone, but as a tool for writers to create characters who are close to life as possible and not mere caricatures of mental illness.
Life with schizophrenia is hard for the person experiencing the symptoms as well as the family providing care. But consider this, there was only one treatment plan for schizophrenia 100 years ago: institutionalization. Although institutionalization is still part of treatment, it is often not the only part. Thanks to new treatments and medications, many people with schizophrenia live at home or in group homes in the community. Some even have jobs. I’ll be the first to say that mental health has a LONG way to go, but I believe it is important to keep in mind where we came from.

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A person with schizophrenia may manifest the following (Videbeck p. 252): 

• Ambivalence: Holding seemingly contradictory beliefs or feelings about the same person, event, or situation.

• Associative Looseness: Fragmented or poorly related thoughts and ideas. Thoughts are tangential—not flowing from point to point but all of the place. For example, one sentence might be about baseball and the next about frogs in a pond without a coherent link.

• Delusions: Fixed false beliefs that have no basis in reality
• Echopraxia: Imitation of the movements and gestures of another person whom the client is observing.
• Flight of ideas: Continuous flow of verbalizations in which the person jumps rapidly from one topic to another
• False sensory perceptions or perceptual experiences that do not exist in reality. These can be auditory (voices), visual, smells, and tactile (feelings, like skitters across the arms).
• Ideas of reference: False impressions that external events have special meaning for that person. (The person on the TV is talking to them specifically.)
• Perseverations: Persistent adherence to a single idea or topic; verbal repetition of a sentence, word, or phrase; resisting attempts to change the topic.

The above list are considered “Positive Symptoms” as in they are added to the person. Most positive symptoms are treatable, but there are “Negative Symptoms” or symptoms that seem to be lacking in a person that generally linger after the positive symptoms abate. These are them:  

• Alogia: tendency to speak very little or to convey little substance of meaning
• Anhedonia: Feeling no joy or pleasure from life or any activities or relationships (characteristic of depression, but is it any wonder with everything else possibly going on? Geez.)
• Apathy: Feeling of indifference toward people, activities and events.
• Blunted Affect: Restricted range of emotional feeling, tone, or mood
• Catatonia: Psychologically induced immobility occasionally marked by periods of agitation or excitement; the client seems motionless, as if in a trance
• Flat affect: Absence of any facial expressions that would indicate emotions or mood.
• Lack of volition: absence of will, ambition, or drive to take action or accomplish tasks. 

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Keep in mind that the person experiencing these bizarre behaviors or thinking patterns may be fully aware of them. I once entered a patient’s room to find her smashing invisible bugs on her bedside table. She told me she knew the bugs weren’t real, but smashing them made her feel better. The extent of the awareness of symptoms is difficult to know since there is a huge communication barrier in many schizophrenic patients. The number of delusions, hallucinations, and their strength are all difficult barriers to break through.
Not every person with schizophrenia will have all of the above symptoms. In fact, schizophrenia is less of a single illness and more of a syndrome. Here are the five major types according to the DSM-IV-TR:

• Paranoid Type: Has persecutory (feeling victimized or spied on) or grandiose delusions, hallucinations, and occasionally, excessive religiosity (delusional religious focus) or hostile aggressive behavior
• Disorganized: Has grossly inappropriate or flat affect, incoherence, loose associations, and extremely disorganized behavior.
• Catatonic Type: has marked psychomotor disturbance, either motionless or excessive motor activity. The excessive movement is not influenced by external stimuli. May also have mutism, echolalia (repetitive nonsensical speech) or echopraxia (imitation of the movements and gestures of someone the person is observing.)
• Undifferentiated Type: Sort of a mix of the above
• Residual Type: Has a history of one previous, but not current, episode.   

Schizophrenia generally starts around age 15-25. There is a genetic component to the disease, but having a genetic predisposition to the illness is not a guarantee it will present. Studies on identical twins show a 50% chance of the previously unaffected twin getting the disease. Through various imaging techniques, we have been able to see that those suffering with schizophrenia have alterations in their overall brain structures. How these came about are still a mystery although some theorize it comes about through viruses, trauma, or immune responses. Basically, the theory is that certain people have a genetic predisposition to get schizophrenia if a certain thing occurs to turn on those genes. For example, a virus comes along and triggers those genes and the brain deteriorates. There’s a similar theory regarding the onset of juvenile diabetes.

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While there can be a sudden onset of schizophrenia, most people generally develop signs and symptoms slowly over time. It starts with social withdrawal, unusual behavior, loss of interest in school or work, and neglected hygiene. Generally, the diagnosis is made when delusions, hallucinations, and disordered thinking begin to appear. The age at which schizophrenia appears often determines the overall impact of the illness. The younger the onset, the worse they tend to do. Also, a slower onset predicts a worse outcome than a sudden onset.
Two years after initial onset, two patterns typically emerge. Either the person continues to experience psychosis and never fully recover (although symptoms may shift in severity over time), or they alternate between episodes of psychosis and near complete recovery.
The intensity of the psychosis also seems to diminish with age. Some may be able to function, live independently, and succeed at jobs with stable expectations and supportive work environments. Most, however, have severe difficulty functioning in their communities.
It is important to keep in mind that a person showing initial signs and symptoms of schizophrenia might lose all symptoms within a period of six months. This is called Schizophreniform disorder. Others might experience a brief psychotic disorder where delusions, hallucinations, or disorganized speech may last from 1 day to 1 month. It may or may not have an identifiable stressor or follow childbirth. 
There is SOOOOOO much to tell when it comes to schizophrenia and this post has already become way to long. Next week, I’ll be creating a post that brings together all of this information in a usable form.
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As I was researching this, I came across this article I found very informative but did not use as a source: http://www.drjack.co.uk/the-future-of-schizophrenia-by-dr-jack-lewis/
Psychiatric-Mental Health Nursing, by Sheila L. Videbeck, fifth ed., Wolters Kluwer/Lippincott Williams & Wilkins, 2011.

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