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Schizophrenia

Schizophrenia is the most persistent and disabling of the major mental illnesses. It usually attacks people between the ages of 16 and 30, as they are beginning to realize their potential. It affects approximately one in 100 people worldwide, (one per cent of the population), affecting men and women almost equally. While it is treatable in many cases, there is as yet no cure for schizophrenia.

The mind controls the basic functions of thinking, feeling (emotions), perception (the five senses) and behaviour. These functions ordinarily work together, enabling us to:

In schizophrenia, the interaction of these mental functions is disturbed in various ways. The word schizophrenia does not mean "split personality" but a disruption of the balance among mental functions.

Causes of Schizophrenia

We do not yet understand what causes schizophrenia. Scientists generally agree that schizophrenia is a group of conditions rather than one simple disease and may therefore be found to have several causes. It is generally accepted by researchers that differences in the brain — chemical or structural, or both — may play a part in the disorder. Genetic research also suggests that while no one gene has been found for schizophrenia, several genes may cause a predisposition that can be triggered by certain life events.

Symptoms of Schizophrenia

Symptoms vary greatly. Common symptoms of schizophrenia are:

Delusions: False, but strongly held beliefs, which feel entirely real to the sufferer. They can cause the individual to have a greatly exaggerated belief in his or her own importance, power, knowledge, abilities, or identity. Some people have delusions of persecution (paranoia)-for example, the false belief that they are being attacked, harassed, cheated, spied on or conspired against by others. Other people with schizophrenia believe that occurrences in the outside world are referring to them (ideas of reference). Examples are believing that other people are doing things because of you or that the TV or radio are referring specifically to you, often in negative ways.

Hallucinations: Seeing, hearing, feeling, touching smelling or tasting things that aren't there. Hallucinations have to do with the senses. Hearing voices is the most common hallucination among people with schizophrenia.

Illusions: Disturbances in perception that are less intense than hallucinations. An individual with schizophrenia may experience periods of heightened sensory awareness, during which sounds seem louder or sharper than usual and colours appear brighter, or periods of muted awareness, when sensory input seems closed off. Other illusions may include objects seeming closer or farther away than they really are, or one's own voice or reflection seeming different or even threatening.

Thought Disturbances: Often called muddled thinking by those who experience them, thought disturbances are characterized by an inability to concentrate, to connect thoughts logically, or to think clearly. Thought processes may speed up (racing thoughts) or slow down, or may seem blocked so that the person's mind feels completely blank. Disturbances in thinking are sometimes compared to a broken filter that allows everything that enters the mind to have the same importance — for example, attaching the same significance to licence plate numbers as to a questions from a teacher.

Emotional & Behavioural Changes: A person with schizophrenia can experience sudden, inexplicable changes in mood, such as intense sadness, happiness, excitement, depression or anger that come on without reason or warning. Lack of feelings can be equally disturbing. Symptoms that deprive a person of a range of normal emotions are often described as "negative." The person seems less able to feel anything, including pain or joy. Sometimes this loss of feeling extends to the "sense of self". The individual experiences a sense of unreality about who and where they are or where their body ends. More than any of the symptoms described above, the behavioural changes indicate to others the possible presence of schizophrenia.

An early sign of disturbance is often social withdrawal, as the individual finds interactions with people and things progressively more difficult. One such common response is inability to take an interest in personal hygiene and appearance. Lack of energy, interest and motivation or decreased levels of activity, movement or speech should alert friends and family that something may be amiss. Similarly, behaviour patterns that are unusual in the particular individual, or responses that are clearly inappropriate (excessive laughing or crying in inappropriate circumstances, or excessive talking to oneself) may indicate the approach of an episode of schizophrenia.

Treating Schizophrenia

New medications for schizophrenia along with better prescribing practices (more appropriate dosing), make treatment more successful than in the past. Schizophrenia is treated with medications called antipsychotics. In the last 10 years new compounds have been introduced that have a significantly reduced side-effect profile. In addition it has been recognized that stabilization and recovery from schizophrenia are significantly enhanced with the complimentary treatment of social, employment, and family supports.

Antipsychotic medications work on several levels. They can have an immediate calming effect, reducing anxiety, agitation and restlessness in the person with symptoms of schizophrenia. It can take up to four weeks to reduce symptoms such as hallucinations. Thought disturbances and paranoia are more resistant to medications.

Some people are unwilling to take tablets, even for a short period, because they do not believe they are ill, or because of a previous unpleasant experience with medication. In addition to tablets, medications are also available by injection every two to three weeks. These are especially helpful for people who forget to take their pills.

People with schizophrenia are particularly vulnerable and need social supports — decent housing, income support, supportive friends and family, and something worthwhile to do. Most people with schizophrenia become ill at the age they would be making career choices, undergoing training and forming adult relationships. As a result, they often lack social and work skills. So in addition to medication, people with schizophrenia may need training in social skills, money management and problem-solving. Those who can work often need further training and employment support.

Course of Schizophrenia

10 Years Later

After 30 years

Recommended Antipsychotic Dosage Ranges for the Treatment of Schizophrenia

Dosage Table from the Schizophrenia Patient Outcomes Research Team (PORT) Report published in 2004 in the Schizophrenia Bulletin (Vol. 30, No.2.)

Medication Chlorpromazine
Equivalence1		 Acute
Therapy 		Maintenance
Therapy
First generation antipsychotic medications
Fluphenazine HCI 2 6-20 mg/day 6-12 mg/day
Fluphenazine decanoate2 NA NA 6.25-25 mg/2weeks
Trifluoperazine 5 15-50 mg/day 15-30 mg/day
Perphenazine 10 30-100 mg/day 30-60 mg/day
Mesoridazine 50 150-400 mg/day 150-300 mg/day
Chlorpromazine 100 300-1,000 mg/day 300-600 mg/day
Thioridazine 100 300-800 mg/day 300-600 mg/day
Butyrophenone
Haloperidol 2 6-20 mg/day 6-12 mg/day
Haloperidol decanoate3 NA NA 50-200 mg/4 weeks
Others
Thiothixene 5 15-50 mg/day 15-30 mg/day
Molindone 10 30-100 mg/day 30-60 mg/day
Loxapine 10 30-100 mg/day 30-60 mg/day
Second generation antipsychotic medications
Clozapine NA 150-600 mg/day 150-600 mg/day
Risperidone NA 2-8 mg/day 2-8 mg/day
Olanzapine NA 10-20 mg/day 10-20 mg/day
Quetiapine NA 300-750 mg/day 300-750 mg/day
Ziprasidone NA 120-160 mg/day 120-160 mg/day
Aripiprazole NA 10-30 mg/day 10-30 mg/day

Note - NA = not applicable

  1. 1: Approximate dose equivalent to 100 mg of chlorpromazine (relative potency); it may not be the same at lower vs. higher doses. Chlorpromazine equivalent doses are not relevant to the second generation antipsychotics and therefore are not provided for these agents.
  2. Fluphenzine decanoate dosage recommendations are based on an empirical rule suggested by Kane (1996) (25 mg every 3 wks of decanoate is equivalent to 665 chlorpromazine equivalents per day). These are theoretically determined values and should be interpreted as approximations only (Baldessarini et al. 1988).
  3. Haloperidol decanoate dosage recommendations are based on the following rules: 5 mg oral haloperidol (250 chlorpromaxzine equivalents) per day is equivalent to 50 mg haloperidol decanoate every month. These are theoretically determined values and should be interpreted as approximations only (Zito 1994).

Medication Side Effects

All medications have side effects to a greater or lesser extent. When beginning a new medication you should consult your doctor as to any side effects that might occur. Some medications cause dryness in the mouth, while others may result in too much saliva. Other medications may make you sleepy. Some may cause muscle stiffness.

If you forget to ask you doctor about possible side effects, your pharmacist will have this information.

Tardive dyskinesia is a side effect that is of particular concen. It is usually only observed after a person has been taking antipsychotics for a number of years and is associated more with first generation medications. It consists of involuntary movements of the tongue and mouth with sucking or chewing movements. Sometimes this side effect includes jerky leg or arm movements.

At the present time this side effect is considered permanent so families should be watchful to advise their sick relative's physician the moment that such side effects are suspected so that current medications may be stopped, modified or changed.

Second generation medications (see above) appear less likely to cause this side effect at the stated doses.

The Tardive Dyskinesia Center is a site specifically devoted to tardive dyskinesia.

Pregnancy

The following advice is from page 286 of Surviving Schizophrenia by E. Fuller Torrey, Fifth Edition, 2006, published by Harper Collins.

 

MEDICATIONS AND PREGNANCY

Given what is currently known, a reasonable plan for pregnant women with schizophrenia is the following:

  1. Stop antipsychotic medication for the first three months of pregnancy if she can do so without a serious relapse.
  2. Remain off medication for as much of the pregnancy as possible beyond three months unless symptoms start to recur.
  3. If it is necessary to restart the medication, use whichever antipsychotic medication she has responded to in the past. There are insufficient data yet to say that one type of antipsychotic medication is more dangerous than another during pregnancy.
  4. There are data, however, to suggest that lithium, carbamazepine (Tegretol), valproic acid (Depakane), and divalproex sodium (Depakote), which are sometimes used as ancillary medications in schizophrenia, should be avoided during pregnancy.
  5. Do not be heroic by avoiding medications at all costs. If the woman needs medication, use it. Having a pregnant woman who is acutely psychotic has risks of its own for both the woman and the fetus.
  6. Discuss the issue of medication in detail before the pregnancy or as early in the pregnancy as possible. Be certain that the woman’s family and all concerned understand the options. If the decision is made to stop medication, draw up a contract that specifies that the woman will resume medication if the doctor deems it advisable. The contract must be binding on the woman—even if she changes her mind because of her psychosis—so that she can be medicated involuntarily if necessary.

 

Regarding the taking of antipsychotic drugs while breastfeeding, this should not be done. Antipsychotic drugs are transmitted in the breast milk in small amounts, but because the baby’s liver and kidneys are not mature the drugs may accumulate in the baby’s body. Since a woman who needs medication has the option of bottle feeding, it seems an unnecessary risk to take.


Surviving Schizophrenia is well researched book written, in its first edition, mainly for families, but described in this edition as “A manual for families, patients, and providers”.

Risk of Suicide

Families must always be aware that there can be a high risk for suicide in people with schizophrenia. One in 10 people with schizophrenia comit suicide and 4 in 10 attempt to end their lives. We direct you to our booklet 2 in the publications section of the site, where some of the risk factors are described.

Information about the Brain in Schizophrenia

We are pleased to reproduce (with permission) text from pages 7-12 of Multifamily Groups in the Treatment of Severe Psychiatric Disorders by Willian R. McFarlane (2002) ISBN 1-57230-743-9.

 

Disorders