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Schizophrenia
Schizophrenia is a serious mental illness that affects the brain, meaning that there are disruptions to the way people think and experience things. It often begins in early adulthood and frequently becomes a chronic, long-term problem which affects all aspects of a person’s life.
Schizophrenia belongs to a group of illnesses called ‘psychoses’. This means that at some stage of the illness, psychosis generally occurs. The term psychosis refers to a temporary or permanent state where a person loses touch with reality, due to a malfunction in the brain. This means that a person suffering from schizophrenia may hear voices which no one else can hear, and which often say cruel or critical things, or see things that other people can’t see, or smell things that other people can’t smell. These features of psychosis are collectively known as hallucinations. A person suffering from schizophrenia may also develop delusions. These are fixed, false beliefs with no basis in reality – for example, believing that people on television are talking about them, or that their thoughts are being controlled by other people. This can be very frightening, and may lead to bizarre behaviour, such as avoiding people or saying odd things to friends and family.
Schizophrenia can affect people in different ways – it has even been said that no two cases of schizophrenia are identical.[1] Often people exhibit a combination of symptoms – but in some cases, different types of symptoms might emerge at different points of the illness.
Symptoms of Schizophrenia
The symptoms of problems of schizophrenia generally fall into two categories: psychotic (or positive) symptoms and negative symptoms. The positive symptoms of schizophrenia are so called because they seem to be experiences that are ‘added on’ to a person – in contrast to negative symptoms, which are considered to be features that are ‘lost’ by a person experiencing schizophrenia.
Positive Symptoms
The positive symptoms of schizophrenia are mostly seen in the acute, or florid stages of the illness. They reflect distortions of reality – and may come on gradually, or very quickly. These symptoms are more responsive to medication than negative symptoms.
Auditory hallucinations are the most common of all positive symptoms. They are mostly experienced as voices. To a person with schizophrenia, these voices sound just like people speaking to them – people with the illness cannot differentiate between what is real (a friend speaking to them) and what is a hallucination. Voices might be heard in the second person (for example someone saying “You stink”, “You’re ugly”. Sometimes, voices might command a person to do something (by saying, for example, “Jump off the bridge”, “Take an overdose”). People with schizophrenia may also have third person hallucinations, which most commonly takes the form of two or more voices taking among themselves, or commenting on the person’s behaviour. Third person hallucinations are considered to be more typical of schizophrenia than any of the other psychoses.
In addition to voices, auditory hallucinations can involve noises, such as buzzing, screeching, and ringing.
Additionally, people with schizophrenia may think that their own thoughts are being broadcast, or can be heard by other people. They also might think that other people’s thoughts are being forced into their own minds, or that their thoughts have been stolen from their heads.
Hallucinations of all five senses may be experienced. In addition to auditory hallucinations, people may have tactile hallucinations (feeling as though they are being pushed, touched, or held down), visual hallucinations (seeing things that aren’t there, feeling that colours are brighter than they should be), hallucinations of smell, and hallucinations of taste.
Delusions are also common in schizophrenia. People develop fixed, unshakable beliefs based on their psychotic reality, and it is very difficult to try and reason with someone experiencing delusions, because to the person, the delusions are very real. They might believe that they are being hunted by government agents, or that aliens are communicating with them through the radio or television. Sometimes, delusional ideas can be grandiose, such as someone believing that they are able to control the weather or are a member of a royal family.
Negative Symptoms
It is often said that the negative symptoms of schizophrenia are harder to cope with than the positive symptoms. These symptoms are also much harder to treat than the psychotic symptoms.
Negative symptoms can lead to a decline in a person’s ability to hold a conversation, their speech might lack inflection, and they may have a ‘blank’ or unchanging expression. People with negative symptoms might be neglectful of the needs and emotions of others, which can be misinterpreted as the person being uncaring, hurtful or callous.
Negative symptoms generally lead to a lack of energy and motivation, a decreased interest in social and recreational activities, and the person often lets social relationships dwindle away. These types of negative symptoms are often misinterpreted as ‘laziness’.
Diagnostic criteria for schizophrenia (USA criteria):
- Characteristic Schizophrenia symptoms:
Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated):
- Delusions - false beliefs strongly held in spite of invalidating evidence, especially as a symptom of mental illness: for example,
- Paranoid delusions, or delusions of persecution, for example believing that people are "out to get" you, or the thought that people are doing things when there is no external evidence that such things are taking place.
- Delusions of reference - when things in the environment seem to be directly related to you even though they are not. For example it may seem as if people are talking about you or special personal messages are being communicated to you through the TV, radio, or other media.
- Somatic Delusions are false beliefs about your body - for example that a terrible physical illness exists or that something foreign is inside or passing through your body.
- Delusions of grandeur - for example when you believe that you are very special or have special powers or abilities. An example of a grandiouse delusion is thinking you are a famous rock star.
- Hallucinations - Hallucinations can take a number of different forms - they can be:
- Visual (seeing things that are not there or that other people cannot see),
- Auditory (hearing voices that other people can't hear,
- Tactile (feeling things that other people don't feel or something touching your skin that isn't there.)
- Olfactory (smelling things that other people cannot smell, or not smelling the same thing that other people do smell)
- Gustatory experiences (tasting things that isn't there)
- Disorganized speech (e.g., frequent derailment or incoherence) - these are also called "word salads". Ongoing disjointed or rambling monologues - in which a person seems to talking to himself/herself or imagined people or voices.
- Grossly disorganized or catatonic behavior (An abnormal condition variously characterized by stupor/innactivity, mania, and either rigidity or extreme flexibility of the limbs).
- "Negative" symptoms of Schizophrenia , these symptoms are the lack of important abilities. Some of these include:
Alogia, or poverty of speech, is the lessening of speech fluency and productivity, thought to reflect slowing or blocked thoughts, and often manifested as short, empty replies to questions.
Affective flattening is the reduction in the range and intensity of emotional expression, including facial expression, voice tone, eye contact (person seems to stare, doesn't maintain eye contact in a normal process), and is not able to interpret body language nor use appropriate body language.
Avolition is the reduction, difficulty, or inability to initiate and persist in goal-directed behavior; it is often mistaken for apparent disinterest. (examples of avolition include: no longer interested in going out and meeting with friends, no longer interested in activities that the person used to show enthusiasm for, no longer interested in much of anything, sitting in the house for many hours a day doing nothing.)
A short summary of a list of negative symptoms are:
- lack of emotion - the inability to enjoy regular activities (visiting with friends, etc.) as much as before
- Low energy - the person tends to sit around and sleep much more than normal
- lack of interest in life, low motivation
- Affective flattening - a blank, blunted facial expression or less lively facial movements, flat voice (lack of normal intonations and variance) or physical movements.
- Alogia (difficulty or inability to speak)
- Inappropriate social skills or lack of interest or ability to socialize with other people
- Inability to make friends or keep friends, or not caring to have friends
- Social isolation - person spends most of the day alone or only with close family
Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person�s behavior or thoughts, or two or more voices conversing with each other.
Cognitive Symptoms of Schizophrenia
Cognitive symptoms refer to the difficulties with concentration and memory. These can include:
- disorganized thinking
- slow thinking
- difficulty understanding
- poor concentration
- poor memory
- difficulty expressing thoughts
- difficulty integrating thoughts, feelings and behavior
- Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement).
- Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).
- Schizoaffective and mood disorder exclusion: Schizoaffective disorder and mood disorder with psychotic features have been ruled out because either (1) no major depressive, manic, or mixed episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.
- Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
- Relationship to a pervasive developmental disorder: If there is a history of autistic disorder or another pervasive developmental disorder, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated).
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Positive Symptoms of Schizophrenia
Delusions are firmly held erroneous beliefs due to distortions or exaggerations of reasoning and/or misinterpretations of perceptions or experiences. Delusions of being followed or watched are common, as are beliefs that comments, radio or TV programs, etc., are directing special messages directly to him/her.
Hallucinations are distortions or exaggerations of perception in any of the senses, although auditory hallucinations (�hearing voices� within, distinct from one�s own thoughts) are the most common, followed by visual hallucinations.
Disorganized speech/thinking, also described as �thought disorder� or �loosening of associations,� is a key aspect of schizophrenia. Disorganized thinking is usually assessed primarily based on the person�s speech. Therefore, tangential, loosely associated, or incoherent speech severe enough to substantially impair effective communication is used as an indicator of thought disorder by the DSM-IV.
Grossly disorganized behavior includes difficulty in goal-directed behavior (leading to difficulties in activities in daily living), unpredictable agitation or silliness, social disinhibition, or behaviors that are bizarre to onlookers. Their purposelessness distinguishes them from unusual behavior prompted by delusional beliefs.
Catatonic behaviors are characterized by a marked decrease in reaction to the immediate surrounding environment, sometimes taking the form of motionless and apparent unawareness, rigid or bizarre postures, or aimless excess motor activity.
Other symptoms sometimes present in schizophrenia but not often enough to be definitional alone include affect inappropriate to the situation or stimuli, unusual motor behavior (pacing, rocking), depersonalization, derealization, and somatic preoccupations.
Negative Symptoms of Schizophrenia
Affective flattening is the reduction in the range and intensity of emotional expression, including facial expression, voice tone, eye contact, and body language.
Alogia, or poverty of speech, is the lessening of speech fluency and productivity, thought to reflect slowing or blocked thoughts, and often manifested as short, empty replies to questions.
Avolition is the reduction, difficulty, or inability to initiate and persist in goal-directed behavior; it is often mistaken for apparent disinterest. (examples of avolition include: no longer interested in going out and meeting with friends, no longer interested in activities that the person used to show enthusiasm for, no longer interested in much of anything, sitting in the house for many hours a day doing nothing.) |
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